HospitalInspections.org

Based on findings from document review, in 1 of 1 medical record (MR) reviewed, the radiological care provided to a patient (Patient A) was not consistent with generally acceptable standards of professional practice. Specifically, the radiology physicians did not correctly interpret and diagnose findings on two chest x-rays performed on Patient A during two emergency department (ED) presentations.

Findings regarding the 1st ED visit include:

-- Per review of Patient A's medical record (MR) for the 1st ED visit on 10-25-09, this 26 year old patient presented with complaints of a 2 to 5 day history of dizziness, fever, cough, and an episode of "passing out" when getting out of bed. Diagnostic testing included frontal and lateral chest x-rays that were reported as "no acute disease." Patient A was discharged with written instructions for supportive treatment and follow up in 1-3 days.

-- Per review of Patient A's chest x-ray films for the 1st ED visit on 10-25-09, by a physician board certified in radiology:

The chest x-rays of 10-25-09 were taken from two views, that is a PA (posterior anterior) and a lateral view. The radiologist did not identify a patchy right upper lobe infiltrate present on the PA view (but not as well seen on the lateral view). This finding would have alerted the ED physician to the presence of pneumonia on the initial ED visit of 10-25-09.

Standard of care not met.


Findings regarding the 2nd ED visit include:

-- Per review of Patient A's MR, on 10-27-09 this patient presented with complaints of congestion, loose cough with productive blood tinged mucus, mild sore throat, painful swallowing, myalgia, weakness and moderate shortness of breath at rest. Diagnostic testing included a portable AP view chest x-ray - the report contained the statements, "...comparison: PA and lateral 10-25-09 A single AP portable radiograph of the chest was obtained. Interval development of bilateral pleural effusions as well as diffuse interstitial and alveolar disease. Impression: Congestive Heart Failure." Patient A deteriorated rapidly with respiratory failure and was admitted to the intensive care unit, where he/she expired 11 days later.

-- Per review of the chest x-ray film for the 2nd ED visit on 10-27-09, by a physician board certified in radiology:

The chest x-ray of 10-27-09 was a PA view which was not correctly evaluated. The radiologist makes the correct findings of interstitial and alveolar disease with pleural effusions. However, attributing the findings to congestive heart failure (CHF) is incorrect. No evidence of cardiomegaly or of pulmonary vessel distention is present to allow attributing the findings to CHF. Given the presence of infiltrate on the prior study and the rapid progression of findings, an infectious process would be a more appropriate diagnosis. The radiologist's duty is to give a differential diagnosis in the interpretation to help the clinician and that did not occur in this case.

Standard of care not met.

(It is acknowledged that the pulmonologist who consulted in the patient's care on 10-27-09 discounted the "Congestive Heart Failure" impression in the radiology report and appropriately identified the x-ray findings as "probably infectious.")

Based on findings from document reviews and interviews, in 2 of 2 medical records (MRs) reviewed, nursing staff did not address age-specific developmental needs of pediatric patients on the nursing care plan, per generally accepted standards.

Findings include:

-- The of MRs for the following patients were reviewed:

* Patient BB (11 years old), who was admitted on 10/08/11 with diagnosis of diabetic ketoacidosis.

* Patient HH (2 years old), who was admitted on 10/11/11 with diagnosis of croup.

Patient BB's and Patient HH's Plan of Care forms do not contain documentation indicating that the patient's age specific developmental needs were assessed and addressed. (The MRs contained Adult Plan of Care forms that were not revised to reflect pediatric developmental issues.)

-- During interview with the Nurse Manager of the Neurology/Pediatric Unit on 10/19/11 at 11:00a.m., he/she acknowleged that nursing staff are expected to address age-specific needs of pediatric patients on the Plan of Care form and document appropriate nursing interventions that address developmental needs.

-- Per interview with the Vice-President of Nursing on 10/19/11 at 11:00a.m., he/she also verified that the nursing Plan of Care should address the age-specific needs of pediatric patients.

Based on findings from document review and interviews, the Licensed Practical Nurses (LPNs) working on the psychiatric unit at this facility are performing patient assessment activites that are not within the scope of practice for LPNs in New York State (per the New York State Education Department). Specifically, in 3 of 3 medical records (MRs) reviewed, a LPN on the Psychiatric Unit was documenting patient assessments pertaining to level of pain, skin integrity and risk to fall.

Facts and findings include:

-- In New York State (NYS), through the Education Department's Office of Professions (OP), the Board of Regents licenses and regulates 47 professions, including nurses (LPNs and RNs). In its publication entitled "Nursing Guide to Practice," the OP has provided information defining the scope of practice for LPNs and RNs.

-- Per review of the "Nursing Guide to Practice," last revised 3/08, on page 43 it states "Nursing diagnosis by a RN is cited in section 6901 of Article 139 of the Education Law as: the identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen.... Nursing diagnosis has been additionally interpreted by the Department as including patient assessment, that is, the collection and interpretation of patient clinical data....Thus, LPNs in NYS do not have assessment privileges; they may not interpret patient clinical data or act independently on such data...."

In summary, this information reveals that the scope of practice for LPNs does not include the performance of patient assessments.

-- Per MR reviews, Patients EE's, FF's and GG's MRs contained documentation revealing that the "Skin Risk Evaluation," "Pain Evaluation," and "Fall Evaluation" were performed by LPN #1.


-- Per interview with the Psychiatric Nurse Manager on 10/19/11 at 11:30 a.m., he/she was not aware that LPN staff were not allowed to perform pain assessments, fall risk assessments and skin risk assessments on the psychiatric unit.


-- Per interview with the Vice President of Nursing (VPN) on 10/19/11 at 8:30 a.m., the hospital's LPNs are not permitted to perform assessments of a patient's risk for fall or skin breakdown, or their level of pain. He/she was not aware that LPNs working on the psychiatric unit were performing patient assessments and acknowledged they should not be doing this.

Based on findings from document review and interview, on 13 occasions in 2 patient's medical records (MRs) respiratory therapy staff did not document pertinent information regarding obtaining an Arterial Blood Gas (ABG) from the patients (Patient T and V).

Findings include:

-- Per review of Patient T's MR, 6 of 6 ABG reports reviewed lacked corresponding documentation regarding where the blood sample was obtained from.

Specifically, ABG results were obtained on:
10/7/11 at 12:47, 18:00, and 22:45
10/8/11 at 05:58
10/9/11 at 06:05
10/10/11 at 05:50
However, there is no documentation that indicates from what site each blood sample was obtained.

-- Per review of Patient V's MR, 7 of 7 ABG reports reviewed lacked corresponding documentation regarding where the blood sample was obtained from.

Specifically, ABG results were obtained on:
10/4/11 at 17:58
10/7/11 at 00:45 and 08:42
10/8/11 at 05:15 and 14:08
10/9/11 at 05:50 and 16:45
However, there is no documentation that indicates from what site each blood sample was obtained.

-- Per interview of the Respiratory Department Manager on 10/18/11 at 2:45 p.m., the Respiratory Therapists should document in a patient's MR when an ABG is drawn. Documentation should include the site from which the sample is taken.