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Based on interviews the hospital failed, for one (Patient #4) of ten patients sampled, to furnish anesthesia services in a well organized manner.

See Tag 1002.

Based on record review and interviews, the hospital failed, for two (Patient #1 and Patient #5) of ten patients sampled, to document provider restraint renewal orders every 4 hours in accordance with hospital policy.

Findings Include:

The policy titled "Restraints or Seclusion for Violent or Self-Destructive Behavior", states under Section 1B, "The physician's order for a physical restraint is time-limited to: 4 hours for adults." Additionally, the policy states under Section 1C, "The physician or LIP (licensed independent practitioner) makes an in-person re-evaluation at least every 8 hours for patients 18 years old or older and every 4 hours for patients 17 and younger." Additionally, the policy states under Section 2C. "Assessment and Care. The staff's experience with the patient and the assessment of the patient's risk for injury to self-determine the method of restraint. Assessment of the patient during restraint will be conducted by qualified staff, staff that has demonstrated competence in the application and monitoring of patients in restraint. The nurse will conduct the assessment of ongoing need for and response to the restraint every 15 minutes."

The surveyor interviewed the Risk Manager on 01/27/25 at 2:40 P.M. The Risk Manager said that all restraint periods of Patient #1 were reviewed. The Risk Manager said that it was identified that the initial four-point restraint order on Patient #1 in the Emergency Department (ED), on 01/01/2024 at 12:00 P.M. (Patient #1 hospital admission was from 01/01/24 until 04/12/24) was missing. Although an ED physician note indicated the physician was aware of Patient #1 being put in restraints, the actual restraint order was not placed/documented in Patient #1's medical record.

The surveyor interviewed the Risk Manager on 01/28/25. The Risk Manager said that during Patient #1's inpatient stay on a unit from 01/06/24 until 01/10/24, Patient #1 was on violent, self-destructive restraints. Although it was identified that indications for the violent, self-destructive restraints were appropriate, the Risk Manager acknowledged that there were gaps (missing or lack of documentation) in provider assessment documentation, provider order renewals and nursing assessments.

Medical record review of an active patient (Patient #5) on 02/03/25 at 2:00 P.M., indicated that there was missing restraint orders during the inpatient care of Patient #5. Patient #5 was on violent, self-destructive restraints while on the neurology intermediate care unit (nICU) from 01/28/25 at 12:17 A.M. until 01/29/25 at 7:21 P.M, (a period of approximately 43 hours). During that time, medical record review indicated a lack of documentation of physician restraint renewal orders, where orders were not being renewed every 4 hours in accordance with hospital policy. The first provider order renewal gap was between 01/28/25 at 12:35 A.M. and 01/28/25 at 12:21 P.M. (12 hour gap). The second provider order renewal gap was between 01/28/25 at 4:32 P.M. and 01/29/25 at 6:02 A.M. (a 14 hour gap).

The surveyor interviewed the Patient Safety Coordinator (PSC) on 02/03/25 at 2:00 P.M. The PSC acknowledged that there was a 12 hour and 14 hour time period without a provider restraint renewal order in accordance with hospital policy while Patient #5 was on violent, self-destructive restraints on the nICU.

Based on record review and interviews, the hospital failed, for one (Patient #5) of ten patients sampled, to conduct and/or document the necessary monitoring required for a patient (Patient #5) on violent self-destructive restraints, in accordance with hospital policy.

Findings Include:

The policy titled, "Restraints or Seclusion for Violent or Self-Destructive Behavior", last revised 05/2023, under section 2C, Assessment of Care states, "Assessment of the patient during restraint will be conducted by qualified staff, staff that has demonstrated competence in the application and monitoring of patients in restraint. The nurse will conduct the assessment of ongoing need for and response to the restraint every 15 minutes."

Medical record review of Patient #5 on 02/03/25 at 2:00 P.M. indicated that there were lapses in documentation of Patient #5's every 15 minute patient checks, in accordance with hospital policy, during Patient #5's restraint episode(s) period.

Medical record review of Patient #5 on 02/03/25 at 2:00 P.M. indicated that Patient #5 transferred from the Emergency Department (ED) to the Neurology Intermediate Care Unit (nICU) on 01/28/25 at 12:17 A.M. and was on violent self-destructive restraint orders until 01/29/2025 at 7:21 P.M, (a period of approximately 43 hours). Medical record review of Patient #5 indicated that the form (the surveyor received this form on 01/29/25) for documenting the every 15 minute checks, titled "Behavioral Restraint Patient Observation, Baystate Health System-Non-Behavioral Units, Mental Status Observation q15 minutes," (BRPO) was lacking the date of when the 15 minute checks were performed. Additionally, the form indicated 15 minute checks from a time period of 10:41 A.M. until 1:45 P.M, roughly 3 hours of every 15 minute checks documentation despite a total time period of 43 hours of Patient #5 on violent self-destructive restraints in the nICU (from 01/28/25 at 12:17 A.M. until 01/29/2025 at 7:21 P.M).

The surveyor interviewed the Patient Safety Coordinator (PSC) on 02/03/2025 at 2:00 P.M. The PSC confirmed that there were no other BRPO forms in Patient #5's medical record for the 43 hour period that Patient #5 was on violent self-destructive restraint orders in the nICU. The PSC said that only the undated BRPO indicating roughly three hours of 15 minute checks, was the only BRPO form that could be located. The PSC said it was required that hospital staff must fill out a BRPO form for every patient that is on violent, self-destructive restraint orders.

Based on interviews the hospital failed for one (patient #4) of ten patients sampled, to appropriately deliver anesthesia services consistent with recognized standards for anesthesia care.

Findings Include:

The hospital report, submitted to the to the Department of Public Health (DPH) on 02/17/2024, reported that Patient #4 presented to the hospital for a lithotripsy procedure (a medical procedure used to break up and remove stones (such as kidney stones) in the urinary tract) in the Operating Room (OR). Once the procedure was completed, Patient #4 was being awakened from anesthesia and became hypoxic (low oxygen levels in the body's tissues) and a code blue was called. The patient was noted to be pulseless, and anesthesia commenced cardiopulmonary resuscitation (CPR). Massive aspiration (breathing foreign objects into the lungs) of gastric (stomach) contents was noted. Despite all efforts of the team, and after discussion with Patient #4's wife, it was decided to stop CPR, and Patient #4 was declared deceased.

The surveyor interviewed the Chair of Anesthesia (CoA) on 02/03/2025 at 10:00 A.M. and again at 3:00 P.M. The CoA said that Patient #4 was ordered for supplemental oxygen during Patient #4's lithotripsy procedure. The CoA said that there was one concern after the CoA reviewed the anesthesia record and after a conversation between the CoA and the attending anesthesiologist for Patient #4 (Anesthesiologist #1) regarding Patient #4's anesthesia during the operation/procedure. The CoA said that the method of how Anesthesiologist #1 applied the supplemental oxygen to the patient was not in accordance with standard practice, not in accordance with hospital policy, and not typically how oxygen is given to a patient who requires supplemental oxygen during an operation/procedure.

The CoA said that Anesthesiologist #1 created his/her own makeshift adapter when connecting Patient #4 to the anesthesia machine. It was Anesthesiologist #1's own method to deliver oxygen to Patient #4 as Patient #4 was more than six feet away from the anesthesia machine (due to the type of procedure, amount of equipment involved, patient distance from the anesthesia machine was farther relative to other procedures). The CoA said that the standard practice would have been to retrieve readily available, commercially manufactured equipment called extension tubing, that would allow for Patient #4 to be connected to the anesthesia machine despite Patient #4 being placed more than six feet from the anesthesia machine. The CoA added that Anesthesiologist #1's makeshift adapter was a deviation from that standard practice.

The CoA said that Anesthesiologist #1 created this makeshift adapter by cutting an endotracheal (ET) tube, and taking part of that ET tube to connect to the anesthesia circuit tubing. The CoA said that this makeshift adapter was not a manufacturer produced adapter. The CoA said that the standard practice would have been to use extension tubing. When the CoA inquired with Anesthesiologist #1 why Anesthesiologist #1 did not use extension tubing, Anesthesiologist #1 claimed that Anesthesiologist #1 did not have the extension tubing available. The CoA said that extension tubing is readily available and added that even if extension tubing was not in Patient #4's OR at the time of preparation for Patient #4's procedure, Anesthesiologist #1 could have asked an anesthesia technician to deliver extension tubing to Anesthesiologist #1.

The CoA said that the circuit (also known as a circle circuit) created by Anesthesiologist #1's version of delivering oxygen to Patient #4 involves a valve. If the valve is open, then there is no pressure in the circuit. This circuit system requires pressure if oxygen is to get delivered to the face mask and ultimately to the patient. The CoA said that Anesthesiologist #1 could not explain to the CoA whether that valve was open or closed, (an open valve meaning no pressure in the circuit system, which would mean oxygen delivery to the patient may be compromised and/or not being delivered to the patient).

The CoA said that Patient #4 was induced (induction phase of anesthesia which is the beginning phase of general anesthesia when the patient starts to be sedated) at 10:14 A.M. At that time, the measured oxygen to Patient #4 was ranging 21 to 23%. The CoA said that standard room air oxygen concentration is 21%. However, the CoA said that based on Patient #4's profile (being that Patient #4 was undergoing a procedure receiving general anesthesia and would be subject to intravenous (IV) sedation) it is typical that when giving supplemental oxygen, the oxygen concentration delivery should be upwards to the 50 to 60% range. However, the CoA said that the highest inspired oxygen concentration at the face mask up until 10:30 A.M. was 26%, far below the 50 to 60 % ideal range.

The CoA said that the oxygen saturation of Patient #4 from 10:15 A.M. until 10:30 A.M. was ranging from the mid-70's to the mid-80's with a low point of 76, indicating Patient #4's body was deficient of oxygen or oxygen deprived, for approximately 15 minutes (standard oxygen saturation ranges 95 to 100%). The CoA said that at approximately 10:30 A.M. Anesthesiologist #1 switched Patient #4 to a different oxygen mask that was directly connected to the anesthesia machine. The measured oxygen concentration at 10:30 A.M. at the face mask was now approaching 100%.

The surveyor inquired with the CoA whether or not an autopsy was performed on Patient #4 and if so, did the CoA have a chance to review the autopsy report. The CoA said that the CoA did not look at any autopsy results, but the CoA added that the CoA believed it was the hypoxic arrest that contributed to the death of Patient #4.

The surveyor asked the CoA if there was any education and/or training to anesthesia staff regarding the inappropriate practice of creating a makeshift adapter as a substitution for retrieving extension tubing for the purposes of providing supplemental oxygen when a patient is placed relatively far from the anesthesia machine. The CoA could not recall any education and/or training to the anesthesia staff.