HospitalInspections.org

Based on document review and interview it was determined that for 1 of 3 (Pt. #1) records reviewed for pronounced death in the Emergency Room (ER), the Critical Access Hospital failed to ensure the physician documentation was complete as required per policy.

Findings include:

1. On 04/24/19 at approximately 11:30 AM, the Critical Access Hospital policy titled, "Medical Staff Documentation" dated 12/2/17 was reviewed. The policy included, "Procedure: 1. The health record will contain information to identify the patient; justify diagnoses and treatment results of care or treatment; describe the condition of patient upon discharge; and document instructions to the patient regarding follow-up care, activity levels, and necessary medications."

2. The clinical record of Pt #1 was reviewed on 04/24/19 at approximately 9:30 AM. Pt #1 was a 97 year old female who was transferred by ambulance from a local nursing home to the ER on 03/12/19 at 3:57 AM, with a chief complaint of shortness of breath. Pt #1 was pronounced dead on 03/12/19 at 11:20 AM.

- The nursing notes dated 03/12/19 at 3:35 AM by Registered Nurse (RN) (E #5) included, "Physician at bed side examining patient (Pt. #1). Put on CPAP (continuous positive airway pressure) (face mask to improve oxygen saturation) per physician orders. O2sat (oxygen saturation) now 93% (percent) on CPAP, daughter at bed side."

- The emergency room physician (MD #3) notes dated 03/12/19 at 3:57 AM included, "She (Pt. #1) is an obese 97 y.o (year old) with h/o (history of) atrial fibrillation (twitching of heart), HTN (hypertension) and pacemaker (device enabled heart functioning). She (Pt. #1) does not usually use supplementary oxygen. She (Pt. #1) was found by the NH (nursing home) staff to have a low SaO2 (saturation of oxygen) and was sent to ER."

- The transfer record notes dated 03/12/19 at 5:17 AM by RN (E#8) included, "Pt. (Pt. #1) to (tertiary level) Hospital for higher level of care."

- The physician's assessment and certification for transfer notes dated 03/12/19 at 9:09 AM, by MD #3 included, "Pt. (Pt. #1) stable to be transferred based on availability of specialized services, facilities, availability of diagnostic equipment and personnel ..."

- The nursing notes dated 03/12/19 at 10:03 AM by RN (E #8) included, "Heart rate 70 (normal 60 -100); respiration rate 24 (normal 12-28); blood pressure 115/57 (normal 120/80); oxygen saturation 90 (normal 90-100); report given, to be transported to tertiary level Hospital by ambulance." At 10:16 AM, "Pt. (Pt. #1) out to ambulance." At 10:40 AM, "Pt. (Pt. #1) back into ER, oxygen saturation dropping to 60s (normal 90 -100); BP (blood pressure) to 53/28; doctor notified; POA (power of attorney) notified; POA with doctor (MD #3) in pts. (Pt. #1's) room."

- The physician notes (no date, no time) (MD #3) included, "This pt. (Pt. #1) had been stable on CPAP and accepted for transfer to (tertiary level) Hospital. When the transfer team finally arrived to the ER (the documentation indicated Pt. #1 was stabilized in the ER prior to planning transfer to tertiary level Hospital). The transfer team left with the patient around 10:15 AM but then called us to inform us at 10:40 AM that, they were returning the pt. (Pt. #1) because she (Pt. #1) was unstable due to her pulse ox (Oxygen saturation) and blood pressure declining. The pt. (Pt. #1) remained in the ER on CPAP. As she never regained consciousness and her blood pressure continued to gradually decline and the pts. (Pt. #1's) respiratory effort weaken and pulse ox (oxygen saturation) drop, she (Pt. #1) was pronounced deceased at 11:20 AM." The clinical record lacked documentation of physician's discussion with Pt. #1's family regarding the disconnection of CPAP.

3. On 04/25/19 at approximately 10:00 AM, an interview was conducted with the Chief Executive Officer (CEO) (E #1). Upon asking about the Physician documentation regarding CPAP removal, E #1 stated, "I would expect the physician (MD #3) documentation regarding CPAP removal, whoever had the conversation with the family, they should have documented."

4. On 04/25/19 at approximately 2:15 PM, an interview was conducted with the ER Physician (MD #3). MD #3 stated, "I do not recall exactly, probably the family members wanted the CPAP to be removed for the patient (Pt. #1). There was an active DNR (Do Not Resuscitate Advance Directive) present in the chart for this patient (Pt. #1). I do not recall documenting the discussion that I had with the family."