HospitalInspections.org

Based on interview and record review, the facility failed to ensure its medical staff bylaws and rules and regulations were implemented, for one of 30 sample patients (Patient 15) when the patient's diagnostic result was missed, and patient was discharged home with an acute medical condition.

This failure led to a delay in patient care and treatment and had the potential to cause harm.


Findings:

On February 4, 2025, at 3 p.m., an interview and review of Patient 15's record was conducted with the Director of Education (DE).

A facility document titled, "ED [Emergency Department] Physician Record," dated January 8, 2024, was reviewed. The document indicated, "...[Patient 15] presents to the ED for evaluation of right sided abdominal pain onset last night exacerbated by deep breaths, movement, and by touch. Patient [Patient 15] states the pain worsened overnight and became localized to right lower quadrant [area of the abdomen that is on the right side below the belly button.]...endorses nausea and rates pain a 6/10 [for pain scale of 1 to 10, a pain scale of six means moderate pain] at rest...Physical Examination...GI [gastro-intestinal, pertains to the esophagus, stomach, and intestines]: soft, non-distended [not swollen or enlarged]...tender [painful] to palpation [touch] over the right lower quadrant. Positive McBurney's point tenderness [specific location on the abdomen where tenderness may indicate an underlying medical condition, typically appendicitis, a medical emergency that occurs when the appendix, a small tube-like organ attached to the large intestine, becomes inflamed and infected]. Negative Murphy's sign [a physical examination maneuver used to assess for inflammation of the gallbladder]...Results review...Lab [labroatory] results...WBC [white blood cells, a component of blood] 11.43 HI [High, can indicate infection, normal is between 4.0 and 11.]..."

A facility document titled, "CT abdomen/Pelvis w/Contrast," dated January 8, 2025, at 8:57 p.m. was reviewed. The document indicated, "...Stomach and bowel [a tube-like organ that is part of the digestive tract]...appendix mild dilated at 7 [seven] mm [milimeter, a unit of measurement]. Large appendicolith [a small, hard deposit that forms in the appendix] within the appendix. There is mild periappendiceal stranding [inflammation and thickening of the fat tissue surrounding the appendix.]. No bowel dilation...Impression: CT [medical imaging technique that uses x-rays to create detailed images of the body] findings of acute appendicitis. No evidence of perforation [hole]..."

A facility document titled, "ED Physician Record," dated January 8, 2024, was reviewed. The document indicated, "ED Course...Based on the patient's [Patient 15's] history and presentation, my workup, the differential diagnoses [list of possible medical conditions that could be causing symptoms] considered for this patient include...appendicitis...I [Medical Doctor, MD 1] reviewed the patient's past medical history, clinical risk factors, comorbidities as per HPI as well as any relevant diagnostic studies. The patient is well-appearing and hemodynamically stable...Plan: Condition: Stable...patient given the following discharge instructions: Vomiting...abdominal pain... Disposition...time 1/8/2025 [January 8, 2025] 2219 [10:19 p.m.]...Patient is currently stable for discharge...no emergent medical condition exists..."

A facility document titled, "ED Physician Record," modified January 12, 2024, was reviewed. The document indicated, "...Addendum...on 1/12/25 [January 12, 2025] I [MD 1] called the patient and emergency contacts...received an answer from the patient's [family member] who updated on the patient, the patient had worsening symptoms so was seen at an ED, subsequently admitted and treated for appendicitis...spoke to the patient's [family member] regarding the CT findings during the visit on 1/8/2025 [January 8, 2025]...Patient overall had an uncomplicated course and was able to be discharged home in care of their parents..."

On February 5, 2025, at 11:40 a.m., an interview was conducted with the Quality Director (QD). The QD stated the patient's family member had filed a grievance related to the patient being discharged with appendicitis. The QD stated the Medical Director is doing an investigation to decide on any disciplinary actions for MD1 for discharging the patient with appendicitis. The QD stated the patient should not have been discharged without the correct results.

On February 5, 2025, at 12:30 p.m. a concurrent interview and review of Patient 15's recrod were conducted with the Emergency Department Director (EDD). The EDD stated there was a Midas (facilities internal reporting system) follow up which has been sent to the Medical Director for this incident. The EDD stated the ED physician receives and reviews diagnostic results as they come in. The EDD stated this was not a case of a critical value so MD 1 read the results on their own and either misread or missed the appendicitis result. The EDD stated MD 1 had the CT results prior to discharging Patient 15 but missed the impression of acute appendicitis and discharged Patient 15. The EDD further stated the result should have been read correctly prior to dicharging Patient 15.

A review of the facilitydocument titled, "Medical Staff Bylaws," dated October 2021, was conducted. The bylaws indicated, "...the ongoing responsibilities of each member of the medical staff include the following basic responsibilities...providing patients with care and coordinating care, treatment, and services...as relevant to the care, treatment, and services of each patient to ensure that all patients admitted to the hospital or treated in any outpatient department are provided with the quality of care meeting the professional standards of the medical staff of this hospital...abiding by the medical staff bylaws...rules and regulations...and other established rules and policies of the hospital..."

A review of the facility policy titled, "Organization Plan for the Provision of Patient Care," dated August 2024, was conducted. The policy indicated, "...The medical staff is responsible for the quality of medical care in the organization...the medical staff assesses and reassesses the patients physical, psychosocial, social and cultural status. The medical staff defines the scope and intensity of each service which include but may not be limited to: performing histories and physicals, ordering of diagnostic testing, timely assessments, timely reports, and discharge planning...Patient safety and stabilization is the primary consideration in the Emergency Department..."

Based on interview and record review, the facility failed to ensure the policy for Patient Controlled Analgesia (PCA, a safe way for patients in pain to give themselves intravenous [IV] pain medicine when they need it) Pump monitoring was implemented, for three patients of 30 sample patients (Patients 2, 8, and 13).

This failure had to the potential for pain treatment to be delayed which may prolong the patient's pain.

Findings:

1. On February 4, 2025, at 1:25 p.m., an interview and review of Patient 2's record were conducted with the Director of Education (DE).

The facility document titled, "History and Physical," dated November 1, 2024, was reviewed. The document indicated, Patient 2 was admitted with a "...chief complaint of abdominal pain... Patient status post [after a procedure was done] exploratory laparoscopy [a minimally invasive surgical procedure that allows the surgeon to directly visualize and examine the abdominal organs]..."

An untitled facility document, dated November 1, 2024, was reviewed. The document indicated, "...Original order...by [name of surgeon] on 11/1/2024 [November 1, 2024] at 15:35 [3:35 p.m.]...Morphine [a narcotic used to treat moderate to severe pain] PCA 1 [one] mg/ml [miligram per mililiter, units of measurement] 30ml 30mg..."

An untitled facility document was reviewed. The document indicated Patient 2's vital signs were taken on the following dates and times:

- November 1, 2024, at 7:45 p.m.;
- November 1, 2024, at 10:34 p.m.;
- November 2, 2024, at 12:35 a.m.;
- November 2, 2024, at 2:18 a.m.;
- November 2, 2024, at 3 a.m.;
- November 2, 2024, at 4:10 a.m.; and;
- November 2, 2024, at 8:30 a.m.

There was no documented evidence Patient 2's vital signs were taken every 15 and 30 minutes in accordance with the facility's policy and procedure.

The DE stated the staff did not follow the specific PCA policy for monitoring documentation, when the vital signs were not documented according to the policy. The DE stated staff did not document Patient 2's vital signs every 15 and 30 minutes in accordance with the facility's policy.

2. On February 4, 2025, at 1:45 p.m., an interview and review of Patient 8's record were conducted with the Director of Education (DE).

The facility document titled, "History and Physical," dated February 3, 2024, was reviewed. The document indicated Patient 8 was admitted with a "...chief complaint of low back pain with radiation into the legs. Patient status post L3-4 [the 3rd and 4th vertabrae in the spine] posterior decompression and fusion [a surgical procedure that relieves pain and pressure on the spinal cord and nerves in the lower back]..."

An untitled facility document was reviewed. The document indicated, "...Original order...by [name of surgeon] on 2/3/2025 [February 3, 2025] at 6:27 a.m...Morphine PCA 1 mg/ml...30ml 30mg..."

An untitled facility document was reviewed and indicated the PCA pump for Patient 8 was initiated on February 3, 2025, at 2:08 p.m.

An untitled facility document was reviewed and indicated Patient 8's vital signs were taken on the following dates and times:

- February 3, 2025, at 2:22 p.m.;
- February 3, 2025, at 3:14 p.m.;
- February 3, 2025, at 4 p.m.;
- February 3, 2025, at 8 p.m.;
- February 3, 2025, at 9 p.m.; and;
- February 4, 2025, at 12 a.m.

There was no documented evidence Patient 8's vital signs were taken every 15 and 30 minutes in accordance with the facility's policy and procedure.

The DE stated the staff did not follow the specific PCA policy for monitoring documentation, when vital signs were not documented according to the facility policy. The DE stated staff did not document Patient 8's vitals for every 15 and 30 minutes in accordance with the facility's policy.

3. On February 4, 2025, at 2:15 p.m., an interview and review of Patient 13's record were conducted with the Director of Education (DE).

The facility document titled, "History and Physical," dated December 24, 2024, was reviewed. The document indicated Patient 13 was admitted with a "...chief complaint of neck pain with radiation to bilateral [both] arms...proceeding with surgery...cervical fusion [a surgical procedure that joins the individual bones that make up the spinal column, in the neck] C4 to C7 [the fourth to seventh vertabrea in the neck]..."

An untitled facility document was reviewed and indicated, "...Order name...on 12/26/2024 [December 26, 2024] at 11:46 a.m...Morphine PCA 1 mg/ml...30 ml 30 mg...Status...Discontinued on 12/27/2024 [December 27, 2024]..."

An untitled facility document was reviewed and indicated, "...Order name...on 12/27/2024 [December 26, 2024] at 11:46 a.m...Dilaudid PCA 0.2mg/ml...6 g..."

An untitled facility document was reviewed and indicated Morphine PCA was started for Patient 13 on December 26, 2024, at 1:38 p.m. and was discontinued on December 27, 2024, at 10:34 a.m. The document indicated the Dilaudid PCA was started for Patient 13 on December 27, 2024, at 10:53 a.m. and was discontinued on December 28, 2024, at 10 a.m.

An untitled facility document indicated Patient 13's vital signs were taken on the following dates and times:

- December 27, 2024, at 1:30 p.m.;
- December 26, 2024, at 2 p.m.;
- December 26, 2024, at 3 p.m.;
- December 26, 2024, at 4 p.m.;
- December 26, 2024, at 5 p.m.;
- December 26, 2024, at 6 p.m.;
- December 27, 2024, at 8:23 a.m.;
- December 27, 2024, at 12:42 p.m.;
- December 27, 2024, at 3:15 p.m.;
- December 27, 2024, at 8:02 p.m.; and
- December 28, 2024, at 12:01 a.m.

There was no documented evidence Patient 8's vital signs were taken every 15 and 30 minutes in accordance with the facility's policy and procedure.

The DE stated the staff did not follow the specific PCA policy for monitoring documentation, when vital signs were not documented according to the policy. The DE stated Patient 13's vital signs should have been documented according to the facility's policy for the initiation of the Morphine and Dilaudid PCA pumps. The DE stated staff did not document Patient 13's vital signs for every 15 and 30 minutes in accordance with the facility's policy.

The facility policy and procedure titled, "Patient Controlled Analgesia (PCA) Policy," revised October 2019, was reviewed. The policy indicated, "...Patient Monitoring- Once PCA is initiated, vital signs will be assessed and documented, at a minimum, as follows...every 15 minutes x2 [two times]...every 30 minutes x2...every 1-hour x2...every 4 [four] hours during PCA therapy...assess the patient's respiratory rate, level of pain, level of sedation every 4 hours..."