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Tag No.: A0266
Based on medical record review, document review and staff interview, the hospital failed to ensure the quality assurance program corrected errors related to the reporting of significant changes in the status and critical laboratory results and failure to notify the county coroner of the death of Patient #7.
Findings include:
Review of hospital documentation revealed the hospital had completed a mortality review of the medical record for Patient #7. Although the mortality review recognized the lack of documentation of notification to the physician for the changes in the patient's status, the documentation revealed no action had been taken by the hospital to prevent a recurrence to other patients. The mortality review also recognized the failure of hospital staff to notify the county coroner of the patient's death within 24 hours of admission to the hospital, as required by hospital policy Autopsy #:5.8, which requires a death that occurs within 24 hours of admission to the hospital be reported to the coroner. The hospital presented evidence of planned education to occur related to this case on 09/14/11, over two months after the occurrence. The hospital was unable to provide evidence any measures had been taken in the interim to prevent a similar occurrence.
An interview was conducted with Staff A, the Director of Accreditation, on 08/11/11 at 2:00 P.M. Staff A stated the hospital became aware of a problem with the reporting of critical lab results. He/she stated last year the compliance rate was 32 to 35%. Staff A stated a team was formed to address this "last year" and a new team was re-formed in July 2011. Critical test result reporting has been monitored since January 2011. The hospital presented a plan benchmark document that revealed a planned of a goal of only 69% compliance for the reporting of critical lab results to the physician. Staff A stated the actions the hospital had taken to improve the reporting of critical lab results included formation of the team and monitoring for compliance. Although Staff A presented documentation from the critical results impact team which revealed plans to change the method of reporting critical lab results, the hospital was unable to present specific steps that had been taken to improve the reporting of critical lab results. The monitoring data revealed the hospital had a compliance rate of only 78% in June 2011.
This substantiates complaint number OH00061451.
Tag No.: A0364
Based on medical record review and staff interview, the hospital failed to ensure the county coroner was notified of patients who died within 24 hours of admission to the hospital to allow the coroner to make a determination regarding the necessity of an autopsy or further investigation. This affected two of twenty medical records reviewed, (Patient #7 and #17).
Findings include:
The medical record for Patient #7 was reviewed on 8/10/11 to 8/15/11. The medical record revealed the 65 yr old patient was admitted on 6/28/11 with a diagnosis of heart failure to the ED at approximately 1:12 P.M. and was pronounced dead on 06/29/11 at 3:03 A.M., less than 24 hours after admission to the hospital. The funeral home/autopsy release form for Patient #7 was also reviewed. The form contained evidence the patient was a coroner's case as indicated as a check mark under "yes" for coroner's case. The section for "body released by: _____" was blank. The section of the form for designation of an autopsy was also blank. The form lacked evidence the coroner was notified of the patient's death and asked to make a determination regarding the necessity of an autopsy. Further review of this form revealed the patient's body was released to a funeral home on 06/29/11 at 9:30 A.M.
An interview was conducted with the coroner by phone on 08/12/11 at 2:42 P.M. The coroner stated the patient's cause of death was still considered pending because an autopsy was not done. The coroner stated he was not notified until two days after the patient's death. The coroner further stated this notification came from a family member of the Patient #7, and confirmed the hospital did not notify him of the patient's death.
The medical record for Patient #17 was selected from a list of patient deaths and was reviewed on 08/11/11. The patient was admitted to the hospital on 06/21/11. Review of nursing note dated 06/21/11 at 8:50 A.M. revealed a chief complaint of low blood pressure. The medical record revealed the patient's condition was unable to be stabilized and the patient was pronounced dead on 06/21/11 at 1:45 P.M. The funeral home/autopsy release form lacked evidence the coroner was notified of the patient's death within 24 hours of hospital admission. This information was shared with Staff A during exit on 08/15/11 at 3:50 P.M.
Review of the hospital policy Autopsy #:5.8 on 08/12/11 regarding coroner notification revealed the coroner is to be notified of all deaths occurring within 24 hours of hospital admission.
During an interview with the coroner by phone on 08/12/11 at 2:42 P.M., the coroner confirmed that it is hospital policy to notify him of any death that occurs within 24 hours of hospital admission.
This substantiates Complaint Number OH00061451.
Tag No.: A0385
Based on document review, medical record review and staff interview, the hospital failed to ensure the telemetry nursing unit was adequately staffed and failed to ensure a patient's change in health status was communicated to the patient's physician.
Findings include:
Please refer to A 392; 482.23(b) Staffing & Delivery of Care.
Please refer to A 395; 482.23(b)(3) RN Supervision of Nursing Care
Tag No.: A0392
Based on review of staffing records, policy review and staff interview, the facility failed to adequately staff the telemetry nursing unit in accordance with the hospital's staffing guidelines. This telemetry unit is also known as 2A and has 24 beds.
Findings include:
Review of the staffing schedule as worked provided to the surveyors on 8/12/11 revealed the nursing staff did not meet the hospital's staffing guidelines for Registered Nurses according to the patient census on the dates of 5/28/11, 6/28/11 and from 11:00 PM on June 27th to June 28 at 3:00 PM.
Review of the staffing schedule as worked provided to the surveyors on 8/12/11 revealed the nursing staff did not meet the hospital's staffing guidelines for registered nurses according to the patient census on the dates of 7/25/11, 7/26/11, 7/29/11, 7/30/11 and 8/07/11.
Interview of Staff C during tour of the telemetry unit on 8/09/11 at 1:40 PM revealed that the unit was full at 24 patients and 5 registered nurses and two Patient Care Assistants (PCAs) on duty. Review of the hospital's staffing grid for 8/09/11 called for 6 Registered Nurses and three PCAs to be on duty. Interview of Staff C at this time confirmed staffing was short.
Interview with Staff F on 8/10/11 at 1:15 PM on the telemetry unit (2A) revealed he/she had worked 80 hours the previous week and was regularly working a lot of overtime.
This substantiates Complaint Number OH00061451.
Tag No.: A0395
Based on medical record review, document review and staff interview, the hospital failed to ensure nursing staff reported changes in a patient's health status and critical laboratory values to the physician. This affected the care provided to Patient #7 and had the potential to affect 140 other patients currently in the hospital if permanent corrective actions are not taken.
Findings include:
Patient # 7 was admitted to the emergency department (ED) on 06/28/11 at 1:12 P.M. with a diagnosis of heart failure. The ED vital signs on triage admission were heart rate 113, respirations 20, blood pressure 160/141, oxygen saturation 96%. The ED record revealed the patients stated weight was 390 lbs. The patient's chief complaint was difficulty breathing. The patient had a history of asthma, hypertension and obesity. The ED record revealed the patient had an EKG ordered by Staff Q, the ED physician at 1:15 P.M. In addition, the patient received an IV and Foley catheter. Staff D, the hospitalist was at the patients bedside at 3:04 P.M.
Admission orders were written for transfer to telemetry unit, under the care of Staff D with diagnoses documented as dyspnea, CHF, EKG changes and reactive airway disease. Report was called to the telemetry floor to Staff S at 3:24 P.M. The patients output was documented at 3:51 P.M. on the ED record as 1000 cc. The ED record revealed the patient transferred at 4:25 P.M.
At the time of admission to the hospital, laboratory tests revealed an initial troponin (cardiac enzyme) level of 0.04 at 1:31 P.M. Orders were written for troponin levels to be re-checked every four hours for a total of three tests and the patient was given medication to remove excess fluid. The medical record revealed the patient's second troponin level was reported by the lab to be 0.13, a level considered by the laboratory to be a critical results. The laboratory staff documented the nursing unit was informed by phone of this result at 7:16 P.M. The hospital listed a normal troponin level as 0 to 0.07. The medical record lacked documentation that the patient's physician was contacted. The patient's blood pressure was documented at 4:30 PM as 162/93, heart rate 105 and at 8:00 PM as 114/76 and heart rate 93 with output documented as 400 cc.
Further review of the medical record revealed a nursing note dated 6/29/11 at 06:35 A.M. by Staff B that revealed on the evening of 06/28/11 at 8:45 PM the patient began to complain of uneasiness, malaise and feeling anxious with a blood pressure of 126/90. The patient was found to be diaphoretic (sweating heavily) and clammy. The patient also complained of nausea. The nursing notes lacked evidence that the patient's physician was notified of the patient's symptoms. The nursing notes also lacked evidence that the registered nurse caring for the patient conducted a further assessment of the patient.
The nursing note at 8:45 PM stated a written order was received to give 4 milligrams of Zofran for nausea IV. The documentation lacked evidence of how this order was obtained, or if the patient's physician was notified of the elevated cardiac enzyme or the patient complaints at that time. The order was written by a nurse practitioner, Staff T, who worked with the patient's physician, but no progress note was written to indicate the nurse practitioner had examined the patient at that time. The medication administration record lacked evidence of the time the Zofran was administered. The laboratory staff documented the nursing unit was informed by phone of the troponin level of 0.17 at 10:30 P.M. There was no evidence in medical record this value was called to the physician. The nursing note then stated "almost to midnight, the patient began to complain again of not feeling well. At this time, the patient was sweaty and cold. BP at this time was 64/43." The documentation revealed a hospitalist, Staff P, was notified, but again lacked evidence of any discussion of the patient's elevated troponin in connection with these symptoms. The patient was given intravenous (IV) fluid bolus ordered by Staff P. No progress note was written to indicate the physician or the nurse practitioner had examined the patient or made a determination as to possible causes of the patient's symptoms. The registered nurse, Staff B, did not document any further assessment of the patient at that time.
The nursing graphic record revealed a blood pressure reading of 103/63 and heart rate of 86 at 01:35 A.M. The medical record revealed an EKG was completed on the patient at 2:03 A.M. The nursing notes then documented,"exactly at 0200" (2:00 AM), the patient's family began yelling for help. The patient was found to be "lying across the bed with eyes rolled back". The rapid response team was called at that time. Resuscitation efforts were documented as starting at 2:25 AM. The medical record lacked evidence as to what occurred for the 25 minutes between 2:00 AM and 2:25 AM when resuscitation began. The resuscitation efforts were unsuccessful and the patient was pronounced dead at 3:03 AM.
The hospital policy Critical Test Completion and Critical Test/Critical Result Report #:10.0 regarding critical lab results was reviewed on 08/11/11. The policy defined a critical result as a value or result of a diagnostic test with such variance from normal as to represent a pathophysiologic state that is life threatening unless some action is taken within a short period of time. The policy stated critical results will be reported to the responsible licensed caregiver within 1 hour from the time that the result is noted to be a new critical result. If the critical result is received by a responsible licensed caregiver who is not the ordering provider, the results must be relayed to the ordering provider or appropriate covering provider within the time frames designated above.
Upon surveyor investigation on 08/12/11, it was determined that two policies existed for the reporting of critical laboratory results. Although both policies contained the same definition of a critical result (a value or result of a diagnostic test with such variance from normal as to represent a pathophysiologic state that is life threatening unless some action is taken within a short period of time), the policies differed in the point at which a troponin level was considered critical. The hospital wide policy, used by nursing staff and last updated 04/09, noted a troponin level was considered critical if greater than 0.20. The laboratory policy, last updated on 2/23/10, noted a troponin level was considered critical if greater than 0.08. Staff L, Director of Laboratory, was interviewed on 08/12/11 at 1:50 P.M. Staff L stated the laboratory policy was updated to lower the level of troponin considered critical from 0.20 to 0.08. Staff L stated the critical results were established based on population studies and manufacturer recommendation (for the laboratory equipment). The level was set at the 99th percentile. Staff L further stated the current procedure for reporting critical laboratory values is for the laboratory staff to call the nurse. The nurse is then to call the patient's physician.
An interview was conducted with Staff A, the Director of Accreditation, on 08/11/11 at 2:00 P.M. Staff A stated the hospital was aware of a problem with the reporting of critical lab results. He/she stated last year the compliance rate was 32 to 35%. Staff A stated a team was formed to address this "last year" and a new team was re-formed in July 2011. Critical test result reporting has been monitored since January 2011. The hospital presented a planned benchmark document with a goal of only 69% compliance for the reporting of critical lab results to the physician. Staff A stated the actions the hospital had taken to improve the reporting of critical lab results included formation of the team and monitoring for compliance. Although Staff A presented documentation from the critical results impact team which revealed plans to change the method of reporting critical lab results, the hospital was unable to present specific steps that had been taken to improve the reporting of critical lab results. The monitoring data revealed the hospital had a compliance rate of only 78% in June 2011.
Review of hospital documentation revealed the hospital had completed a mortality review of the medical record for Patient #7. Although the mortality review recognized the lack of documentation of notification to the physician for the changes in the patient's status, the documentation revealed no action had been taken by the hospital to prevent a recurrence to other patients.
This substantiates complaint number OH00061451.