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Based on medical record review and staff interview, it was determined the hospital failed to ensure timely and appropriate assessment of a post-operative patient (Patient #7) exhibiting signs of clinical deterioration. This failure directly impacted the quality of care for 1 of 8 patient records reviewed and had the potential to negatively affect all patients receiving care in the facility.

Findings included:

Patient #7 was a 58-year-old female admitted to the hospital on 2/21/25 after a right hip arthroscopy with femorplasty, and acetabuloplasty and was discharged 3/06/25 . Patient #7's medical record was reviewed. Patient #7's medical record included nursing notes from 2/21/25 documenting vital signs from her admission to the PACU post surgery at 11:08 AM. Upon admission to the PACU, her airway was removed. Patient #7 continued with nasal cannula and oxygen at 3 L/min. Patient #7's medical record noted she was transferred to the next level of PACU at 2:00 PM on room air and oxygen saturation of 98%.

Parameters in the chart noted 90-100 for oxygen saturation, pulse of 60-100 beats/min and respirations of 12 -24/min.

Patient #7's medical record indicated she was admitted to the inpatient unit of the hospital at 6:57 PM with orders for vital signs every 4 hours and hourly rounding. Patient #7's chart also indicated she had "nausea, retching" with Zofran prescribed and vital signs documented as 95% oxygen on room air with respirations of 16 and pulse of 92.

Patient #7's medical record included a nursing note dated 2/23/25 at 7:37 AM. The note included; "Tachycardic at times, other VSS[vital signs stable]. Pt desatting [oxygen saturation decreasing outside of parameters] to high 80s while asleep, 2L 02 administered. Pain and nausea controlled with PRNs. PIV infiltrated, attempted multiple attempts for new PIV without success. Provider aware, PO antiemetic ordered." Patient #7's medical record indicated the Patient's condition was deteriorating as follows:

- "2/23/25 10:36 [name] ARNP notified [Pt #7] O2 sats 89% on RA, RR in the upper 20's at times [RR outside of parameters] and HR 116 [HR outside of parameters]
- 2/23/24 15:37 Notified ARNP that Pt's respiratory rate in the 20s and up to 27 at times [RR outside of parameters].
- 2/24/25 6:44 SBA when walking w/ FWW. ... Tachycardic and tachypneic slight temperature at beginning of shift, provider aware, no new orders. PRNs given for nausea and pain with relief. Pt resting in bed."
- On 2/24/25 17:38 a RT note stated, "Pt with increased WOB and oxygen needs. Bilateral basal crackles. Pursed lip breathing and SOB during evaluation and discussion. Will place pt on NIV support PRN to support respiratory effort. Dr. aware."
- Nurse notes continued, " 2/25/25 00:14 Placed on CPAP at 2200 due to her refusal of bipap. She states it feels better ...Pt requested to have her CPAP off for the night as it making her nauseous. Placed back on 2L NC fo HS."

There was no documentation a physician or midlevel provider assessed Patient #7 and addressed her increased respiratory effort and elevated heart rate.

Patient #7 was taken to CT and diagnosed with a PE on 2/25/25, 2 days after presenting symptoms appeared.

It was unclear why the physician or midlevel provider did not assess patient #7 for 2 days after new symptoms post-surgery.

Enoxaprin sodium 40mg/.4ml (anticoagulant) was not prescribed until 2/23/25 two days post operatively with only aspirin 81 mg being given previously, beginning on 2/21/25 twice a day.

The Executive Director of Clinical Services was interviewed 6/3/25 beginning at 2:00 PM and Patient #7's medical record was reviewed in her presence. She confirmed there were no additional orders or provider assessments which addressed pulmonary concerns between 2/23/25 at 7:37 AM when the nurse made the provider aware of pulmonary concerns and 2/24/25 at 17:38 when RT assessed the patient. The Executive Director of Clinical Services stated, "Would I want the loop to be closed, absolutely."

The hospital failed to assess and treat a patient in a timely manner.

Based on medical record review, staff interview and medical guidelines it was determined the hospital failed to ensure a safe discharge was provided for 1 of 3 patients (Patients #7) whose records were reviewed as inpatients and were discharged to their homes. This had the potential to cause serious harm for patients discharged and had the potential to affect all patients receiving care at the hospital.

Findings include:

Patient #7 was a 58-year-old female admitted to the hospital on 2/21/25 after a right hip arthroscopy with femorplasty, and acetabuloplasty and was discharged 3/06/25 at 4:50 PM. Patient #7's medical record was reviewed. Patient #7 per her medical record was admitted to inpatient due to uncontrolled nausea at the hospital at 6:57 PM with orders for vital signs every 4 hours and hourly rounding.

From Faix, J. D. (2013). Biomarkers of sepsis. Critical reviews in clinical laboratory sciences (Accessed https://pubmed.ncbi.nlm.nih.gov/23480440/ onJune 12, 2205) the "SIRS definition: Two or more of the following are required:
oBody temperature >38°C or <36°C
oHeart rate >90 beats/min
oRespiratory rate >20 breaths/min (or arterial pCO2 <32?mmHg, indicating hyperventilation)
oWhite blood cell count >12.0×109/L or <4.0×109/L (or >10% immature forms)
Sepsis=Infection+SIRS"

Additionally, UpToDate (Accessed https://www.uptodate.com/contents/definition-classification-etiology-and-pathophysiology-of-shock-in-adults?search=sirs%20definition&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H532957346 on June 12, 2025) "the presence of SIRS, however, should increase a clinician's vigilance for progression of disease severity."

Patient #7's medical record included that on day of discharge she had labs drawn and findings include
-"WBC 21.2 10*3/uL with a reference of 4.0 - 11.0,
-Absolute Neutrophils 17. 70 10*3/uL with a reference of 2.0 - 7.3,
- Platelet Count 769 H 10*3 /ul with a reference of 150-400."
All of the above labs were outside of normal parameters with no physician follow up or noted.

Vitals in the last 24 hours prior to discharge included a pulse above 90 in 6 out 8 readings, a respiratory rate above 20 in 6 out of 8 readings, as well as a temperature reading of 100.4F and as noted above elevated WBC which had remained elevated throughout patient's whole hospital stay. There was no mention of or treatment for sepsis in Patient #7's hospital's medical record.

Patient #7's medical record included a progress note dated 3/5/25 which documented "Tachycardia, persistent -Does appear improved today, heart rate of 99, will continue to monitor with telemetry but likely due to continued SIRS response."

Patient #7 was on antibiotics while inpatient but there was no documentation of a prescription for antibiotics provided upon discharge although the medical record documented a stop date of 3/10/25.

Patient #7's medical record included case management note dated 3/06/25 which stated, "No evidence of infection requiring inpatient care." However, Patient #7 was receiving antibiotics. Patient #7's case management note included the hemodynamic stability box marked although the definition in the chart requires "tachycardia absent" and client was tachycardic over 30 times during the inpatient stay and the multiple events in the 24 hours prior to discharge including but limited to 3/5/25 at 17:57 with a pulse of 110 BPM and 3/5/25 at 21:40 with a pulse of 100 BPM. Patient #7's medical record recorded tachypnea with respiratory distress none of which were not marked or noted in any of the daily case management forms.

Patient #7 presented within 24 hours to an outside facility's ER for acute hypoxia and sepsis. Patient #7's medical record from outside admitting hospital documented, "[Patient #7] was hospitalized at Northwest specialty and received IV fluids for acute pancreatitis. Her course there was also complicated by the development of pleural effusion which required 2 thoracenteses at that facility and evaluation by pulmonary [MD]. 7 days of IV Zosyn while at Northwest specialty Hospital. She was discharged to home and then presented to [local hospital] emergency department on 3/7/2025 with the complaints of shortness of breath and fever. She was admitted for acute hypoxic respiratory failure attributed to volume overload and anasarca from her resuscitation that she received for acute pancreatitis."

The executive director of clinical services was interviewed 6/13/25 and confirmed Patient #7 was discharged with one tank of oxygen and follow up appointments with GI and pulmonary. The executive director of clinical services confirmed she was not aware that Patient #7 later presented to the ED and was admitted for acute hypoxia and sepsis.

The hospital failed to ensure safe discharge for Patient #7.