HospitalInspections.org

The patient has the right to receive care in a safe setting.

Based on review of documentation and interview, it was determined that the facility failed to respond in a timely manner to Patient # 1's rapidly deteriorating condition.

Findings were:

Facility policy entitled " Physician/Nurse Chain of Command for Issues of Clinical Concern " stated " The purpose of the Chain of Command policy is to identify the process for a timely resolution of clinical issues of concern when the physician is not available in the needed time frame or if the nurse and physician have conflicting approaches to the issue that they cannot resolve. " ...the same policy continued, " If upon assessment, an RN has a concern regarding a change of the patient ' s status to clinically unstable, the RN contacts the CRT and the patient ' s appropriate physician(s). If the RN is unable to reach the patient ' s physician in the needed time frame, then the RN contacts the Charge Nurse. The Charge Nurse assesses the issue and, as appropriate to specific department and/or site protocol contacts the CRT, house supervisor and the following:
Attending physician, other physician designated as in charge of patient or call partner. If the attending/other designated physician/call partner physician is contacted but cannot be at the bedside in the needed timeframe, then the attending/designated physician/call employee, contractor partner will contact the Facility Medical Director and ask him to facilitate finding a physician to attend to the patient. "

Nurse ' s note dated 9/18/10 20:51 for Patient # 1:
" Preceding Events: Acute abdominal pain, Change in LOC, Change in vital signs, Respiratory distress
Event Type: Respiratory event
Medical Status Change Event description: Abd pain began worsening approx 1400, starting as epigastric and gradually lower in abd. Pt complaining of being unable to have BM by 1600. Calls to Staff Member # 10 (resident physician) and Staff Member # 11 (resident physician) advising that they would be up multiple times. Checked pt at 1845, respirations at 20. Called Staff Member # 10, he will get with Staff Member # 11 and she or they would be up soon. Hung potassium approx 1910-1915. Checked on pt at approx 1915, respires in low 30 ' s, bp 93/48, O2 was 43% on RA, HR 137. Called RT. Started O2 per NC at 4L. Had Staff Member # 11 paged overhead, advised her that I was going to call a CRT or Code to get someone to look after pt. Called CRT approx 1920. CRT arrived within 5 minutes. Staff Member # 12 and RT also arrived sometime thereafter. Gave Ativan 2mg per Staff Member # 12 approx 1940 to assist RT in taking AGBs. Staff Member # 11 arrived sometime there after. Started IV NS bolus at 999 mls/hr per Staff Member # 11. Per Staff Member # 13 (onc on call) stopped Cytarabine with 201 left to give per IV pump setting; made admin note of same. By this time, RT and CRT were arranging to take PT to ICU. RT had started O2 per nonbreather mask at 15L. "

Page Report 9th Floor UMCB 9/18/10 indicated that Staff Member 14 (RN) attempted to page the medical staff 7 times between the hours of 3 and 8 PM.

On 9/18/10, Patient # 1's condition deteriorated rapidly. His nurse (Staff Member # 14) attempted to call for medical assistance 7 times between 3 and 8 PM. A doctor did not arrive at the patient's bedside until the Critical Response Team appeared at approximatly 7:25 PM.

In an interview with the the Director of Risk Managment and with Patient # 1's attending MD on 2/1/11, it was acknowledged that medical staff did not respond in a timely manner in response to Patient # 1's deteroriating condition.

Based on review of documentation and interview, it was determined that the facility failed to track adverse events in its Performance Improvement Activities.

Findings were:

Facility policy entitled " Significant Event Management and Response " stated " Seton personnel will report all occurrences that have the potential to be considered Significant Events in accordance with this policy. This policy also applies to any occurrence arising from services provided by persons who, at the time of providing services, are employed or under contract by Seton, regardless of the location at which those services are provided. ...A ' major permanent loss of function ' means sensory, motor, physiological or intellectual impairment not present on admission, which requires or will require continued treatment or lifestyle change.
Internal Reporting:
A Seton employee, contractor, medical staff member, allied health professional or other affiliated person who witnesses or has knowledge of an occurrence that may constitute a Significant Event or a Near Miss shall immediately report the occurrence to his/her supervisor and the Medical Director for the facility in which the occurrence took place if the person who witnesses or has knowledge of the occurrence is a Seton medical staff member or allied health professional. "

Patient # 1 died at University Medical Center at Brackenridge on 9/19/10 from acute hemorrhagic necrotizing enterocolitis related to the clostridium perfringens bacterium. There was no evidence of this unexpected death in Performance Improvment review.

In an interview with the Director of Risk Managment and the Director of Nurses on 2/1/11, the above findings were confirmed.

All verbal orders must be authenticated based upon Federal and State law. If there is no State law that designates a specific timeframe for the authentication of verbal orders, verbal orders must be authenticated within 48 hour

Based on Review of documentation, it was determined that the facility's medical staff failed to authenticate verbal orders within 48 hours.

Findings were:

The following verbal orders for Patient # 1 were not authenticated by the prescribing MD within 48 hours:
? Order written at 608 AM 9/16/10 was not authenticated until 10/11/10 at 3 PM
? Order written at 828 PM 9/16/11 was not authenticated until 10/11/10 at 3 PM
? Order written at 331 PM 9/18/11 was not authenticated until 10/12/10 at 1 PM
? Order written at 726 PM 9/18/11 was not authenticated until 10/12/10 at 1 PM
? Order written at 730 PM 9/18/11 was not authenticated until 10/12/10 at 5 PM
? Order written at 8 PM 9/18/11 was not authenticated until 10/12/10 with no noted time
? Order written 9/18/11 with no noted time was not authenticated until 10/20/10 at 12 PM
? Order written at 12:30 AM 9/19/11 was not authenticated until 10/20/10 at 12 PM
? Order written at 12:30 AM 9/19/11 was not authenticated until 10/07/10 at 12 PM

In an interview with the Director of Risk Management and the Director of Nurses on 2/1/11, the above delinquent authentication of Doctor ' s Orders was acknowledged.

Based on review of documentation and interview, it was determined that the facility did not effectivelly track infections in all of its patients.

Findings were:

Epidemiology Report 9/01/10-10/15/10 revealed only one case of Clostridium Perfringens reported at University Medical Center at Brackenridge: Patient # 1

The Director of Infection Control spoke with the survey team on 2/1/11. She was not aware that Patient # 1 had died as a result of clostridium perfringens. When asked why she was unaware of a death related to food poisoning in the hospital, she stated, " A part time staff member was reviewing the lab cases when that report came through. She did not recognize the bacteria and didn ' t inform anyone of the problem. Nobody was aware of it. "

In an interview with the Risk Manager and the Director of Nurses on 2/1/11, it was confirmed that the Infection Control officer was unaware of the death of Patient #1 as a result of infection with clostridium perfringens.
.