HospitalInspections.org

A. Based on review of Hospital policy, review of the 2010 Hospital Performance Distinction Plan, review of the 2010 Intensive Care Unit (ICU) quality data report, review of Hospital incident reports for 2010, clinical record review and staff interview, it was determined that, in 2 of 2 (Pts #1 and 6) clinical records reviewed of self extubated patients, the Hospital failed to ensure incident reports were completed to ensure that all adverse patient events were captured for analysis.

Findings include:

1. Hospital policy entitled, "Incident Reporting: Patient and Visitor," reviewed on 2/8/11 at approximately 9:50 AM required, "Process: 1. Definitions. 1.1 'Incident' is any event or omission which is inconsistent with the routine operation of the institution and caused an error, accident or situation that could have or has resulted in an injury..."

2. The Hospital's "Performance Distinction Plan - FY 2010," was reviewed on 2/10/11 at approximately 8:45 AM. The Plan required, "IV. SCOPE; The quality of services provided at Our Lady of the Resurrection Medical Center...is monitored and evaluated. The identification of standards used to monitor the quality of the important aspects of performance; and the evaluation of the quality of performance...Results from performance distinction activities are used primarily to study and improve processes that affect performance outcomes, patient safety and, when relevant to the performance of an individual, are used as a component of the evaluation of individuals' capabilities..."

3. The Quality Assurance data reports for Fiscal Year 2010 for the ICU was reviewed on 2/10/11 at approximately 8:45 AM. The data lacked tracking of patients that had self extubated, for possible adverse outcomes.

4. The Hospital's incident reports for year 2010 were reviewed on 2/9/11 at approximately 2:00 PM. There was no evidence that reports were completed for Pt's # 1 and 6 regarding their self extubations.

5. On 2/9/11 between 11:45 AM and 12:15 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 50 year old male, admitted on 9/27/10 at 9:48 AM, with diagnoses of Altered Mental Status and Narcotic Over Dose. The ICU nursing flow sheet dated 9/28/10 at 11:05 AM, included, " Extubated self. " Nursing notes dated 9/28/10 at 11:00 AM, included, Doctor ... here to see patient. As soon as everybody was out of the room Patient extubated himself.
surveyor #19843

6. The clinical record of Pt #6 was reviewed on 2/10/11 at approximately 9:00 AM. Pt #6 was a 51 year old male admitted on 9/26/10 through the Emergency Department with a diagnosis of Hepatic Encephalopathy. Pt #1 presented in acute respiratory distress and documentation included that Pt #6 was intubated and placed on a ventilator at 9:30 AM, prior to transportation to the ICU. Clinical documentation indicated that Pt #6 self extubated on 10/3/10 at approximately 11:15 AM.

7. The Director of Quality and Utilization was interviewed on 2/10/11 at approximately 9:00 AM. The Director confirmed that the Hospital does not have incident reports for Pt # 1 and 6 concerning their self extubations.

8. The Director of Quality and Utilization and the Vice President of Patient Care Services confirmed the findings during an interview on 2/10/11 at approximately 9:15 AM.