HospitalInspections.org

Based on review of facility medical staff rules and regulations, medical record review and interviews the hospital failed to do a thorough physical examination and timely response to critical labs for one patient (#3) of three sampled, resulting in a delay in care and life sustaining measures requiring transfer to a high level of care. Refer to A0347, Standard.

The facility provided an Immediate Jeopardy removal plan on 12/13/2023, which included review of 100% of current hospitalized patients to identify active medical diagnoses that were not appropriate for hospitalization at the facility. For new admissions, staff will reconcile clinical documentation from transferring facilities to ensure active medical conditions have been addressed on the history and physical documentation by medical staff.

Nurses will be re-educated on the exclusionary criteria and chain of command notification for identified patients. Medical and psychiatric providers re-educated on medical exclusionary criteria. Intake nurses reeducated on review of patient information for exclusionary criteria., and training on skin assessments per policy

Verification of education was completed with interviews of nurses in 5 different units. Verification of audits of transfer patients had begun via interviews. 40% of staff had been educated with phone calls and emails continuing. Staff are unable to work without acknowledging education. Verification of 100% of medical staff have educated via email attestation.

Through verification of the hospital Immediacy Removal Plan, it was determined the immediacy was removed for A0338 on 12/13/2023 at 4:00 PM.

Based on the hospital medical staff Rules and Regulations, medical record review and interviews the facility failed to provide quality medical care to one patient (#3) of three sampled, which resulted in a delay in care and life sustain measures requiring transfer to a higher level of care.

Findings included:
Review of the facility Medical Staff Rules and Regulations showed that admission to the facility a history and physical examination to be performed by a practitioner with clinical privileges to perform such tasks ...The following shall be included in the documentation ...review of systems, physical examination ...

Review of the sending hospital documentation in Patient #3's record, revealed a nephrology assessment and plan dated 11/15/23: patient making minimal urine at this time continue HD (hemodialysis) Tuesday, Thursday, Saturday. S/P (status post) tunneled HD catheter. Further review of the sending hospital documentation dated 11/17/23 reflected a physician progress note CM (case management) to help with outpatient HD. Needs inpatient psychiatry and HD capabilities.

Review of the medical record for Patient #3 reflected he was transferred from a medical hospital on 11/17/2023, for inpatient treatment. A review of the nursing admission assessment entered by Staff A reflected a "dialysis port" was present on Patient #3's right upper chest. The nursing admission note dated 11/18/2023 12:50 AM reflected "patient is a dialysis patient". A review of nursing notes dated 11/23/2023 revealed Patient #3 was transported to hospital for dialysis access removal. Documentation in nursing notes dated the same day at 6:30 PM reflected Patient #3 was admitted to ICU for stat (immediate) dialysis.

Review of medical staff documentation reflected an H and P (History and Physical Examination) dated 11/18/2023, entered by Staff C, PA (physician assistant). There wasn't any documentation Staff C was aware of Patient #3's dialysis access site.

A review of lab results dated 11/20/23 and a report date of 11/22/23 showed a CMP (complete metabolic panel) was completed. Report reflected the results were verified by repeat analysis, and that specimen was received hemolyzed and the value may be increased by hemolysis. Clinical correlation indicated. The report reflected a Creatinine of 12.7 (normal is 0.76-1.27), and was marked as high, and a potassium level of 6.1 (normal is 3.5-5.2), marked as critical. Staff E, APRN (advanced practiced nurse practitioner) noted the lab report and ordered stat (immediate) repeat of creatinine, potassium, CMP, and EKG (electrocardiogram-a test that looks at the electrical activity of the heart).
Review of an order entered by Staff D dated 11/23/2023 10:06 AM, reflected Staff D ordered maintain dialysis access with daily flushing with heparin/saline, PICC line dressing change every 7 days, Change caps every 7 days with dressing change, Apply curasol caps to double lumen, followed by Transfer to hospital for dialysis access removal.
Review of the lab report dated 11/29/23 for 11/22/23 labs, revealed a Creatinine of 14.07 verified by repeat analysis, and a potassium of 6.7, also verified by repeat analysis.

During an interview on 12/12/2023 at 9:20 AM with Staff D, APRN. Staff D said she is a medical, family nurse practitioner. Staff D, APRN disclosed that it was brought to her attention that Patient #3 had dialysis access. That was the first time that she saw the patient. Staff D, APRN said she had not reviewed his record yet. Staff D, APRN said she knew Patient #3 could not be in that facility with the dialysis catheter because this hospital had no way to maintain it. Staff D, APRN said she looked at his last dressing change and it was dated November 14th. He needed flushes and dressing changes and maintenance.

During an interview on 12/12/2023 at 10:05 AM with Staff C, PA (physician's assistant), Staff C said she documented Patient #3's History and Physical. She doesn't recall that he had dialysis access.

During a follow up interview with Staff C, PA on 12/12/2023 at 11:10 Staff C, PA said her assessment doesn't include removing their clothes. Whatever she can see.

During a telephone interview on 12/12/2023 at 1:23 PM with the CMO (Chief Medical Officer), he said the medical staff look at the patients' labs and should have seen that [abnormal results] in his labs. They may have thought he was finished with dialysis. The hospital does not take care of patients who are getting dialysis.

During a telephone interview on 12/12/2023 at 5:16 PM with Staff E, APRN (Advanced Registered Nurse Practitioner), Staff E said she was not sure if the hospital had any medical exclusions for admission. Stat medical orders would be completed by the next day. The lab usually calls with critical results. They would call the nurse on the unit. They are also supposed to fax the results. Critical results should be called to a nurse or provider. But the medical staff look when they come in.

Based on record review, interviews, and policy review the hospital failed to ensure nursing services provided met professional standards of practice for a dialysis patient in 1 (#3) of 3 patients sampled. A system-wide failure of nursing services resulted in a dialysis patient requiring a higher level of care in the ICU (intensive care unit) and could have resulted in death. Refer to A0396, Standard.

The facility provided an Immediate Jeopardy removal plan on 12/13/2023, which included review of 100% of current hospitalized patients to identify active medical diagnoses that were not appropriate for hospitalization at the facility. For new admissions, staff will reconcile clinical documentation from transferring facilities to ensure active medical conditions have been addressed on the history and physical documentation by medical staff.

Nurses will be re-educated on the exclusionary criteria and chain of command notification for identified patients. Medical and psychiatric providers re-educated on medical exclusionary criteria. Intake nurses reeducated on review of patient information for exclusionary criteria., and training on skin assessments per policy

Verification of education was completed with interviews of nurses in 5 different units. Verification of audits of transfer patients had begun via interviews. 40% of staff had been educated with phone calls and emails continuing. Staff are unable to work without acknowledging education. Verification of 100% of medical staff have educated via email attestation.

Through verification of the hospital Immediacy Removal Plan, it was determined the immediacy was removed for A0385 on 12/13/2023 at 4:00 PM.

Based on medical record review, interviews, and policy review the hospital failed to ensure the identification of care needs for a dialysis patient prior to admission, after admission, and during the hospitalization, for one patient (#3) of three patients sampled for transfer to a higher level of care.

Findings included:

A review of the sending hospital referral dated 11/02/2023 revealed Patient #3 needed to be discharged to an inpatient psychiatric hospital with hemodialysis capabilities, for continuation of dialysis Tuesday, Thursday, and Saturday for major depressive disorder with suicidal ideation and attempt.
Review of the sending hospital documentation in Patient #3's record, revealed a nephrology assessment and plan dated 11/15/2023: patient making minimal urine at this time continue HD (hemodialysis) Tuesday, Thursday, Saturday. S/P (status post) tunneled HD catheter. Further review of the sending hospital documentation dated 11/17/2023 reflected a physician progress note CM (case management) to help with outpatient HD. Needs inpatient psychiatry and HD capabilities.

Review of the medical record for Patient #3 reflected he was transferred from an acute care hospital on 11/17/2023, for inpatient psychiatric treatment. A review of the nursing admission assessment entered by Staff A, RN (Registered Nurse) reflected a "dialysis port" was present on Patient #3's right upper chest. The nursing admission note dated 11/18/2023 12:50 AM reflected "patient is a dialysis patient". Further review of the record revealed a care plan was started 11/18/2023 at 1:05 AM. The care plan did not reflect the presence of a dialysis access site. Review of nursing documentation from 11/18/2023 to 11/22/2023 revealed no other documentation related to the dialysis access site, nor any notification to a provider of the presence of the dialysis access, until 11/23/2023, six days after Patient #3 was admitted.

Review of an order entered by Staff D, APRN dated 11/23/2023, reflected transfer to medical hospital for dialysis access removal.

A review of nursing notes dated 11/23/2023 revealed Patient #3 was transported to hospital for dialysis access removal. Documentation in nursing notes the same day at 6:30 PM reflected Patient #3 was admitted to ICU for stat (immediate) dialysis.

During an interview on 12/11/2023 at 1:25 PM with the RM (Risk manager), the RM said she was told Patient #3 was not on dialysis. "That would be exclusionary criteria." She reported that Nursing staff said the patient was being sent to the acute care hospital for dialysis port removal, but they kept him for dialysis. The RM said she was going to talk to the nurse, because they don't accept this kind of patient and they should be letting them know and escalating it up the chain of command. Usually, intake identifies that, and it wouldn't even make it to the floor. Intake does the exclusion form, and they get a nursing verbal report and review the hospital record for orders.

During an interview on 12/11/2023 at 2:30 PM with Staff H, Director of Admissions, Staff H said the nurse reviews the hospital record. "We would deflect. We don't take dialysis patients. We ask if they have ports or other medical devices. If they say no, we accept them. I heard his dialysis was completed, and the port needed to be removed. Medical is supposed to review the chart. I didn't hear he had dialysis orders."

During an interview on 12/12/2023 at 9:20 AM with Staff D, APRN (Advanced Practice Registered Nurse), Staff D said she is a medical, family nurse practitioner. Staff D, APRN disclosed that it was brought to her attention that Patient #3 had dialysis access. That was the first time that she saw the patient. Staff D, APRN said she had not reviewed his record yet. Staff D, APRN said she knew Patient #3 could not be in the facility with the dialysis catheter because the hospital had no way to maintain it. Staff D, APRN said she looked at Patient #3's last dressing change and it was dated November 14th. Staff D, APRN said she involved the supervisor because the hospital could not maintain his line. He could not be here.

During an interview on 12/12/2023 at 10:26 AM with the Chief Nursing Officer (CNO), the CNO said Patient #3's record was reviewed and identified he had a port. That's why he went to the hospital. "We reviewed the nursing process to see where the problem was. The staff need to escalate when they find a port because we don't take patients with ports. The port was identified on admission. If they make it through admissions with the port, it should have been identified and escalated. The assumption is they are cleared from a medical facility, and we accept them based on that clearance. He never should have been accepted."

During a telephone interview with Staff A, RN on 12/12/2023 at 2:52 PM, Staff A said she put the patient in the medical consult book for the nurse practitioner to review. She was not sure if she had put the reason. She said she gave report to the next nurse. Staff A, RN said it was the first time she had a patient with a dialysis port. "Usually if they come with something like that, we send them back to the hospital, pending review by the nurse practitioner."

A review of the medical consult book for the dates of 11/17/2023 to 11/18/2023 revealed no entry for Patient #3.

Review of the policy, Medical Exclusionary Guidelines, last review, 7/20/2023, revealed:
Purpose:
To prevent the presentation for admission of individuals with the following conditions ...
2. Chronically physically ill individuals who require clinical services not available or not appropriate to provide in a free-standing psychiatric hospital.
Appropriate identification of individuals in each of the above categories prior to referral and presentation for admission allows that individual to be referred to a more appropriate treatment setting ...
Policy
All patients will be medically screened to ensure that North Tampa Behavioral Health has the competency to appropriately treat psychiatric and medical conditions concurrently. NTBH uses a four-tier approach to allow all intake staff to accurately vet referrals for appropriateness.
Procedure
Medical exclusionary guidelines
The following four tier medical exclusionary guideline information is to be applied when considering persons for referral to NTBH who present with known or suspected medical conditions ... If questions or concerns arise contact the director of admissions or designated administrator to discuss the appropriateness of accommodation or alternative placement options. Individuals referred that are medically inappropriate or unstable will be followed up by NTBH with the referring facility.
Tier 4
Patients in this category have been determined by the medical staff to be outside the capability to provide care for in the facility ...hemo or peritoneal dialysis.

Based on review of facility documents, medical records and interviews, the facility failed to ensure a provisional or admitting diagnosis made included the diagnosis of intercurrent diseases and psychiatric diagnosis at the time of admission,
for one patient (#3) of three sampled, resulting in delayed care requiring transfer to a higher level of care for life saving treatment.

Findings included:

Review of the facility Medical Staff Rules and Regulations showed that admission to the facility a history and physical examination to be performed by a practitioner with clinical privileges to perform such tasks ...The following shall be included in the documentation ...review of systems, physical examination ...

Review of the sending acute care hospital documentation in Patient #3's record, revealed a nephrology assessment and plan dated 11/15/2023: patient making minimal urine at this time continue HD (hemodialysis) Tuesday, Thursday, Saturday. S/P (status post) tunneled HD catheter. Further review of the sending hospital documentation dated 11/17/2023 reflected a physician progress note CM (case management) to help with outpatient HD. Needs inpatient psychiatry and HD capabilities.

Review of the medical record for Patient #3 reflected he was transferred from an acute care hospital on 11/17/2023 for inpatient psychiatric treatment. A review of the nursing admission assessment entered by Staff A, RN (Registered Nurse) reflected a "dialysis port" was present on Patient #3's right upper chest. (A central venous catheter, also known as dialysis line, or port is a flexible, hollow tube inserted into a large vein in the chest, close to the heart which allows dialysis to occur. Dialysis is a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly by diverting blood to a machine to be cleaned.) The nursing admission note dated 11/18/2023 12:50 AM reflected "patient is a dialysis patient".

Review of medical staff documentation reflected documentation of an H and P (History and Physical Examination) dated 11/18/2023, entered by Staff C, PA (Physician's Assistant). Diagnoses listed were Hypertension, HLD ( Hyperlipidemia), Diabetes Mellitus, Diarrhea, and MDD rec severe w/o PF (Major depressive disorder, recurrent, severe, without psychotic features). There was no documentation that Staff C, PA was aware of Patient #3's dialysis access site located in his right upper chest, had kidney failure, or that she was aware Patient #3 needed dialysis, as documented by the transferring hospital physician.

A review of lab results for Patient #3 dated 11/20/2023 and a report date of 11/22/2023, showed a CMP (complete metabolic panel) was completed. The report documented the results were verified by repeat analysis, and that the specimen was received hemolyzed (breakdown of the red blood cells) and the value may be increased, clinical correlation indicated. The report reflected a Creatinine of 12.7 mg/dl (normal is 0.76-1.27mg/dl), and was marked as high, and a potassium level of 6.1 mmol/L (normal is 3.5-5.2mmol/L), marked as critical. Staff E, APRN (Advanced Practiced Nurse Practitioner) noted the lab report and ordered stat (immediate) labs to repeat a creatinine, potassium, CMP, and EKG (electrocardiogram-a test that looks at the electrical activity of the heart).

A review of nursing notes dated 11/23/2023 revealed Patient #3 was transported to an acute care hospital for dialysis access removal. Documentation in nursing notes the same day at 6:30 PM reflected Patient #3 was admitted to ICU for stat (immediate) dialysis.

During an interview on 12/12/2023 at 10:05 AM with Staff C, PA (physician's assistant), Staff C said she documented Patient #3's History and Physical. She doesn't recall that he had dialysis access.

During a follow up interview with Staff C, PA on 12/12/2023 at 11:10 Staff C, PA said her assessment doesn't include removing their clothes, it inlcudes whatever she can see without disrobing the patient.