HospitalInspections.org

The Condition of Participation: Quality Assessment and Performance Improvement Program was not met.

Findings included:

The Hospital Quality Assessment & Performance Program failed for two patients (Patients #1 & #6) to ensure data collected was monitored (audited) for effectiveness, safety of services and quality of care.

Refer to TAG: A-0273.

Hospital Quality Assessment & Performance activities failed for five patients (Patients #1, #6, #8, #9 & #10) in a sample of ten patients to ensure actions aimed at performance improvement were identified, (corrective action plans were) implemented, and measured (monitored, audited) for compliance.

Refer to TAG: A-0283.

Based on records reviewed and interviews, the Hospital's Quality Assessment and Performance Program failed for two patients (Patients #1 & #6) to ensure data collected was monitored (audited) for effectiveness, safety of services and quality of care.

Findings included:

The document titled Performance Improvement Plan, undated, indicated the purpose of the Performance Improvement Plan was to ensure that the Governing Body, medical staff, and nurses endeavored to deliver the highest quality care. Continuously monitoring and improvement of performance served to improve patient safety and outcomes. Medical and Administrative Executive members were responsible for ensuring the implementation and monitoring to improve performance. The Performance Improvement Plan indicated the Hospital used a methodology to validate a final solution with data and implement changes and monitor results.

Regarding Patient #1:

The Hospital Report, dated 3/29/2021, indicated Patient #1's adverse patient event regarding a retained foreign object, during surgery on 3/22/2021.

During an interview, at 9:30 A.M. on 9/23/2021, the Chief of Surgery said he did not review the case (regarding Patient #1), it was not brought to his attention or he did not remember. The Chief of Surgery said he did not know the Hospital reported the event to the Department of Public Health as a Serious Reportable Event. During the interview, Risk Manager #1 said the case was presented at the Patient Care Assessment Committee (Governing Body Quality Committee), the Chief of Surgery was not in attendance and participants received meeting minutes and case reports. The Chief of Surgery said he did not remember reading about this case.

Hospital Report for Surgical Services, dated 3/1/2021 through 9/22/2021 indicated a History and Physical Examination report in the patient's medical record was not up-to-date (a requirement prior surgery).

The Chief of Surgery said that the Hospital did not get back to him regarding Histories & Physicals (a requirement prior to Surgery) that were not up to date or missing from the patient's medical record and he would want to know.

During an interview, at 10:30 A.M. on 9/23/2021, the Quality and Patient Safety Executive Director said follow-up actions (regarding adverse patient event was the responsibility of the Department Service and the Chiefs of Service). The Quality and Patient Safety Executive Director said the Hospital did not have the information (that Hospital Service Lines, for example: Surgical Services, Obstetric Services, implemented and monitored corrective actions following adverse patient events).

Hospital Quality Assessment and Performance Program provided no documentation to indicate Surgical Services monitored their corrective action plan that included a review of all procedures identifying additional miscellaneous items that were not currently counted but posed a high risk for retention and if identified, the items would be added to procedural, surgical counts, to ensure compliance, following Patients #1's adverse patient event.

Regarding Patient #6:

The Hospital Report, dated 3/1/2021, indicated Patient #6 was diagnosed with preeclampsia (toxemia of pregnancy) during a prenatal visit. Patient #6 presented to the Hospital for evaluation of lower abdominal pain, headache not relieved by acetaminophen (Tylenol) and right upper quadrant pain. Patient #6's examination revealed hypertension with a blood pressure of 220/112. The newborn delivered on 2/14/2021, with no respiratory effort, poor tone, and a placental abruption (can be a life-treating complication of pregnancy where the placenta separated from the uterus causing hemorrhage). The newborn died four day later at a Neonatal Intensive Care Unit.

Hospital Quality Assessment and Performance Program provided no documentation to indicate Obstetric Services monitored Obstetric Patients with hypertension, consistent with their corrective action plan for auditing obstetric hypertension, to ensure compliance, following Patients #6's adverse patient event.

Refer to TAG: A-0283.

Based on observations, records reviewed and interviews the Hospital Quality Assessment & Performance activities failed for five patients (Patients #1, #6, #8, #9 & #10) in a sample of ten patients to ensure actions aimed at performance improvement were identified, (corrective action plans were) implemented, and measured (monitored, audited) for compliance.

Findings included:

A.) The Hospital failed to implement and monitor corrective actions following Patient #1's adverse patient event regarding a retained foreign object.

The Hospital Report, dated 3/29/2021, indicated Patient #1's adverse patient event regarding a retained foreign object, during surgery on 3/22/2021. The Hospital Report indicated corrective actions included Surgical Services would undertake a review of all procedures to identify any additional miscellaneous items that were not currently counted but posed a high risk for retention and if identified, the items would be added to procedural, surgical counts.

During an interview, at 2:30 P.M. on 9/22/2021, the Executive Director of Perioperative Services said they (Surgical Services) did not find any other at-risk items. The Executive Director of Perioperative Services said the Hospital now had Service Leads (Operating Room Lead Staff) that reviewed new instrument kits with the team, including the Physician prior to the surgery and she said it was a "good question" (when asked about an evaluation of how the new system was working, indicating the Executive Director of Perioperative Services did not know how the new system was working).

During an interview, at 12:00 P.M. on 9/23/2021, the Operating Room Nurse Manager said (Surgical Services) was still in the process of reviewing procedure instrument kits (review of procedures to identify any additional miscellaneous items that were not currently counted but posed a high risk for retention and if identified, the items would be added to procedural, surgical counts).

Surgical Services provided no documentation to indicate Surgical Services reviewed all procedures to identify any additional miscellaneous items that were not currently counted but posed a high risk for retention and if identified, the items would be added to procedural, surgical counts, in accordance with their corrective action plan six months after Patient #1's adverse patient event.

B.) The Hospital failed to monitor patients with obstetric hypertension following Patient #6's adverse patient events.

The Hospital Report, dated 3/1/2021, indicated Patient #6 was diagnosed with preeclampsia (toxemia of pregnancy) during a prenatal visit. Three days later Patient #6, at 36 weeks-2 days gestational age, presented to the Hospital for evaluation of lower abdominal pain, headache not relieved by acetaminophen (Tylenol) and right upper quadrant pain. Patient #6's examination revealed hypertension with a blood pressure of 220/112. The newborn delivered on 2/14/2021, with no respiratory effort, poor tone, and a placental abruption (can be a life-treating complication of pregnancy where the placenta separated from the uterus causing hemorrhage). The newborn died four day later at a Neonatal Intensive Care Unit.

During an interview, at 11:30 A.M. on 9/22/2021 with the Obstetric Nurse Director said the corrective plan included education on hypertension for the team, Obstetricians, Certified Nurse Midwives and Registered Nurses.

The document titled Electronic Fetal Monitoring Report from HealthStream indicated 83% of staff assigned (Registered Nurses) Electronic Fetal Monitoring education completed this correction action by 9/22/2021.

The document titled Report on Hypertension Education HealthStream indicated 88% of staff assigned Hypertension education completed this correction action by 9/22/2021 (seven months after Patient #6's adverse patient event).

During an interview, at 8:00 A.M. on 9/23/2021, the Obstetric Nurse Director said the Obstetric Service monitored (the corrective action plan for compliance following the death of Patient #6's newborn with the following two methods):

1.) A Midas report (Hospital's electronic patient safety event reporting system) on hypertension (obstetric patients), and

2.) A Dashboard (a quality tool with a graphic representation of obstetric patients with hypertension, visualized on a computer screen for quality management analysis and reporting) that triggered (by patients' electronic medical record) for hypertension was created.

The document titled Emergency Treatment Administer Within 60 Minutes (Dashboard), dated for 6/2021, indicated five patients triggered (identified) for hypertension; dated 7/2021, indicated eighteen patients triggered for hypertension, dated 8/2021, indicated nine patients triggered for hypertension. The Hospital provided no documentation to indicate the data collected regarding the thirty-two obstetric patients whose electronic medical identified (triggered for) hypertension were reviewed and analyzed for the highest quality care in accordance with the Hospital's Performance Improvement Plan, seven months after Patients #6's adverse patient event.

The Email, dated 9/22/2021, indicated a Midas report did not generate any reports for (obstetric) patients with severe hypertension. The Email indicated that using Midas reporting as a corrective action and data collection method of patients with severe hypertension was ineffective. The Email indicated another Midas report generated seven patients with hypertension and preeclampsia; however, the Email indicated it (the Hospital) was not sure if these (hypertensive obstetric patients) were included in case reviews.

Obstetric Department Meeting Minutes dated, 6/3/2021, 8/5/2021, indicated no documentation the Obstetric Department monitored the corrective action plan regarding hypertensive obstetric patients.

The document titled Quality Oversight, Outcomes and Process, CY 2020-2021, did not indicate the Obstetric Department monitored outcomes and process regarding hypertensive obstetric patients.

During an interview, at 8:30 A.M. on 9/23/2021, the Chief Medical Officer said as I understand (data regarding monitoring of obstetric hypertension was) reported in the Midas system, the Obstetric Nurse Director monitored the report and reported to the Chief of Obstetrics who determined (if the case met criteria for) peer (doctor to doctor evaluation in accordance with Medical Staff By-Laws) review. The Chief Medical Officer said this was an individual case, not every case gets to the level of the Board of Trustees (Governing Body) and the Governing Body did not know about Patient #6's case (adverse patient event).

Regarding Patients #8, #9 & #10:

The document titled Emergency Treatment Administer Within 60 Minutes (Dashboard), dated 8/2021, indicated Patients #8, #9 & #10 triggered for hypertension.

During an interview, at 3:30 P.M. on 9/23/2021, the Obstetric Nurse Director said that Patient #8's hypertension was not given back to the Obstetricians (consistent with their corrective action plan for monitoring obstetric hypertension).

Hospital Quality Assessment and Performance activities provided no documentation to indicate Obstetric Services monitored Patients #8, #9 nor #10s' hypertension, consistent with their corrective action plan for monitoring obstetric hypertension, to ensure compliance.

The document titled Performance Improvement Plan, undated, indicated the purpose of the Performance Improvement Plan was to ensure that the Governing Body, medical staff, and nurses endeavored to deliver the highest quality care.

The document titled Emergency Treatment Administer Within 60 Minutes (dashboard), dated for 6/2021, 7/2021, 8/2021, indicated thirty-two obstetric patients triggered for hypertension. The Hospital provided no documentation to indicate the data collected regarding the thirty-two obstetric patients whose electronic medical identified (triggered for) hypertension were reviewed and analyzed for the highest quality care in accordance with the Hospital's Performance Improvement Plan, seven months after Patients #6's adverse patient event.

C.) The Hospital failed to monitor a report regarding rapid sequence intubation (RSI).

Hospital Report for Surgical Services, dated 3/1/2021 through 9/22/2021 indicated an Anesthesiologist requested Succinylcholine (short-term muscle relaxant medication used for intubation) be stocked in the post anesthesia care unit (PACU) medication distribution machine (Pyxis) for rapid sequence intubation, (RSI, rapid insertion of a breathing tube).

During an interview, at 2:30 P.M. on 9/22/2021, the Executive Director of Perioperative Services said the RSI request was implemented.

During a tour of the main operating room PACU, on 9/24/2021, the Surveyor observed Succinylcholine was not stocked in the Pyxis.

D.) The Hospital did not identify Obstetric Hypertension as an opportunity to improve their patient discharge instructions.

The document titled After Visit Summary (Discharge Instructions), dated 8/9/2021, indicated Patient #9 was discharged to start taking nifedipine (medication to lower blood pressure in people with hypertension). The After Visit Summary indicated no discharge instructions regarding complications, including cerebral hemorrhagic, or hypertensive disorders of pregnancy.

The document titled Get Care for these Post-Birth Warning Signs indicated to Call your healthcare provider if you have headache that does not get better, even after taking medicine, or bad headache with vision changes. If you can't reach your health care provider, call 911 or go to an emergency room. (This document was included with many other documents in a folder provided to obstetric patients and is not included in the patient's medical record).