HospitalInspections.org

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Based on Medical Record review, document review and interview, the facility failed to implement and maintain a standardized, Hospital-Wide Mortality Review Program.

This lack of a standardized Mortality Review process may lead to missed opportunities for improvement by failing to identify and analyze adverse patient events or errors, and implement corrective actions, placing all patients at risk.

See Tag A 286.
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Based on Medical Record review, observation, document review, and interview, the facility failed to:

1) Ensure completion of 100% of all Mortality Reviews, having only completed seventeen (17) of five hundred thirty-two (532) (3.2%) Mortality Reviews from December 2018 to June 2019;

2) Ensure completion of timely, systematic Mortality Reviews to identify scope (prevalence) of potential problems identified with death by Sepsis. The facility completed one (1) Mortality Review of the forty-seven (47) Sepsis-Related Mortalities (2.1%) from December 2018 to June 2019;

3) Implement timely, systematic measures to correct the identified problems related to the high volume of incomplete Mortality Reviews;

4) Ensure ongoing integration and evaluation of the data collected, and implementation of any corrective actions for the effectiveness of patient care.

These failures may have placed patients at risk for adverse outcomes.

Findings included:

1) Review of the Hospital-Wide Mortality Log dated December 2018 to June 2019 revealed five hundred thirty-two (532) mortalities. Of the five hundred thirty-two (532) mortalities, seventeen (17) (3.2%) Mortality Reviews had been completed:

- December 2018: Seventy-one (71) deaths with one (1) Mortality Review completed.

- January 2019: Ninety-nine (99) deaths with five (5) Mortality Reviews completed.

- February 2019: Sixty-eight (68) deaths with two (2) Mortality Reviews completed.

- March 2019: Sixty-seven (67) deaths with two (2) Mortality Reviews completed.

- April 2019: Seventy-three (73) deaths with two (2) Mortality Reviews completed.

- May 2019: Sixty-nine (69) deaths with three (3) Mortality Reviews completed.

- June 2019: Eighty-five (85) deaths with two (2) Mortality Reviews completed.

Per interview of Staff C (PI RN/Performance Improvement Registered Nurse) and Staff D (PI RN) on 05/29/19 at 11:30AM, Staff Members C and D revealed that 100% of mortalities/deaths are reviewed for questionable quality issues of concern, but they had fallen behind and have not been able to keep up with the numbers [volume].

These findings were confirmed by Staff E (Assistant Risk Manager) and Staff F (Senior Vice President) on 05/30/19 at 12:30 PM.

2) Review of the Hospital-Wide Mortality Logs and Sepsis Logs, dated December 2018 to June 2019, revealed five hundred thirty-two (532) mortalities. Of the five hundred thirty-two (532) mortalities, forty-seven (47) mortalities had a diagnosis of Sepsis at the time of expiration.

- December 2018: Eight (8) deaths with a diagnosis of Sepsis, and zero (0) Mortality Reviews completed.

- January 2019: Three (3) deaths with a diagnosis of Sepsis, and zero (0) Mortality Reviews completed.

- February 2019: Eleven (11) deaths with a diagnosis of Sepsis, and zero (0) Mortality Reviews completed.

- March 2019: Ten (10) deaths with a diagnosis of Sepsis, and one (1) Mortality Review initiated (Patient #1).

- April 2019: Twelve (12) deaths with a diagnosis of Sepsis, and one (1) Mortality Review completed (Patient #12).

- May 2019: Three (3) deaths with a diagnosis of Sepsis, and zero (0) Mortality Reviews completed.

Of the forty-seven (47) Sepsis-Related Mortalities, one (1) Mortality Review (2.1%) had been completed, and one (1) was initiated but incomplete. The incomplete Mortality Review was initiated on 06/19/19, after this surveillance investigation was initiated, and was incomplete at the time of the survey exit.

Comparative reviews of the Medical Records for Patient #1 and Patient #12 revealed the following similarities: Both Patient #1 and Patient #12 had two (2) hospital encounters within hours of the first discharge; both presented with Hypothermia (a medical emergency that occurs when your body loses heat faster than it can produce heat, causing a dangerously low body temperature) on their first admission; Neither patient had a Sepsis work-up performed for the first admission, and no urine cultures had been obtained; Both patients were readmitted with a diagnosis of Severe Sepsis; and both died while hospitalized with a diagnosis of Septic Shock.

Patient #1 was 34-year-old with Cerebral Palsy admitted on 02/26/19 and treated for infection of unknown origin. On admission, the patient presented with a rectal temperature of 90.3 Fahrenheit (the normal body temperature range is 97 to 99) not due to external environment, and was diagnosed with Hypothermia and suspected infection. The Sepsis Huddle/Protocol was not initiated, although the patient was treated with antibiotics and warming blankets. Patient #1 was discharged on 03/04/19 at 1:55PM and readmitted thirteen (13) hours later, on 03/05/19 at 2:51AM, with a diagnosis of Septic Shock. Patient #1 subsequently died on 03/09/19. The final diagnosis documented was Sepsis due to unspecified organism.

Patient #12 was an 81-year-old with Dementia admitted on 04/05/19 and treated for a fall with contusion to his right eye. On admission, the patient presented with a rectal temperature of 83.3 Fahrenheit (not due to external environment) and was diagnosed with Hypothermia. He was discharged on 04/09/19 at 5:15PM and readmitted forty-eight (48) hours later on 04/11/19 at 5:25PM with a diagnosis of Septic Shock. Patient #12 subsequently died on 04/12/19. The final diagnosis documented was Sepsis due to unspecified organism.

Review of the Medical Peer Review conducted for Patient #12, dated 04/23/19, revealed that opportunity for improvement was identified. No Sepsis work-up was performed for the first admission and no urinalysis or urine culture was obtained. On the second admission, Patient #12 was found to have a Urinary Tract Infection with Sepsis that was thought to have been present during the first admission.

During interview of Staff C (PI RN) on 07/02/19 at 2:30PM, Staff C was asked why Patient #12 had a Mortality Review performed but Patient #1 had not? Staff C stated, "Patient #12 was a readmission within thirty (30) days." When this surveyor informed Staff C that Patient #1 was a readmission after thirteen (13) hours and did not have a review, Staff C acknowledged that and stated, "I don't know why that happened."

This finding was acknowledged by Staff I (Clinical Risk Manager) on 07/03/19 at 11:15AM.

3) Implement timely, systematic measures to correct the identified problems related to the high volume of incomplete Mortality Reviews:

As per interview of Staff Members C and D on 05/29/19 at 11:30AM, Staff C stated that they will, "Review all patients who die in the hospital and also review all patients who are readmitted within thirty (30) days. There is no policy or written criteria for this, but that is the facility's practice." Staff D stated, "We are very behind and have not kept current with the volume. When a patient dies on the Unit, then the Nurse Manager will do an initial screen and if they feel there is a concern, for instance an unexpected death or an inappropriate discharge, they will make a referral to us. We will start a review on these 'flagged' cases and when there is a concern, we go to the CMO [Chief Medical Officer]. Ideally, we would like to initiate mortality reviews for all patients who die daily."

When asked what criteria is utilized by the Nurse Managers to know which mortalities to 'flag' and bring to Staff C and Staff D's attention, Staff C stated, "The Nurses on the Units rely on their own clinical judgment and there are no written criteria for why some cases are flagged and others are not." Staff Members C and D revealed that no hospital policies or written criteria for emergent Mortality Reviews exist. Mortalities of concern are flagged for emergent Mortality Review based on Nursing's clinical judgment.

These findings were confirmed with Staff Members E and F on 05/30/19 at 12:30PM who verified that there is no written criteria/policy for this practice.

The facility failed to develop, implement and maintain a standardized, Hospital-Wide Mortality Review Program.

This lack of a standardized Mortality Review process may lead to missed opportunities for improvement by failing to identify and analyze adverse patient events or errors, and implement corrective actions, placing all patients at risk.

4) Ensure integration and evaluation of hospital data collected and ongoing systemic processes for implementation of corrective actions:

During interview of Staff A (Chief Medical Officer) on 05/30/19 at 2:45PM, Staff A stated that the facility does not have a specific Mortality and Morbidity Committee. Each individual Department head conducts a Mortality Review within their service. "An Incident [Mortality] will come to my attention when it has been flagged as a concern. The quality staff who work with these incidents in Medias [a contracted vendor who receives data entries for incidents and occurrences] will run a daily report and then discussion takes place in our safety huddles." When asked if there was any documented evidence that Mortality Reviews are discussed at huddles, Staff A stated, "No".

The facility could not furnish documented evidence of the hospital-wide integration of QA/PI that included Medical Executive responsibilities specific to Morbidity/Mortality and Standards of Quality Care.
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Based on Medical Record review, document review, and interview, in two (2) of six (6) Medical Records, the facility did not ensure that Medical Staff attempted to secure Autopsies from patients' families or next of kin, as per facility policy.

Findings include:

The Report on Death of a Patient for Patient #1, dated 03/09/2019, revealed the question which asked, "Was an Autopsy requested by family or next of kin", was incomplete and not answered.

Review of Patient #1's Medical Record identified that there was no documented evidence that the Medical Staff had attempted to secure an Autopsy to the patients' family or next of kin.

The Report on Death of a Patient for Patient #7, dated 01/01/19, revealed the question which asked, "Was an Autopsy requested by family or next of kin", was incomplete and not answered.

Review of Patient #7's Medical Record identified that there was no documented evidence that the Medical Staff had attempted to secure an Autopsy to the patients' family or next of kin.

Per interview of Staff D (Clinical Risk Manager) on 05/30/19 at 2:10PM, Staff D acknowledged that the question asking "Was an Autopsy requested by family or next of kin" on this Report of Death, should have been completed/answered.

The facility Policy and Procedure titled, "Autopsies-Death, Funeral Direct..." last revised May 2018, contained the following statement: "Responsibilities at the time of the patient's death ... Physicians: notification must be made immediately to Nursing Supervision/Nursing Administration as to family, hospital or Medical Examiner requests for Autopsy with every patient death."