Bringing transparency to federal inspections
Tag No.: A0286
Based on review of facility policy and procedures, facility documents, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure that performance improvement activities analyzed causes and implemented preventive actions and mechanisms that include feedback and learning throughout the hospital for adverse patient events, for four (4) of four (4) medical records reviewed. (MR1, MR24, MR31, MR32).
Findings include:
Review on May 8, 2017, of facility's policy, Einstein Healthcare Network (EHN) Quality Improvement Plan for FY17," revealed, "... I. ... Plan for improvement: The EHN Quality Assessment and Improvement Plan is: ... designed to eliminate avoidable harm and injury and improve patient outcomes." Further review revealed, "... IV. ... Communication: ... The Chief Quality Officer oversees the Patient Safety & Performance Improvement Network Program."
Review on May 8, 2017, of facility's policy, "Albert Einstein Healthcare Network Patient Safety Improvement and Management Program Plan," no date, revealed "Purpose: ... to support and improve health and safety of the patients of Albert Einstein Healthcare Network. ... Authority and Responsibility: The Patient Safety Officer shall: ... ensure the investigation of serious events and, as appropriate , identified incidents. ... All members of the medical staff will: ... attending physicians who have been involved in serious events or incidents will: assume responsibility for the physician's own professional development and education to improve individual performance and promote patient safety. ... Key Definitions: Action Plan the product of root cause analysis that identifies the strategies that the organization intends to implement to reduce the risk of similar events occurring in the future. The plan addresses responsibility for implementation, oversight, pilot testing, as appropriate, time lines and strategies for measuring the effectiveness of the actions. ... Patient Safety freedom from accidental injury while receiving health care services. ... Root Cause Analysis (RCA) a process for identifying the basic or causal factor(s) that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. A root cause analysis focuses primarily on systems and processes, not individual performance. It progresses from special causes in clinical processes to common causes in organizational processes and identifies potential improvements in processes or systems that would tend to decrease the likelihood of such events in the future. Serious Event an event, occurrence or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health services to the patient."
Review of MR1, on May 8, 2017, revealed the patient was admitted on July 29, 2017. Further review of MR1 revealed that the patient was found "looking pale" and unresponsive" at " 21:12" on "8/3/16". A "rapid response" was initiated by the Nursing staff. The rapid response escalated into a "Code Blue" when the patient was found to have "no pulse" and "no rhythm." CPR was initiated. The patient required intubation, administration of emergency medications and defibrillation. The patient did have "return of spontaneous circulation" (ROSC) and was transferred to the "MICU". The patient required mechanical ventilation, use of "pressors" for hemodynamic support, and the use of hypothermia cooling while in the MICU. MRI revealed physician documentation while the patient was in the MICU from consulting Cardiology Services that stated "PEA, 2nd hypercapnea, sedative OD" and "excessive sedative use leading to hypoventilation and brain anoxia." Further review of MR1 revealed on "8/7/16" at "11:00 A.M." a family meeting was held. The family agreed to "withdraw care" at that meeting. Further review of MR1 revealed a signed death certificate dated "8/7/16" at 12:43" pronouncing the patient. Cause of death was documented as "multiple organ failure, cardiac arrhythmia."
Review on May 8, 2017, of MR24 revealed this patient was admitted for a colonoscopy procedure on September 23, 2016. Further review of MR24, revealed " ... re-presented on 09/24/2016 with worsening abdominal pain ... a CT scan was obtained because of ... increasing abdominal pain that did demonstrate free air concerning for a sigmoid colon perforation status post colonoscopy. ... All the medical therapy was exhausted and patient was on maximum presser support with maximum ventilatory support ... and the patient continued to have a declining medical picture. ... The family decided to make patient DNR (do not resuscitate) and it was discussed to withdrawal [sic] care for the patient. On 9/26, after the decision of withdrawal of care was made, patient passed away in the SICU (Surgical Intensive Care unit) while being surrounded by ... family members. ... Patient's original time of death was 1:35 PM on 9/26/2016. The cause of death listed was multi-organ failure, sepsis secondary to bowel ischemia or necrosis."
A request was made to EMP1 on May 8, 2017, for facility RCA related to the events documented in MR1 and MR24. None were provided.
Review on May 8, 2017, of facility's meeting minutes "Patient Safety Improvement and Management Program Committee," dated June 21, 2016, revealed the patient in MR32, "presented to the Emergency Department with agitation and psychiatric symptoms. Patient was medically cleared and plan was to transfer the patient to the Crisis Response Center for psychiatric evaluation. Patient asked staff for something to eat and was provided a sandwich. Nurse found patient choking. Nurse and Physician immediately responded and began removing food. Patient became bradycardic and then loss pulses; CPR was initiated. Patient was intubated and admitted to ICU (Intensive Care Unit). The patient expired on 5/31/16."
A request was made to EMP1 and EMP4 on May 9, 2017 at 2:30 PM, for documented evidence of case reviews for MR24 and MR32. None were provided.
Review on May 10, 2017, of "[facility document]" related to events documented in MR24 dated October 6, 2016, revealed "Case Summary: It was not clear to physician performing study whether a fistula was noted at stricture site, as there appeared to be an area that communicated outside the lumen or a perforation. At this point the procedure was aborted. ... CT ordered, insurance pre-certification efforts were undertaken, yet unsuccessful. Decision to proceed without certification, patient declined to wait despite being informed of the need to have CT and potential for procedural related complications. Teaching Points: Recommendation that attending physician contact the Chairman of GI/Hepatology, appropriate to communicate and facilitate stat imaging needs to the chairman of Radiology. Conversations between GI/Hepatology to create a Fast Track System for urgent imaging and circumvent insurance authorization. Refer patients to ED from Endoscopy for urgent imaging until process can be put in place. Need to make process easier to obtain CT studies from endoscopy suite. Providers may benefit from service on using clips to close perforations. Consents may benefit from revision and being endoscopy specific."
Review on May 10, 2017, of facility's meeting minutes "Patient Safety Improvement and Management Program Committee," dated July 12, 2016, revealed the patient in MR31, ... ... Esophageal Intubation ... case that occurred on February 5, 2016. Patient presented to ED (emergency department) on February 4, 2016 with complaint of mid-sternal CP (chest pain) x 2 days and was admitted. ... was unable to tolerate a CT scan due to anxiety and was transported to the floor from ED. The test was later completed after the patient received Ativan 2 mg. The nurse contacted the physician with change in condition-increased heart rate, increased respiratory rate, decreased pulse ox. Physician came to bedside to assess. Anesthesia was called and intubated the patient. ... Patient continued to decompensate and code blue was initiated. Patient expired. ... will report within 3 months the status of the action plan."
Review on May 10, 2017, of the, "[Facility document]" related to events documented in MR31, Date of Event 2/5/16," revealed "action items "#2", "#3", and "#4." Further review revealed no targeted completion date nor completed date for these action items.
Request was made to EMP1 on May 10, 2017 at 11:20 AM, for documented evidence of implementation of "[Facility document] teaching points" for MR24 case review and implementation of "[Facility document] Action Plan" for MR31. No documentation was provided.
Review on May 10, 2017, of the facility document, "[facility document]", revealed "Action item #1 ... Team huddle ... target completion 11/16 ... Action item #2 ... Medication reconciliation in the CRC to inpatient psych ... target completion 10/16 ... Action #3 ... Communication tool ... target completion 10/16 ... Action #4 ... Educate Nursing ... target completion 10/16 ... Action item #5 ... Audit rounding ... target completion date 11/16."
Interview with EMP1, on May 8, 2017, between 8:30 A.M. and 9:30 A.M., confirmed that the facility did not complete a RCA related to the events documented in MR1 and MR24.
Interview with EMP1 and EMP4 on May 9, 2017, at 2:30 PM, confirmed, a RCA was not completed for MR32.
Interview with EMP1, on May 10, 2017, between 12:30 P.M. and 1:30 P.M., confirmed that the facility did complete an RCA related to the events documented in MR1. Further interview with EMP1 confirmed that the facility would not allow the surveyor to view the entire RCA document as it was considered a "protected" document by the facility. Further interview with EMP1 confirmed that the "RCA Action Plan" did not have documented evidence of a date of completion and did not have documented evidence that "action items" listed as "#1", "#2", "#3", "#4" and "#5" were completed.
Interview with EMP1 on May 10, 2017 between 12:30 P.M. and 1:30 PM, confirmed the facility would not allow the surveyor to view the entire RCA document related to MR31, as it was considered a "protected" document by the facility.
Interview with EMP1 on May 10, 2017 confirmed OTH1 would not be available for interview to discuss events documented in MR24.
Interview with EMP7, on May 10, 2017, between 12:30 P.M. and 1:30 P.M., confirmed that the facility did complete an RCA related to the events documented in MR1. Further interview with EMP7 confirmed that the facility would not allow the surveyor to view the entire RCA document as it was considered a "protected" document by the facility. Further interview with EMP7 confirmed the "RCA Action Plan" did not have documented evidence of a date of completion and did not have documented evidence that "action items" listed as "#1", "#2", "#3", "#4", and "#5" were completed. Further interview with EMP7 confirmed that several "action items" completion dates needed to be "delayed." Further interview with EMP7 confirmed that the new completion dates for action items "were not" determined and that the RCA document "was not" amended to reflect the new completion dates.
Request was made to EMP7, on May 10, 2017, at 1:24 PM, for any documented evidence of a case review for MR32. No documentation was provided.