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Based on the review of the facility's policy and procedure and medical record and interview it was determined the Chief Executive Officer failed to ensure the Emergency Department (ED) Physician's followed the facility policy of Strokes. This affected Medical Record (MR) # 1, # 2, and # 3, which was 3 of 4 patients who were admitted from the ED with a diagnoses including Intracranial Hemorrhage or Cerebral Infarct. This also had the potential to affect all patients served by this facility.

Findings include:

Emergency Department Policy: Stroke Team Activation
Effective Date: 7/19/12

Policy:

The stroke team is a multi-disciplinary team assembled in an organized fashion to perform the tasks necessary to provide effective and efficient resuscitation to the potentially and severely debilitated stroke patient. Upon arrival at Medical Center Barbour Emergency Department the patient will be placed into one of the treatment rooms where the ED physician will be waiting to quickly assess the patient. Team members (RN') (Registered Nurses) will assist the ED physician and establish IV (intravenous) access, obtain a glucose level rapidly and prepare the patient to go to CT (computerized axial tomography) scan. Talking and noise should be kept at a minimum, team members should remain in the ED until called upon or dismissed if not performing direct patient care. The Tele-Medicine cart will be moved to the treatment room and the ED nurse will notify the Neurologist on call at that time.

Procedure:

2. The ED nurse along with the team members will set up the Tele-Medicine cart in the awaiting while the patient is getting the CT of the head.

3. The nurse will activate the Tele-Medicine cart and contact the Neurologist on call for the day. Once contact is made and the patient has returned from the CT scan the nurse will stay with the patient and assist with the assessment of the patient with Neurologist.

4. An NIH (National Institutes of Health) score will be given to the patient by the Neurologist and at that time it will be determined if the patient will receive TPA (Tissue Plasminogen Activator) or not.

1. MR # 1 was seen in the ED on 11/22/14 at 12:04 PM. The family states the patient was doing well on the night of 11/21/14. When the family came to check on the patient on the morning of the 11/22/14, the patient had slurred speech, generalized weakness, and the family called an ambulance.

Review of the physician's exam revealed the patient was not moving the left lower extremity and right sided generalized weakness. The patient was able to move upper extremities and right leg fine but did have slurred speech.

Review of the Nurse Chart revealed the family stated the patient had some altered mental status and increased weakness that started this morning. Patient also had slurred speech which was abnormal. The family also stated the patient normally ambulates and was unable to get out of bed.

There was no documentation the Tele-Medicine cart was set up, an NIH score was given to the patient by the Neurologist nor was there documentation of a determination if the patient would receive TPA or not.

An interview was conducted with Employee Identifier (EI) # 1, Clinical IT (Information Technology) and Director of Education on 3/24/15 at 1:00 PM who verified the above findings.

An interview was conducted on 3/24/15 at 1:45 PM with EI # 3, ED physician who saw the above patient. The surveyor asked if the hospital had reviewed the Stroke Team Activation with him and the response was, "I am not sure they have". The surveyor asked if the Neurologist had been consulted and the response was, "no". The surveyor asked if an evaluation of the TPA was conducted and the response was, "the CT scan result stated an old infarct."

The patient was admitted to the hospital on 11/22/14 for ongoing evaluation.

Review of the Physical Therapy Evaluation dated 11/24/15 revealed the patient was unresponsive to any stimuli.

Review of the Nurse Practitioner Progress Notes dated 11/24/14 at 7:08 PM revealed the following, "I'm unable to obtain any meaningful or detailed review of systems from the patient. She/he is somnolent. She/he responds to painful stimuli only. I have spoken with the nurse and she/he remain obtunded draw today. She/he has not had any p.o. (by mouth) intake or purposeful movement other than response to painful stimuli."

Review of the Nurse Practitioner Progress Notes dated 11/25/14 at 7:08 PM revealed the following, "...The nursing staff tells me that she/he has difficulty maintaining her own airway secretions and that she/he is requiring intermittent oropharyngeal suctioning..."

Review of the physician's order dated 11/26/14 at 10:44 AM revealed the patient was going to be discharged home with Hospice.

An interview was conducted with the Hospice Director on 3/24/15 at 3:30 PM who stated the patient expired on 11/28/15.

2. MR # 2 was seen in the ED on 10/28/14 with facial droop on the right side, dysphasia and slow speech.

Review of the physician's ED documentation dated 10/29/14 revealed a preliminary diagnosis of Transient Ischemic Attack.

There was no documentation the Tele-Medicine cart was set up, an NIH score was given to the patient by the Neurologist nor was there documentation of a determination if the patient would receive TPA or not.

An interview was conducted with EI # 1 on 3/24/15 at 10:00 AM who verified the above findings.

3. MR # 3 was seen in the ED on 10/30/14 at 1:12 AM with symptoms that included weakness of the entire body, slurred speech and less responsive than usual.

Review of the ED physician's documentation at 3:20 AM revealed no thrombolytic was given due to unable to determine eligibility.

There was no documentation the Tele-Medicine cart was set up for a consult with the Neurologist nor was there documentation of a determination if the patient would receive TPA or not.

An interview was conducted with EI # 1 on 3/24/15 at 12:00 PM who verified the above findings.

Based on review of the facility's policy and procedure and grievances for the last 6 months and interview, it was determined the facility failed to follow their own policy for 1 of 1 grievance that was written and mailed to the facility to include a resolution within 5 days. This had the potential to affect all patients served by this facility.

Findings include:

Facility Policy: Patient/Customer Concerns and/or Grievances

Policy:

All patient concerns and/or grievances should be considered an opportunity to foster sound customer relations, therefore immediate attention is required at the point of care/service by utilizing approved procedures.

Procedure:

...When a grievance is received, an occurrence report should be initiated...

Upon receipt of written or phone grievances the Administrative staff or Quality Director will contact the appropriate Department Director to begin investigation and follow-up.

A letter or phone call acknowledging the complaint will be done by the Quality Director or the Department Director in the area of concern.

Resolution to a grievance should be complete within five (5) days, a letter indicating such is sent to the complainant with potential timeframe for resolution. All resolution letters should be sent to the Quality Department for recording and mailing...

Review of a letter dated January 20, 2015 from a patient's family member revealed the following issues related to the patient's hospital stay dated 11/22/14 to 11/26/14:

1. Patient seen in the Emergency Department (ED) on 11/22/14 with stroke symptoms and no documentation the patient received tPA (tissue Plasminogen Activator).

2. Patient became unresponsive overnight.

3. Patient had an elevated temperature and nothing was done until the family suggested a suppository.

4. The patient was not able to eat and was not given nourishment intravenously until the family questioned the doctor.

5. Sending the patient home before the family had the patient's room ready with a hospital bed.

Further review of the grievance on 3/25/15, revealed no documentation of a resolution.

An interview with Employee Indentifer (EI) # 2, Chief Executive Officer was conducted on 3/25/15 at 8:30 AM. EI # 2 stated that no follow-up had been conducted on this complaint.

Based on review of the facility's policy and procedure and grievances for the last 6 months and interview, it was determined the facility failed to follow their own policy for 1 of 1 grievance that was written and mailed to the facility to include a written response nor a phone call had been made to the complainant to verify a resolution. This had the potential to affect all patients served by this facility.

Findings include:

Facility Policy: Patient/Customer Concerns and/or Grievances

Policy:

All patient concerns and/or grievances should be considered an opportunity to foster sound customer relations, therefore immediate attention is required at the point of care/service by utilizing approved procedures.

Procedure:

...When a grievance is received, an occurrence report should be initiated...

Upon receipt of written or phone grievances the Administrative staff or Quality Director will contact the appropriate Department Director to begin investigation and follow-up.

A letter or phone call acknowledging the complaint will be done by the Quality Director or the Department Director in the area of concern.

Resolution to a grievance should be complete within five (5) days, a letter indicating such is sent to the complainant with potential timeframe for resolution. All resolution letters should be sent to the Quality Department for recording and mailing...

Resolution to a grievance should be complete within five (5) days, a letter indicating such is sent to the complainant with potential timeframe for resolution. All resolution letters should be sent to the Quality Department for recording and mailing...

Review of a letter dated January 20, 2015 from a patient's family member revealed the following issues related to the patient's hospital stay dated 11/22/14 to 11/26/14:

1. Patient seen in the Emergency Department (ED) on 11/22/14 with stroke symptoms and no documentation the patient received TPA (tissue Plasminogen Activator).

2. Patient became unresponsive overnight.

3. Patient had an elevated temperature and nothing was done until the family suggested a suppository.

4. The patient was not able to eat and was not given nourishment intravenously until the family questioned the doctor.

5. Sending the patient home before the family had the patient's room ready with a hospital bed.

An interview with Employee Indentifer (EI) # 2, Chief Executive Officer was conducted on 3/25/15 at 8:30 AM. EI # 2 stated that no follow-up had been conducted on this complaint nor had the complainant been contacted.

A telephone interview was conducted with the complainant on 3/25/15 at 11:00 AM. The complainant stated there had been no response from the hospital at all.

Based on the review of the facility's policy and procedure and medical records and interviews, it was determined the facility failed to obtain a physician's order for the use of restraints. This affected 1 of 1 records reviewed with restraints, which was Medical Record (MR) # 3 and had the potential to affect all patients at this facility.

Findings include:

Facility Policy: Use of Restraints and Seclusion

Guidelines for Restraint Use In Acute Medical and Surgical Care

2. ...The Physician (LIP) (Licensed Independent Practitioner) order should be obtained within twelve (12) hours of application of restraints. Restraint orders for medical-surgical patients expire every 24 hours. The 24-hour time period begins at the time the restraints are applied...

Note: The order may be written for less than twenty-four hours, but may never exceed the twenty-four hour time limit.

1. MR # 3 was admitted to the facility on 10/31/14 with diagnoses including Intracranial Hemorrhage or Cerebral Infarct.

Review of the Clinical Documentation Report dated 11/1/14 at 1:00 AM revealed the patient was in soft wrist restraints. Review of the medical record revealed no documentation of a physician's order for the soft wrist restraints.

Review of the Clinical Documentation Report dated between 11/4/14 at 10:30 AM and 11/5/14 at 3:00 PM revealed the patient was in soft wrist restraints. Review of the Physican's orders for restraints revealed no documentation of an order between 11/4/14 at 10:30 AM and 11/5/14 at 3:00 PM, which was 29 hours.

An interview was conducted with Employee Identifier (EI) # 1, Clinical IT (Information Technology) and Director of Education on 3/24/15 at 2:00 PM. EI # 1 vewrified the above findings.

Based on the review of the facility's policy and procedure and medical records and interviews, it was determined the facility failed to document the patient in restraints was assessed every 2 hours while in restraints. This affected 1 of 1 records reviewed with restraints, which was Medical Record (MR) # 3 and had the potential to affect all patients at this facility.

Findings include:

Facility Policy: Use of Restraints and Seclusion

Guidelines for Restraint Use In Acute Medical and Surgical Care

4. It is the responsibility of the Registered Nurse to ensure that restraints are applied properly and appropriate monitoring activities are implemented. The purpose of monitoring a patient in restraints is to address the individual's physical safety and to ensure that the patient's rights, dignity and safety are maintained.

a. When restraints are implemented, patients should be monitored/assessed/assisted frequently and the following documented every 2 hours and must be completed on the even hour:
Mental status checked
Bathroom offered/elimination needs met
Fluids and/or nutrition offered
Hygiene needs met
Comfort measures (includes presence of pain/pain relief needs)
Skin and circulatory checks

1. MR # 3 was admitted to the facility on 10/31/14 with diagnoses including Intracranial Hemorrhage or Cerebral Infarct.

Review of the Clinical Documentation Report dated between 11/1/14 at 11:00 PM revealed the patient was in soft wrist restraints. There was no documentation of an entry on the restraint log until 11/2/14 at 3:00 AM, which was 4 hours an not the two hours as per policy.

An interview was conducted with Employee Identifier (EI) # 1, Clinical IT (Information Technology) and Director of Education on 3/24/15 at 2:00 PM. EI # 1 verified the above findings.