HospitalInspections.org

Based on document review, medical record review (MR) and interview, the medical staff was not accountable for the quality of the medical care provided to patients (Patient #1 and Patient #2) as evidenced by the lack of documentation regarding patient complications, (i.e., pain management, abnormal heart rhythm) during interventional radiology procedures.

Findings include:

-- Per review of the facility's Medical Staff Bylaws, effective 4/25/16 and Rules and Regulations, effective 5/23/19, documentation in the MR shall be timely, pertinent, accurate, reflective of the treatment rendered and the patients response to that treatment, and consistent with professionally recognized and hospitals-specific standards as to content and form.

-- Per MR review Patient #1 presented to the hospital on 5/28/19 with right lower extremity ischemia (lack of blood flow). On 5/29/19 at approximately 10:30 am, the patient had bilateral lower extremity angiography (examination of blood vessel using x-ray imaging), bilateral superficial femoral artery angioplasty (opening artery using tiny balloon) and stent placement (placement of small tube to prevent closure of blood vessel) under sedation.

Vital signs at 10:30 am were blood pressure (BP)-170/86, pulse (P)-61, respirations (R)-16, oxygen saturation (O2sat)-100 percent.

At 10:40 am - per physician order, nursing administered Fentanyl 50 micrograms (mcg) and Versed 1 milligram (mg)
BP -161/88, P-62, R-16, O2sat-100%

At 10:45 am - per physician order, nursing administered Fentanyl 50 mcg and Versed 1 mg
BP-163/86, P-62, R-16, O2sat - 98%

At 10:59 am - per physician order, nursing administered Fentanyl 50 mcg and Versed 1 mg

At 11:00 am - BP-142/83, P-63, R-16, O2sat-100%

At 11:05 am - per physician order, nursing administered Fentanyl 50 mcg and Versed 1 mg
BP-140/88, P-62, R-16, O2sat-100%

At 11:10 am - pain level 6/10

At 11:15 am - per physician order, nursing administered Fentanyl 50 mcg
BP-132/82, P-64, R-16, O2sat-100%

At 11:21 am - per physician order, nursing administered Fentanyl 50 mcg

At 11:25 am - BP-150/91, P-64, R-16, O2sat- 100%, sedation level - 1 (awake, alert)

At 11:35 am - per physician order, nursing administered Fentanyl 50 mcg and Versed 1 mg
BP-131/72, P-63, R-16, O2sat-100%

At 11:45 am - pain 6/10

At 11:53 am - per physician order, nursing administered Fentanyl 50 mcg and Versed 1 mg

At 11:55 am - BP-132/77, P-62, R-16, O2sat-100%, sedation level - 1

At 12:14 pm - per physician order, nursing administered Fentanyl 50 mcg and Versed 1 mg

At 12:15 pm - BP-207/102, P-65, R-16, O2sat-100%

At 12:25 pm - pain 6/10

At 12:35 pm - per physician order, nursing administered Fentanyl 50 mcg and Versed 1 mg
BP-203/108, P-67, R-16, O2sat-100%

Patient #1 received 8 milligrams of Versed and 500 micrograms of Fentanyl during the procedure.

At 12:45 pm, Morphine 4 mg was administered. Procedure was completed. Patient exited procedure room at 1:19 pm.

-- Per review of Staff A's (Physician) post procedure radiology note dated 5/29/19 at 12:45 pm and the typed report dictated on 6/7/19 at 11:18 am, both revealed no complications occurred during the patient's procedure.

-- Per interview of Staff A on 8/28/19 at 11:15 am, Patient #1 had very bad vascular disease. He/she indicated the amount of sedation administered to the patient during the procedure was at the upper limit. During the procedure the patient was alert, squirming on the table and in significant pain. He/she was torn between stopping the procedure or continuing. He/she indicated he/she couldn't stop the procedure because the patient would end up losing her leg. He/she had to continue ordering sedation to try to keep the patient still.

-- Per review of Patient #2's MR, she arrived at the hospital on 5/30/19 at approximately 12:00 pm, via ambulance with complaints of weakness, shortness of breath (SOB) and cough for a couple of days. Computerized tomography (CT) of chest revealed Patient #2 had extensive bilateral pulmonary emboli (blood clots in lungs). Patient #2 was started on anticoagulant (blood thinner). Patient #2 was taken to interventional radiology on 5/30/19 at approximately 4:00 pm for inferior vena cava (IVC) filter placement, peripherally inserted central catheter (PICC) placement and initiation of pulmonary thrombolysis (process to dissolve blood clots in lungs).

During the procedure, at 4:15 pm, Patient #2's heart rate increased to 178 beats and cardiac monitor showed she was in supraventricular tachycardia (SVT) (abnormally fast heart rate).

At 4:19 pm Lopressor (medication) was administered.

At 4:20 pm patient was instructed to bear down, hold her breath and cough to break SVT, but was unable to break.

At 4:23 pm SVT converted to normal sinus rhythm (regular heart beat).

Procedure completed.

Review of Patient #2's radiology procedure note dated 5/30/19 at 4:30 pm, indicated no complications and typed procedure report (dictated on 6/7/19) revealed there were no complications during the procedure.

-- Per interview of Staff D, Chief Medical Officer on 8/28/19 at 2:30 pm, he/she acknowledged these complications should have been documented in the physician's procedure reports.

Based on medical record (MR) review and interview, nursing staff did not adequately document a patient's (Patient #1) condition during an interventional radiology procedure.

Findings include:

-- Per MR review Patient #1 presented to hospital on 5/28/19 with right lower extremity ischemia (lack of blood flow). On 5/29/19 at approximately 10:30 am, the patient had bilateral lower extremity angiography (examination of blood vessel using x-ray imaging), bilateral superficial femoral artery angioplasty (opening artery using tiny balloon) and stent placement (placement of small tube to prevent closure of blood vessel) under sedation.

Nursing documentation revealed the patient received the following sedation (intravenously) during the procedure on 5/29/19:

10:40 am - Fentanyl 50 micrograms (mcg) and Versed 1 milligram (mg).
10:45 am - Fentanyl 50 mcg and Versed 1 mg
10:59 am - Fentanyl 50 mcg and Versed 1 mg
11:05 am - Fentanyl 50 mcg and Versed 1 mg
11:15 am - Fentanyl 50 mcg
11:21 am - Fentanyl 50 mcg
11:35 am - Fentanyl 50 mcg and Versed 1 mg
11:53 am - Fentanyl 50 mcg and Versed 1 mg
12:14 pm - Fentanyl 50 mcg and Versed 1 mg
12:35 pm - Fentanyl 50 mcg and Versed 1 mg

Patient #1 received a total of 8 mg of Versed and 500 mcg of Fentanyl during the procedure.

-- Per review of the nursing procedural notes, they lacked accurate description of patient's pain condition and documentation related to the need for increased doses of pain medication.

-- Per interview of Staff C, Registered Nurse (RN) on 8/28/19 at 9:45 am, Patient #1 took a lot of pain medication at home. He/she did question the physician about the amount of pain medication administered however, the patient's vitals signs remained stable. Patient #1 was alert, complaining of pain and moving around throughout the procedure. After a dose of pain medication was administered the patient would calm down for a little while.