HospitalInspections.org

Based on observation and staff interview, it was determined that the facility failed to ensure patient's receive care in a safe setting.

Findings include:

1. During an interview in the Trauma Emergency Department on 6/01/17, Staff #7 and Staff #8 were asked, "What is the largest size endo-tracheal tube in the Infant Airway Kit?"

a. Staff #7 and Staff #8 did not know the size of the largest endo tracheal tube in the Infant Airway Kit.

b. Staff #8 unlocked and opened an Infant Airway Kit.

i. A list of the contents was inside.

ii. The largest endo tracheal tube in the Infant Airway Kit is 3.5.

2. Upon interview in the Pediatric Intensive Care Unit on 6/02/17, Staff #20 was asked, "What is the largest size endo tracheal tube in the Infant Airway Kit?"

a. Staff #20, stated, "I think the largest size in the Infant Airway Kit is a 4. There is a list inside the kit."

b. A size 4 endo tracheal tube is in the Pediatric Airway Kit.

c. The largest size endo tracheal tube in the Infant Airway Kit is 3.5.

3. The staff did not know the size of the largest endo tracheal tube in the Infant Airway Kit.

4. In an emergency, the staff would have difficulty identifying the appropriate airway kit.

5. The above findings were confirmed with Staff #18 and Staff #19.

Based on a medical record review, review of facility policy and procedure, and staff interview, it was determined that the facility failed to ensure that the patient's health care status is assessed according to hospital policy.

Findings Include:

Reference: Facility policy, Intensive Care/Progressive Care Patient Transport, states, "... 5. Documentation of vital signs and other relevant information is completed ... by the RN (Registered Nurse) and RT (Respiratory Therapist) transporting the patient. a) For critically ill patients: Document HR (heart rate), BP (blood pressure), RR (respiratory rate), oxygen saturation ... during transport, on arrival to the procedure location ..."

1. Review of Medical Record #1 revealed the following:

a. Patient #1 was critically ill.

b. Patient #1's heart rate, blood pressure, respiratory rate, and oxygen saturation were not documented during transport and on arrival to CT (computed tomography) Scan.

2. The above findings were confirmed with Staff #2.

Based on document review and staff interview, it was determined that the facility failed to ensure that all medical records, included documented reports of treatment, interventions and assessments of the patient's condition. .

Findings include:

1. On 4/23/17 at 22:40, Patient #1 was taken to CT Scan:

a. Upon review of Medical Record #1, the patient was accidentally extubated in the CT Scan, had desaturated and was hypotensive.

i. The "Progress Notes", by the Physician stated, "patient accidentally extubated in CT, had desaturation and then hypotension... was reintubated with 3.5 uncuffed ETT... but had large airleak... O2 saturations increased, Epi 0.025 mg given, BP increased to 70's and patient returned to PICU..."

ii. The "Progress Notes", by the Therapist, stated, "patient accidentally extubated during Cat Scan, reintubated by Dr. [name] with uncuffed 3.5 ETT... Endtidal CO2 detector turn [sic] yellow, positive... large air leak from ETT, then transferred patient to PICU without incident. HR 170, SPO2 100% at this time..."

ii. The "Progress Notes", by the registered nurse, stated, at 22:40 "patient taken to CT Scan via bed with ECG monitor, on ventilator accompanied by Respiratory therapist and Doctor [name]"... At 23:20 "patient extubated while in CT Scan, ...reintubated by Doctor [name]."

iii. The vital signs on 4/23/17 were documented prior to CT Scan at 22:30... "Pulse 187, Resp 34, BP 92/46... and O2 Sat 99%"... The next documented set of vital signs were at 23:30, after return from CT Scan to PICU. "Temp 98.2 F, Pulse 173, Resp 20, BP 72/56, O2 Sat 85%..."

iv. Upon interview Staff #1 stated, The MAR (medication administration record) does not reflect that the Epinephrine 0.025 milligrams (mg) was given to Patient #1 by the physician in CT Scan. Staff #1 confirmed that the medication, vital signs and supportive treatment for the accidental extubation, desaturation and hypotensive incident in the CT Scan room should have been recorded in the Code Navigator in the EMR.

2. The facility failed to ensure that all necessary information during the time that Patient #1 was accidentally extubated in CT Scan and upon arrival back to the PICU, were documented in the medical record for Patient #1.