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A. Based on clinical record review and staff interview it was determined that the Hospital failed to ensure timely and appropriate interventions for patients with improper endotracheal tube (ETT) placement (A347 A) and failed to ensure the Emergency Physician Record was complete for each patient to indicate that complete medical care was provided to patients (A 347 B). The cumulative effect of these systemic problems resulted in the Hospital's inability to ensure and maintain safe patient care. As a result, it was determined that the Condition for Medical Staff was not in compliance.

A. Based on clinical record review and staff interview it was determined that in 2 of 7 (Pt. #1 and #8) clinical records reviewed for intubated patients, the Hospital failed to ensure timely and appropriate interventions for patients with improper endotracheal tube (ETT) placement.

Findings include:

1. The clinical record for Pt. #1 was reviewed on 1/19/10 at approximately 11:00AM. Pt. #1, a 54 year old female, was admitted to the ED by Chicago Fire Department ambulance on 11/10/09 at 4:59PM with complaints of respiratory distress due to allergy to shellfish. The triage nurse assessed Pt. #1 at 5:04PM. The triage nurse documented, " ... Pt. appears flushed. Dr (E #1) at bedside ... " Initial vital signs, documented at 5:04PM were: Temp 97.8, pulse 156, resp 24, B/P 99/67. The pulse ox was 92% on room air. Pt. #1 was listed as alert and oriented times 3. On 11/10/09 at 5:52PM, the nurse documented that Pt. # 1 was intubated. The physician (E#1) documented on the physical exam form (untimed) "decided to intubate"

According to documentation from the computerized portion of the clinical record, a chest x-ray was ordered on 11/10/09 at 5:42PM and completed at 6:08PM (post intubation). The radiologist report dated 11/11/0 (next day) documented, "...ET tube is seen and its distal end is in the right main stem bronchus ...The heart and mediastinal structures are shifted to the left suggestive of collapsed lung." On 11/10/09 at 6:31PM, a nurse documented, "ET tube was moved back to 22cm with Dr.'s (E#1) assistance and the lung sounds reassessed. Noted diminished left side lung sounds."

A second chest x-ray was ordered at 7:00PM on 11/10/09 and completed at 7:11PM. The radiology results documented on 11/11/09 included, " The ET tube is slightly pulled out but remains in the right stem bronchus. There is partial clearing of the opacification of the left chest. The heart is enlarged. The right lung remains clear "

On 11/10/09 at 6:47PM a CT of the chest was ordered and at 9:29PM the CT scan was completed. The result dated 11/11/09 included, "The distal end of the endotracheal tube remains in the proximal right main stem bronchus. There is noted collapse of the left lung..impression: ET tube remains in the right main stem bronchus. Complete collapse of the left lung. "
The ET tube remained incorrectly position from approximately 5:42PM until 9:29PM (approximately 3 1/2 hrs)
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The above finding was verified by the Director of Quality during an interview on 1/19/10 at approximately 3:00PM.


2. On 1/19/10, the clinical record for Pt. #8 was reviewed. This was a 67-year-old female who presented unresponsive to the Emergency Department (ED) on 1/12/10 at 1:40 P.M. The "Emergency Physician Record... Critical Care...," dated 1/12/10 at 1:45 P.M. included documentation that the patient was intubated on 1/12/10 at 2:25 P.M. with a #7.5 endotracheal tube (ETT), positioned at the patient' lip at the level of 21 cm. The record also included documentation that a chest Xray was done on 1/12/10 at 2:48 P.M. that included, "ET tube is seen and its distal end is in the right mainstem bronchus. Please pull up 1.5 inches." The nursing note dated 5:00 P.M. included, "ET tube was moved back to 20 cm at the lip per Dr....verbal order. Repeat CXR was ordered." This intervention was less than the required 1.5 inches. The record further included a repeat chest Xray dated 1/12/10 at 5:02 P.M. that included, "The distal end of the ET tube remains in the right main stem bronchus and please pull up 1.5 inches." The nursing note dated 1/12/10 at 5:21 P.M. included, Dr... re-adjusted the ET tube to 18 cm." Another chest Xray dated 1/12/10 at 6:34 P.M. included, "ET tube is pulled up and its distal end is above the carina." The ETT remained improperly placed for 2 hours and 12 minutes without intervention. When the initial intervention was performed at 5:00 P.M., ( ET tube moved back to 20 cm), it was not done in accordance with the radiologist's order to pull the ET up 1.5 inches.

3. The above findings were confirmed during an interview with the Director of Emergency Room Services on 1/20/10 at approximately 11:00 A.M.


B. Based on a review of the Hospital's Emergency Department Quality Minutes, a review of the Hospital's Emergency Physician Record form, clinical record review, and staff interview, it was determined that in 8 of 10 (Pt. #s 1-2 and 4-9) Emergency Department clinical records reviewed, the Hospital failed to ensure the Emergency Physician Record was complete for each patient.

Findings include:

1. The Hospital's Emergency Department Quality Minutes for 2009 were reviewed on 1/20/10 at approximately 1:00 P.M. The Department of Emergency Services Quality Management Report Indicator included, "Aspect of Care Indicator... All Emergency patient medical records will include complete documentation accurately detailing pertinent findings quality indicators for medical record documentation."

2. The Hospital's Emergency Physician Record Forms for Dyspnea, Critical Care, and Code Blue were reviewed on 1/19 and 1/20/10. The forms require documentation of the following: the patient's progress; intubation procedures to include nasal/oral endotracheal tube, curved or straight laryngoscope blade, premedication, assessment of post intubation breath sounds, pulse oximetry reading, evaluation of the end-tidal CO2 detector; and disposition and condition of the patient at disposition.

3. The Hospital's Emergency Physician Record Forms for Allergic Reaction Physical exam and Intubation Continuation were reviewed on 1/20/10. The forms required documentation of chest Xray review, treatments rendered such as oxygen, IV fluids and medications including the time for re-evaluation (progress), time case was discussed with the on call physician. Intubation Continuation forms require lacked timely entries. (07105)

4. The clinical record for Pt. #1 was reviewed on 1/1910 at approximately 11:00AM. Pt. #1, a 54 year old female, was admitted to the ED by Chicago Fire Department ambulance on 11/10/09 at 4:59PM with complaints of respiratory distress after in-advertently ingesting shellfish. The triage nurse assessed Pt. #1 at 5:04PM. The triage nurse documented, " Presented to ED with complaints of having an allergic reaction to shrimp. Pt. appears flushed. Dr (E #1) at bedside ... " The triage nurse listed an allergy to shellfish. Initial vital signs, documented at 5:04PM were: Temp 97.8, pulse 156, resp 24, B/P 99/67. The pulse ox was 92% on room air. Pt. #1 was listed as alert and oriented times 3. The physician (E#1) documented a medical screening exam on 11/10/09 5:10PM. The documented physical exam by E #1 included, "moderate distress, angioedema tongue and uvula, skin rash, respiratory distress, tachycardia and alert and oriented X3. Respiratory breath sounds nml (normal)

The clinical record under physical exam ( page 2 of 2) lacked documentation of the following:

* chest x-ray review and interpretation
* pulse ox.
* treatment
* "Progress time, unchanged, improved, reexamined"
* time admitted

* The clinical record Emergency Physician Record Intubation Continuation forms were not completed on the day of admission (11/10/09) for Pt. #1 in accordance with Hospital aspects of care requirements. The forms were completed 2 days later (11/12/09) by E#1.

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5. On 1/19/10 at approximately 9:39 A.M., the clinical record for Pt. #2 was reviewed. This was an 81-year-old female who presented to the Emergency Department (ED) on 1/18/10 at 5:13 P.M. with a complaint of shortness of breath. The "Emergency Physician Record... Dyspnea...," dated 1/18/10 at 5:40 P.M., failed to include documentation of the patient's progress while in the ED (from 5:40 - 10:16 P.M.). The Emergency Physician Record included the disposition that the patient was admitted in stable condition.

6. On 1/19/10 at approximately 10:43 A.M., the clinical record for Pt. #4 was reviewed. This was a 59-year-old male who presented unresponsive to the Emergency Department (ED) on 1/5/10 at 2:46 P.M. The "Emergency Physician Record... Critical Care...," dated 1/5/10 included documentation that the patient was intubated with a #8 endotracheal tube (ETT), using a curved blade (laryngoscope). The Emergency Physician Record lacked documentation of the following:

* nasal or oral placement of the ETT
* assessment of post intubation breath sounds
* patient's condition at the time of disposition (admission).

7. On 1/19/10 at approximately 11:07 A.M., , the clinical record for Pt. #5 was reviewed. This was a 66-year-old male who presented the Emergency Department (ED) on 11/26/09 at 11:25 A.M. with Respiratory Distress. The "Emergency Physician Record... Critical Care...," dated 11/26/09 at 12:45 P.M. included documentation that the patient was orally intubated with a #7.0 endotracheal tube (ETT), using a curved blade (laryngoscope). The Emergency Physician Record lacked documentation of the following:

* assessment of post intubation breath sounds
* assessment of the patient's progress while in the ED (12:45-4:45 P.M.)
* patient's condition at the time of disposition (admission).

8. On 1/19/10 at approximately 1:40 P.M., the clinical record for Pt. #6 was reviewed. This was a 69-year-old male who presented to the Emergency Department (ED) on 11/10/09 at 4:28 P.M. with complaints of dyspnea and gastrointestinal bleeding. The "Emergency Physician Record... Critical Care...," dated 11/10/09 at 4:40 P.M. included documentation that the patient was intubated with a #8 endotracheal tube (ETT). The Emergency Physician Record lacked documentation of the following:

* nasal or oral ETT placement
* curved or straight laryngoscope blade
* patient's pulse oximetry reading before and after the intubation
* condition of the end-tidal CO2 detector
* assessment of the post intubation breath sounds
* patient's condition at the time of disposition (admission).

9. On 1/19/10 at approximately 2:35 P.M., the clinical record for Pt. #7 was reviewed. This was a 56-year-old female who presented to the Emergency Department (ED) on 11/4/09 at 5:53 P.M. with acute respiratory failure. The "Emergency Physician Record... Dyspnea...," dated 11/4/09 at 5:53 P.M. and the "Emergency Physician Record... Critical Care...," dated 11/4/09 at "7" collectively included documentation that the patient was intubated with a #7.5 endotracheal tube (ETT). The Emergency Physician Record lacked documentation of the following:

* nasal or oral ETT placement
* curved or straight laryngoscope blade
* premedication administration
* patient's pulse oximetry reading before and after the intubation
* condition of the end-tidal CO2 detector
* assessment of the post intubation breath sounds
* patient's condition at the time of disposition (admission).

10. On 1/19/10 at approximately 3:30 P.M., the clinical record for Pt. #8 was reviewed. This was a 67-year-old female who presented unresponsive to the Emergency Department (ED) on 1/12/10 at 1:40 P.M. The "Emergency Physician Record... Critical Care...," dated 1/12/10 at 1:45 P.M. included documentation that the patient was intubated with a #7.5 endotracheal tube (ETT). The record included documentation of a physician's order, dated 1/12/10 to admit the patient. The Emergency Physician Record lacked documentation of the following:

* nasal or oral ETT placement
* curved or straight laryngoscope blade
* premedication administration
* patient's pulse oximetry reading before and after the intubation
* condition of the end-tidal CO2 detector
* assessment of the post intubation breath sounds
* patient's disposition and condition at that time
* signature of the examining physician.

11. On 1/20/10 at approximately 10:05 A.M., the clinical record for Pt. #9 was reviewed. This was a 69-year-old female who presented unresponsive to the Emergency Department (ED) on 1/9/10 at 3:08 P.M. The "Emergency Physician Record... Code Blue...," dated 1/9/10 included documentation that the patient was intubated with a #7.0 endotracheal tube (ETT). The Emergency Physician Record lacked documentation of the following:

* time of examination by the physician
* patient's progress while in the ED (3:10-6:48 P.M.)
* patient's condition at the time of disposition (admission).

12. The above findings were confirmed during an interview with the Director of Emergency Room Services on 1/20/10 at approximately 11:00 A.M.

A. Based on clinical record review, a review "Computerized Tomography Log, and staff interview, it was determined that in 1 of 1 closed record (Pt. #1) reviewed who required angiography, the Hospital failed to ensure documentation for the amount of contrast medium administered.

Findings include:

1. The clinical record for Pt. #1 was reviewed on 1/19/10 at approximately 11:00AM. Pt. #1, a 54 year old female, was admitted to the ED by Chicago Fire Department ambulance on 11/10/09 at 4:59PM with complaints of respiratory distress after in-advertently ingesting shellfish. The triage nurse assessed Pt. #1 at 5:04PM. The triage nurse documented, " Presented to ED with complaints of having an allergic reaction to shrimp. Pt. appears flushed. Dr (E #1) at bedside ... " The triage nurse listed an allergy to shellfish. Initial vital signs, documented at 5:04PM were: Temp 97.8, pulse 156, resp 24, B/P 99/67. The pulse ox was 92% on room air. Pt. #1 was listed as alert and oriented times 3. The physician (MD #1 ) ordered a Chest CT with infusion on 11/10/09.

2. A Computerized Tomography Log dated 11/10/09 at 8:35PM included documentation that Pt. #1 had a "chest" with "Visi" ( Visipaque iodixanol injection). The amount infused was not documented in the computer or on the log.

3. The Director of Diagnostic Imaging was interviewed on 1/21/09 at approximately 12:00PM. The Director stated that staff should document the amount administered in the computer.

4. The above finding was confirmed by the Director during an interview on 1/21/10 at approximately 1:00PM.