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The Condition of Participation for Quality Assessment and Performance Improvement Program was not met. Based on record review, observations and interviews the Hospital failed to review their internal incident report to identify opportunities for improvement, consider the incidence, prevalence, and severity of problems and implement changes that will lead to improvement.

Findings include:

Based on records reviewed, observations and interviews for two (Patient #1 & Patient #2) patients of 12 sampled patients, the Hospital failed to identify opportunities for improvement, implement changes that will lead to improvement, and thoroughly review two incidents involving: 1) an Anesthesiologist who administered paralytics (contraindicated) during Patient #1's procedure requiring facial nerve monitoring resulting in total right facial palsy and 2) an incident involving a Nurse who did not appropriately assess Patient #2's intravenous line insertion site resulting in compartment syndrome requiring emergency surgery.


Refer to TAG: A-0283

Based on records reviewed, observations and interviews for two (Patient #1 & Patient #2) patients of 12 sampled patients, the Hospital failed to identify opportunities for improvement, implement changes that will lead to improvement, and thoroughly review two incidents involving: 1) an Anesthesiologist who administered paralytics (contraindicated) during Patient #1's procedure requiring facial nerve monitoring resulting in total right facial palsy and 2) an incident involving a Nurse who did not appropriately assess Patient #2's intravenous line insertion site resulting in compartment syndrome requiring emergency surgery.

Findings include:

1. On 12/13/19, Patient #1 underwent a tumor dissection during a suboccipital microsurgical craniotomy under general anesthesia. Facial nerve monitoring is typically used throughout these cases to monitor facial nerve function during tumor dissection to prevent nerve damage. The need for monitoring the nerves was discussed prior to the surgery with the surgical team. Anesthesiologist #1 was providing anesthesia to Patient #1 and did not appreciate that the facial nerves would need to be monitored during the dissection and administered a paralytic agent (Rocuronium), which was contraindicated. The Surgeon performed the resection unaware that the patient was paralyzed. When Patient #1's surgeon discovered that Patient #1 was paralyzed he asked the Anesthesiologist to reverse the effects of the paralytic and discovered that Patient #1 had total right facial palsy.

On 2/11/20, the Hospital submitted a document titled Paralytic and Facial Nerve Palsy (no date) to the Surveyor. The document indicated that upon negative stimulation of Patient #1's facial nerves it was discovered that the paralytic was administered, although contraindicated, and Patient #1 sustained total right facial palsy. The document indicated that interventions would include a second time out prior to nerve stimulation, which will be documented by the neuromonitoring personnel and EPIC (Electronic Health Record) training to include special instructions to the Anesthesia dashboard.

During an interview on 2/18/20 at 8:30 A.M., the Anesthesia Quality Chair said that Anesthesiologist #1 was a senior resident and acknowledged that the surgeon involved discussed that there would be nerve monitoring during the resection. The Anesthesia Quality Chair said that Anesthesiologist #1 did not administer anesthesia as planned and gave the paralytic Rocuronium. The Anesthesia Quality Chair said that Anesthesiologist #1 did not realize the error until the surgeon asked if Patient #1 was paralyzed. The Anesthesia Quality Chair acknowledged that Anesthesiologist #1 paralyzed Patient #1 in error and that paralytics were contraindicated for this type of procedure. The Anesthesia Quality Chair said that the Hospital's intervention to use a second time out was still being discussed by Surgical Leadership and was not yet implemented. The Anesthesia Quality Chair said that the EPIC changes were scheduled to begin during the second quarter starting in April 2020. The Anesthesia Quality Chair acknowledged that no corrective actions were fully implemented by 2/11/20.

2. The Hospital procedure manual titled, Massachusetts General Hospital Nursing Procedure Manual, IV Therapy General, IV Therapy Overview (no date), indicated that the intravenous insertion site must be observed before, during and after intermittent IV administration. For continuous infusions the insertion site should be assessed, minimally, every four hours, and every two hours for those patients who are sedated or have cognitive deficits.

The Hospital's incident report dated 11/26/19, indicated that, on 11/20/19, Patient #2, a two month old, was admitted to the Pediatric Intensive Care Unit (PICU) after undergoing surgery for laparoscopic gastrostomy tube placement. Patient #2's right arm had intravenous (IV) fluid running through a venous catheter. Patient #2's right arm intravenous line was covered with a "Welcome Sleeve" (a protective sleeve that covers the IV site). During the evening shift, the patient became restless, agitated and uncomfortable, related to postoperative pain, hunger and attempted transition to a Bilevel Positive Airway Pressure (BiPAP) mask. Patient #2 was administered pain medication with no positive effect. On 11/21/19 at 12:30 A.M., Precedex (a sedative used for pain control) was administered through the IV via a continuous infusion to address Patient #2's agitation. At 7:45 A.M., Nurse #2 entered Patient #2's room at the start of her shift and noticed Patient #2's right hand was white and swollen. Nurse #2 then removed the "welcome sleeve" and assessed Patient #2's right hand and forearm and found both areas were swollen, discolored, and blistered. Plastic Surgery was consulted and Patient #2 underwent emergent surgical intervention for compartment syndrome.

During an interview on 2/12/20 at 8:24 A.M., the Nursing Director of the PICU and the Practice Specialist acknowledged that Nurse #1 did not remove Patient #2's "welcome sleeve" to assess the intravenous insertion site directly as indicated in the Nursing Procedure Manual. The Nursing Director said that Nurse #1 was focused on Patient #2's comfort and did not want to disturb the patient after he/she finally fell asleep and appeared comfortable. The Nursing Practice Specialist said that Nurse #1 incorrectly chose not to directly observe the IV site for several hours during her overnight shift. The Nursing Director said that Nurse #2, who started her shift on 11/21/19 at 7:00 A.M., entered Patient #2's room at 7:45 A.M. The Nursing Director said that Nurse #2 removed Patient #2's "Welcome Sleeve" and found Patient #2's right hand and forearm was swollen, discolored and blistered. Nurse #2 notified the physician and Patient #2 was brought to surgery for emergent fasciotomies (surgical procedure where the fascia is cut to relieve tension or pressure to treat the resulting loss of circulation to an area of tissue or muscle) of the right hand and forearm.

The Nursing Director said that as a result of this incident, the PICU staff were informed of the incident and the Hospital's IV policy was reviewed with the PICU staff. The information was communicated through staff meetings and morning huddles. The Nursing Director said that there was no documentation of this communication/policy review and that staff nurses did not attest to receiving this information. The other two pediatric departments (Elison 17 &18) have a total of 44 pediatric bed spaces did not review the policy or incident with their staff.

During an interview on 2/18/20 at 11:00 A.M., the Associate Chief of Patient Safety acknowledged that the Hospital's corrective measures for this event were not implemented in all pediatric departments that care for patients with IVs and use "Welcome Sleeves", were not documented or measured, and there were no efforts to track performance to ensure that improvements were sustained through all pediatric departments.