HospitalInspections.org

Based on review of hospital policy, medical record review, incident reports, and staff interviews, the hospital staff failed to report, analyze, and track adverse patient care incidents for 2 of 4 patients reviewed (#15, #13).

The findings include:

Review of the hospital policy, "Care Event Reporting" approved 07/21/2020, revealed, " ...expects its employees to complete a CARE Event for any occurrence which occurs in the facility or on its premises that is not consistent with routine patient care or operation of the facility that either did or could directly result in injury to a patient or visitor. DEFINITIONS A. Event: 1) is any unexpected or unintended incident/accident/occurrence relating to patients, or visitors .... PROCEDURE A. The person discovering, directly involved, or closest to the event should complete an online CARE Event Report within 24 hours ..."

1. Closed medical record review of Patient #15 revealed the patient was admitted to the hospital on 03/22/2021 at 1153 with chief complaints of stroke like symptoms and acute aphasia (loss of ability to understand or express speech). Review of Patient Status Rounding Comments dated 04/08/2021 at 2024 revealed, "pt (patient) son turning VPO (Virtual Patient Observer) to where they cannot see pt and trying to give her thin liquids, disegaurding (sic) her diet for thickened liquids. Worried for pt health" Review of Virtual Patient Observation Log dated 04/11/2021 at 1055 revealed, "family took mittens off patient ..." Review of Virtual Patient Observation Log dated 04/12/2021 at 1915 revealed, "family in room. Family removed mittens and restraints ..." Review of the Event - Notifications dated 04/13/2021 at 1313 revealed, "VPO (Virtual Patient Observer) called me to informed (sic) me that sister had removed the lap belt from the patient who is now in bed .... (Sister) refused to allow me to reapply it." Record review revealed Patient #15 was discharged on 04/24/2021 at 1618 to a skilled nursing facility.

Review of Incident Reports related to Patient #15 revealed one incident. Incident #1 was entered 04/11/2021 at 0657 and stated, "Date Occurred 04/11/2021 ... Time of Event: 0200 ... Pt was found twisted in bed covered in copious amounts of vomit. VPO was on but no one had been monitoring pt. When asked, VPO did not respond ..." Review of incident reports failed to reveal reports related to events on 04/08/2021 at 2024, 04/11/2021 at 1055, 04/12/2021 at 1915, or 04/13/2021 at 1313.

Interview on 06/16/2021 at 0940 with RN #32 revealed she provided nursing care for Patient #15 on multiple night shifts (1900 - 0700) throughout the entire hospital stay. Interview revealed that the family of Patient #15 often impeded the care of the patient and removed restraints. Interview revealed the son of Patient #15 removed the lap belt and used it to tie the patient ' s left arm down. Interview revealed the son of Patient #15 had removed the lap belt and took the patient out of bed without provider permission. Interview revealed no incident reports were completed.

Interview on 06/16/2021 at 1000 with RN #33 revealed she provided nursing care for Patient #15 on multiple day shifts. Interview revealed the family of Patient #15 removed the lap belt and refused to let staff reapply the restraint. Interview revealed no incident reports were completed.

Interview on 06/16/2021 at 1428 with the AVP (Assistant Vice President) #38 revealed the expectation of staff was to report events and incidents so that leadership can investigate and address safety concerns.

Interview on 06/16/2021 at 1505 with NM (Nurse Manager) #35 revealed the expectation of staff was to communicate care concerns with leadership and report events. Interview revealed NM#1 was made aware of multiple care incidents by various staff members, not via the incident reporting system.



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2. Review on 06/15/2021 of the medical record for Patient #13 revealed the 85-year-old male was admitted to the named hospital on 10/26/2020 for SOB (Shortness of Breath), chest and abdominal pain. Review of the H&P (History and Physical) electronically signed by MD (Medical Doctor) #1 on 10/26/2020 at 0408 revealed, "...Physical Exam...Extremities: Status post BLE [Bilateral Lower Extremity] AKA [Above Knee Amputation]. Neurologic: Awake, alert, and oriented x3..." Review of the Activities of Daily Living (ADL) Flowsheets between 10/26/2020 and 11/06/2020 revealed documentation that Patient #13 required "Maximum/Two-Person Assistance" for activity. Review of Physician Notifications revealed no documentation of an injury to Patient #13. Review of Physician Orders revealed a CT (Computed Tomography) Scan of the Head was ordered by MD #3 on 11/02/2020 at 1600 for "dizziness, head injury." Review of the Discharge Summary electronically signed by MD #2 on 11/06/2020 at 1020 revealed, "...CT Head...IMPRESSION...No CT findings of acute infarct, intracranial hemorrhage, or mass..." Review revealed Patient #13 was discharged home on 11/06/2020 at 1820.

Review of the hospital's Incident Report Log failed to reveal documentation of an incident involving Patient #13.

Interview on 06/16/2021 at 1324 with RN #7 revealed a recollection of being told (by family) that Patient #13 hit his head on the headboard while being pulled up in bed on the night of 11/01/2020. Interview revealed RN #7 did not complete an Incident Report related to the report by Patient #13's family.

Interview on 06/16/2021 at 1107 with NM (Nurse Manager) #11 revealed an expectation that patient injuries be reported to the NM and a Care Event (Incident Report) documented. NM #11 revealed no report of an injury to Patient #13 was made to her, nor was an incident report completed.

Interview on 06/17/2021 at 1032 with MD #3 revealed no documentation of a patient's injury was done. MD #3 stated that she did not typically document on patient events if subsequent test results were unremarkable (no significant findings) or no obvious injury was noted. Interview revealed MD #3 did not document being notified about Patient #13's head injury or details surrounding the event.

Based on review of hospital policies and procedures, medical record reviews, and staff interviews, the nursing staff failed to provide discharge instructions for a bile duct catheter in 1 of 1 patient charts reviewed. (Patient #12)

Findings included:

Review on 06/16/2021 of the hospital policy titled "Discharge" revised May 15, 2020 revealed "...Discharge planning aims to teach the patient and family or other caregivers about the patient's illness and its effect on the patient's lifestyle, provide instructions for home care,...activity instructions, and explain the purpose, adverse effects, and scheduling of ongoing ...required treatments. It can also include ...necessary follow-up care, and coordination of outpatient and home health care services...Implementation: Ask the patient, responsible family member, or caregiver to verbalize understanding of the discharge instructions. As the patient, responsible family member, or caregiver to sign the discharge instruction sheet, attesting to receipt of the information...Document the procedure...Whenever possible, involve the patient's family or caregivers in discharge planning so that they can better understand and perform patient care procedures...Patient Teaching: should provide the patient and the family or caregiver with the knowledge and skills they need to manage the patient's health care needs after discharge...Discharge teaching should aim to ensure that the patient: understands the illness...understands ordered treatments...knows about possible complications, and knows when and where to seek follow-up care...Remember that discharge teaching should include the patient's family members and other caregivers to ensure that the patient receives proper home care...documentation typically includes the time and date of discharge;...the devices that remain in the patient;...family members and caregivers present for teaching; details of instructions the health care team gave to the patient, including...treatments...signs and symptoms to report to the practitioner; and the date and time of follow-up appointments.

Closed medical record review on 06/15/2021 for Patient #12 revealed a 58-year-old female patient admitted 01/05/2021 at 0310 for abdominal pain. Review of the History and Physical dated 01/05/2021 at 0610 by Medical Doctor (MD) #17 revealed "...complex past medical and surgical history including chronic pancreatitis (inflammation of the pancreas) with exocrine pancreatic insufficiency (the pancreas doesn't produce enough digestive enzymes, the body cannot break down food into nutrients), diabetes (high blood sugar), and hypothyroidism (the thyroid gland does not produce enough thyroid hormone) now s/p (status post) robotic Whipple's (sic) procedure (surgical removal of the head of the pancreas, part of the small intestines, gallbladder and bile duct) on 06/25/2020 by (named) MD #18 (of note patient is deaf and requires a see through mask in order to read lips). Her husband serves as a mediator for the bulk of our discussion...Given concern for contained perforation versus ulceration in the vicinity of her gastrojejunal anastomosis (surgical connection between the stomach and reconstructed middle part of the intestine), patient will be admitted for close monitoring, fluid resuscitation, antibiotics with plans to further evaluate this area. Review of the Consent for Procedure for 01/08/2021 at 0750 by MD #19 revealed Patient #12 underwent "Percutaneous transhepatic cholangiogram with biliary drain placement ((through the skin imaging study and drain placement into the liver bile duct)." Review of the Physician Orders for 01/09/2021 diagnosis/active revealed: biliary (relating to the bile duct) anastomotic stricture (narrowing resulting from previous surgery). Review of the Consent for Procedure or Operation dated 01/12/2021at 0735 for Patient #12 by Surgeon, MD #19 revealed she had a "Biliary Catheter Upsize procedure." Review of the Physician Progress Note for 01/12/2021 at 0934 by Nurse Practitioner (NP) #21 revealed, "...Patient is having pain at drain site when seen this morning after catheter upsize. Catheter was flushed with sterile normal saline and sediment was seen with flushing. Pain improved after flushing and evacuation of sediment. No nausea, vomiting, fever, or chills...Impression and Plan:...flushing biliary catheter TID (three times a day) with sterile normal saline, will keep to gravity until pain improves..." Review of the Discharge Summary dated 01/16/2021 at 0851 by MD #20 revealed "Discharge diagnosis of Jejunal (middle part of the small intestine) ulcer,...Procedures: PTC (percutaneous transhepatic cholangiography) placement, PEG (percutaneous endoscopic gastrostomy) tube. Drains/Devices/Lines in place at D/C (discharge): PEG, Biliary Catheter...admitted on 01/05/2021 with concern for ulcer vs contained perforation ...Has no longer been needing IV pain medications. Is appropriate for discharge. Discharge Condition: Improved and Stable. Disposition: Home. Activity/Instructions: Discharge instructions have been given in detail and explained to the patient at length; including but not limited to: instructions for activity, bathing, incision/wound care, concerning signs/symptoms for which the patient should be evaluated ahead of their scheduled follow-up,..." Review of the Patient Summary Discharge Instructions for 01/16/2021 at 1539 by Registered Nurse (RN) #22 revealed there were no home care bile duct catheter care instructions for Patient #12. Review on 06/17/2021 of the nursing Education Teaching Record and Nursing documentation from 01/08/2021 through 01/16/2021 revealed no documentation of patient teaching, no documentation of how to care for a bile duct catheter at home, nor return demonstration of biliary duct catheter care given to Patient #12.

Interview on 06/17/2021 at 1210 with Patient #12's discharge nurse, RN #22 revealed, that biliary catheter care was something expected to be done daily. Interview revealed "I can't say that I chart those instructions, it's just the standard of care for teaching, I don't always document it." Interview revealed when RN #8 was asked, if teaching and discharge instructions should be charted, she replied "yeah, probably." Interview confirmed discharge teaching and instructions for care of the bile duct catheter for Patient #12 were not documented. Interview confirmed hospital policy for discharge care was not followed.

Interview on 06/17/2021 at 1430 with Vice President of Nursing, RN #23 revealed "the expectation if discharge teaching should be given (sic) was to document it in the education teaching record. I would think a return demonstration of the patient performing the task to ensure understanding was done (sic). If the patient cannot talk, you would need to ensure the patient was capable and had the knowledge needed for catheter care at home." Interview revealed discharge teaching and instructions were to be documented in the medical record. Interview revealed that Patient #12's discharge teaching and instructions for biliary catheter care was not documented and policy was not followed.

Based on review of the hospital policies and procedures, medical record reviews, and staff interviews, the hospital staff failed to include a patient's legal guardian with coordination of discharge plans, and facility choice for 1 of 4 discharged patients reviewed (#1).

Findings include:

Review on 06/16/2021 of the hospital policy titled "CONSENT FOR TREATMENT" with a revision date of 08/2018 revealed "... G. In the event the patient is unavailable to give any consent (i.e., unconscious or lacks decisional or physical capacity to make and communicate health care decisions) then the following people in the following order can give informed consent on behalf of the patient: 1. Health Care Agent pursuant to a Health Care Power of Attorney (unless a Guardian has been appointed and the court has issued a specific order suspending the Health Care Agent's authority, in which case the Guardian is in first position) 2. Legal Guardian (if no order suspending health Care Agent's authority) ... All efforts to locate authorized representatives should be documented in the medical record ..."

Review on 06/15/2021 of the closed medical record for Patient #1 revealed a 24-year-old male admitted to the hospital on 11/24/2020 at 0217 with a diagnosis of COVID-19. Review of the History and Physical note dated 11/24/2020 at 0206 revealed "Contact Info (information): Prior 11/18/2020 SNF (skilled nursing facility) note patient is a ward of the state. Guardian is (Name #1)..." Review revealed Patient #1 had a past medical history significant for "MVA (motor vehicle accident) resulting in TBI (traumatic brain injury) and quadriplegia (paralysis of all four limbs) status post trach (tracheostomy - hole in windpipe to help you breathe with a tube that leads into your lungs)/PEG (percutaneous endoscopic gastrostomy - a flexible feeding tube placed through the abdominal wall and into the stomach)/chronic indwelling Foley (catheter used to manage urinary retention) ... " Review of the CM (case manager) Narrative Note dated 11/24/2020 at 1604 revealed "Was unable to reach DSS (Department of Social Services) guardian [Name #2] (left VM [voice message] (Name #1) from H&P (history and physical) (no ph# [phone number]). (Name #3) from last admission is no longer patient guardian. Chart review/info from previous admission ..." Review of the CM Narrative Note dated 11/27/2020 at 1438 revealed "From (Facility Name #1) SNF but will need to go to (Facility Name #2) d/t (due to) Covid status. Left VM with legal guardian, (Name #2) (telephone number). Not medically ready, still with hematuria." Review of the CM Narrative Note dated 11/30/2021 at 1227 revealed "Dispo (disposition): (Facility Name #2) SNF when medically ready. Unable to return to (Facility Name #1) until 21 days past first Covid test. Hematuria has resolved, but with low grade fever overnight." Review of the CM Narrative Note dated 12/02/2020 at 1125 revealed "Covid positive on 11/22, will be 21 days out on 12/13. Will need to DC (discharge) to (Facility #2). If ready before then, but can return to (Facility #1) if discharged after 12/13. Remains on 7L (liters) through trach collar, baseline is 3L." Review of the CM Narrative Note dated 12/04/2020 at 1331 revealed "Dispo: Return to (Facility Name #2) SNF vs (Facility Name #1) if patient remains admitted after 12/13. Oxygen requirements went up to 8L with T-Collar, baseline is 3L. (Name #1) (telephone number) is Legal Guardian. Update: DC sunday (sic) at 3PM via medic at (Facility Name #2). Left VM with legal guardian." Review of the CM Narrative Note dated 12/06/2020 at 1545 revealed "Did not dc today; per facility request, will dc tomorrow so resp (respiratory) therapy at facility can have trach supplies prepared. Confusion over VS (vital signs) flowsheet documentation - appears as though patient is on 8L O2 (oxygen) via trach collar. He is actually on no supplemental O2 but his trach collar humidifier is set to 8L/min (8L per minute) for thickened secretion. New medic transport time is Monday at 12pm." Review of the CM Narrative Note dated 12/07/2020 at 1013 revealed "Update: Discharge cancelled for today d/t facility's nurses needing more education on trach care. Delayed for now." Review of the CM Narrative Note dated 12/09/2020 at 1353 revealed DC tomorrow to (Facility Name #2) SNF via medic at 1pm." Review of the Discharge Planning Follow-Up dated 12/10/2020 at 1100 revealed "Anticipated Discharge Date: 12/10/2020 EST (eastern standard time) ... Discharge To/Transition To: Skilled Nursing Facility (resume facility) ... Ability to Obtain Medications Confirmed: Yes. Patient Preference List Offered for Home Health Services: NA (not applicable). Patient Preference List/Bed Offers Provided for Skilled Nursing Facilities: Resumption. CCM DCP Brochure: No. Reason DCP Brochure not Discussed: AMS/Confusion. TOC Model Recommendation: Home health ... Personal and Support Reasons: Current resident of discharge facility." Review of the CM Narrative Note dated 12/10/2020 at 1100 revealed "DC today to (Facility Name #2) via medic @ (at) 1pm. Number for report provided to bedside RN (Registered Nurse). DC summary and Golden Rod in DC packet. Left VM with EC/Legal Guardian (telephone number)." Review revealed Patient #1 was discharged to (Facility Name #2) on 12/10/2020 at 1330.

Interview on 06/15/2021 at 1403 with a Clinical Case Manager (CM) revealed she remembered Patient #1. Interview revealed the CM tried to contact the legal guardian (Name ) whose name she found in the medical record from a previous visit. Interview revealed the legal guardian "(Name) stated she no longer wanted to have anything to do with the patient." Interview revealed the CM found another name listed in the medical record as the legal guardian. Interview revealed the CM left a voice message for this person regarding Patient #1 being in the hospital and to his care as it was a confidential voice mail. Interview revealed the CM searched the inpatient, outpatient visits, the care connect notes and the "entire medical record" to identify who the legal guardian was. Interview revealed the CM did not receive a telephone call back from (Name) after leaving the voicemail. Interview revealed there were multiple voicemails (4) left for (Name) identified in a previous visit as the legal guardian. Interview revealed the CM did not escalate the attempt to (Name's) supervisor nor was an attempt made to clarify/identify who Patient #1's legal guardian was.

Interview on 06/15/2021 at 1425 with a Social Worker (SW) revealed she remembered Patient #1. Interview revealed Patient #1 came from (Named Facility) however due to having COVID, Patient #1 could not return to (Named Facility) till after 21 days from his positive test. Interview revealed Patient #1 was medically ready for discharge and there were only three facilities in the area that would take a COVID positive patient. Interview revealed staff tried to reach the legal guardian (Name), multiple times and left voice messages each time with no return telephone call. Interview revealed the normal practice would have been to contact the supervisor for (Name) . Interview revealed the "reasons" this did not take place was the facility was "double bunking patients", the facility "needed the beds", and the SW had a "double case load as she was covering another unit also." Interview revealed Patient #1 went to a sister facility of the facility where he was a long-term resident of. Interview revealed the SW did not discuss the discharge plan with the legal guardian nor did the legal guardian get to participate in the discharge plan or selection of facility to discharge to.

Interview on 06/16/2021 at 0940 with the Director of Case Management revealed the complainant was listed as the legal guardian in the H&P dated 11/24/2020, and in a Care Alignment Tool note dated 11/14/2021 (previous hospitalization). Interview revealed complainant also listed as the Emergency contact for Patient #1 in the medical record. Interview revealed the expectation would have been when not getting a return telephone call, the staff should have either escalated and called the person they were calling's supervisor or if it was her she would have reached out to the facility where he came in from to identify who the legal guardian was and get a contact number.

NC00173066, NC 00173179, NC00171620, NC00175802, NC00178119, NC00173855, NC00176392, NC00175650, NC00175005