HospitalInspections.org

Based on record review and interview, facility staff failed to assess and treat post-operative complications for 1 of 2 post-operative patients (Patient #1) admitted for a higher level of care in a total sample of 10 patients reviewed.

Findings:

Medical staff failed to consult Infectious Disease and Surgery and failed to address changes in a patient's condition. See Tag 0347.

Based on record review and interview the facility staff failed to immediately report an allegation of caregiver abuse/misconduct in 1 of 1 staff-witnessed caregiver misconduct allegations (Patient #1) in a total sample of 4 caregiver misconduct allegations reviewed.

Findings include:

A review of facility policy #16215889 titled, "Reporting and Investigating Caregiver Misconduct Policy & Procedure" last revised 12/2024 revealed, "...The immediate reporting of alleged or actual mistreatment, neglect, or abuse to any patient, is essential to ensure the highest quality of patient care and safety...Any employee witnessing alleged or actual misconduct is required to report this occurrence immediately to leader or supervising authority."

A review of Patient #1's medical record revealed Patient #1 is a 78-year old female who was seen at the facility on 2/7/2025 for an aortic valve replacement for a diagnosis of Aortic root dilation and severe aortic stenosis. The surgery was conducted under general anesthesia with Anesthesiologist V. OR RN (Operating Room Registered Nurse) Z was the circulating RN in the OR room with Patient #1 for this case.

During an interview on 04/08/2025 at 9:57 AM with Surgical Services Director H, she stated that if staff witness any sort of abuse or misconduct, they are to report it immediately. When asked about this specific reported allegation and who was involved, Surgical Services Director H stated OR RN Z alleged that ST (Surgical Technician) Y inquired if Patient #1 had breast implants, then witnessed ST Y poke Patient #1's left breast while the patient was under general anesthesia. Surgical Services Director H stated that the incident happened in the afternoon of 2/7/2025 and was reported to her the following Wednesday (2/12/2025) by OR RN Z. She stated that OR RN Z told her she was overwhelmed, and it was the weekend, so she did not report it right away.

During an interview on 04/08/2025 at 1:35 PM, OR RN Z stated that she was the circulating nurse in the OR the day of the allegation (2/7/2025) with Patient #1. OR RN Z stated that she had just completed the surgical prep and was holding Patient #1's legs and ST Y kept bringing up if Patient #1's breasts were fake. ST Y then took his sterile hand and poked Patient #1's left breast. OR RN Z stated she went to OR Supervisor AA in the afternoon on 2/11/2025 to report this. When asked why there was a delay in reporting, OR RN Z stated that it was late in the day on a Friday and OR Supervisor AA was not in that day. She also stated that it had been an "internal struggle", and she was questioning, "Did I see what I actually saw" because this was out of character for ST Y. She stated she should have reported it the day it happened.

During an interview on 04/08/2025 at 2:00 PM, Surgical Assist N stated she witnessed ST Y "poke" Patient #1's left breast, but did not report it because it was such a busy day and she was only in the room for draping and left. Surgical Assist N stated this should have been reported to OR Supervisor AA or OR Manager BB as soon as witnessed or shortly after.

Based on record review and interview medical staff failed to consult infectious disease and surgery, and failed to address changes in patient condition for 1 of 2 post-operative patients admitted for a higher level of care (Patient #1) in a total sample of 10 patients reviewed.

Findings:

Patient (Pt.) #1 was admitted to the facility (Facility B) on 08/24/2024 after having a splenectomy (removal of spleen) on 08/21/2024 at Facility A. Pt. #1 had a history of Chronic (long term) Lymphocytic Leukemia (blood cancer) (CLL), heart enlargement, pacemaker, high blood pressure and high cholesterol. On 08/26/2024 Pt. #1 had exploratory surgery after developing post operative complications while hospitalized at Facility B. Pt. #1 expired on 08/27/2024.

Review of Facility document last revised 04/04/2024, "[Name] General Surgery," revealed, "A location that has general surgery...surgeon should evaluate patient prior to transfer request. The general surgeon and accepting surgeon should be connected."

Review of Pt. #1's medical record revealed Pt. #1 required a higher level of care for abdominal pain, rapid heart rate and rapid breathing. Pt. #1 was admitted to the Cardiac Telemetry Unit at Facility B with a diagnosis of sepsis secondary to a left lower lobe pneumonia (lung infection) on 08/24/2025 (post-operative day 3) under hospitalist and cardiology services without a consult to surgical services or infectious disease service.

Review of Pt. #1's MD (Medical Doctor) Admission note on 08/24/2024 at 2:13 PM completed by Hospitalist JJ revealed, "Assessment: 66-year-old...with history of CLL ...experienced traumatic splenic rupture and is now status post splenectomy. Following the procedure, he was demonstrating signs of infection through no obvious source has been identified. It is possible fluid collection in the splenic fossa (space formed after a spleen is removed) is the source of infection. In addition, the patient has developed a postop ileus (bowel stops working). Plan...CT (Computerized Tomography) scan did not show any obvious source of infection. Ascites (fluid) and air are filling the remaining splenic fossa...discussed with General surgery from [Transferring Hospital] who performed the splenectomy. There was no obvious purulence (cloudy fluid), infection, and no known injury to the bowel...plan to discuss with infectious diseases tomorrow if signs of infection not improving, we will also discuss with General Surgery here."

Review of 08/25/2024, 11:01 AM MD JJ's Progress Note revealed, "No acute events overnight. Patient did not have any further fevers. Today, he states his abdomen still feels bloated. He was passing flatus (air) but has not had a bowel movement. Vitals: Blood pressure (!) 147/76, pulse 117, temperature 98.8 degrees F (Fahrenheit), resp. (respiratory) rate 18...Abdomen: Firm, moderately distended. Bowel sounds are nearly absent...I personally reviewed the patient's CT abdomen/pelvis which shows an air/fluid collection filling the cavity left by the splenectomy. No obvious abscess."

Review of Pt. #1's medical record revealed there was no evidence of Infectious Disease or surgical involvement with Pt. #1 until 8/26/2024, when another CT scan was completed. A paracentesis (removal of fluid from the abdomen) was performed with removal of feculent (stool) fluid. Surgery was then consulted and Pt. #1 was taken back to the operating room for an urgent exploratory laparotomy on 08/26/2024 to repair a gastric (stomach) perforation (hole) and abdominal washout. Following surgery Pt. #1 was taken to the ICU with life-threatening complications of acute respiratory failure, requiring ventilator support, life threatening blood pressure instability requiring multiple medications to maintain blood pressure, renal (kidney) failure, and required multiple blood transfusions due to internal bleeding. Pt. #1 expired on 08/27/2024 at 2:12 PM.

On 04/09/2025 at 10:00 AM during an interview with Doctor KK, who is responsible for the transfer process of patients and hospitalists within the system facilities, Doctor KK stated, "Initially the patient was on a wait list, there was no peer to peer conversation. In the notes there is no documentation of a verbal handoff." When asked what should have happened when Pt. #1 was transferred from Facility A to Facility B, Doctor KK stated, "There should have been a consult with the surgeon... and that didn't occur. There was a breakdown in communication, no peer to peer was completed, no verbal handoff was done, it was like Swiss cheese. There was no call to Infectious Disease because, it was thought they were all ready aware. No consult was done until Monday."

On 04/09/2025 at 12:05 PM in an interview with Infectious Disease Doctor LL, LL stated he saw Patient #1 next on Monday and that Patient #1 "looked ill" and his condition wasn't recognized over the weekend. Per LL, "I consulted Interventional Radiology in the morning and ordered a paracentesis (removal of fluid from the abdomen) and thoracentesis (removal of fluid from the lung), he couldn't tolerate the thoracentesis, and the paracentesis results were feculent and he had a perforation. I talked to surgery right after. The vital signs, belly distention wasn't recognized, he was overly anesthetized because of his history of CLL and on transfer it was thought he had a problem with the pacemaker." When asked if a surgeon to surgeon consult was occurring now, LL said, "Not always."

On 04/09/2025 at 1:12 PM in an interview with Vice President of System/Senior Medical Doctor MM, when asked what has been done to improve the transfer process of surgical patients, Doctor MM said, "We evaluated the mechanisms and are working on an algorithm, to include surgery in the transfer process." When asked if this had been implemented, MM said it is being implemented, consistency isn't in place. We have a monitoring plan for transfer and audits and to evaluate at 30-60-90 days." When asked what the audit results have showed as a result of the education provided, MM stated, "Right now education has been disseminated by word of mouth and we aren't to the point of auditing." When asked if all of the hospitalists that are involved in the transfer/admission process have been educated on the expectation of surgeon to surgeon consult when transferring a surgical patient, MM said, "I cannot." When asked Doctor MM if it was fair to say that this type of incident could happen again, MM stated, "Yes it is fair to say that it could."

On 04/09/2025 at 2:50 PM in an interview with Surgeon II when asked how could what happened with Pt. #1 have been prevented, II stated, "There should be a better mechanism to notify us." When asked if there was a process for notifying surgeons when a surgical patient is being transferred to the facility, II stated, "I don't know if there is a definite process but there should be. I first heard about this on Monday from [Dr. LL] and was asked if I could see him. After looking at the images there was a massive amount of fluid, more than expected as a normal post op. Gastric perforation is a known complication of splenectomy and when I did surgery, I removed well over a liter of gastric contents and the perforation was 2 cm long. He was septic and had no clotting ability after surgery and was bleeding from a lack of clotting, not from the surgery. When the CT scan was completed, he should have gone back to surgery immediately and not 48 hours after the CT was done." When asked how this could have been prevented II stated, "Medical staff should have let surgery know and the same with radiology."