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Based on record review and interview, the facility failed to ensure it's QAPI (Quality Assessment and Performance Improvement) program investigation and review of a 11/26/18 patient grievance identified opportunities of improvement, in that,

the investigation did not identify:

1) Missing medical record documentation for Patient #1 including:
missing pre and post procedure orders, post sedation assessment, immediate post-op note, post operative nursing care, and care plan update for a behavioral issue.

2) Missing incident report for Patient #1's behavioral issue.

Findings included

The 11/26/18 Patient #1 complaint record reflected, "meeting with staff...case discussed...all nursing care was found appropriate..."

Patient #1's record did not contain complete pre-procedure orders. The faxed-in, pre-procedure order sheets did not contain time, date, and physician signature.

The nurse did not document a nurse call to verify orders and secure a telephone order prior to Patient #1's care.

Pre-operative care provided by the nurse without an order included laboratory work, intravenous (IV) catheter insertion, pre-operative IV medications.

Patient #1 had moderate sedation administered by a registered nurse during their procedure without a post sedation physician assessment documented.

Patient #1 had no immediate post-operative note by the physician available to post-op caregivers.

There was no nurse documentation for Patient #1's unexpected events including the behavioral issues of the patient pre and post procedure, the sheath removal, precautions taken for risk of bleeding with the patient being resistant to medical care and direction post sheath removal.

Patient #1 was discharged after their procedure without a discharge order from the physician.

Patient #1's Cardiac Cath Report reflected, "extreme precaution in managing her groin site due to prior history of pseudo-aneurysm. The patient threatened to leave the hospital right after the Cath today and she therefore had to be sedated for groin management to reduce the risk of major bleeding and death..."

There was no documented incident report for Patient #1's unexpected events/behavior that occurred.

During an interview and record review on 1/23/19 ending at 12:02 PM, Personnel #3 discussed multiple behavior issues of the patient prior to and post procedure including hitting the husband, and staff members which utilized multiple staff to contain. Personnel #3 discussed conversation with Personnel #6 during the complaint investigation. Personnel #3 was asked about pre and post operative orders. Personnel #3 reviewed the orders and stated, "I should have called to verify orders." Personnel #3 was informed there was no updated care plan for the behavioral issues. Personnel #3 stated, "No." Personnel #3 was asked if an incident report was completed. Personnel #3 stated, "No."

The December 2018 "Interventional Care Center" policy required, "establish an approved scoring guideline/discharge criteria for patients receiving outpatient anesthesia and conscious sedation, in order to assess the patient's readiness for discharge...the physician will order the discharge...the patient must have a total score of 18 before discharge...discharge criteria score...Modified Post-Anesthesia Recover (PAR) Score for Ambulatory Patients..."

Based on record review and interview, the facility failed to ensure clear expectations for safety were enforced/an incident report and follow-up investigation was completed for 1 of 11 (Patient #1) procedure patients.

Findings included

Patient #1's Cardiac Cath Report reflected, "extreme precaution in managing her groin site due to prior history of pseudo-aneurysm. The patient threatened to leave the hospital right after the Cath today and she therefore had to be sedated for groin management to reduce the risk of major bleeding and death..."

There was no documented incident report for Patient#1's unexpected events that occurred for follow-up.

During an interview and record review, Personnel #3 discussed multiple behavior issues of the patient prior to and post procedure which utilized multiple staff to contain. Personnel #3 was asked if an incident report was completed. Personnel #3 stated, "No."

The July 2017 "Incident Reporting" policy required, "identify patient safety and risk events...minimize injury...ensure adequate documentation...not consistent with routine care of the patient...unsafe/disruptive behaviors...at the time of discovery...patient injury...any adverse effect...security incident...alters the current treatment plan..."

Based on record review and interview, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient, in that,

A)
3 of 11 patients (Patient #1, #6, and #11) did not have pre-procedure (Cardiac Cath) orders prior to being cared for by the nurses;

B)
3 of 11 patients (Patient #1, #7, and #10) did not have post-procedure orders including discharge after the procedure was completed; and

C)
4 of 11 (Patient #1, #3, #5, and #7) patients did not have post-op nurse documentation to reflect their post op care and outcomes.

Findings included

A)
Patient #1's, #6's, and #11's record did not contain complete pre-procedure orders. The faxed-in, pre-procedure order sheets did not contain time, date, and physician signature.

The nurse did not document a nurse call to verify orders and secure a telephone order prior to care. Pre-operative care provided by the nurse without an order included laboratory work, intravenous (IV) catheter insertion, pre-operative IV medications.

During a telephone interview and record review on 1/25/19 from 7:30 AM to 9:56 AM, Personnel #2 reviewed the records and confirmed the findings.

B)
Patient #1, #7, and #10 were discharged after their procedure without a discharge order from the physician. There was no Modified Post-Anesthesia Recover (PAR) Score for Ambulatory Patients documented post operatively to determine readiness for discharge.

During a telephone interview and record review on 1/25/19 from 7:30 AM to 9:56 AM, Personnel #2 reviewed the records and confirmed the findings.

The December 2018 "Interventional Care Center" policy required, "establish an approved scoring guideline/discharge criteria for patients receiving outpatient anesthesia and conscious sedation, in order to assess the patient's readiness for discharge...the physician will order the discharge...the patient must have a total score of 18 before discharge...discharge criteria score...Modified Post-Anesthesia Recover (PAR) Score for Ambulatory Patients..."

The 8/26/15 "Medical Staff Rules and Regulations" required, "routine orders...dated, timed, and signed by the practitioner..."

C)
There was no nurse documentation for Patient #1's unexpected events including the behavioral issues of the patient pre and post procedure, the sheath removal, subsequent hematoma size, precautions taken for risk of bleeding with the patient being resistant to medical care and instructions post sheath removal.

Patient #1's Cardiac Cath Report reflected, "extreme precaution in managing her groin site due to prior history of pseudo-aneurysm. The patient threatened to leave the hospital right after the Cath today and she therefore had to be sedated for groin management to reduce the risk of major bleeding and death..."

During an interview and record review, Personnel #3 discussed multiple behavior issues of the patient prior to and post procedure which utilized multiple staff to contain. Personnel #3 was informed there was no documentation that reflected the verbal account of what occurred. Personnel #3 stated, "No. I didn't document it. I didn't want that to follow her around in her medical record."

Patient #3, #5, and #7 record did not reflect post-op nurse documentation including post-procedure vital signs, level of consciousness, oxygen saturations, dressing/site, pain, and activity/ambulation status.

During a telephone interview and record review on 1/25/19 from 7:30 AM to 9:56 AM, Personnel #2 reviewed the records and confirmed the findings.

Based on record review and interview, the facility failed to ensure:

A.) an updated care plan to reflect the care and outcome for 1 of 11 (Patient #1) procedure patients; and

B.) a post procedure care plan for 1 of 11 (Patient #7) procedure patients.

Findings included

A.) Patient #1's Cardiac Cath Report reflected, "extreme precaution in managing her groin site due to prior history of pseudo-aneurysm. The patient threatened to leave the hospital right after the Cath today and she therefore had to be sedated for groin management to reduce the risk of major bleeding and death ..."

There was no nurse documentation for Patient #1's unexpected events including the behavioral issues of the patient pre and post procedure, the sheath removal, precautions taken for risk of bleeding with the patient being resistant to medical care and direction post sheath removal.

During an interview and record review, Personnel #3 discussed multiple behavior issues of the patient prior to and post procedure including hitting the husband, and staff members which utilized multiple staff to contain. Personnel #3 was informed there was updated care plan for the behavioral issues. Personnel #3 stated, "No."

B.) Patient #7 record did not reflect post-op nurse documentation including a post-op care plan.

During a telephone interview and record review on 1/25/19 from 7:30 AM to 9:56 AM, Personnel #2 reviewed the record and confirmed the finding.

Based on record review and interview, the facility failed to ensure adequate provisions for immediate postoperative care, in that,

A)
7 of 11 post-op patients (Patient #1, #4, #5, #6, #8, #9, and #10) did not have available to post-op caregivers an immediate post-operative note by the physician; and

B)
3 of 11 post-op patients (Patient #1, #7, and #10) did not have Post-procedure orders including discharge after the procedure was completed.

Findings included

A)
Patient #1, #4, #5, #6, #8, #9, and #10 all had procedures with no immediate post-operative note by the physician available to post-op caregivers.

During a telephone interview and record review on 1/25/19 from 7:30 AM to 9:56 AM, Personnel #2 reviewed the records and confirmed the findings.

The 8/26/15 "Medical Staff Rules and Regulations" required, "Operative reports...procedures...must be dictated or electronically documented immediately following the procedure. If the report is dictated, a timed operative progress note shall be completed to provide all caregivers information about the procedure until the transcribed report is placed in the record...physicians who fail to complete operative reports in a timely manner will have admitting privileges suspended..."



B)
Patient #1, #7, and #10 were discharged after their procedure without a discharge order from the physician.

During a telephone interview and record review on 1/25/19 from 7:30 AM to 9:56 AM, Personnel #2 reviewed the records and confirmed the findings.

The December 2018 "Interventional Care Center" policy required, "establish an approved scoring guideline/discharge criteria for patients receiving outpatient anesthesia and conscious sedation, in order to assess the patient's readiness for discharge...the physician will order the discharge...the patient must have a total score of 18 before discharge...discharge criteria score...Modified Post-Anesthesia Recover (PAR) Score for Ambulatory Patients..."

The 8/26/15 "Medical Staff Rules and Regulations" required, "routine orders...dated, timed, and signed by the practitioner..."

Based on record review and interview, the facility failed to ensure

a physician operative/procedure report for 1 of 11 patients (Patient #10) after their procedure.

Findings included

Patient #10 did not have a physician operative/procedure report after their procedure.

During a telephone interview and record review on 1/25/19 from 7:30 AM to 9:56 AM, Personnel #2 reviewed the records and confirmed the findings.

The 8/26/15 "Medical Staff Rules and Regulations" required, "Operative reports...procedures...must be dictated or electronically documented immediately following the procedure...physicians who fail to complete operative reports in a timely manner will have admitting privileges suspended..."

Based on record review and interview, the facility failed to ensure post sedation physician assessment for

8 of 11 patients (Patient #1, #3, #4, #5, #6, #7, #8, and #9) that received moderate sedation by a registered nurse during their procedure.

Findings included

Patient #1, #3, #4, #5, #6, #7, #8, and #9 had moderate sedation administered by a registered nurse during their procedure without a post sedation physician assessment documented.

During a telephone interview and record review on 1/25/19 from 7:30 AM to 9:56 AM, Personnel #2 reviewed the records and confirmed the findings.

The 8/26/15 "Medical Staff Rules and Regulations" required, "...accurately dated, timed, and authenticated by the prescribing practitioner...the cardiologist is responsible for documenting a post-anesthesia/sedation note for all patients who receive sedation...include the presence or absence of anesthesia related complications, vital signs, level of consciousness; medications...discharge from the post sedation care area...the name of the practitioner responsible for discharge...note must be written before the patient is discharged..."