HospitalInspections.org

Based on medical record review and staff interview, in one (1) of 18 medical records reviewed, it was determined the doctors failed to document their assessments and interventions in the medical record when there was a change in the patient's condition and a rapid response team (RRT) (#1) was called. This was evident in Medical Record #1.

Findings include:

Review of MR # 1 identified: This 85-year-old patient arrived in the Emergency Department (ED) on 4/16/23 at 4:13 PM with a complaint of shortness of breath and chest pain for two (2) days, despite being on oxygen 4 Liters via nasal cannula (NC) at home. The patient also had "worsening bilateral lower extremity edema." The patient's previous medical history was significant for Coronary Artery Disease, Chronic Congestive Heart Failure, Hypertension, Pulmonary Hypertension, Chronic Obstructive Pulmonary Disease, Deep Vein Thrombosis, Major Depression and Dementia. At 5:03 PM on 4/16/23, the RN documented that the patient was alert and oriented to person, place, and time and that there was bilateral leg edema. The patient had a steady gait, was obese and ill-appearing. The patient's oxygen saturation was 72% on room air in the ED, but it increased to 100% when she was placed on 5L of oxygen via NC (nasal cannula; a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help), and she was not in acute distress at that time.

On 4/17/23 at 3:28 PM, the patient was admitted to the telemetry unit with diagnoses of Acute on Chronic Congestive Heart Failure and Cellulitis of her lower extremities. Treatment included administration of Lasix and antibiotics. On 4/18/23 nursing documentation revealed the patient was alert and oriented x 4 and the patient was not in acute distress on 4L of oxygen via nasal cannula, at 2:17 AM that day.

On 4/19/23, the patient was on the medical surgical unit and her condition was stable according to the nurses and doctors' documentation.

On 4/21/23 at 8:00 AM, the nurse documented the patient's vital signs were temperature 99.4 F, pulse 57, respiration 19, B/P 125/65 and oxygen saturation was 95%, all of which were within normal limits.
On 4/21/23 at 10:44 AM, a caseworker documented this case was discussed during the interdisciplinary rounds with the resident who reported the patient will be medically cleared for discharge tomorrow.
On 4/21/23 at 1:46 PM, two doctors documented that they "saw and examined" the patient. The treatment "plan was to continue current treatment. Treat chronic condition." The discharge summary was completed. The patient's "discharge condition was baseline." The patient was to be discharged home with physical therapy and follow-up with her primary care doctor.

On 4/21/23 at 2:42 PM, the patient's nurse, Staff A, RN, documented that the patient's son called her to the room to check on his mother. "Upon assessment patient found unresponsive and disconnected from oxygen and turning blue. Patient was placed on non-Rebreather mask (NRB) and a rapid response team (RRT) (#1) was called. (A non-rebreather mask is a special medical device that helps provide oxygen in emergencies). Rapid response cancelled after patient started responding with SP02 (oxygen saturation), 100 NRB mask. Patient was placed on continuous oxygen monitoring."

On 4/21/23 at 3:42 PM, Staff A, RN, documented, "Patient son reported that patient's SP02 was low. Patient was found to be unresponsive with SP02 81 on NRB. Rapid response (#2) called, patient was observed pulseless. CPR begun. Pacemaker was initiated at 2:54 PM per protocol. At 3:11 PM pulse felt, and B/P was 170/122, pulse 110. Patient was orally intubated (at 3:02 PM) on mechanical ventilator."

The family consented to placing the patient on a Do Not Resuscitate (DNR) status at 3:17 PM and the patient was transferred to the Intensive Care Unit at 6:40 PM. The patient was extubated the following day and she was initially breathing comfortable on high flow oxygen however, the patient's condition deteriorated, and she died on 4/26/23 at 1:28 AM.


There was no documented evidence the patient was reassessed by a physician after the first RRT (#1) activation at 2:30 PM, on 4/21/23.


During interview on 6/12/23, at 1:08 PM, Staff E, Hospitalist, stated he was outside the patient's room with Staff D, PGY3 (Post Graduate Year) when the RRT #1 was activated. They had both seen the patient on rounds and they felt the patient was good. The patient's baseline was poor from the beginning. They both responded to the activation within seconds, assessed the patient and noted she was mildly cyanotic, the oxygen was disconnected, and the patient's eyes were closed, and she was not talking. The oxygen was increased until the patient returned to her baseline status when the patient was placed back on 4 L nasal cannula oxygen. Staff D, PGY3 and Staff E, Hospitalist, Attending MD stated they remained with the patient for 20 - 30 minutes, suctioned the patient, a fingerstick was done and they cancelled the rapid response activation at 2:33 PM, because all assessments (vital signs, fingerstick, lung sounds and mental state) were at her baseline and they were normal.
Staff E, Hospitalist also stated they were talking to the family at the patient's bedside when they were called to another RRT activation. Since the patient's condition was stable, they went to the other rapid response, and upon arrival at that RRT, another RRT (#2) was activated for patient #1. They immediately returned to patient #1 and participated in the resuscitative activities. Staff E, Attending MD stated the patient's prognosis was poor prior to the rapid response activations "but as long as the family wants care, we provide the best care for our patients."

There was no documentation of the any of the physician's assessments, reassessments, and interventions for the patient, for the first RRT activation at 2:30 PM on 4/21/23.

These findings were shared with the Chief Quality Officer on 5/17/23 at 2:00 PM.