HospitalInspections.org

Based on record review and interview, facility staff failed to report an adverse safety event for 1 of 1 patient (Patient #1), in a total universe of 10 medical records reviewed.

Findings include:

A review of the facility's policy #80100-002 titled, "Patient Safety Event Reporting and Investigation," no date, revealed, " ...Any safety event, error or unusual occurrence involving patients (inpatient/outpatient), visitors, staff and/or providers must be reported upon discovery ...An online event report should be completed as soon as possible, prior to the end of the shift, so that facts are documented immediately and further review is initiated ..."

A review of Patient #1's Emergency Department (ED) medical record revealed the following:

Patient #1 presented to the facility's ED on 01/05/2022 at 1:30 PM with chief complaints of shortness of breath, fever, and chills.

A review of the "ED Provider Notes," on 01/05/2022 at 2:04 PM revealed Patient #1 was diagnosed with, "Pneumonia of both lungs due to infectious organism ...Urinary tract infection without hematuria ...Chronic obstructive pulmonary disease ...ILD (interstitial lung disease) ..."

On 01/05/2022 at 3:50 PM, acetaminophen (Tylenol; a fever reducer) tablet, 1,000 mg (milligrams) oral was ordered.

On 01/05/2022 at 5:09 PM, the acetaminophen tablet was administered to Patient #1.

On 01/05/2022 at 5:17 PM, "ED Notes" revealed, "Pt (Patient) given Tylenol and appeared to aspirate (inhale into the airway) water while doing. Pt coughing and shaking and pale in color. Hospitalist paged. ED MD at bedside for quick assessment. Pt hypoxic (low oxygen level) and placed on NRB (non-rebreather mask) 15L (15 liters of oxygen). Rapid Response called."

On 01/05/2022 at 5:32 PM, "ED Notes" revealed, "Pt placed on Bipap (a non-invasive positive pressure airway management device that can deliver higher levels of oxygen). [Hospitalist Q] at bedside."

On 01/05/2022 at 5:46 PM, "ED Notes" revealed, "Prepping for intubation (placement of a breathing tube into the airway) after little improvement."

Patient #1 was intubated on 01/05/2022 at 6:15 PM.

On 01/05/2022 at 7:37 PM, the, "ED Provider Notes ...Addendum" revealed, "After patient was admitted to the floor and transition to boarding status, I was called to the bedside after patient had an episode of respiratory distress. It appears that [s/he] drank water to swallow a pill of Tylenol, likely aspirated, and had a severe coughing fit. Patient had increased work of breathing, and was tight bilaterally with some expiratory wheezing on my examination. Increased work of breathing continued despite verbal reassurance, and patient was ultimately placed on BiPAP. This did not help much, and patient was administered a small dose of Ativan (Lorazepam; and anti-anxiety medication) for anxiolysis (anxiety relief). [His/Her] respiratory distress continued, [s/he] was tachypneic (fast breathing), with increased work of breathing, tachycardic (fast heart rate), and well-appearing. Ultimately, the decision was made to intubate ..."

On 01/05/2022 at 8:20 PM, the "H&P ...Addendum" revealed, " ...I did see the patient after a rapid response was called due to sudden onset of dyspnea (difficulty breathing). Patient was seen after [his/her] CT scan and [s/he] was taking Tylenol when [s/he] apparently started choking on water. Patient was found to be in acute respiratory distress at bedside. [S/He] was not able to complete any sentences and was breathing about 30-40 times per minute. Appeared to be in major distress. Patient was trialed on BiPAP, which did not improve [his/her] symptoms. Also try (sic) of Ativan occurred. Likely, patient did have an aspiration that caused bronchospasm (a tightening of the muscles in the airways of the lungs, causing narrowing of the airways. Typically caused by swelling or irritation of the airways) ..."

A review of the facility's listing of adverse safety events reported between 11/01/2021 and 02/14/2022 revealed no evidence that an adverse safety event report was completed regarding Patient #1's unexpected aspiration and resulting need for intubation.

During an interview on 02/15/2022 at 4:11 PM, Patient #1's medical record review findings were discussed with and confirmed by ED Manager C. When asked if it would be expected that a safety event report be completed for Patient #1's aspiration and intubation, Manager C stated, "Yes," s/he would have expected a safety event to be completed. Manager C confirmed that there was no safety event completed for Patient #1.