HospitalInspections.org

A. Based on a review of the Hospitals's Medical Staff Bylaws, clinical record review and staff interviewed it was determined that the Hospital failed to ensure patients received safe medical care(347 A), failed to ensure physician competency (347B), lement Hospital Bylaws for documentation requirement (A 347), failed to ensure complete and accurate records(353A), failed to ensure the medical staff was credentialed to perform endotracheal intubations(A357).
As a result, the Condition of Medical staff was not met. In addition, an Immediate Jeopardy (IJ) was identified on 2/3/10 at 12:15PM, as the Hospital failed to implement comprehensive training, and provide evaluation and monitoring related to physician endotracheal intubation competency for 3 of 7 Hospitalist (E #s 1,2, and 3). An Immediate Jeopardy and serious threat to patients safety was created from the cumulative effect of these systematic practices.

The Director of Nursing and the Director of Critical Care/Emergency Department was notified of the IJ on 2/3/10 at 12:15PM.

On 2/3/10 at 3:00PM, the Director of the Emergency Department provided a memo, signed by the Executive Vice President of the Hospital, indicating that Emergency Department Attending Physicians must be called for all patient intubations when E #1,2 and 3 are scheduled to work as Hospitalists. The memo is addressed to all Hospital Units. In addition, a second memo from the Director of Emergency Medicine dated 2/3/10 also informed E#s 1, 2 and 3 of the above changes. As a result, the IJ was removed. However, the Condition of Medical Staff is not met.

A. Based on review of Medical Staff Bylaws, clinical record review, incident report review, and staff interview it was determined for 3 of 5 clinical records reviewed (Pts. #1, 4, & 5) that the Hospital failed to ensure all patients received safe medical care.

Findings include:

1. The Medical Staff Rules and Regulations were reviewed on 2/3/10 at 9:30 AM. The Rules included, " The Medical Staff of Our Lady of the Resurrecton Medical Center has overall responsibility for the quality of professonal services provided by individuals with Clinical Privileges..."

2. On 2/1/10 at 10:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was an 85 year old female, admitted on 11/5/09, with diagnoses of Septicemia and Hypertension. Pt. #1's CPR record dated 11/6/09, included an unsuccessful resuscitation attempt beginning at 5:48 AM and called off at 6:43 AM, 55 minutes. Endotracheal tube intubation was attempted by the Hospitalist (E #1). The CPR record documented that E #1 attempted 2 intubations which were unsuccessful. An Emergency Room Physician arrived at 6:19 AM, (31 minutes after the start of the code) and attempted intubation, but a breathing tube was never placed before Pt. #1 expired. However, Emp #1, placed a progress note in the pt's clinical record and included "pt intubated from second attempt".

3. On 2/1/10 at 11:00 AM, a Summary of Incident Reports for November 2009 was reviewed and included Pt. #1's code blue incident on 11/6/09. The report indicated that E #1 attempted to intubate Pt. #1 five times, including placement in the Esophogas on the second attempt. Two Emergency Room Physicians (E # 4 & 7) arrived and were also unsuccessful in intubation. The Summary included: "...Noted patient's tongue to be swollen and with subcutaneous emphysema... Patient was bleeding from the mouth all over the place in spite of frequent suctioning..."

4. On 2/1/10 at 11:00 AM, the clinical record of Pt. #4 was reviewed. Pt. #4 was a 75 year old male, admitted on 11/2/09, with diagnoses of Renal Failure and Pneumonia. A Hospitalist ' s (E #1) progress note dated 11/3/09 at 7:00 AM, indicated Pt. #4 became bradycardic with heart rate in the 40s, lethargic, and less responsive. Pt. #1 was "intubated after two attempts" and CPR was initiated. A CPR record dated 11/3/09, indicated the code blue started at 8:02 AM and ended successfully at 8:15 AM. Pt. #4 was intubated by an ER Doctor (E #12) during the code and not by Emp#1..

5. The Summary of Incident Reports for November 2009, which included Pt. #4, was reviewed on 2/1/10 at 11:00 AM. The summary included E #1: "...tried to intubate him for approximately 30 - 40 minutes..."

6. The Director of Nursing was made aware of the findings related to Pt. #1 & 4 during the exit conference on 2/3/10 at 3:50 PM.


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7. The clinical record for Pt. #5 was reviewed on 2/2/10 at 8:30 AM. Pt. #5 was a 59 year old male admitted on 11/1/09 with the diagnosis of Suicide Attempt. Pt. #5 had an episode of unresponsiveness on 11/2/09 and a code blue was called. The Hospitalist (E#1) was paged and arrived in the unit. The Hospitalist attempted to intubate Pt. #5 for 30 minutes. Pt. was intubated, bilateral breath sounds were heard by E#1. After Pt. #5 was connected to the ventilator, he continued to desaturate. The Emergency Room (ER) physician was on the scene and listened to the chest and abdomen. The ER physician indicated that breath sounds were heard in the stomach. Pt. #5 was extubated and re-intubated by the ER physician. Pt. #5 required re-intubation due to improper placement of the endotracheal tube. The improper placement was not identified by E#1.

8. The findings related to Pt. #5 were confirmed with the Director of Nursing on 2/2/10 at 11:00 AM, during an interview.

surveyors: 27125 & 19843




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B. Based on a review of the Hospitals's Medical Staff Bylaws and staff interview, it was determined that the Hospital failed to ensure, 3 of 3 physician Hospitalists (E#s 1,2 and 3)demonstrate competency in endotracheal intubation.

Findings include:


1. The Hospital's Bylaws and Rules and Regulations were reviewed on 2/2/10 at approximately 2:00PM. Section 4 of the Bylaws included," Each Department and Section Shall ...include analysis of the quality of care provided by the department and make recommendations for maintaining and improving the quality of care provided...additional responsibilities include reviewing and evaluating department adherence to Medical Staff Policies and Procedures...training appropriate action when important problems in patient care and clinical performance or opportunities to improve care are identified. "


2. On 2/2/10 at approximately 10:00AM, the Director of the Hospitalist Program was interviewed. The Director stated that the ICU nurses complained in November of 2009 that E#1 did not have the required skills to intubate. The complaint was investigated by the Director who also identified a total of three physicians (E#s 1, 2 and 3) who would benefit from re-training. The Director arranged retraining times in conjunction with the Chairman of Anesthesia for November 2009 and December 2009. The Director of the Hospitalist Program was unable to provide evidence of:

* Formalized and documented Quality Performance Measures prior to training.

* documentation of communication between the trainers (anesthesiologists), the Chairman of
Anesthesia and Director of the Hospitalist Program to evidence physician performance in
intubation.

*documentation for on going monitoring and evaluation of the effectiveness of the training that
was completed January 5, 2010.

3. The above findings were confirmed by the Director of the Hospitalist Program during an interview on 2/2/10 at approximately 10:30AM and The Chief of Medical Staff during an interview on 2/3/10 at approximately 2:00PM.

A. Based on review of the Medical Staff Rules and Regulations, Hospital policy review, clinical record review, physician interview and staff interview, it was determined that for 3 of 5 (Pts. #1, 4 and 5) clinical records reviewed, the Hospital failed to ensure a complete and accurate record was maintained for each patient.

Findings include:

1. The Medical Staff Rules and Regulations were reviewed on 2/3/10 at 9:30 AM. The Rules included "12. The attending physician shall be responsible for the complete record of each patient...." .

2. The Hospital Medical Staff policy titled "Consultation" was reviewed on 2/2/10 at 2:00 PM. The policy included "A satisfactory consultation includes examination of the patient, and a legible written opinion that is dated, timed and signed by the consultant and is made part of the patients record. When operative procedures are involved, the consultation note shall be recorded prior to the operation."

3. The clinical record for Pt. #5 was reviewed on 2/2/10 at 8:30 AM. Pt. #5 was a 59 year old male admitted on 11/1/09 with the diagnosis of Suicide Attempt. The clinical record included an operative report dated 11/3/09 that indicated a central line via the right femoral vein had been inserted. The record lacked a written physician note indicating the consultation or explanation for this insertion.
4. An interview with the operating physician (E#5) for Pt. #5 was conducted on 2/2/10 at 10:20 AM. E#5 indicated that the nursing staff informed him of the placement of the Central Venous Catheter (CVC) on Pt. #5. E#5 indicated that the CVC that was in place was being used, but the direction of the line was going up towards the head. This caused an increased risk for a thrombus (blood clot). E#5 decided to remove the existing line and place a femoral line for increased safety to the patient. E#5 stated that he did not write a progress note as he should have in Pt. #5's chart to explain this procedure.
5. The findings related to Pt. #5 were confirmed with the Director of Critical Care on 2/2/10 at 10:30 AM, during an interview.

6. On 2/1/10 at 10:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was an 85 year old female, admitted on 11/5/09, with diagnoses of Septicemia and Hypertension. Pt. #1's CPR record dated 11/6/09, included an unsuccessful resuscitation attempt beginning at 5:48 AM and called off at 6:43 AM. Endotracheal tube intubation was attempted by the Hospitalist (E #1). An Emergency Room Physician arrived at 6:19 AM, and attempted intubation, but a breathing tube was never placed.

7. On 2/1/10 at 11:00 AM, a Summary of Incident Reports for November 2009 was reviewed and included Pt. #1's code blue incident on 11/6/09. The report indicated that E #1 was unsuccessful in intubating Pt. #1 after 5 attempts and that 2 ED Physicians (E #4 & 7) attempted intubation, but also unsuccessful.

8. Both ED physicians (E #4 & E #7) who responded to the code, failed to document the number of intubation attempts on the code sheet or progress notes. Pt. #1's swollen tongue, subcutaneous emphysema, and copious bleeding from the mouth were not included in the clinical record

9. The Director of Critical Care confirmed the finding for Pt. #1 during an interview on 2/2/10 at 1:10 PM

10. On 2/1/10 at 11:00 AM, the clinical record of Pt. #4 was reviewed. Pt. #4 was a 75 year old male, admitted on 11/2/09, with diagnoses of Renal Failure and Pneumonia. A Hospitalist ' s (E #1) progress note dated 11/3/09 at 7:00 AM, indicated Pt. #4 became bradycardic with heart rate in the 40s, lethargic, and less responsive. Pt. #1 was " intubated after two attempts " and CPR was initiated. A CPR record dated 11/3/09, indicated the code blue started at 8:02 AM and ended successfully at 8:15 AM. Pt. #4 was intubated by an ER Doctor (E #12) during the code.

11. The Summary of Incident Reports for November 2009, which included Pt. #4, was reviewed on 2/1/10 at 11:00 AM. The summary included: E #1 was " on site to evaluate ICN-2 [Pt. #4] ... unresponsive ... bradycardic. Dr ... [E #1] tried to intubate him for approximately 30 - 40 minutes. ER was called and Doctor ... [E #12] arrived. He [ER Doctor] intubated the Patient... Pt. was connected to vent and then began to desaturate. Doctor ... [E #8] auscultated breath sounds and said pull ET out 2 cm. It is in the right bronchus ...pulled it out. Patient continued to desaturate. Doctor ... [E #12] was called back in room. He listened to breath sounds and didn't hear any ... Pt. was extubated and re-intubated successfully. About the time of the second intubation, Patient ' s heart rate was in 30s. Code blue was called and ACLS was given to Patient. Pt. was successfully resuscitated

12. The clinical record lacked documentation of the intubation delay (30 - 40 minutes) by E #1, wrong placement, removal, and reintubation by E #12.

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A. Based on a review of the Hospitals's Medical Staff Bylaws, credential file review and staff interview, it was determined that in 1 of 7 credential files (E#1) reviewed, the Hospital failed to ensure the medical staff was credentialed to perform endotracheal intubations.

Findings include:

1. The Medical Staff Bylaws were reviewed on 2/2/10 at approximately 2:00PM. The Bylaws approved 3/1/09 included (Page 20) , "...recommendation of initial, revised and renewed Clinical Privileges shall be based upon, the applicant or member's education, training, experience, demonstrated current competence and judgement, clinical and technical skills..."

2. On 2/1/10 at approximately 10:00AM credential files were reviewed. The credential file for E #1 contained approved privileges dated 10/2/09. E#1 was not approved for endotracheal intubation although E#1 has been responding to codes and having unsuccessful attempts at endotracheal intubations.

3. The above finding was confirmed by the Physician Director of the Emergency Department during an interview on 2/1/10 at approximately 11:00AM