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Based on records reviewed and interviews, the Hospital failed to implement corrective actions to prevent a like occurrence from happening for 3 Patients (#1, #2, and #3) out of a sample of 10 patients.

Refer to tag A-0283.

Based on records reviewed and interviews for 3 patients (#1, #2, and #3) out of a total sample of 10 patients, the Hospital failed to ensure that actions aimed at performance improvement were implemented for 3 incidents involving: 1) a Physician performing a bronchoscopy with a contaminated bronchoscope resulting in COVID-19 and possible HIV exposure, 2) an incident involving a nasogastric tube being utilized while misplaced in a Patient's lung resulting in pneumonitis and Acute Respiratory Distress Syndrome (ARDS), and 3) an incident involving a nurse administering a medication incorrectly resulting in increased monitoring for a Patient.

Findings include:

1. Patient #1 was admitted to the Hospital in November 2021 with diagnoses of Staph Aureus Bacteremia secondary to osteomyelitis and acute hypoxic respiratory failure.

Review of the Hospital report to the State Agency dated 12/29/21 indicated Patient #1 was transferred to the Intensive Care Unit (ICU) on 12/11/21 after experiencing a cardiac arrest. On 12/16/21, a bronchoscopy was performed at Patient #1's bedside to remove blood clots from his/her left lung's lower lobe and bronchus. After the procedure had been performed, the Physician #1 realized the bronchoscope used in the procedure had been located with a red cover, indicating it had been previously used and had not undergone full sterilization. The bronchoscope had previously been used on another procedure for a patient positive for the COVID-19 virus. Patient #1 was treated with monoclonal antibodies for the COVID-19 exposure and HIV prophylaxis.

Review of Patient #1's medical record indicated on 12/16/21 at 4:16 P.M., the bronchoscopy was performed for Patient #1. The medical record indicated a time out was conducted immediately prior to the procedure and the time out verified the correct patient, procedure, and equipment used for the procedure. The procedure was performed by the Fellow with the Attending Physician (Physician #1) present. Further review of Patient #1's medical record indicated Physician #1 contacted the patient's Health Care Proxy (HCP) to discuss the potential exposure to infection from the bronchoscopy procedure performed.

Review of the Hospital's Root Cause Analysis (RCA) of the incident for Patient #1 occurring on 12/16/21 indicated Physician #1 had brought the cart with the contaminated bronchoscope into Patient #1's room for the bedside bronchoscopy. Physician #1 did not register the scope had a red cover over its bin, which indicated it had been used and was not fully sterilized and removed the cover for the bronchoscope to be used in the procedure. The RCA indicated education was sent via email to the staff of the pulmonary unit to remind them of the following procedures:

-All scopes must be signed out on the sign out sheep in the Pulmonary Specialty Procedure Unit (PSPU).

-Immediately pre-procedure, the yellow tag around the scope indicating the scope is clean must be cut off.

-Immediately post-procedure, first step of bedside precleaning must be done, the red biohazard cover is to be placed on top of the scope in the rigid container immediately after the first step process is completed.

-Scopes should be brought back down to the PSPU or Central Sterile Processing (CSP) as soon as possible after the bedside procedure is completed.

Review of the Hospital Policy titled "Department-Specific Infection Control Policy", dated 12/2019, indicated the following:

-Reusable instruments/equipment are cleaned and disinfected of sterilized as required by device classification between patients according to manufacturer's instructions for use.

-Rigid and flexible scopes are thoroughly cleaned and at a minimum high-level disinfected between patients according to manufacturer's instructions for use and according to infection control policies for cleaning, disinfection, and sterilization.

During an interview with the CSP Director on 5/10/22 at 10:08 A.M., she said after any bronchoscopes have been cleaned by the CSP unit, they will have a yellow band placed on them to indicate the bronchoscope has been cleaned and is safe for use. When sent to the units, the clean bronchoscopes are placed in a storage contained and covered with a green cover indicating they are clean. She said immediately post procedure with a bronchoscope, it must be cleansed with an enzymatic precleanser and then placed in a storage container and covered with a red cover to indicate the bronchoscope has been used and is contaminated.

During an interview with the ICU Nurse Manager on 5/10/22 at 11:30 A.M., she said once a bronchoscope has been used for a procedure in the ICU, the scope is placed back into the storage container, covered with the red cover, and the PSPU is called to pick up the cart with the bronchoscope and other equipment, and the cart should be removed from the unit once the PSPU is notified for pick up.

During an interview with Physician #1 on 5/11/22 at 2:00 P.M., she said at the time of the incident on 12/16/21, she was unaware of the yellow tag system used to identify if a bronchoscope has been processed/cleaned and is safe for use.

During an interview with the Hospital's Pulmonary Attending Division Quality Chairman on 5/11/22 at 2:00 P.M., he said the practice is after a physician performs a bronchoscopy on the ICU, the physician performs the initial precleanse on the scope, places in the container and covers with the red cover; the physicians bring the bronchoscopes back to the PSPU. If a physician is unable to transport the scope/equipment back to the PSPU, they are now instructed to remove the cart to the soiled utility room on the unit. He said all pulmonary providers were informed of this process.

The Hospital was unable to provide verification that all Providers performing bronchoscopies in the Hospital had received and reviewed the education on the process for the use of bronchoscopes.

2. Patient #2 was admitted the Hospital in August 2021 with a diagnosis of respiratory failure and was awaiting a bilateral lung transplant.

Review of the Hospital report to the State Agency dated 9/28/21 indicated on 9/22/21 a Nurse Practitioner (NP) placed a Nasogastric (NG) tube for Patient #2 and a chest x-ray was ordered for placement. The Patient's chest x-ray was not reviewed and correct placement of the NG tube was not confirmed. The Registered Nurse (RN) was told by another NP the NG tube was okay for use, and the RN administered medications through the NG tube. The chest x-ray showed the NG tube was in the left lower lung bronchus which led to an aspiration event when medications were administered by the bedside nurse. The patient developed a clinical aspiration pneumonia and required an increase in ventilatory requirements.

Review of Patient #2's medical record failed to indicate an order for the insertion of a NG tube for Patient #2 on 9/22/21, a progress note regarding the NP's insertion of a NG tube for Patient #2, nor orders to not use the NG tube until placement was verified on 9/22/21.

Further Review of Patient #2's medical record indicated a chest x-ray obtained on 9/22/21 at 7:37 P.M., which indicated Patient #2 had a feeding tube terminating in the left lower lobe bronchus.

Review of Patient #2's Nursing Progress Note dated 9/23/21 indicated on 9/22/21 Patient #2 was administered his/her 8:00 P.M./9:00 P.M., and had a desaturation event and drop in blood pressure at 9:10 P.M. While the RN was administering Patient #2's medications, he/she woke suddenly and began coughing up yellow and orange liquid. Another chest x-ray was obtained and the NG tube was reported to be improperly placed. On the early morning of 9/23/21, Patient #2 was chemically paralyzed to manage his/her respiratory status.

Further review of Patient #2's medical record indicated a bronchoscopy was performed on 9/22/21 at 11:20 P.M. for the indication of hypoxemia. A moderate amount of granular material was aspirated in the left main bronchus. Review of a Physician's progress note dated 9/22/21 indicated aspiration, accidental insertion of small bore feeding tube into left lung and crushed pills and suspensions of medications given. Bronchoscopy was performed. Worsened hypoxemia. Review of another Physician's note dated 9/23/21 indicated Patient #2 had an aspiration event overnight leading to pneumonitis/ARDS and increased oxygen requirements.

Review of the Hospital's Root Cause Analysis (RCA) of the incident for Patient #2 on 9/22/21 indicated corrective actions for this event included: 1) notifying the intensive care unit (ICU) attending prior to any procedure, including feeding tube placement, and 2) for APP staff with less than six months of clinical experience in the Heart Center ICU, all x-rays will need to be reviewed with the ICU attending. A practice advisory email was sent to all Cardiac Surgical Advanced Practice Practitioner (APP) staff members with the feeding tube placement guidelines.

Review of the Hospital procedure manual titled "Nasogastric and Oral Gastric Tube Insertion", Revised July 2021, indicated the following:

-A provider order is required prior to insertion of a nasogastric or oral gastric tube.

-Do not inject any fluid or air through the nasogastric tube until x-ray confirmation has occurred.

-Document the insertion of the tube in the electronic medical record. Include size, date of insertion, length of tube in centimeters (cm), placement of tube, and type of tube.

During an interview with the Critical Care Division Chief on 5/12/22 at 4:00 P.M., he said in review of this incident, there was a communication issue between nurse practitioners; the oncoming nurse practitioner thought the NG tube was in place for the patient but the x-ray placement had never been verified. He also said a chest xray should have been obtained as the NG tube was being advanced to ensure it was not in the patient's lung, then should be advanced into the stomach and confirmed with another x-ray exam. He said all NG tube placements should also have procedure notes recorded following insertion in the patient's medical record. He said practice advisory emails were sent to all providers and APP staff regarding education on NG tube placement and the updates to the process; the case was presented at the Hospital M&M as well.

The Hospital was unable to provide evidence that all APP staff who insert NG tubes in the Hospital had received and reviewed the education on the process for NG tube insertion or the changes to the process developed from this incident.


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3. Patient #3 presented to the Emergency Department on 2/11/22 with left sided headache and photophobia of 2 weeks duration with associated blurred vision in the left eye, neck stiffness and fatigue.

Record Review indicated an order dated 2/11/22 for Sumatriptan (a medication used for the treatment of migraines) 6mg subcutaneous (injection given in the fatty tissue, just under the skin) x 1 dose. Nurse #1 obtained the Sumatriptan and administered it by slow IV (Intravenous) push at which point Patient #3 complained of a tingling sensation in his/her neck.

Further Review of the Medical Record indicated a Physician's note dated 2/11/22 indicating the Attending MD in the Emergency Department was informed by RN that the medication Sumatriptan was administered to Patient #3 by IV push instead of SC (Subcutaneous) injection which resulted in increased cardiac monitoring (continuous monitoring of heart activity), an EKG (records the electrical signal from the heart to check for different heart conditions), and monitoring Troponin Levels (a type of protein found in the muscles of the heart that releases into the bloodstream when the heart muscle has been damaged) of Patient #3 due to the risk of coronary vasospasm.

Review of the Hospital Incident Report for the medication event on 2/11/22, indicated Nurse #1 assigned Patient #3 to himself using the Epic Rover application, which would allow him to scan and document medication administered. Nurse #1 inadvertently gave Patient #3 Sumatriptan 6mg by the wrong route. Nurse #1 was assisting Patient #3 primary nurse who asked Nurse #1 for help medicating one of her patient's after she acknowledged the order for Sumatriptan 6mg subcutaneous x 1. Nurse # 1 scanned the medication after administering it and realized that the medication was intended to be given by the subcutaneous route. Nurse #1 felt the medication looked very concentrated and it was unusual to have such a concentrated medication administered IV. Nurse #1 reported that he was unfamiliar with the medication Sumatriptan and that he did not look it up prior to administration and did not look up the original order. The Hospital Incident Report further indicated Nurse #1 had asked another nurse if the Sumatriptan needed to be diluted and was advised by this nurse that it did not need to be diluted, but a slow push. Nurse #1 indicated that he did not scan the medication prior to administration to Patient #3 as there were multiple codes on the vial and unable to read the barcode.

Review of the Hospital Policy "Medication Administration Inpatient Policy", dated 4/24/19 indicated Medication Administration procedures outlining before the administration of medication, the individual administering the medication will:

-Discuss any unresolved concerns about the medication with the ordering provider, and /or staff involved with the patient's care, treatment, and services.

-Verify that the medication selected matches the medication order and product label.

-Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route.

-Medication references such as LexiComp, Ellucid, and a unit based clinical pharmacist that may be used for more information about medications or any unfamiliar medications.

-Barcode Scanning of patient and medication must be done prior to each administration of medication.

-Any administrations that do not utilize the functionality of barcode scanning must include confirmation of the 5 rights prior to administration which include right drug, dose, route, time and patient.

During an Interview on 5/11/22 at 12:30 P.M., the Patient Safety and Staff Specialist said the Hospital felt the medication incident on 2/11/22 was a one off specific to Nurse #1 practice and was not felt to be a system issue; therefore, system wide education was not done, and that the hospital has adequate policies for medication administration in place. She said Nurse #1 said contributing factors was that it was a busy day, he was rushing, and was too confident. The Patient Safety and Staff Specialist said that counseling was done with Nurse #1 on the correct process for medication administration including the 5 rights of medication administration and the sequence for barcode scanning with a positive response to the education with no further issues.

The Hospital failed to provide system wide education and corrective actions to prevent a like occurrence from happening again with other licensed professionals administering medications after Nurse #1 administered a medication incorrectly to Patient #3; resulting in the need for increased monitoring and a potential adverse reaction.