The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ADVENTIST HEALTH BAKERSFIELD 2615 CHESTER AVENUE BAKERSFIELD, CA 93301 Aug. 14, 2012
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on interview and record review, the hospital failed to use an interpreter for one Spanish speaking patient's (5) surgical consent. This had the potential to result in violation of Patient 5's rights to be fully informed of his medical care.

Findings:

The clinical record for Patient 5 was reviewed on 8/9/12. The "Physician Face Sheet" listed language preference as Spanish. The patient data profile had Spanish as the preferred language and no comprehension of English. There were three "Authorization for consent to surgery or special procedure" in English without the use of an interpreter. The consents were for; "Right supratentorial ventriculostomy (procedure to create a hole for drainage of fluid in the posterior part of the brain) with monitored/local anesthesia (having sensation blocked or temporarily taken away by use of drugs)" on 4/29/12 at 10:40 PM, "Cervical laminectomy (surgery in posterior neck region to relieve pressure on spinal cord) for treatment of arterio-venous malfunction (abnormal connection between veins and arteries in the brain)" on 5/11/12 at 4 PM, and "Selective cervical arteriogram for arterio-venous malformation (x-ray with dye to see inside of arteries in the brain and the abnormal connection between veins and arteries)" on 5/13/12 at 2 PM.

During an interview with the Director Project Intellicare (Dir PI), on 8/9/12, at 12:05 PM, she reviewed the three "Authorizations for Consent to Surgery or Special Procedure" and stated, "They should be in Spanish or have a translator."

The hospital policy and procedure titled "Interpretation services" dated and approved by Governing Body on 3/28/12, read B. "Interpretative services are available 24 hours a day, 7 days a week." C. "Hospital clinical personnel shall request an interpreter...relative to treatment/procedure/consent..."

The hospital policy and procedure titled "Consent/Informed Consent", dated and approved by the Governing Body on 5/30/12, indicated 7. a. "Patients and surrogate decision-makers must be able to understand what they are being asked to authorized... If there is a communication barrier, the hospital must arrange for communication in a language...understood by the patient..." 7. c. "The person providing the interpretation shall complete the interpreter statement on the form itself."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview and record review, the hospital's Intensive Care Unit staff failed to provide ongoing monitoring and assessment for one Patient's critical nursing needs. This failure allowed Patient 1's blood pressure to drop as his condition worsened to the point that he had to be resuscitated.
(refer to A 392)

The effect of these cumulative failures had the potential to place all critical care patients at risk.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to ensure that one Intensive Care Unit patient (1) received ongoing assessments and vital signs as ordered and that his nurse was immediately available for Patient 1's critical nursing needs.

Findings:

Patient 1 was admitted on [DATE] with an infected right arm and was subsequently transferred to the Medical Intensive Care Unit (MICU) when his blood pressure dropped. He was transferred to the MICU blood pressure support with Intravenous medications which required closer patient monitoring.

The clinical record for Patient 1 was reviewed on 8/9/12, at 10 AM, the Physician Progress Record Pulmonary Critical Note dated 5/15/12, indicated in part, "according to bedside nurse at 5:20 not able to get temperature, noted very restless-Patient 1 had just received some Dilaudid (narcotic pain medicine given intravenously) but at 5:45 BP (blood pressure) dropped to 75/58 (expected blood pressure would be over 90/40), but was not reported to RN (Registered Nurse) 4 who was busy with another patient, Patient 1 was agitated at that time on low dose levophed (an intravenous medication which raises the blood pressure) at 6:45 he was noted to be apneic (not breathing) a code was called and he was pulseless. Patient 1 was intubated (breathing tube connected to a ventilator). At this juncture Patient 1 remains extremely critical." Patient 1 was pronounced dead on 5/16/12 at 9:40 AM.

During an interview with Physician 1, on 8/13/12 at 1:40 PM, he reviewed the clinical record and stated these notes were written after Patient 1 was resuscitated, he had recorded his notes as RN 4 explained that she had not been told that Patient 1's blood pressure alarms had sounded.

The clinical record for Patient 1 was reviewed on 8/9/12. A Physician Order, dated 5/13/12, indicated in part, "Levophed: maintain systolic blood pressure over 90 (the top number of a blood pressure)."

The Nursing Flowsheet dated 5/15/2012 indicated the following:

"1. Blood pressure at 5 PM 130/c34 (small c indicates a critical value, which should have triggered a red alarm on the bedside and front desk monitor)
2. Blood pressure at 5:15 PM "in error"
3. Blood pressure at 5:30 PM 75/48
4. Blood pressure at 5:45 PM 75/48
5. Blood pressure at 6 PM (none recorded)
6. Blood pressure at 6:15 PM (none recorded)
7. Blood pressure at 6:30 PM (none recorded)
8. Blood pressure at 6:45 PM 78/48" (Patient 1 in process of being resuscitated.)

During an interview with PL (Physician Liaison RN) on 8/14/12 at 2 PM, she reviewed the electronic chart and was unable to locate documentation of any nursing interventions to manage Patient 1's low blood pressure or vital signs from 5:30 PM until Patient 1 was resuscitated at 6:45 PM.

During an interview with RN 4 and Unit Manager (UM) 1 on 8/13/12 at 12:45 PM, RN 4 stated, "I was busy with another patient and I don't know what happened, no one told me about his blood pressures. No one said his alarms went off. I just don't know what happened." UM 1 stated, We were both so confused as to what happened, why weren't we alerted about the alarms or blood pressures. We talked to the Unit Director (UD) as well. The low blood pressures as well as no blood pressure should trigger a red alarm"

During an interview with the UD on 8/13/12 at 3 PM, she stated, "The UM 1 and RN 4 both talked to me about this, we looked at the vital sign record and we were stumped as to what happened."

During an interview with RN 5 on 8/16/12 at 9:35 AM, she stated, "RN 4 was very busy that day, she had a new admission and he needed a lot of care. I helped by giving her patient a pain medicine, but did not notice any alarms. RN 4 asked me why no one told her about the alarms going off. The main monitor alarms all day long, people here are not aware of their alarms. The charge nurse was sitting at the desk and she ignored the alarms. I go in many times and the nurse before me has turned of the monitor alarms. This can be a dangerous practice"

The hospital policy and procedure titled, "Intensive Care Unit Clinical Standards of Practice", indicated in part, "Each RN is responsible for total patient care on their assigned patients. This includes the assessment, planning, intervention and evaluation of their status and progress. Prioritization of care is based on addressing needs necessary to ensure the safety of the patient. Document vital signs every 15 minutes when using titratable vasoactive medications (medication given intravenously that can alter the blood pressure as needed by the nurse).
VIOLATION: ADEQUACY OF LABORATORY SERVICES Tag No: A0582
Based on interview and record review, the hospital failed to ensure that stat (immediate) laboratory tests for two patients (3 and 5) were obtained and results available to nursing staff in a safe and reasonable time frame. This failure had the potential for delay in treatment for the affected critical care area patients.

Findings:

1. The clinical record for Patient 3 was reviewed on 8/14/12 at 3 PM, the "Patient Collections Inquiry", indicated a stat PTT (partial thromboplastin time a laboratory test to determine clotting time) was ordered by Registered Nurse (RN) 5 at 9:03 PM. The stat PTT was collected by a phlebotomist (a person who is trained to draw blood for laboratory tests) at 10:20 PM (an hour and seventeen minutes later). The results of the stat PTT were available to the nurse at 10:26 PM. The total time it took for the nurse to have the results of the PTT, after it was ordered was one hour and 43 minutes.

During an interview with the Director of Laboratory on 8/14/12, at 3 PM, she stated, "Our usual turn around for stat labs is 30 minutes. I can find no documentation for this delay. It looks like the phlebotomist drew the routine lab tests before the stat test."

During an interview with RN 5 on 8/16/12, at 9 AM, she stated, "Patient 3 had a Deep Vein Thrombosis (a blood clot), he needed to be on a Heparin drip (intravenous medication to thin the blood). We ordered a stat (immediate) PTT and it took two hours to get the results. I called the lab numerous times to come and draw the blood, I finally called the Doctor and asked if I could start the Heparin without the lab results and he said no."

The clinical record for Patient 3 was reviewed on 8/14/12 at 3 PM, the "Physician Progress Note" dated 8/2/12 at 11 AM, indicated "Deep Vein Thrombosis to Left Arm."

The hospital policy and procedure titled, "Laboratory STAT Policy", indicates in part, "A. Recognition shall be made that a STAT request initiates an immediate response by the Laboratory. Other works in progress shall be stopped to respond to a STAT. A. After receiving a STAT request from a nursing unit, a laboratory phlebotomist shall immediately go to the patient location to obtain a specimen. In life threatening situations all efforts will be made for a thirty-minute turn around time."





2. The clinical record for Patient 5 was reviewed on 8/13/12. Patient 5 had a history of diabetes and came in with diabetic ketoacidosis (DKA, a potentially life threatening situation when blood sugar gets too high) with disorientation and dehydration. Patient 5's glucose (blood sugar) was 892 (normal 70-110) on admission. The plan was to admit to the Intensive Care Unit and start an intravenous drip to bring his blood sugar down.

On 8/2/12 a stat (immediate) blood test was ordered at 3:38 AM. This stat blood test was critical to evaluate the effectiveness of Patient 5's medical management. The blood test was not drawn until 4:35 AM, almost an hour after the stat blood test was ordered. The results of the stat test was available at 5:18 AM. The total time it took from placing the order to receiving the results was one hour and 40 minutes.

During an interview with RN 2, on 8/13/12, at 1:05 PM, he reviewed the above information and stated, "I remember this day, because the patient came in with DKA and I had to stress to the lab the glucose test needed to be put in. I told them I had to adjust the Human Regular insulin drip (medication to lower blood sugar) depending on the results, so I needed them. At one point there was a problem with the specimen and lab staff was behind"

During an interview with RN 3, on 8/14/12, at 9:45 AM, she reviewed Patient 5's laboratory test and results. She stated, "I was dependant on lab for results because our meter (device to check blood sugars) couldn't do it, because the glucose levels were too high. There was about a 2 hour span for a stat glucose in the morning. I was told by the lab, 'We are very busy and trying to get caught up.'

During an interview with the Laboratory Supervisor, on 8/14/12, at 9:55 AM, she stated, "I think there was a lack of communication all around."

The hospital policy and procedure titled, "Laboratory STAT Policy", indicates in part, "A. Recognition shall be made that a STAT request initiates an immediate response by the Laboratory. Other works in progress shall be stopped to respond to a STAT. A. After receiving a STAT request from a nursing unit, a laboratory phlebotomist (person that draws laboratories) shall immediately go to the patient location to obtain a specimen. In life threatening situations all efforts will be made for a thirty-minute turn around time."