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.
|BRIDGEPORT HOSPITAL||267 GRANT STREET BRIDGEPORT, CT 06610||Dec. 12, 2013|
|VIOLATION: CONTENT OF RECORD||Tag No: A0449|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on clinical record review and interviews with staff the hospital failed to ensure that the medical record for 1 of 11 (Patient #1) patients reviewed contained the appropriate information regarding allergies. The findings include:
a. Patient (P) #1 had been previously admitted on [DATE] and the electronic medical record (EMR) Program A indicated P#1 had no known drug allergies (NKDA). According to the EMR on 9/3/13 an allergy to Vancomycin was added to P#1's profile.
b. On 9/13/13 the hospital underwent an EMR conversion from EMR Program A to EMR Program B. Interview with the Clinical Information Officer (CIO) on 12/11/13 at 3:30 PM identified that on the day of the EMR conversion, the facility was aware that the two systems did not transfer identified information including allergies. Therefore identified areas of all current (9/13/13) inpatient medical records were cross referenced from Program A to Program B and information was compared and updated, including allergies. Upon surveyor inquiry the CIO indicated this was the usual plan used by facilities when converting one EMR to another.
c. During admission to the hospital on [DATE] P#1 and his/her family indicated to the admitting nurse that P#1 did not have any known drug allergies. P#1 was admitted to the hospital with diagnoses that included [DIAGNOSES REDACTED].
d. Upon admission P#1 was diagnosed with [DIAGNOSES REDACTED].5 grams was administered on 10/5/13 at 9:51 PM.
e. On 10/6/13 P#1 developed skin excoriation, shortness of breath, increased heart rate and he/she required administration of oxygen. P#1 was transferred to the medical intensive care unit (MICU). In the MICU the medical team reviewed P#1's prior electronic medical record (Program A) and noted the documentation of an allergy to Vancomycin. The Vancomycin was discontinued and P#1 was treated with alternate antibiotics. P#1's condition deteriorated and palliative care was initiated in consultation with his/her family and given P#1's poor prognosis. P#1 expired on [DATE].
f. Interview with the Chief Medical Officer (CMO) on 12/12/13 at 1:15 PM, the CMO indicated the cause of P#1's deterioration and subsequent demise was related to sepsis and the advanced [DIAGNOSES REDACTED].