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.

Based on record review and interview, the facility failed to ensure that performance improvement activities that track medical errors and/or adverse patient events is implemented hospital wide in 1 Sample Patient (SP#1) of 10 sample patients.

The findings include:

Clinical record review of SP#1 conducted from 11/13/2012 to 11/14/2012 revealed that SP#1 underwent a left total hip replacement.

Review of the Rehabilitation Medical Doctor's Consultation report dictated on 03/21/2012 states under the section "Concerns: Possibility of developing an ileus/urine retention?- nursing was made aware to monitor."

Dr. [Attending Physician's name] aware. On 03/22/2012 at 20:30 P.M., telephone orders were received from the Medical Doctor (M.D.) covering for the A.P. for a Kidney Ureter Bladder (K.U.B.) "stat".The K.U.B. was done at the bedside. On 03/22/2012 at 23:00 P.M., the facility's Radiology Resident read the K.U.B. films. The documented results stated SP#7 had "dilated loops of the small intestine." A computerized tomography (C.T.) Scan of the abdomen and pelvis with IV Contrast was recommended "stat". The C.T. Scan was done as ordered and upon return to the floor.

Review of the 24 Hour Nursing Flowsheet showed that SP#1 had a "stat" C.T. Scan of the abdomen and pelvis on 03/23/2012 at 2:10 A.M. There is no documented evidence that the results of the "stat" C.T. Scan of the abdomen and pelvis were followed-up or obtained. There is no documentation that the Charge Nurse or the Nursing Supervisor were informed about the patient's condition as well as the results of the K.U.B. done earlier. The nurse spoke to the M.D. at 0600 on 03/23/2012 but there is no documented evidence that the C.T. Scan results were discussed.

On 11/14/2012 at 09:30 A.M., surveyor was provided with the facility's Root Cause Analysis (R.C.A.) Action Plan for Nursing and Radiology. Review of the R.C.A. Action Plan for Nursing showed 5 areas of improvement. Action # 1 was to review the process of Head to Toe assessment/re-assessment with all nurses and monitor charts to assure compliance with assessment/re-assessment process and documentation. Action # 2 was to in-service nurses and unit secretaries on importance of entering correct physician when ordering a test and for Radiology Department to monitor for compliance. Action # 3 was to review with nurses the importance of physician calling back where there is a change in patient's condition and if nurses were to notice changes to call R.R.T.
Action # 4 was to re-iterate importance of R.R.T. (rapid response team) activation and dial 1-2-3 to summon help from R.R.T. Action # 5 was to review process for nurse chain of command when calls are placed to physicians and there is no call back response, inform Nursing Supervisor and only wait 30 minutes for a STAT situations or total of 2 hours for routine calls.

Interview with the Asst. V.P. of Nursing and 5 South N.M. was conducted on 11/14/2012 at 02:30 P.M. The Asst. V.P. of R.M. and the Accreditation Services Manager were also present during interview. Surveyor was informed that a team of people (Risk Management, Nursing, Radiology, I.T. and Physicians) participated in the R.C.A. and the team's recommendation was to focus education on 5 South. As per A.V.P. of Nursing education was not mandatory for all nursing staff.