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|HIALEAH HOSPITAL||651 E 25TH ST HIALEAH, FL 33013||March 17, 2014|
|VIOLATION: REASSESSMENT OF A DISCHARGE PLAN||Tag No: A0821|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview the facility failed to reassess the patient's discharge plan for the appropriateness of the plan in 1 of 10 sampled patients (SP) #1.
Clinical record review of SP#1 revealed an admitted on 1/31/2014 with the pre-operative diagnoses of [DIAGNOSES REDACTED]. Hydrogen Peroxide topical 3% solution daily as needed for wound care. On 2/1/2014 at 10:53 am, the patient ' s pain score was 7 and Demerol 25 mg IM was given. The response after this medication was given showed that on 2/1/2014 at 11:53, the pain score was zero. On 2/1/2014 at 14:20 pm the Medication Administration Record (MAR) showed that Registered Nurse (RN) #2 performed wound care as ordered using the hydrogen peroxide solution. The patient was discharged on [DATE] at 14:30 pm.
There is no documentation of how to take care of the surgical site in the post discharge instructions, and the post discharge pain medication was inadequate for a patient who was receiving Demerol IM prior to discharge.
Review of SP#1 ' s clinical record revealed that the patient was brought to the ER via rescue on 2/1/2014 at 20:40 pm (approx. 6 hours later) with the chief complaints of post-surgical pain and shortness of breath. The patient reports severe pain at the laparoscopic sites with drainage from the wounds. The ER notes revealed that the patient was short of breath, the abdomen was positive for abdominal pain of the umbilical area and right upper quadrant, skin was positive for laparoscopic wounds from cholecystectomy with drainage, moderate abdominal tenderness diffusely. Laparoscopic staples in place, sero-sanguineous discharge, laparoscopic wounds, RUQ (right upper quadrant) and umbilical, draining sero-sanguineous fluid, tender to palpation. The patient had a cardiac arrest and was intubated. The patient developed a-systole and a Code Blue was called. A second resuscitation episode was initiated and the patient expired at 05:24 am.
The Surgeon stated during a telephone interview conducted on 3/17/2014 from 2:20 p.m. to 2:38 p.m. I remember the patient. The surgery took a while because the stomach was stuck to the gall bladder; I had to separate the stomach. Then, my service called me that the patient 's son called late about the patient not looking good, she was in pain, that there was a brownish discharge from the belly button, that ' s how he described it. Then, the ER doctor called me that the patient was very sick and she had to be intubated. I went over to see her, around 10 p.m. I saw the incision, it was dry, and there was no brownish discharge. The incision looked healthy, it was closed. The patient had staples, the wound was clean, it was a normal abdomen. I spoke to the patient ' s son and explained to him that the abdomen was OK, her condition was not related to the surgery. I told him the options, to do a CT (Computed Tomography) of the abdomen; I can even take her to surgery although the abdomen was benign but that she might not tolerate the surgery, it was better to work her up. There was no need to do any laboratory work up after the surgery, the surgery went fine, and she didn ' t have any fever. Most of the time, the patient ' s discharge is handled over the phone, I spoke to the nurse of the patient. I don ' t remember seeing any pictures or video in the ER. The ER doctor and I discussed the patient ' s case; I think it was to rule out pulmonary embolism or myocardial infarction. The WBC (white blood count) was not elevated, she didn ' t have any fever. I learned from my answering service that the patient expired " .