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KERALTY HOSPITAL 2500 SW 75TH AVE MIAMI, FL 33155 Nov. 14, 2013

Based on record review and interview the facility failed to ensure that the medical staff is accountable for the quality of care provided to 1 of 10 sampled patients (SP) #1.

Findings include:

Record review showed that SP#1 was admitted on [DATE] with the chief complaint as abdominal pain, bloating, and distention. Patient presented with ascites, abdominal distention of 5 days, with no improvement from home medications. She also presented with lower extremity swelling, and difficulty breathing. Initial work up included a CT(computed tomography) Scan of the abdomen and pelvis and a V/Q study. Consults were requested for a Pulmonary, Gastroenterologist (GI), and Nephrologist specialist.
According to the nursing notes dated 09/14/2013 at 11:50am the patient complained of abdominal pain and the physician was called. At 22:30 the patient complained of being short of breath and abdominal distention. The physician was called.

On 9/15/13 at 13:50 pm - nursing notes showed patient and family was requesting to have the Paracentesis to be done today. Nursing Supervisor was made aware. GI Physician was called regarding the family ' s request and stated that it will be done on Monday 09/16/13 as scheduled, and that the procedure was not an emergency.
At 1500 - patient was complaining of pain. Medicated with oxycodone/acetaminophen 5/325mg as ordered. Patient was noted to be in no distress after one hour.
At 1700 - Physician called to check on patient status and reconfirm the paracentesis will be done as scheduled.. Patient was noted to be resting up until 21:30 pm.

On 09/15/2013 according to the nursing notes at 21:30 pm - patient complained of SOB, Respiratory treatment was given O2 Saturation was at 84%. Resident on duty was notified. Patient was anxious. Patient was given Ativan 1 mg IV and Bi-Pap at 50%. Patient was less anxious after the medication.
At 22:30 - Nursing Supervisor spoke with family in the room. Patient was stable.
At 22:49 - Nursing Supervisor noted that " Patient ' s family complained and demands that patient was in distress and must have the paracentesis done NOW . Nursing supervisor noted that the staff already spoke with the attending and the GI doctor regarding the patient ' s condition and that the procedure will be done in the morning. Patient was repositioned and appears to be tolerating the Bi-pap. Nursing staff was advised to continue to monitor patient.

On 9/16/13 at 03:55 patient was mostly cooperative but has been removing her respiratory mask. Patient was anxious, pale and sweaty. O2 sat was at 83%. Patient was transferred to ICU and placed on 100% rebreather mask. Emergency Department Physician and Respiratory Therapist came to see and assessed patient.

According to the nursing progress note dated 09/17/2013 at 13:43 pm a right chest tube was inserted at the bedside. Another entry in nursing noted at 14:00 pm that there is now 2 liters of bloody drainage on the collection chamber of the chest tube.
Review of sampled patient #1 medical record (discharge summary) revealed that an x-ray showed a moderate large right-sided pleural effusion. A follow up CT scan of the abdomen and pelvis was performed that showed a large effusion in the upper cuts of the CT of the abdomen, and that there is a widening in lateral upper abdominal wall which is 3.2 cm thick with a CT number of 8 Hounsfield units suggestive of fluid or hematoma in the right upper abdomen and right lower chest. According to the progress notes dated 09/20/2013 the Thoracentesis reports about 500 to 520 ml of pleural fluid.

Interview with the Nursing Supervisor on 11/13/2013 at around 2:40 PM revealed that the family (friends) were convinced that by doing the paracentesis immediately will bring much relief to the patient. They were very insistent and demanding. We called attending physician and GI specialist as requested by family. The attending physician has seen the patient the previous day and scheduled the paracentesis and endoscopy on Monday (9/16/2013). There was nothing that our nursing staff could do other than monitor the patient and keep the patient comfortable. Patient was not in distress at that time but the patient ' s condition changed. Patient became agitated and de-saturated. Patient was taking off the O2 mask. Patient was eventually transferred to the ICU. GI specialist came in as scheduled in the morning and performed the paracentesis but drained a very small amount of fluids.
Based on interview and record review the facility failed to reassess the patient's discharge plan to see if there were factors that may affect the continuing care needs or the appropriateness of the discharge plan in 1 of 10 sampled patients (SP) #2.

Findings include:

Clinical record review showed on triage that SP#2 came to the Emergency Department on 09/11/2013 around 20:42 pm with the chief complaint of Left shoulder pain radiating to left arm with swelling to left forearm and left hand for 2 days. The Patient also has noted a history of hypertension. Initial BP taken at 20:42 pm showed the Blood Pressure (BP) to be elevated 244/143 . Attending physician was called and patient was admitted to Telemetry with preliminary diagnosis that included Hypertensive Emergency. According to the nurses notes in the medical record, it showed that at the time of discharge on 09/17/2013 patient ' s vital signs was 135/85 at 12:30 PM. The patient prior Blood pressure reading on 09/17/2013 at 07:52 am was 150/100.

Review of sampled patient (SP) #2 Emergency Department(ED) records from the second visit (approximately 5 hrs. later) dated 09/17/2013 at 17:41 pm, has noted that the patient has an elevated blood pressure and that he discovered this at a relative home, and that SP #2 was recalled to the hospital by the cardiologist. The note also stated that SP#2 was discharged from the hospital today by (another named physician) yet was not cleared for discharge by the cardiologist. The note then stated that SP#2 has a renal mass and continues to have uncontrolled HTN (hypertension). The note further stated that in the emergency department the blood pressure is are actually (meb) worse and that the patient has experienced similar episodes in the past.

The ED record on 9/17/2013 at 17:39 pm also showed BP of 158/100 on the left arm and 200/105 on right arm. Patient was medicated with clonidine and Procardia. Patient was advised to stay for further observation/admission but SP#2 signed AMA (Against Medical Advice).
The discharge disposition dated 09/17/2013 at 18:11 pm has that the patient left against medical advice -condition is serious.

Interview with Cardiologist #2 on 11/14/13 around 12 noon revealed that he usually makes rounds in the afternoon so he didn ' t get the chance to see SP#2 prior to discharge but he didn ' t have any objection for patient to be discharge. Cardiologist #2 also stated that he called the patient just to make sure that he was aware of the findings of the Ultrasound of the Kidneys. The patient was told that there was a mass or cyst that was identified on the upper portion of the left kidney. The patient was instructed to follow with him as an outpatient and an MRI was still pending. However, during the conversation the patient stated that he was at his friend ' s house and his blood pressure was checked and the reading was high. Cardiologist #2 added that of course when a patient stated his concern about his elevated BP, I asked the patient to come to the ED so he can be checked but not because of the Ultrasound result.

Review of the policy with the subject Hospital-Wide Discharge Planning Program revealed that the objective to ensure that effective discharge planning is provided through a coordinated, multi-disciplinary team approach that will follow a systematic procedure for discharge planning in all units and departments, and that collaboration with the physician to discuss and confirm the patient ' s discharge plan.