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.
|SAINTS MEDICAL CENTER INC||1 HOSPITAL DRIVE LOWELL, MA||April 4, 2011|
|VIOLATION: CONTENT OF RECORD - OTHER INFORMATION||Tag No: A0467|
|Based on record review, physician and staff interview there was no documentation by both certified registered nurse anesthetist (CRNA) #1 and Anesthesiologist #2 for the medical interventions provided to one of one Patient #1 who remained in Post Anesthesia Care Unit (PACU) for five hours with unstable blood pressures in February 2011.
The findings are as follow:
Patient #1 was admitted to Surgical Day Care for an elective right inguinal hernia repair on 02/23/11. Patient #1 had liver failure and was a candidate for a liver transplant.
Review of the PACU documentation indicated Registered Nurse #1 documented vasopressor medications were administered by CRNA #1 at the time of transfer of care into PACU.
Review of the PACU Nursing Notes indicated Patient #1 arrived in PACU at 10:15 AM.
At 10:20 AM, RN #1 documented CRNA #1 administered Ephedrine 10 milligrams by intravenous injection to Patient #1.
CRNA #1 documented the administration of the Ephedrine on the Anesthesia Record instead of in the PACU Note or Progress Note. CRNA #1 further documented Patient #1 was released to PACU at 10:28 AM.
Continued review of the PACU Nursing Note indicated on 02/23/11 at 11:10 AM, Patient #1's blood pressure dropped to 77/50. Anesthesiologist #2 was consulted.
There was no documentation in the medical record for the numerous interventions provided to Patient #1 by Anesthesiologist #2 during the five hour period until Patient #1 was urgently sent for a CT scan.
Anesthesiologist #2 said Patient #1's blood pressure was a little low, given ephedrine and Patient #1 responded to the medication. Anesthesiologist #2 said the CRNA might have been there. Anesthesiologist #2 said Patient #1's blood pressure dropped again and Hespan was given which is a volume expander. Anesthesiologist #2 said Surgeon #1 did not think there was any bleeding from the surgery. Anesthesiologist #2 said there were no obvious signs of bleeding, no tachycardia or abdominal guarding or tenderness and if blood was present in the perineum Patient #1 would be very uncomfortable. Anesthesiologist #2 said on second examination, Patient #1's abdomen was distended. Anesthesiologist #1 said when the arterial line and central lines were inserted, Patient #1's blood was like water. Anesthesiologist #2 said Patient #1's hemoglobin and hematocrit were low indicating Patient #1 was bleeding. Anesthesiologist #1 said Patient #1 needed to go to the operating room but Surgeon #1 wanted to obtain a CT scan.
Patient #1 was then transferred back to the operating room for an intraabdominal bleed.
Surgeon #1 failed to document the acknowledgement of Patient #1 low platelet count of 101 ( normal values range between 150 to 400) prior to Patient #1's surgery.