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UNIVERSITY OF NEW MEXICO HOSPITAL 2211 LOMAS BOULEVARD NE ALBUQUERQUE, NM 87106 Oct. 22, 2015
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on interview and record review, the Governing Body of the facility (Hospital #2) failed to ensure that the medical staff reviewed communication of crucial medical information on a patient transferred from another facility, Hospital #1, on 06/30/15. This failure by the facility contributed to the unsafe, premature discharge of a patient who was admitted to another facility (#3) the next day to be treated for a stroke. Note: Stroke is defined as sudden loss of consciousness followed by paralysis caused by hemorrhage or clot in the brain. The findings are:

A. On 10/20/15 at 3:00 pm during interview, Complainant #1 (son of Patient #1) stated the following:
1. "My father started feeling weak and dizzy at home on Monday 06/29/15 in the afternoon around 2 [pm]. I was not with him but my sister was. By 4 pm my father [Patient #1] was not responding. My sister became more concerned about his condition and decided to take him to the closest hospital [Hospital #1]. On arrival [to Hospital #1] my dad had a very high blood pressure. They arrived at the hospital around 9 pm and he was admitted . His blood pressure was highly elevated, 220/120 [normal is 120/80]. They started a drip [antihypertensive medicine] and planned to transfer him to [Hospital #2] where a neurologist was available. He arrived at [Hospital #2] around 3:30 am on 06/30/15."
2. "He was discharged from Hospital #2 to home later that morning. I believe he may have had a major stroke on the way home. He was very tired and lethargic. But he had been up and traveling for the last 20 plus hours. He fell at home the next day around noon. They went to his family doctor appointment that day. His Primary Care Doctor (PCP) sent him via ambulance to [Hospital #3.] He was diagnosed with a massive stroke. [Hospital #3] did everything -- blood work, x-rays, CT [computed tomography, a detailed x-ray] of his head, and ultra sound of his neck. It turns out one of his carotid arteries [which supplies blood to the brain] was totally occluded [blocked]."
3. "I am most concerned that [Hospital #2] did not have a protocol to monitor stroke victims for 24 or 48 hours. He has been in rehab at various facilities since then." The son felt that the severity of the stroke could have been avoided if he stayed at Hospital #2.

B. On 10/21/15 at 9 am during interview, Complainant #2, daughter of Patient #1, stated the following:
1. Patient #1 had been seen several times at Hospital #1 before, once for pneumonia (infection in the lungs). They had his records. The Emergency Department (ED) Physician for Hospital #1 said that Patient #1 had a mini-stroke and needed to see a neurologist. Hospital #2 had the only neurologist available.
2. "I arrived at [Hospital #2] around 11 am. I found him in the ICU [intensive care unit]. He was discharged around noon. My question was, "Why was he not kept for observation?''

C. Record review of page 7 of the 25 page transfer packet from Hospital #1 to Hospital #2 for Patient #1 dated 06/29/15 recorded at 08:47 pm indicated the following under "History of present illness": Chief Complaint: weakness, facial droop and difficulty standing and walking. The patient has had new onset of weakness of the right face (moderate) right arm (moderate), right leg (moderate), right foot (moderate). No numbness, tingling, impaired speech, or swallowing or visual disturbance. No recent fall. The patient has difficulty walking. This started today at 1400 [2:00] PM but is better now. At its maximum deficit described as moderate. When seen in the E.D. [emergency department], it was gone. No dizziness, altered mental status, seizure or blackouts....Similar symptoms previously: None."

D. On 10/21/15 at 2:15 pm during interview, the Attending Physician confirmed that she had not seen the packet for Patient #1 from Hospital #1 on the night of his admission to the Medical Intensive Care Unit at Hospital #2. She stated she was not aware of the stroke symptoms. She confirmed she had spoken with a physician at Hospital #1 and accepted the patient. From that verbal report she believed that the only issue was malignant (extreme) hypertension. The patient departed Hospital #1 on a blood pressure medicine drip and was transferred via ambulance. She also confirmed that she was rounding (visiting patients) with the medical and nursing team when Patient #1 was discharged by the intern. She did not sign off on the intern's discharge note. Note: the attending or senior physician is responsible for the intern while in training and is responsible for the intern. The intern was on his first shift on the Medical Intensive Care Unit. The intern stated that he had not seen the transfer packet from Hospital #1 for Patient #1.

E. Record review of Patient #1's Nursing Notes for his stay in Hospital #1 on 06/30/15 identified no physical weakness or problems. His blood pressure remained normal throughout the night.

F. On 10/22/15 at 11:45 am during interview, the Risk Manager offered the following:
1. "Once we heard from the family I started my investigation."
2. "The quality team met with the Medical Director of the MICU and her team to discuss how we could ensure the attending physicians sign off on all discharges [produced by interns]."

G. On 10/21/15 at 3:30 pm during interview, the MICU Manager stated the following: "The problem my investigation revealed is the attending did not sign off on the discharge of [Patient #1]. We are looking at how we can fix that. I think it is a training issue."