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.
| UNIVERSITY HEALTH SYSTEM | 4502 MEDICAL DR SAN ANTONIO, TX 78229 | Sept. 5, 2013 |
| VIOLATION: PATIENT SAFETY | Tag No: A0286 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to follow their Clinical Quality Improvement Performance Improvement Plan policies and procedures related to an adverse event that occurred to Patient #1 while he was admitted to the facility emergency room . Findings included: Record review of patient #1's medical record revealed that he was admitted on [DATE] and was seen by the physician at 2148 PM. Patient's admitting diagnosis included but was not limited to: (1) fall; (2) light headed; (3) right femur contusion; and (4) hyperamonia. Patient #1 was listed under past history as having Hepatitis B, Cirrhosis, and Cerebella Degeneration. Patient remained in the emergency department until he was transferred to intensive care unit on 03/16/13 at 2200 PM after he went into respiratory distress on 03/16/13 at 1604 PM. Record review of a complaint, dated 05/08/13, filed with facility Patient Relations by Patient #1's wife revealed but was not limited to the following concern: "A friend who was with my husband (Patient #1) in emergency room (ER) told me that medical staff asked him to bring Ensure as it was not available in ER, he brought Ensure and nurse fed him through PEG tube in front of him. I asked the Intensive Care Unit (ICU) doctor about it and they looked into ER notes and told me that there is no documentation about feeding him in the ER. I want you to look into this matter. Why he was fed in ER and why it was not documented?. " Record review of emergency room Physician's Orders, entered into facility ordering system on 03/15/13 at 10:44 PM revealed that "Patient (#1) is not to be given anything PO (by mouth), only via PEG (Percutaneous endoscopic gastronomy) tube. The Emgency Room Physician's orders did not have a documented order for Ensure. Record review of narrative nursing notes, dated 03/16/13 at 0854 revealed the following documentation by registered nurse (RN) #1: "Notified ____, dietician, patient (Patient #1) requesting Ensure As per PA (Physician's Assistant) Wells, patient can have Ensure or equivalent". Continued review of narrative nursing notes for 03/16/13 at 1300 revealed the following documentation by RN #1: "No new orders at this time. Pending admit. Family member states patient can have 2 Ensure for lunch. Will continue to monitor." Continued review of the narrative nursing notes, dated 03/16/13 at 1604 revealed the following documentation by RN#1: "Patient began to produce gargling sound and head of bed elevated. Patient sats (referring to oxygen saturations) began to drop and was placed on oxygen. Patient then began to vomit into basin and wall suctioning performed into mouth. Notified PCC (Primary Care Provider) about change in patients conditions and was told to upgrade to Medical Resuscitation." At 1606 PM, RN #1 documented: "Notified MD (Medical Doctor) about change in patient's condition. MD ordered 4 mg zofran X2, and ordered wall suction to PEG tube." Record review of facility emails related to the complaint filed by Patient #1's wife revealed the following: In an email dated 06/17/13 from staff in the Emergency Department to the Patient Relations Department staff: " I have reviewed the medical record (of Patient #1) and can find no order for or documentation of Ensure being given. The RN makes reference to patient requesting Ensure and PA saying patient could indeed have Ensure. I have requested that the RN in question review the chart and respond back to me." Continued review of an email from the Emergency Department to Patient Relations, dated 06/18/13, revealed the following: " I spoke with the RN involved and he states that the family member at bedside insisted that the patient have Ensure as it was his regular time to have it. The RN states he obtained a "verbal order" for Ensure from the PA caring for the patient. The family did not wait for the Ensure to come from Dietary, left and came back with Ensure and gave it to the RN who then in turn gave it through he patient's PEG tube". Record review of Emergency Department Overview and Observations regarding the use of Ensure by Patient #1 in the ER , prepared by Peer Review Coordinator on 05/17/2013, revealed but was not limited to the following concerns documented regarding the nursing care received by Patient #1: "Did the patient get Ensure?, Who gave it?, How was it given? By mouth or PEG?, How much?, Was the head of bed (HOB) elevated?" Record review of Clinical Quality Improvement Performance Improvement Plan Policy , effective 03/27/13, revealed but was not limited to the following: The objectives of the Quality Plan included "to review deviations from desired or expected outcomes; and to identify important single clinical events in the process or outcome of care which may warrant an indepth review, evaluation and/or action. The Quality/Risk Management (QRM) Committee is the forum to assess and direct the improvement of the quality and safety of patient care though the Health System. The QRM Committee will collect, receive, disseminate and coordinate information related to clinical quality improvement, risk management activities and patient satisfaction. The QRM will promote information sharing among clinical services/department and other appropriate areas of the Health System where interrelated processes's are cross-disciplinary and cross departmental." Interview on 08/29/13 at 11:35 and again on 09/05/13 at 12:10 PM with the Peer Review Coordinator confirmed that she began her Emergency Department Overview and Observations form after Patient #1's spouse filed her complaint on 05/08/13. She further confirmed that the information contained in her Emergency Department Overview and Observations regarding the use of Ensure by Patient #1 were not incorporated into the facility Clinical Quality Improvement Performance Improvement Plan. She confirmed this information had not been documented as an adverse clinical outcome nor had it been discussed by a QRM committee. |
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| VIOLATION: NURSING CARE PLAN | Tag No: A0396 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that for one of one patients (Patient #1), the nursing staff accurately documented Patient #1's nursing care that included a verbal order for Ensure and documentation of Patient #1 receiving Ensure while admitted to the hospital emergency department. Findings included: Record review of patient #1's medical record revealed that he was admitted on [DATE] and was seen by the physician at 2148 PM. Patient's admitting diagnosis included but was not limited to: (1) fall; (2) light headed; (3) right femur contusion; and (4) hyperamonia. Patient #1 was listed under past history as having Hepatitis B, Cirrhosis, and Cerebella Degeneration. Patient remained in the emergency department until he was transferred to intensive care unit on 03/16/13 at 2200 PM after he went into respiratory distress on 03/16/13 at 1604 PM. Record review of a complaint, dated 05/08/13, filed with facility Patient Relations by Patient #1's wife revealed but was not limited to the following concern: "A friend who was with my husband (Patient #1) in emergency room (ER) told me that medical staff asked him to bring Ensure as it was not available in ER, he brought Ensure and nurse fed him through PEG tube in front of him. I asked the Intensive Care Unit (ICU) doctor about it and they looked into ER notes and told me that there is no documentation about feeding him in the ER. I want you to look into this matter. Why he was fed in ER and why it was not documented?. " Record review of emergency room Physician's Orders, entered into hospital ordering system on 03/15/13 at 10:44 PM revealed that "Patient (#1) is not to be given anything PO (by mouth), only via PEG (Percutaneous endoscopic gastronomy) tube. The Emgency Room Physician's orders did not have a documented order for Ensure. Record review of narrative nursing notes, dated 03/16/13 at 0854 revealed the following documentation by registered nurse (RN) #1: "Notified ____, dietician, patient (Patient #1) requesting Ensure As per PA (Physician's Assistant) Wells, patient can have Ensure or equivalent". Continued review of narrative nursing notes for 03/16/13 at 1300 revealed the following documentation by RN #1: "No new orders at this time. Pending admit. Family member states patient can have 2 Ensure for lunch. Will continue to monitor." Continued review of the narrative nursing notes, dated 03/16/13 at 1604 revealed the following documentation by RN#1: "Patient began to produce gargling sound and head of bed elevated. Patient sats (referring to oxygen saturations) began to drop and was placed on oxygen. Patient then began to vomit into basin and wall suctioning performed into mouth. Notified PCC (Primary Care Provider) about change in patients conditions and was told to upgrade to Medical Resuscitation." At 1606 PM, RN #1 documented: "Notified MD (Medical Doctor) about change in patient's condition. MD ordered 4 mg zofran X2, and ordered wall suction to PEG tube." Record review of Emergency Department Overview and Observations, prepared by Peer Review Coordinator on 05/17/2013, revealed but was not limited to the following concerns documented regarding the nursing care received by Patient #1: "Did the patient get Ensure?, Who gave it?, How was it given? By mouth or PEG?, How much?, Was the head of bed (HOB) elevated?" Record review of hospital emails related to the grievance filed by Patient #1's wife revealed the following: In an email dated 06/17/13 from staff in the Emergency Department to the Patient Relations Department staff: " I have reviewed the medical record (of Patient #1) and can find no order for or documentation of Ensure being given. The registered nurse (RN) makes reference to patient requesting Ensure and PA saying patient could indeed have Ensure. I have requested that the RN in question review the chart and respond back to me." Continued review of an email from the Emergency Department to Patient Relations, dated 06/18/13, revealed the following: " I spoke with the RN involved and he states that the family member at bedside insisted that the patient have Ensure as it was his regular time to have it. The RN states he obtained a "verbal order" for Ensure from the PA caring for the patient. The family did not wait for the Ensure to come from Dietary, left and came back with Ensure and gave it to the RN who then in turn gave it through he patient's PEG tube". Record review of facility policy entitled Placement Confirmation of Enteral or Gastric Tubes Used for Administration of Medications and Tube Feeding Guidelines, effective date of 10/05/12, revealed but was not limited to the following: "Level of Responsibility for RN: "Written order to begin use of feeding tube indicating type of formula, strength and rate of feeding. Elevate head of bed (HOB) 30 to 45 degrees while tube feedings are in progress. Elevate HOB for at least 30 minutes after documentation of bolus feedings. Documentation: Record formula intake amount and periodic flush/irrigation amounts on the intake and output flow sheet of the record. Record formula strength, volume hung, rate and "Kangaroo Pump tube change on the Routine MAR (Medication Administration Record). Document patient response or tolerance to tube feedings in the medical record." Interview on 08/29/13 at 11:35 and again on 09/05/13 at 12:10 PM with the Peer Review Coordinator confirmed that RN #1 did not document a verbal order for the use of the Ensure and did not follow the facility policy for documenting giving the Ensure through Patient #1's PEG tube. She confirmed it is unknown how much Ensure was given, what time the Ensure was given, and whether Patient #1's head of bed (HOB) was elevated while and after the Ensure was being given. |
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| VIOLATION: VERBAL ORDERS AUTHENTICATED BASED ON LAW | Tag No: A0457 | |
| Based on record reviews and interviews, the facility failed to ensure that a verbal order for the use of Ensure was documented and signed by a facility approved practitioner in patient #1's medical record. Patient #1 was given the Ensure after being admitted to the facility emergency department. Findings included: Record review of patient #1's medical record revealed that he was admitted to the facility emergency department on 03/15/13 and first seen by the physician at 2148 PM. Patient's admitting diagnosis included but was not limited to: (1) fall; (2) light headed; (3) right femur contusion; and (4) hyperamonia. Patient #1 was listed under Past history as having Hepatitis B, Cirrhosis, and Cerebella Degeneration. Record review of emergency room Physician's Orders, dated 03/15/13 to 03/16/13, failed to reveal an order for the use of Ensure. Record review of Emergency Department Nursing Narrative Notes, dated 03/16/13 at 0854 AM, and completed by Registered Nurse (RN) #1 revealed the following statement: Notified _____ , dietician patient (#1) was requesting Ensure. As per PA ______(physician's assistant #1), patient can have Ensure or equivalent. Continued review of Emergency Department Nursing Narrative Notes, dated 03/16/13 at 1300, included but was not limited to the following: " No new orders at this time. Pending admit. Family member states patient can have 2 Ensure for lunch. Will continue to monitor." Record review of facility emails related to the compliant filed by Patient #1's wife revealed the following: In an email dated 06/17/13 from staff in the Emergency Department to the Patient Relations Department staff: " I have reviewed the medical record (of Patient #1) and can find no order for or documentation of Ensure being given. The RN makes reference to patient requesting Ensure and PA saying patient could indeed have Ensure. I have requested that the RN in question review the chart and respond back to me." Continued review of an email from the Emergency Department to Patient Relations, dated 06/18/13, revealed the following: " I spoke with the RN involved and he states that the family member at bedside insisted that the patient have Ensure as it was his regular time to have it. The RN states he obtained a "verbal order" for Ensure from the PA caring for the patient. The family did not wait for the Ensure to come from Dietary, left and came back with Ensure and gave it to the RN who then in turn gave it through he patient's PEG tube". Record review of facility Record Content and Completion Requirements policy, effective 02/28/13, revealed the following: Diagnostic and Therapeutic Orders in all Settings: Verbal orders may be accepted by designated registered nurses (RN), but are to be used infrequently and must be signed by the practitioner within 48 hours of having been issued. Interview on 08/29 and again on 09/05/13 with facility Peer Review Coordinator confirmed that no order for the Ensure was found in Patient #1's medical record. She also confirmed that based on facility interview with Emgency Room RN, Patient #1 was given the Ensure by PEG tube. |
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