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CLEVELAND CLINIC HOSPITAL 3100 WESTON RD WESTON, FL 33331 Nov. 13, 2019
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on document review and staff interview, the hospital failed to ensure the medical staff was held accountable for the quality of care provided to patients when failing to write orders instructing the nursing staff on the care to provide to the patient's post-operative incision and drains in 1 of 3 sampled patients (#1).
The findings:

Patient #1

On 09/21/2019 at 7:06 AM, patient #1 presented, via private transportation to the emergency room . His complaint was shortness of breath. The clinical impression revealed Dyspnea, Pleural effusion, Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present, metastatic cancer.

On 09/23/2019, the cardio thoracic surgeon was consulted regarding the management of recurrent pleural effusion. The surgeon's assessment and plan, on 09/24/2019, was to perform a Bronchoscopy, Right Video-assisted thoracoscopic surgery (VATS), pleural biopsy, decortication, pleurx catheter insertion. The rest of the care as per the Medical Intensive Care Team.

On 09/24/2019, Review of the cardio thoracic surgeon's operative note revealed the procedure was a right thoracoscopy with biopsy(ies) of Pleura. The postoperative diagnosis: Loculated right pleural effusion with entrapped lung Metastatic renal cell cancer/lung metastasis. 3 28 French 4-channel drains were placed to adequately drain the entire hemithorax. 4 grams of talc were then insufflated covering the pleural surfaces of the lung and the chest wall.

Review of the cardio thoracic team/physician post-operative orders failed to reveal an order instructing nursing on how to care for the patient's post-operative incision, drains, and drainage.

Review of the General Surgery Resident progress note, on 09/28/2019, revealed chest tubes to water seal, rest of care per Medical Intensive Care Unit team, thoracic surgery will follow as a consulting service. There were no orders instructing nursing on how to care for the patient's post-operative incision, drains, and drainage.

Review of the General Surgery Resident progress note, on 10/03/2019, revealed continue the chest tubes to bulb suction, daily chest x-ray in AM, rest of care as per primary team. There were no orders instructing nursing on how to care for the patient's post-operative incision, drains, and drainage.

On 10/21/2019, nursing noted they paged the physician as the patient's 3 Jackson Pratt drains have clots in the lines, not draining effectively. Patient asking about changing the drains; physician with cardio thoracic surgical team, at bedside changing dressings on right flank and changing Jackson Pratt bulbs. The cardio thoracic surgical team will come by to do debridement and to have Lidocaine and Dakin's.

On 10/21/2019, review of the Wound Debridement performed, at the patient's bedside, by the cardio thoracic team/surgeon, revealed a wound dehiscence.

During an interview with the wound care nurse, on 11/13/2019 at 11:00 AM, she stated she received the consult for patient #1, on 10/21/19, specifically for the right flank wound (the surgical incision). She stated the cardio thoracic surgeon had already performed the debridement and there were wound care orders in place including wet to dry which is saline gauge and then covered with ABDs.

On 10/24/2019, a second Wound Debridement was performed at the bedside, by the cardio thoracic team/surgeon. It was a right chest wound debridement and wound vac placement.

During an interview with the Director of Quality and the Associate Chief Nursing Officer, on 11/13/2019 at 5:00 PM, they both agreed there were no physician orders from the cardio thoracic team/surgeon, or the physicians managing the patient's care in the Medical Intensive Care Unit, instructing nursing on how to care for the post-operative incision, drains, and the drainage, until 10/21/2019, when the cardio thoracic team/surgeon was contacted to examine the incision. Subsequent to that examination by the cardio thoracic team/surgeon's, two debridement's were performed, a wound vac was applied, and the wound care nurse was consulted.

The Director of Quality and the Associate Chief Nursing Officer both agreed the cardio thoracic team/surgeon and physicians managing the patient's care in the Medical Intensive Care Unit, should have written orders instructing nursing on the care to provide to the patient's post-operative incision, drains, and the drainage.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on document review and staff interviews, the hospital failed to ensure the nursing staff developed a nursing care plan that was consistent with the plan for medical care of the practitioner responsible for the care of the patient by not obtaining an order from that practitioner on the care to provide to the patient's post-operative incision and drains in 1 of 3 sampled patients (#1).

The findings:

Patient #1

On 09/21/2019 at 7:06 AM, patient #1 presented, via private transportation to the emergency room . His complaint was shortness of breath. The clinical impression revealed Dyspnea, Pleural effusion, Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present, metastatic cancer.

On 09/23/2019, the cardio thoracic surgeon was consulted regarding the management of recurrent pleural effusion. The surgeon's assessment and plan, on 09/24/2019, was to perform a Bronchoscopy, Right Video-assisted thoracoscopic surgery (VATS), pleural biopsy, decortication, pleurx catheter insertion. The rest of the care as per the Medical Intensive Care Team.

On 09/24/2019, Review of the cardio thoracic surgeon's operative note revealed the procedure was a right thoracoscopy with biopsy(ies) of Pleura. The postoperative diagnosis: Loculated right pleural effusion with entrapped lung Metastatic renal cell cancer/lung metastasis. 3 28 French 4-channel drains were placed to adequately drain the entire hemithorax. 4 grams of talc were then insufflated covering the pleural surfaces of the lung and the chest wall.

Review of the cardio thoracic team/physician orders failed to reveal an order instructing nursing on how to care for the incision, drains, and drainage.

Review of the Nursing Progress Notes revealed nursing was following the incision and drains without a physician order instructing nursing on how to care for the incision, drains, and drainage.

09/24/2019, nursing noted chest tubes x3 - sanguineous drainage present. Air leak present.

09/25/2019, nursing noted chest tubes x3 connected to 1 pleurevac.

Review of the General Surgery Resident progress note, on 09/28/2019, revealed chest tubes to water seal, rest of care per Medical Intensive Care Unit team, thoracic surgery will follow as a consulting service. There were no orders instructing nursing on how to care for the incision, drains, and drainage.

Review of the Nursing Progress Notes revealed nursing continued following the incision and drains without a physician order instructing nursing on how to care for the incision, drains, and drainage.

10/02/2019, nursing noted chest tubes verified

10/03/2019, nursing noted emptied all Jackson Pratt drainage.

Review of the General Surgery Resident progress note, on 10/03/2019, revealed continue the chest tubes to bulb suction, daily chest x-ray in AM, rest of care as per primary team. There were no orders instructing nursing on how to care for the incision, drains, and drainage.

Review of the Nursing Progress Notes revealed nursing continued following the incision and drains without a physician order instructing nursing on how to care for the incision, drains, and drainage.

10/06/2019, nursing noted they changed patient right chest tube dressing

10/12/2019, nursing noted they changed the Jackson Pratt bulb suctions

10/21/2019, nursing noted they paged the physician as the patient's 3 Jackson Pratt drains have clots in the lines, not draining effectively. Patient asking about changing the drains; physician with cardio thoracic surgical team, at bedside changing dressings on right flank and changing Jackson Pratt bulbs. The cardio thoracic surgical team will come by to do debridement and to have Lidocaine and Dakin's.

On 10/21/2019, review of the Wound Debridement performed, at the patient's bedside, by the cardio thoracic team/surgeon, revealed a wound dehiscence.

During an interview with the wound care nurse, on 11/13/2019 at 11:00 AM, she stated she received the consult for patient #1, on 10/21/19, specifically for the right flank wound (the surgical incision). She stated the cardio thoracic surgeon had already performed the debridement and there were wound care orders in place including wet to dry which is saline gauge and then covered with ABDs.

On 10/24/2019, a second Wound Debridement was performed at the bedside, by the cardio thoracic team/surgeon. It was a right chest wound debridement and wound vac placement.

During an interview with the Director of Quality and the Associate Chief Nursing Officer, on 11/13/2019 at 5:00 PM, they both agreed there were no physician orders from the cardio thoracic team/surgeon, or the physicians managing the patient's care in the Medical Intensive Care Unit, instructing nursing on how to care for the post-operative incision, the drains, and the drainage, until 10/21/2019, when the cardio thoracic team/surgeon was contacted to examine the incision. Subsequent to that examination by the cardio thoracic team/surgeon's, two debridement's were performed, a wound vac was applied, and the wound care nurse was consulted.

The Director of Quality and the Associate Chief Nursing Officer stated they do not have a policy and procedure instructing nursing on how to care for a post-operative incision, drains, and drainage. They both looked in the Lippincott Nursing Guidelines, which they state they often refer to, and could not locate anything regarding how to care for a post-operative Bronchoscopy, Right Video-assisted Thoracoscopic Surgery (VATS), Right Thoracotomy, Pleural Effusion drainage, 3 Right Chest Tubes insertion, and talc pleurodesis. They both agreed nursing should have obtained an order regarding the care for patient #1's incision, drains, and drainage.