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Based on record review and interview the facility failed to provide documented evidence that an evaluation and analysis was conducted following an adverse patient outcome resulting in the death of a patient.

The facility failed to ensure patients leaving the facility for higher level of care were evaluated prior to transfer to ensure optimum health and quality of care is maintained during the transfer.

The facility failed to implement its quality policy to ensure adverse occurrences are evaluated and analyzed in an effort to improve and maintain quality of care and patient safety. Citing two(2) of two(2) patients identified in a complaint investigation TX 00155002 and TX 00155003.

Findings:

Review of complaint narative revealed allegations that on two occassions when two transferred patients arived at Hospital S from Hospital G, the patients were immediately assessed to be in critical condition requiring advanced cardiac life support when report from Hospital G and transport documentation reflected the patients were stable for transport.

( Refer to 482.21(a)(2) for details.).

Based on record review, and interview the facility failed to implement its discharge policy and procedure to ensure critically ill patients who required specialized life saving intervention at another facility was transferred to that facility in a timely manner with the necessary life sustaining equipment needed to maintain the patient in optimal condition during the transfer process;

The facility's physicians and nurses failed to evaluate and develop a plan of care for the patients prior to transfer to determine the appropriate care, and equipment needed during the transfer, citing two patients identified in complaint investigation TX00155002 & TX 00155003 patient #s 1 and 2.

Findings:

Review of complaint narative revealed allegations that on two occassions when two transferred patients arived at Hospital S from Hospital G, the patients were immediately assessed to be in critical condition requiring advanced cardiac life support when report from Hospital G and transport documentation reflected the patients were stable for transport.

( Refer to 482.43(d) fo details. )

Based on record review, and interview the facility failed to implement its discharge policy and procedure to ensure critically ill patients who required specialized life saving intervention at another facility was transferred to that facility in a timely manner with the necessary life sustaining equipment needed to maintain the patient in optimal condition during the transfer process;

The facility's physicians and nurses failed to evaluate and develop a plan of care for the patients prior to transfer to determine the appropriate care, and equipment needed during the transfer, citing two (2) of two (2) patients identified in a complaint investigation TX00155002 & TX00155003 patient #s 1 and 2.

Findings:

Review of complaint narative revealed allegations that on two occassions when two transferred patients arived at Hospital S from Hospital G, the patients were immediately assessed to be in critical condition requiring advanced cardiac life support when report from Hospital G and transport documentation reflected the patients were stable for transport.


Review of the facility's Current Discharge Planning Policy # 900-326 revised 5/08 documented the following information:

"Discharge Planning will be integrated with the interdisciplinary department to assure collaboration of services of discharge planning. Discharge Planning will ensure that the patient will be assisted in regaining optimum level of functioning by identifying the patients' continuing physical, emotional, symptom management ( for example: pain, nausea, dysphasia) housekeeping, transportation, social and other needs and arranges for services to meet them.


The relationship of Discharge Planning with other departments is as follows:

The physician will make referrals for discharge planning needs and make recommendations for the plan of care. He/She is responsible for written orders for same.

Documentation

Communication between appropriate disciplines regarding the discharge planning process will be documented on the physician progress notes. This mechanism serves as a means of communication with the physician and other members of the healthcare team any clinical/financial /psychological issues related to discharge. Patient and family education is documented on the discharge summary. The discharge instruction sheet is given to the patient at the time of discharge and a copy is retained in the medical
record".

Review of clinical record for Patient (# 1) dated 10/4/11- 10/7/11.

Review of demographic data revealed twenty (20) years old Patient (# 1) was 39 weeks pregnant with her first child.

Review of admission nursing notes revealed the following information:
On 10/4/11 at 6:40 am she was admitted to the hospital ' s labor and delivery suite for induction of labor.

There was documentation that the patient voided 80 cc (cubic centimeter) of yellow urine which tested with a trace of protein and 2+ of ketone. She had edema 1+ on both lower extremities up to her knees.
Her hematology report dated 10/4/11 documented Patient (# 1) had a Hemoglobin level of 7.3

Intravenous(IV) line was inserted and at 0723 bolus of Dextrose 5% Lactaid Ringers solution was administered. Cytotec 100 mcg was administered orally to induce labor.

Between the hours of 08:00 am and 12:27 pm on 10/4/11 Patient # 1 was started on oxygen via face mask. An amniotomy was done (artificial rupture of membranes) and she was given 4(four) milligrams of Zofran IV (Intra Venous) push.

Nurses ' notes at 08:30 made documentation that the patient complained of feeling cold, nauseous and that she was coughing and spitting up pink tinge mucous. There was documentation that the Obstetrician was aware.
At 11:50 the patient complained of pain and an epidural was started, she voided 30 cc of urine. (Bolus IV fluid infusing since 07:30).

Further review revealed between 12:30 and 16:15 the patient ' s blood pressure was dropping and remained with systolic 80-90 and diastolic in the 50s. Her heart rate remained elevated at 116-129.
documented vital signs at 1315 blood pressure 90/50

There was documentation that Patient # 1 was having occasional episode of cough and spitting up pink tinge mucous.

Patient # 1 had a Foley catheter placed on 10/4/11 at 12:51.
At 16:50 the Foley was discontinued with 100 cc of dark urine in bag. IV fluid was still infusing.

Further review of the nurses ' notes revealed Patient # 1 delivered a live male infant at 17:05 on 11/4/11. Blood pressure was 100/56, pulse 131, respiration 22. Placenta was delivered at 17:09 and the patient lost 600 cc of blood.

Patient #1 was transfused two units of packed Red Cells. There was documentation that the blood was transfused rapidly. The first unit started at 17:24 and the second unit started at 17:45. (Infused less than 30 minutes).Intra Venous fluid 500 mills bolus was also infusing.

Vital signs at that time were as follows: Blood pressure 80/31, heart rate 116, respiration 22, ten (10) Liters of oxygen via nasal catheter with oxygen saturation at 86%.

There was documentation that the patient was still coughing and spitting up pink tinge mucous. The second unit of blood was completed at 18:00. Foley catheter was re-inserted.

At 18:04 a portable chest x-ray was ordered. Oxygen saturation was 92% with oxygen via face mask. Blood pressure still very low (70/45). The patient complained of increased difficulty breathing, she was still coughing. Her color was pale; she had normal saline infusing at 30 cc (cubic centimeters) an hour.

At 18:20 Lactaid Ringers solution was infusing at 100 cc an hour. Her urinary out put was very low 45 cc (she received 1500ccs of fluid since 17:24).

Review of radiology report revealed a chest x-ray done on 10/4/11 at 6:15 pm.
Reason for examination, cough.
Diagnosis is coughing with post partum bleeding.

Findings: There is mild Cardiomegaly with mild central vascular congestion. There are air space opacities throughout the right lung, most prominently in the right lower lung.
There is also left retro cardiac opacity. No pleural effusion or pneumothorax. No acute bony abnormality.

Impression: Opacities throughout the right lung as well as Left retro cardiac opacity, which may represent multifocal pneumonia or pulmonary edema.

Mild cardiomegaly with mild central vascular congestion

Review of nurses notes dated 10/4/11 revealed at 19:00 Patient (#1) was transferred to the Intensive Care Unit (ICU). She was on 10 liters of oxygen (O 2) via non re-breather mask. O 2 saturation was 86%. Blood pressure 128/64, pulse 132.

Review of Physician notes dated 10/4/11 documented the physician was consulted for respiratory distress and pneumonia. The physician summarized his findings as follows:
"the patient is in respiratory distress, afebrile, blood pressure 128/74, pulse 140-150 sinus tachycardia, oxygen saturation 70% -90% on non rebreather mask.

Lungs: bibasilar rales with ronchi on right side all the way up. Rales in the left base. Increased respiratory rate and effort.
Heart: tachycardia but regular. Bilateral pedal edema (1+). The patient was saying she wanted to sit up because she could not breathe".
The physician's plan was for intubation and multiple medications

Review of ICU nursing documentation timed at 1930-00:00 revealed the following information:

No other time was noted on the narrative. There was documentation that the physicians were aware of the patient ' s condition and orders were administered per prescribed order.

There was documentation that the physician placed a central line. The patient remained pale, she was afebrile, normal saline was infusing at 200 cc an hour. There were decreased breath sounds to the right side, she was restless, still coughing, had orange color secretions. Oxygen saturation in the 70-80s.( normal oxygen saturation is 100% on room air).

Propofol (sedative) was administered for light sedation. She was orally intubated and a nasogastric tube was placed.

The nurses ' notes documented that a portable x-ray was done. IV fluid was infusing at 200 cc an hour. Urinary output from 19:30 to midnight was 55 cc and from midnight to morning was 20 cc, physician aware.

Review of physician's notes dated 10/5/11 at 4:15 pm gave the following information:

"we tried to do pressure control ventilation unfortunately with this the patient desatted even further and could not tolerate.
I increased the PEEP to 20 with the inverse ratio ventilation.
At the same time we increased her rocuronium. She was already on maximum dose of diprivan. With this her O 2 saturation started to slowly rise. She is currently holding at around 90% o2 saturation. blood pressure is 99/70 and heart rate around 135. She is on levophed at maximum dose, neo-synepherine at 40 mcg/kg/minute and vasopressin.
Lungs remain unchanged. It doesn ' t ' t sound as bad as what is seen on chest x-ray. She is now completely paralyzed.

Current ventilator settings: include "assist control rate of 18, tidal volume of 500, Fi02 of 100, PEEP( Positive End Expiratory Pressure) of 20 and peak flow of 25".

Review of Nurses notes dated 10/5/11 - 10/6/11 revealed documentation that Patient (# 1) remained sedated with increasing respiratory distress. She was suctioned copious amount of orange colored secretion. Her oxygen saturation fluctuated, heart rate in the 120s with low blood pressure. Urinary output remained low. The patient also developed low grade fever (100.5).
.
Nurse ' s notes dated 10/7/11 at 07:15 documented that the patient was received sedated and paralyzed. She was still intubated and on a vent with PEEP at 12. She was on multiple IV medications.

Review of the Memorandum of Transfer (MOT) dated 10/7/11 revealed the facility requested Emergency Medical Personnel, Ventilator, Monitor and IV pumps. The patient was to be transferred for higher level of care due to respiratory distress.


On 10/7/11 at 12:00 there was documentation that a call was received from Hospital S, that the patient was accepted for admission. Report was called to Hospital S, and the facility ' s contracted ambulance service was called.

There was documentation that at 13:00 the patient was transported out by the ambulance service. At that time her blood pressure was 122/77 and pulse 122, vasopressin 0.04 units per minute, ativan 2 mg an hour, normal saline at 100 cc an hour, Fentanyl at 25 mcg an hour and oxygen saturation at 92%. There was no documentation that the patient went out on a ventilator. There was no mention of the patient ' s level of consciousness when she left the unit.

Review of physician orders revealed there were no documented physician ' s instructions for the transfer.

Review of Intensive Care Unit (ICU) nurses notes dated 10/7/11 at 14:00 documented the patient was back on the unit due to decrease in oxygen saturation to 40 per EMS. Bag was initiated and the patient returned to room 808.

On arrival vital signs were as follows: blood pressure 112/76, pulse 129, respiration 31, pulse Oximetry 96% on ambu bag. The patient was placed back on the respirator at previous settings". No mention of the patient's level of consciousness.

When the patient returned to the ICU there was documentation of medication changes per verbal order. There was no documentation that the physician evaluated the patient ' s condition after she returned to the ICU.

Further review of the nursing documentation revealed there were three entries on the document all timed at 16:00 with the following information:

(1)16:00: patient transferred out by EMS to Hospital S with blood pressure of 100/73, pulse 117, respiration 23, oxygen saturation 100% with current ventilator setting settings.(last documentation on vent settings was on 10/7/11 at 0715).

(2)1600: 'diprivan drip at 3 mcg, levophed drip at 16 mcg/min, arterial line to RRA good waveform peripheral nerve stimulator 44". Pupils sluggishly reactive, sclera edema, no facial grimace to sternal rub.

Vasopressin drip at 0.04 units/min Normal saline 100ccan hour Po 2 saturation 100%. Nail bed blanching well, elevate head of bed, general swelling to body. Urine dark yellow, Sinus tachycardia.

(3)1600: Auscultated for breath sound, crackles present bilateral, O 2 saturation 100%. EMS here, family to follow.

There was no documentation of the patient's level of consciousness or wether or not she was stable for transfer. There was no documentation on the patient's respiratory status and the type of respiration support used to transport the patient from the facility to the accepting hospital. There was no documentation of the amount of oxygen support the patient was on.

Review of clinical record at Hospital S.

Review of the Patient's information flow sheet at Hospital S revealed Patient (#1) arrived at the facility on 10/7/11 at 16:52 and was placed in room 207 on the Intensive Care Unit.

Nurses ' notes documented the patient was received from Hospital G accompanied by ambulance attendants. The patient was being bagged by EMT.

The Ambulance attendants told nursing staff that when the patient was placed on the ventilator she was desaturating and the balloon on the Endo Tracheal Tube (ETT) was deflated to make bagging easier.

On 10/7/11 at 17:02 blood pressure dropped in the 50s and heart rate 55. Two physicians on the floor rushed to the patient ' s room.

The Levophed drip was increased. While attempting to check for Carotid pulse, noted patient ' s neck and upper chest with subcutaneous emphysema.

Physician at bedside, stat chest X-ray ordered. A- line on right wrist with poor wave form, unable to obtain blood pressure, no pulse audible or palpable.

At 17:12 Patient(#1) was received with ETT(Endo Tracheal Tube) Pilot deflated. Pilot Cuff re-inflated . Ventilator initialized, then 100% Ambu Bag used for Cardio Pulmonary Resuscitation (CPR).

History and Physical dated 10/7/11 by Physician D at Hospital S documented that when the patient arrived at Hospital S, she was hypoxic and dropped her oxygenation. She was also hypotensive. They could not feel her pulse initially and CPR was started right away. She regained her pulse but was also found to have subcutaneous emphysema; she was connected to a ventilator, although she had a very high peak pressure, the stat chest x-ray done at that time showed bilateral large pneumothorax. Bilateral chest tubes were placed immediately at the bedside.

She was on norepinepherine and vasopressin drip, she was given multiple rounds of epinephrine, atropine and CPR was resumed. Through out the course she remained in PEA (Pulseless Electrical Activity). CPR continued for more than an hour the patient never regained her pulse and despite all the efforts there was no change in her status. The patient was pronounced dead at 6:20 pm on October 7, 2011.

Review of Radiology Report at Hospital S documented the following information:
Chest examination dated 10/7/11
1. There are large bilateral pneumothroaces. The lungs are partially collapsed as a result of the pneumothroaces limiting evaluation of the lung parenchyma. No pneumothorax is seen. There is subcutaneous emphysema in the neck and right chest wall.
2. Impression: large bilateral pneumothroaces.( information was urgently communicated to the clinical team)
3. Subcutaneous emphysema
4. endotracheal tube tip approximately 2 cm to the carina.


Review of EMS first report

Review of EMS run sheet revealed the following information:

Arrived on location to find patient sedated and on ventilator. Diagnosis was ARDS (acute respiratory distress syndrome).

Patient was on multiple drips, vasopressin, levophed, propofol, fenrtanyl, and normal saline. Patient was moved from bed and placed on portable vent with setting of RR 22, Vt-500,100% O 2. Peak pressure-50.

When patient was moved to EMS vent noted pink fluid in tube. Suction patient ' s tube with little return. As the patient was loaded into the ambulance the monitor started to beep. The SPo2 was dropping, the vent was working properly. EMT got help from ER Nurse, EMT staff told the Nurse they had to take the patient back to the ICU to be re-evaluated.

The patient was unloaded from the ambulance and taken to the ER, when EMT staff started to use BMV( bag mask valve) to ventilate the patient with great success, the patient ' s saturation went to the high 90s. Patient(#1) was taken back to the ICU and placed on bed (8). Care was transferred to the unit ' s nurses.

There was no documentation on the nurses or physicians' notes at Hospital G that the EMT took the patient to their Emergency Room and what intervention if any was performed by hospital personnel.

Second report

Patient was being transferred to Hospital S, for need of a Pulmonologist for ARDS( Acute Respiratory Distress Syndrome). The patient was on a ventilator and on multiple IV medications. Patient ' s nurse stated that the patient ' s O 2 saturation has been 100% for a long time.

"Moved patient from bed to stretcher. Patient was taken off of ICU ' s ventilator and ventilation. Bag Mask Valve (BMV) was started by EMT. Loaded patient into ambulance".

The EMT documented they unloaded the patient from the ambulance and took her to the ER at Hospital S(should have taken patient to the ICU, because the patient was a direct admission).

Staff in ER wanted to register the patient. EMT documented that they told ER staff to take the patient quickly to her room because of the lack of oxygen. The portable cylinder could hold 1000 pounds of oxygen. and the patient was receiving 15 liters an hour.

The report documented that Respiratory Therapist at Hospital S told the EMT they were bagging the patient too slowly and took over the bagging.
The patient was still on the monitor the patient was transferred on. Nurses and physicians were in attendance trying to find a pulse they could not, and CPR was started.

Patient # 2

Review of nurses ' notes dated 12/14/11 documented patient was admitted to the unit at 1810 from the Emergency Room. She was alert; the patient was hypotensive (low blood pressure) and had generalized edema of the whole body. Patient had multiple whelps on body but no skin breakdown.

Review of nurses notes dated 12/17/11 at 1930 revealed the following information:
Received patient obtunded. Open eyes to sternal rub, makes grunting sound.
12/18/11 at 0745 patient received lethargic, eyes opened at times. Right groin triple lumen site healthy. Pupils remain unequal.

Physician ' s progress notes dated 12/18/11 documented the patient to be transferred to Hospital S today.

Nurses ' notes on 12/18/11 at 0830 documented " spoke with nurse at Hospital S, clinical report regarding transfer given to the nurse; she will call when a bed is ready ' .

Nurses ' notes dated 12/18/11 at 12:00 blood pressure 91/50, rechecked and confirmed. Physician informed new order received and initiated. Started normal saline bolus 250 wide open at 12:10, blood pressure dropped to 72/55. Patient was asymptomatic and when asked how she feels mumbled " okay " . Pupils remain unchanged.

At 12:30 blood pressure 117/50, no sign or symptom of respiratory distress noted.

Called transfer center to check on status, nurse stated the patient was accepted but still awaiting a bed.

At 15:00 no changes in neurological status, pupils still unequal, sluggish, altered mental status, no seizure activity noted. Received call from the transfer center. Report given at 15:45.

Review of the facility ' s Memorandum of Transfer (MOT) dated 12/18/11 revealed a request was made for EMS, O 2, EKG, IV and EMT Personnel.

Further review of the nurses notes dated 12/18/11 revealed documentation that at 16:30 the patient left the unit by stretcher with EMS without incident.

There was no documentation that the physician evaluated the patient after her drop in blood pressure. No documented vital signs or assessment at time of transfer.

No documentation that Patient (#2) was transferred with the required medical equipment that was requested to ensure optimum medical stability during the transfer. There was no documentation from 0745 to 16:30 when the patient left the unit that she was receiving oxygen. There was no documentation regarding her oxygen saturation status. On admission there was documentation that the patient had edema of her entire body, there was no mention in the nurses noted dated 12/18/11 between the hours of 07:45 and 16:30 when she left the unit.

Patient is a 71 year old lying in bed responsive to verbal stimuli only. ICU nurse stated that the patient had been admitted because of neurological changes. Patient on O 2 at 2 LPM with oxygen saturation in the 90s.

According to the nursing staff that was normal for her. IV with Clinimix. Patient was transported to the ICU without incident. Condition remains unchanged.

Review of Discharge Summary from Hospital S dated 2/29/12 documented:

Patient # 2 was transferred from Hospital G on 12/18/11 to be treated for Encephalopathy The transferring staff told the facility that the patient was hemodynamically stable at the time of transfer. On arrival at Hospital S, the patient was hypotensive ( low blood pressure) , and was in respiratory distress.

There was also bleeding from the central venous catheter site. Emergency Room ( ER) physician was called in and the patient was intubated and a new central line was placed. The bleeding was controlled.

Review of policy

Policy #900-338 titled Transfer of patients from GCMC to another facility dated 5/2008 documented the following information:

"The transferring physician must personally examine and evaluate the patient before an attempt to transfer is made.

The transferring physician shall determine and order life support measures which are medically appropriate to stabilize the patient prior to transfer and to sustain the patient during the transfer '
The transferring physician shall determine and order the utilization of appropriate personnel and equipment for transfer.

In determining the use of medically appropriate life support measures, personnel, and equipment, the transferring physician shall exercise that degree of care which a reasonable and prudent physician exercising ordinary care in the same or similar locality would use for the transfer.

If a patient at a hospital has an emergency medical condition which has not been stabilized or when stabilization of the patient ' s vital sign is not possible because the hospital or emergency department does not have the appropriate equipment or personnel to correct the underlying process, evaluation and treatment should be performed and transfer should be carried out as quickly as possible."

During an interview on 3/1/12 at 10:15 am with Staff # 52 RN that transferred the patient, she stated she could not re call if the patient was transferred on ventilator. She reviewed the record but was not able to tell whether or not the patient left the unit on a ventilator.

During an interview on 3/1/11 at 9:30 am with Physician # 53( Hospitalist) he stated the patient was initially in his care and was taken over by physicians from his group. The physician stated a transfer order should have been written. He further stated the patient was not stable enough to be transferred prior to the time she was transferred.( The patient's stability was never evaluated prior to transfer).



During an interview on 2/29/12 at 3:00 pm with Physician # (50) Obstetrician she stated there was a breakdown in communication, she was not informed when the patient was being transferred from the facility. The physician stated she would have ensured the patient was appropriately transferred.

Physician (# 50) stated the patient should have been transferred by air ambulance instead of ground transport especially after the patient desaturated and had to be returned to the unit.

During an interview on 2/29/12 at 1:35 pm with the Chief Nursing Officer she stated she wanted the patient to be transferred by air ambulance but the order was for ground ambulance. The Chief Nursing officer also stated "Administrative personnel were not aware until after the fact that the patient was transferred out without the vent. She further stated patients like those did not do well with bagging " .

During an interview on 3/1/12 at 11:35 am with the Director of the ambulance service, he gave the following information:

The Ambulance Service did not have PEEP (Positive End Expiratory Pressure) capability on their ventilators. The request was made for a vent, PEEP capability was not ordered.

During the interview on 3/1/12 at 11:25 am with the Director of the Ambulance Service he stated the EMT personnel initially took the patient from the unit on a portable vent. When EMT personnel arrived downstairs to the ambulance the patient began to desaturate, her oxygen saturation dropped and they had to get the ER personnel to assist. After two hours had elapsed the EMT personnel were called to transport the patient. There was a discussion with Nurses on the floor and the EMT and nurses decided that since the patient did well on the BVM with PEEP the patient would be transported with the BVM instead of the ventilator.

(There was no assessment by the physician to determine the patient's respiratory status and the type of respiratory support that was needed for the transfer).

Based on record review and interview the facility failed to provide documented evidence that an evaluation and analysis was conducted following an adverse patient outcome resulting in the death of a patient.

The facility failed to ensure patients leaving the facility for higher level of care were evaluated prior to transfer to ensure optimum health and quality of care is maintained during the transfer.

The facility failed to implement its quality policy to ensure adverse occurrences are evaluated and analyzed in an effort to improve and maintain quality of care and patient safety. Citing two(2) of two(2) patients identified in a complaint investigation TX 00155002 and TX 00155003.

Findings:

Review of complaint narative revealed allegations that on two occassions when two transferred patients arived at Hospital S from Hospital G, the patients were immediately assessed to be in critical condition requiring advanced cardiac life support when report from Hospital G and transport documentation reflected the patients were stable for transport.


Review of the facility's curent policy titled Patient Safety Plan dated 8/11 documented the following information:

"The Patient Safety Program is an essential part of the hospital ' s mission of providing exceptional care and services in a safe environment " . The purposes and objectives of this program are to:

Promote a patient safe environment through review of high-risk patient care processes, collection and analysis of adverse patient incident data, and routine investigation of significant adverse events.

Develop proactive patient safety risk reduction strategies based on the National Patient Safety Goals, Sentinel Events Alerts and other related guidelines or best practices.

Aggregate patient safety related data and information to improve professional and organizational performance with a focus on processes and systems.

Provide staff education related actual and potential medical and health care errors and utilize the knowledge gained to improve patient safety. "

There was no evidence the facility investigated the circumstances surrounding two transferred patient complaints sent to the facility to by a receiving hospital. The patients were transferred in October 2011 and December 2011.

Review of clinical record for Patient (# 1) dated 10/4/11- 10/7/11.

Review of demographic data revealed twenty (20) years old Patient (# 1) was 39 weeks pregnant with her first child.

Review of admission nursing notes revealed the following information:
On 10/4/11 at 6:40 am she was admitted to the hospital ' s labor and delivery suite for induction of labor.

There was documentation that the patient voided 80 cc (cubic centimeter) of yellow urine which tested with a trace of protein and 2+ of ketone. She had edema 1+ on both lower extremities up to her knees.
Her hematology report dated 10/4/11 documented Patient (# 1) had a Hemoglobin level of 7.3

Intravenous(IV) line was inserted and at 0723 bolus of Dextrose 5% Lactaid Ringers solution was administered. Cytotec 100 mcg was administered orally to induce labor.

Between the hours of 08:00 am and 12:27 pm on 10/4/11 Patient # 1 was started on oxygen via face mask. An amniotomy was done (artificial rupture of membranes) and she was given 4(four) milligrams of Zofran IV (Intra Venous) push.

Nurses ' notes at 08:30 made documentation that the patient complained of feeling cold, nauseous and that she was coughing and spitting up pink tinge mucous. There was documentation that the Obstetrician was aware.
At 11:50 the patient complained of pain and an epidural was started, she voided 30 cc of urine. (Bolus IV fluid infusing since 07:30).

Further review revealed between 12:30 and 16:15 the patient ' s blood pressure was dropping and remained with systolic 80-90 and diastolic in the 50s. Her heart rate remained elevated at 116-129.
documented vital signs at 1315 blood pressure 90/50

There was documentation that Patient # 1 was having occasional episode of cough and spitting up pink tinge mucous.

Patient # 1 had a Foley catheter placed on 10/4/11 at 12:51.
At 16:50 the Foley was discontinued with 100 cc of dark urine in bag. IV fluid was still infusing.

Further review of the nurses ' notes revealed Patient # 1 delivered a live male infant at 17:05 on 11/4/11. Blood pressure was 100/56, pulse 131, respiration 22. Placenta was delivered at 17:09 and the patient lost 600 cc of blood.

Patient #1 was transfused two units of packed Red Cells. There was documentation that the blood was transfused rapidly. The first unit started at 17:24 and the second unit started at 17:45. (Infused less than 30 minutes).Intra Venous fluid 500 mills bolus was also infusing.

Vital signs at that time were as follows: Blood pressure 80/31, heart rate 116, respiration 22, ten (10) Liters of oxygen via nasal catheter with oxygen saturation at 86%.

There was documentation that the patient was still coughing and spitting up pink tinge mucous. The second unit of blood was completed at 18:00. Foley catheter was re-inserted.

At 18:04 a portable chest x-ray was ordered. Oxygen saturation was 92% with oxygen via face mask. Blood pressure still very low (70/45). The patient complained of increased difficulty breathing, she was still coughing. Her color was pale; she had normal saline infusing at 30 cc (cubic centimeters) an hour.

At 18:20 Lactaid Ringers solution was infusing at 100 cc an hour. Her urinary out put was very low 45 cc (she received 1500ccs of fluid since 17:24).

Review of radiology report revealed a chest x-ray done on 10/4/11 at 6:15 pm.
Reason for examination, cough.
Diagnosis is coughing with post partum bleeding.

Findings: There is mild Cardiomegaly with mild central vascular congestion. There are air space opacities throughout the right lung, most prominently in the right lower lung.
There is also left retro cardiac opacity. No pleural effusion or pneumothorax. No acute bony abnormality.

Impression: Opacities throughout the right lung as well as Left retro cardiac opacity, which may represent multifocal pneumonia or pulmonary edema.

Mild cardiomegaly with mild central vascular congestion

Review of nurses notes dated 10/4/11 revealed at 19:00 Patient (#1) was transferred to the Intensive Care Unit (ICU). She was on 10 liters of oxygen (O 2) via non re-breather mask. O 2 saturation was 86%. Blood pressure 128/64, pulse 132.

Review of Physician notes dated 10/4/11 documented the physician was consulted for respiratory distress and pneumonia. The physician summarized his findings as follows:
"the patient is in respiratory distress, afebrile, blood pressure 128/74, pulse 140-150 sinus tachycardia, oxygen saturation 70% -90% on non rebreather mask.

Lungs: bibasilar rales with ronchi on right side all the way up. Rales in the left base. Increased respiratory rate and effort.
Heart: tachycardia but regular. Bilateral pedal edema (1+). The patient was saying she wanted to sit up because she could not breathe".
The physician's plan was for intubation and multiple medications

Review of ICU nursing documentation timed at 1930-00:00 revealed the following information:

No other time was noted on the narrative. There was documentation that the physicians were aware of the patient ' s condition and orders were administered per prescribed order.

There was documentation that the physician placed a central line. The patient remained pale, she was afebrile, normal saline was infusing at 200 cc an hour. There were decreased breath sounds to the right side, she was restless, still coughing, had orange color secretions. Oxygen saturation in the 70-80s.( normal oxygen saturation is 100% on room air).

Propofol (sedative) was administered for light sedation. She was orally intubated and a nasogastric tube was placed.

The nurses ' notes documented that a portable x-ray was done. IV fluid was infusing at 200 cc an hour. Urinary output from 19:30 to midnight was 55 cc and from midnight to morning was 20 cc, physician aware.

Review of physician's notes dated 10/5/11 at 4:15 pm gave the following information:

"we tried to do pressure control ventilation unfortunately with this the patient desatted even further and could not tolerate.
I increased the PEEP to 20 with the inverse ratio ventilation.
At the same time we increased her rocuronium. She was already on maximum dose of diprivan. With this her O 2 saturation started to slowly rise. She is currently holding at around 90% o2 saturation. blood pressure is 99/70 and heart rate around 135. She is on levophed at maximum dose, neo-synepherine at 40 mcg/kg/minute and vasopressin.
Lungs remain unchanged. It doesn ' t ' t sound as bad as what is seen on chest x-ray. She is now completely paralyzed.

Current ventilator settings: include "assist control rate of 18, tidal volume of 500, Fi02 of 100, PEEP( Positive End Expiratory Pressure) of 20 and peak flow of 25".

Review of Nurses notes dated 10/5/11 - 10/6/11 revealed documentation that Patient (# 1) remained sedated with increasing respiratory distress. She was suctioned copious amount of orange colored secretion. Her oxygen saturation fluctuated, heart rate in the 120s with low blood pressure. Urinary output remained low. The patient also developed low grade fever (100.5).
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Nurse ' s notes dated 10/7/11 at 07:15 documented that the patient was received sedated and paralyzed. She was still intubated and on a vent with PEEP at 12. She was on multiple IV medications.

Review of the Memorandum of Transfer (MOT) dated 10/7/11 revealed the facility requested Emergency Medical Personnel, Ventilator, Monitor and IV pumps. The patient was to be transferred for higher level of care due to respiratory distress.


On 10/7/11 at 12:00 there was documentation that a call was received from Hospital S, that the patient was accepted for admission. Report was called to Hospital S, and the facility ' s contracted ambulance service was called.

There was documentation that at 13:00 the patient was transported out by the ambulance service. At that time her blood pressure was 122/77 and pulse 122, vasopressin 0.04 units per minute, ativan 2 mg an hour, normal saline at 100 cc an hour, Fentanyl at 25 mcg an hour and oxygen saturation at 92%. There was no documentation that the patient went out on a ventilator. There was no mention of the patient ' s level of consciousness when she left the unit.

Review of physician orders revealed there were no documented physician ' s instructions for the transfer.

Review of Intensive Care Unit (ICU) nurses notes dated 10/7/11 at 14:00 documented the patient was back on the unit due to decrease in oxygen saturation to 40 per EMS. Bag was initiated and the patient returned to room 808.

On arrival vital signs were as follows: blood pressure 112/76, pulse 129, respiration 31, pulse Oximetry 96% on ambu bag. The patient was placed back on the respirator at previous settings". No mention of the patient's level of consciousness.

When the patient returned to the ICU there was documentation of medication changes per verbal order. There was no documentation that the physician evaluated the patient ' s condition after she returned to the ICU.

Further review of the nursing documentation revealed there were three entries on the document all timed at 16:00 with the following information:

(1)16:00: patient transferred out by EMS to Hospital S with blood pressure of 100/73, pulse 117, respiration 23, oxygen saturation 100% with current ventilator setting settings.(last documentation on vent settings was on 10/7/11 at 0715).

(2)1600: 'diprivan drip at 3 mcg, levophed drip at 16 mcg/min, arterial line to RRA good waveform peripheral nerve stimulator 44". Pupils sluggishly reactive, sclera edema, no facial grimace to sternal rub.

Vasopressin drip at 0.04 units/min Normal saline 100ccan hour Po 2 saturation 100%. Nail bed blanching well, elevate head of bed, general swelling to body. Urine dark yellow, Sinus tachycardia.

(3)1600: Auscultated for breath sound, crackles present bilateral, O 2 saturation 100%. EMS here, family to follow.

There was no documentation of the patient's level of consciousness or wether or not she was stable for transfer. There was no documentation on the patient's respiratory status and the type of respiration support used to transport the patient from the facility to the accepting hospital. There was no documentation of the amount of oxygen support the patient was on.

Review of clinical record at Hospital S.

Review of the Patient's information flow sheet at Hospital S revealed Patient (#1) arrived at the facility on 10/7/11 at 16:52 and was placed in room 207 on the Intensive Care Unit.

Nurses ' notes documented the patient was received from Hospital G accompanied by ambulance attendants. The patient was being bagged by EMT.

The Ambulance attendants told nursing staff that when the patient was placed on the ventilator she was desaturating and the balloon on the Endo Tracheal Tube (ETT) was deflated to make bagging easier.

On 10/7/11 at 17:02 blood pressure dropped in the 50s and heart rate 55. Two physicians on the floor rushed to the patient ' s room.

The Levophed drip was increased. While attempting to check for Carotid pulse, noted patient ' s neck and upper chest with subcutaneous emphysema.

Physician at bedside, stat chest X-ray ordered. A- line on right wrist with poor wave form, unable to obtain blood pressure, no pulse audible or palpable.

At 17:12 Patient(#1) was received with ETT(Endo Tracheal Tube) Pilot deflated. Pilot Cuff re-inflated . Ventilator initialized, then 100% Ambu Bag used for Cardio Pulmonary Resuscitation (CPR).

History and Physical dated 10/7/11 by Physician D at Hospital S documented that when the patient arrived at Hospital S, she was hypoxic and dropped her oxygenation. She was also hypotensive. They could not feel her pulse initially and CPR was started right away. She regained her pulse but was also found to have subcutaneous emphysema; she was connected to a ventilator, although she had a very high peak pressure, the stat chest x-ray done at that time showed bilateral large pneumothorax. Bilateral chest tubes were placed immediately at the bedside.

She was on norepinepherine and vasopressin drip, she was given multiple rounds of epinephrine, atropine and CPR was resumed. Through out the course she remained in PEA (Pulseless Electrical Activity). CPR continued for more than an hour the patient never regained her pulse and despite all the efforts there was no change in her status. The patient was pronounced dead at 6:20 pm on October 7, 2011.

Review of Radiology Report at Hospital S documented the following information:
Chest examinationDATED 10/7/11
1. There are large bilateral pneumothroaces. The lungs are partially collapsed as a result of the pneumothroaces limiting evaluation of the lung parenchyma. No pneumothorax is seen. There is subcutaneous emphysema in the neck and right chest wall.
2. Impression: large bilateral pneumothroaces.( information was urgently communicated to the clinical team)
3. Subcutaneous emphysema
4. endotracheal tube tip approximately 2 cm to the carina.


Review of EMS first report

Review of EMS run sheet revealed the following information:

Arrived on location to find patient sedated and on ventilator. Diagnosis was ARDS (acute respiratory distress syndrome).

Patient was on multiple drips, vasopressin, levophed, propofol, fenrtanyl, and normal saline. Patient was moved from bed and placed on portable vent with setting of RR 22, Vt-500,100% O 2. Peak pressure-50.

When patient was moved to EMS vent noted pink fluid in tube. Suction patient ' s tube with little return. As the patient was loaded into the ambulance the monitor started to beep. The SPo2 was dropping, the vent was working properly. EMT got help from ER Nurse, EMT staff told the Nurse they had to take the patient back to the ICU to be re-evaluated.

The patient was unloaded from the ambulance and taken to the ER, when EMT staff started to use BMV( bag mask valve) to ventilate the patient with great success, the patient ' s saturation went to the high 90s. Patient(#1) was taken back to the ICU and placed on bed (8). Care was transferred to the unit ' s nurses.

There was no documentation on the nurses or physicians' notes at Hospital G that the EMT took the patient to their Emergency Room and what intervention if any was performed by hospital personnel.

Second report

Patient was being transferred to Hospital S, for need of a Pulmonologist for ARDS( Acute Respiratory Distress Syndrome). The patient was on a ventilator and on multiple IV medications. Patient ' s nurse stated that the patient ' s O 2 saturation has been 100% for a long time.

"Moved patient from bed to stretcher. Patient was taken off of ICU ' s ventilator and ventilation. Bag Mask Valve (BMV) was started by EMT. Loaded patient into ambulance".

The EMT documented they unloaded the patient from the ambulance and took her to the ER at Hospital S(should have taken patient to the ICU, because the patient was a direct admission).

Staff in ER wanted to register the patient. EMT documented that they told ER staff to take the patient quickly to her room because of the lack of oxygen. The portable cylinder could hold 1000 pounds of oxygen. and the patient was receiving 15 liters an hour.

The report documented that Respiratory Therapist at Hospital S told the EMT they were bagging the patient too slowly and took over the bagging.
The patient was still on the monitor the patient was transferred on. Nurses and physicians were in attendance trying to find a pulse they could not, and CPR was started.

Patient # 2

Review of nurses ' notes dated 12/14/11 documented patient was admitted to the unit at 1810 from the Emergency Room. She was alert; the patient was hypotensive (low blood pressure) and had generalized edema of the whole body. Patient had multiple whelps on body but no skin breakdown.

Review of nurses notes dated 12/17/11 at 1930 revealed the following information:
Received patient obtunded. Open eyes to sternal rub, makes grunting sound.
12/18/11 at 0745 patient received lethargic, eyes opened at times. Right groin triple lumen site healthy. Pupils remain unequal.

Physician ' s progress notes dated 12/18/11 documented the patient to be transferred to Hospital S today.

Nurses ' notes on 12/18/11 at 0830 documented " spoke with nurse at Hospital S, clinical report regarding transfer given to the nurse; she will call when a bed is ready ' .

Nurses ' notes dated 12/18/11 at 12:00 blood pressure 91/50, rechecked and confirmed. Physician informed new order received and initiated. Started normal saline bolus 250 wide open at 12:10, blood pressure dropped to 72/55. Patient was asymptomatic and when asked how she feels mumbled " okay " . Pupils remain unchanged.

At 12:30 blood pressure 117/50, no sign or symptom of respiratory distress noted.

Called transfer center to check on status, nurse stated the patient was accepted but still awaiting a bed.

At 15:00 no changes in neurological status, pupils still unequal, sluggish, altered mental status, no seizure activity noted. Received call from the transfer center. Report given at 15:45.

Review of the facility ' s Memorandum of Transfer (MOT) dated 12/18/11 revealed a request was made for EMS, O 2, EKG, IV and EMT Personnel.

Further review of the nurses notes dated 12/18/11 revealed documentation that at 16:30 the patient left the unit by stretcher with EMS without incident.

There was no documentation that the physician evaluated the patient after her drop in blood pressure. No documented vital signs or assessment at time of transfer.

No documentation that Patient (#2) was transferred with the required medical equipment that was requested to ensure optimum medical stability during the transfer. There was no documentation from 0745 to 16:30 when the patient left the unit that she was receiving oxygen.

There was no documentation regarding her oxygen saturation status. On admission there was documentation that the patient had edema of her entire body, there was no mention in the nurses noted dated 12/18/11 between the hours of 07:45 and 16:30 when she left the unit.

Patient is a 71 year old lying in bed responsive to verbal stimuli only. ICU nurse stated that the patient had been admitted because of neurological changes. Patient on O 2 at 2 LPM with oxygen saturation in the 90s.

According to the nursing staff that was normal for her. IV with Clinimix. Patient was transported to the ICU without incident. Condition remains unchanged.

Review of Discharge Summary from Hospital S dated 2/29/12 documented:

Patient # 2 was transferred from Hospital G on 12/18/11 to be treated for Encephalopathy The transferring staff told the facility that the patient was hemodynamically stable at the time of transfer. On arrival at Hospital S, the patient was hypotensive ( low blood pressure) , and was in respiratory distress.

There was also bleeding from the central venous catheter site. Emergency Room ( ER) physician was called in and the patient was intubated and a new central line was placed. The bleeding was controlled.


During an interview on 3/1/12 at 10:15 am with Staff # 52 RN that transferred the patient, she stated she could not re call if the patient was transferred on ventilator or not. She reviewed the record but was not able to tell whether or not the patient left the unit on a ventilator.

During an interview on 3/1/11 at 9:30 am with Physician # 53( Hospitalist) he stated the patient was initially in his care and was taken over by physicians from his group. The physician stated a transfer order should have been written. He further stated the patient was not stable enough to be transferred prior to the time she was transferred. ( The patient's stability was never evaluated prior to transfer).


During an interview on 2/29/12 at 3:00 pm with Physician # (50) Obstetrician she stated there was a breakdown in communication, she was not informed when the patient was being transferred from the facility. The physician stated she would have ensured the patient was appropriately transferred to the receiving hospital.

Physician (# 50) stated the patient should have been transferred by air ambulance instead of ground transport especially after the patient desaturated and had to be returned to the unit.

During an interview on 2/29/12 at 1:35 pm with the Chief Nursing Officer she stated she wanted the patient to be transferred by air ambulance but the order was for ground ambulance. The Chief Nursing officer also stated "Administrative personnel were not aware until after the fact that the patient was transferred out without the ventilator. She further stated patients like those did not do well with bagging " .

During the interview with the Chief Nursing Officer (CNO) she stated an official root cause analysis was not conducted. She also stated a Peer review was not done because all the physicians involved felt Patient # (1) had an amniotic embolus and if that was the case nothing could be done for her.

According to the CNO an unofficial review of the record was done and some issues with documentation was identified, she further stated there was no official analysis of the record and no plans were implemented.


During an interview on 3/1/12 at 11:35 am with the Director of the ambulance service, he gave the following information:

The Ambulance Service did not have PEEP (Positive End Expiratory Pressure) capability on their ventilators. The request was made for a vent, PEEP capability was not ordered.

During the interview on 3/1/12 at 11:25 am with the Director of the Ambulance Service he stated the EMT personnel initially took the patient from the unit on a portable vent. When EMT personnel arrived downstairs to the ambulance the patient began to desaturate, her oxygen saturation dropped and they had to get the ER personnel to assist. After two hours had elapsed the EMT personnel were called to transport the patient. There was a discussion with Nurses on the floor and the EMT and nurses decided that since the patient did well on the BVM with PEEP the patient would be transported with the BVM instead of the ventilator.

(There was no assessment by the physician to determine the patient's respiratory status and the type of respiratory support that was needed for the transfer).