HospitalInspections.org

The CONDITION IS NOT MET:
Based on review of hospital documentation and interviews with facility personnel, the governing body failed to ensure that a corrective action plan to address concerns identified by senior medical management was developed as appropriate after an adverse event.
The findings include:

Patient #5 was admitted to the Emergency Department on 1/16/10 at 7:00 p.m. in critical condition with complaints of abdominal and chest pain. Review of the clinical record, hospital documentation related to an adverse event and interviews with hospital staff on 8/10/10 identified that diagnostic studies were delayed and the patient failed to receive a surgical consult while in the Emergency Deparmtment. Additionally, surgical intervention was unduly delayed for Patient #5. See (A288)

The CONDITION IS NOT MET:
Based on clinical record reviews, review of hospital documentation and interviews with facility personnel, the facility failed to ensure for 1 of 10 sampled patients (Patient #5), that an acute medical patient was managed and treated in a timely manner in the Emergency Department (ED). In addition, the patient failed to receive a surgical consult by an attending surgeon and failed to receive surgical intervention in a timely manner. As a result, Patient #5 had a delay in diagnosis and a delay in surgical intervention. Subsequently, Patient #5 expired from septic shock due to peritonitis secondary to a perforated duodenal viscus. See (A347)

Based on medical record reviews, review of hospital documentation/policies/rules and regulations and interviews the hospital failed to ensure that medical records were completed by physicians in a timely manner and failed to follow the medical record policy for delinquent records. Please refer to deficiencies A0438.

Based on medical record reviews, review of facility policies and interviews the hospital failed to develop and/or implement surgical count policies in accordance with the Association of Perioperative Registered Nurses (AORN) standards for surgical counts. Please refer to federal deficiency A-0951 and A-0959.

Based on clinical record reviews, review of hospital documentation and interviews with facility personnel for 1 of 10 sampled acutely ill patients evaluated in the ED, (Patient #5), the facility failed to ensure appropriate medical management including surgical intervention in a timely manner.

The findings include:

1a. Patient #5 was admitted to the Emergency Department (ED) on 1/16/10 at 7:00pm with complaints of abdominal and chest pain and altered mental status. Review of the ED record identified that the patient was triaged as a level I acuity (critical, life threatening, unstable). Review of the ED physician notes identified that that the patient was somnolent, icteric, confused and restless with a abdominal assessment noted as soft with moderate tenderness. In addition, the ED assessment identified that the patient was hypotensive, and a nonrebreather mask at 15 liters was applied. Further review identified that the patient's arterial blood gases (ABG's) determined that the patient was acidotic and the patient was intubated. Patient #5 had a naso-gastric tube inserted with large amounts of dark fluid from stomach in the ED. AT 8:10 p.m. Patient #5 was waiting for an ordered CT scan, however was not sent to CT Scan until 9:20pm. Interview with Radiology Resident # 1 on 8/10/10 identified that he was not notified that Patient #5 was an emergent case. Further review identified that the ED physician failed to notify the radiology department that Patient #5 needed to have CT Scan immediately.

1b. The ED physician assessment dated 1/16/10 identified that the physician had reviewed the CT scan and determined that the patient had a "normal aorta" however the ED physician failed to contact the Radiology Resident to obtain final interpretation of the CT Scan prior to admitting the patient to the medical intensive care unit (MICU). Review of the Medical Resident's MICU progress notes dated 1/16/10 at 10:05pm identified that Patient #5's abdomen was "tympanic, difficult exam secondary to distention, abdomen very tense and bowel sounds absent." Review of the CT scan report dated 1/16/10 at 10:57pm identified that the patient had extensive pneumoperitoneum and evidence of portal and mesenteric venous air. At 11:20pm, the progress note by the Medical Resident identified that the patient had evidence of a pneumoperitoneum, that the covering attending physician was notified and indicated that the patient should have a surgical consult. The ED physician failed to notify the covering attending MD regarding Patient #5's critical status while the patient was in the Emergency Department and/or failed to consider the need for a surgical consult.

1d. Review of the progress notes dated 1/16/10 at 11:30pm identified that Patient #5 was evaluated by Surgical Resident #11 and noted to be lethargic, intubated and with poor prognosis. Further review identified that the patient needed stabilization before surgical exploration. Surgical Attending #10 as notified and agreed with the plan. At 3:30am, Patient #5 had responded well with resuscitative efforts with improved ABG's, hematocrit (Hct), temperature and urinary output. Further review identified that Surgical Attending Physician # 10 was notified by Surgical Resident # 11, however Surgical Attending #10 never came in to evaluate Patient #5 until 7:00am. At 8:00am, Patient #5 was taken to the operating room and had a exploratory laparotomy with primary closure of duodenal perforation with placement of vascularized omental patch and an abdominal washout. Review of medical staff rules and regulations identified that patients assigned to the critical care areas shall be seen by an attending physician in a timely manner, not to exceed eight hours. Interview with Surgical Attending #10 on 8/10/10 identified that at 3:30am he had instructed Surgical Resident #11 that Patient #5 needed further resuscitation before taking to the operating room. Interview with the Department of Surgery Chairman on 8/10/10 identified that the Attending Surgeon should have come in to evaluate Patient #5 since the patient was critically ill. Further interview with the Department of Surgery Chairman identified that at 3:30am, Patient #5 had improved and needed to go to the operating room at that time. Subsequently, Patient #5 expired on 1/17/10 from septic shock due to peritonitis secondary to a perforated duodenal viscus. Review of the hospital's analysis identified that there was a delay in any attending evaluating the patient and that clinical judgements were made by remote control.

Based on review of clinical records and facility documentation, the facility failed to ensure that the suspension policy was followed for physicians who were identified as delinquent with medical records.

The findings include:
1. A tour of the medical records department was conducted on 8/3/10 with the Director of Quality. Observations identified an area in the medical records department that contained incomplete records. Patient #27 's record indicated that the patient was discharged on 12/19/10 and that discharge summary was dictated by MD #2 on 2/28/10 (71 days after discharge). The dictated discharge summary also lacked authentication by MD #2. From 8/3/10 to 8/6/10, the records of Patient ' s #1, #4, #5 and #10 were also reviewed for discharge summary documentation and it was noted that although the patients had been discharged greater than 30 days, the records lacked a dictated/authenticated discharge summary.
In addition the first 10 pages of a 143-page facility document for incomplete records dated 8/5/10 was reviewed on 8/5/10 with the Director of Quality. Fifteen patients' records lacked discharge summaries with a delinquency range of 31 to 292 days. The documentation also noted that the hospital had 1208 privileged staff physicians and 114 of these physicians had incomplete medical records that were delinquent for greater than 30 days after patient discharge.
Interview with the Director of Health Information Management on 8/3/10 at 2PM noted that physicians receive a weekly letter regarding their delinquent records and although the Medical Records department was supposed to send the Chairman of that physician's department a letter when the records remained delinquent for 30 days this had not been done for at least 16 months.
Interview with the Director of Quality on 8/6/10 at 2PM indicated that the Chief Medical Officer had instructed the Director of Health Information Management to reinstitute the suspension letter process during February- March 2010 but did not believe that this had been implemented. Physicians who should have been referred for potential suspension due to delinquent records were not referred.

2. Review of the Medical Record Department's delinquency list dated 12/04-6/29/10 identified that Surgical Attending #10 was delinquent with dictated operative reports, discharge summaries and history and physicals. Further review identified that from 5/09-6/10, Surgical Attending MD #10 had 26 discharge summaries, 29 operative reports and 5 history and physicals that had not been completed.
Interview with the Director of Quality on 8/6/10 at 2PM identified that physicians who should have been referred for action due to delinquent records had not been referred. Interview with the Director of Quality on 8/16/10 identified that Surgical Attending MD #10's delinquency in completing medical records had not been addressed.

Review of hospital rules and regulations dated 12/17/09 identified that a comprehensive operative report should be written or dictated for all cases in the operating room, authenticated within 24 hours and include, in part, a technical description of the procedure (not included in the brief operative note). The hospital rules and regulations also identified that discharge summaries must be written or dictated after a patient's discharge or death and must be completed within 30 days after discharge.
The hospital delinquent record policy identified that if a record remained delinquent for 21 days, the physician would receive a warning letter of potential suspension and would qualify for suspension if the record remained incomplete for 30 days.

Based on medical record reviews, review of facility documentation/medical staff rules and regulations, a tour of the medical records department and interviews, the hospital failed to ensure that discharge summaries were dictated, dictated in a timely manner and/or authenticated.
The findings include:
A tour of the medical records department was conducted on 8/3/10 with the Director of Quality. Observations identified an area in the medical records department that contained incomplete records. Review of Patient #27 's record noted that the patient was discharged on 12/19/10 but that the discharge summary was dictated by MD #2 on 2/28/10 (71 days after discharge). The dictated discharge summary also lacked authentication by MD #2. From 8/3/10 to 8/6/10, the records of Patient ' s #1, #4, #5 and #10 were also reviewed for discharge summary documentation and it was noted that although the patients had been discharged greater than 30 days, the records lacked a dictated/authenticated discharge summary.
In addition the first 10 pages of a 143-page facility document for incomplete records dated 8/5/10 was reviewed on 8/5/10 with the Director of Quality and it was noted that 15 patient's records lacked discharge summaries with a delinquency range of 31 to 292 days. The documentation also noted that the hospital had 1208 privileged staff physicians and 114 of these physicians had incomplete medical records that were delinquent for greater than 30 days after patient discharge.
Interview with the Director of Health Information Management on 8/3/10 at 2PM noted that physicians receive a weekly letter regarding their delinquent records and although the Medical Records department was supposed to send the Chairman of that physician's department a letter when the records remained delinquent for 30 days, this had not been done for at least 16 months.
Interview with the Director of Quality on 8/6/10 at 2PM indicated that the Chief Medical Officer had instructed the Director of Health Information Management to reinstitute the suspension letter process during February- March 2010 but did not believe that this had been implemented. Physicians who should have been referred for potential suspension due to delinquent records were not referred.
The hospital rules and regulations dated 12/17/09 identified that a discharge summary must be written or dictated after a patient's discharge or death and must be completed within 30 days after discharge.
The hospital delinquent record policy identified that if a record remained delinquent for 21 days, the physician would receive a warning letter of potential suspension and would qualify for suspension if the record remained incomplete for 30 days.



Based on medical record reviews, review of facility documentation/medical staff rules and regulations, a tour of the medical records department and interviews, the hospital failed to ensure that discharge summaries were dictated, dictated in a timely manner and/or authenticated.

The findings include:

1. Review of medical record's delinquency list dated 12/04-6/29/10 identified that Surgical Attending #10 was delinquent with discharge summaries. Further review identified that from 5/09-12/09, Surgical Attending #10 had 16 discharge summaries that had not been completed. The hospital rules and regulations dated 12/17/09 identified that a discharge summary must be written or dictated after a patient's discharge or death and must be completed within 30 days after discharge. The hospital delinquent record policy identified that if a record remained delinquent for 21 days, the physician would receive a warning letter of potential suspension and would qualify for suspension if the record remained incomplete for 30 days. Interview with the Director of Quality on 8/16/10 identified that MD #10 was never suspended due to delinquent medical records. Further interview identifed that as of 9/09, the Medical Records Department and hospital senior management were aware of the delinquency of medical records by physicians.














Based on medical record reviews, review of facility documentation/medical staff rules and regulations, a tour of the medical records department and interviews, the hospital failed to ensure that operative reports were dictated in a timely manner and/or authenticated.
The findings include:

1. A tour of the medical records department was conducted on 8/3/10 with the Director of Quality. Observations identified an area in the medical records department that contained incomplete records. Patient #27 's record lacked a dictated operative report for an operative procedure that was performed by MD #2 on 12/15/09.
In addition the first 10 pages of a 143-page facility document for incomplete records dated 8/5/10 was reviewed on 8/5/10 with the Director of Quality and noted that operative reports were not dictated/written for two additional patients. Patient #60's operative report was 66 days delinquent, Patient #61's operative report was 26 days delinquent and both reports required dictation. The first 10 pages of the 143-page facility document for incomplete records dated 8/5/10 also indicated that an additional 19 patients had operative reports that were delinquent for online verification. Interview with the Operations Manager for Health Information on 8/3/10 at 11:10 AM noted that physicians receive a weekly report of their delinquent records and that the current hospital policy directed that physicians would qualify for suspension when a record was greater than 30 days delinquent.
The hospital rules and regulations dated 12/17/09 identified that a comprehensive operative report should be written or dictated for all cases in the operating room, authenticated within 24 hours and include, in part, a technical description of the procedure (not included in the brief operative note).
The hospital delinquent record policy identified that if a record remained delinquent for 21 days, the physician would receive a warning letter of potential suspension and would qualify for suspension if the record remained incomplete for 30 days.


2. Review of the operative report for Patient #5 dated 1/17/10 identifed that the operative report was dictated on 1/24/10 (7 days later). Review of hospital rules and regulations dated 12/17/09 identified that a comprehensive operative report should be written or dictated for all cases in the operating room, authenticated within 24 hours and include, in part, a technical description of the procedure (not included in the brief operative note).

3. Review of medical record's delinquency list dated 12/04-6/29/10 identified that Surgical Attending #10 was delinquent with dictated operative reports. Further review identified that from 5/09-12/09, Surgical Attending #10 had 19 operative reports that have not been completed. Review of hospital rules and regulations dated 12/17/09 identified that a comprehensive operative report should be written or dictated for all cases in the operating room, authenticated within 24 hours and include, in part, a technical description of the procedure (not included in the brief operative note).

Based on medical record reviews, review of hospital policies/procedures and interviews for 1of 6 patients who had a laparoscopic surgical procedure (Patient #9), the hospital failed to conduct sponge counts in accordance with acceptable standards. The findings include:

1. Patient #9 was admitted to the hospital and had laparoscopic gastric banding on 10/5/09. The intraoperative report dated 10/5/09 identified that surgical counts, to include sponge counts, were performed by a scrub technician and a circulator nurse prior to incision and prior to wound closure (final count). The documentation also noted that both the scrub technician and the circulator nurse who had performed the final count, were replaced after the count and the replacements were present at the end of the surgical procedure and for total wound closure. The record lacked documentation that additional surgical counts had been performed at the end of the case or with the permanent change in both the scrub technician and the circulator nurse. The operative report for 10/5/09 and/or discharge documentation noted that the patient was discharged to home on 10/5/09 and that surgical counts were correct at the end of the case. Although the routine abdominal x-ray (x-ray taken after all gastric banding surgery) dated 10/5/09 noted no abnormal findings, the abdominal scan dated 12/9/09 identified that the patient had incision leakage and a questionable retained foreign body near the infusion port. Facility documentation dated 1/19/10 indicated that an incision and drainage of the patient's wound was conducted at the physician's office and a sponge was removed from the patient's abdomen. Interview with RN #4 on 8/4/10 at 2:15 PM indicated that the final replacement scrub technician (ST #2) might not have been aware that although closure count was correct, the count included a sponge that was left in the surgical field. Interview on 8/4/10 at 2:45 PM with ST #1, who performed the closing count, identified that when h/she was relieved, and the wound closure continued, another count should have been conducted at the end of the case. Interview with the Senior Quality Improvement Coordinator on 8/5/10 at 11:25 AM noted that the hospital count policy mirrored the Association of perioperative Registered Nurses (AORN) standards for surgical counts. Although the hospital count policy identified, in part, that sponge counts are done prior to incision and prior to wound closure, skin closure or the end of the procedure, AORN standards note, in part, that sponge counts should be performed before the procedure, before wound closure begins and at skin closure or end of the procedure (skin closure or end of procedure count was not performed for Patient #9).
In addition, AORN standards also recommend that a sponge count be performed at the time of permanent relief of either the scrub person or the circulating nurse. The hospital policy did not reflect this additional count and this additional count had not been performed for Patient #9 on 10/5/09.
Although the hospital revised the count policy on 4/14/10 as the corrective action plan (CAP) to prevent recurrence, the revision directed additional performance of x-rays per nurse discretion (x-ray was performed in this case) for extended cases involving shift changes and/or multiple personnel changes. The CAP did not include revisions to the hospital count policy per AORN standard for the skin closure/end of procedure count or the permanent relief count.

Based on medical record reviews, review of facility documentation/medical staff rules and regulations, a tour of the medical records department and interviews, the hospital failed to ensure that operative reports were dictated in a timely manner and/or authenticated.
The findings include:

1. A tour of the medical records department was conducted on 8/3/10 with the Director of Quality. Observations identified an area in the medical records department that contained incomplete records. Patient #27 's record lacked a dictated operative report for an operative procedure that was performed by MD #2 on 12/15/09.
In addition the first 10 pages of a 143-page facility document for incomplete records dated 8/5/10 was reviewed on 8/5/10 with the Director of Quality and noted that operative reports were not dictated/written for two additional patients. Patient #60's operative report was 66 days delinquent, Patient #61's operative report was 26 days delinquent and both reports required dictation. The first 10 pages of the 143-page facility document for incomplete records dated 8/5/10 also indicated that an additional 19 patients had operative reports that were delinquent for online verification. Interview with the Operations Manager for Health Information on 8/3/10 at 11:10 AM noted that physicians receive a weekly report of their delinquent records and that the current hospital policy directed that physicians would qualify for suspension when a record was greater than 30 days delinquent.
The hospital rules and regulations dated 12/17/09 identified that a comprehensive operative report should be written or dictated for all cases in the operating room, authenticated within 24 hours and include, in part, a technical description of the procedure (not included in the brief operative note).
The hospital delinquent record policy identified that if a record remained delinquent for 21 days, the physician would receive a warning letter of potential suspension and would qualify for suspension if the record remained incomplete for 30 days.


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2. Review of the operative report for Patient #5 dated 1/17/10 identifed that the operative report was dictated on 1/24/10 (7 days later). Review of hospital rules and regulations dated 12/17/09 identified that a comprehensive operative report should be written or dictated for all cases in the operating room, authenticated within 24 hours and include, in part, a technical description of the procedure (not included in the brief operative note).

3. Review of medical record's delinquency list dated 12/04-6/29/10 identified that Surgical Attending #10 was delinquent with dictated operative reports. Further review identified that from 5/09-12/09, Surgical Attending #10 had 19 operative reports that have not been completed. Review of hospital rules and regulations dated 12/17/09 identified that a comprehensive operative report should be written or dictated for all cases in the operating room, authenticated within 24 hours and include, in part, a technical description of the procedure (not included in the brief operative note).

Based on review of hospital documentation and interviews with facility personnel, the governing body failed to ensure that a corrective action plan identified by senior medical management was developed and implemented as appropriate after an adverse event.

The findings include:


1a. Patient #5 was admitted to the Emergency Department (ED) on 1/16/10 at 7:00pm with complaints of abdominal and chest pain and altered mental status. Review of the ED record identified that the patient was triaged as a level I acuity (critical, life threatening, unstable). Review of the ED physician notes identified that that the patient was somnolent, icteric, confused and restless with a abdominal assessment noted as soft with moderate tenderness. In addition, the ED assessment identified that the patient was hypotensive, and a nonrebreather mask at 15 liters was applied. The patient's arterial blood gases (ABG's) determined that the patient was acidotic and the patient was intubated. Patient #5 had a naso-gastric tube inserted with large amounts of dark fluid from stomach in the ED. AT 8:10 p.m. Patient #5 was waiting for a CT scan, however, was not sent until 9:20pm. Interview with the Radiology Resident # 1 on 8/10/10 identified that he was not notified that Patient #5 was an emergent case. Further review identified that the ED physician failed to notify the radiology department that Patient #5 needed a CT Scan immediately.

1b. Review of the ED physician assessment dated 1/16/10 identified that the physician had reviewed the CT scan and determined that the patient had a "normal aorta" however the ED physician failed to contact the Radiology Resident to obtain final interpretation of the CT Scan prior to admitting the patient to the medical intensive care unit (MICU). Review of MICU progress notes by the Medical Resident #12 dated 1/16/10 at 10:05pm identified that Patient #5's abdomen was "tympanic, difficult exam secondary to distention, abdomen very tense and bowel sounds absent." Review of the CT scan report dated 1/16/10 at 10:57pm identified that the patient had extensive pneumoperitoneum and evidence of portal and mesenteric venous air. At 11:20pm, the progress note by the Medical Resident identified that the patient had evidence of a pneumoperitoneum, identified that the covering attending physician was notified and indicated that the patient should have a surgical consult. The ED physician failed to notify the attending MD regarding Patient #5's critical status while the patient was in the Emergency Department and/or failed to consider the need for a surgical consult.

1c. Review of the progress notes dated 1/16/10 at 11:30pm identified that Patient #5 was evaluated by Surgical Resident #11 and noted to be lethargic, intubated and with poor prognosis. Further review identified that the patient needed stabilization before surgical exploration. Surgical Attending #10 was notified and agreed with the plan. At 3:30am, Patient #5 had responded well with resuscitative efforts with improved ABG's, hematocrit (Hct), temperature and urinary output. Further review identified that Surgical Attending Physician # 10 was notified by Surgical Resident # 11, however Surgical Attending #10 never came in to evaluate Patient #5 until 7:00am. At 8:00am, Patient #5 was taken to the operating room and had a exploratory laparotomy with primary closure of duodenal perforation with placement of vascularized omental patch and an abdominal washout. Review of medical staff rules and regulations identified that patients assigned to the critical care areas shall be seen by an attending physician in a timely manner, not to exceed eight hours. Interview with Surgical Attending #10 on 8/10/10 identified that at 3:30am he had instructed Surgical Resident #11 that Patient #5 needed further resuscitation before taking to the operating room. Interview with the Department of Surgery Chairman on 8/10/10 identified that the Attending Surgeon should have come in to evaluate Patient #5 since the patient was critically ill. Further interview with the Department of Surgery Chairman identified that at 3:30am, Patient #5 had improved and needed to go to the operating room at that time. Subsequently, Patient #5 expired on 1/17/10 from septic shock due to peritonitis secondary to a perforated duodenal viscus. Review of the hospital's analysis identified that there was a delay in any attending evaluating the patient and that clinical judgements were made by remote control.

Interviews with Chairman of Surgery and the Chairman of the Emergency Department on 8/10/10 identified that they had reviewed the adverse event for Patient #5 at various medical staff meetings. Further interview failed to identify preventive actions and/or mechanisms that were implemented by each Department to provide feedback to the ED physician and the Attending surgeon related to the medical management of Patient #5 including timely assessments and interventions.