HospitalInspections.org

Based on review of hospital policy, surveyor observations, interviews, and medical record review, the hospital's governing body was unaware that Interventional Radiology (IR) department physicians were performing invasive procedures in the Computerized Tomography (CT) and Ultrasound (US) rooms, and without having policies that provide direction relative to the monitoring and documentation of patients who return to their assigned units post an IR invasive procedure.
As a result, there is no documentation to affirm facility staff interview statements that they observed Patient Identifiers (PI) #1 and PI #2 following an IR invasive procedure, but failed to record their (staff) assessment of the patients, the procedure site, and or record the patient's vital signs after the patients returned to their rooms.
This deficient practice affected sampled PI #1 and #2, two and ten sampled patients, and has the potential to effect any patient undergoing an IR procedure in the radiology department.

Finding Include:

Facility Policy:
The facility policy entitled "Patient Assessment, Radiology" has a revised date of 10/1/2012 (no documented approved date) and includes:
"POLICY STATEMENT:
The Radiologic Technologist will assess the patient prior to and throughout Radiologic procedures/examinations to ensure correctness of the procedures, patient safety, and patient response/condition. Patients having invasive procedures will be assessed by a Registered Nurse prior to beginning the procedure and thereafter, as needed or directed by physician, throughout the recovery period...
PROCEDRUE:
A patient presenting for examination will have an assessment of the following:
Ability to cooperate ...
Comprehension of the procedure ...
Ability to communicate ...
Reassessment
The Registered Nurse assigned to radiology will reassess the patient undergoing invasive procedures, such as angiography, according to established protocols to determine response to the procedure. The RN will assess other patients in Radiology as their condition warrants. The intensive care patient will be reassessed by the accompanying ICU nurse per ICU time frames and their condition warrants while in Radiology setting. Notation is documented on the ICU flow sheet..."

Patient Identifier (PI) #1 presented to the emergency department on 4/12/2012, complaining of a two week history of left sided chest pain, shortness of breath, swelling and pain in the left and right foot. PI #1 was admitted with diagnoses that includes: Dyspnea, Erythema, Edema, Lesion of the Left Lower Extremity, Decreased Appetite, and past history of Anemia.

On 4/16/2012 at 2:55 p.m., the Interventional Radiology (IR) physician documented a Progress Note that includes:
"Procedure: U/S [ultrasound] guided paracentsis...
Anesthesia: Local...
Findings: Pocket of fluid in LLQ [left lower quadrant] 12 - 13 cc asp s [aspirated without] difficulty sent to lab for studies..."

The 4/16/2012 typed Interventional Radiology report includes:
"US [ultrasound] Paracentesis w [with] Guidance ...
"HISTORY:
...history of ascites and leukocytosis presents for diagnostic paracentesis ...
PROCEDURE:
...Preliminary ultrasound of abdomen was performed and a mild amount of ascites was noted. The most appropriate approach for a safe needle entry site was planned and the site for puncture was marked. The left lower quadrant was prepped and draped in the usual fashion....used for local anesthesia along the expected needle tract. Under ultrasound guidance...needle was inserted carefully into the peritoneal space towards the abdominal ascites fluid collection. A total of 3 cc [cubic centimeter] of clear sanguinous ascites was aspirated. The decision was then made to insert a...gauge needle into the same space towards the ascetic fluid collection. An additional 10 cc of clear, sanguinous ascites was aspirated. Sonographic evaluation of the overlying soft tissues revealed no evidence of post-procedure hematoma. The patient tolerated the procedure well without immediate complications and was discharged after observation to her hospital room.
IMPRESSION:
Ultrasound-guided therapeutic paracentesis with aspiration of approximately 13 cc of clear, sanguinous ascites..."

The post IR physician's post procedure orders (dated 4/16/2012 at 1530) include:
"(1) VS q [vital signs every] 15 minutes x 4 [times four], then VS q 30 minutes x 4, then q hour x 4, please
(2) Notify MD for acute changes in BP [blood pressure] or HR [heart rate]..."

The post procedure "Vital Sign Record" (dated 4/16/2012) includes:
Time BP [blood pressure] Pulse Respirations
3:45 p.m. 141 / 86 86 20
4:15 p.m. 137 / 77 98 18
4:30 p.m. 130 / 82 84 18
4:45 p.m. 142 / 84 89 20
5:00 p.m. 128 / 70 99 20
6:00 p.m. 138 / 84 86 20
There are no vital signs recorded on this form/record after 6:00 p.m.

The Vital signs recorded on the 4/16/2012 " Medical / Surgical Flow sheet " include:
1600 (4:00 p.m.)
B/P 146 / 66 Pulse 102 Respirations 22
2000 (10:00 p.m.)
B/P 117/61 Pulse 95 Respirations 18
At 11:00 p.m. (2100) staff documented that PI #1 was found unresponsive with a faint pulse. A code was called and PI #1 was subsequently moved to an intensive care unit.

Staff failed to document post procedure vital signs as ordered by the IR physicians, and failed to document observations of PI #1's paracentsis procedure site on 4/16/12.

Employee Identifier (EI) #6, the nurse on duty when patient PI#1 returned to the unit on 4/16/2012, was interviewed on 6/15/2012 at 11:18 a.m. EI #6 acknowledged she did not check PI #1's the vital signs as ordered on 4/16/2012. She (EI #6) stated she checked PI #1's abdomenal paracentsis site and recalled the patient's abdomen was distended. EI #6 failed to document these observations.

EI #7, the evening nurse who checked PI#1 on 4/16/12 was interviewed on 6/15/2012 at 5:40 p.m. EI # 7 stated he provided care to PI #1 about four hours before the patient was found unresponsive on 4/16/2012. According to EI #7, he was called to the room by another nurse. When EI #7 arrived to the room, PI #1 was unresponsive, had a faint left carotid pulse, and was pale but not cyanotic. EI #7 said he checked the PI #1's paracentsis site but could not recall the condition or location of the site. EI #7 failed to document observations of the site and failed to check the vital signs as ordered.

Patient Identifier (PI) #2 was admitted to the hospital on 6/12/2012. The admission "Nurses Notes" include:
"Pt [patient] is admitted with dx [dianosis] of constipation. Upon arrival, pt's [patient] has generalized edema all over body. Upon my assessment, left foot has diabetic ulcer (dried/closed), and right foot 2nd toe also has a closed dried ucler. Left arm with an open wound stage 2 r/t [related to] grease burn per patient. Dr...notified of status. Pt's abd [abdomen] is disteend and firm. no bs [bowel sounds] heard. Will send for ct of abd/pelvis when po [oral] contrast completed. Patien has no other complaint..."

The Patient Care Orders, dated 6/14/2012 at 11:25 a.m. include:
"...Return to room
Have pt. (patient) lie flat on R (right ) side for at least 1 hour...
Please check vital signs q (every) 15 min. (minutes) x 1 hr (hour),
then every 30 mins. x 2 hours, then every hour x 2 hours, then every 2 hours x 1. Then, routine checks..."

The Nursing Shift Summary documentation, dated 6/14/2012 at 15:44, indicates PI #2 returned to the unit following a renal biposy.

There is no documentation regarding the PI #2 biopsy site and staff failed to document the post procedure vital signs as ordered by the IR physician.

During an interview on 6/15/2012 at 10:20 AM, Employee Identifier (EI) # 10 stated PI # 2's vital signs were taken as ordered by the physician, but the vital signs were not documented.

The Director and Assistant Director of Radiology (EI #3 and EI #4) were interviewed during the 4/16/12 tour (at 2:10 p.m.). These Directors stated radiology department do not have specific policies for interventional radiology (IR) because the hospital has nursing policies and procedures.

During the 6/14/2012 tour, EI #9, a CT [computerized tomography) technician stated that CT guided needled biopsies and other procedures are done in both CT rooms, but most are done on the 64 slice CT machine.

During an on 6/16/2012 at 10:10 a.m., the Radiology Technician/ EI #8 said radiology doctors perform abdominal paracentsis, thoracentesis, thyroid biopsies, and some liver and kidney oblations in the radiology ultrasound rooms.

On 6/16/12 at 11:05, the hospital Assistant Administrator / EI #1 stated the patient (PI #1) record had been reviewed by multiple committees but administration were not aware that IR invasive procedures were being done in CT and Ultrasound, areas outside the designated IR area, prior to this survey.


This citation written as result of the investigation of complaint AL00026768.

Based on review of the facility policies, surveyor observations, interviews, and record reviews, the registered nurses responsible for the care for Patient Identifiers (PI) #1 and PI #2 failed to document assessments and vital signs after the patients returned to the unit following an invasive procedure in the Interventional Radiology (IR) Department.
As a result, there is no documented evidence that affirms the facility staff members statments that they observed Patient Identifiers (PI) #1 and PI #2 following an IR invasive procedure, but failed to record their (staff) assessment of the patients, their observations of the procedure site, and the patient's vital signs after the patients returned to their rooms.
This deficient practice effected 2 of 10 sampled patients and has the potetnial to effect any patient having an IR procedure.

Findings Include:

Facility Policy:
The facility policy entitled " Patient Assessment, Radiology " has a revised date of 10/1/2012 (no documented approved date) and includes:
" POLICY STATEMENT:
The Radiologic Technologist will assess the patient prior to and throughout Radiologic procedures/examinations to ensure correctness of the procedures, patient safety, and patient response/condition. Patients having invasive procedures will be assessed by a Registered Nurse prior to beginning the procedure and thereafter, as needed or directed by physician, throughout the recovery period.
PROCEDRUE:
A patient presenting for examination will have an assessment of the following:
Ability to cooperate ...
Comprehension of the procedure ...
Ability to communicate ...
Reassessment
The Registered Nurse assigned to radiology will reassess the patient undergoing invasive procedures, such as angiography, according to established protocols to determine response to the procedure. Te RN will assess other patients in Radiology as their condition warrants. The intensive care patient will be reassessed by the accompanying ICU nurse per ICU time frames and their condition warrants while in Radiology setting. Notation is documented on the ICU flow sheet. "

Patient Identifier (PI) #1 presented to the emergency department on 4/12/2012, complaining of a two week history of left sided chest pain, shortness of breath, swelling and pain in the left foot, and swelling in the right foot that began about a week prior to admission. PI #1 was admitted to the hospital with diagnosis that includes: Dyspnea, Erythema, Edema, and Lesion of the left lower extremity, Decreased appetite, and past history of Anemia.

On 4/16/2012 at 2:55 p.m., the Interventional Radiology (IR) physician documented a Progress Note that includes:
"Procedure: U/S [ultrasound] guided paracentsis...
Anesthesia: Local
Findings: Pocket of fluid in LLQ [left lower quadrant] 12-13 cc asp s [aspirated without] difficulty sent to lab for studies..."

The 4/16/2012 typed Interventional Radiology report includes:
"US [ultrasound] Paracentesis w [with] Guidance ...
"HISTORY: ...history of ascites and leukocytosis presents for diagnostic paracentesis ...
PROCEDURE:
...Preliminary ultrasound of abdomen was performed and a mild amount of ascites was noted. The most appropriate approach for a safe needle entry site was planned and the site for puncture was marked. The left lower quadrant was prepped and draped in the usual fashion ....used for local anesthesia along the expected needle tract. Under ultrasound guidance ...needle was inserted carefully into the peritoneal space towards the abdominal ascites fluid collection. A total of 3 cc [cubic centimeter] of clear sanguinous ascites was aspirated. The decision was then made to insert a ...gauge needle into the same space towards the ascetic fluid collection. An additional 10 cc of clear, sanguinous ascites was aspirated. Sonographic evaluation of the overlying soft tissues revealed no evidence of post-procedure hematoma. The patient tolerated the procedure well without immediate complications and was discharged after observation to her hospital room.
IMPRESSION:
Ultrasound-guided therapeutic paracentesis with aspiration of approximately 13 cc of clear, sanguinous ascites.."

The post IR physician's post procedure orders (dated 4/16/2012 at 1530) include:
"(1) VS q [vital signs every] 15 minutes x 4 [times four], then VS q 30 minutes x 4, then q hour x 4, please
(2) Notify MD for acute changes in BP [blood pressure] or HR [heart rate] ... "

The post procedure "Vital Sign Record" (dated 4/16/2012) includes:
Time BP [blood pressure] Pulse Respirations
3:45 p.m. 141 / 86 86 20
4:15 p.m. 137 / 77 98 18
4:30 p.m. 130 / 82 84 18
4:45 p.m. 142 / 84 89 20
5:00 p.m. 128 / 70 99 20
6:00 p.m. 138 / 84 86 20
There are no vital signs recorded on this form/record after 6:00 p.m.

The Vital signs recorded on the 4/16/2012 "Medical / Surgical Flow sheet" include:
1600 (4:00 p.m.)
B/P 146 / 66 Pulse 102 Respirations 22
2000 (10:00 p.m.)
B/P 117/61 Pulse 95 Respirations 18
At 11:00 p.m. (2100) staff documented that PI #1 was found unresponsive with a faint pulse. A code was called and PI #1 was subsequently moved to an intensive care unit.

Employee Identifier (EI) #6, the nurse on duty when patient PI#1 returned to the unit on 4/16/2012, was interviewed on 6/15/2012 at 11:18 a.m. EI #6 acknowledged she did not check PI #1's the vital signs as ordered on 4/16/2012. She (EI #6) stated she checked PI #1's abdomenal paracentsis site and recalled the patient's abdomen was distended. EI #6 failed to document these observations.

EI #7, the evening nurse who checked PI #1 on 4/16/12 was interviewed on 6/15/2012 at 5:40 p.m. EI # 7 stated he provided care to PI #1 about four hours before the patient was found unresponsive on 4/16/2012. According to EI #7, he was called to the room by another nurse. When EI #7 arrived to the room, PI #1 was unresponsive, had a faint left carotid pulse, and was pale but not cyanotic. EI #7 said he checked the PI #1's paracentsis site but could not recall the condition or location of the site. EI #7 failed to document observations of the site and failed to check the vital signs as ordered.

The unit staff failed to document PI #1's post procedure vital signs as ordered by the IR physicians, and there is no indication that staff observed PI #1's paracentsis procedure site on 4/16/12.

Patient Identifier (PI) # 2 was admitted to the hospital on 6/12/2012 and the admission "Nurses Notes" include:
"Pt [patient] is admitted with dx [dianosis] of constipation. Upon arrival, pt's [patient] has generalized edema all over body. Upon my assessment, left foot has diabetic ulcer (dried/closed), and right foot 2nd toe also has a closed dried ucler. Left arm with an open wound stage 2 r/t [related to] grease burn per patient. Dr...notified of status. Pt's abd [abdomen] is disteend an firm. no bs [bowel sounds] heard. Will send for ct of abd/pelvis when po [oral] contrast completed. Patient has no other complaint..."

The Patient Care Orders, dated 6/14/2012 at 11:25 document the following:
"...Return to room...
Have pt. (patient) lie flat on R (right ) side for at least 1 hour...
Please check vital signs q (every) 15 min. (minutes) x 1 hr (hour),
then every 30 mins. x 2 hours, then every hour x 2 hours, then every 2 hours x 1. Then, routine checks..."

According to the Nursing Shift Summary, dated 6/14/2012 at 15:44, PI # 2 returned to the unit following a IR renal biposy.

There is no documentation about the post procedure site. There is no documentation to indicate if PI # 2 had a dressing. No post procedure vital signs(consistent with physician orders) are documented.

During an interview on 6/15/2012 at 10:20 AM, Employee Identifier (EI) #10 stated PI # 2's vital signs were taken as ordered by the physician, but the vital signs were not documented.


This citation written as result of the investigation of complaint AL00026768.

Based on review of hospital policy, surveyor observations, interviews, and medical record review, the hospital's governing body was unaware that Interventional Radiology (IR) department physicians were performing invasive procedures in the Computerized Tomography (CT) and Ultrasound (US) rooms, and without having policies that provide direction relative to the monitoring and documentation of patients who return to their assigned units post an IR invasive procedure.
As a result, there is no documentation to affirm facility staff interview statements that they observed Patient Identifiers (PI) #1 and PI #2 following an IR invasive procedure, but failed to record their (staff) assessment of the patients, the procedure site, and or record the patient's vital signs after the patients returned to their rooms.
This deficient practice affected sampled PI #1 and #2, two and ten sampled patients, and has the potential to effect any patient undergoing an IR procedure in the radiology department.

Finding Include:

Facility Policy:
The facility policy entitled "Patient Assessment, Radiology" has a revised date of 10/1/2012 (no documented approved date) and includes:
"POLICY STATEMENT:
The Radiologic Technologist will assess the patient prior to and throughout Radiologic procedures/examinations to ensure correctness of the procedures, patient safety, and patient response/condition. Patients having invasive procedures will be assessed by a Registered Nurse prior to beginning the procedure and thereafter, as needed or directed by physician, throughout the recovery period...
PROCEDRUE:
A patient presenting for examination will have an assessment of the following:
Ability to cooperate ...
Comprehension of the procedure ...
Ability to communicate ...
Reassessment
The Registered Nurse assigned to radiology will reassess the patient undergoing invasive procedures, such as angiography, according to established protocols to determine response to the procedure. The RN will assess other patients in Radiology as their condition warrants. The intensive care patient will be reassessed by the accompanying ICU nurse per ICU time frames and their condition warrants while in Radiology setting. Notation is documented on the ICU flow sheet..."

Patient Identifier (PI) #1 presented to the emergency department on 4/12/2012, complaining of a two week history of left sided chest pain, shortness of breath, swelling and pain in the left and right foot. PI #1 was admitted with diagnoses that includes: Dyspnea, Erythema, Edema, Lesion of the Left Lower Extremity, Decreased Appetite, and past history of Anemia.

On 4/16/2012 at 2:55 p.m., the Interventional Radiology (IR) physician documented a Progress Note that includes:
"Procedure: U/S [ultrasound] guided paracentsis...
Anesthesia: Local...
Findings: Pocket of fluid in LLQ [left lower quadrant] 12 - 13 cc asp s [aspirated without] difficulty sent to lab for studies..."

The 4/16/2012 typed Interventional Radiology report includes:
"US [ultrasound] Paracentesis w [with] Guidance ...
"HISTORY:
...history of ascites and leukocytosis presents for diagnostic paracentesis ...
PROCEDURE:
...Preliminary ultrasound of abdomen was performed and a mild amount of ascites was noted. The most appropriate approach for a safe needle entry site was planned and the site for puncture was marked. The left lower quadrant was prepped and draped in the usual fashion....used for local anesthesia along the expected needle tract. Under ultrasound guidance...needle was inserted carefully into the peritoneal space towards the abdominal ascites fluid collection. A total of 3 cc [cubic centimeter] of clear sanguinous ascites was aspirated. The decision was then made to insert a...gauge needle into the same space towards the ascetic fluid collection. An additional 10 cc of clear, sanguinous ascites was aspirated. Sonographic evaluation of the overlying soft tissues revealed no evidence of post-procedure hematoma. The patient tolerated the procedure well without immediate complications and was discharged after observation to her hospital room.
IMPRESSION:
Ultrasound-guided therapeutic paracentesis with aspiration of approximately 13 cc of clear, sanguinous ascites..."

The post IR physician's post procedure orders (dated 4/16/2012 at 1530) include:
"(1) VS q [vital signs every] 15 minutes x 4 [times four], then VS q 30 minutes x 4, then q hour x 4, please
(2) Notify MD for acute changes in BP [blood pressure] or HR [heart rate]..."

The post procedure "Vital Sign Record" (dated 4/16/2012) includes:
Time BP [blood pressure] Pulse Respirations
3:45 p.m. 141 / 86 86 20
4:15 p.m. 137 / 77 98 18
4:30 p.m. 130 / 82 84 18
4:45 p.m. 142 / 84 89 20
5:00 p.m. 128 / 70 99 20
6:00 p.m. 138 / 84 86 20
There are no vital signs recorded on this form/record after 6:00 p.m.

The Vital signs recorded on the 4/16/2012 " Medical / Surgical Flow sheet " include:
1600 (4:00 p.m.)
B/P 146 / 66 Pulse 102 Respirations 22
2000 (10:00 p.m.)
B/P 117/61 Pulse 95 Respirations 18
At 11:00 p.m. (2100) staff documented that PI #1 was found unresponsive with a faint pulse. A code was called and PI #1 was subsequently moved to an intensive care unit.

Staff failed to document post procedure vital signs as ordered by the IR physicians, and failed to document observations of PI #1's paracentsis procedure site on 4/16/12.

Employee Identifier (EI) #6, the nurse on duty when patient PI#1 returned to the unit on 4/16/2012, was interviewed on 6/15/2012 at 11:18 a.m. EI #6 acknowledged she did not check PI #1's the vital signs as ordered on 4/16/2012. She (EI #6) stated she checked PI #1's abdomenal paracentsis site and recalled the patient's abdomen was distended. EI #6 failed to document these observations.

EI #7, the evening nurse who checked PI#1 on 4/16/12 was interviewed on 6/15/2012 at 5:40 p.m. EI # 7 stated he provided care to PI #1 about four hours before the patient was found unresponsive on 4/16/2012. According to EI #7, he was called to the room by another nurse. When EI #7 arrived to the room, PI #1 was unresponsive, had a faint left carotid pulse, and was pale but not cyanotic. EI #7 said he checked the PI #1's paracentsis site but could not recall the condition or location of the site. EI #7 failed to document observations of the site and failed to check the vital signs as ordered.

Patient Identifier (PI) #2 was admitted to the hospital on 6/12/2012. The admission "Nurses Notes" include:
"Pt [patient] is admitted with dx [dianosis] of constipation. Upon arrival, pt's [patient] has generalized edema all over body. Upon my assessment, left foot has diabetic ulcer (dried/closed), and right foot 2nd toe also has a closed dried ucler. Left arm with an open wound stage 2 r/t [related to] grease burn per patient. Dr...notified of status. Pt's abd [abdomen] is disteend and firm. no bs [bowel sounds] heard. Will send for ct of abd/pelvis when po [oral] contrast completed. Patien has no other complaint..."

The Patient Care Orders, dated 6/14/2012 at 11:25 a.m. include:
"...Return to room
Have pt. (patient) lie flat on R (right ) side for at least 1 hour...
Please check vital signs q (every) 15 min. (minutes) x 1 hr (hour),
then every 30 mins. x 2 hours, then every hour x 2 hours, then every 2 hours x 1. Then, routine checks..."

The Nursing Shift Summary documentation, dated 6/14/2012 at 15:44, indicates PI #2 returned to the unit following a renal biposy.

There is no documentation regarding the PI #2 biopsy site and staff failed to document the post procedure vital signs as ordered by the IR physician.

During an interview on 6/15/2012 at 10:20 AM, Employee Identifier (EI) # 10 stated PI # 2's vital signs were taken as ordered by the physician, but the vital signs were not documented.

The Director and Assistant Director of Radiology (EI #3 and EI #4) were interviewed during the 4/16/12 tour (at 2:10 p.m.). These Directors stated radiology department do not have specific policies for interventional radiology (IR) because the hospital has nursing policies and procedures.

During the 6/14/2012 tour, EI #9, a CT [computerized tomography) technician stat