HospitalInspections.org

Based on review of clinical records, review of hospital policies, review of hospital documentation and interviews with hospital personnel, the hospital failed to ensure that outpatient surgical services developed, implemented and evaluated comprehensive post-operative care policies. See A 0951, A 1005

Based on review of the clinical records, review of hospital policies, review of hospital documentation and interviews with hospital personnel for 1 of 10 patients who underwent laparoscopic abdominal surgery, the hospital failed to ensure that surgical care policies were designed to achieve and maintain post-operative medical care standards. The findings include:

1. Patient #1 was admitted to the One Day Surgery Department on 9/18/09 at 6:43 AM for a laparoscopic mesh repair of a ventral hernia and supraumbilical incisional hernia. The patient's past medical/surgical history included atrial fibrillation, hypertension, chronic obstructive pulmonary disease (COPD) and status post (s/p) bowel resection/colostomy, s/p reversal colostomy in 1985. Review of the clinical record and interview with the attending surgeon, MD #3 on 4/8/10 indicated that the laparoscopic surgery was without complications and that the patient was discharged home in stable condition at 1:15 PM. Later, on 9/18/09 at 8:43 PM, Patient #1 returned to the Emergency Department (ED) complaining of abdominal pain, fever and chills. The patient was discharged from the ED with the diagnoses of fever and atelectasis. Interview with MD #3 on 4/8/10 identified that although not documented in the clinical record, he spoke with the patient by telephone the following morning (9/19/09) and that the patient had some pain (expected) and was voiding. Interview with RN #2 on 4/22/10 identified that RN #2 initiated 3 post-operative, follow-up phone calls to the patient (9/19/09, 9/20/09 & 9/21/09). RN #2 did not contact anyone on the first 2 calls (calls not documented), but left a message that she called. Review of the clinical record and interview with RN #2 identified that the third call was completed on 9/21/09 (time not documented, RN #2 did not recall time) and that she spoke with Patient #1's wife. The wife explained to RN #2 that the patient was seen in the ED on 9/18/09 and was confused since Saturday (9/19/09). Interview with RN #2 identified that she encouraged the wife to stay in touch with the physician (MD #3) and instructed her to call the physician's office to get Patient #1 in sooner. RN #2 indicated that she overhead paged MD #3 with no response and called MD #3's office and told the office receptionist that the wife would be calling. Patient #1 returned to the ED on 9/22/09 at 1:16 AM in septic shock due to perforated small bowel and expired on 9/25/09. Review of the One Day Surgery Postoperative Follow-up Phone Call Policy indicated that the telephone call would be completed within 72 hours of the procedure. However, the policy failed to address the purpose of the phone call and/or specifiy interventions in the event of a patient's change in condition. Interview with MD #3 on 4/8/10 identified that he would expect to be informed regarding the patient's change in condition and was not. Interview with the One Day Surgery Manager on 4/8/10 identified that if the patient's condition was considered serious, the nurse would instruct the patient to call 911 or go to the ED. Documentation, hospital policy and interviews failed to reflect comprehensive post-operative care planning, coordination and provisions for follow-up care.

Based on review of clinical records, review of hospital policy and interviews with hospital personnel for 7 of 10 patients who required anesthesia during laparoscopic surgery, documentation failed to reflect a post-anesthesia evaluation and/or evaluation date and time as per hospital policy. The findings include:

1. Review of the anesthesia records for 7 of 10 surgical patients (Patients #1, #2, #11, #13, #15 and #17) identified that clinical records lacked a post-anesthesia evaluation and or evaluation date/time post-operatively. Review of the Department of Anesthesia Rules and Regulations identified that a post-anesthesia follow-up note would be placed in the chart by an anesthesiologist within 48 hours describing the recovery from the anesthesia and management of anesthesia related complications.

Based on review of the clinical records, review of hospital policies, review of hospital information and interviews with hospital personnel for 3 of 10 patients who underwent outpatient laparoscopic abdominal surgery (and returned to the hospital ED within 72 hours postoperatively), hospital documentation and hospital staff interviews failed to reflect that comprehensive patient assessments, reassessments and monitoring were completed according to hospital policy. The findings include:

1. Patient #1 was admitted on 9/18/10 at 6:43 AM as an outpatient and underwent laparoscopic mesh repair of a ventral hernia and a supraumbilical incisional hernia. Review of the clinical record and interview with the attending surgeon, MD #3 on 4/8/10 indicated that the laparoscopic surgery was without complications and the patient was discharged home in stable condition at 1:15 PM. Later that evening on 9/18/10 at 8:43 PM, Patient #1 returned to the Emergency Department (ED) complaining of abdominal pain, chills and failure to void s/p procedure. Review the record and interview with the ED physician, MD #4 on 4/8/10 identified that the patient indicated the pain was 9 on the pain scale (1-10, 10 = worst pain), temperature 99, pulse 100, blood pressure 129/72, respirations 18 and oxygen saturation (SPO2) 86% (? room air, not documented). A chest xray identified bilateral atelectasis. Treatment included Morphine Sulfate 4 mg intravenously (IV), IV fluids, antibiotic by mouth (po) and incentive spirometry instruction. Interviews with MDs #3 & #4 on 4/8/10 indicated that after a phone consultation between MDs #3 & #4, the patient was discharged home at 11:30 PM with diagnoses that included fever and atelectasis. Patient #1 returned to the ED on 9/22/09 at 1:16 AM (triaged a level 1= Life Threatening Emergency per ED Triage Categories Policy) in septic shock due to perforated small bowel and subsequently expired on 9/25/09. Review of the ED Assessment -Reassessment Policy indicated that patient reassessment would consist of vital signs, pain level and a focused reassessment and that patients triaged I and II would have vital signs completed within 30 minutes prior to discharge. The policy also identified that adults patients with abnormal vital signs: SPO2 less than 92% would have their vital signs rechecked at least once prior to discharge. Documentation and interviews with hospital personnel failed to reflect that vital signs, SPO2 and a comprehensive reassessment were completed (as per hospital policy) prior to the patient's discharge from the ED on 9/18/09.

2. Patient #2 was admitted to the hospital on 3/23/10 at 8:02 AM for a laparoscopic cholecystectomy. The patient was readmitted to the hospital ED on 3/23/10 at 10:21 PM complaining of nausea, vomiting, as well as right and left shoulder pain (9 on pain scale, 1-10, 10= worst pain) radiating to the abdomen that was unrelieved with Percocet. Admission vital signs: temperature 98, pulse 88, respirations 24 and BP 110/70. Admission SPO2 was not documented. Review of the clinical record and interview with MD #4 on 4/8/10 identified that the patient's complete blood cell count and physical exam were within normal limits. Treatment included IV fluids, IV Morphine Sulfate 4 mg and Zofran 8 mg. MD #4 indicated that after consultation with the attending surgeon, MD #5, the patient was discharged home at 12:55 AM with instructions to follow up with MD #5 in the morning. Repeat vital signs were not completed. Review of the ED Assessment -Reassessment Policy indicated that the patient would receive a reassessment prior to discharge to determine the response to care, treatment or change in condition that would consist of vital signs, pain level and a focused reassessment as pertinent to the patient's complaint. Documentation and interviews with hospital personnel failed to reflect that vital signs, SPO2 and a comprehensive reassessment were completed (as per hospital policy) prior to the patient's discharge from the ED on 3/23/10.

3. Patient #12 was discharged from the hospital on 10/9/09 at 3:30 PM and returned to the ED at 4:40 PM complaining of wound leaking s/p laparoscopic (converted to open) cholecystectomy. Review of the ED record indicated that the patient called MD #5's office and was directed to go to the ED for a dressing change. Review of the ED Nurse's Note identified that the MD #5's "office" told the ED RN to change the abdominal wound dressing. The Triage Note identified that the dressing was saturated with serous sanguinous fluid draining from the insertion site (Jackson Pratt). The patient was not seen by an ED physician and documentation failed to reflect a verbal physician order for the dressing change. Interview with the ED Nurse Manager on 4/20/10 indicated that physicians would call ED nurses and would refer the patients to the ED nurse (not to be seen by the ED physician). Interview with the ED Nurse Manager on 4/20/10 identified that the hospital ED lacked a policy regarding the practice and that a policy was currently being drafted.

Based on review of clinical records, review of hospital documentation and interviews with hospital personnel, the hospital failed to ensure that performance improvement evaluation and monitoring were completed. The findings include:

1. Patient #1 was admitted to the One Day Surgery Department on 9/18/09 at 6:43 AM for a laparoscopic mesh repair of a ventral hernia and supraumbilical incisional hernia. Later, on 9/18/09 at 8:43 PM, Patient #1 returned to the Emergency Department (ED) complaining of abdominal pain, fever and chills. Patient #1 again returned to the ED on 9/22/09 at 1:16 AM in septic shock due to perforated small bowel and expired on 9/25/09. As a result, several actions were identified in a corrective action plan that included medical review of post-operative patients presenting to the ED, as well as review of physician and surgeon consultation documentation. Review of hospital documentation and interviews with MD #1, the Chief Medical Officer, MD #2, the Chief of Emergency Services and MD #5, the Chief of Surgery failed to reflect that continuous monitoring of the quality assessment indicators was conducted after implementation of the corrective action plan (10/16/09).