HospitalInspections.org

Based on interview and review of records, the hospital did not ensure that 1 of 1 patient (Patient #1) received care in a safe setting in that critical care services were not immediately available for Patient #1 on 10/03/08, after Patient #1 had been placed on a ventilator and had a respiratory arrest. A critical care consult was ordered on 10/03/08 and not completed until 10/06/08. There was no indication in the medical record that a pulmonologist was consulted.

Findings included:

The "Operative Report" transcribed 10/01/08 noted Patient #1, age 49, was admitted to the hospital on 10/01/08 with "profound malnutrition" and had a diagnostic laparoscopy and laparoscopic jejunostomy tube placement on 10/01/08.

The 10/03/08 "Interdisciplinary Progress Notes" noted Patient #1 had a respiratory arrest on 10/03/08, "... bagged...ACLS [Advanced Cardiac Life Support] protocol followed..." Patient #1 was resuscitated, intubated, ventilated and sedated. A call was placed to the "critical care doctor...we are awaiting call back..."

The 10/04/08 "Progress Notes" indicated that "cardiac...consult was initiated..."

The 10/06/08 "Progress Notes" included the "Cardiac Consult" (approximately 3 days after the consult was ordered).

The 10/07/08 "Progress Notes" included that Patient #1 was on a ventilator, "...worsening...consistent...ARDS [Acute Respiratory Distress Syndrome]..." There was no indication in the medical record that a pulmonary consult was initiated for Patient #1 at this hospital.

During an interview on 12/29/10 at 10:30 AM, the President of the Governing Board/Medical Director (Personnel #16) was asked what he remembered about Patient #1's hospitalization. Personnel #16 stated that the issue of not having critical care physician coverage for Patient #1's medical needs was addressed by the Governing Body and Medical Executive Committee for both the attending physician and the on-call pulmonologist on 10/08/08. Personnel #16 confirmed that the cardiac consult was not done until later in Patient #1's care.

The "Pulmonary Services Agreement" signed 03/06/08 for the period beginning 02/01/08 noted, "Services...provide on-call coverage for pulmonary services 24 hours per day, 7 days per week for the entire year...available (via pager) at all times...to provide pulmonary care for any and all patients requiring such services..."

The "Medical Staff Rules and Regulations" 2007 noted that "...is strongly suggested that all patients admitted to the Medical/Surgical ICUs receive consultation from a qualified physician who routinely treats patients in the critical care setting...to provide prompt and expert specialty evaluation and management advice that benefits the patient and meets the expectation of both the patient and requesting physician...if a practitioner is called, he must respond within a reasonable amount of time to meet the timely, adequate professional care for his patients."

Based on interview and review of records, the hospital failed to complete a discharge summary with outcome of hospitalization, disposition of care, and provisions for follow-up care for 3 of 8 patients (Patients #1, #4, and #5) who were discharged from the hospital from August 2008 to present.

Findings included:

1) The "Operative Report" transcribed 10/01/08 noted Patient #1, age 49, was admitted to the hospital on 10/01/08 with "profound malnutrition" and had a diagnostic laparoscopy and laparoscopic jejunostomy tube placement on 10/01/08. The MOT (Memorandum of Transfer) noted Patient #1 was to be transferred to another hospital on 10/07/08. Patient #1's diagnosis was "sepsis." Patient #1's medical record did not include the physician's "Discharge Summary."

2) The "Operative Report" transcribed 11/21/08 noted Patient #4, age 41, was admitted to the hospital on 11/11/08 with "morbid obesity" and had a sleeve gastrectomy on 11/11/08. The 11/13/08 physician's medical note indicated Patient #4 was to be transferred to the care of her pulmonary doctor at another hospital due to her history of pneumonia. Patient #4's medical record did not include the physician's "Discharge Summary."

3) The "Operative Report" transcribed 08/20/08 noted Patient #5, age 38, was admitted to the hospital on 08/19/08 with "recurrent abdominal pain" and had a diagnostic laparoscopy, lysis of adhesions, and partial omentectomy on 08/20/08. The 08/25/08 physician's orders noted Patient #5 was to be transferred to another hospital for "mesenteric venous thrombosis." Patient #5's medical record did not include the physician's "Discharge Summary."

During an interview on 12/29/10 at approximately 03:15 PM, the Director of Acute Care Services (Personnel #4) was asked if he had the discharge summaries of Patients #1, #4, and #5. After reviewing the medical records and checking with transcription, Personnel #4 stated that the discharge summaries for Patients #1, #4, and #5 were not completed.

The "Medical Staff Rules and Regulations"(2007) noted, "Discharge summaries are to be completed within thirty (30) days after the patient's discharge."

Based on interview and review of records, the Governing Body/Medical Executive Committee failed to evaluate the proposed new protocol (improvement action) regarding "Emergent Bariatric Admissions - ICU (intensive care unit)" that was to be created subsequent to the Governing Body/Medical Executive Committee 11/18/08 Patient #1 case review.

Findings included:

The "Operative Report" transcribed 10/01/08 noted Patient #1, age 49, was admitted to the hospital on 10/01/08 with "profound malnutrition" and had a diagnostic laparoscopy and laparoscopic jejunostomy tube placement on 10/01/08.

The 10/02/08 12:30 PM "Interdisciplinary Progress Notes" included a "Bariatric Consult" that noted Patient #1 had bariatric surgery four months ago with nausea and excessive weight loss and "...muscle wasting..." The physician was to follow Patient #1's care when he was "... feeling better..."

The 10/02/08 06:00 PM "Interdisciplinary Progress Notes" indicated that Patient #1 was transferred to the "ICU" after Patient #1 had "...sinus tachycardia...episode of hypotension..."

The 10/03/08 "Interdisciplinary Progress Notes" documented that Patient #1 had a respiratory arrest and an attempt was made to transfer Patient #1 to another hospital. A "verbal ok" was given by the receiving hospital and then that hospital "refused" the transfer. The "current" plan was to "...maximize pressors...maintain good urine output." Patient #1 remained on the ventilator and received blood transfusions.

The 10/07/08 "Progress Notes" included that Patient #1 was on the ventilator, "...worsening...consistent...ARDS..." The MOT (Memorandum of Transfer) noted Patient #1 was to be transferred to another hospital on 10/07/08. Patient #1's diagnosis was "sepsis."

The "Governing Board/Medical Executive Committee Meeting Minutes October 2008" (10/08/08) noted that the meeting was called "to evaluate the issues regarding critical care patients that are beyond the scope for our facility and the difficulty we are having transferring them to other facilities..."

The "Governing Board/Medical Executive Committee Meeting Minutes November 2008" (11/18/08) noted the Committee reviewed the follow-up information to the 10/08/08 meeting and made the recommendation that a new protocol regarding "Emergent Bariatric Admissions - ICU" was to be created.

The "Governing Board/Medical Executive Committee Meeting Minutes" (02/17/09) noted the Emergency Bariatric Admissions - ICU protocol was to be created by a physician and submitted to the Medical Executive Committee for approval.

Review of the Governing Board/Medical Executive Committee Meeting Minutes after 02/17/09 revealed that the Emergency Bariatric Admissions - ICU protocol was not submitted for approval to the Committee as proposed.

During an interview on 12/29/10 at 10:30 AM, the President of the Governing Board/Medical Director (Personnel #16) was asked for the Emergent Bariatric Admissions - ICU policy or protocol. Personnel #16 said that he thought he had seen the information, but did not know if it was reviewed in the Meeting Minutes.

The "Medical Staff Bylaws, Rules & Regulations" (undated) noted, "...it is recognized that the governing board of the hospital delegates to the medical staff and hold the Medical Staff accountable for certain responsibilities relating to the quality, efficiency and appropriateness of practitioner performance...Medical Staff hereby dedicates itself to provide quality medical care to the patients, to ensure a high standards of professional performance of its members...to further the education of health care providers...The Medical Staff is accountable to the Governing Board ..."