HospitalInspections.org

Based on record review and interview the Governing Body failed to review the quality of care provided to patient ID# 1 after he was allegedly transferred to another hospital in unstable condition.

Findings include:

Based on medical record review of the chart for patient ID# 1 at Select Specialty Hospital from 8/3/11 to 9/13/11 revealed the following:
Discharge Summary written by physician ID# 90 dated 9/13/11 stated " This is a 90 year-old African American male with past medical history of locally advance prostate cancer and urothelial carcinoma of the bladder. The patient had recently been admitted to MD Anderson Hospital where he had pneumonia, plus pelvic abscess. The patient developed respiratory failure and had to have tracheostomy and pelvic catheter. He had been on antibiotics for 2 weeks. The patient also had atrial fibrillation ...and was transferred to Select Specialty Hospital to continue care essentially for respiratory failure, pelvic abscess, recent pneumonia, and to continue intravenous antibiotics. "

Hospital Course stated " The patient was admitted to Select Specialty Hospital. The patient continued antibiotics, checked laboratories, chest x-ray, pulmonary consultation. The patient was here at Select Specialty Hospital for 40 days. In general, he did well, although there were several things along the way including pseudomonas in the sputum for which he completed a course of 7 days of ceftazidime. The patient was with a tracheostomy for all this time, initially with ventilator support and then on his own. The patient has been doing exceptionally well, although he is sick, and he is old and fragile. The patient was transferred today to Quentin Mease Community hospital. "
Discharge Diagnoses: " Respiratory failure, status post tracheostomy, still with some secretions; Pelvic abscess resolved; Prostate and bladder cancer; Atrial fibrillation; hypertension; anemia, weakness; deconditioning. "

Interview 10/28/11 at 8:30 a.m. with the accepting physician (ID# 71) at Quentin Mease Hospital revealed she was the physician on duty 9/13/11 when patient
ID# 1 was transferred from Select Specialty Hospital. Quentin Mease Hospital had accepted this patient from Select Specialty Hospital for admission to their Skilled Nursing Facility (SNF). The physician stated that she was immediately notified by the nurse practitioner that upon patient ID# 1's arrival he was in unstable condition. The physician evaluated the patient and found the patient in respiratory distress, delirious with altered mental status and febrile (103 degree fever). Initially the nurse practitioner called Select Specialty Hospital to take the patient back but was told by a Registered Nurse that a physician would have to accept the patient back to their hospital. Since the patient was acutely ill the decision was made to immediately transfer the patient to an Acute Care Hospital emergency room where he was admitted for pneumonia.

Further review of the medical record for patient ID# 1 at Select Specialty Hospital revealed he had a fever of 101 degrees Fahrenheit the night prior to transfer (9/12/11) and also had an elevated White Blood Cell count of 16.9 on the day of transfer (9/13/11). The primary physician failed to note these findings in his progress notes prior to transferring the patient.

Nursing staff vital signs taken prior to transfer on 9/13/11 at 12:00 p.m.
failed to document if the patient had a fever. The last temperature was documented 9/13/11 at 06:30 a.m. (fever 99.6 degrees)

The Chief Nursing Officer (CNO ID# 50) acknowledged 10/28/11 at 3 p.m. that he was aware that Quentin Mease Hospital called Select hospital back on 9/13/11 and said the patient was unstable upon arrival to their hospital. The CNO stated Select Specialty Hospital discussed the case of patient ID# 1 but did not complete a formal review of the case or conduct a peer review of physician ID# 90.