HospitalInspections.org

Based on interviews and record reviews, the Governing Body failed to oversee the affairs of the hospital, in that on 01/18/22 at 19:00 PM Patient #1 who was unresponsive was admitted the medica-surgical floor. Physician orders at 19:56 PM included cardiac monitoring, vital signs every 4 hours, continuous pulse oximetry, glucose monitoring every 6 hours, and patient code status was a full code. These orders were not implemented in a timely manner. In less than 9 hours the Patient #1 expired. A root cause analysis was completed on 01/24/22. Corrective Action Plans were not implemented until 03/03/22, 38 days later.

Cross refer to Tag 0049

Based on the interview and record review, the hospital did not protect or promote patients' right to treatment, care, and services within the hospital's capability and mission. Between 10/01/21 to 03/01/22, 4 of 8 patients (Patient #1, #2, #3, and #4) who had physician orders for cardiac telemetry monitoring were not implemented in a timely manner, and 1 of 11 patients did not have an accurate patient code status.

Cross Refer to Tag 0144

Based on interview and record review, the Medical Staff did not ensure action plans from a root cause analysis (RCA) dated 01/24/22 were implemented in a timely manner. The RCA was about Patient #1's demise on 01/19/22, less than 9 hours after admission, citing 1 of 11 patients admitted on 01/18/22.

Findings included:

Patient #1 was admitted for continued care of the lumbar spine osteomyelitis/abscess, Enterococcal Mitral Valve Endocarditis, and CVA multiple infarcts and was in the medical-surgical floor at 19:00. Progress Notes at 21:10 by Physician #4 reflected "HPI (history of present illness): Patient is not alert or awake to answer questions...History obtained via chart review...Physical Exam...Constitutional...not alert, chronically ill appearing...Plan. Agree with medications per discharge paperwork...Tele monitoring..."

Physician orders at 19:56 PM included cardiac monitoring, vital signs every 4 hours, continuous pulse oximetry, glucose monitoring every 6 hours, and patient code status was a full code. These orders were not implemented in a timely manner.

Code Blue was activated at 03:40 (01/19/22). Physician #14 noted in the Code Blue Note "...Patient was not on telemonitoring...patient was not breathing, had no pulse, and he remained unresponsive...Temp checked at the start of the code was 91F axillary...glucose checked at start of the code and was <20...Code was ran per ACLS protocol (advanced cardiovascular life support) for 40 minutes...Patient remained asystole after 40 minutes of ACLS protocol and time of death was called at 0421..."

During an interview on 03/01/22 at 11:05 AM, Personnel #1 confirmed Patient #1 expired without implementing physician orders that included cardiac telemonitoring, pulse oximetry, and vital signs. Personnel #1 stated a RCA was conducted. When asked for the RCA and corrective action plan documentation, Personnel #1 referred the question to Personnel #4 (via phone call). At 11:16 AM, Personnel #4 initially responded she could only provide the RCA, but not the corrective action plan documentation since the action plans was given to the Chief Clinical Officer who was no longer employed since 02/02/22. Later that afternoon, the surveyors were told Personnel #4 had a copy of the action plans at her residence. On 03/02/22 at 09:15 AM, a copy of a handwritten RCA and corrective action plans were provided to the surveyors.

Policy and Procedure Medical Executive Committee (MEC) undated indicated "Procedure...A. Composition. 1. President of Medical Staff...c. Accountable to the Governing Body as representative of the medical staff for quality and appropriateness and efficiency of clinical services...B... i. Risk Management...k. Mortality review...C. MEC Meetings...9. Risk Management - Take action on risk management matters where it is necessary that they do so for patient safety and efficient, safe hospital functioning. 10 Mortality Review - Review deaths..."

Based on interview and record review, the hospital did not ensure A) 4 of 8 patients (Patient #1, #2, #3, and #4) receive care in a safe setting between 10/01/21 to 03/01/22, in that, these patients had physician orders for cardiac telemetry monitoring and were either not implemented and/or not implemented in a timely manner. One of the patients (Patient #1) expired in less than 9 hours after admission and was not placed in a cardiac telemetry. And B) 1 of 11 patients did not have an accurate patient code status.

Findings included:

A. The following patients had physician orders for cardiac telemetry monitoring:

Patient #1 was admitted on 01/18/22 and was in the nursing floor at 19:00. Patient #1 was admitted for continued care of the lumbar spine osteomyelitis/abscess, Enterococcal Mitral Valve Endocarditis, and CVA multiple infarcts. At 19:56, a verbal physician orders were received and verified that included "pulse oximetry: continuously and telemetry: cardiac monitoring." A code blue was called on 01/19/22 at 03:40. The code was run per ACLS protocol for 40 minutes. Patient #1 expired at 04:21 (01/19/22). The cardiac telemetry and pulse oximetry devices were not placed on Patient #1 prior to the activation of the code blue.

Patient #2 was admitted on 01/25/22 for antibiotics therapy and chronic non-healing right foot wound. At 23:08 a physician order for cardiac telemetry was received. Patient #2's first telemonitor strip was documented on 01/26/22 at 19:51, almost 21 hours after the order was received (20 hours and 43 minutes to be exact) after the order was received.

Patient #3 was admitted on 11/03/21 for wound care and antibiotic therapy. On 11/04/21 at 20:14 a physician order for cardiac telemetry was received. The patient's first telemetry strip was documented on 11/06/21 at 19:10, almost 50 hours (46 hours and 56 minutes or 1 day, 12 hours, and 56 minutes to be exact) after the order was received.

Patient #4 was admitted on 10/01/21 for acute respiratory failure, status-post COVID-19. On 10/01/21 at 20:36, a physician order for cardiac telemetry was received. The patient's first telemetry strip was documented on 10/01/21 at 23:46, 3 hours and 10 minutes after the order was received.

During the medical records review, Personnel #3 navigated the electronic medical records for the surveyors. Personnel #3 confirmed Patient #1, #2, #3, and #4 had physician orders for cardiac telemetry. The cardiac monitor devices were not attached to Patient #1. And, for Patient #2, #3, and #4 the cardiac telemetry and monitoring were not placed in a timely manner ranging from 3 hours to 46 hours and 56 minutes or 1 day, 12 hours, and 56 minutes.

Policy and Procedure "Cardiac Monitoring" approved date 02/10/22 reflected "Purpose. To provide for safe monitoring of patient's cardiac rhythm in order to appropriately treat dysrhythmias...in real time...Policy. All patients requiring cardiac monitoring...will have a telemetry monitor attached and monitored at a remote station...Procedure...C. Tracings will be printed, interpreted, and placed in the patient's medical record at the following times: 1. When cardiac monitoring is initiated...2...beginning of shift and every 4 hours..."

B. Patient #5 was admitted on 01/03/22 for self-inflicted gunshot wound to the head and acute hypoxic respiratory failure secondary to a gunshot wound. The patient's code status on 01/04/22 was DNR (do not resuscitate). On 01/18/22 at 18:00 per documentation of Personnel #8, primary care nurse-day shift, and witnessed by Personnel #7, Patient #5 became a full code status. This documentation did not have a physician's signature. Patient #5 was subsequently transferred to an acute care hospital for bleeding in the PEG tube area. The previous patient code status, DNR form dated 01/04/22 was not found in the medical record.

In an interview on 03/01/22 at 1:59 PM, Personnel #6 stated this was investigated and the findings were substantiated. Personnel #6 stated Personnel #8 was given a verbal warning. When asked for evidence of the verbal warning, Personnel #6 stated there was none.

In an interview on 03/03/22 at 11:00 AM via telephone call, Personnel #8 confirmed she threw away the previous DNR document and placed the Full Code documentation in Patient #5's medical record.

Policy and Procedure "Patient Rights and Responsibilities" effective 11/14/2019 indicated "Purpose. Policies and mechanisms are established to preserve the human rights, dignity and safety of patients admitted to the facility and ...Patient Rights ...F. The patient has the right to formulate advance directives and to have hospital staff and practitioners ...comply with these directives ...Q. Patients have the right to receive care in a safe setting ..."

Personnel File of Personnel #8 did not contain documentation of a verbal warning regarding destruction of a patient code status.

Policy and Procedure "Progressive Discipline "revised 05/17/21 reflected A. Disciplinary Action...Verbal Warning...This conversation should take place as soon as supervisor observes or becomes aware of the issue...Supervisors should document the conversation including the date and content of the conversation and verbal warning form will be place in employee's personnel file."