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Based on interviews and documentation review Hospitalist #1 failed to ensure that physician orders requiring immediate attention were transcribed in a timely manner for one of one patients (Patient #1).

Findings included:

Review of Patient #1's medical record, dated 9/13/10, indicated that at approximately 11:15 A.M., Hospitalist #1 wrote orders for stat arterial blood gases and cardiac enzymes. Additional orders included a cardiology consult.

Review of the record of dates/times that physician orders were entered into the automated system indicated that the orders were not entered until approximately 3:00 P.M.

The Unit Secretary, responsible for transcription of physician orders, was interviewed on 10/12/10 at 9:15 A.M. The Unit Secretary said he/she was not provided with the orders until sometime after 2:00 P.M. The Unit Secretary said he/she could not recall how he/she came across the orders. The Unit Secretary said Hospitalist #1 tended to walk around the Unit holding onto order sheets and progress notes and in the past he/she told Hospitalist #1 they had to be filed in the medical record. The Unit Secretary said he/she did not want to take responsibility for the delay in transcription and therefore spoke to the Director of the Unit.

The Director of the Critical Care Unit was interviewed intermittently throughout the survey. The Director said the Unit Secretary reported that Hospitalist #1 had handed him/her the physician orders.

Hospitalist #1 was interviewed on 10/12/10 at 7:00 A.M. Hospitalist #1 reported telling Nurse #1 about the stat orders prior to handing in the orders then handed the order sheet over to Nurse #1. Hospitalist #1 said he/she could not remember how long he/she had held onto the orders.

Nurse #1 was not available for a second interview to clarify Hospitalist #1's statement because he/she was out of the country.

The Director of Risk Management was interviewed intermittently throughout the survey. The Risk Manager said the Hospital's investigation determined Hospitalist #1 would walk the Unit and keep physician orders on his/her person and would give verbal orders in the corridor.

Based on interview and documentation review the Hospital failed to ensure that Nurse #1 communicated with Hospitalist #1 when there was concern regarding an Ativan order.

Findings included:

1) Medical record documentation, dated 9/13/10, indicated that a continuous Ativan drip was ordered to begin at 5:00 P.M. but was not administered.

Hospitalist #1 was interviewed on 10/12/10 at 7:00 A.M. Hospitalist #1 reported seeing Patient #1 approximately 5 times throughout the day, the last time being approximately 3:30 P.M. Hospitalist #1 said Patient #1 was anxious, was not lethargic and did not have signs of respiratory distress. Hospitalist #1 said Patient #1 asked about his/her accent then spoke of past travel destinations and did so without shortness of breath. Hospitalist #1 said at that time he/she wrote the order for the continuous Ativan drip.

Hospitalist #1 said and Progress Notes, dated 9/13/10, indicated that Hospitalist #1 was not told that the Ativan order was not implemented.

The nurse assigned to Patient #1 on 9/13/10 (Nurse #1) was interviewed on 10/7/10 at 10:10 A.M. Nurse #1 said he/she did not implement the Ativan drip order because he/she was uncomfortable with the order. Nurse #1 said he/she did not tell Hospitalist #1.

Based on documentation review, the Hospital failed to ensure that: 1) medical record entries were legible and were properly authenticated for one of one patient (Patient #1) on the Critical Care Unit (CCU), and 2) Nurse #1 monitored/documented Patient #1's oxygen saturation levels.

Findings included:

1) Review of entries made on the Critical Care Flow Sheet, dated 9/13/10, by Nurse #1 (confirmed with the Director of CCU) indicated that the entries were illegible.

Review of Physician Orders, written by Hospitalist #1 and dated 9/12/10 and 9/13/10, indicated that Hospitalist #1 authenticated the orders with initials only.


2) The nurse assigned to Patient #1 on 9/13/10 (Nurse #1) was interviewed on 10/7/10 at 10:10 A.M. Nurse #1 said that on 9/13/10 Patient #1's oxygen saturation levels were monitored and remained greater than 90% throughout the day.

Review of the Critical Care Flow Sheet, dated 9/13/10, indicated that vital signs were recorded at 11:00 A.M. and 4:00 P.M. however; Patient #1's oxygen saturation levels were not recorded

Based on interviews and documentation review the Hospital failed to ensure that its investigation of Patient #1's identified all areas of deficient practice and included a timely medical review of care provided.

Findings included:

Medical record documentation, dated 9/12/10, indicated that Patient #1 presented via ambulance to the Hospital's Emergency Department (ED) with acute abdominal pain (rated as 6/10), abdominal distention, nausea, and loss of appetite. Patient #1 reported drinking heavily the night before. Patient #1 had mild to moderate jaundice and upper extremity tremors. Patient #1's medical history was significant for high blood pressure, high cholesterol level, depression, anxiety, sleep disorder, pneumonia, and heavy alcohol consumption. Diagnostic testing was ordered and performed. An electrocardiogram (ECG) was performed and the results indicated Patient #1 was in normal sinus rhythm with tachycardia, premature ventricular contractions and diffuse t-wave inversion. A computerized tomography (CT) scan of the abdomen was ordered and was significant for pancreatitis, some duodenal edema without obstruction, severe diffuse fatty infiltrate of the liver, and granulomas of the liver and spleen.. Patient #1 was admitted to the Critical Care Unit (CCU) with acute pancreatitis (caused by alcohol use; symptoms include nausea and abdominal pain; the disease may be mild enough to resolve in several days or severe enough to cause multisystem organ failure and death), acute renal failure, and hepatitis.

Medical record documentation, dated 9/12/10, indicated that the plan of care included: cardiac monitoring; Ativan 2 milligram (mg) IV every 4 hours as needed, and Ativan 1 mg every 6 hours scheduled. Documentation indicated that if withdrawal symptoms were not controlled with the current Ativan order then a continuous Ativan drip would be ordered.

Hospitalist #1 was interviewed on 10/12/10 at 7:00 A.M. Hospitalist #1 said Patient #1 had pancreatitis with multisystem involvement. Hospitalist #1 said Patient #1's monitor readings (tachycardia and premature ventricular contractions) were indicative of alcohol withdrawal. Hospitalist #1 said Patient #1 was expected to go through alcohol withdrawal which usually started within 24 hours of the last drink consumed. Hospitalist #1 said Ativan was chosen because it was shorter acting and it was easier to regulate the dosage. Hospitalist #1 said Librium, which was part of the Hospital's Alcohol Withdrawal Policy, was not suitable for patients with liver failure. Hospitalist #1 said an Ativan drip was ordered when Ativan was given consistently because it provided steadier dosing and was easier to control.

Medical record documentation, dated 9/12/10 and 9/13/10, indicated the following: Patient #1 was alert and oriented to person and place with episodes of confusion, tremors, restlessness, and diaphoresis. Patient #1's lung sounds were diminished and respirations ranged from 20-30 breaths per minute. Patient #1 was administered oxygen at 2 liters via nasal cannula which he/she periodically removed. When removed Patient #1's oxygen saturation levels dropped to 87% (normal range is 95% to 100% on room air). Patient #1 was given scheduled Ativan 2 mg at 12:40 A.M., 5:41 A.M., and 11:56 A.M. and was given nonscheduled Ativan 1 mg at 2:57 A.M., 9:21 A.M. and 1:26 P.M.

The nurse assigned to Patient #1 on 9/13/10 (Nurse #1) was interviewed on 10/7/10 at 10:10 A.M. Nurse #1 said Patient #1 was very ill-looking and was mostly alert and cooperative. Nurse #1 said as the day went on, Patient #1 became weaker and more restless. Nurse #1 said later in the afternoon Patient #1 removed the cardiac monitor leads several times. Nurse #1 said Patient #1's oxygen saturation (SpO2) levels were stable throughout the day at greater than 90%.

Hospitalist #1 reported seeing Patient #1 approximately 5 times throughout the day, the last time being approximately 3:30 P.M. Hospitalist #1 said Patient #1 was anxious, was not lethargic and did not have signs of respiratory distress. Hospitalist #1 said Patient #1 asked about his/her accent then spoke of past travel destinations and did so without shortness of breath. Hospitalist #1 said at that time he/she wrote the order for the continuous Ativan drip.

Nurse #1 said he/she did not implement the Ativan drip order because he/she was uncomfortable with the order. Nurse #1 said he/she did not tell Hospitalist #1. Nurse #1 said he/she went into see Patient #1 at approximately 5:10 P.M. to adjust the intravenous fluid rate and at that time Patient #1 was awake and had slid down in the bed. Nurse #1 reported asking Patient #1 if he/she was okay and Patient #1 told Nurse #1 to leave him/her alone. Nurse #1 said he/she did not look at Patient #1's monitor leads and did not look at the cardiac monitor. Nurse #1 said he/she went to attend to another patient then went to the nursing station. Nurse #1 said he/she was able to visualize Patient #1. Nurse #1 said he/she did not look at the central board, located at the nursing station. Nurse #1 said Hospitalist #1 came by, asked how Patient #1 was, and Nurse #1 told him/her that Patient #1 had been restless.

Hospitalist #1 said he/she went into see Patient #1, found Patient #1 unresponsive. Hospitalist #1 said he/she looked at the monitor and it read leads off. Hospitalist #1 called for Nurse #1 and called for a Code.

Nurse #1 said when he/she went into Patient #1's room the monitor leads were off and the IV line was disconnected.

A strip report, dated 9/13/10, indicated that the leads were removed at approximately 5:03 P.M.

Medical record documentation, dated 9/13/10, indicated that Patient #1 was revived and remained intubated on mechanical ventilation. A cardiologist reviewed electrocardiogram information and determined Patient #1 did not suffer from a cardiac event. An electroencephalogram was performed and showed Patient #1 suffered from a hypoxic ischemic brain injury.

Following the event the Hospital conducted an investigation. The investigation did not identify the following: medication reconciliation process was inconsistent; Nurse #1's documentation was illegible; Hospitalist #1 did not properly authenticate orders; Nurse #1 did not document Patient #1's SpO2 levels prior to the event, and Hospitalist #1 wrote stat orders at 11:15 A.M. that were not transcribed until approximately. 3:00 P.M.

At the time of the survey the Chief Hospitalist had not yet conducted a medical review of the case.

Based on interview and documentation review, the Hospital failed to ensure that corrective actions were developed for all identified issues and that corrective actions related to patient safety were addressed in a timely manner.

Findings included:


Please Refer to A-0287 for medical information regarding Patient #1.

The Hospital developed a corrective action plan that was submitted to the Department of Public Health and included the following:
(1) A mandatory staff meeting was scheduled for 10/19/10 to review: staffing at the time of the event; implementation of ensuring the charge nurse take a less acute assignment; monitoring the charge nurse's assignment for changes in acuity and adjusting either the assignment or the charge nurse duties; monthly review of assignments to ensure the above changes were occurring and were effective; the need for increased communication among nursing staff when one of the nurses has a patient or event that requires the nurse's attention for greater than 30 minutes, and nursing accountability for answering alarm notifications and call lights regardless of their assignment.
(2) Physician orientation concerns were going to be reviewed with the Chief Hospitalist by 9/28/10 (done) for a follow-up and remediation plan by 10/1/10 (not done).
(3) All nurses were going to be held accountable for answering alarm notifications and patient call lights effective immediately; rounds to monitor for compliance were to begin on 11/1/10.
(4) Development of a task force to look at options for improving cardiac monitoring process with attention to capital needs and/or resource utilization; recommendations to be presented by 1/1/11.

The action plan did not address identified incomplete code documentation.

At the onset of the survey the only action that had occurred was a meeting with the day shift nurses regarding awareness of monitor notifications.

Based on interviews and documentation review the Hospital failed to ensure that Nurse #1 acted upon medication orders for one of one patients (Patient #1).

Findings included:

Medical record documentation, dated 9/13/10, indicated that a continuous Ativan drip was ordered to begin at 5:00 P.M. but was not administered.

Hospitalist #1 was interviewed on 10/12/10 at 7:00 A.M. Hospitalist #1 reported seeing Patient #1 approximately 5 times throughout the day, the last time being approximately 3:30 P.M. Hospitalist #1 said Patient #1 was anxious, was not lethargic and did not have signs of respiratory distress. Hospitalist #1 said Patient #1 asked about his/her accent then spoke of past travel destinations and did so without shortness of breath. Hospitalist #1 said at that time he/she wrote the order for the continuous Ativan drip.

Hospitalist #1 said and Progress Notes, dated 9/13/10, indicated that Hospitalist #1 was not told that the Ativan order was not implemented.

The nurse assigned to Patient #1 on 9/13/10 (Nurse #1) was interviewed on 10/7/10 at 10:10 A.M. Nurse #1 said he/she did not implement the Ativan drip order because he/she was uncomfortable with the order. Nurse #1 said he/she did not tell Hospitalist #1.