**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of facility policy, review of The Joint Commission (TJC) Sentinel Event Alert, review of the Food and Drug Administration (FDA) guidelines, medical record review, review of facility documentation, observation, and interview, the facility failed to provide care in a safe setting for 1 patient (#2) of 5 patients reviewed for surgical services. The findings included: During the survey it was found one patient (#2) was admitted to the facility on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. During the patient's admission the staff were unable to gain Intravenous (IV) access. On 5/24/17 an attempt to place a central line into the patient's right jugular resulted in placement of the catheter into the patient's right carotid artery. On 5/25/17 the patient was taken to the Operating Room (OR) for an insertion of a femoral central line and ligation of a hole and right internal carotid artery repair. Prior to the surgery an Endotracheal tube (ETT) was inserted into the patient's tracheostomy site and the patient was placed on 100% oxygen with Continuous Airway Positive Pressure (CPAP), was given inhalation anesthesia, and ventilated with an ambu bag. During the surgical procedure a right femoral line was inserted by the surgeon and the patient remained on 100% oxygen (O2). A surgical incision was made to the patient's right carotid artery, which required the incision site to the previously placed central line site to be made larger. A cautery machine was used during the surgery and during use of the cautery device a flame was observed, resulting in burns to the patient's lips, neck, and singeing to the patient's facial hair. The flame was extinguished, the singed surgical drapes were removed, and the ETT was removed by anesthesia. The patient required reintubation with 100% supplemental oxygen. The surgical procedure was continued and the surgical wound was closed. During a conference on 6/2/17 at 10:10 AM, in the Chief Nursing Executive's office, with the Administrator, the Chief Nurse Executive (CNE), and the Director of Regulatory Compliance, the facility was informed of the Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation, has cause, or is likely to cause injury, harm, or impairment, or death) at 42 CFR PART 482.13 Patient Rights (Condition). Review of an Immediate Action Plan (MDS) dated [DATE] revealed the following actions were implemented: 1. Fire risk assessment for cases not identified prior to the procedure (a) Implement fire risk scoring process to be completed by anesthesia provider and identified to the team during the timeout process. The circulating Registered Nurse (RN) will be the responsible party to communicate the score during the time out process. (b) Responsible Party: The Director of Patient Safety, Director of Surgical Services, CNE, and Chief of Anesthesia. (c) Implementation date: 6/2/17 (d) Prior to every OR procedure the fire risk score will be communicated during the time out process. (e) Expected compliance: 100% (f) Director or Manager of OR will complete direct observations on all regular scheduled cases and Nursing Supervisor will complete observations of emergent cases during the next 3 days and then 30 cases per month x (times) 3 months. (g) Oversight: Patient Safety Committee, Medical Executive Committee, and the Board of Governance (BOG) 2. Training- staff further need education regarding surgical site fire risk (a) Staff will attend stand-up education sessions covering the risk assessment scoring tool and the measures to implement based on scores. (b) Responsible Party: The Director of Patient Safety, Director of Surgical Services, CNE, and Chief of Anesthesia. (c)Implementation date: 6/2/17. Completion date 6/7/17. (d) Huddles to review surgical site fire risk tool with staff attestation of completing education. Huddles will provide time for staff to ask questions and seek any needed clarification. (e) All full time (FT), part time (PT), and PRN (as needed) staff who participate in the time out process. Staff on family medical leave (FMLA) and vacation will receive education on return and prior to entering OR. (f) 100% of staff will receive education prior to entering the OR. (g) Director or Manager of OR will provide education to staff and obtain attestation. (h) Oversight: Patient Safety Committee, Medical Executive Committee, and the Board of Governance (BOG) 3. Anesthesia did not inform surgeon of difficulties of maintain O2 saturations and the need to increase O2 delivery. (a) Implement a communication and documentation process for communicating high risk airway, high fractioned inspired oxygen (FIO2), and fire risk score prior to case by anesthesia provider and surgeon. Documentation of communication will be noted on anesthesia form. (b) Responsible Party: The Director of Patient Safety, Director of Surgical Services, CNE, Chief of Anesthesia, Chief of Surgery. (c) Implementation: 6/2/17. Completion 6/7/17. (d) OR Director and Manager will meet with Anesthesia providers to review surgical site fire risk tool and new documentation process. All anesthesia providers will complete attestation that they have been informed. (e) 100% of anesthesia providers will provide anesthesia services. (f) OR Director and Manager along with Chief of Anesthesiology will provide education to the anesthesia providers and obtain attestation forms. (g) Oversight: Patient Safety Committee, Medical Executive Committee, and the Board of Governance (BOG) 4. Fire Drills did not include evaluation of surgical site fire risk assessment. (a) Enhance current quarterly fire drills to include evaluation of surgical site fire risk assessment completion and communication prior to start of procedure during the time out process. Develop staff competency form which will be completed with initial drill and new hire orientation. (b) Responsible Party: The Director of Patient Safety, Director of Surgical Services, CNE, Chief of Anesthesia, Chief of Surgery. (c) Implementation date: 6/2/17 (d) First fire drill will be conducted on 6/7/17. (e) Three drills to be completed prior to 7/15/17. Then quarterly. (f) Oversight: Patient Safety Committee, Medical Executive Committee, and the Board of Governance (BOG) Review of recent changes to the facility policy Safe Procedural and Surgical Verification 6/2017, (as part of the allegation of compliance) revealed ...the verification process, which starts during the pre-procedure phase, will be conducted throughout all phases of procedural care, and will include the continuous sharing of information to include patient, procedure and site, and fire risk score... Further review revealed ...a time out, which is led by the surgeon/proceduralist, will be performed prior to starting the procedure...surgical site fire risk score will be communicated to the team by the circulator... Continued review revealed ...relevant documents...to be reviewed include...surgical site fire risk assessment guide... Further review revealed ...if the patient will be moved to the surgical/procedural area, a final verification will be conducted prior to the transfer. Members of the Surgical/Procedure team will perform a reconfirmation of each of the following items...in addition, fire risk score will be calculated... Continued review revealed ...safety concerns are addressed in relation to scheduled procedure. Safety concerns may include but are limited to...risk of fire associated with skin prep dry time [if alcohol based] and high risk airway... Review of a Surgical Site Fire Risk Assessment Guide (tool used to evaluate surgical fire risk) revealed the fire risk protocol addressed in the facility policy. Further review revealed the form will be used to score all surgical cases for surgical site fire risk of high, medium, or low risk. Continued review revealed fire risk protocols for each category of fire risk. Refer to A144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of facility policy, review of the Joint Commission (TJC) Sentinel Event Alert, review of the Food and Drug Administration (FDA) guidelines, medical record review, review of facility documentation, and interview, the facility failed to ensure surgical services were provided in accordance with acceptable standards of practice for 1 patient (#2) of 5 patients reviewed for surgical services. The findings included: During the survey it was found one patient (#2) was admitted to the facility on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. During the patient's admission the staff were unable to gain Intravenous (IV) access. On 5/24/17 an attempt to place a central line into the patient's right jugular resulted in placement of the catheter into the patient's right carotid artery. On 5/25/17 the patient was taken to the Operating Room (OR) for an insertion of a femoral central line and ligation of a hole and right internal carotid artery repair. Prior to the surgery an Endotracheal tube (ETT) was inserted into the patient's tracheostomy site and the patient was placed on 100% oxygen with Continuous Airway Positive Pressure (CPAP), was given inhalation anesthesia, and ventilated with an ambu bag. During the surgical procedure a right femoral line was inserted by the surgeon and the patient remained on 100% oxygen (O2). A surgical incision was made to the patient's right carotid artery, which required the incision site to the previously placed central line site to be made larger. A cautery machine was used during the surgery and during use of the cautery device a flame was observed, resulting in burns to the patient's lips, neck, and singeing to the patient's facial hair. The flame was extinguished, the singed surgical drapes were removed, and the ETT was removed by anesthesia. The patient required reintubation with 100% supplemental oxygen. The surgical procedure was continued and the surgical wound was closed. During a conference on 6/2/17 at 10:10 AM, in the Chief Nursing Executive's office, with the Administrator, the Chief Nurse Executive (CNE), and the Director of Regulatory Compliance, the facility was informed of the Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation, has cause, or is likely to cause injury, harm, or impairment, or death) at 42 CFR PART 482.13 Patient Rights (Condition). Review of an Immediate Action Plan (MDS) dated [DATE] revealed the following actions were implemented: 1. Fire risk assessment for cases not identified prior to the procedure (a) Implement fire risk scoring process to be completed by anesthesia provider and identified to the team during the timeout process. The circulating Registered Nurse (RN) will be the responsible party to communicate the score during the time out process. (b) Responsible Party: The Director of Patient Safety, Director of Surgical Services, CNE, and Chief of Anesthesia. (c) Implementation date: 6/2/17 (d) Prior to every OR procedure the fire risk score will be communicated during the time out process. (e) Expected compliance: 100% (f) Director or Manager of OR will complete direct observations on all regular scheduled cases and Nursing Supervisor will complete observations of emergent cases during the next 3 days and then 30 cases per month x (times) 3 months. (g) Oversight: Patient Safety Committee, Medical Executive Committee, and the Board of Governance (BOG) 2. Training- staff further need education regarding surgical site fire risk (a) Staff will attend stand-up education sessions covering the risk assessment scoring tool and the measures to implement based on scores. (b) Responsible Party: The Director of Patient Safety, Director of Surgical Services, CNE, and Chief of Anesthesia. (c)Implementation date: 6/2/17. Completion date 6/7/17. (d) Huddles to review surgical site fire risk tool with staff attestation of completing education. Huddles will provide time for staff to ask questions and seek any needed clarification. (e) All full time (FT), part time (PT), and PRN (as needed) staff who participate in the time out process. Staff on family medical leave (FMLA) and vacation will receive education on return and prior to entering OR. (f) 100% of staff will receive education prior to entering the OR. (g) Director or Manager of OR will provide education to staff and obtain attestation. (h) Oversight: Patient Safety Committee, Medical Executive Committee, and the Board of Governance (BOG) 3. Anesthesia did not inform surgeon of difficulties of maintain O2 saturations and the need to increase O2 delivery. (a) Implement a communication and documentation process for communicating high risk airway, high fractioned inspired oxygen (FIO2), and fire risk score prior to case by anesthesia provider and surgeon. Documentation of communication will be noted on anesthesia form. (b) Responsible Party: The Director of Patient Safety, Director of Surgical Services, CNE, Chief of Anesthesia, Chief of Surgery. (c) Implementation: 6/2/17. Completion 6/7/17. (d) OR Director and Manager will meet with Anesthesia providers to review surgical site fire risk tool and new documentation process. All anesthesia providers will complete attestation that they have been informed. (e) 100% of anesthesia providers will provide anesthesia services. (f) OR Director and Manager along with Chief of Anesthesiology will provide education to the anesthesia providers and obtain attestation forms. (g) Oversight: Patient Safety Committee, Medical Executive Committee, and the Board of Governance (BOG) 4. Fire Drills did not include evaluation of surgical site fire risk assessment. (a) Enhance current quarterly fire drills to include evaluation of surgical site fire risk assessment completion and communication prior to start of procedure during the time out process. Develop staff competency form which will be completed with initial drill and new hire orientation. (b) Responsible Party: The Director of Patient Safety, Director of Surgical Services, CNE, Chief of Anesthesia, Chief of Surgery. (c) Implementation date: 6/2/17 (d) First fire drill will be conducted on 6/7/17. (e) Three drills to be completed prior to 7/15/17. Then quarterly. (f) Oversight: Patient Safety Committee, Medical Executive Committee, and the Board of Governance (BOG) Review of recent changes to the facility policy Safe Procedural and Surgical Verification 6/2017, (as part of the allegation of compliance) revealed ...the verification process, which starts during the pre-procedure phase, will be conducted throughout all phases of procedural care, and will include the continuous sharing of information to include patient, procedure and site, and fire risk score... Further review revealed ...a time out, which is led by the surgeon/proceduralist, will be performed prior to starting the procedure...surgical site fire risk score will be communicated to the team by the circulator... Continued review revealed ...relevant documents...to be reviewed include...surgical site fire risk assessment guide... Further review revealed ...if the patient will be moved to the surgical/procedural area, a final verification will be conducted prior to the transfer. Members of the Surgical/Procedure team will perform a reconfirmation of each of the following items...in addition, fire risk score will be calculated... Continued review revealed ...safety concerns are addressed in relation to scheduled procedure. Safety concerns may include but are limited to...risk of fire associated with skin prep dry time [if alcohol based] and high risk airway... Review of a Surgical Site Fire Risk Assessment Guide (tool used to evaluate surgical fire risk) revealed the fire risk protocol addressed in the facility policy. Further review revealed the form will be used to score all surgical cases for surgical site fire risk of high, medium, or low risk. Continued review revealed fire risk protocols for each category of fire risk. Refer to A951
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of facility policy, review of the Joint Commission (TJC) Sentinel Event Alert, review of the Food and Drug Administration (FDA) guidelines, medical record review, review of facility documentation, and interview, the facility failed to ensure anesthesia services were provided in a safe setting for 1 patient (#2) of 5 patients reviewed for surgical services. The findings included: During the survey it was found one patient (#2) was admitted to the facility on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. During the patient's admission the staff were unable to gain Intravenous (IV) access. On 5/24/17 an attempt to place a central line into the patient's right jugular resulted in placement of the catheter into the patient's right carotid artery. On 5/25/17 the patient was taken to the Operating Room (OR) for an insertion of a femoral central line and ligation of a hole and right internal carotid artery repair. Prior to the surgery an Endotracheal tube (ETT) was inserted into the patient's tracheostomy site and the patient was placed on 100% oxygen with Continuous Airway Positive Pressure (CPAP), was given inhalation anesthesia, and ventilated with an ambu bag. During the surgical procedure a right femoral line was inserted by the surgeon and the patient remained on 100% oxygen (O2). A surgical incision was made to the patient's right carotid artery, which required the incision site to the previously placed central line site to be made larger. A cautery machine was used during the surgery and during use of the cautery device a flame was observed, resulting in burns to the patient's lips, neck, and singeing to the patient's facial hair. The flame was extinguished, the singed surgical drapes were removed, and the ETT was removed by anesthesia. The patient required reintubation with 100% supplemental oxygen. The surgical procedure was continued and the surgical wound was closed. During a conference on 6/2/17 at 10:10 AM, in the Chief Nursing Executive's office, with the Administrator, the Chief Nurse Executive (CNE), and the Director of Regulatory Compliance, the facility was informed of the Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation, has cause, or is likely to cause injury, harm, or impairment, or death) at 42 CFR PART 482.13 Patient Rights (Condition). Review of an Immediate Action Plan (MDS) dated [DATE] revealed the following actions were implemented: 1. Fire risk assessment for cases not identified prior to the procedure (a) Implement fire risk scoring process to be completed by anesthesia provider and identified to the team during the timeout process. The circulating Registered Nurse (RN) will be the responsible party to communicate the score during the time out process. (b) Responsible Party: The Director of Patient Safety, Director of Surgical Services, CNE, and Chief of Anesthesia. (c) Implementation date: 6/2/17 (d) Prior to every OR procedure the fire risk score will be communicated during the time out process. (e) Expected compliance: 100% (f) Director or Manager of OR will complete direct observations on all regular scheduled cases and Nursing Supervisor will complete observations of emergent cases during the next 3 days and then 30 cases per month x (times) 3 months. (g) Oversight: Patient Safety Committee, Medical Executive Committee, and the Board of Governance (BOG) 2. Training- staff further need education regarding surgical site fire risk (a) Staff will attend stand-up education sessions covering the risk assessment scoring tool and the measures to implement based on scores. (b) Responsible Party: The Director of Patient Safety, Director of Surgical Services, CNE, and Chief of Anesthesia. (c)Implementation date: 6/2/17. Completion date 6/7/17. (d) Huddles to review surgical site fire risk tool with staff attestation of completing education. Huddles will provide time for staff to ask questions and seek any needed clarification. (e) All full time (FT), part time (PT), and PRN (as needed) staff who participate in the time out process. Staff on family medical leave (FMLA) and vacation will receive education on return and prior to entering OR. (f) 100% of staff will receive education prior to entering the OR. (g) Director or Manager of OR will provide education to staff and obtain attestation. (h) Oversight: Patient Safety Committee, Medical Executive Committee, and the Board of Governance (BOG) 3. Anesthesia did not inform surgeon of difficulties of maintain O2 saturations and the need to increase O2 delivery. (a) Implement a communication and documentation process for communicating high risk airway, high fractioned inspired oxygen (FIO2), and fire risk score prior to case by anesthesia provider and surgeon. Documentation of communication will be noted on anesthesia form. (b) Responsible Party: The Director of Patient Safety, Director of Surgical Services, CNE, Chief of Anesthesia, Chief of Surgery. (c) Implementation: 6/2/17. Completion 6/7/17. (d) OR Director and Manager will meet with Anesthesia providers to review surgical site fire risk tool and new documentation process. All anesthesia providers will complete attestation that they have been informed. (e) 100% of anesthesia providers will provide anesthesia services. (f) OR Director and Manager along with Chief of Anesthesiology will provide education to the anesthesia providers and obtain attestation forms. (g) Oversight: Patient Safety Committee, Medical Executive Committee, and the Board of Governance (BOG) 4. Fire Drills did not include evaluation of surgical site fire risk assessment. (a) Enhance current quarterly fire drills to include evaluation of surgical site fire risk assessment completion and communication prior to start of procedure during the time out process. Develop staff competency form which will be completed with initial drill and new hire orientation. (b) Responsible Party: The Director of Patient Safety, Director of Surgical Services, CNE, Chief of Anesthesia, Chief of Surgery. (c) Implementation date: 6/2/17 (d) First fire drill will be conducted on 6/7/17. (e) Three drills to be completed prior to 7/15/17. Then quarterly. (f) Oversight: Patient Safety Committee, Medical Executive Committee, and the Board of Governance (BOG) Review of recent changes to the facility policy Safe Procedural and Surgical Verification dated 6/2017, (as part of the allegation of compliance) revealed ...the verification process, which starts during the pre-procedure phase, will be conducted throughout all phases of procedural care, and will include the continuous sharing of information to include patient, procedure and site, and fire risk score... Further review revealed ...a time out, which is led by the surgeon/proceduralist, will be performed prior to starting the procedure...surgical site fire risk score will be communicated to the team by the circulator... Continued review revealed ...relevant documents...to be reviewed include...surgical site fire risk assessment guide... Further review revealed ...if the patient will be moved to the surgical/procedural area, a final verification will be conducted prior to the transfer. Members of the Surgical/Procedure team will perform a reconfirmation of each of the following items...in addition, fire risk score will be calculated... Continued review revealed ...safety concerns are addressed in relation to scheduled procedure. Safety concerns may include but are limited to...risk of fire associated with skin prep dry time [if alcohol based] and high risk airway... Review of a Surgical Site Fire Risk Assessment Guide (tool used to evaluate surgical fire risk) revealed the fire risk protocol addressed in the facility policy. Further review revealed the form will be used to score all surgical cases for surgical site fire risk of high, medium, or low risk. Continued review revealed fire risk protocols for each category of fire risk. Refer to A1002
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of facility policy, review of Medical Staff Bylaws, medical record reviews, and interviews, the facility failed to provide an appropriate Medical Screening Examination (MSE) and stabilizing treatment within it's capabilities for 1 patient (Patient #2) with Abdominal Pain of 36 patients review. The facility's failure resulted in Patient #2 traveling 27 miles by private vehicle in severe pain to obtain diagnosis and treatment for his Emergency Medical Condition (EMC). The findings included: Patient #2 presented to the Emergency Department (ED) at Hospital A's West Campus on 6/10/2021 at 1:08 AM with a complaint of severe lower abdominal pain and the patient rated his pain as a 4 (on the pain scale of 1-10 with level 10 being the most severe pain). Patient #2 had a history of Diverticulitis (inflammation of abnormal pouches which can develop on the lining of the large intestine). The patient was seen by an ED physician and laboratory tests and a Computed Tomography (CT) of the Abdomen were ordered. The patient's white blood count was 12.8 (normal 5.0 to 10.8, elevated typically means infection or inflammation in the body). The CT of the Abdomen showed ...Possible enteritis. Recommend clinical correlation [clinical correlation recommended usually indicates inadequate clinical information was provided, or there was an unexpected finding requiring clinical assessment]. If mechanical obstruction is a concern clinically recommend followup plain film examination in 4-6 hours... Patient #2 was re-evaluated by the physician and diagnostic tests were discussed. Patient #2 was discharged home from Hospital A 6/10/2021 at 2:31 AM with instructions to ...FOLLOWUP WITH PCP [primary care physician] 2-3 DAYS... The patient left Hospital A on 6/10/2021 at 2:41 AM. Patient #2 then (MDS) dated [DATE] at 4:29 AM (1 hour 50 minutes after leaving Hospital A's ED) with a complaint of abdominal pain. The patient rated his pain as an 11. Review of an ED Provider's Note dated 6/10/2021 at 4:48 AM showed ...presents today for evaluation of abdominal pain. Location of abdominal pain is diffuse but more pronounced on the right lower quadrant...description of the pain is sharp...uncomfortable appearing male...there is abdominal tenderness in the left lower quadrant...Abdomen moderately tender to palpation. Peritonitis is present...peritonitis is present on exam... Patient #2 was taken to the operating room that afternoon for robotic small bowel resection and was discharged home from Hospital B on 6/14/2021. Refer to A2406 and A2407.
Based on facility policy reviews, review of Medical Staff Bylaws, medical record reviews, and interviews, the facility failed to provide an appropriate Medical Screening Examination (MSE) within the capabilities of the hospital to diagnose the Emergency Medical Condition (EMC) of 1 patient (Patient #2) with Abdominal Pain of 36 Emergency Department (ED) patients reviewed. The facility's failure to complete an appropriate MSE led to a delay in diagnosis of Patient #2's EMC. The findings included: Review of the facility's policy titled EMTALA [Emergency Medical Treatment and Labor Act] - Tennessee Medical Screening Examination & Stabilization, approved 6/2017 revealed, ...An EMTALA obligation is triggered when an individual comes to a Dedicated Emergency Department (DED) and...the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition...then an appropriate MSE, within the capabilities of the Hospital's DED...including ancillary services routinely available...shall be performed... Review of the facility's Medical Staff Rules and Regulations - 2019 approved 4/2020 revealed ...A physician/APP [Advanced Practice Provider] or qualified medical person provides medical screening and determines the scope of assessment and care for patients in need of emergency care... Review of the Patient #2's medical record at Hospital A showed the patient presented to the ED at the facility's West Campus Emergency Department (ED) on 6/10/2021 at 1:08 AM for complaint of severe lower abdominal pain. Continued review revealed the patient stated his pain was severe and he rated his pain as a 4 (on a scale of 1-10 with 10 being the most severe pain). Continued review revealed the patient's vital signs at 1:17 AM were ...Pain 4...Temperature F: 97.8 [normal is 97 to 99]...Pulse: 89 [normal is 60 to 100]....Blood pressure: 146/98 [normal is less than 120/80]... Continued review revealed the nurse re-assessed the patient's vital signs at 2:40 AM and they were documented as ...Temperature F: 98.0...Pulse 78...Blood Pressure: 136/99... Further review revealed Patient #2's pain was not re-assessed after 1:17 AM. Review of a physician's EMERGENCY PROVIDER REPORT at Hospital A dated 6/10/2021 revealed Physician #1 began the MSE of Patient #2 at 1:10 AM. Continued review revealed ...Chief Complaint: Abdominal pain...PT [patient] PRESENTS C/O [complaining of] ONE HOUR OF DIFFUSE [wide spread] ABDOMINAL PAIN A/W [also with] NAUSEA...PT HAS PMH [past medical history] DIVERTICULITIS [inflammation of abnormal pouches which can develop on the lining of the large intestine]...IN MODERATE DISTRESS SECONDARY TO PAIN...Abdomen/GI [gastro-intestinal] Atraumatic, Soft, No guarding, No rebound, BS [bowel sounds] normoactive [normal], No distention, No hernia, No palpable mass, DIFFUSE TENDERNESS... The ED physician ordered laboratory tests and a Computed Tomography (CT) of the Abdomen for Patient #2. Review of the laboratory results at Hospital A dated 6/10/2021 at 1:40 revealed Patient #2's White Blood Count was 12.8 (normal 5.0 to 10.8, elevated typically means infection or inflammation in the body). Review of the CT of the Abdomen for Patient #2 at Hospital A dated 6/10/2021 at 1:45 AM revealed ...Possible enteritis. Recommend clinical correlation [usually indicates inadequate clinical information was provided, or there was an unexpected finding requiring clinical assessment] If mechanical obstruction is a concern clinically recommend followup plain film examination in 4-6 hours... Review of Physician #1's re-assessment of Patient #1 dated 6/10/2021, not timed, revealed ...discussed lab and ct findings with pt...pt has had some improvement...abd [abdomen] remains soft...no vomiting will d/c [discharge] with pcp [primary care physician] followup... Continued review revealed the patient was discharged home from Hospital A on 6/10/2021 at 2:31 AM with instructions to ...FOLLOWUP WITH PCP [primary care physician] 2-3 DAYS... Continued review reveled the patient left the facility on 6/10/2021 at 2:41 AM. Review of the medical record at Hospital B showed Patient #2 presented to the ED 6/10/2021 at 4:29 AM (1 hour 50 minutes after leaving Hospital A's ED). Review of ED Triage Notes at Hospital B dated 6/10/2021 at 4:39 AM revealed ...Pt. arrived to triage desk via wheelchair. C/o of abd [abdominal] pain...Says pain is '11/10' [indicating severe pain/more severe than the 1-10 scale indicates]... Continued review revealed the patient's vital signs were ...Temp: 98.2...Heart Rate: 106...B/P [blood pressure]: 113/70... Review of an ED Provider Note at Hospital B dated 6/10/2021 at 4:48 AM revealed ...presents today for evaluation of abdominal pain. Location of abdominal pain is diffuse but more pronounced on the right lower quadrant...Patient stated he felt every bump on the rolled [road] on route to the emergency room ...description of the pain is sharp...uncomfortable appearing male...there is abdominal tenderness in the left lower quadrant...Abdomen moderately tender to palpation. Peritonitis is present...peritonitis is present on exam. Patient's history of presentation and exam warrants evaluation with blood work-up, EKG and 1 set troponin [laboratory test for heart attack], and CT of abdomen and pelvis... Review of a laboratory report at Hospital B dated 6/10/2021 at 5:42 AM revealed Patient #2's white blood count was 20. Review of an ED Provider Note at Hospital B dated 6/10/2021 at 7:32 AM revealed ...The patient fulfills septic [life threatening response to infection] criteria with a pulse of 106 and white count of 20,900. I have started septic protocol... Review of Radiology Report of a CT Abdomen and Pelvis with Contrast at Hospital B dated 6/10/2021, not timed, revealed ...Focal inflammatory changes surrounding a blind-ending pouch arising from the small bowel in the midabdomen concerning for a Meckel's diverticulitis... Review of an ED Provider Note at Hospital B dated 6/10/2021 at 8:12 AM revealed ...CT Scan is back and suggest Meckel's diverticulitis [a rare disease involving an infected pouch on the lining of the small intestine] per the radiologist. I have paged on surgery... Review of General Surgery Operative Note at Hospital B dated 6/10/2021 at 1:16 PM revealed Patient #2 had a Robotic Abdominal Exploration and a Small Bowel Resection and Intracorporeal Anastomosis (surgical removal of a section of bowel and reattachment of the bowel ends). Continued review of the operative note revealed ...the small bowel was run until the inflamed diverticulum was identified...used to amputate the distal and proximal small bowel...Purulence [pus] was noted in the pelvis and this was all removed... Review of a discharge summary for Patient #2 at Hospital B dated 6/14/2021, not timed, revealed ...presented on 6/10 [6/10/2021] with acute abdominal pain and CT scan was concerning for Meckel's diverticulitis. Patient was taken to the operating room that afternoon for robotic small bowel resection...Patient was discharged home with plans for follow-up...in 2 weeks... Continued review revealed Patient #2 was discharged home from Hospital B in good condition on 6/14/2021 at 3:42 PM. During a telephone interview on 6/22/2021 at 12:53 PM, Physician #1 stated she was on duty at Hospital A's ED on 6/10/2021 and she remembered Patient #1. Physician #1 stated she examined the patient and did not find any evidence the patient was having an acute abdominal problem requiring surgery or emergency interventions. Continued interview revealed the patient did not have severe pain or severe abdominal tenderness, and his diagnostic tests did not show any evidence of acute disease. Continued interview revealed there were no acute problems found with the patient's CT Scan and laboratory tests and she believed the patient was stable for discharge. Physician #1 stated she examined the patient prior to discharge and he had no signs or symptoms of an acute surgical abdomen. Continued interview revealed the patient's condition had improved while he was in the ED and the physician believed the patient was stable for discharge and did not have an emergency medical condition. Physician #1 confirmed she did not consult the general surgeon or gastroenterologist on call regarding Patient #2 and she did not transfer the patient to the main campus ED. During a telephone interview on 6/23/2021 at 8:45 AM, Patient#2 stated he presented to Hospital A's ED on 6/9/2021 around midnight. The patient stated his pain was very severe and that he told the ED staff his pain severity was above a 1-10 scale and was a 15-20 level of pain. Continued interview revealed he was treated with morphine for pain and he told staff it was not helping. The patient stated he continued to complain of severe pain. Patient #2 stated x-rays and a CT scan without contrast was performed on the patient. The patient stated he was told he might have a virus and to go home and put a hot towel to his abdomen. Continued interview revealed he told the ED staff that his pain was still very severe and unrelieved at discharge. Patient #2 stated he went directly to Hospital B by private vehicle for further treatment and at Hospital B he had a CT scan with contrast and was told he had a ruptured bowel. The patient stated he was taken to the operating room immediately after his CT Scan. During an interview on 6/23/2021 at 11:00 AM, Hospital A's Vice President of Quality stated the facility has a general surgeon and a gastroenterologist on call daily for additional consults, assessments, and treatments for ED patients. Continued interview revealed consults with on-call specialists are requested by the ED physician when the ED physician determines a consult is needed.
Based on facility policy reviews, medical record reviews, and interviews the facility failed to provide stabilizing treatment within the capabilities of the hospital to treat the Emergency Medical Condition (EMC) of 1 patient (Patient #2) patient with Abdominal Pain of 36 patients reviewed. The facility's failure resulted in Patient #2's seeking further medical treatment at Hospital B located 29 miles from Hospital A. The findings included: Review of the facility's policy titled EMTALA - Tennessee Medical Screening Examination & Stabilization approved 6/2017 revealed, ...if an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility... Review of the Patient #2's medical record at Hospital A showed the patient presented to the ED at the facility's West Campus Emergency Department (ED) on 6/10/2021 at 1:08 AM for complaint of severe lower abdominal pain. Continued review revealed the patient stated his pain was severe and he rated his pain as a 4 (on a scale of 1-10 with 10 being the most severe pain). Continued review revealed the patient's vital signs at 1:17 AM were ...Pain 4...Temperature F: 97.8 [normal is 97 to 99]...Pulse: 89 [normal is 60 to 100]....Blood pressure: 146/98 [normal is less than 120/80]... Continued review revealed the nurse re-assessed the patient's vital signs at 2:40 AM and they were documented as ...Temperature F: 98.0...Pulse 78...Blood Pressure: 136/99... Further review revealed Patient #2's pain was not re-assessed after 1:17 AM. Review of a physician's EMERGENCY PROVIDER REPORT at Hospital A dated 6/10/2021 revealed Physician #1 began the MSE of Patient #2 at 1:10 AM. Continued review revealed ...Chief Complaint: Abdominal pain...PT [patient] PRESENTS C/O [complaining of] ONE HOUR OF DIFFUSE [wide spread] ABDOMINAL PAIN A/W [also with] NAUSEA...PT HAS PMH [past medical history] DIVERTICULITIS [inflammation of abnormal pouches which can develop on the lining of the large intestine]...IN MODERATE DISTRESS SECONDARY TO PAIN...Abdomen/GI [gastro-intestinal] Atraumatic, Soft, No guarding, No rebound, BS [bowel sounds] normoactive [normal], No distention, No hernia, No palpable mass, DIFFUSE TENDERNESS... The ED physician ordered laboratory tests and a Computed Tomography (CT) of the Abdomen for Patient #2. Review of the medical record at Hospital B showed Patient #2 presented to the ED 6/10/2021 at 4:29 AM (1 hour 50 minutes after leaving Hospital A's ED). Review of ED Triage Notes at Hospital B dated 6/10/2021 at 4:39 AM revealed ...Pt. arrived to triage desk via wheelchair. C/o of abed [abdominal] pain...Says pain is '11/10' [indicating severe pain/more severe than the 1-10 scale indicates]... Continued review revealed the patient's vital signs were ...Temp: 98.2...Heart Rate: 106...B/P [blood pressure]: 113/70... Review of an ED Provider's Note at Hospital B dated 6/10/2021 at 4:48 AM revealed ...presents today for evaluation of abdominal pain. Location of abdominal pain is diffuse but more pronounced on the right lower quadrant...Patient stated he felt every bump on the rolled [road] on route to the emergency room ...description of the pain is sharp...uncomfortable appearing male...there is abdominal tenderness in the left lower quadrant...Abdomen moderately tender to palpation. Peritonitis is present...peritonitis is present on exam... Review of Radiology Report of a CT Abdomen and Pelvis with Contrast at Hospital B dated 6/10/2021, not timed, revealed ...Focal inflammatory changes surrounding a blind-ending pouch arising from the small bowel in the midabdomen concerning for a Meckel's diverticulitis... Review of an ED Provider's Note at Hospital B dated 6/10/2021 at 8:12 AM revealed ...CT Scan is back and suggest Meckel's diverticulitis [a rare disease involving an infected pouch on the lining of the small intestine] per the radiologist. I have paged on surgery... Review of General Surgery Operative Note at Hospital B dated 6/10/2021 at 1:16 PM revealed Patient #2 had a Robotic Abdominal Exploration and a Small Bowel Resection and Intracorporeal Anastomosis (surgical removal of a section of bowel and reattachment of the bowel ends). Continued review of the operative note revealed ...the small bowel was run until the inflamed diverticulum was identified...used to amputate the distal and proximal small bowel...Purulence [pus] was noted in the pelvis and this was all removed... During a telephone interview on 6/22/2021 at 12:53 PM, Physician #1 stated she was on duty at Hospital A's ED on 6/10/2021 and she remembered Patient #1. Physician #1 stated she examined the patient and did not find any evidence the patient was having an acute abdominal problem requiring surgery or emergency interventions. Continued interview revealed the patient did not have severe pain or severe abdominal tenderness, and his diagnostic tests did not show any evidence of acute disease and she believed the patient was stable for discharge. Physician #1 stated she examined the patient prior to discharge and he had no signs or symptoms of an acute surgical abdomen. Continued interview revealed the patient's condition had improved and the physician felt the patient did not have an emergency medical condition. Physician #1 confirmed she did not consult the general surgeon or gastroenterologist on call and she did not transfer the patient to the main campus ED. During a telephone interview on 6/23/2021 at 8:45 AM, Patient#2 stated he presented to Hospital A's ED on 6/9/2021 around midnight. The patient stated his pain was very severe and that he told the ED staff his pain severity was above a 1-10 scale and was a 15-20 level of pain. Continued interview revealed he was treated with morphine for pain and he told staff it was not helping. The patient stated he continued to complain of severe pain. The patient stated he was told he might have a virus and to go home and put a hot towel to his abdomen. Continued interview revealed he told the ED staff that his pain was still very severe and unrelieved at discharge. Patient #2 stated he went directly to Hospital B by private vehicle for further treatment and at Hospital B he had a CT scan with contrast and was told he had a ruptured bowel. The patient stated he was taken to the operating room immediately after his CT Scan.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on facility policy review, medical record review, and interview, the facility failed to obtain a properly executed informed consent prior to performing a surgical procedure for one patient (Patient #1) of 5 patients reviewed for informed consent. The findings included: Review of facility policy titled Informed Consent last revised 4/2019 revealed ...The nurse or other appropriate healthcare professional should place in the patient's medical record an executed informed consent...Specific informed consent is considered necessary for any procedures or treatments which are invasive and/or have potentially serious side effects or complications. These included but may not be limited to...Insertion of devices and/or appliances the skin...all procedures in which anesthesia is administered... Review of the medical record revealed Patient #1 was admitted to the facility on [DATE] with diagnosis of Non-ST Elevated Myocardial Infarction (a heart attack with the absence of ST wave elevation on an electrocardiogram). Medical record review of a Nurse's Note dated 2/6/2021 at 8:00 AM revealed the patient was alert and oriented. Medical record review of a review of a Cath Post Procedure Report dated 2/6/2021 at 8:27 AM revealed the patient had a Diagnostic Coronary Angiography with Left Heart Catheterization (surgical procedure where a catheter is inserted into the heart for diagnostic and medical treatment). Continued review of a Consent for Surgical or Invasive Treatment dated 2/6/2021 revealed the consent was not signed by Patient #1 or the patient's representative. Continued review revealed no properly executed informed consent was documented in the medical record. During an interview on 2/23/2021 at 2:30 PM the Quality Director confirmed there was no properly executed informed consent documented in Patient #1's medical record for the heart catheterization performed on 2/6/2021.
For documentation purposes: Facility A is Parkridge East Hospital (a satellite facility of Parkridge Medical Center) located at 941 Spring Creek Road, Chattanooga, TN . Facility B is Erlanger Medical Center located at 975 East Third Street, Chattanooga, TN (located 6 miles from Facility A). Based on review of facility policy, review of facility Medical Staff Rules and Regulations, review of the Tennessee Nurse Practice Act, medical record review, review of facility investigation, and interview, the facility failed to provide a medical screening examination (MSE) by a qualified medical provider (QMP) for 1 patient (#29) and failed to prevent a delay in treatment for 1 patient (#27) of 35 medical records reviewed. Refer to A-2406 Refer to A-2408
Based on facility policy review, review of facility Medical Staff Rules and Regulations, review of Tennessee Nurse Practice Act, medical record review, and interview, the facility failed to provide a medical screening examination (MSE) for 1 patient (#29) of 35 medical records reviewed. The findings included: Review of facility policy EMTALA - Tennessee Medical Screening Examination and Stabilization dated 06/2017, revealed ...hospital must provide an appropriate MSE within the capability of the hospital's emergency department...to any individual, including a pregnant woman having contractions...Only qualified licensed independent practitioner (LIP) with appropriate competencies and privileges...A qualified staff member who...is functioning within the scope of his or her license and in compliance with state law and appropriate practice acts...QMPS [qualified medical providers) may perform an MSE if licensed and certified, approved by the hospital's governing board...QMP's in the labor and delivery DED [designated emergency department] may be appropriately-approved RNs [Registered Nurse]... Review of facility policy Labor and Delivery Medical Screening approved 09/2016, revealed ...In the Labor and Delivery setting, emergency medical screening examinations may be performed by...a Labor and Delivery Registered Nurse [RN] who has completed the Qualified Medical Provider (QMP) competencies [fetal monitoring training]...It is permissible for a Labor and Delivery Registered Nurse to conduct an emergency labor screening examination on a patient of 20 weeks gestation or greater utilizing the Obstetrical Medical Screening Tool... Review of Medical Staff Rules and Regulations - 2017 dated 03/2017, revealed ...qualified medical person provides medical screening...Qualified Medical Person or Personnel - means an individual other than a licensed physician who is certified in one of the following categories...Registered Nurse in Perinatal Services... Review of the Tennessee Code Annotated 63-7-103 ...Title 63 Professions of the Healing Arts...Nursing...General Provisions... dated 2016, revealed ...professional nursing includes...(A) Responsible supervision of a patient...(B) Promotion, restoration and maintenance of health or prevention of illness of others...(C) Counseling, managing, supervising and teaching of others...(D) Administration of medications and treatments as prescribed by a licensed physician...or nurse authorized to prescribe...(E) Application of such nursing procedures as involve understanding of cause and effect...(F) Nursing management of illness, injury or infirmity...(b) the practice of professional nursing does not include acts of medical diagnosis or the development of a medical plan or care... Continued review did not specify Registered Nurses were permitted to complete Medical Screening Examinations under the Tennessee Nurse Practice Act. Medical record review revealed Patient #29 presented to Facility A on 8/3/17 at 3:39 AM at 38 weeks gestation with complaints of contractions and a pain score of 6 (severe pain). Further review revealed a vaginal examination and fetal heart monitoring was done by a Registered Nurse (RN). Further review revealed no documentation the patient was provided a MSE by a physician, physician's assistant (PA), or advanced practice nurse (APN) prior to being discharged home at 5:30 AM. Medical record revealed Patient #29 returned to Facility A on 8/3/17 at 3:06 PM (9 hours and 36 minutes later) for complaint of contractions with a pain score of 9 (severe pain). Further review revealed a vaginal examination and fetal heart monitoring was done by a RN. Further review revealed no documentation the patient was provided a MSE by a physician, PA, or an APN prior to being discharged home on 8/3/17 at 5:30 PM. Interview with Facility A's Women's Service Director on 9/6/17 at 4:00 PM, in the conference room, revealed some Obstetrics (OB) patients who present in labor are not seen by a physician, PA, or APN, and are only seen by a RN. Continued interview confirmed OB RNs provide a MSE for patients in possible labor and ...a Hospitalist...laborist... is available every night from 7:00 PM to 7:00 AM and every weekend from 7:00 PM Friday to 7:00 AM on Monday. Further interview confirmed a MSE was not provided by a licensed physician, PA, or APN.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to prevent a delay in treatment for 1 patient (#27) of 35 medical records reviewed. The findings included: Review of facility policy On-call Pay dated 1/1/14, revealed ...designated on-call employees must be available to be reached electronically or by phone and must be able to report to work within thirty [30] minutes of being contacted... Medical record review revealed Patient #27 was admitted to the Emergency Department (ED) at Facility A on 7/29/17 at 3:47 AM with complaints of right lower quadrant pain for 2 weeks. Further review revealed the patient had reported the onset of symptoms started on 7/15/17 and were not getting better and had a pain score of 9 [indicating severe pain]. Continued review revealed her Last Menstrual Period (LMP) was 9/1/15 and she had been on Depo-Provera (injections to prevent pregnancy). Further review revealed the patient was transferred to Facility B on 7/29/17 at 9:33 AM (5 hours and 14 minutes later). Medical record review of an Emergency Provider Report at Facility A dated 7/29/17 at 3:49 AM revealed the patient was evaluated by the ED physician. Further review revealed ...abdominal pain, nausea...urinary frequency...pain for 2 weeks...slowly worse...nausea... Medical record review of a Laboratory Results Interpretation report from Facility A dated 7/29/17 at 4:25 AM revealed a Positive Pregnancy test. Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 4:35 AM revealed the Ultra Sound (US) Tech was called for a transvaginal ultrasound (pelvic ultrasound) order. Further review revealed ...called [named US tech]...no answer...left message on her voice mail... Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 4:37AM revealed ...no call back from...US Tech...re-paged... Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 4:41 AM revealed ...no call back from [named] US Tech...re-paged... Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 5:05 AM revealed ...no call back from [named US Tech]...re-paged... Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 5:05 AM revealed ...Nursing supervisor was notified of the multiple attempts to contact US Tech to no avail [no success]. Advised that following US Tech's shift begins at 7:00 AM MD [Medical Doctor] notified... Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 5:11 AM revealed ...no call back from US Tech...re-paged... Medical record review of an Emergency Patient Record at Facility A dated 7/29/17 at 7:06 AM revealed ...[named US Tech] in US called and std [stated] she is here and will be down to get patient in just a few minutes... Medical record review of an Ultrasound Transvaginal report at Facility A revealed the US was completed on 7/29/17 at 7:30 AM (3 hours and 5 minutes after the US was ordered). Medical record review of an Ultrasound Transvaginal report at Facility A dated 7/29/17 at 8:04 AM revealed the report was signed by [named radiologist]. Further review revealed ...impression...a live ectopic [outside the uterus] pregnancy at 9 weeks and 5 days of the right ovary...recommend stat Obstetrics and Gynecology [OB/GYN] consultation... Medical record review of an Emergency Provider Report at Facility A dated 7/29/17 at 8:05 AM revealed the ED physician contacted the on-call OB/GYN physician for Facility A. Continued review revealed the patient requested to be transferred to Facility B because her OB physician was located there. Medical record review of an Emergency Medical Condition (EMC) form at Facility A dated 7/29/17 revealed the patient was transferred to Facility B at 9:33 AM with a diagnosis of [DIAGNOSES REDACTED] Review of a facility investigation report from Facility A dated 8/11/17 revealed ...ED Director and Assistant Chief Nursing Officer [ACNO] were made aware of patient issue r/t [related to] call received from Facility B with concern about patient transfer...delay in u/s [ultrasound] and direction provided...the delay in u/s [ultrasound] tech response was a schedule issue/confusion with tech who was sick and the covering technician... Further review revealed ...review of patient medical record: 7/29/17: 3:47 AM: patient arrived in ED 4:00 AM: triaged with pain of 9. Right Lower Quadrant [RLQ] pain x [times] 2 weeks. Much worse that day with nausea and vomiting 4:30 AM: transvaginal u/s ordered. Positive Pregnancy Test U/S tech paged at 4:37 AM, 4:41 AM, 5:05 AM. Nursing supervisor notified at 5:05 AM. Advised that following US tech shift begins at 7:00 AM. MD notified. 7:06 AM: US tech on site and on way to get patient 8:00 AM: transvaginal u/s interpretation...live [DIAGNOSES REDACTED] at 9 weeks 5 days of the right ovary. Recommend stat [now] OB/GYN consultation. 8:05 AM: [named ED physician] and [named on-call OB/GYN] phone conversation 8:10 AM: pain 9 (scale of 1-10, indicating intense pain) 9:33 AM: pt. transferred to Facility B by EMS [emergency medical services]... Medical record review of an Operative Report from Facility B dated 7/29/17 at 1:44 PM revealed ...procedure: diagnostic laparoscopy [surgical procedure in which a fiber optic instrument is inserted through the abdominal wall to view the organs in the abdomen or to permit a surgical procedure]...partial omentectomy [surgical procedure to remove thin fold of abdominal tissue]... Interview with the Director of Imagining Services at Facility A on 9/6/17 at 11:10 AM, in the conference room, confirmed ...the US technicians are on call after 11:00 PM...the technician had notified me on Thursday [7/28/17] that she had strep throat and could not return to work...the schedule technician thought she was on call for the main hospital [not Facility A]...did not realize she was on call for [Facility A]...they had called her 3 times...the order was put in at 4:31 AM and the US was completed at 7:13 AM by the day shift US technician... Further interview revealed ...they are responsible for their own schedules... Telephone interview with the ED Medical Director at Facility A on 9/6/17 at 11:00 AM revealed the patient (MDS) dated [DATE] with a chief complaint of RLQ pain. Further interview revealed ...I saw the patient around 4:00 AM...she had no idea she was pregnant...her HCG came back elevated which indicated she was pregnant...after we got her labs back I ordered an Ultrasound to rule out an [DIAGNOSES REDACTED]... Further interview confirmed ...there was a delay in the getting the US...the test was done around 7:30 AM which did reveal an [DIAGNOSES REDACTED]... Telephone interview with ED Physician #2 at Facility A on 9/6/17 at 11:30 AM confirmed ...the patient came in with RLQ pain...her HCG [Human chorionic gonadotropin] [hormone produced during pregnancy] was positive indicating she was pregnant...the US was performed after I came in and showed a 9 week 5 day old right ovarian [DIAGNOSES REDACTED]...she said she had an OB/GYN physician at [Facility B] and had seen the physician to get her birth control...wanted to go to [Facility B]...the patient was very stable...no acute abdomen... Interview with the Cooperate Risk Manager at Facility A on 9/7/17 at 9:50 AM, in the conference room, revealed ...I was notified about the patient and the delay in getting the US...the technician did not realize she was on-call for Facility A and had not got anyone to cover for her due to sickness...they called her 3 times then they got in touch with the day shift technician who performed the US... Continued interview confirmed ...the delay in the US has been discussed and referred to the department manager for follow up...the nursing supervisor was notified by the ED staff...further calls to the US staff were made and the day shift technician did the US as soon as she got in the facility... Further interview revealed ...we discussed the delay in obtaining the US with our ED Medical Director and CMO [Chief Medical Officer]... Interview with the Chief Nursing Officer (CNO) on 9/7/17 at 10:00 AM, in the conference room, revealed ...I was notified by the RM [Risk Manager] regarding the US and the patient's transfer... Further interview confirmed ...there was a delay in getting the US...
Based on review of facility policy, review of Tennessee Code Annotated 63-7-103 (Tennessee Practice of Professional Nursing), review of medical staff rules and regulations, medical record review, and interviews, the facility failed to provide a Medical Screening Examination by a Qualified Medical Provider for 2 patients (#34 and #37) of 37 patients reviewed, and failed to accept the appropriate transfer of 1 patient (#4) when the facility had the capacity and capability to treat the patient. Refer to 2406 for failure to provide a medical screening examination. Refer to 2411 for failure to accept an appropriate transfer.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of facility policy, review of medical staff rules and regulations, review of Tennessee Code Annotated 63-7-103 (Tennessee Practice of Professional Nursing), medical record reviews, and interviews, the facility failed to provide a Medical Screening Examination (MSE) by a Qualified Medical Person (QMP) for 2 patients (#34 and #37) of 37 patients reviewed. The findings included: Review of facility policy EMTALA - Tennessee Medical Screening Examination and Stabilization dated 06/2017 revealed, ...hospital must provide an appropriate MSE within the capability of the hospital's emergency department...to any individual, including a pregnant woman having contractions...Only the following individuals may perform an MSE...A qualified physician with appropriate privileges...Other qualified licensed independent practitioner (LIP) with appropriate competencies and privileges...A qualified staff member who...is functioning within the scope of his or her license and in compliance with state law and appropriate practice acts...QMPs may perform an MSE if licensed and certified, approved by the hospital's governing board...QMPs in the labor and delivery DED [designated emergency department] may be appropriately-approved RNs [Registered Nurse]... Review of facility policy Labor and Delivery Medical Screening approved 09/2016 revealed, ...In the Labor and Delivery setting, emergency medical screening examinations may be performed by...a Labor and Delivery Registered Nurse [RN] who has completed the Qualified Medical Provider (QMP) competencies...It is permissible for a Labor and Delivery Registered Nurse to conduct an emergency labor screening examination on a patient of 20 weeks gestation or greater utilizing the Obstetrical Medical Screening Tool... Review of Medical Staff Rules and Regulations - 2017 dated 03/2017 revealed, ...qualified medical person provides medical screening...Qualified Medical Person or Personnel - means an individual other than a licensed physician who is certified in one of the following categories...Registered Nurse in Perinatal Services... Review of the Tennessee Code Annotated 63-7-103 ...Title 63 Professions of the Healing Arts...Nursing...General Provisions... dated 2016, revealed ...professional nursing includes...(A) Responsible supervision of a patient...(B) Promotion, restoration and maintenance of health or prevention of illness of others...(C) Counseling, managing, supervising and teaching of others...(D) Administration of medications and treatments as presribed by a licensed physician...or nurse authorized to prescribe...(E) Application of such nursing procedures as involve understanding of cause and effect...(F) Nursing management of illness, injury or infirmity...(b) the practice of professional nursing does not include acts of medical diagnosis or the development of a medical plan or care... Continued review revealed the Code did not specify Registered Nurses were permitted to complete Medical Screening Examinations under the Tennessee Nurse Practice Act. Medical record review revealed Patient #34 presented to the facility's East campus on 7/3/17 at 2:26 PM with complaint of 37 weeks pregnant with contractions. Further review of the medical record revealed the patient was assessed by an RN with fetal heart monitoring and a vaginal exam being provided by an RN. Further review of the medical record revealed no documentation of the patient being provided a MSE by a physician, physician's assistant (PA), or advanced practice nurse (APN) prior to being discharged home at 4:47 PM. Further review of the medical record revealed the patient returned to the facility on [DATE] at 11:59 PM for complaint of labor and elevated blood pressure. Further review of the medical record revealed the patient was admitted on [DATE] at 6:01 AM. Medical record review revealed Patient #37 presented to the facility's East campus on 6/25/17 at 2:15 AM for complaint of being 36 weeks pregnant with contractions. Further review of the medical record revealed the patient was assessed by an RN with a vaginal exam and fetal heart monitoring being provided by an RN. Further medical review revealed no documentation of the patient being provided a MSE by a physician, PA, or APN prior to being discharged home on 6/25/17 at 10:40 AM. Further review of the medical record revealed the patient returned to the facility on [DATE] at 8:15 AM and delivered her baby on 7/6/17 at 12:43 PM. Interview with the Womens Service Director on 8/1/17 at 11:42 AM, in the Labor and Delivery classroom at the facility's East campus, confirmed on the first 7/3/17 visit, Patient #34 was not provided a MSE by a physician, PA, or APN. Further interview confirmed Patient #34 was assessed by an RN only during the first 7/3/17 visit. Further interview revealed pregnant patients presenting in possible labor to the facility's East campus may routinely be provided a MSE by an RN only. Further interview revealed the East campus provides 24 hour labor and delivery (L&D) services and has a physician that specializes in L&D in the hospital each night from 7:00 PM to 7:00 AM and every weekend from Friday at 7:00 PM to Monday at 7:00 AM. Interview with the Womens Service Director on 8/1/17 at 11:58 AM, in the Labor and Delivery classroom at the facility's East campus, confirmed on the 6/25/17 visit Patient #37 was not provided a MSE by a physician, PA, or APN. Further interview confirmed Patient #37 was assessed by an RN only during the 6/25/17 visit.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of facility policies, review of Medical Staff Rules and Regulations 2017, review of a facility letter, review of medical records, review of an audio recording, and interviews, the facility failed to accept an appropriate transfer of 1 patient (#4) of 37 patients reviewed. The findings included: Review of facility policy EMTALA-Transfer Policy approved 03/2016 revealed, ...A hospital with specialized capabilities...shall accept from a transferring hospital an appropriate transfer of an individual with an EMC [Emergency Medical Condition] who requires specialized capabilities if the receiving hospital has the capacity to treat the individual... Review of the facility policy EMTALA-Provisions of On-Call Coverage approved 01/2017 revealed, ...The on-call physician does not have the authority to refuse an appropriate transfer on the behalf of the facility...Only the CEO [Chief Executive Officer], Administrator-on-Call (AOC), or a hospital leader who routinely takes administrative call has the authority to verify that the facility does not have the capability and capacity to accept a transfer. Any transfer request which may be declined must first be reviewed with this individual before a final decision to refuse acceptance is made. This requirement applies to all transfer requests... Review of Medical Staff Rules and Regulations - 2017 dated 3/2017 revealed, ...Each medical staff member shall comply with the hospital EMTALA policies... Review of a letter from the facility dated 7/7/17 revealed, ...Parkridge Medical Center...may constitute a potential violation of the Emergency Medical Treatment and Labor Act (EMTALA) as Parkridge unintentionally misrepresented that the hospital did not have the capability to accept the transfer of a patient...On June 5, 2017 at 7:44 PM...[Facility B] contacted Tristar Transfer Center to request the transfer of [Patient #4] who was diagnosed with a ST-Elevated Myocardial Infarction (STEMI) [heart attack]...[Facility B] indicated cardiology services were not available at their facility and reported the patient requested to be transferred to Parkridge...the on-call cardiologist [MD #1] questioned the transfer to Parkridge, asking if [Facility C] had been contacted and also noting that he did not believe that Parkridge had a helipad...The Transfer Center Representative also attempted to intercede and reported that Parkridge did have a helipad...the On-Call Cardiologist continued to advise that it would be best to transfer the Patient to [Facility C] again indicating he did not believe Parkridge had a helipad...Parkridge's Intake Center Representative contacted Parkridge Administration and confirmed that Parkridge did have a helipad... Further review of the letter revealed the facility believed this incident was a possible violation of EMTALA requirements and implemented these interventions to prevent additional violations: A. On June 5, 2017, the On-Call Cardiologist was advised that the hospital did have a helipad and that declining the transfer request of the Patient was inappropriate. This information was also re-iterated via email to the On-Call Cardiologist on July 5, 2017. B. The On-Call Cardiologist was not paid for call coverage on June 5, 2017, as a result of the inappropriate declination of the transfer request. C. On June 8, 2017, the Division Ethics and Compliance Officer discussed the incident with the Transfer Center Director, specifically regarding the importance of immediately notifying the AOC prior to any official potential declinations. D. On June 13, 2017, the On-Call Cardiologist was also reminded of the hospital's EMTALA obligations, noting that all transfer requests must be accepted unless Parkridge does not have the capability and capacity to provide the requested care. E. On June 13, 2017, the On-Call Cardiologist was advised that according to Parkridge policy, on-call physicians do not have the authority to decline transfer requests, as the AOC should be contacted to make the final determination as to whether Parkridge has the capability and capacity to accept or deny a transfer request. F. On July 5, 2017, a letter was sent to all on-call physicians reminding the physicians of Parkridge's EMTALA policies and advising that on-call physicians do not have the authority to decline transfer requests, as the CEO or AOC should be contacted to make the final determination as to whether Parkridge has the capability and capacity to accept or deny a transfer request. G. On July 7, 2017, this incident was reported by Parkridge to the Tennessee Bureau of Health Licensure and Registration. H. The On-Call Cardiologist was assigned an EMTALA educational course with a required completion date of July 31, 2017. Review of the medical record from Facility B revealed Patient #4 (MDS) dated [DATE] at 7:32 PM with complaint of chest pain. Further review of the medical record physician's notes dated 6/5/17 revealed, ...Primary Impression: Acute ST segment elevation myocardial infarction [heart attack]... Further review of the medical record revealed nurses notes on 6/5/17 at 7:50 PM which stated, ...AIR EVAC [helicopter ambulance] CALLED AT THIS TIME... Further review of the nurses notes revealed, ...[MD #1/On-Call Cardiologist at Facility A] REPORTS THAT PT [patient] NEEDS TO GO TO [Facility C] AND TO CALL AND SET UP ACCEPTANCE THERE... Further review of nurses notes revealed the patient left Facility B on 6/5/17 by Air Ambulance at 8:20 PM transferred to Facility C. Review of the medical record from Facility C revealed Patient #4 was admitted there on 6/5/17 at 9:42 PM by air ambulance with diagnosis of ST-Elevated Myocardial Infarction (heart attack). Further review of the record revealed air ambulance notes dated 6/5/17 at 9:19 PM which stated, ...patient initially requested transfer to [Facility A] however the ED staff states they were unable to obtain acceptance...[Facility C] was contacted and accepted... Further review of the medical record revealed the patient had a Cardiac Catheterization (a tiny flexible tube is inserted in the blood vessels of the heart for diagnosis and treatment) performed on 6/5/17 at 10:11 PM. Further review of the medical record revealed the patient was monitored overnight in Facility C's Intensive Care Unit and then moved to a step-down unit. Further review of the medical record revealed the patient was discharged home in stable condition on 6/7/17. Review of an undated and untimed audio recording of a telephone conversation between Facility A's Transfer Center Staff (TCS) and MD #1 revealed, ...[TCS] They are going to fly him...[MD #1] Where are they landing?...[TCS] at the helipad...[MD #1] Which helipad?...[TCS] at [Facility A] you all have one somewhere...[MD #1] I don't know where it is...[MD #1] [Facility C] has a helipad... Further review of this recording revealed a telephone conversation between TCS and Facility A's nursing office (NO) which revealed, ...[TCS] where is your helipad?...[NO] Behind the hospital...[TCS] Doctor [MD #1] is telling them that you don't have a helipad...he denied a transfer for a STEMI [heart attack]...[NO] He can't deny it for that, we have a helipad...[TCS] He conferenced the physician at [Facility B] and he denied accepting... Physician (MD) #1 was interviewed by telephone on 7/31/17 at 1:30 PM. MD #1 confirmed he was the cardiologist on-call at Facility A on 6/5/17, and he remembers Patient #4's requested transfer on that date. MD #1 stated ...I did not refuse to accept the patient...I told them I did not think [Facility A] had a helipad and I thought it would be better if he was taken to [Facility C]...it was because I did not know we had a helipad here...I called them back to accept the transfer, but the patient had already been transferred to [Facility C]...I have never refused to accept a transfer...I could have treated him here but I thought there was no place for the helicopter to land with him...I never knew we had a helipad here... Interview with the Administrator On-Call (AOC #1) on 7/27/17 at 12:15 AM, in Facility A's Quality Department's conference room, revealed she was the AOC on duty on 6/5/17 and she remembers the attempted transfer of Patient #4 from Facility B to Facility A on 6/5/17. AOC #1 stated she was called by the transfer center employee who told her, ...[MD #1] had denied acceptance of a transfer from [Facility B] because we do not have a place to land the helicopter... AOC #1 stated she told the transfer center ...'we will accept the patient,' but he had already denied it...the patient had been sent to [Facility C] already... Further interview revealed MD #1 should not have denied acceptance of a transfer without consulting and involving the AOC. Further interview with AOC #1 revealed, ...This should have come to the AOC...the physicians are not supposed to deny a transfer without the AOC being involved... Further interview with AOC #1 revealed Facility A had a helipad, and had both the capacity and capability to treat Patient #4 on 6/5/17. Interview with the Chief Operating Officer and the Ethics and Compliance Director on 7/31/17 at 2:11 PM, in Facility A's Quality Management conference room, revealed the Facility has implemented the following corrective actions and as a result this was considered a past non compliance.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of facility policy, review of The Joint Commission (TJC) Sentinel Event Alert, review of the Food and Drug Administration (FDA) guidelines, medical record review, review of facility documentation, and interview, the facility failed to ensure anesthesia was administered in a safe setting for 1 patient (#2) of 5 surgical patients reviewed. The findings included: Review of facility policy Safe Procedural and Surgical Verification last revised on 11/2015, revealed ...briefing: time-out and debriefing: once the patient is in the operating room or procedure area, team members will stop and respond through active verbal acknowledgement and confirmation to each question of the briefing, time-out, and debriefing...briefing/pre-anesthesia time out immediately before administration of any type of anesthesia and/or sedation...completion of safety check of anesthesia machine, if applicable...delineation of any specific anesthesia risk... Further review revealed ...safety concerns are addressed in relation to scheduled procedure. Safety concerns may include...risk of fire associated with skin prep dry time... Review of a Sentinel Event Alert from The Joint Commission (TJC) Preventing Surgical Fires dated 6/24/03 revealed ...common ignition sources found in the OR [operating room] are electrosurgical or electrocautery [ESU's, ECU's]...recommendations include: staff should question the need of 100% O2 [oxygen] for delivery during facial surgery and as a general policy, use air or FIO2 [fractionated inspired oxygen] at < [less than] 30% for open delivery...informing staff members, including surgeons and anesthesiologist, about the importance of controlling heat sources by following laser and ESU safety practices; managing fuels by allowing sufficient time for patient prep; and establishing guidelines for minimizing oxygen concentration under the drape... Review of the Food Drug Administration (FDA) document Preventing Surgical Fires: FDA Safety Communication dated 10/31/11 revealed ...surgical fires can occur at any time all three elements of the fire triangle are present...[1] ignition source [lasers, electrosurgical units]...[2] fuel source [surgical drapes, alcohol based skin preparations agents]...[3] oxidizer [oxygen, nitrous oxide, room air]... Further review revealed ...recommendations to reduce the risk of surgical fires: use supplemental oxygen safety...evaluate if supplemental oxygen is needed on each patient. Any increase in oxygen concentration in the surgical field increased the chance of fire...if supplemental oxygen is necessary, particularly for surgery in the head, neck, or upper chest area: deliver minimum concentration of oxygen needed to maintain adequate oxygen saturation for your patient...take additional precautions to exclude oxygen from the field if using an open delivery system...consider alternatives to using an ignition source for surgery of the head, neck, and upper chest if high concentrations of supplemental oxygen [greater than 30 percent] are being delivered...encourage communication among members of your surgical team...encourage the anesthesia professional delivering the gases is communicating with the surgeon controlling the ignition source and the clinician applying the skin preparation agent... Medical record review revealed Patient #2 was admitted the facility on 5/21/17 at 12:13 PM with a chief complaint on a rash to his body. Further review revealed the patient was discharged from the facility on 6/1/17. Medical record review of an Emergency Department (ED) Provider Report (ED physician documentation) dated 5/21/17 at 12:24 PM revealed ...chief complaint: chicken pox...33 y/o [year old] male with [DIAGNOSES REDACTED], ulcerative colitis [UC], presents with a rash. It is all over his body, it is itchy. He is non-verbal, his parents give most of the history. He gets Humira [anti-inflammatory medication] shots for UC, he had one last week as recently... Further review revealed ...Immunocompromised with chicken pox. Need admission for IV [intravenous] Acyclovir [antiviral medication]. Further review revealed the patient received Acyclovir and Benadryl [medication used for itching] while in the ED. The patient was admitted to the hospital. Medical record review of an Admission History and Physical dated 5/21/17 revealed ...[AGE] year old male with [DIAGNOSES REDACTED], who was taken to the emergency room by his parents for rash...minimally verbal...receives Humira, methotrexate [medication used to treat rheumatoid arthritis] and sulfasalazine [anti-inflammatory medication] for UC...developed rash on Thursday, 5/18/17 prior to admission. It started on the left lower abdomen and groin area and spread to his trunk and now spreading to his extremities. The patient did have a fever of 100.3 yesterday. The patient had a lot of itching. The parents gave Benadryl...parents called gastrointestinal doctor...who advised to come to the emergency room ... Further review revealed ...initially the parents thought the patient had a reaction to the Humira, but the patient has been on Humira for over several years... Further review revealed ...he has a tracheostomy and PEG [percutaneous gastrostomy] tube...all review of systems otherwise negative... Further review revealed ...Assessment: immunosuppressed patient...UC...[DIAGNOSES REDACTED]... Further review revealed ...Plan: we will admit the patient for IV Zovirax [antiviral medication]. [Named Infection Specialist] to see the patient in consultation. We will check pending admit labs. We will begin Lovenox [anticoagulant] for deep venous thrombosis prophylaxis... Medical record review of a Pulmonary Consult dated 5/24/17 at 11:45 PM revealed ...on Acyclovir, phone orders were given for administration of IV fluids and steroids but I was informed that we lost peripheral IV access. PICC [peripheral intravenous central catheter] but was unable to place midline or PICC... Further review revealed ...patient needs CVC [central venous catheter] for IV fluid resuscitation, possible infusion of vasoactive agents, administration of IV medications, and access for phlebotomy [blood draws]... Further review revealed ...CVC placed in the R [right] neck, intended for RIJV [right internal jugular vein]...ABG [arterial blood gases] from distal port compatible with ARTERIAL blood...vascular surgery consult requested, case discussed with [named surgeon] re: request for CVC removal/artery repair and placement of CVC in the operating theater... Medical record review of an Invasive Procedure History and Physical dated 5/25/17 at 6:39 AM revealed ...neck exploration central line...[DIAGNOSES REDACTED]...contractures of BLE [bilateral lower extremities...ASA Classification: 4 [indicating severe systemic disease-constant life threat...will try MAC [monitored anesthesia care] if possible...may need ETT...without cuff or obturator [fits inside the tracheostomy tube and provides smooth surface]... Medical record review of an Anesthesia Record dated 5/25/17 at 8:00 AM revealed ...transported from MICU [medical intensive care unit] monitored, ventilated per ambu with O2. Monitors connected in OR. Anesthesia induced via [by] inhalation... Further review revealed ...8:38 AM: start procedure...8:48 AM: fire on field. Drapes and ETT [endotracheal tube] removed immediately. ETT replaced, patient vital signs stable throughout... Further review revealed FIO2 during the surgical procedure was 0.9% [90%]. Medical record review of an operative report dated 5/25/17 at 9:47 AM revealed ...operation: insertion of right femoral vein CVP [central venous peripheral] line using [named ultrasound device], right neck exploration, removal of CVP line right internal carotid artery, ligation of hole in right internal carotid artery... Further review revealed ...admitted to the hospital last night...could not get a routine line in place for intravenous therapy. Pulmonary medicine service was consulted for central line. Central line was placed last night. It was thought, after placement, to be in the carotid artery. This was confirmed with pressure transducer. I was asked to remove the line... Further review revealed ...he [the] tracheostomy tube was then replaced with an endotracheal tube placed through the stoma [opening]...the right groin was prepped and draped in the usual sterile manner. [Named ultrasound device] was used to easily find the right femoral vein...[blank space] inserted through the right femoral vein. It was sutured into place and irrigated with heparinized saline... Further review revealed ...I then changed my attention to the upper part of the right neck. A central line was going into the neck in this location. This area was prepped and draped in a sterile manner as possible. I initially started with a small neck incision, which had to be made larger on several occasions. We carefully dissected down to the catheter and down into the deeper layers of the neck. I then noticed a flame in the wound. This was immediately extinguished...the area was then reprepped with [named antiseptic cleanser]. We then continued the dissection deeper into the neck... Further review revealed ...the case was then turned over to the pulmonary medicine service to do a bronchoscopy. The patient seemed to tolerate the procedure reasonable well considering everything. Intraoperative complications including the flame...I then went out and talked to the family and told them frankly all the details of the case including the flame. At this point in time, it appears that he patient had some...[blank space] but no other skin burn is seen at this point in time... Medical record review of a Physicians Anesthesia Clinical Note dated 5/25/17 at 11:04 AM revealed ...patient with interop surgical fire. Fire immediately extinguished and ET tube immediately removed. [Named pulmonary doctor] notified at surgery conclusion and performed bronchoscopy, which revealed no airway burns in trachea or bronchi. Burns noted on face and lips, however no burns noted inside lips or mouth. Plastic surgery is being consulted to evaluate burns. Will discuss with patient's parents... Review of facility documentation dated 5/25/17 at 1:20 PM revealed ...5/25/17 at 8:48 AM...invasive procedure...burn...first aid treatment...refer to administration...seen by physician... Medical record review of a Hospitalist Progress Note dated 5/25/17 at 1:39 PM revealed ...events in OR noted and events surrounding tlc [triple lumen catheter]...s/p [status post] flash fire...looks better overall to me today...discussed with nurse continue aerosols and steroids... Medical record review of a Skin/Wound/Ostomy consult dated 5/26/17 at 5:39 PM revealed ...consult placed for burns to the face received during surgerical [surgical] procedure...Pt. has dark red pustules over entire epidermis. Father points out raw place on right earlobe. This looks like burst of 3rd degree blister. Pt. also has red area to right jaw line with small amount of serous drainage. Pt. has swollen place flesh to left side upper lip and lower lip... Interview with the Patient Safety Director, on 6/1/17 at 9:30 AM, in the conference room, revealed ...the patient was admitted to the facility with chicken pox on May 21, 2017...he had a history of [DIAGNOSES REDACTED] and contractures ...he had a customized trach...the staff had a difficult time inserting an intravenous line and a central line was required to administer medications... Further interview revealed ...a jugular central line was inserted that night but it was found to be in the carotid artery and needed to be surgically removed and repaired...while in the OR the patient required a high concentration of oxygen...an endotracheal tube was inserted through the trach site to administer the oxygen... when the surgeon removed the jugular carotid line he used a [named cautery device] to cauterize the area...the patient was on a high concentration of oxygen... when the surgeon used the [named cautery device] anesthesia and the staff heard a pop...the CRNA [Certified Registered Nurse Anesthetist] stated he felt heat under the drape...the drapes were singed to the upper part of the drape...there were burns observed to the patient's mouth, lips, earlobe and nose...wound care was consulted... Interview with CRNA #1 on 6/1/17 at 10:20 AM, in OR room #2, revealed the CRNA provided anesthesia to the patient on 6/25/17. Further interview revealed ...the patient was brought to the OR without an IV access...we were going to use inhalation gases to put the patient to sleep...he had a customized trach with an inner cannula...we intubated the patient through the trach site with a 7.0 endotracheal tube and we were having a hard time in keeping his oxygen saturations up...we were using 100% oxygen via ambu and we had to use Continuous Positive Airway Pressure [CPAP-positive pressure ventilation to keep the alveoli open] to keep his oxygen saturations at 91-93%... Further interview revealed ...the surgeon placed a femoral central venous line first...we had to turn the patient on to his left side for the surgeon to get to the right side to work on the carotid jugular line...when the surgeon used the [named cautery device] to cauterize the area, we heard a pop and I felt heat around my hand where I was assisting the patient's ventilations with an ambu bag...we removed the drape and a saline sponge was thrown on the area...in addition the surgical technician used the saline which was located on the sterile tray and placed the saline on the area...we pulled the endotracheal tube immediately...we reintubated the patient immediately...the left side of the patient's face was singed...a bronchoscopy was performed after the surgical procedure which revealed no airway burns... Further interview confirmed ...we were focused on maintaining the patient's airway and keeping his oxygen saturations up...again, the patient was on 100% oxygen with CPAP...we were overwhelmed with this patient so I do not remember having any conversation with the surgeon on the high oxygen percentage... Further interview confirmed ...a time out procedure was done but we did not talk about the high oxygen percentage and the use of the [named cautery device]... Telephone interview with Anesthesiologist #1 on 6/1/17 at 12:45 PM revealed he provided care to the patient on 5/25/17. Further interview revealed...we have talked about this patient's case...the CRNA had to use high concentration of oxygen to keep the patient's saturations up...in addition, the patient required CPAP...it was a high stressed situation... Further interview revealed ...the oxygenated fraction of oxygen is normally decreased when a [named cautery machine] is used but it was not due to the patient's requirement for the increased oxygen need... Further interview revealed ...the pulmonologist was notified and he performed a bronchoscopy after the surgical procedure to ensure no airway burns were present... Telephone interview with Registered Nurse (RN) #1, on 6/1/17 at 1:10 PM, revealed the nurse was the circulating nurse assigned to the patient on 5/25/17. Further interview revealed ...the patient arrived in the OR...he had a prior permanent tracheostomy tube...the patient had to be intubated through the trach site with an endotracheal tube per anesthesia...he did not have an IV access and they had to give him inhalation anesthesia for induction... Further interview revealed ...there were 2 CRNA's in the room, one holding the tube and the other one bagging the patient...it was somewhat stressful because they were trying to keep the patient oxygen saturations up...anesthesia had ventilation issues... Further interview revealed ...the patient was complex. He had [DIAGNOSES REDACTED] and was very contracted...he came in with chicken pox... Continued interview revealed ...a [named cautery device] was used and I heard someone say they heard a pop...the CRNA said he felt heat...we removed the drape...[named surgeon] was well aware of the patient's condition... Further interview confirmed ...the patient had a burn to his right ear, left lip, and some facial hair singeing... Continued interview confirmed ...a time out was performed prior to the surgery but there was no discussion regarding the high concentration of oxygen prior to the use of the [named cautery device]... Telephone interview with the Chief of Anesthesia, on 6/1/17 at 1:50 PM, confirmed ...there should always be some conversation between anesthesia and the surgeon when high concentrations of oxygen are being used and when [named cautery device] would be used during a surgical procedure... Further interview confirmed ...we do a time out but no fire safety checklist... Telephone interview with Surgeon #1 on 6/5/17 at 5:25 PM revealed ...anesthesia had placed an endotracheal tube into the stoma site and were ventilating the patient with 100% oxygen...they were having problems keeping his oxygen saturations up...I was using a cautery device to ligate the blood vessels when I felt a hot sensation and we saw a flash...we immediately put the fire out, removed the drapes and endotracheal tube, and placed gauze sponges on the surgical fire site...the patient did have some singeing of his facial hair, burns to his lips, and eyebrows...a bronchoscopy was performed after the surgery to ensure no airway injury was present... Further interview confirmed ...I do not remember any discussion about the high oxygen concentration prior to the cauterization...but apparently he was on a high concentration of oxygen... Continued interview confirmed the Surgeon and the CRNA did not discuss the increased fire risk associated with the high oxygen administered during anesthesia during the use of a cautery device.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of facility policy, review of The Joint Commission (TJC) Sentinel Event Alert, review of The Food and Drug Administration (FDA) guidelines, medical record review, review of facility documentation, and interview, the facility failed to ensure safety checks were performed during a surgical procedure for 1 patient (#2) of 5 surgical patients reviewed. The findings included: Review of facility policy Safe Procedural and Surgical Verification last revised on 11/2015, revealed ...briefing: time-out and debriefing: once the patient is in the operating room or procedure area, team members will stop and respond through active verbal acknowledgement and confirmation to each question of the briefing, time-out, and debriefing...briefing/pre-anesthesia time out immediately before administration of any type of anesthesia and/or sedation...completion of safety check of anesthesia machine, if applicable...delineation of any specific anesthesia risk... Further review revealed ...safety concerns are addressed in relation to scheduled procedure. Safety concerns may include...risk of fire associated with skin prep dry time... Review of a Sentinel Event Alert from The Joint Commission (TJC) Preventing Surgical Fires dated 6/24/03 revealed ...common ignition sources found in the OR [operating room] are electrosurgical or electrocautery [ESU's, ECU's]...recommendations include: staff should question the need of 100% O2 [oxygen] for delivery during facial surgery and as a general policy, use air or FIO2 [fractionated inspired oxygen] at < [less than] 30% for open delivery...informing staff members, including surgeons and anesthesiologist, about the importance of controlling heat sources by following laser and ESU safety practices; managing fuels by allowing sufficient time for patient prep; and establishing guidelines for minimizing oxygen concentration under the drape... Review of the Food Drug Administration (FDA) document Preventing Surgical Fires: FDA Safety Communication dated 10/31/11 revealed ...surgical fires can occur at any time all three elements of the fire triangle are present...[1] ignition source [lasers, electrosurgical units]...[2] fuel source [surgical drapes, alcohol based skin preparations agents]...[3] oxidizer [oxygen, nitrous oxide, room air]... Further review revealed ...recommendations to reduce the risk of surgical fires: use supplemental oxygen safety...evaluate if supplemental oxygen is needed on each patient. Any increase in oxygen concentration in the surgical field increased the chance of fire...if supplemental oxygen is necessary, particularly for surgery in the head, neck, or upper chest area: deliver minimum concentration of oxygen needed to maintain adequate oxygen saturation for your patient...take additional precautions to exclude oxygen from the field if using an open delivery system...consider alternatives to using an ignition source for surgery of the head, neck, and upper chest if high concentrations of supplemental oxygen [greater than 30 percent] are being delivered...encourage communication among members of your surgical team...encourage the anesthesia professional delivering the gases is communicating with the surgeon controlling the ignition source and the clinician applying the skin preparation agent... Medical record review revealed Patient #2 was admitted the facility on 5/21/17 at 12:13 PM with a chief complaint on a rash to his body. Further review revealed the patient was discharged from the facility on 6/1/17. Medical record review of an Emergency Department (ED) Provider Report (ED physician documentation) dated 5/21/17 at 12:24 PM revealed ...chief complaint: chicken pox...33 y/o [year old] male with [DIAGNOSES REDACTED], ulcerative colitis [UC], presents with a rash. It is all over his body, it is itchy. He is non-verbal, his parents give most of the history. He gets Humira [anti-inflammatory medication] shots for UC, he had one last week as recently... Further review revealed ...Immunocompromised with chicken pox. Need admission for IV [intravenous] Acyclovir [antiviral medication]. Further review revealed the patient received Acyclovir and Benadryl [medication used for itching] while in the ED. The patient was admitted to the hospital. Medical record review of an Admission History and Physical dated 5/21/17 revealed ...[AGE] year old male with [DIAGNOSES REDACTED], who was taken to the emergency room by his parents for rash...minimally verbal...receives Humira, methotrexate [medication used to treat rheumatoid arthritis] and sulfasalazine [anti-inflammatory medication] for UC...developed rash on Thursday, 5/18/17 prior to admission. It started on the left lower abdomen and groin area and spread to his trunk and now spreading to his extremities. The patient did have a fever of 100.3 yesterday. The patient had a lot of itching. The parents gave Benadryl...parents called gastrointestinal doctor...who advised to come to the emergency room ... Further review revealed ...initially the parents thought the patient had a reaction to the Humira, but the patient has been on Humira for over several years... Further review revealed ...he has a tracheostomy and PEG [percutaneous gastrostomy] tube...all review of systems otherwise negative... Further review revealed ...Assessment: immunosuppressed patient...UC...[DIAGNOSES REDACTED]... Further review revealed ...Plan: we will admit the patient for IV Zovirax [antiviral medication]. [Named Infection Specialist] to see the patient in consultation. We will check pending admit labs. We will begin Lovenox [anticoagulant] for deep venous thrombosis prophylaxis... Medical record review of a Pulmonary Consult dated 5/24/17 at 11:45 PM revealed ...on Acyclovir, phone orders were given for administration of IV fluids and steroids but I was informed that we lost peripheral IV access. PICC [peripheral intravenous central catheter] but was unable to place midline or PICC... Further review revealed ...patient needs CVC [central venous catheter] for IV fluid resuscitation, possible infusion of vasoactive agents, administration of IV medications, and access for phlebotomy [blood draws]... Further review revealed ...CVC placed in the R [right] neck, intended for RIJV [right internal jugular vein]...ABG [arterial blood gases] from distal port compatible with ARTERIAL blood...vascular surgery consult requested, case discussed with [named surgeon] re: request for CVC removal/artery repair and placement of CVC in the operating theater... Medical record review of an Anesthesia Record dated 5/25/17 at 8:00 AM revealed ...ventilated per ambu with O2...Anesthesia induced via [by] inhalation... Further review revealed ...8:38 AM: start procedure...8:48 AM: fire on field. Drapes and ETT [endotracheal tube] removed immediately... Further review revealed FIO2 during the surgical procedure was 0.9% [90%]. Medical record review of a Physicians Anesthesia Clinical Note dated 5/25/17 at 11:04 AM revealed ...patient with interop surgical fire. Fire immediately extinguished and ET tube immediately removed. Burns noted on face and lips, however no burns noted inside lips or mouth... Medical record review of a Physicians Progress Note dated 5/25/17, with no time, revealed ...stable...burn seems to be limited to lips, facial hair...available as needed... Medical record review of a Hospitalist Progress Note dated 5/25/17 at 1:39 PM revealed ...events in OR noted and events surrounding tlc [triple lumen catheter]...s/p [status post] flash fire... Interview with the Patient Safety Director, on 6/1/17 at 9:30 AM, in the conference room, revealed ...the patient was admitted to the facility with chicken pox on May 21, 2017...he had a history of [DIAGNOSES REDACTED] and contractures ...he had a customized trach...the staff had a difficult time inserting an intravenous line and a central line was required to administer medications... Further interview revealed ...a jugular central line was inserted that night but it was found to be in the carotid artery and needed to be surgically removed and repaired...while in the OR the patient required a high concentration of oxygen...an endotracheal tube was inserted through the trach site to administer the oxygen...they were going to insert a femoral central line while in surgery which was successfully inserted...when the surgeon removed the jugular carotid line he used a [named cautery device] to cauterize the area...the patient was on a high concentration of oxygen...the area was prepped and allowed to dry... Continued interview revealed ...when the surgeon used the [named cautery device], anesthesia and the staff heard a pop...the CRNA [Certified Registered Nurse Anesthetist] stated he felt heat under the drape where he had his hand...the drapes were immediately removed and a saline sponge was thrown on the site...the drapes were singed to the upper part of the drape...the staff did not observe any burns at that time... Further interview revealed ...the staff reported they immediately placed saline on the area, the endotracheal tube was removed and the patient was reintubated... Continued interview revealed ...after the surgery procedure was completed a bronchoscopy was performed which revealed no airway burns...there were burns observed to the patient's mouth, lips, earlobe and nose...wound care was consulted... Interview with CRNA #1 on 6/1/17 at 10:20 AM, in OR room #2, revealed the CRNA provided anesthesia to the patient on 6/25/17. Further interview revealed ...the patient was brought to the OR without an IV access...we were going to use inhalation gases to put the patient to sleep...he had a customized trach with an inner cannula...we intubated the patient through the trach site with a 7.0 endotracheal tube and we were having a hard time in keeping his oxygen saturations up...we were using 100% oxygen via ambu and we had to use Continuous Positive Airway Pressure [CPAP-positive pressure ventilation to keep the alveoli open] to keep his oxygen saturations at 91-93%... Continued interview revealed ...when the surgeon used the [named cautery device] to cauterize the area, we heard a pop and I felt heat around my hand where I was assisting the patient's ventilations with an ambu bag...we removed the drape and a saline sponge was thrown on the area...in addition the surgical technician used the saline which was located on the sterile tray and placed the saline on the area...we pulled the endotracheal tube immediately...we reintubated the patient immediately...the left side of the patient's face was singed...a bronchoscopy was performed after the surgical procedure which revealed no airway burns... Further interview confirmed ...we were focused on maintaining the patient's airway and keeping his oxygen saturations up...again, the patient was on 100% oxygen with CPAP...we were overwhelmed with this patient so I do not remember having any conversation with the surgeon on the high oxygen percentage... Further interview confirmed ...a time out procedure was done but we did not talk about the high oxygen percentage and the use of the [named cautery device]... Telephone interview with Anesthesiologist #1 on 6/1/17 at 12:45 PM revealed he provided care to the patient on 5/25/17. Further interview revealed...we have talked about this patient's case...the CRNA had to use high concentration of oxygen to keep the patient's saturations up...in addition, the patient required CPAP...it was a high stressed situation... Further interview revealed ...the oxygenated fraction of oxygen is normally decreased when a [named cautery machine] is used but it was not, due to the patient's requirement for the increased oxygen need... Interview with Certified Surgery Technologist (CST) #1, on 6/1/17 at 12:55 PM, in the conference room, revealed the tech was the surgical assistant on the patient's case on 6/25/17. Further interview revealed ...we perform a time out on every patient but there was no conversation regarding the oxygen and the use of a [named cautery device]... Further interview revealed ...I saw a flame when the [named cautery device] was used...there was a small flame from the hole where we were working...I immediately threw saline solution and a wet saline prep over the area...I used a Asetpo [hypodermic syringe with a bulb or slender nozzle used for injecting fluids or cleansing wounds] syringe to put the fire out...the drapes were removed from the area... Interview with CST #2, on 6/1/17 at 1:00 PM, in the conference room, revealed the technician assisted during the patient's case on 6/25/17. Further interview revealed ...the physician had just made an incision and the [named cautery device] was used to cauterize a few spots...there was a small flash which lasted for less than 5 seconds...[CST #1] placed a wet sponge pad on the area and poured the saline over the area...the drapes were removed immediately... Further interview confirmed ...I do not remember any conversations regarding the use of high concentrations of oxygen and the use of the cautery device... Telephone interview with Registered Nurse (RN) #1, on 6/1/17 at 1:10 PM, revealed the nurse was the circulating nurse assigned to the patient on 5/25/17. Further interview revealed ...the patient had to be intubated through the trach site with an endotracheal tube per anesthesia...he did not have an IV access and they had to give him inhalation anesthesia for induction...they were trying to keep the patient's oxygen saturations up...anesthesia had ventilation issues...I prepped both areas using Chlorhexidine and Chloraprep...they have a 3 minute dry time...the field was completely dried before we draped the patient...a [named cautery device] was used and I heard someone say they heard a pop...the CRNA said he felt heat...we removed the drape...[CST #1] put a wet saline gauze on the site...the gases were turned off and the endotracheal tube was removed...the drapes were singed... Further interview revealed ...[named surgeon] was well aware of the patient's condition... Further interview confirmed ...the patient had a burn to his right ear, left lip, and some facial hair singeing...a bronchoscopy was performed which revealed no oral, nasal or airway injuries... Continued interview confirmed ...a time out was performed prior to the surgery but there was no discussion regarding the high concentration of oxygen prior to the use of the [named cautery device]... Telephone interview with the Chief of Anesthesia, on 6/1/17 at 1:50 PM, confirmed ...there should always be some conversation between anesthesia and the surgeon when high concentrations of oxygen are being used and when [named cautery device] would be used during a surgical procedure... Further interview confirmed ...we do a time out but no fire safety checklist... Telephone interview with Surgeon #1 on 6/5/17 at 5:25 PM revealed ...anesthesia had placed an endotracheal tube into the stoma site and were ventilating the patient with 100% oxygen...they were having problems keeping his oxygen saturations up...I was using a cautery device to ligate the blood vessels when I felt a hot sensation and we saw a flash...we immediately put the fire out, removed the drapes and endotracheal tube, and placed gauze sponges on the surgical fire site...there did not appear to be any issues with that... Further interview revealed ...the patient was reintubated and we continued on with the surgical procedure... Continued interview revealed ...the patient did have some singeing of his facial hair, burns to his lips, and eyebrows...a bronchoscopy was performed after the surgery to ensure no airway injury was present... Further interview confirmed ...I do not remember any discussion about the high oxygen concentration prior to the cauterization...but apparently he was on a high concentration of oxygen... Continued interview confirmed the Surgeon and the CRNA did not discuss the increased fire risk associated with the administration of high oxygen during use of a cautery device.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of facility policy, review of The Joint Commission (TJC) Sentinel Event Alert, review of The Food and Drug Administration (FDA) guidelines, medical record review, review of facility documentation, observation, and interview, the facility failed to provide care in a safe setting for 1 patient (#2) of 5 patients reviewed for surgical services. The findings included: Review of facility policy Safe Procedural and Surgical Verification last revised on 11/2015, revealed ...briefing: time-out and debriefing: once the patient is in the operating room or procedure area, team members will stop and respond through active verbal acknowledgement and confirmation to each question of the briefing, time-out, and debriefing...briefing/pre-anesthesia time out immediately before administration of any type of anesthesia and/or sedation...completion of safety check of anesthesia machine, if applicable...delineation of any specific anesthesia risk... Further review revealed ...safety concerns are addressed in relation to scheduled procedure. Safety concerns may include...risk of fire associated with skin prep dry time... Review of a Sentinel Event Alert from The Joint Commission (TJC) Preventing Surgical Fires dated 6/24/03 revealed ...common ignition sources found in the OR [operating room] are electrosurgical or electrocautery [ESU's, ECU's]...recommendations include: staff should question the need of 100% O2 [oxygen] for delivery during facial surgery and as a general policy, use air or FIO2 [fractionated inspired oxygen] at < [less than] 30% for open delivery...informing staff members, including surgeons and anesthesiologist, about the importance of controlling heat sources by following laser and ESU safety practices; managing fuels by allowing sufficient time for patient prep; and establishing guidelines for minimizing oxygen concentration under the drape... Review of the Food Drug Administration (FDA) document Preventing Surgical Fires: FDA Safety Communication dated 10/31/11 revealed ...surgical fires can occur at any time all three elements of the fire triangle are present...[1] ignition source [lasers, electrosurgical units]...[2] fuel source [surgical drapes, alcohol based skin preparations agents]...[3] oxidizer [oxygen, nitrous oxide, room air]... Further review revealed ...recommendations to reduce the risk of surgical fires: use supplemental oxygen safety...evaluate if supplemental oxygen is needed on each patient. Any increase in oxygen concentration in the surgical field increased the chance of fire...if supplemental oxygen is necessary, particularly for surgery in the head, neck, or upper chest area: deliver minimum concentration of oxygen needed to maintain adequate oxygen saturation for your patient...take additional precautions to exclude oxygen from the field if using an open delivery system...consider alternatives to using an ignition source for surgery of the head, neck, and upper chest if high concentrations of supplemental oxygen [greater than 30 percent] are being delivered...encourage communication among members of your surgical team...encourage the anesthesia professional delivering the gases is communicating with the surgeon controlling the ignition source and the clinician applying the skin preparation agent... Medical record review revealed Patient #2 was admitted the facility on 5/21/17 at 12:13 PM with a chief complaint on a rash to his body. Further review revealed the patient was discharged from the facility on 6/1/17. Medical record review of an Emergency Department (ED) Provider Report (ED physician documentation) dated 5/21/17 at 12:24 PM revealed ...chief complaint: chicken pox...33 y/o [year old] male with [DIAGNOSES REDACTED], ulcerative colitis [UC], presents with a rash. It is all over his body, it is itchy. He is non-verbal, his parents give most of the history. He gets Humira [anti-inflammatory medication] shots for UC, he had one last week as recently... Further review revealed ...Immunocompromised with chicken pox. Need admission for IV [intravenous] Acyclovir [antiviral medication]. Further review revealed the patient received Acyclovir and Benadryl [medication used for itching] while in the ED. The patient was admitted to the hospital. Medical record review of an Admission History and Physical dated 5/21/17 revealed ...[AGE] year old male with [DIAGNOSES REDACTED], who was taken to the emergency room by his parents for rash...minimally verbal...receives Humira, methotrexate [medication used to treat rheumatoid arthritis] and sulfasalazine [anti-inflammatory medication] for UC...developed rash on Thursday, 5/18/17 prior to admission. It started on the left lower abdomen and groin area and spread to his trunk and now spreading to his extremities. The patient did have a fever of 100.3 yesterday. The patient had a lot of itching. The parents gave Benadryl...parents called gastrointestinal doctor...who advised to come to the emergency room ... Further review revealed ...initially the parents thought the patient had a reaction to the Humira, but the patient has been on Humira for over several years... Further review revealed ...he has a tracheostomy and PEG [percutaneous gastrostomy] tube...all review of systems otherwise negative... Further review revealed ...Assessment: immunosuppressed patient...UC...[DIAGNOSES REDACTED]... Further review revealed ...Plan: we will admit the patient for IV Zovirax [antiviral medication]. [Named Infection Specialist] to see the patient in consultation. We will check pending admit labs. We will begin Lovenox [anticoagulant] for deep venous thrombosis prophylaxis... Medical record review of a Pulmonary Consult dated 5/24/17 at 11:45 PM revealed ...on Acyclovir, phone orders were given for administration of IV fluids and steroids but I was informed that we lost peripheral IV access. PICC [peripheral intravenous central catheter] but was unable to place midline or PICC... Further review revealed ...patient needs CVC [central venous catheter] for IV fluid resuscitation, possible infusion of vasoactive agents, administration of IV medications, and access for phlebotomy [blood draws]... Further review revealed ...CVC placed in the R [right] neck, intended for RIJV [right internal jugular vein]...ABG [arterial blood gases] from distal port compatible with ARTERIAL blood...vascular surgery consult requested, case discussed with [named surgeon] re: request for CVC removal/artery repair and placement of CVC in the operating theater... Medical record review of an Anesthesia Record dated 5/25/17 at 8:00 AM revealed ...transported from MICU [medical intensive care unit] monitored, ventilated per ambu with O2. Monitors connected in OR. Anesthesia induced via [by] inhalation... Further review revealed ...8:38 AM: start procedure...8:48 AM: fire on field. Drapes and ETT [endotracheal tube] removed immediately. ETT replaced, patient vital signs stable throughout... Further review revealed FIO2 during the surgical procedure was 0.9% [90%]. Medical record review of an Immediate Post-Procedure Note dated 5/25/17, with no time, revealed ...procedure: removal, insertion of central line R groin...ligation of hole and right internal carotid artery... Further review revealed ...complications: flame during case... Medical record review of an operative report dated 5/25/17 at 9:47 AM revealed ...operation: insertion of right femoral vein CVP [central venous peripheral] line using [named ultrasound device], right neck exploration, removal of CVP line right internal carotid artery, ligation of hole in right internal carotid artery... Further review revealed ...admitted to the hospital last night...could not get a routine line in place for intravenous therapy. Pulmonary medicine service was consulted for central line. Central line was placed last night. It was thought, after placement, to be in the carotid artery. This was confirmed with pressure transducer. I was asked to remove the line... Further review revealed ...he [the] tracheostomy tube was then replaced with an endotracheal tube placed through the stoma [opening]...the right groin was prepped and draped in the usual sterile manner. [Named ultrasound device] was used to easily find the right femoral vein...[blank space] inserted through the right femoral vein. It was sutured into place and irrigated with heparinized saline... Further review revealed ...I then changed my attention to the upper part of the right neck. A central line was going into the neck in this location. This area was prepped and draped in a sterile manner as possible. I initially started with a small neck incision, which had to be made larger on several occasions. We carefully dissected down to the catheter and down into the deeper layers of the neck. I then noticed a flame in the wound. This was immediately extinguished...the area was then reprepped with [named antiseptic cleanser]. We then continued the dissection deeper into the neck... Further review revealed ...the case was then turned over to the pulmonary medicine service to do a bronchoscopy. The patient seemed to tolerate the procedure reasonable well considering everything. Intraoperative complications including the flame...I then went out and talked to the family and told them frankly all the details of the case including the flame. At this point in time, it appears that he patient had some...[blank space] but no other skin burn is seen at this point in time... Medical record review of a Physicians Anesthesia Clinical Note dated 5/25/17 at 11:04 AM revealed ...patient with interop surgical fire. Fire immediately extinguished and ET tube immediately removed. [Named pulmonary doctor] notified at surgery conclusion and performed bronchoscopy, which revealed no airway burns in trachea or bronchi. Burns noted on face and lips, however no burns noted inside lips or mouth. Plastic surgery is being consulted to evaluate burns. Will discuss with patient's parents... Further review revealed ...cuffed ET tube used during surgery. Patient's trach replaced at the end of surgery... Medical record review of a Physicians Progress Note dated 5/25/17, with no time, revealed ...stable...burn seems to be limited to lips, facial hair...available as needed... Review of facility documentation dated 5/25/17 at 1:20 PM revealed ...5/25/17 at 8:48 AM...invasive procedure...burn...first aid treatment...refer to administration...seen by physician... Further review revealed ...family notified...mother and father on 5/25/17 at 10:40 AM... Medical record review of a Hospitalist Progress Note dated 5/25/17 at 1:39 PM revealed ...events in OR noted and events surrounding tlc [triple lumen catheter]...s/p [status post] flash fire...looks better overall to me today...discussed with nurse continue aerosols and steroids... Medical record review of a Pulmonary Critical Care Progress Note dated 5/26/17 at 11:12 AM revealed ...no new respiratory complaints. Family is concerned about neck swelling/fullness...facial burns are superficial, wound care input is appreciated... Medical record review of a Skin/Wound/Ostomy consult dated 5/26/17 at 5:39 PM revealed ...consult placed for burns to the face received during surgerical [surgical] procedure...Pt. has dark red pustules over entire epidermis. Father points out raw place on right earlobe. This looks like burst of 3rd degree blister. Pt. also has red area to right jaw line with small amount of serous drainage. Pt. has swollen place flesh to left side upper lip and lower lip. Discussed with nurse the need to watch pt. closely for respiratory distress. Distress in the near future as internal swelling of esophagus may occur... Interview with the Patient Safety Director, on 6/1/17 at 9:30 AM, in the conference room, revealed ...the patient was admitted to the facility with chicken pox on May 21, 2017...he had a history of [DIAGNOSES REDACTED] and contractures ...he had a customized trach...the staff had a difficult time inserting an intravenous line and a central line was required to administer medications... Further interview revealed ...a jugular central line was inserted that night but it was found to be in the carotid artery and needed to be surgically removed and repaired...while in the OR the patient required a high concentration of oxygen...an endotracheal tube was inserted through the trach site to administer the oxygen...they were going to insert a femoral central line while in surgery which was successfully inserted...when the surgeon removed the jugular carotid line he used a [named cautery device] to cauterize the area...the patient was on a high concentration of oxygen...the area was prepped and allowed to dry... Continued interview revealed ...when the surgeon used the [named cautery device], anesthesia and the staff heard a pop...the CRNA [Certified Registered Nurse Anesthetist] stated he felt heat under the drape where he had his hand...the drapes were immediately removed and a saline sponge was thrown on the site...the drapes were singed to the upper part of the drape...the staff did not observe any burns at that time... Further interview revealed ...the staff reported they immediately placed saline on the area, the endotracheal tube was removed and the patient was reintubated... Continued interview revealed ...after the surgery procedure was completed a bronchoscopy was performed which revealed no airway burns...there were burns observed to the patient's mouth, lips, earlobe and nose...wound care was consulted... Interview with CRNA #1 on 6/1/17 at 10:20 AM, in OR room #2, revealed the CRNA provided anesthesia to the patient on 6/25/17. Further interview revealed ...the patient was brought to the OR without an IV access...we were going to use inhalation gases to put the patient to sleep...he had a customized trach with an inner cannula...we intubated the patient through the trach site with a 7.0 endotracheal tube and we were having a hard time in keeping his oxygen saturations up...we were using 100% oxygen via ambu and we had to use Continuous Positive Airway Pressure [CPAP-positive pressure ventilation to keep the alveoli open] to keep his oxygen saturations at 91-93%... Further interview revealed ...the surgeon placed a femoral central venous line first...we had to turn the patient on to his left side for the surgeon to get to the right side to work on the carotid jugular line... Continued interview revealed ...when the surgeon used the [named cautery device] to cauterize the area, we heard a pop and I felt heat around my hand where I was assisting the patient's ventilations with an ambu bag...we removed the drape and a saline sponge was thrown on the area...in addition the surgical technician used the saline which was located on the sterile tray and placed the saline on the area...we pulled the endotracheal tube immediately...we reintubated the patient immediately...the left side of the patient's face was singed...a bronchoscopy was performed after the surgical procedure which revealed no airway burns... Further interview confirmed ...we were focused on maintaining the patient's airway and keeping his oxygen saturations up...again, the patient was on 100% oxygen with CPAP...we were overwhelmed with this patient so I do not remember having any conversation with the surgeon on the high oxygen percentage... Further interview confirmed ...a time out procedure was done but we did not talk about the high oxygen percentage and the use of the [named cautery device]... Observation in the Surgical Intensive Care Unit (SICU) on 6/1/17 at 10:40 AM revealed the Patient #2 remained in the unit and was in respiratory isolation. Telephone interview with Anesthesiologist #1 on 6/1/17 at 12:45 PM revealed he provided care to the patient on 5/25/17. Further interview revealed...we have talked about this patient's case...the CRNA had to use high concentration of oxygen to keep the patient's saturations up...in addition, the patient required CPAP...it was a high stressed situation... Further interview revealed ...the oxygenated fraction of oxygen is normally decreased when a [named cautery machine] is used but it was not due to the patient's requirement for the increased oxygen need... Further interview revealed ...the pulmonologist was notified and he performed a bronchoscopy after the surgical procedure to ensure no airway burns were present... Interview with Certified Surgery Technologist (CST) #1, on 6/1/17 at 12:55 PM, in the conference room, revealed the tech was the surgical assistant on the patient's case on 6/25/17. Further interview revealed ...we perform a time out on every patient but there was no conversation regarding the oxygen and the use of a [named cautery device]... Further interview revealed ...I saw a flame when the [named cautery device] was used...there was a small flame from the hole where we were working...I immediately threw saline solution and a wet saline prep over the area...I used a Asetpo [hypodermic syringe with a bulb or slender nozzle used for injecting fluids or cleansing wounds] syringe to put the fire out...the drapes were removed from the area... Interview with CST #2, on 6/1/17 at 1:00 PM, in the conference room, revealed the technician assisted during the patient's case on 6/25/17. Further interview revealed ...the physician had just made an incision and the [named cautery device] was used to cauterize a few spots...there was a small flash which lasted for less than 5 seconds...[CST #1] placed a wet sponge pad on the area and poured the saline over the area...the drapes were removed immediately... Further interview revealed ...I did not see any big burns to the patient at that time...the patient had chicken pox and it was hard to tell what was chicken pox and what was a burn...I did not smell anything...we re-draped the patient and the surgery continued... Telephone interview with Registered Nurse (RN) #1, on 6/1/17 at 1:10 PM, revealed the nurse was the circulating nurse assigned to the patient on 5/25/17. Further interview revealed ...the patient arrived in the OR...he had a prior permanent tracheostomy tube...the patient had to be intubated through the trach site with an endotracheal tube per anesthesia...he did not have an IV access and they had to give him inhalation anesthesia for induction... Further interview revealed ...there were 2 CRNA's in the room, one holding the tube and the other one bagging the patient...it was somewhat stressful because they were trying to keep the patient oxygen saturations up...anesthesia had ventilation issues... Further interview revealed ...the patient was complex. He had [DIAGNOSES REDACTED] and was very contracted...he came in with chicken pox... Continued interview revealed ...[named surgeon] put a right femoral central line in first...I prepped both areas using Chlorhexidine and Chloraprep...they have a 3 minute dry time...the field was completely dried before we draped the patient... Further interview revealed ...[named surgeon] was in the room...when he completed the femoral line he moved up to the neck area...a [named cautery device] was used and I heard someone say they heard a pop...the CRNA said he felt heat...we removed the drape...[CST #1] put a wet saline gauze on the site...the gases were turned off and the endotracheal tube was removed...the drapes were singed... Further interview revealed ...once the fire was out, a new endotracheal tube was placed, the area was redraped and the surgery was completed...[named surgeon] was well aware of the patient's condition... Further interview confirmed ...the patient had a burn to his right ear, left lip, and some facial hair singeing...a bronchoscopy was performed which revealed no oral, nasal or airway injuries... Continued interview confirmed ...a time out was performed prior to the surgery but there was no discussion regarding the high concentration of oxygen prior to the use of the [named cautery device]... Telephone interview with the Chief of Anesthesia, on 6/1/17 at 1:50 PM, confirmed ...there should always be some conversation between anesthesia and the surgeon when high concentrations of oxygen are being used and when [named cautery device] would be used during a surgical procedure... Further interview confirmed ...we do a time out but no fire safety checklist... Telephone interview with Surgeon #1 on 6/5/17 at 5:25 PM revealed the surgeon was called by the Pulmonologist after a jugular central line was inserted into the patient's right carotid artery. Further interview revealed ...the young man had multiple issues...he was contracted and had a history of [DIAGNOSES REDACTED]...he had spontaneous movements throughout his entire body...there had been multiple attempts to gain IV access which were unsuccessful...the patient had a permanent tracheostomy... Further interview revealed ...I saw the patient the next morning and took the patient to the OR for a femoral central line insertion and repair of the carotid artery jugular line...I inserted the femoral line with difficulty and then moved up to the neck to repair the hole in the carotid artery... Further interview revealed ...anesthesia had placed an endotracheal tube into the stoma site and were ventilating the patient with 100% oxygen...they were having problems keeping his oxygen saturations up... Continued interview revealed ...I was using a cautery device to ligate the blood vessels when I felt a hot sensation and we saw a flash...we immediately put the fire out, removed the drapes and endotracheal tube, and placed gauze sponges on the surgical fire site...there did not appear to be any issues with that... Further interview revealed ...the patient was reintubated and we continued on with the surgical procedure... Continued interview revealed ...the patient did have some singeing of his facial hair, burns to his lips, and eyebrows...a bronchoscopy was performed after the surgery to ensure no airway injury was present... Further interview confirmed ...I do not remember any discussion about the high oxygen concentration prior to the cauterization...but apparently he was on a high concentration of oxygen... Continued interview confirmed the Surgeon and the CRNA did not discuss the increased fire risk associated with the administration of high oxygen during use of a cautery device.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of facility policy, medical record review, and interview, the facility failed to ensure a consent form for a surgical procedure was timed for 1 patient (#2) of 5 records reviewed. The findings included: Review of facility policy Record of Care, Treatment and Services, Medical Record Documentation, last revised on 3/2016, revealed ...entires are made timely and each entry included the complete date of the entry, month, day, year and time of day and the signature [written or electronic] of the person making the entry... Medical record review revealed Patient #2 was admitted to the facility on [DATE] with a diagnosis of Varicella (Chicken Pox). Further review revealed the patient was discharged from the facility on 6/1/17. Medical record review of a Consent for Surgical or Invasive Treatment to Remove Central Venous Catheter Line from Neck. Insertion of New Central Venous Catheter Line for Patient #2 dated 5/25/17 revealed the consent was not timed. Interview with the Director of Quality Management on 6/1/17 at 2:30 PM, in the conference room, confirmed the consent form was not timed and the facility failed to follow policy.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on facility policy review, medical record review, review of facility documentation, observation, and interview, the facility failed to ensure care was provided in a safe setting for 1 patient (#2) of 4 patients reviewed for safety. The findings included: During the survey it was found Patient #2 was admitted to the facility on [DATE] with a diagnosis of Bipolar Disorder and Self-Inflicted Laceration to the Left Wrist. Continued review revealed the facility failed to ensure unsafe objects were not available to Patient #2 and failed to maintain 1 to 1 (1:1) observation of Patient #2 allowing the patient to self-injure. The facility was found to not be in compliance with Condition for Participation, Patient Rights 482.13. Please refer to A142 and A144.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure care was provided in a safe environment for 1 patient (#2) of 4 patients reviewed for safety. The findings included: Review of a facility policy Behavioral Health Suicide Prevention Plan last revised 3/2016, revealed ...will foster the accurate identification and successful management of patients who are at an increased risk...self-destructive behaviors. Patient at risk for...self-destructive behavior require...close observation...protective measures for their emotional and physical well-being at all times...1:1 monitoring and observation...staff responsibilities: The patient is NEVER to be out of arms reach or the assigned and dedicated staff member...patients on...heightened observation levels for...self-destructive behaviors may have the following restrictions...plastic eating utensils...collect at end of meal...staff are to be continually aware of the environment and immediately correct or report any identified risks... Medical record review revealed Patient #2 was admitted to the facility on [DATE] with the diagnosis of Bi-Polar Disorder and Self-Inflicted Laceration to the Left Wrist. Continued review revealed the patient was ...depressed & suicidal... Medical record review of a nursing shift assessment dated [DATE] at 7:02 PM revealed ...Patient presented to nurses station after having gone to bathroom and presented to staff with self-inflicted deep lacerations on left and right forearms. Blood on fingers. Patient reports using fingernails to dig into arms... Medical record review of a transfer form dated 10/7/16 revealed the patient was transferred to the emergency room (ER) due to ...self-inflicted wound... Medical record review of a physician's order dated 10/8/16 revealed ...suicide risk precautions...monitoring frequency: One to One [1:1]... Medical record review of a Psychiatric Evaluation Note dated 10/8/16 revealed ...cut open old wounds on arm yesterday...cuts were sutured yesterday in the ER...agitation/anxiety, depression, hallucinations, irritability... Medical record review of a nurse's shift assessment dated [DATE] at 7:34 PM revealed ...was found in bathroom shower sitting on the floor at approximately 1820 [6:20 PM] covered in blood on hands, arms and clothes from cutting self with a staple she stated she found on the floor... Medical record review of a nurse's shift assessment dated [DATE] at 7:17 PM revealed ...Pt on 1:1 but finding ways to harm self with plastic instruments on unit...Patient had a plastic fork in the MPR [multi-purpose room] and used it to tear open wounds on her arm. The plastic fork had been left in the MPR... Medical record review of a transfer form dated 10/17/16 revealed the patient was transferred to the ER due to ...self-inflicted wound... Interview with the Quality Director (QD) and the Market Regulatory Director (MRD), on 1/4/17 at 2:40 PM, in the conference room, confirmed ...tech did not maintain 1:1... Interview with Registered Nurse (RN) #1 on 1/4/17 at 3:30 PM, at the 300 nursing station, confirmed ...1:1 is within arm's reach at all times... Observation on 1/4/17 at 3:30 PM, of the MPR, revealed the nursing station is diagonally across the hallway from the MPR and the MPR cannot be seen from the nursing station. Interview with Mental Health Technician (MHT) #1 on 1/5/17 at 9:50 AM, in the conference room, confirmed ...it was about pass off time [shift change 2:45 PM to 3:00PM]...I stepped away to get a cup of coffee...have to step behind the nursing station to get coffee...she [Patient #2] wore a coat...when I came back I noticed a change in her demeanor...had her back to me, she had been looking out the window...I couldn't see it but she was actually digging inside her coat...couldn't see the fork because of the coat...I went out to tell the charge nurse [about the change in demeanor]...she [patient] came out into the hallway without her coat...I saw the fork sticking out...normally forks are kept out up on the counter on a tray...1:1 is arm's length...I stepped away probably not within arm's length...I got a feeling about her something was wrong, a definite change... Interview with QD and MRD on 1/5/17 at 10:50 AM, in the conference room, confirmed ...[MHT #1]...couple of times not in close proximity...couple of times out of room...forks were delivered with supplies for the unit and put in the multi-purpose room and not supposed to be in there...we don't keep them there... Interview with MHT #2 on 1/5/17 at 1:15 PM, in the conference room, confirmed ...no do not leave them alone except when they go to the bathroom and I leave the door open a crack... Interview with the QD and MRD on 1/5/17 at 1:30 PM, in the conference room, confirmed the facility failed to provide care in a safe setting and the facility failed to follow facility policy.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of facility policy review, medical record review, and interview, the facility failed to provide care per the care plan for 1 patient (#2) of 4 patients reviewed. The findings included: Review of a facility policy Behavioral Health Suicide Prevention Plan last revised 3/2016 revealed ...will foster the accurate identification and successful management of patients who are at an increased risk...self-destructive behaviors. Patient at risk for...self-destructive behavior require...close observation...protective measures for their emotional and physical well-being at all times...1:1 monitoring and observation...staff responsibilities: The patient is NEVER to be out of arms reach or the assigned and dedicated staff member...patients on...heightened observation levels for...self-destructive behaviors may have the following restrictions...plastic eating utensils...collect at end of meal...staff are to be continually aware of the environment and immediately correct or report any identified risks... Medical record review revealed Patient #2 was admitted to the facility on [DATE] with the diagnosis of Bi-Polar Disorder and Self-Inflicted Laceration to the Left Wrist. Medical record review of a physician's order dated 10/8/16 revealed ...suicide risk precautions...monitoring frequency: One to One [1:1]... Medical record review of a nurse's shift assessment dated [DATE] at 8:55 PM revealed ...1:1 observation in place per orders... Medical record review of a nurse's shift assessment dated [DATE] at 6:11 AM revealed ...continuing 1:1 observation... Medical record review of a nurse's shift assessment dated [DATE] at 7:17 PM revealed ...self-inflicted injuries...Pt on 1:1 but finding ways to harm self with plastic instruments on unit... Medical record review of a transfer form dated 10/17/16 revealed the patient was transferred to the emergency room at a sister facility due to ...self-inflicted wound... Interview with Quality Director (QD) and Market Regulatory Director (MRD) on 1/4/17 at 2:50 PM, in the conference room, confirmed ... tech did not maintain 1:1... Interview with MHT #1 on 1/5/17 at 9:50 AM, in the conference room, confirmed ...it was about pass off time [shift change, 2:45 PM to 3:00PM]...I stepped away to get a cup of coffee...have to step behind the nursing station to get coffee...she [Patient #2] wore a coat...when I came back I noticed a change in her demeanor...had her back to me, she had been looking out the window...I couldn't see it but she was actually digging inside her coat...couldn't see the fork because of the coat...I went out to tell the charge nurse [about the change in demeanor]...she [patient] came out into the hallway without her coat...I saw the fork sticking out...normally forks are kept out up on the counter on a tray...1:1 is arm's length...I stepped away probably not within arm's length...I got a feeling about her something was wrong, a definite change... Interview with QD and MRD on 1/5/17 at 10:50 AM, in the conference room, confirmed ...[MHT #1]...couple of times not in close proximity...couple of times out of room...forks were delivered with supplies for the unit and put in the multi-purpose room and not supposed to be in there...we don't keep them there...
Based on facility policy review, review of Bylaws Of The Medical Staff, medical record review, review of physician call schedules, review of audio recordings, and interviews, the facility failed to provide on-call ENT/Otolaryngology (a physician specializing in treating diseases of ears, nose, and throat) physician services, for 1 patient (#14) of 34 Emergency Department (ED) patients reviewed. Review of the facility's investigations, communications, and action plans revealed the facility had identified the past non-compliance and had placed interventions (primarily directing the ED physicians and Administrators on Call to bypass the Transfer Center and bypass the physician specialists on call and accept all appropriate transfers) and the facility is currently in compliance with 42 CFR 489.20 and 489.24, Emergency Medical Treatment and Active Labor Act (EMTALA) requirements. Refer to A 2404 for failure to provide on-call physician.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on facility policy review, review of Bylaws Of The Medical Staff, medical record review, review of physician call schedules, review of audio recordings, review of credentialing files, and interviews, the facility failed to provide on-call ENT/Otolaryngology (a physician specializing in treating diseases of ears, nose, and throat) physician services for 1 patient (#14) of 34 Emergency Department (ED) patients reviewed. Review of the facility's investigations, communications, and action plans revealed the facility had identified the past non-compliance and had placed interventions in place (primarily directing the ED physicians and Administrators on Call to bypass the Transfer Center and bypass the physician specialists on call and accept all appropriate transfers) and the facility is currently in compliance with 42 CFR 489.20 and 489.24, Emergency Medical Treatment and Active Labor Act (EMTALA) requirements. The findings included: Review of the facility's policy EMTALA-Provision of On-Call Coverage last revised 3/2013, revealed, ...Physicians on the list must be available after the initial examination to provide treatment...Immediate availability...or to secure a qualified alternate...Arrival or response to the DED (Dedicated Emergency Department) within a reasonable timeframe...The on-call physician has a responsibility to provide specialty care services as to needed...The on-call list maintained for the main hospital Emergency Department shall be the on-call list for the hospital, including any Off-Campus Provider-based Emergency Departments Review the facility's Bylaws of the Medical Staff dated 2014 revealed, ...Obligations of Active Staff...accept emergency on-call coverage for emergency care services within his/her clinical specialty...or arrange a suitable alternative... Review of the medical record revealed Patient #14 presented to the ED at Hospital #1's West campus (A satellite facility of Hospital #1 with a DED but no surgical or medical inpatient services. The West Campus is located 28 miles from Hospital #1's Main campus, a 275-bed hospital which did have surgical and inpatient services) on 1/23/16 at 3:24 AM, with a police officer, for complaint of auditory and visual hallucinations and paranoia. Further review of the medical record revealed the patient had a Medical Screening by a physician beginning at 3:24 AM, which included a physical examination and laboratory tests. The patient was medically cleared and diagnosed with Homicidal Ideation and Paranoia, and a consultation with Crisis Intervention services was made on 1/23/16 at 4:30 AM. The patient was kept on 1:1 (one to one) observation and was assessed by Crisis Response staff. The physician signed a commitment form for the patient and arrangements were made for transfer to an area psychiatric hospital on [DATE] at 6:20 AM. Review of the medical record revealed Patient #14 complained of a sore throat on 1/23/16 at 8:45 AM and was re-evaluated by the physician. Further medical record review revealed on 1/23/16 at 9:02 AM the physician applied topical analgesia, treated the patient with oral pain medication, then performed a strep swab (laboratory test for group A Streptococcus infection) and attempted twice to aspirate a tonsillar pillar abscess without success. The patient was treated with Rocephin 1 gram IM (an injection into the muscle of antibiotics to fight the infection) and Dexamethasone 8 mg (milligrams) IM (an injection into the muscle of a steroidal anti-inflammatory drug to reduce swelling) at 9:15 AM on 1/23/16. Review of the medical record revealed a CT Scan (computerized tomography scan, a series of computer assisted 3 dimensional x-ray images) was ordered by the ED Physician on 1/24/16 10:21 PM and revealed ...Tonsillitis with right peritonsillar abscess... Review of the medical record revealed a nurses note dated 1/24/16 at 11:27 PM stating, ...Spoke to...at...transfer center to arrange transfer to...main for admission ... Further review of nurse's note dated 1/24/16 at 11:33 PM revealed, ...spoke to...at transfer center, arranging ER to ER transfer... Review of the transfer form revealed Patient #14's transfer form was completed on 1/25/16 at 1:00 AM to transfer the patient by ambulance from Hospital #1's West Campus to Hospital #2 . Further review of the transfer sheet revealed the medical benefits of the transfer were, ...Obtain a level of care/service unavailable at this facility...Service ENT/Admission... Review of a physician's addendum note dated 1/25/16 at 1:06 AM, revealed the physician reassessed Patient #14 for continued complaint of throat pain and the doctors note stated, ...The patient's clinical condition seems to be worsening and his pain persists. It was decided to obtain a CT Scan to see the extent of the peritonsillar abscess. The patient has an abscess measuring 2.4 inches in diameter...It was decided to transfer the patient to a facility for in patient management of this condition... Review of the medical record from Hospital #2 (a large medical center located 26.9 miles from Hospital #1's West Campus) revealed Patient #14 (MDS) dated [DATE] at 2:58 AM and was admitted as an inpatient with diagnosis which included Right Peritonsillar Abscess and Tonsillitis, Reported History of Homicidal Ideation, more likely, Paranoia and Auditory Hallucinations secondary to Methamphetamine Use, and Polysubstance Abuse. Further review of the medical record revealed the patient was seen by an ENT/Otolaryngologist and had an Incision and Drainage of the Peritonsillar Abscess while still in the ED on 1/25/16. Further review revealed the patient's medical and mental condition improved significantly and he was discharged home in stable condition on 1/26/16. Review of Hospital #1's Emergency Department Unattached Call Schedule for January 2016 revealed the facility had an ENT/Otolaryngologist on call 1/23/16, 1/24/16, and 1/25/16. The schedule showed ENT/Otolaryngology on call coverage every night except 1/1, 1/2, and 1/18 in January 2016. Review of an undated and untimed recording, identified by the Compliance Officer and Risk Manager as the recording of a conversation regarding Patient #14's transfer to the main campus on 1/25/16, between the facility's Transfer Center and the main campus ED Physician revealed the ED Physician told the Transfer Center, ...don't send unless [ENT on-call physician] agrees to take patient... Review of an undated and untimed recording, identified by the Compliance Officer and Risk Manager as the recording of a conversation regarding Patient #14's transfer to the main campus on 1/25/16, between the facility's Transfer Center and the facility's on-call ENT/Otolaryngologist revealed the on-call physician was asked if he would be available to treat the patient and the ENT told the Transfer Center, ...No, I would not be available to come in and evaluate...transfer to [Hospital #2] or [Hospital #3]... Review of an undated and untimed recording, identified by the Compliance Officer and Risk Manager as the recording of a conversation regarding Patient #14's transfer to the main campus on 1/25/16, between the facility's Transfer Center and the ED physician at the West Campus revealed the Transfer Center staff told the West ED physician, [Hospital #1 main campus] is not able to take the patient there...ENT unable to come in and see the patient... Review of physician credentialing files revealed Physician #1 is a licensed Medical Doctor, Board Certified in Otolaryngology, and had privileges at this facility which included Otolaryngological procedures. Telephone interview with Physician #1 (the ENT on-call on 1/25/16) on 3/16/16 at 3:00 PM, revealed he did not remember Patient #14's case or the phone call from the Transfer Center. Interview with the Marketing Compliance Officer and the Risk Manager on 3/15/16 at 1:14 PM, in the Risk Management Conference Room, revealed they had investigated the incident that involved Patient #14 and confirmed Physician #1 was on-call for ENT coverage on 1/25/16 and had told the transfer center he was unavailable to see the patient if transferred to the main campus ED. Further interview confirmed the on-call physicians were to be available to examine and treat patients in the Main Campus ED when needed for their specialty. Further interview revealed the ENT physician had stated he was busy at another facility when the transfer center had contacted him on 1/25/16. Further interview revealed the on-call ENT physician had not notified this facility's ED or Medical Staff Office of his unavailability. Review of a letter from the facility given to the surveyor on 3/15/16, during the entrance conference, revealed, ...Enclosed is a set of facts that we have determined constitutes a potential violation of the Emergency Medical Treatment and Labor Act (EMTALA)...declined the transport of a patient when the facility appeared to have the capability and capacity to accept the request...On 1/24/16 at 11:22 PM...House Supervisor was contacted by...Transfer Center to request...[Patient #14]...be moved from...West...to the main campus...was diagnosed with a peritonsillar abscess...would need to be seen by an Otolaryngologist...The transfer center then contacted...ED Physician regarding the request...The ED Physician responded that he accepted the transfer request but the On-Call ENT would need to evaluate the Patient...On 1/25/16 at approximately 12:00 a.m., the Transfer Center Representative telephoned the On-Call ENT and asked if he was available to evaluate a patient in the ED. The On-Call ENT stated he was unavailable and recommended transferring the patient to another facility...In a discussion with the On-Call ENT he claimed he was at another facility when the Transfer Center contacted him about the transfer request...Medical Staff Office (MSO) and ED had not been notified that he would be unavailable...the Transfer Center notified West's ED Physician...and facilitated a transfer...the patient was transferred... Interview with the Marketing Compliance Officer and the Risk Manager on 3/15/16 at 1:14 PM, in the Risk Management Conference Room, revealed their investigation identified additional information. The West Campus did not have an ENT on-call there, but the Main Campus did have an ENT on call. Patient #14 was a Certificate of Need (CON) patient committed to a psychiatric facility for but there were no ICU Beds available, and this patient having been committed for Homicidal Ideation and Paranoia and required an ICU bed or a bed in the ED with 1:1 observations. At the time of the referral, the ICU was full with no beds available and the ED had 3 patients on hold in the ED for an ICU bed. Review of the facility's actions to correct the EMTALA violation revealed, ...we have taken immediate measures to ensure this type of incident does not occur in the future... The facility's interventions were verified during the survey and included: 1. On 3/7/16 the CEO spoke with the On-Call ENT about his obligations under EMTALA and explained the ENT must present to the ED upon request when he is scheduled for call coverage 2. On 3/7/16 the 1/24/16 incident that involved the on-call ENT refusing to accept an in-house transfer from the West campus to the Main Campus was submitted to Medical Staff Peer Review. At the next Peer Review Committee on April 12, 2016, this case will be reviewed then. 3. On 3/8/16 the CEO sent a letter to all physicians taking on-call coverage notifying them of their obligations under EMTALA regulations, which require the physicians to come to the ED upon request. 4. On 3/4/16 the Medical Director spoke with all ED physicians about the requirement to accept all transports and transfers when the facility has the capability and capacity to provide the care requested. The ED physicians are going to bypass the specialist and the transfer center and accept any transfers that are requested if they have the capacity and capability to treat. 5. On 3/15/16 the Chief Nursing Executive and the Ethics and Compliance Officer (ECO) met with all Administrators on Call (AOCs) and explained the importance of gathering information from the transfer center representative to ensure a declined transfer is appropriate. 6. The Facility ECO and Division ECO (DECO) developed an improved process for ED staff and House Supervisors to utilize when a transport vs a transfer (a transfer is from another hospital, the transport is from one of the satellite hospitals) is requested. The ECO and DECO also incorporated scenarios involving behavioral health patients. 7. The Facility ECO and Division ECO developed scripting for the ED staff, House Supervisors and Transfer Center Representatives to utilize when a transport vs a transfer is requested. This scripting is going to be an algorithm form that helps staff make decisions regarding transfers vs transports and provides scripted responses for physicians that refuse transfers or transports. 8. On or before 4/11/16, the Transfer Center Director will review appropriate scripting with the Transfer Center Representatives and provide education on the difference between a transfer and a transport. Until this is completed, the ED medical staff and hospitalist have been told to bypass the Transfer Center and accept any appropriate transfers requested. 9. EMTALA education with all House Supervisors and AOC which was completed 3/15/16. Similar education is provided to the ED Nursing Staff every year now, and updated education has already been provided 3/4/16. The new scripting is being developed and education on this will be provided when it is developed. 10. All ED physicians have been assigned the Sullivan EMTALA training course. The required completion date for all ED Physicians is 4/15/16. 11. All house supervisors, including the House Supervisors at issue, are assigned the online Health Stream EMTALA Education Course. The required completion date is 4/25/16. The Marketing Compliance Officer confirmed she is currently in the process of entering all the House Supervisors and Managers into the computer system and will monitor for completion of all education. Interview with the Marketing Compliance Officer (MCO) and the Risk Manager on 3/15/16 at 1:14 PM, in the Risk Management Conference Room, revealed 100% of patient transfers and transports are being audited for appropriateness and completeness of transfers. Further interview revealed 100% of incoming transfer and requests for transfer are being reviewed by the ED Directors and the MCO for compliance with EMTALA requirements. Completion of all EMTALA education and training is being monitored by the ED Directors and the MCO.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on policy review, medical record review, and interviews, the facility failed to provide safe and appropriate discharge planning for 1 patient (Patient #1) of 29 patients reviewed. The findings included: Review of the facility's policy titled Case Management-Discharge Planning Documentation Guidelines revised date 7/10 revealed, ...All patients admitted to the hospital will be screened as soon as possible for recognition of those who may have complex post-hospital care needs...This screening assessment and documentation may include...Environmental limitations and resources...Financial ability to meet medical needs...Identified discharge needs... Review of the medical record revealed Patient #1 was admitted to the facility on [DATE] with diagnoses which included Dementia with Behavioral Disturbances. Review of the medical history revealed the patient is [AGE] years old with a known history of dementia and prior to admission the patient was found wandering in the street. Review of the Discharge Summary revealed the patient was discharged on [DATE]. Further review of the discharge summary revealed the patient was, ...homeless on admission...patient did not qualify for skilled nursing...the patient is confused and needs consistent with redirection and reorientation to the surroundings...no group home due to his limited income...He was discharged to Homeless Healthcare...Homeless Healthcare has been notified that the patient is coming and needs housing...Thought processes is disorganized...Thought content is delusional...His memory is impaired long term and impaired short term...intellect impaired... Review of Case Management notes from admission on 9/10/15 until discharge on 10/15/15 revealed no documentation the facility's case manager contacted Homeless Healthcare regarding the patient's referral. The first documentation of contact with Homeless Healthcare was dated 10/14/15 at 1:42 PM, in the discharge summary, which stated, ...pt [patient] is confused and needs consistent redirection and reorientation to his surroundings...No group home would take him due to his limited income...discharged to Homeless Healthcare as they assured the pt would see a case manager and assessed for needed services...Homeless Healthcare has been notified that patient is coming and needs housing... There was no documentation of who the hospital staff spoke to at Homeless Healthcare. There was no documentation of the patient's family member being notified or involved in this discharge plan. Review of the Discharge Instruction Form completed 10/15/15 revealed the patient was discharged at 5:20 AM and sent by cab to Homeless Healthcare. There was no documentation of the patient being accompanied by any staff or family members. The discharge form stated, ...Accompanied By: Cab... Continued review of the discharge instructions revealed there were no follow-up appointments, no medication management referrals, no case management referrals, and no referrals or follow-up appointments of any type. Interview with the Director of Behavioral Health Services on 1/21/16 at 2:00 PM, in a consultation room, confirmed Patient #1 was confused when discharged on [DATE], and that he was put in a taxi/cab on 10/15/15 with instructions to transport the patient to Homeless Healthcare Services. Further interview confirmed there was no documentation of the family being involved in this discharge plan or notified of this discharge. Further interview with the Director revealed the Case Manager that worked on the patient's referral to Homeless Healthcare was no longer working at the facility. Telephone interview with the Medical Director at Homeless Healthcare, on 2/23/16 at 10:00 AM, revealed, ...I was the person who the hospital staff would have spoken to and they did not speak to me...he [Patient #1] just arrived at our facility...we were not called before he was sent to us...This facility does not have any inpatient services and does not have any housing resources...This facility is an outpatient clinic for homeless people...I do not know how he got here, he just showed up in the lobby...
Based on medical record review and interview, the facility failed to implement and evaluate the care plan for one patient (#24) of sixty patients reviewed. The findings included: Patient #24 was admitted to Facility #1 on June 30, 2014, with an indwelling urinary catheter and diagnoses including Parkinson's Disease, Post-operative Ileus (locked bowel), Unable to Bear Weight, and Prolonged Immobilization. Electronic medical record review of the Care Plan revealed if an indwelling urinary catheter was in ...=/> (equal to or greater than) 2 (two) days... staff were to notify the Physician for an order to either discontinue or leave in the catheter. Electronic medical record review of the Physician's Order Entry revealed no documentation of an order to continue the indwelling urinary catheter. Interview with RN #13 on July 7, 2014, at 2:00 p.m., at the 4 West nursing station, confirmed there was not an order to continue the indwelling urinary catheter.
Based on observation and interview, the facility failed to store food in a sanitary manner for two facility kitchens (#2, #4); failed to maintain kitchen equipment in a sanitary manner for one facility kitchen (#2); and failed to prepare food in a sanitary manner for one facility kitchen (#4) of five facility dietary departments. The findings included: Observation on July 8, 2014, at 11:20 a.m., in the Facility #2 kitchen area walk in freezer revealed a partially uncovered, undated pan of uncooked sausage patties and uncooked bacon. Further observation of the kitchen area revealed the outside of the ice machine had dust build-up above the door and the microwave had food debris. Interview with the Dietary Supervisor on July 8, 2014, at 11:20 a.m., in the kitchen, confirmed the uncooked food in the freezer was uncovered and undated, the ice machine had dust build-up, and the microwave had food debris present.
Observation at Facility #4 on July 9, 2014, at 8:30 a.m., in the kitchen refrigerator #1, revealed five pans with ten desserts on top of each pan, with no date on the pan to indicate when the dessert was prepared. Further observation in refrigerator #2 revealed a half full container of cole slaw uncovered and unlabeled stored in the refrigerator. Interview with the Dietary Manager on July 9, 2014, at 8:30 a.m., revealed the pans must be labeled by the staff when they are prepared and placed in the refrigerator. Further interview confirmed the dessert pans were not labeled and the cole slaw was uncovered and unlabeled in the refrigerator. Observation at Facility #4 on July 9, 2014, at 8:45 a.m., in the kitchen, revealed kitchen employee #2 wrapping food bowls with plastic and preparing the food to be placed back into the refrigerator. Further observation revealed employee #2 dropped an opened half stick of butter on the floor, picked the stick of butter up from the floor with the bare hands and threw the butter in the trash can. Continued observation revealed the employee did not wash or sanitize the hands, picked up a bowl of cheese, wrapped the bowl with plastic, and then placed the bowl of cheese on the cart to be stored in the refrigerator. Interview with employee #2 on July 9, 2014, at 8:55 a.m., in the kitchen, confirmed the employee dropped the butter on the floor, picked the butter up, and threw the butter in the trash can. Further interview confirmed the employee did not wash or sanitize the hands prior to touching the other foods.
Based on observation, interview, review of facility policy, and medical record review, the facility failed to implement the infection control program for storage of equipment and supplies in the GI Labs of two facilities (#1, #2), medication rooms of two facility inpatient units (#1, #3), the Emergency Department of one facility (#1), and the Surgical Departments of two facilities (#2, #3); for cleaning of patient areas for the Same Day Surgery of one facility (#1); for isolation precautions for two facilities (#1, #2); and for indwelling urinary catheter care for one patient (#32) of sixty patients reviewed. The findings included: Observation and interview with Registered Nurse (RN) #10 on July 7, 2014, at 12:00 p.m., in the Gastrointestinal (GI) Lab at facility #1, revealed a three-shelved metal cart stored in the holding area of the GI lab. Continued observation revealed the two bottom shelves had computer cords, blood pressure cuffs, and face shields stored. Further observation revealed a buildup of dust on the bottom of the shelves and the items stored on the shelves. Interview with RN #10 confirmed the patient items were stored with non-patient items and the shelves and items stored on the shelves had a buildup of dust. Observation and interview with RN #10 on July 7, 2014, at 12:19 p.m., in the GI lab at Facility #1, revealed two cabinets containing Endoscopes (scopes used to visualize the GI tract). Continued observation revealed the cabinets had a buildup of dust on the bottom of both cabinets. Further observation revealed one of the doors on one of the cabinets would not stay closed. Interview with RN #10 confirmed the Endoscopes were clean and ready for patient use and the cabinets had a buildup of dust on the bottom of both cabinets. Continued interview confirmed the door would not close properly. Review of the facility policy Reprocessing of Flexible Endoscopes, Ultrasound Probes, and other Semi-Critical Equipment, revised May, 2012, revealed, ...hang the endoscope vertically...in a clean well-ventilated, dust-free area... Observation and interview with RN #10 on July 7, 2014, at 12:25 p.m., in procedure room #3 in the GI lab of Facility #1, revealed two packages of 7.5 millimeter (mm) Endotracheal tubes (ETT) (tube used to maintain a patient airway) and one package of a 8.0 mm ETT stored in a drawer with the package opened on one end. Continued observation revealed one of the 7.5 mm ETTs had a stylet (wire inserted while inserting an ETT to maintain rigidity) inserted in it and a syringe (used to inflate balloon to hold ETT in place) was attached to the end of the ETT. Interview with RN #10 revealed the Certified Registered Nurse Anesthetists (CRNA) open the packages to save time. Further interview confirmed the ETT packages were open and available for patient use. Observation and interview with RN #10 on July 7, 2014, at 12:35 p.m., in procedure room #1 in the GI lab of Facility #1, revealed an unpackaged Laryngoscope handle and blade (device used to visualize the airway) and three unpackaged syringes stored in the CRNA cart. Interview with RN #10 confirmed they shouldn't be there...I can't tell if they are clean or dirty. Review of the facility policy Laryngoscope Blade Cleaning, Handling, and Storage, dated April, 2014, revealed, ...examples of noncompliant storage would include unwrapped blades, open oral airways, and open ETTs in an anesthesia drawer, as well as unwrapped blades on top of a code cart... Observation at Facility #2 on July 8, 2014, at 10:25 a.m., in the GI Lab, revealed a purse stored in a cabinet with clean towels and washcloths for patient use. Interview with the GI Lab Nurse Manager (NM) on July 8, 2014, at 10:25 a.m., in the GI Lab, confirmed the purse was an employee's purse and the purse was stored with the towels and wash clothes which were used for patient care. Observation of the medication room on 4 East of Facility #1 on July 7, 2014, at 1:20 p.m., revealed a bathroom in the medication room. Patient equipment was stored inside the bathroom. The toilet in the bathroom was blackened with debris. Interview with RN #6 on July 7, 2014, at 1:20 p.m., in the medication room, confirmed the toilet was stained with blackened debris and patient equipment was stored in the bathroom. Observation of the medication room on the Medical Surgical Floor of Facility #3, on July 8, 2014, at 10:40 a.m., revealed one plastic liter bag of Dextrose 5% (sugar solution) and Normal Saline (a salt solution) with the protective outer cover removed. Further observation of the IV bag revealed a label stating, ...Do not remove over-wrap until ready for use... Interview with Facility #3's pharmacist, on July 8, 2014, at 10:41 a.m., in the medication room, confirmed the outer wrap was removed from the IV bag and the IV bags were not to be stored with the outer wraps removed. Observation at Facility #1 on July 7, 2014, at 1:30 p.m., in the Emergency Department (ED) storage cabinet in the ambulance entrance, revealed four pre-packaged 15 gauge Interosseous (IO) needles (alternative technique in providing a rapid and effective route for fluid resuscitation and medication administration for pediatrics and adults) with an expiration date of January, 2014 available for patient use. Interview with the ED NM on July 7, 2014, at 1:35 p.m., in the ED hallway, confirmed the IO needles were expired and were available for patient use. Observation on July 8, 2014, at 9:25 a.m., in the Facility #2 Operating Room Medication Room revealed an opened, uncovered bag of 0.9 NaCl IV (Normal Saline Intravenous) solution 250 ml (milliliters) in the IV storage bin. RN #2 confirmed the IV solution was not to be in the bin once it was removed from the protective cover. Observation at Facility #2 on July 8, 2014, at 9:45 a.m., in the surgery hallway, revealed a hanging rack with multiple x-ray aprons hanging on the rack. Further observation revealed four of the apron bottoms and straps were touching the floor. Interview with the Surgical Services NM on July 8, 2014, at 9:50 a.m., in the surgery hallway, confirmed the apron bottoms and the straps were in contact with the floor. Further interview revealed the aprons were available for use by the staff in the surgery suites. Observation of the Holding Area of the Surgical Department of Facility #3, on July 8, 2014, at 10:00 a.m., revealed a glucometer (a device used to measure blood sugar levels) on the counter of the nursing station. Interview with RN #16 on July 8, 2014, at 10:00 a.m., at the nurses station, revealed the RN used the glucometer to test patient's blood sugar levels and cleaned it with alcohol pads after use. Interview with RN #17, on July 8, 2014, at 10:20 a.m., in the Holding Area nursing station, revealed the RN had used the glucometer for blood testing that morning and had not cleaned the glucometer after use. The RN confirmed the glucometer was not cleaned routinely after use. The RN described the procedure for blood glucose testing. The nurse brings the blood sample to the nurses station inside an Intravenous (IV) needle and the specimen is placed on the meter at the nurses station. Review of the facility's policy number PC-PRO-3.107.002, titled ...Blood Glucose by Accuchek... revised April 2001, revealed, ...Disinfect meter after each use using pre-moistened wipe with a bleach solution... Interview with Facility #3's Chief Nursing Executive (CNE) on July 8, 2014, at 10:22 a.m., in the Holding Area, confirmed the glucometers were to be cleaned with Sani-cloths (a commercial germicidal wipe) after each use. Observation in Facility #1 Same Day Surgery Unit (SDS) on July 7, 2014, at 12:55 p.m., in room 215 (an empty clean patient room ready for use), revealed an opened package of 2 x (by) 2 gauze squares and a partial roll of ace wrap tape on the window sill. Interview with RN #11 confirmed the supplies were left in the room from the previous patient and were to be discarded when the room was cleaned. Further observation in the clean room on July 7, 2014, at 12:55 p.m., revealed an empty suction canister ready for use with dust build-up covering the top. Interview with RN #9 confirmed the suction canister was soiled. Observation with RN #15 on July 7, 2014, at 1:15 p.m., of the Medical Intensive Care Unit (MICU) at Facility #1, revealed patient #50 had signs posted outside the door to the patient's room which read, Contact Isolation and Wash hands with soap and water. Continued observation at 1:21 p.m., revealed Medical Doctor (MD) #1 exited patient #50's room, cleansed the hands with hand sanitizer located outside the patient's room, walked to the nurses' station, spoke to a nurse, and then exited MICU without washing the hands with soap and water. Interview with RN #15 on July 7, 2014, at 1:25 p.m., at the nurses' station, revealed patient #50 was in isolation for possible Clostridium difficile (C diff) (infectious diarrhea caused by a spore) and the facility was waiting on laboratory results. Continued interview confirmed MD #1 did not wash the hands with soap and water. Review of the facility policy Transmission Based Precautions revised on February, 2014, revealed, ...cleanse hands with soap and water...when working in an area with spores (in a room with a patient with Clostridium difficile...). Patient #57 was admitted to Facility #2 on July 7, 2014, with diagnoses including Pain in Foot Right and surgical procedure Right Foot, Right Amputation 5th Toe and Metatarsal (bone in the toe). Patient #57 was transferred from the in-patient room to the surgical suite for surgery at 7:00 a.m., on July 8, 2014. Observation in the post-operative (post op) holding area at Facility #2 on July 8, 2014, at 9:09 a.m., revealed RN #3 and RN #4 delivering care to patient #57 post operatively. RN #3 and RN #4 were observed not wearing gloves or gowns while touching the patient. Electronic medical record review on July 8, 2014, at 9:10 a.m., revealed patient #57 had a history of Methicillin Resistant Staphylococcus Aureus (MRSA) and was to be placed on Contact Precautions (Isolation requiring wearing a gown and gloves when touching the patient). Continued review of the electronic medical record PreProcedure Checklist revealed on July 8, 2014, at 5:09 a.m., ...Please contact the department for isolation precautions...Type of Precautions: Contact, Who notified: RN... Interview with RN #3 on July 8, 2014, at 9:15 a.m., at the post op nursing station, revealed the RN did not wear gloves and gown and confirmed the RN did not know the patient was to be on contact precautions. Continued interview confirmed RN #3 had not been told the patient was on contact precautions. Patient #32 was admitted to Facility #1 on March 19, 2014, for a lumbar sacral spinal fusion. Medical record review revealed the patient had an indwelling urinary catheter (tube inserted into the bladder) from March 19, 2014, through March 22, 2014. Further medical record review revealed no documentation of catheter care being done for the dates of March 19-22, 2014. Interview with the Vice President of Quality on July 8, 2014, at 2:00 p.m., in the conference room, revealed indwelling urinary catheter care was to be documented by the tech on the unit and if it wasn't documented then can't say the care was done. Further interview confirmed the catheter care was not documented. Interview with the Infection Control Director, Infection Control Specialist, and the Assistant Chief Nursing Officer on July 8, 2014, at 2:39 p.m., in the conference room, confirmed indwelling urinary catheter care was to be done daily using Chlorhexidine Gluconate (CHG) cloths (antiseptic cloths) for the prevention of catheter related infections.
complaint #
Based on observations, it was determined the facility failed to ensure Alcohol Based Hand Rub (ABHR) dispensers were not installed over or adjacent to an ignition source. The finding included: Observation on 7/7/14 at 9:49 AM revealed ABHR dispensers installed over or adjacent to an ignition source in the following locations: Rooms 540, 539, 527, 431, Evidence Base Care Coordinator Office on 4th floor, MICU 9, MICU 11, MICU 4, MICU 3, and Cath Lab 4. This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.
Based on Observations, it was determined the facility failed to ensure Alcohol Based Hand Rub (ABHR) dispensers were installed in the correct locations. The finding included: Observation on 7/8/14 at 7:13 AM revealed ABHR dispensers installed over or adjacent to an ignition source in the following locations: Room 217, 212, ICU 3, 219, 221, and EEG Exam Room. This finding was verified by engineering and acknowledged by administration during the exit conference on July 8, 2014.
An investigation of a self reported EMTALA violation, complaint numbered TN 729, was conducted on November 5, 2013. Review of the facility self reported Fact Statement revealed the facility reported the ncident to the Tennessee Bureau of Licensure and Registration on October 14, 2013 and also implemented corrective actions. CMS is not proceeding with a termination of your Medicare provider agreement. Facility was notified by overnight mail on January 7, 2014. Based on review of a self reported EMTALA violation notification, medical record review, review of facility policy, observation, interview, and review of employee education, the facility failed to provide a medical screening examination for one patient (#1) of thirty patients reviewed. The findings included: Review of a Fact Statement submitted by the facility on October 14, 2013, revealed the facility identified and reported a potential Emergency Medical Treatment and Labor Act (EMTALA) violation of failing to provide a medical screening examination to a patient seeking medical examination and treatment. The Fact Statement revealed on September 5, 2013, at approximately 7:00 p.m., a twenty-two year old female patient arrived by car at the Emergency Department (ED) of the facility. According to Registrar #1, after taking and completing a Sign-in sheet, the patient returned from the lobby seating area to the ED front desk window and asked Registrar #1 if the registration form had been changed, and if there were forms for the patient to complete to indicate why the patient came to the ED. Registrar #1 instructed the patient to complete Sections A and B on the form and the question was on the form. The patient stayed at the window, completed the form, gave the form to Registrar #1, and returned to the lobby seating area. Further review revealed Registrar #1 was entering the data into the computer on patient #1 and another patient, while talking to co-workers in the registration area, when patient #1 returned to the window, became agitated, began yelling at Registrar #1, and reached a hand through the registration window. Another registrar (registrar #2) walked into the area where Registrar #1 and the patient were, saw what was occurring, and told a staff member to contact the Security Department. Further review revealed two Security Officers (#1 and #2) responded to the ED. When the SO went to the lobby seating area, patient #1 was agitated and cursing in front of staff members and other patients. Further review revealed SO #2 asked the patient if they could speak with the patient outside, and the patient partially responded to the request for the patient to calm down, but the patient continued to yell and curse. Further review revealed the patient indicated the registration staff had treated the patient unfairly, and after calming down, the patient was allowed to go back into the ED lobby. Further review revealed the SO advised the patient of the facility's policy on verbal and physical abuse against staff members and those behaviors would not be tolerated, and the patient acknowledged understanding. Further review revealed the staff told the SO the patient was trying to reach a hand through the window and trying to get to Registrar #1. The SO had not been advised of this previously and stated, ...if that is true, then (patient #1) will have to leave ... Continued review revealed the SO asked the patient to step outside and asked the patient if had put a hand through the window. The patient admitted had and also admitted to making threats to staff members. The SO told the patient would have to leave due to the threats and the patient indicated would leave and go to another facility. Further review revealed, as the SO was escorting the patient to the car, the ED Registered Nurse (RN) came outside and called the patient's name. The SO asked the patient if the patient wanted to go back into the ED and told the patient would have to calm down. The patient indicated did not want to go back into the ED and began cursing again. Medical record review of patient #1 Emergency Department (ED) registration Sign-in Sheet for Emergency Services dated September 5, 2013, with no time documented, revealed the patient signed in with complaints of foot pain. Further review revealed 1st call for triage 19:30 (7:30 p.m.) and no information documented in the triage notes below the triage time. Medical record review of the Emergency Patient Record dated September 5, 2013, at 1948 (7:48 p.m)., written by ED Registered Nurse (RN) #1, revealed, ...went to call pt (patient)...pt outside with security...was informed per (by) registration that as pt. was signing in, (patient #1) became violent and was reaching through the glass in attempt to get girl at front desk...we called security and (patient #1) has been escorted off the campus because (patient #1) was running around cussing everyone out and reaching through the glass at us...pt. was walking around rapidly, yelling at security, pt. off campus per security... Further medical record review revealed, Primary Impression: LPT (left prior to triage)...disposition: Routine Home/Self care. Medical record review of an amendment note on the Emergency Patient Record dated September 10, 2013, at 9:42 a.m., written by ED RN #1, revealed, ...late entry-I went to lobby and called pt for triage. I was informed that patient was outside. (Patient #1) refused to come in stating 'you have some rude staff'. Patient in NAD (no additional stress), ambulatory with steady gait... Review of facility policy Emergency Department Patient Triage, policy #19.020.004, last revised on March, 2013, revealed, ...it is the policy of (Named Facility), that upon presentation to the ED, all patients will be triaged by a Registered Nurse... Review of facility policy, EMTALA-Tennessee Medical Screening Examination and Stabilization, last revised on March 2013, revealed, ...an EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and (1) the individual or a representative acting on the individuals behalf request an examination or treatment for a medical condition... Review of facility policy Patient Access-Procedure for Emergency Department Registration-Compliance EMTALA/QMP program, dated July 25, 2005, revealed, ...it is the policy of the Patient Access Department to adhere to EMTALA standards and state laws when performing Emergency Department (ED) patient registration. Every patient presenting in the Emergency Department is entitled to a Medical Screening Examination and stabilizing treatment for an emergency medical condition... Observation on November 4, 2013, at 9:05 a.m., in the ED, revealed staff and patients leaving the ED and no regulatory violations observed. Further observation and review revealed all patients in the ED received a medical screening and were either treated, admitted , transferred appropriately, or left AMA (Against Medical Advice). Continued observation revealed new patients coming into the ED were registered and triaged for treatment. Further observation revealed all patients in the ED were observed to have call lights within reach. Continued observation in the ED lobby revealed EMTALA signage posted in public viewing areas. Observation on November 5, 2013, at 2:30 p.m., in the ED, revealed new patients coming into the ED were triaged directly back to the ED for treatment, and bedside registration was done after the patients were triaged. Telephone interview on November 5, 2013, at 8:40 a.m., with patient #1 (who was indicated in the complaint), revealed the patient presented on September 5, 2013. Further interview revealed the patient was given a sign in sheet to fill out indicating the patient's chief complaint and basic demographical information. Further interview revealed, ...filled the information out and took the sheet back to the registration desk and went and sit back down in the Emergency Department (ED) lobby...a few minutes later...went back up to the registration desk...the registration clerk had an attitude...I asked (clerk) if (clerk) had a problem...the clerk was talking to someone else and was shaking...head...it made me mad and...(clerk) just had a problem...I was yelling and they called security on me...never threatened anyone...it just made me mad... Further interview revealed the security guard came to the ED, talked with the patient, and took the patient outside. Continued interview revealed the patient came back into the ED with the security officer and then was taken back outside by the security officer. Further interview revealed, ...security officer told me the hospital policy was I had to leave the facility since I had threatened the registration clerk...stayed outside and never went back into the (ED) after that... Continued interview revealed the patient left the facility, was never seen by a nurse or a physician at the facility, and did not seek treatment at another facility. Interview with the Risk Manager on November 5, 2013, at 9:20 a.m., in the conference room, revealed the alleged incident was reported to the risk manager the next day, September, 6, 2013. Further interview revealed the ED charge nurse had called the ED Nurse Manager on September 5, 2013, and told the ED manager patient #1 had come to the ED and left prior to seeing the doctor. Continued interview revealed the facility started an investigation immediately. Further interview revealed, ...we reviewed the surveillance tape of the registration area, which does not include audio recording, but we could see the patient was very upset and was visually using the hands...it does not appear the patient was trying to strike the employees...we think it was just a miscommunication between the employees and the patient... Continued interview revealed the registration clerks felt threatened, called security, and when the officers came to the ED, they took the patient outside to try to calm the patient down. Further interview revealed once the officers felt they had calmed the patient down, the patient came back in the ED, and once again became upset and started yelling and cursing at the staff. Continued interview revealed, ...once the officer came back in the ED, the staff told SO #2 the patient had tried to strike at the staff and asked if the patient was going to be removed from the ED...at that point the SOs took the patient outside and informed the patient due to the situation, the patient would have to leave the facility premises...nursing was not aware of the incident and the charge nurse or the nursing supervisor was not notified of the situation...the ED nurse went out to call the patient back for triage and found the patient outside in the parking lot with the SOs...tried to get the patient to come back in but the patient would not come back inside...the patient stated the registration staff were rude...no aggressive behavior by the staff was reported or no suggestions of any inappropriate behavior exhibited from our employees to the patient...the ED staff, registrars, charge nurses, nursing supervisors and security officers all went through retraining for EMTALA, and CPI (Crisis Prevention Intervention)... Continued interview revealed the investigation was started and Risk Management, the Compliance Department, the ED Manager, the Director of Plant Operations, the Director of Patient Access, and the Corporate Offices were all notified of the situation. Interview with the Director of Patient Access on November 5, 2013, at 9:30 a.m., in the conference room, revealed, ...the registration staff felt the environment was not safe when the patient started yelling and they described the patient reached through the glass window toward the staff...they called security to come to the ED...once the SOs came to the ED, they talked with the patient and took the patient outside to try to calm the patient down...the patient did come back into the ED lobby after that and started yelling at (registrar #1), who was the initial contact person when the patient came into the ED...(registrar #1) took the patient's actions as being physically aggressive toward the employees...there was never any suggestions made regarding registrar #1 making inappropriate gestures toward the patient...we have never had any behavior issues with any of the employees involved in this situation... Telephone interview with RN #1, on November 5, 2013, at 9:50 a.m., revealed the RN was on duty September 5, 2013, when patient #1 presented to the ED. Further interview revealed the RN only saw the patient outside of the ED lobby when the nurse went to call the patient back for triage. Continued interview revealed, ...went out into the lobby and was told the patient was outside with the SOs...when I called the patient's name, the SO told me they had asked the patient to leave...I told the SO the patient was here to be seen in the ED...when I asked the patient if...wanted to be seen in the ED, the patient stated 'oh no, you have some rude staff' and would not come back into the ED... Further interview revealed the patient was very upset, yelling, and walked away from the RN. Continued interview revealed, ...when I went back into the ED I told the charge nurse about the situation and documented the situation in the nurses notes...did not see any of the employees using any inappropriate behaviors toward the patient... Further interview revealed the employee had attended EMTALA training and had received counseling regarding the incident. Interview with the Clinical ED Manager on November 5, 2013, at 9:50 a.m., in the conference room, revealed, ...the physician was never involved in the situation, never seen the patient or knew about the situation...the patient did not receive a medical screening evaluation while in the ED... Interview with the ED Medical Director on November 5, 2013, at 11:00 a.m., in the ED waiting room, revealed, ...any patient who comes to the ED should receive a medical screening by a licensed qualified medical practitioner...was told the patient was very hostile... Continued interview revealed the patient's medical record was very limited on information because the patient was not seen by a physician while in the ED on September 5, 2013. Further interview revealed, ...security talked with the patient... Interview with SO #2 on November 5, 2013, at 1:35 p.m., in the conference room, revealed, ...called to the ED by the registration staff...patient was verbally threatening to the registration staff...when we got to the ED there were three people telling us what happened and the patient was yelling and cursing in the ED lobby...we asked the patient to step outside the ED lobby and the patient was cooperative...we were trying to de-escalate the situation as quickly as possible...the patient was upset and said ...did not feel anyone wanted (patient #1) in the facility...the patient said the registration staff was rude...the patient told us...would go to another hospital to be seen...it all happened so fast...we were just trying to calm the situation as much as possible...when I went back inside, I asked the registration employees to write a statement for our records...our report was turned in to our supervisor...did not notify the charge nurse or nursing supervisor...the registration employees told us they had notified their supervisor... Further interview revealed the employee had attended EMTALA training and had received counseling regarding the incident. Telephone interview with the ED charge RN on November 7, 2013, at 2:50 p.m., revealed the charge nurse was not aware of the incident until the patient had left the facility. Further interview revealed RN #1 told the charge nurse patient #1 had come to the ED for treatment, had been taken outside by the security officer, and had left the facility without having a medical screening. Further interview revealed, ...RN #1 went out to triage the patient...the patient was outside with the officers...the RN asked the patient if the patient wanted to come back in for evaluation, and the patient declined. Further interview revealed the charge nurse notified the clinical manager on September 5, 2013, and informed the manager the patient had not had a medical screening. Further interview revealed the employee had attended EMTALA training and had received counseling regarding the incident. Interview with the Risk Manager on November 5, 2013, at 3:00 p.m., in the conference room, confirmed the patient did not receive a medical screening examination and the facility failed to stabilize the patient's emergency medical condition. Review of the facility self reported Fact Statement revealed the facility reported the incident to the Tennessee Bureau of Licensure and Registration on October 14, 2013, and implemented the following corrective actions: (1) Corrections were made on the facility ED Central log. The patient was originally documented in the ED Central Log as arriving by ambulance and Leaving Prior to Triage. The ED Central log was revised to show the patient was a walk-in patient and was refused treatment. (2) Registrar #1, Registrar #2, SO #1, and SO #2 were counseled on the importance of ensuring each patient coming to the ED for examination and treatment received an appropriate medical screening examination. (3) Registrar #1, Registrar #2, SO #1, and SO #2 were counseled a patient cannot be removed from the premises without involvement of a member of Administration or the Nursing Supervisor. (4) Security officers now have access to EMTALA training via on-line education and are assigned the course as mandatory training and as part of New Employee Orientation training before they are able to work in any hospital unit. (5) The ED RN was counseled on the importance of ensuring each patient coming to the ED for examination and treatment received an appropriate medical screening examination. (6) The ED RN was counseled on ensuring when a patient indicated they were going to leave the ED without receiving a medical screening examination, the patient was advised of the risks associated with leaving without receiving a medical screening examination and the benefits of staying for a medical screening evaluation. (7) The ED RN was counseled on the importance of requesting any patient who indicated they were leaving without receiving a medical screening evaluation, sign a Waiver to Right to Medical Screening Examination form or document the patient was asked to sign the form. The ED RN completed the web-based EMTALA training course on January 14, 2013. (8) ED staff members, registrars, nursing supervisors, and security personnel were re-educated on EMTALA regulations. (9) The EMTALA policies were reviewed with all staff members, charge nurses, nursing supervisors, security personnel, and registrars to re-educate staff members on the appropriate procedures to be followed when a patient presents to the ED for examination and treatment. (10) ED registrars received de-escalation training to enable recognition of early signs of escalating behavior and how to diffuse a situation before it becomes a crisis. Based on reivew of the Fact Statement and review of facility EMTALA training, all staff had completed education on EMTALA violations by October 31, 2013. The facility has not had any EMTALA violations since the reported violation on September 5, 2013.
An unannounced onsite EMTALA investigation was conducted on January 24, 2013 for complaint numbered TN 067. The findings of the investigation were forwarded to the CMS Regional office in Atlanta, Georgia. The hospital's Chief Executve Officer was notified by the CMS Regional Office on June 11, 2013, by overnight mail that deficiencies were cited, but the hospital had identified the violation on its own, took effective corrective action prior to the investigation, and has had no violations for the past six months. Based on review of a facility report, record reviews, policy reviews, and interviews, the facility failed to meet the requirements of the Emergency Medical Treatment and Labor Act for one (#26) patient of twenty-six Emergency Department (ED) patients reviewed. Refer to A-2405: The hospital is to maintain a central log on each individual who comes to the emergency department seeking assistance; Refer to A-2406: The hospital must provide an appropriate medical screening examination within the capability of the hospital's emergency room to determine if an emergency medical condition exists. Refer to A-2407: The hospital must provide within it's capabilities further medical examination and treatment as required to stabalize the medical condition. Refer to A-2409: The hospital may not transfer individuals unless the transfer is appropriate; the individual requests the transfer; that the medical benefits outweigh the risks of the transfer and that the transfer is provided through qualified personnel.
Based on review of a facility report, record review, policy review, and interviews, the facility failed to document in the Emergency Department (ED) Central Log one (#26) patient presenting to the ED for examination and treatment, of twenty-six ED patients reviewed. The findings included: Review of a letter from the facility (Hospital #1), written to the Department of Health (DoH), dated December 21, 2012, revealed the facility, wished to self-report...a potential violation of the Emergency Medical Treatment and Labor Act... Further review of the letter revealed Patient #26 was brought to Hospital #1's satellite facility's Emergency Department (ED) on December 18, 2012, at approximately 1:45 a.m., by family members and friends for complaint of possible drug ingestion and behaving wild Further review of the letter revealed Patient #26, ...slapping her boyfriend...refusing to get out of the car...cursing...belligerent...fighting...head butted RN1 in the stomach...running...cursing RN1 and slapped RN1 in the face...kicked the security officer in the arm... Further review of the letter revealed Patient #26 was placed in a wheelchair and staff attempted to take the patient into the ED with the patient cursing and yelling at the family members. The letter revealed that before staff could transport the patient into the ED, the patient, began cursing RN1 and slapped RN1 in the face...the patient's boyfriend restrained the patient...when the security officer tried to talk to the patient, the patient kicked the security officer in the arm. Further review of the letter revealed, RN1 had called the...Police Department for assistance...When the...Police Officers arrived they asked RN1 what...wanted them to do with the patient...RN1 indicated the ED was full and the patient was too violent to be brought into the ED. The letter also stated, The Police Officers advised the patient and those that brought...to the ED that they would have to leave the property or the patient would be arrested. Further review of the letter revealed, The patient's friends placed the patient in the car and transported the patient to (Hospital #2) for treatment. The letter also stated, The patient was admitted ...with diagnosis of...altered mental status...hypokalemia...alcohol poisoning. Further review of the letter revealed Hospital #1, ...failed to enter the patient's name in the ED Central Log as a patient presenting to the ED for which examination and treatment was requested... Further review of the letter revealed, A late manual entry regarding this incident has been made in the...ED Central Log. Review of the ED log pages dated December 18, 2012, revealed no documentation of Patient #26 presenting to the ED that date. Review of an addendum to the ED log, run date December 31, 2012, revealed Patient #26 presented on December 18, 2012, at 2:00 a.m. for Evaluation. Further review of the addendum revealed the patient's disposition was documented as, left prior to triage. Review of facility policy titled, EMTALA-Definitions and General Requirement effective date September 1, 2012, revealed, Central Log is a log that a hospital is required to maintain on each individual who comes to the emergency department seeking assistance...Log the individual into the Central Log. Interview with the ED Director, on January 22, 2013, at 2:15 p.m., in the Administration Conference Room of Hospital #1's satellite facility, revealed hospital policy required Patient #26's name, date and time of presentation, reason for visit, and disposition, be documented on the ED Log. Further interview with the ED Director confirmed the ED staff did not follow facility policies, by failing to enter Patient #26 into the Central Log on December 18, 2012. Further interview revealed the facility had added an addendum to the Central ED Log which included Patient #26, as part of the facility's corrective actions. Interview with RN#2, by telephone, on January 24, 2013, at 11:15 a.m., revealed this nurse went out to assist RN#1 with transporting Patient #26 into the ED. RN#2 stated the patient did not want to come inside the ED and was resisting verbally and physically. RN#2 stated the patient fought with family and staff. RN#2 stated the patient appeared manic and paranoid. RN #2 stated he saw the patient head butt RN#1 in the stomach, and later slap RN#1 in the face. RN#2 stated he saw the patient also kick the security officer in the chest area. RN#2 stated the patient was being restrained outside the ED by a male friend when the local police arrived. RN#2 stated the police told the patient to, calm down and be seen, be arrested, or leave. RN#2 stated the patient and family/friends got in their car and left. RN#2 confirmed the patient visit to the ED was not documented in the ED Central Log. Interview with RN#1, by telephone, on January 24, 2013, at 3:20 p.m. revealed the nurse remembered the incident with Patient #26 on December 18, 2012. RN #1 stated, I went out to help a patient out of a car and the patient's friend told me I had to get the patient out of the car, I told the friend, the patient had to come out of car on their own. RN#1 stated Patient #26 was, beating on a man in the back seat of the car when I arrived, and the patient was saying over and over 'I don't want to be here, and why did you bring me here? RN#1 also stated, the patient was coaxed out of the car and was in the wheelchair and when I unlocked the brakes the patient rushed at me and tried to tackle me. The patient then ran to the north side of the hospital where the male friend caught her and they fought on the ground. I went and called security and ...police department. We put her back in wheelchair and almost got inside the ED when patient jumped up and slapped me on the face. The patient's male friend restrained the patient again, and they struggled outside the ED. RN#1 stated, I explained that the patient had a right to a medical examination, but that the patient would have to come into the ED. I told the patient and family that the patient could come into the ED and be seen, or they could take the patient home. RN#1 stated the patient was never told to go to another facility, and confirmed the patient was never examined by anyone at Hospital #1. RN#1 stated the ED physician was never aware the patient had presented to the ED. RN #1 confirmed the local police arrived and told the patient and family, the patient could calm down and be seen, leave or be arrested, and they decided to leave. RN#1 stated the patient was not added to the ED log. The hospital took the following actions: Hospital #1 investigated this incident, and reported the findings of the incident to the Department of Health. Hospital #1's investigation found the ED staff did not follow the Hospital's policies and practices on December 18, 2012. Hospital #1 implemented a plan of correction which included: 1. Counseled staff involved in the incident on EMTALA requirements and management of violent patients. 2. Educated all ED and Labor/Delivery staff at the main hospital and all satellites on EMTALA requirements and management of violent patients. Security officers were also included in the training. All staff were also educated on the facility's Chain of Command Policy and the Violent Patient Policy. 3. An Addendum was added to the ED Log on 12/31/12 that included Patient #26's name. Documentation of staff's attendance and completion of the training was provided to the Surveyor. ED staff interviewed during the compliant investigation confirmed the training had occurred and demonstrated knowledge of EMTALA requirements. Interview with the Market Director of Quality, by telephone, confirmed facility compliance with the EMTALA requirements and other facility policies is being monitored by monthly chart and ED Log reviews, and of all incidents of patients leaving the ED without a Medical Screening Exam are investigated.
Based on review of a facility report, record review, policy review, and interviews, the facility failed to provide an appropriate medical screening examination for one (#26) patient of twenty-six patients reviewed. The findings included: Review of a letter from the facility (Hospital #1), written to the Department of Health (DoH), dated December 21, 2012, revealed the facility, wished to self-report...a potential violation of the Emergency Medical Treatment and Labor Act... Further review of the letter revealed Patient #26 was brought to Hospital #1's satellite facility's Emergency Department (ED) on December 18, 2012, at approximately 1:45 a.m., by family members and friends for complaint of possible drug ingestion and behaving wild Further review of the letter revealed Patient #26, ...slapping her boyfriend...refusing to get out of the car...cursing...belligerent...fighting...head butted RN1 in the stomach...running...cursing RN1 and slapped RN1 in the face...kicked the security officer in the arm... Further review of the letter revealed Patient #26 was placed in a wheelchair and staff attempted to take the patient into the ED with the patient cursing and yelling at the family members. The letter revealed that before staff could transport the patient into the ED, the patient, began cursing RN1 and slapped RN1 in the face...the patient's boyfriend restrained the patient...when the security officer tried to talk to the patient, the patient kicked the security officer in the arm. Further review of the letter revealed, RN1 had called the...Police Department for assistance...When the...Police Officers arrived they asked RN1 what...wanted them to do with the patient...RN1 indicated the ED was full and the patient was too violent to be brought into the ED. The letter also stated, The Police Officers advised the patient and those that brought...to the ED that they would have to leave the property or the patient would be arrested. Further review of the letter revealed, The patient's friends placed the patient in the car and transported the patient to (Hospital #2) for treatment. The letter also stated, The patient was admitted ...with diagnosis of...altered mental status...hypokalemia...alcohol poisoning. Further review of the letter revealed Hospital #1, ...failed to provide the patient with a medical screening examination regarding the patient's behavior and emergency medical condition... Review of the ED log and ED records revealed no documentation of Patient #26 being examined or treated in the ED of Hospital #1. Review of the medical record from Hospital #2, revealed Patient #26 presented on December 18, 2012, at 2:35 a.m. with complaint of Altered Mental Status. Review of the ED Triage Notes from Hospital #2, revealed, pt (patient) was brought in by family ...was given unknown drugs, was taken to (Hospital #1) and they wouldn't take...so...came here. Pt is combative, altered. Pt immediately brought back to room...had to restrain pt for safety... Review of the physician's admitting history and physical from Hospital #2, dated December 18, 2012, revealed , ...took some unknown substances which rendered...confused and agitated...had to be physically and chemically restrained...alcohol level 304 (toxic above 400). Further review of the history and physical revealed, admit to ICU (Intensive Care Unit) with diagnosis of: Altered Mental Status, Alcohol Intoxication, Unknown Drug Consumption, Hypokalemia, and Dehydration. Review of RN#1's written statement dated December 18, 2012, revealed the nurse went outside the ED on December 18, 2012, to assist a patient out of a car. Further review of RN #1's statement revealed, ...is slapping boyfriend and refuses to get out of car...I informed them I would not get...out of the vehicle and...would need to exit on...own. The statement also revealed, ...charged out of the wheelchair and head butted me in the stomach...then took off running toward the north side of the hospital...boyfriend chased...tripped and fell ...I noticed abrasions to left knee ...attempted to approach...again placed...in the wheelchair...we got up ramp ...almost to ER (emergency room ) door when...began cursing and yelling at the two women who transported...here...then slapped me across the face...then was pulled out of wheelchair by...boyfriend onto the ground... Further review of the statement revealed RN#1 called the local police department (PD) and when the police arrive they find, the boyfriend has the pt in a headlock because...is still yelling and cussing at everyone and striking out at the security guard... Further review of the written statement revealed the police, told them to leave the property or...would be arrested...I informed PD that...was too dangerous to bring back into the ER because we are completely full and the...is too violent... Review of facility policy titled, EMTALA-Definitions and General Requirement effective date September 1, 2012, revealed, ...an emergency department must provide to any individual...who comes to the emergency department and appropriate Medical Screening Examination. Review of facility policy titled, Emergency Department-Combative or Difficult to Manage Patient, reviewed date October 2011, revealed, Patients who are difficult to manage, due to alcohol, drugs, or emotional problems, will be treated with care and dignity in a safe and secure environment. Staff are trained on how to care for and interact with combative or difficult patients... Interview with Security Officer #1 (SO#1), on January 22, 2013, at 1:05 pm, in the Administration Conference Room, revealed the officer recalled the incident involving Patient #26 on December 18, 2012. Interview revealed SO#1 was called to the ED to meet RN #1 in the ED Lobby. SO#1 stated there was loud arguing outside the ED, and the officer went outside and saw RN #1 and Patient #26 arguing. The security officer stated RN#1 and family tried to calm the patient, but the patient became irate and at one time a male friend or family member was physically restraining the patient. The security officer stated the patient kicked the officer in the right arm and slapped RN#1 in the face, and was very out of control. The security officer stated the local police arrived and told the patient to leave. The security officer stated the patient left in a car with the family and/or friends. The security officer confirmed the patient never entered the ED. Interview with the ED Director, on January 22, 2013, at 2:15 p.m., in the Administration Conference Room of Hospital #1's satellite facility, revealed hospital policy required Patient #26 be brought into the ED and provided a Medical Screening Examination . Further interview with the ED Director confirmed the ED staff did not follow facility policies, in regard to Patient #26's treatment on December 18, 2012. Interview, on January 22, 2013, at 3:00 p.m. in the ED of Hospital #1's satellite facility, with MD#1, the physician working the ED of Hospital #1, when Patient #26 presented on December 18, 2012, revealed MD#1 did not see or examine the patient. Interview with RN#2, by telephone, on January 24, 2013, at 11:15 a.m., revealed this nurse went out to assist RN#1 with transporting Patient #26 into the ED. RN#2 stated the patient did not want to come inside the ED and was resisting verbally and physically. RN#2 stated the patient fought with family and staff. RN#2 stated the patient appeared manic and paranoid. RN #2 stated he saw the patient head butt RN#1 in the stomach, and later slap RN#1 in the face. RN#2 stated he saw the patient also kick the security officer in the chest area. RN#2 stated the patient was being restrained outside the ED by a male friend when the local police arrived. RN#2 stated the police told the patient to, calm down and be seen, be arrested, or leave.RN#2 stated the patient and family/friends got in their car and left. RN#2 confirmed the patient was not given a medical screening examination and did not sign out AMA. Interview with RN#1, by telephone, on January 24, 2013, at 3:20 p.m. revealed the nurse remembered the incident with Patient #26 on December 18, 2012. RN #1 stated, I went out to help a patient out of a car and the patient's friend told me I had to get the patient out of the car, I told the friend, the patient had to come out of car on their own. RN#1 stated Patient #26 was, beating on a man in the back seat of the car when I arrived, and the patient was saying over and over 'I don't want to be here, and why did you bring me here? RN#1 also stated, the patient was coaxed out of the car and was in the wheelchair and when I unlocked the brakes the patient rushed at me and tried to tackle me. The patient then ran to the north side of the hospital where the male friend caught her and they fought on the ground. I went and called security and...police department. We put her back in wheelchair and almost got inside the ED when patient jumped up and slapped me on the face. The patient's male friend restrained the patient again, and they struggled outside the ED. RN#1 stated, I explained that the patient had a right to a medical examination, but that the patient would have to come into the ED. I told the patient and family that the patient could come into the ED and be seen, or they could take the patient home. RN#1 stated the patient was never told to go to another facility, and confirmed the patient was never examined by anyone at Hospital #1. RN#1 stated the ED physician was never aware the patient had presented to the ED. RN #1 confirmed the local police arrived and told the patient and family, the patient could calm down and be seen, leave or be arrested, and they decided to leave. RN#1 stated the patient was not added to the ED log and the patient did not sign a leaving Against Medical Advise (AMA) release. The hospital took the following actions: Hospital #1 investigated this incident, and reported the findings of the incident to the Department of Health. Hospital #1's investigation found the ED staff did not follow the Hospital's policies and practices on December 18, 2012. Hospital #1 implemented a plan of correction which included: 1. Counseled staff involved in the incident on EMTALA requirements and management of violent patients. 2. Educated all ED and Labor/Delivery staff at the main hospital and all satellites on EMTALA requirements and management of violent patients. Security officers were also included in the training. All staff were also educated on the facility's Chain of Command Policy and the Violent Patient Policy. 3. An Addendum was added to the ED Log on 12/31/12 that included Patient #26's name. Documentation of staff's attendance and completion of the training was provided to the Surveyor. ED staff interviewed during the compliant investigation confirmed the training had occurred and demonstrated knowledge of EMTALA requirements. Interview with the Market Director of Quality, by telephone, confirmed facility compliance with the EMTALA requirements and other facility policies is being monitored by monthly chart and ED Log reviews, and of all incidents of patients leaving the ED without a Medical Screening Exam are investigated.
Based on review of a facility report, record review, policy review, and interviews, the facility failed to provide treatment to stabilze the medical condition of one (#26) patient of twenty-six patients reviewed. The findings included: Review of a letter from the facility (Hospital #1), written to the Department of Health (DoH), dated December 21, 2012, revealed the facility, wished to self-report...a potential violation of the Emergency Medical Treatment and Labor Act... Further review of the letter revealed Patient #26 was brought to Hospital #1's satellite facility's Emergency Department (ED) on December 18, 2012, at approximately 1:45 a.m., by family members and friends for complaint of possible drug ingestion and behaving wild Further review of the letter revealed Patient #26, ...slapping her boyfriend...refusing to get out of the car...cursing...belligerent...fighting...head butted RN1 in the stomach...running...cursing RN1 and slapped RN1 in the face...kicked the security officer in the arm... Further review of the letter revealed Patient #26 was placed in a wheelchair and staff attempted to take the patient into the ED with the patient cursing and yelling at the family members. The letter revealed that before staff could transport the patient into the ED, the patient, began cursing RN1 and slapped RN1 in the face...the patient's boyfriend restrained the patient...when the security officer tried to talk to the patient, the patient kicked the security officer in the arm. Further review of the letter revealed, RN1 had called the...Police Department for assistance...When the...Police Officers arrived they asked RN1 what...wanted them to do with the patient...RN1 indicated the ED was full and the patient was too violent to be brought into the ED. The letter also stated, The Police Officers advised the patient and those that brought...to the ED that they would have to leave the property or the patient would be arrested. Further review of the letter revealed, The patient's friends placed the patient in the car and transported the patient to (Hospital #2) for treatment. The letter also stated, The patient was admitted ...with diagnosis of...altered mental status...hypokalemia...alcohol poisoning. Further review of the letter revealed Hospital #1, ...failed to stabilize the patient's emergency medical condition... Review of the ED log and ED records revealed no documentation of Patient #26 being examined or treated in the ED of Hospital #1. Review of the medical record from Hospital #2, revealed Patient #26 presented on December 18, 2012, at 2:35 a.m. with complaint of Altered Mental Status. Review of the ED Triage Notes from Hospital #2, revealed, pt (patient) was brought in by family...was given unknown drugs, was taken to (Hospital #1) and they wouldn't take...so...came here. Pt is combative, altered. Pt immediately brought back to room...had to restrain pt for safety... Review of the physician's admitting history and physical from Hospital #2, dated December 18, 2012, revealed , ...took some unknown substances which rendered...confused and agitated...had to be physically and chemically restrained...alcohol level 304 (toxic above 400). Further review of the history and physical revealed, admit to ICU (Intensive Care Unit) with diagnosis of: Altered Mental Status, Alcohol Intoxication, Unknown Drug Consumption, Hypokalemia, and Dehydration. Review of RN#1's written statement dated December 18, 2012, revealed the nurse went outside the ED on December 18, 2012, to assist a patient out of a car. Further review of RN #1's statement revealed, ...is slapping boyfriend and refuses to get out of car...I informed them I would not get...out of the vehicle and...would need to exit on...own. The statement also revealed, ...charged out of the wheelchair and head butted me in the stomach...then took off running toward the north side of the hospital...boyfriend chased...tripped and fell ...I noticed abrasions to left knee...attempted to approach...again placed...in the wheelchair...we got up ramp...almost to ER (emergency room ) door when...began cursing and yelling at the two women who transported...here ...then slapped me across the face ...then was pulled out of wheelchair by...boyfriend onto the ground... Further review of the statement revealed RN#1 called the local police department (PD) and when the police arrive they find, the boyfriend has the pt in a headlock because...is still yelling and cussing at everyone and striking out at the security guard ... Further review of the written statement revealed the police, told them to leave the property or...would be arrested...I informed PD that...was too dangerous to bring back into the ER because we are completely full and the...is too violent... There is no documentation in the written statement of the patient being informed of risks regarding leaving without a medical examination or being asked to signed an informed refusal of treatment and/or leaving against medical advise (AMA) consent form. Review of facility policy titled, EMTALA-Definitions and General Requirement effective date September 1, 2012, revealed, ...provide necessary stablizing treatment to the individual or provide for an appropriate transfer...Obtain or attempt to obtain in writing an informed refusal of examination or treatment...in the case of an individual who refuses... Review of facility policy titled, Emergency Department-Combative or Difficult to Manage Patient, reviewed date October 2011, revealed, Patients who are difficult to manage, due to alcohol, drugs, or emotional problems, will be treated with care and dignity in a safe and secure environment. Staff are trained on how to care for and interact with combative or difficult patients ... Interview with Security Officer #1 (SO#1), on January 22, 2013, at 1:05 pm, in the Administration Conference Room, revealed the officer recalled the incident involving Patient #26 on December 18, 2012. Interview revealed SO#1 was called to the ED to meet RN #1 in the ED Lobby. SO#1 stated there was loud arguing outside the ED, and the officer went outside and saw RN #1 and Patient #26 arguing. The security officer stated RN#1 and family tried to calm the patient, but the patient became irate and at one time a male friend or family member was physically restraining the patient. The security officer stated the patient kicked the officer in the right arm and slapped RN#1 in the face, and was very out of control. The security officer stated the local police arrived and told the patient to leave. The security officer stated the patient left in a car with the family and/or friends. The security officer confirmed the patient never entered the ED. Interview with the ED Director, on January 22, 2013, at 2:15 p.m., in the Administration Conference Room of Hospital #1's satellite facility, revealed hospital policy required Patient #26 be brought into the ED, provided a Medical Screening Examination, and provided stabilizing treatment if needed. Further interview with the ED Director confirmed the ED staff did not follow facility policies, in regard to Patient #26's treatment on December 18, 2012. Interview, on January 22, 2013, at 3:00 p.m. in the ED of Hospital #1's satellite facility, with MD#1, the physician working the ED of Hospital #1, when Patient #26 presented on December 18, 2012, revealed MD#1 did not examine or treat the patient. Interview with RN#2, by telephone, on January 24, 2013, at 11:15 a.m., revealed this nurse went out to assist RN#1 with transporting Patient #26 into the ED. RN#2 stated the patient did not want to come inside the ED and was resisting verbally and physically. RN#2 stated the patient fought with family and staff. RN#2 stated the patient appeared manic and paranoid. RN #2 stated he saw the patient head butt RN#1 in the stomach, and later slap RN#1 in the face. RN#2 stated he saw the patient also kick the security officer in the chest area. RN#2 stated the patient was being restrained outside the ED by a male friend when the local police arrived. RN#2 stated the police told the patient to, calm down and be seen, be arrested, or leave. RN#2 stated the patient and family/friends got in their car and left. RN#2 confirmed the patient was not provided any treatment and did not sign out AMA. Interview with RN#1, by telephone, on January 24, 2013, at 3:20 p.m. revealed the nurse remembered the incident with Patient #26 on December 18, 2012. RN #1 stated, I went out to help a patient out of a car and the patient's friend told me I had to get the patient out of the car, I told the friend, the patient had to come out of car on their own. RN#1 stated Patient #26 was, beating on a man in the back seat of the car when I arrived, and the patient was saying over and over 'I don ' t want to be here, and why did you bring me here? RN#1 also stated, the patient was coaxed out of the car and was in the wheelchair and when I unlocked the brakes the patient rushed at me and tried to tackle me. The patient then ran to the north side of the hospital where the male friend caught her and they fought on the ground. I went and called security and...police department. We put her back in wheelchair and almost got inside the ED when patient jumped up and slapped me on the face. The patient's male friend restrained the patient again, and they struggled outside the ED. RN#1 stated, I explained that the patient had a right to a medical examination, but that the patient would have to come into the ED. I told the patient and family that the patient could come into the ED and be seen, or they could take the patient home. RN#1 stated the patient was never told to go to another facility, and confirmed the patient was never examined by anyone at Hospital #1. RN#1 stated the ED physician was never aware the patient had presented to the ED. RN #1 confirmed the local police arrived and told the patient and family, the patient could calm down and be seen, leave or be arrested, and they decided to leave. RN#1 stated the patient was not given any treatment and the patient was not asked to sign a leaving Against Medical Advise (AMA) release. The hospital took the following actions: Hospital #1 investigated this incident, and reported the findings of the incident to the Department of Health. Hospital #1's investigation found the ED staff did not follow the Hospital's policies and practices on December 18, 2012. Hospital #1 implemented a plan of correction which included: 1. Counseled staff involved in the incident on EMTALA requirements and management of violent patients. 2. Educated all ED and Labor/Delivery staff at the main hospital and all satellites on EMTALA requirements and management of violent patients. Security officers were also included in the training. All staff were also educated on the facility's Chain of Command Policy and the Violent Patient Policy. 3. An Addendum was added to the ED Log on 12/31/12 that included Patient #26's name. Documentation of staff's attendance and completion of the training was provided to the Surveyor. ED staff interviewed during the compliant investigation confirmed the training had occurred and demonstrated knowledge of EMTALA requirements. Interview with the Market Director of Quality, by telephone, confirmed facility compliance with the EMTALA requirements and other facility policies is being monitored by monthly chart and ED Log reviews, and of all incidents of patients leaving the ED without a Medical Screening Exam are investigated.
Based on review of a facility report, record review, policy review, and interviews, the facility failed to provide an appropriate transfer for one (#26) patient of twenty-six patients reviewed. The findings included: Review of a letter from the facility (Hospital #1), written to the Department of Health (DoH), dated December 21, 2012, revealed the facility, wished to self-report...a potential violation of the Emergency Medical Treatment and Labor Act... Further review of the letter revealed Patient #26 was brought to Hospital #1's satellite facility's Emergency Department (ED) on December 18, 2012, at approximately 1:45 a.m., by family members and friends for complaint of possible drug ingestion and behaving wild Further review of the letter revealed Patient #26, ...slapping her boyfriend...refusing to get out of the car...cursing...belligerent...fighting...head butted RN1 in the stomach...running...cursing RN1 and slapped RN1 in the face...kicked the security officer in the arm... Further review of the letter revealed Patient #26 was placed in a wheelchair and staff attempted to take the patient into the ED with the patient cursing and yelling at the family members. The letter revealed that before staff could transport the patient into the ED, the patient, began cursing RN1 and slapped RN1 in the face...the patient's boyfriend restrained the patient...when the security officer tried to talk to the patient, the patient kicked the security officer in the arm. Further review of the letter revealed, RN1 had called the...Police Department for assistance...When the ...Police Officers arrived they asked RN1 what...wanted them to do with the patient ...RN1 indicated the ED was full and the patient was too violent to be brought into the ED. The letter also stated, The Police Officers advised the patient and those that brought...to the ED that they would have to leave the property or the patient would be arrested. Further review of the letter revealed, The patient's friends placed the patient in the car and transported the patient to (Hospital #2) for treatment. The letter also stated, The patient was admitted ...with diagnosis of...altered mental status...hypokalemia...alcohol poisoning. Further review of the letter revealed Hospital #1, ...failed to follow appropriate transfer procedures when the patient was transported to (hospital #2). Review of the ED log and ED records revealed no documentation of Patient #26 being examined or treated in the ED of Hospital #1. Further review of the ED records revealed no documentation of the patient being transferred from Hospital #1 to Hospital #2 on December 18, 2012. Review of medical record from Hospital #2, revealed Patient #26 presented on December 18, 2012, at 2:35 a.m. with complaint of Altered Mental Status. Review of the ED Triage Notes from Hospital #2, revealed, pt (patient) was brought in by family ...was given unknown drugs, was taken to (Hospital #1) and they wouldn't take...so...came here. Pt is combative, altered. Pt immediately brought back to room...had to restrain pt for safety... Review of the physician's admitting history and physical from Hospital #2, dated December 18, 2012, revealed , ...took some unknown substances which rendered...confused and agitated ...had to be physically and chemically restrained...alcohol level 304 (toxic above 400). Further review of the history and physical revealed, admit to ICU (Intensive Care Unit) with diagnosis of: Altered Mental Status, Alcohol Intoxication, Unknown Drug Consumption, Hypokalemia, and Dehydration. Review of RN#1's written statement dated December 18, 2012, revealed the nurse went outside the ED on December 18, 2012, to assist a patient out of a car. Further review of RN #1's statement revealed, ...is slapping boyfriend and refuses to get out of car...I informed them I would not get...out of the vehicle and...would need to exit on ...own. The statement also revealed, ...charged out of the wheelchair and head butted me in the stomach...then took off running toward the north side of the hospital...boyfriend chased...tripped and fell ...I noticed abrasions to left knee...attempted to approach...again placed...in the wheelchair...we got up ramp...almost to ER (emergency room ) door when...began cursing and yelling at the two women who transported...here...then slapped me across the face...then was pulled out of wheelchair by...boyfriend onto the ground... Further review of the statement revealed RN#1 called the local police department (PD) and when the police arrive they find, the boyfriend has the pt in a headlock because...is still yelling and cussing at everyone and striking out at the security guard... Further review of the written statement revealed the police, told them to leave the property or ...would be arrested...I informed PD that...was too dangerous to bring back into the ER because we are completely full and the...is too violent... Review of facility policy titled, EMTALA-Definitions and General Requirement effective date September 1, 2012, revealed, ...provide for an appropriate transfer for the individual... Review of facility policy titled, Emergency Department-Combative or Difficult to Manage Patient, reviewed date October 2011, revealed, Patients who are difficult to manage, due to alcohol, drugs, or emotional problems, will be treated with care and dignity in a safe and secure environment. Staff are trained on how to care for and interact with combative or difficult patients ... Interview with Security Officer #1 (SO#1), on January 22, 2013, at 1:05 pm, in the Administration Conference Room, revealed the officer recalled the incident involving Patient #26 on December 18, 2012. Interview revealed SO#1 was called to the ED to meet RN #1 in the ED Lobby. SO#1 stated there was loud arguing outside the ED, and the officer went outside and saw RN #1 and Patient #26 arguing. The security officer stated RN#1 and family tried to calm the patient, but the patient became irate and at one time a male friend or family member was physically restraining the patient. The security officer stated the patient kicked the officer in the right arm and slapped RN#1 in the face, and was very out of control. The security officer stated the local police arrived and told the patient to leave. The security officer stated the patient left in a car with the family and/or friends. The security officer confirmed the patient never entered the ED. Interview with the ED Director, on January 22, 2013, at 2:15 p.m., in the Administration Conference Room of Hospital #1's satellite facility, revealed hospital policy required Patient #26 be brought into the ED and provided a Medical Screening Examination, stabilizing treatment, and an appropriate transfer to another facility if needed. Further interview with the ED Director confirmed the ED staff did not follow facility policies, in regard to Patient #26's treatment on December 18, 2012. Interview, on January 22, 2013, at 3:00 p.m. in the ED of Hospital #1's satellite facility, with MD#1, the physician working the ED of Hospital #1, when Patient #26 presented on December 18, 2012, revealed MD#1 did not see or examine the patient. Interview with RN#2, by telephone, on January 24, 2013, at 11:15 a.m., revealed this nurse went out to assist RN#1 with transporting Patient #26 into the ED. RN#2 stated the patient did not want to come inside the ED and was resisting verbally and physically. RN#2 stated the patient fought with family and staff. RN#2 stated the patient appeared manic and paranoid. RN #2 stated he saw the patient head butt RN#1 in the stomach, and later slap RN#1 in the face. RN#2 stated he saw the patient also kick the security officer in the chest area. RN#2 stated the patient was being restrained outside the ED by a male friend when the local police arrived. RN#2 stated the police told the patient to, calm down and be seen, be arrested, or leave. RN#2 stated the patient and family/friends got in their car and left. RN#2 confirmed the patient was not transferred to another facility. Interview with RN#1, by telephone, on January 24, 2013, at 3:20 p.m. revealed the nurse remembered the incident with Patient #26 on December 18, 2012. RN #1 stated, I went out to help a patient out of a car and the patient's friend told me I had to get the patient out of the car, I told the friend, the patient had to come out of car on their own. RN#1 stated Patient #26 was, beating on a man in the back seat of the car when I arrived, and the patient was saying over and over 'I don ' t want to be here, and why did you bring me here? RN#1 also stated, the patient was coaxed out of the car and was in the wheelchair and when I unlocked the brakes the patient rushed at me and tried to tackle me. The patient then ran to the north side of the hospital where the male friend caught her and they fought on the ground. I went and called security and ...police department. We put her back in wheelchair and almost got inside the ED when patient jumped up and slapped me on the face. The patient's male friend restrained the patient again, and they struggled outside the ED. RN#1 stated, I explained that the patient had a right to a medical examination, but that the patient would have to come into the ED. I told the patient and family that the patient could come into the ED and be seen, or they could take the patient home. RN#1 stated the patient was never told to go to another facility, and confirmed the patient was never examined by anyone at Hospital #1. RN#1 stated the ED physician was never aware the patient had presented to the ED. RN #1 confirmed the local police arrived and told the patient and family, the patient could calm down and be seen, leave or be arrested, and they decided to leave. RN#1 stated the patient was not transferred to another facility, and was not told to go to another facility. The hospital took the following actions: Hospital #1 investigated this incident, and reported the findings of the incident to the Department of Health. Hospital #1's investigation found the ED staff did not follow the Hospital's policies and practices on December 18, 2012. Hospital #1 implemented a plan of correction which included: 1. Counseled staff involved in the incident on EMTALA requirements and management of violent patients. 2. Educated all ED and Labor/Delivery staff at the main hospital and all satellites on EMTALA requirements and management of violent patients. Security officers were also included in the training. All staff were also educated on the facility's Chain of Command Policy and the Violent Patient Policy. 3. An Addendum was added to the ED Log on 12/31/12 that included Patient #26's name. Documentation of staff's attendance and completion of the training was provided to the Surveyor. ED staff interviewed during the compliant investigation confirmed the training had occurred and demonstrated knowledge of EMTALA requirements. Interview with the Market Director of Quality, by telephone, confirmed facility compliance with the EMTALA requirements and other facility policies is being monitored by monthly chart and ED Log reviews, and of all incidents of patients leaving the ED without a Medical Screening Exam are investigated.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review, facility policy review, and interview, the facility failed to ensure a greivance was addressed in a timely manner for one patient (#15) of fifteen patients reviewed. The findings included: Medical record review revealed patient #15 was admitted to the facility on on [DATE], with diagnoses to include Psychotic Disorder Not Otherwise Specified and Depressive Disorder Not Otherwise Specified. Medical record review of the Admit Physician Medication Reconciliation Order (home medications on admit), dated February 16, 2012, at 12:53 a.m., revealed the patient was admitted to the facility on on the following medications: Prozac (used to treat depression) 20 milligrams at bedtime and Naltrexone (used to treat alcohol abuse) 25 milligrams at bedtime, and these medications were continued by the admitting physician. Continued review of the patient's Physician's Order, dated February 17, 2012, at 9:18 a.m., revealed Lithium 300 milligrams twice daily was added for mood disorder and the Naltrexone was increased to 50 milligrams at bedtime. Medical record review of the Social Services Contact Note, dated February 18, 2012, at 9:00 a.m., revealed the social worker (named) met individually with the patient to discuss treatment goals and plans to deal with anger. No other notation by the social worker. Medical record review of the Physician's Progress Note, dated, February 21, 2012, at 9:45 a.m., revealed the patient was very irritable, more easily angered than upon admission, tearful, more agitated, and experiencing anxiety. Continued review revealed the patient ...is responding opposite to all meds... Medical record review of the Physician's Order, dated February 21, 2012, at 10:45 a.m., revealed the Lithium, Prozac, and Naltrexone were discontinued. Medical record review of the Physician's Progress Note, dated February 22, 2012, at 10:50 a.m., revealed ...had a family session yesterday which had to be ended early because (patient) made threats to the social worker...angry and disrespectful to mother...family session had to be stopped for safety concerns...talked to reviewer (insurance) who didn't feel (patient) needed inpatient ...it was explained that with medications she is like a ticking time bomb with no warning of emotional stability. Discussed stopping medications with her recent behavior...after all meds stopped (patient) reports less intense today...more somber...discussed not starting meds and trial of partial hospital program (day treatment) without meds...more of a home environment... Medical record review revealed patient was discharged on no medications on February 22, 2012. Continued review revealed the patient was admitted to the partial hospital program on February 23, 2012. Interview in the conference room with the Utilization Review (UR) Manager on October 10, 2012, at 10:35 a.m., revealed the UR Manager had contacted the patient's insurance company on February 16, 2012, for pre-certification for inpatient hospitalization and was approved for one day. Continued interview revealed the continued stay review was conducted on February 17, 2012, and further inpatient stay was denied. Continued interview revealed there was no documentation of the review of February 17, 2012. Continued interview revealed the case was sent for a doctor (facility) to doctor (insurance) review. Continued interview revealed the closed chart had been sent to the insurance company after the insurance company denied payment for continued stay through February 22, 2012. Continued interview revealed the insurance company had not yet responded. Continued interview revealed the UR manager would have notified the patient's social worker the patient had not been approved for further days. Interview in the conference room with the Director of Social Services on October 10, 2012, at 10:40 a.m., confirmed the social worker was to notify the patient (or family of a minor child) the insurance company had denied further inpatient coverage; the case was sent for physician to physician review; the patient would be responsible for the hospital bill if the insurance company did not cover the stay; and the physician recommended further treatment. Continued interview confirmed there was no documentation the social worker had informed the patient (or family of a minor child) of the denial of insurance benefits for the inpatient stay beyond February 17, 2012. Interview in the conference room with the Director of Social Services on October 10, 2012, at 10:40 a.m., confirmed the facility was notified in writing on April 9, 2012 the family had complained to the insurance company regarding being very upset by the treatment the patient received. The mother complained not seeing the social worker for five days, the patient being dirty, and being billed for the deductable for the entire stay. The mother reported being told by a social worker the facility had not filled out paperwork for authorization and the social worker lied and said the authorization had been gotten when insurance said it had not. Mother said the state had been notified and mother felt the patient's rights had been violated. Continued interview revealed the facility investigated the complaint and the patient was only charged for one day and any days not covered were not billed. Continued interview revealed the patient bill was adjusted after it became apparent the denial was not proceeding and only the deductable for the one day was charged. Continued interview confirmed the facility responded in writing to the patient's mother's complaint on May 7, 2012, (29 days after receipt of the complaint). Review of the facility's document Patient Rights and Responsibility, revealed ...13. The patient has the right to be informed of the cost of his/her care including an itemized accounting of the bill, if requested, and to appeal any funding decisions regarding treatment, care, or services...14. The patient has the right to initiate the hospital's mechanism for the review and resolution of patient complaint/grievance, conflicts, and ethical issues... Interview in the conference room on October 10, 2012, at 12:10 p.m., with the Director of Clinical Services and the Director of Regulatory Compliance confirmed the patient's right had been violated related to notification of denial of payment by the insurance company. C/O #
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review, facility policy review, and interview, the facility failed to ensure a greivance was addressed in a timely manner for one patient (#15) of fifteen patients reviewed. The findings included: Medical record review revealed patient #15 was admitted to the facility on on [DATE], with diagnoses to include Psychotic Disorder Not Otherwise Specified and Depressive Disorder Not Otherwise Specified. Medical record review of the Admit Physician Medication Reconciliation Order (home medications on admit), dated February 16, 2012, at 12:53 a.m., revealed the patient was admitted to the facility on on the following medications: Prozac (used to treat depression) 20 milligrams at bedtime and Naltrexone (used to treat alcohol abuse) 25 milligrams at bedtime, and these medications were continued by the admitting physician. Continued review of the patient a Physician's Order, dated February 17, 2012, at 9:18 a.m., revealed Lithium 300 milligrams twice daily was added for mood disorder and the Naltrexone was increased to 50 milligrams at bedtime. Medical record review of the Social Services Contact Note, dated February 18, 2012, at 9:00 a.m., revealed the social worker (named) met individually with the patient to discuss treatment goals and plans to deal with anger. No other notation by the social worker. Medical record review of the Physician's Progress Note, dated, February 21, 2012, at 9:45 a.m., revealed the patient was very irritable, more easily angered than upon admission, tearful, more agitated, and experiencing anxiety. Continued review revealed the patient ...is responding opposite to all meds... Medical record review of the Physician's Order, dated February 21, 2012, at 10:45 a.m., revealed the Lithium, Prozac, and Naltrexone were discontinued. Medical record review of the Physician's Progress Note, dated February 22, 2012, at 10:50 a.m., revealed ...had a family session yesterday which had to be ended early because (patient) made threats to the social worker...angry and disrespectful to mother...family session had to be stopped for safety concerns...talked to reviewer (insurance) who didn't feel (patient) needed inpatient ...it was explained that with medications she is like a ticking time bomb with no warning of emotional stability. Discussed stopping medications with her recent behavior...after all meds stopped (patient) reports less intense today...more somber...discussed not starting meds and trial of partial hospital program (day treatment) without meds...more of a home environment... Medical record review revealed patient was discharged on no medications on February 22, 2012. Continued review revealed the patient was admitted to the partial hospital program on February 23, 2012. Interview in the conference room with the Utilization Review (UR) Manager on October 10, 2012, at 10:35 a.m., revealed the UR Manager had contacted the patient's insurance company on February 16, 2012, for pre-certification for inpatient hospitalization and was approved for one day. Continued interview revealed the continued stay review was conducted on February 17, 2012, and further inpatient stay was denied. Continued interview revealed there was no documentation of the review of February 17, 2012. Continued interview revealed the case was sent for a doctor (facility) to doctor (insurance) review. Continued interview revealed the closed chart had been sent to the insurance company after the insurance company denied payment for continued stay through February 22, 2012. Continued interview revealed the insurance company had not yet responded. Continued interview revealed the UR manager would have notified the patient's social worker the patient had not been approved for further days. Interview in the conference room with the Director of Social Services on October 10, 2012, at 10:40 a.m., confirmed the social worker was to notify the patient (or family of a minor child) the insurance company had denied further inpatient coverage; the case was sent for physician to physician review; the patient would be responsible for the hospital bill if the insurance company did not cover the stay; and the physician recommended further treatment. Continued interview confirmed there was no documentation the social worker had informed the patient (or family of a minor child) of the denial of insurance benefits for the inpatient stay beyond February 17, 2012. Interview in the conference room with the Director of Social Services on October 10, 2012, at 10:40 a.m., confirmed the facility was notified in writing on April 9, 2012 the family had complained to the insurance company regarding being very upset by the treatment the patient received. The mother complained not seeing the social worker for five days, the patient being dirty, and being billed for the deductable for the entire stay. The mother reported being told by a social worker the facility had not filled out paperwork for authorization and the social worker lied and said the authorization had been gotten when insurance said it had not. Mother said the state had been notified and mother felt the patient's rights had been violated. Continued interview revealed the facility investigated the complaint and the patient was only charged for one day and any days not covered were not billed. Continued interview revealed the patient bill was adjusted after it became apparent the denial was not proceeding and only the deductable for the one day was charged. Continued interview confirmed the facility responded in writing to the patient's mother's complaint on May 7, 2012, (29 days after receipt of the complaint). Review of the facility policy Patient Grievance and Customer Complaint Management, policy: RI-POL/PRO-2.016.002, dated as revised May 2010, revealed ...to establish a process for timely referral, prompt review, investigation and resolution of patient grievances or complaints...upon receipt of a grievance, the Risk Manager with the assistance from the department manager should review, investigate and resolve with the patient and/or representative within seven days...if the grievance is not resolved or if the investigation is not or will not be completed within seven days, the complainant should be informed the facility is working to resolve the grievance and that the facility will follow-up with a written response within 30 days... Interview in the conference room on October 10, 2012, at 12:10 p.m., with the Director of Clinical Services and the Director of Regulatory Compliance confirmed the patient's right had been violated related to the facility policy to respond to a grievance and the facility policy had not been followed. C/O #
Based on observation and interview, the facility failed to ensure the contract services staff for disposal of hazardous waste utilized proper hand hygiene in one (Intensive Care Unit) of two patient care areas observed. The findings included: Observation with the Clinical Manager and Chief Nursing Officer in the Intensive Care Unit on October 8, 2012, at 12:10 p.m., revealed an employee of the contract service for disposal of hazardous waste in the Intensive Care Unit walking about with a full sharps container (device for disposal of used syringes); entered room #9, occupied by a patient, with gloved hands and the full sharps container; removed the sharps container in the room; replaced a new sharps container in the bracket; without removing the gloves and washing the hands, exited the room; entered room #8, occupied by a patient, without removing the gloves or washing the hands and carrying two full sharps containers; removed the sharps container in the room; replaced a new sharps container in the bracket; without removing the gloves and washing the hands, exited the room carrying three full sharps containers. Interview with the employee of the contract service for disposal of hazardous waste in the Intensive Care Unit on October 8, 2012, at 12:10 p.m., confirmed the hands were never washed or sanitized and the gloves were never removed between entering the different rooms. Interview with the Clinical Manager and Chief Nursing Officer in the Intensive Care Unit on October 8, 2012, at 12:10 p.m., confirmed the full sharps containers were soiled; the soiled sharps containers were not to go from room to room; the hands were to washed or sanitized before entering a patient room; gloves are only to be utilized in the patient room then discarded in the patient room; and the hands were to be washed or sanitized prior to exiting the room. C/O #
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