Based on interview and record review the facility failed to ensure Patient 1 received a proper diagnosis and treatment.
Based on interview and record review the facility failed to ensure Patient 1 received a proper diagnosis and treatment. This failure resulted in the delay in surgery for Patient 1.
Findings:
a). During a review of the medical record for Patient 1 on January 3, 2018 at 1:56 PM the admission record indicated Patient 1 was admitted on [DATE] and discharged on [DATE] with a diagnosis of acute urinary tract infection (an infection of the urinary tract).
During a review of the Nursing assessment dated [DATE] at 5:53 PM, indicated: "Patient 1 complained of vomiting and low abdominal pain for two days. Patient is a seven day post partum (the period following birth).
During a review of the Emergency Department Physician Notes dated August 14, 2017 at 6:03 PM and written by the Emergency Department Physician Assistant (ER PA 1) indicated: "The twenty-eight year old female presented with vomiting x 2 days. Patient 1 claimed approximately ten episodes and denied diarrhea (loose stools) or dysuria (painful or difficult urinating). Patient 1 was post partum (the period following birth) x 7 days.
During the review of the medical record for Patient 1 was conducted with the Quality Coordinator Registered Nurse (QCRN) on January 8, 2018 at 8:40 AM indicated there was no documentation that the Emergency Department Physician (ER MD 1) saw the patient on August 14, 2017.
During a concurrent interview with the QCRN confirmed that there was no documentation that the ER MD 1 saw patient on August 14, 2017.
b). During a review of the medical record for Patient 1 on January 3, 2018 at 1:57 PM the admission record indicated Patient 1 was admitted on [DATE] with a diagnosis of small bowel obstruction (a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of the digestion. The signs and symptoms include abdominal pain and vomiting. In mechanical obstruction is the cause of about 5 to fifteen percent of cases with severe abdominal pain of sudden onset requiring admission to hospital) and passed away on August 17, 2017.
During a review of the Emergency Department Physician Notes dated August 15, 2017 at 9:50 AM and written by the Emergency Department Physician Assistant (ED PA 2) indicated: "Twenty-eight year old female complained of lower back pain and abdomen pain for two days. Patient 1 reported her back pain was in the center, and denied injury. Pain was worse with movement and touch. Abdomen pain in the left lower quadrant that began at 01:00 this AM. History of a caesarean section that was done eight days ago and also had history of previous caesarean sections (a surgical procedure in which one or more incisions are made through a mothers abdomen and uterus to deliver a baby). Patient 1 reported that this pain was different. Patient 1 was seen in the emergency department yesterday (August 14, 2017) with the same issue. Patient also reported heavy vaginal bleeding..."
During a review of the CT of the abdomen and pelvis without a contrast (x-ray tests that produce cross-sectional images of the body using x-rays and a computer) dated August 15, 2017 at 10:50 AM indicated: "Distal small bowel obstruction (a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of the digestion. The signs and symptoms include abdominal pain and vomiting. In mechanical obstruction is the cause of about 5 to fifteen percent of cases with severe abdominal pain of sudden onset requiring admission to the hospital).
During a review of the Emergency Department Physician Notes dated August 15, 2017 at 3:50 PM and written by the Emergency Department Physician (ED MD 2) indicated: ..."Care was transitioned to the Obstetrics and Gynecology (a physician that delivers babies and specializes in treating diseases of the female reproductive organs) (OBGYN MD 1) at 1:00 PM. At 3:30 PM her heart rate had increased to 180's. Her blood pressure had dropped in the high 60's. Her pulse was palpable but rapid. There was approximately one liter of nasogastric tube (insertion of a plastic tube through the nose, past the throat and down the stomach) output which was dark in color and tested positive for hemacult (abnormal bleeding is occurring in the digestive tract). The OBGYN MD 1 was contacted from the emergency department and updated her about the patient's condition, expressing that the patient was critically ill and would require intensive care unit care. The OBGYN MD 1 stated she was currently at another hospital . The OBGYN MD 1 arrived at this hospital's emergency department at around 5:00 PM as well as Physician (MD 1) . The MD 1 called the (On Call Surgeon MD1) to request emergent surgical consultation for possible ischemic bowel (narrowing of the arteries that supply blood and oxygen to the intestines. As the narrowing worsens, the arteries become unable to supply enough oxygen to meet demand. This can cause abdominal pain and damage to the intestines). The ED MD 2 went off shift at 6:00 PM. At that time patient had not yet been taken to the operating room."
During a review of the Nursing progress notes dated August 15, 2017 at 7:15 PM written by the Intensive Care Unit Registered Nurse (ICU RN 1) indicated: "Received patient from the emergency department. Patient 1 was oriented but drowsy. Patient 1 was cool and clammy. Lung sounds were clear. Patient 1 was complaining of pain to lower back and abdomen was distended. Unable to get blood pressure reading. One was in the 70's. Patient was still complaining of pain.."
During a review of the Nursing Progress Note dated August 15, 2017 at 10:35 PM written by the Intensive Care Unit Registered Nurse (ICU RN 2) indicated: "The On Call Surgeon MD 1 was at the bedside, spoke with Patient one's family and discussed surgery to be done..."
During a review of the operative report dated August 18, 2017 at 7:25 PM, written by the On Call Surgeon MD 1 indicated: "Preoperative diagnosis was septic schock (a condition in which the blood pressure falls dangerously and it may occur in patients with serious infections) with small bowel obstruction and the post operative diagnosis were Septic shock with small bowel obstruction, severe ischemia with patchy necrosis of the entire small bowel (restriction of blood supply to the organ and the death of most of the cells in the organ), from just below the ligament of Treitz (a bad smooth muscle extending from the junction of the duodenum and jejunum) to just above the ileocecal valve (a sphincter muscle valve that separates the small intestine and the large intestine), and small bowel obstruction, due to a knuckle of distal ileum (final section of the small intestine) stuck within the superior aspect of the closure of the cesarean section which she had seven days ago..."
During a review of the final autopsy report (a post mortem exam to discover the cause of death) dated August 23, 2017 at 10:30 AM, indicated: "Cause of Death were complications of diffuse small bowel ischemic necrosis (damage to part of the intestine. It is due to a decrease in the blood supply to the area), including acute myocardial infarction
(a heart attack happened when the blood vessels that supply blood to the heart (coronary arteries) are blocked and leaded to heart failure) and multi-organ failure (a progressive dysfunction of two or more organ systems in a critically ill patient)."
During an interview with the Surgeon (S 2) on January 4, 2018 at 2:24 PM, he stated that the Emergency Department Physician Assistant (ER PA 1) should have recommended a (KUB) Kidneys, Ureters, and Bladder (x-ray of the abdomen, providing information about abdominal organs).
During an interview with the On Call Surgeon MD 1 on January 4, 2018 at 3:36 PM, the Emergency Department Physician Assistant (ED PA 2) that saw the patient in the emergency department told me that Patient 1 was stable.
During an interview with the On Call Surgeon MD 1 on January 4, 2018 at 3:37 PM, the On Call Surgeon MD 1 stated, whoever closed the caesarean section is at fault. The Emergency Department Physician Assistant ( ER PA 1) should have called the Obstetrics and Gynecology because patient 1 was a post op caesarean section for seven days.
which is a common complication of a status post C-section.
During an interview with the Physician (MD 1) on January 5, 2017 at 9:34 AM, the MD 1 stated he saw her in the emergency department and her abdomen was distended and was tachycardia (high pulse rate). The Emergency Department Physician Assistant (ER PA 1) should have ordered a KUB (KUB) Kidneys, Ureters, and Bladder (x-ray of the abdomen, providing information about abdominal organs) and Cat scan (x-ray tests that produce cross-sectional images of the body using x-rays and a computer).
During an interview with the Emergency Department Physician (ER MD 1) on January 5, 2018 at 9:59 AM, the ER MD 1 stated he trusted the Emergency Department Physician Assistant (ER PA 1) assessment of Patient 1 and also stated he cannot be everywhere at the same time.
During an interview with the Emergency Department Physician (ED MD 2) on January 5, 2018 at 10:52 AM, the ED MD 2 stated he spoke with the Obstetrics and Gynecology (OBGYN MD1) and I told her the patient was unstable. We should have seen the patient sooner and called a second surgeon and placed Patient on a monitor (monitors the patients heart rate blood pressure, and heart electrical wave activity) sooner. The ED MD 2 also stated they had limited number of monitors and that's why patient was in the emergency department hallway.
During an interview with the Obstetrics and Gynecology (OBGYN MD 2) on January 5, 2018 at 11:38 AM, the OBGYN MD 2 stated that the facility should enforce two surgeons because they only had one surgeon on call.
During an interview with the Chief of Surgery (COS) on January 5, 2018 at 2:45 PM, stated that the physicians should've called any available surgeon and followed the chain of command because she was never notified regarding patient 1. I would have called another available surgeon.
During an interview with the President of Medical Staff (POMS) on January 8, 2018 at 10:29 AM, stated that next time the physicians will have better communication among them and have other opportunities for improvement for example,the time frame for which the consultants should see the patient.
A review of the facility's "Medical Staff Rules and Regulations" dated March 22, 2017 indicated: ..."In the event that the Emergency Department physician requests an in person consultation, the consultant on-call should attend to the patient in the Emergency Department and perform an appropriate consultation. The timeframe of the in-person consultation shall be dependent upon the urgency of the patient's medical condition. In the event that the on-call physician cannot respond because of situations beyond his or her control, the alternate covering physician will be contacted..."