Case Study: Initiating Plans of Correction

Introduction:

A Third Eye Health Care Coordination Manager, conducting the daily report, came across an encounter for a change in condition, noting skin discoloration, signaling an end of life.  Eventually, the patient did pass away.  Upon further review of the patient's past medical records, the Care Coordination Manager uncovered several concerns that, if reviewed by the Department of Health, could be seen as deficient practice by the center.

Challenge:

Reviewing the deceased patient’s medical records, the Care Coordination Manager noticed the patient had a central line. Further analysis revealed no orders for care, treatment, or flushing of the central line. Additionally, redness, possibly indicating an early-stage infective process, had been noted, but there was no mention of a doctor being notified. Whether protocols were not in place or not followed for patients with a central line, this is an issue that would raise red flags if the Department of Health reviewed this case.

Solution:

The Third Eye Health Care Coordination Manager presented the facts of the case to the center’s Director of Nursing and Regional Medical Director during a routine metric review. Noting that it could be flagged by the Department of Health for several issues, this became a teaching moment for the center. By catching the issues before any state audits, they were able to create and execute a plan of correction for central line protocols and several other issues identified by the Care Coordination Manager.

Benefit:

Taking the time to review a patient’s complete medical history, while ideal, is a rarity for a Director of Nursing with no shortage of tasks on their plate. Unfortunately, in most cases, the state ends up finding these errors in care. By meticulously reviewing this patient’s record, the Third Eye Health Care Coordination Manager brought several issues to the center’s clinical leadership, pinpointing areas that would raise alarms in any state audit.  While the patient’s death itself was not unusual, by looking back through the complete medical record, areas where protocols were not in place or applied were now identified. With this information, the center proactively expedited a plan of correction, trained its nurses, and put processes in place to prevent future recurrences. This will be especially beneficial if the Department of Health reviews this case; they will see that the building took the initiative to improve the quality of care it provides.

Result:

By immediately creating this correction plan, showing that they have educated the nurses, and that the changes have been put into action, the center is now prepared when the Department of Health arrives. After investigating the deaths, the Director of Nursing will be fully prepared with a well-documented plan of correction, showing what measures have already been put in place to ensure quality improvements and prevent recurrence. By showing diligence in recognizing the issue and already initiating a plan of correction and future prevention, the center may receive a tag for this case, but will be able to prevent an even more severe punishment such as being put in jeopardy by pausing new admissions, inflicting punitive financial damages, and declining CMS star ratings and reimbursements.