HospitalInspections.org

Based on medical record review and staff interview, it was determined that the facility failed to ensure that every patient is assessed as warranted by changes in the patient's condition, in accordance with the Nurse Practice Act.

Findings include:

Reference: The Nursing Practice Act for the State of New Jersey states: "The practice of nursing as a registered professional nurse RN is defined as diagnosing and treating human responses to actual or potential physical and emotional problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist."

1. On 5/23/19 at 10:29 AM, review of Medical Record #1 revealed the following:

a. The physician's Progress Note, dated 4/8/19 at 11:52 AM stated, "Pt (patient) accidentally shocked today while testing machine, pt is ok, a little apprehensive. ..."

b. Review of the cardiac rhythm strip, dated 4/8/19, indicated the patient received a 100-joule test shock at 10:10 AM.

c. The medical record lacked evidence of a nursing note documenting the incident.

(i) On 5/22/19 at 11:00 AM, Staff #2 confirmed there was no nursing note in Medical Record #1.

d. The medical record lacked evidence of a nursing assessment of Patient #1 immediately following the accidental test shock.

(i) On 5/22/19 at 1:30 PM, Staff #3 confirmed there was no documented assessment of Patient #1 until 11:26 AM, approximately one (1) hour and 16 minutes after the accidental test shock.

Based on medical record review and staff interview, it was determined that nursing care is not provided in accordance with the special needs of the patient.

Findings include:

1. On 5/23/19 at 10:29 AM, review of Medical Record #1 revealed the following:

a. The physician's Progress Note, dated 4/8/19 at 11:52 AM, stated, "Pt (patient) accidentally shocked today while testing machine, pt is ok, a little apprehensive. ..."

(i) Review of the cardiac rhythm strip from the HealthStart XL Defibrillator, dated 4/8/19, indicated the patient received a 100-joule test shock at 10:10 AM.

2. On 5/22/19 at 11:28 AM, Staff #19 indicated that the accidental shock administered to Patient #1 occurred due to a miscommunication between Staff #38, a Registered Nurse (RN), and Staff #39, a Patient Care Secretarial Associate (PCSA),

a. Staff #19 indicated that Patient #1 was experiencing runs of V-Tach (Ventricular Tachycardia-a shockable cardiac rhythm) the night before, and the defibrillator was brought into the patient's room. The patient was connected to the defibrillator pads, and the cables were connected to the defibrillator; however, the defibrillator was turned off.

(i) Staff #19 indicated that Staff #39 asked Staff #38 if the defibrillator needed to be tested, and he/she replied "yes." However, Staff #38 failed to inform Staff #39 that the defibrillator was connected to the patient, prior to delivering the test shock.