HospitalInspections.org

Based on the scope and severity of the deficiency related to nursing services, the facility failed to substantially comply with this condition.

See Tag A-0398

Based on medical record review, interviews, and document review, it was determined the facility staff failed to follow the facility's policies and procedures related to pediatric patient monitoring for one (1) pediatric patient.

Based on medical record review, interviews, and document review, it was determined the facility staff failed to follow the facility's policies and procedures related to pediatric patient monitoring for one (1) pediatric patient.

Findings:

A surveyor review of the facility's policy titled "PICU Nursing Unit Norms for Patient Care" states in part: "... Monitoring: ... Patients remain on continuous monitor: pulse ox, HR, RR unless otherwise ordered by physician ... Vital signs: Perform and document BP, HR, RR, and O2 saturations every 2H [hour], temp every 4H and more frequently if needed...."

On 5/1/2023 and 5/2/2023, the surveyor reviewed the medical record for Patient #3, a pediatric patient in the PICU.

Flowsheet Data for Patient #3 contained the following documentation: At 10:00 a.m. on 1/1/2023 the SpO2 [obtained by a pulse oximeter and is the measure of oxygen saturation] was documented at 94%. There were no other vital signs documented after 10:00 a.m. until 12:45 p.m., more than two (2) hours later. Patient #3's blood pressure was obtained on 1/1/2023 at 12:00 a.m., 4:00 a.m., 8:56 a.m., and then at 1:11 p.m., which was during the code that started at 12:45 p.m. Patient #3's blood pressure was not documented every two (2) hours as per the facility's policy.

During an interview on 5/2/2023 at 10:04 a.m., SM9 advised that patients' SpO2 is placed on a screen in the treatment room and the nurse's station. Multiple patients can be viewed at once on the screen and viewed in other treatment rooms if necessary. While working with another delicate patient, SM9 and another staff member noticed that Patient #3's heart rate was low. SM9 advised they did not receive an audible alarm for the low heart rate reading. SM9 and and the other staff member responded to Patient #3's room where a cardiologist and sonographer were conducting an echocardiogram. SM9 noticed the patient to be cold and lethargic and the monitor displayed a heart rate of 60. SM9 advised they did not hear any audible alarms sounding, and additionally, the nurse's phone did not alarm as is supposed to occur when the monitor receives a critical reading.

During an interview on 5/2/2023 at 10:44 a.m., SM12, who was in the room during the echocardiogram, stated that SM25 and the sonographer performed the echocardiogram on 1/1/2023. SM12 stated that the echocardiogram images looked the same as on the previous study the prior day. SM12 stated during the last image, Patient #3's heart rate dropped and SM12 advised SM24 and SM25 to move out of the way and call the nurse so they could work on the patient. SM12 stated that the only thing that SM12 noticed after the fact was that the pulse oximeter had not been picking up a reading for a few hours prior to the event. SM12 stated that the heart rate was stable until the last echocardiogram image. SM12 stated that SM25 acknowledged that the pulse oximeter was not "picking up" when SM25 initially went into the room, and all persons in the room at that time were aware.

During an interview on 5/2/2023 at 2:30 p.m., SM25 stated that "apparently the pulse ox was not connected."

A review of the facility's policy titled "PICU Nursing Unit Norms for Patient Care" states in part:
... Monitoring:
Ensure the patient is being monitored in the appropriate monitor setting - this should be verified with each handoff.
Patients remain on continuous monitor: pulse ox, HR, RR unless otherwise ordered by physician...

Electrodes and pulse ox probe should be changed daily with bath and pulse-ox should be rotated every four hours and more frequently if needed.

... Vital signs:
Perform and document BP, HR, RR, and O2 saturations every 2H [hour], temp every 4H and more frequently if needed. This requires direct visualization to ensure cuff in proper position, arm not bent, etc.

Closely monitor respiratory status and oxygen saturation with any alteration in oxygen therapy.
Auscultate breath sounds with assessment and PRN ...

Based on medical record review, interviews and document review, it was determined the facility staff failed to report a medication administration error as per facility policy. Specifically, the staff administered two (2) medications via an alternate route other than what was ordered by the physician and failed to submit a safety event report once discovered.

The findings included:

The surveyor conducted medical record reviews on 5/1/23 and 5/3/23. Patient #2's review revealed the following:

Patient #2 presented on 1/24/23 with "acute on chronic respiratory failure requiring increased respiratory support...". The patient received the following orders for albuterol (2.5MG/3ML) 0.083% nebulizer solution 2.5mg (albuterol is a medication used to dilate bronchi and bronchioles in the airway, to reduce airway resistance. https://www.ncbi.nlm.nih.gov/books. Retrieved 5/4/23) to be given via a nebulization (changing the medication from a liquid to a fine spray so the patient can breath it in. https://dictionary.cambridge.org/dictionary/english/nebulize. Retrieved 5/4/23):
1/24/23 at 10:54 a.m. - albuterol every 2 hours as needed (discontinued on 1/24/23 at 2:51 p.m.)
1/24/23 at 2:51 p.m. - albuterol every 4 hours as needed (discontinued on 1/30/23 at 9:20)
1/30/23 at 9:20 a.m. - albuterol every 6 hours as needed (discontinued on 2/1/23 at 2:02 p.m., patient discharged)

Patient #2 received the following orders for 3% hypertonic saline (HTS) to be given via nebulizaton:
1/24/23 at 10:54 - 3% HTS ONCE via nebulization - after administration, order completed
1/24/23 at 2:50 p.m. - 3% HTS via nebulization three times a day (discontinued 1/24/23 at 5:06 p.m.)
1/24/23 at 5:06 p.m. - 3% HTS via nebulization every 6 hours (discontinued 1/30/23 at 11:35 a.m.)
1/30/23 at 11:35 a.m. - 3% HTS via nebulization 4 times per day (discontinued on 2/1/23 at 2:02, patient discharged)

The documentation reveals that Staff Member (SM) #33 administered a dose of albuterol 2.5mg and 3% NTS via nebulization to Patient #2 on 1/24/23 at 11:08 a.m.

An interview was conducted with SM #32 on 5/3/23 at 12:29 p.m. SM #32 investigated a concern raised by Patient #2's parent on 2/1/23 after the parent refused to allow SM #33 to provide respiratory care to the patient. SM #32 recalled the following: "I was the admin [administrator] on call that week... the team leader for that day informed me that the [parent] was refusing to allow [SM #33] back into to the room... I grabbed [SM #15] so we could go talk to the [parent]... I saw [SM #33] on the way and did a quick chart review, [SM #33] replied 'I just think [parent] doesn't like me'... the incident had occurred a week prior... [SM #33] lavaged the [patient] instead of nebulizing... I asked [SM #33] if there was an order to lavage, [SM #33] replied 'absolutely'... I reviewed the chart and it was documented that [SM #33] nebulized the patient, not lavaged... I went to talk to the [parent], but they had been discharged... I did a more in depth chart review, interviewed [SM #33] who questioned 'why am I asking' and then said 'there was a provider in the room, I don't know who it was, gave verbal permission'... I spoke to the providers involved and none of them said they gave permission and it was determined that there was no provider in the room... [SM #33] practiced outside of [SM #33's] scope and was terminated...". SM #32 acknowledged that a safety event report had not been submitted for this incident. SM #32 said, "I meant to put one in, but had so much going on I never did... I can still do it and will".

A facility policy titled, Medication Administration, was reviewed and reads, in part: "Policy A. The 6 Rights of Medication Administration are followed when administering any medication... E. Drug routes, dosage forms, dosages and frequency are changed only by provider order... M. If a medication error, adverse drug event, or incompatibility occurs, the provider is notified and submission of a Safety Event Report is encouraged...".

The concern was shared with SM #4 in the afternoon of 5/3/23 and again with multiple SMs at the exit conference on 5/3/23.