HospitalInspections.org

Based on review of hospital policies/procedures, Electronic Medical Records (EMR), and interviews, it was determined that the nurse executive failed to require nursing staff to:

1. monitor vital signs as required by hospital policy ( for patient #2 and #3). Failure to monitor the patient's vital signs poses a potential risk to the patient's health and safety when the nurse does not obtain vital signs to ensure that the patient's condition is stable.

2. provide oronasopharyngeal suctioning to patient #2. This deficient practice jeopardizes the patient's health and safety when nursing interventions are not implemented to protect the patient's airway.

3. obtain the urinalysis ordered by the provider (for patient #3). This deficient practice poses the potential risk to health and safety of the patient when the physician does not have test results to fully treat the patient's medical condition.

Findings Include:

#1

The "Emergency Department Triage" policy reviewed 07/2018, requires: "...The Triage or Primary RN assessment includes but is not limited to: "...Vital signs as per policy...ESI Level 2: When identified, the triage process stops, the patient is taken directly to a bed an immediate physician intervention is requested...."

The "Emergency department vital signs and pain reassessment" policy reviewed 10/2018, requires the following: "...Pediatric patients require a blood pressure to be attempted at least once and repeated when requested or if their clinical condition warrants it...Appropriate vital signs are recorded every 60 minutes while the patient is in the ED for ESI level 2 and 3 or more frequently as indicated...Vital signs are recorded every 15 minutes x 3 to determine trends if the initial readings were abnormal from the individual patient's typical baseline...Abnormal vital signs are usually: Temperature above 101 degrees orally or 102 degrees rectally...Pediatric Patient: Age 3 mo - 2 yr: Heart rate greater than 160...Respirations...greater than 40 in pediatric patients...."

PATIENT #2

Patient #2's first set of vital signs included a rectal temperature of 102.0, respiratory rate of 48, heart rate of 162 and did not contain a blood pressure reading. The vital signs were not monitored every 15 minutes x 3 to establish a trend as required by policy.

Employee #13 confirmed in an interview conducted on 8/21/2019 that nursing staff did not document vital signs per hospital policy. The vital signs were not documented every 15 minutes to establish a trend, and the blood pressure was not attempted or recorded.

PATIENT #3

The "Emergency department vital signs and pain reassessment" policy reviewed 10/2018, requires the following: "...Waiting room patients: appropriate vital signs are recorded every 60 minutes for (ESI) level 2 and 3 after triage while waiting for ED room placement...Appropriate vital signs are recorded every 60 minutes while the patient is in the ED for ESI level 2 and 3 or more frequently as indicated...."

Patient #3 was triaged at 08:58. The medical record did not contain vital signs from 08:59 through 12:59.

Employee #13 confirmed in an interview conducted on 8/21/2019, that nursing staff did not document the patient's vital signs every 60 minutes as required by hospital policy from 08:59 through 12:59.

#2

The "Registered Nurse, Job Description" revised 03/2019, requires the following: "...Identifies, initiates and coordinates therapeutic interventions consistent with the legislated scope of practice and level of competence...Implements prescribed interventions (e.g. diagnostic tests, medications) and performs independent nursing interventions...Documents complete accurate and relevant data for every patient according to...policies and guidelines...."

The "Lippincott Nursing Procedures, Oronasopharyngeal suction" document, 2019, requires the following: "...Used to maintain a patent airway, this procedure helps the patient who can't clear the airway effectively with coughing and expectoration...Verify the practitioner's order for oronpharyngeal suctioning if you facility requires one...."

Provider #10 documented the following: "...RR: 48...Profuse, thick, clear rhinorrhea present...given transient desat to 88% here, report of desat to 84% at home...."

Employee #13 confirmed in an interview conducted on 8/21/2019 that a physician's order was not required for nursing staff to perform oronasopharyngeal suctioning. The previous method of collecting a sample to test for RSV required nursing staff to suction the patient to obtain the sample, treating the patient while obtaining the sample for the lab. Employee #13 confirmed that the "new method" of collecting specimens to test for RSV utilizes a swab and does not require nursing staff to suction the patient to collect the sample for the lab, resulting in the nurses not maintaining competency in pediatric suctioning.

#3

The "Registered Nurse, Job Description" revised 03/2019, requires: "...Identifies, initiates and coordinates therapeutic interventions consistent with the legislated scope of practice and level of competence...Implements prescribed interventions (e.g. diagnostic tests, medications) and performs independent nursing interventions...Documents complete accurate and relevant data for every patient according to...policies and guidelines...."

Provider #8 ordered a "STAT Urinalysis/Microscopic Examination" on 08/02/2019 at 12:08.

Nursing staff documented the following at 13:48: "...assisted pt to bathroom LR completed...."

The medical record did not contain the results of the urinalysis (UA).

Employee #13 confirmed in an interview conducted on 8/21/2019, the medical record did not contain documentation that nursing staff obtained the urinalysis or the results of the urinalysis ordered by the physician.