HospitalInspections.org

BASED ON record review and interview, the facility registered nurse (RN) failed to supervise and evaluate the nursing care of each patient according to the patient specific needs. Patient #1 did not have a nurse assessment/re-assessment documented for 49 hours from 10/26/2024 to 10/28/2024 while receiving a Cardiac drip for an arrythmia as an Emergency Department (ED) hold patient awaiting a Heart and Vascular Unit (HVU) bed.

FINDINGS

Patient #1 came in with Atrial Fibrillation with Rapid Ventricular Rate (Afib with RVR) and was initiated on a Cardizem Drip in the Emergency Department (ED). Admission orders for the Heart/Vascular Stepdown Unit (HVU) were obtained, but the patient was held in ED awaiting a bed. During the ED hold from 10/26/2024 through 10/28/2024, there were no nurse assessment/re-assessments completed. The patient had bradycardia and Cardizem was stopped. Cardizem was restarted when the heart rate elevated again.

Emergency Patient Record Triage Note noted, "Arrival 10/26/2024 18:01...Triage 18:04...Stated Complaint Afib with RVR...Chief Complaint: Cardiac related...Priority: 2...10/26/2024 22:43 Admit Patient...10/28/2024 12:01 Off Tracker..."

There were 49 hours in between the "10/26/2024 18:35 (6:35 PM) Emergency Department nurse assessment" and the "10/28/2024 1930 (7:30 PM) Initial assessment/Health History" in HVU.

There were 32 hours in between the "10/26/2024 22:43 (10:43 PM) Order Admit Heart/Vascular Stepdown (HVU)" and the "10/28/2024 1930 (7:30 PM) Initial Assessment/Health History" in HVU.

Order: Diltiazem/Cardizem 10/26/2024 21:10 (9:10 PM) 100MG/100 ML Normal Saline (1 mg/mil -milligrams/milliter) Initial rate 5 mg/hour Titrate by 5 mg/hr (milligrams/hour) every 15 minutes ***Maximum rate 15 mg/hr for up to 24 hours Goal: Maintain hr 60 - 100; Hold for SBP (Systolic Blood Pressure) less than or equal to 100 mmHg.

Cardizem Administration was recorded by Personnel #16 on 10/27/2024 at 3:19 AM for all the following "occurred" times:
10/26/2024
21:40 (9:40 PM) Cardizem started at 5 mg/hr with Heart Rate of 137;
2200 (10:00 PM) Heart Rate 101;
2215 (10:15 PM) Cardizem titrated up to 10mg/hr HR 112;
2230 (10:30 PM) Cardizem titrated up to 15 mg/hr HR 112;
10/27/2024
0345 (3:45 AM) Nurse Note: converted to sinus brady 50's Cardizem stopped ...
0400 (4:00 AM) HR 54

There were no meals evidenced with the "10/27/2024 0158 Heart Healthy diet order."

During a telephone interview on 2/11/2025 at 3:59 PM, Personnel #2 and #3 were asked if the investigation had found there were no nurse assessments. Personnel #2 stated, "no. I did not." They were informed there was no nurse assessment documented for > 48 hours and the date/times were given. Personnel #2 stated, "it was 49 hours. It (initial admit assessment) was done on the 6th Floor." They were asked if assessments were required. Personnel #2 stated, "yes. Once they are admitted, they are to be monitored at the admit level. Med Surg is 12 hours and ICU is 8 hours." Personnel #3 stated, "initial nursing assessments are to be completed within 12 hours of the ordered admit." They were asked if the patient was in the ED the whole time until the 10/28/2024 Cath Lab transfer. Personnel #2 stated, "yes, it looks like they were. The patient went to the Cath Lab at noon and then the 6th floor at 1600 (4:00 PM)." They were asked if the 6th floor was HVU. Personnel #2 stated, "yes." They were asked about nurse monitoring on a Cardiac drip. Personnel #3 stated, "we have a titration protocol, but I don't think we have a specific monitoring policy." They were asked what food and fluids the patient received on the Heart Healthy diet. Personnel #2 stated, "I see a 500-milliliter bag of Normal Saline and a Saline lock. I am not seeing meals." They were given the opportunity to provide further evidence if they found it. No further evidence was provided.

From: Personnel #3 Sent: Wednesday, February 12, 2025 8:16 AM
"...I did clarify that we do not have a specific titration policy, the titration is order dependent and vital signs are dependent on titration timing and are reassessed depending on level of care. We also do not have a policy on boarding/holding in the Emergency Department..."

The facility's policy for the ED required every 15-minute vitals and every hour for 4 hours focused reassessments for Priority: Level 2 / Emergent patient care. The HVU required an initial assessment within 12 hours. Re-assessment every 4-hour vitals and every 4-hour re-assessments per the policy.

The Facility's 2024 Plan for the Provision of Care & Services / Assessment / Reassessment Policy required, "The initial assessment is initiated upon admission or initiation of service by a licensed professional. For inpatients, the initial assessment is completed within 12 hours ...Reassessment frequency is defined by each inpatient and outpatient care area based on the usual course of care for the patient population. Reassessment is also undertaken whenever a change in patient condition is identified and at key points in the treatment process including at change of shift, and/or at transition of caregiver or care unit...Frequency of vital signs monitoring; including Modified Early Warning Scoring System (MEWS) is defined by each care area. More frequent vital signs monitoring is required during and after procedures, in relation to specific medications or treatments, and whenever a change in condition is identified...Emergency Department Re-Assessment:
- Prior to a medical screening exam (MSE), a registered nurse initiates evaluation of the patient,
including assessing the patient's vital signs, conducting a focused physical assessment including
pain assessment, assessing general appearance, and collecting pertinent medical history
information. Patients waiting for the initiation of the MSE should have a reassessment performed at
a minimum of...Level 2 / Emergent: Every 15 minutes...Reassessments after initiation of the MSE are performed by RN's according to acuity...Level 2 / Emergent: At least every hour based on clinical presentation for a minimum of 4 hours and more frequently if needed...
HVU (Heart and Vascular Unit) Assessment:
- Initiated upon arrival and at the beginning of each shift
- Completed by RN within 8 hours
- Plan of Care initiated within first 8 hours of admission
- Routine vital signs every 4 hours including blood pressure, pulse, respiration rate, temperature, O2 saturation.
- Daily weights on specific populations: heart failure, renal, dialysis and TPN
- Input and output monitored on all patients and recorded at the end of each shift
- Continuous cardiac monitoring
Re-assessments:
- At a minimum of every 4 hours, focused reassessment."