HospitalInspections.org

Based on medical record review and staff interviews, the hospital failed to provide an environment that a reasonable person would consider to be safe. The hospital failed to provide services consistent with the patient's condition and the results of periodic assessments by the nursing staff. These deficient practices contributed to the deterioration of Patient #1, requiring the transfer of the patient from the 4th floor/Telemetry unit to the intensive care unit where she passed away on 07/29/14.

The findings are:

A. Review of Patient #1's medical record revealed that the patient had been a patient at a local rehabilitation hospital recovering from a right total hip replacement.

She had a significant medical history of the following: a cerebrovascular accident, osteoarthritis, a myocardial infarction 10 years ago, cardiac catheterization, hypertension, renal artery stenosis, gastroesophageal reflux disease, right total shoulder replacement, back surgery with a fusion of the lumbar 4-5, two knee replacements, and an intramuscular rodding of the left hip.

While at the rehabilitation hospital, she had relentless belching and poor oral intake of fluids and nutrition. At one point during the rehabilitation hospital stay, Patient #1 required bowel disimpaction (manual removal of hard stool). A PICC (peripherally inserted central catheter) was placed on 07/21/14.

Patient #1 was transferred to the hospital on 07/25/14 with a markedly high white blood count and hypotension (low blood pressure).

1. The following was a time line of events that occurred during Patient #1's hospitalization from 07/25/14 - 07/29/14:

a. Patient Care Notes and Clinical Documentation Reports dated 07/25/14 indicated the following:

1. 1530 (3:30 pm) - Patient #1 was transferred from the local rehabilitation hospital to 4th floor/Telemetry with bacteremia (infection in the blood), urinary tract infection (UTI), status post (s/p) right total hip replacement, atrial fibrillation, and an elevated white blood count (WBC) of 31,000; with vital signs (VS) of temperature (temp) 98.5 and blood pressure (bp) 118/69. The last bowel movement (BM) was documented on 07/24/14. Patient was started on the medications vancomycin and Rocephin (intravenous antibiotics) upon admission.

2. 1830 (6:30 pm) - [Patient #1] Reports pain to the left hip 9 out of 10

3. 1851 (6:51 pm) - RN (registered nurse) calls MD for pain medication

4. 1857 (6:57 pm) - Pain medication given, patient temp 102.5 given ice packs

5. 2000 (8:00 pm) - VS: temp 99.0 AX (axillary), bp 145/50

6. 2011 (8:11 pm) - VS: temp 98.5 AX, bp 118/69

7. 2039 (8:39 pm) - temp 100

8. 2131 (9:31 pm) - bladder scanned; 418 cc of urine present

9. 2345 (11:45 pm) - 16 French Foley catheter (indwelling urinary catheter) inserted - urine output of 150 cc


B. Patient Care Notes and Clinical Documentation Reports dated 07/26/14 indicated the following:

1. 0000 (12:00 am) - VS: temp 98.2 AX, bp 77/36; MEWSS 2. (During Patient #1's hospital stay the Modified Early Warning Scoring System (MEWSS) was used by the nursing staff to assist in identifying "at risk" patients who may display physical signs of deterioration before an adverse event occurs.)

2. 0400 (4:00 am) - VS: temp 98.3 AX, bp 89/45, MEWSS 1, WBC 31.7

3. 0828 (8:28 am)- VS: temp 98.3, bp 90/54, MEWSS 2

4. 1230 (12:30 pm) - Primary care physician rounded, VS: temp 98.5 AX, bp 96/49, MEWSS 1, WBC 31,000, PICC line removed (inserted on 07/21/14)

5. 1602 (4:02 pm) - Pain level 0/10

6. 1655 (4:55 pm) - VS: temp 98.4 AX, bp 86/60, MEWSS 2

7. 2000 (8:00 pm) - VS: temp 100.4, bp 100/45

8. 2007 (8:07 pm) - complains of (c/o) left hip pain 5/10

9. 2034 (8:34 pm) - Nursing Note: "Patient has low BP, not comfortable giving patient Xanax for anxiety with low BP. MD aware, no changes."

10. 2059 (8:59 pm) - 20 gauge (Ga.) angiocatheter (angiocath) to right AC (antecubital) placed

11. 2110 (9:10 pm) - Temp 99.8 axillary (AX), meds given, cool washcloth applied, MD notified and blood cultures ordered.


C. Patient Care Notes and Clinical Documentation Reports dated 07/27/14 indicated the following:

1. 0015 (12:15 am) - Pain 0/10, VS: temp 99.6 AX, bp 118/58, MEWS 1

2. 0400 (4:00 am) - Pain 0/10, VS: temp 98.6 AX, bp 133/72, MEWS 0

3. 0730 (7:30 am) - VS: temp 98.8 tympanic (TA), bp 144/76, MEWS 0, "primary care physician [PCP] rounded, WBC down to 20,000"

4. 0827 (8:27 am) - "... Patient is max assist to bsc [bedside commode]. Patient is hemodynamically stable. Patient's pain managed with PRN hydrocodone. Patient also had slight low grade temperature. Physician notified. Patient turned q [every] 2 hrs through the night ..."

5. 0830 (8:30 am) - "c/o right hip pain 8/10, changed position and pain 2/10, last BM reported on 07/27/14 small and hard, PICC right brachial, 20 Ga. in right antecubital [AC]."

6. 11:00 am - VS: temp 97.6 TA, bp 110/61, MEWS 0

7. 1500 (3:00 pm) - VS: temp 99.1 TA, bp 122/81, MEWS 0
8. 1514 (3:14 pm) - PT evaluation completed
9. 1600 (4:00 pm) - 0/10 pain
10. 2026 (8:26 pm) - VS: temp 99.3 TA, bp 107/49, MEWS 1

11. 2059 (8:59 pm) - "20 Ga. angiocatheter to the right AC, infiltrated and removed. Times 6 attempts by 3 different nurses, 22 Ga. angio to right forearm."

12. 2105 (9:05 pm) - "Report taken from [RN #1, day shift nurse], [Patient] complaining of pain and discomfort to right hip. Medicated and repositioned. IV [intravenous] to left AC has infiltrated, IV removed new IV started x 6 attempts [by] three different nurses. New 22 Ga. to right forearm. Pt is complaining of nausea [name of physician] called for Zofran IV given with good results. Pt has complained all day that the service here is terrible ..."


D. Patient Care Notes and Clinical Documentation Reports dated 07/28/14 indicated the following:

1. 0039 (12:39 am) - VS: temp 99.3 TA, bp 125/94, MEWS 1

2. 0349 (3:49 am) - "Assisting patient with turning every 2 hours, midnight temp 99.3, asking for Tylenol and Xanax. At 0300 patient c/o pain 8/10 medication given."

3. 0512 (5:12 am) - VS: bp 111/42, MEWS 0

4. 0758 (7:58 am) - "[Patient] continues to be assisted with reposition at least every 2 hours. All concerns attended to throughout the shift."

5. 0812 (8:12 am) - oxygen saturation (O2 saturation) 99% on 2 Liters.

6. 0825 (8:25 am) - VS: temp 97.6 TA, bp 116/80, MEWS 0

7. 1246 (12:46 pm) - VS: temp 98.6 TA, bp 132/58, MEWS 0. PCP (primary care physician) rounded, WBC 16.8

8. 1430 (2:30 pm) - Foley catheter discontinued, patient medicated at 1421 (2:21 pm) with Xanax per daughter's request.

9. 1500 (3:00 pm), "Braden Score Skin Assessment, Braden Score: 15 Skin Assessment: sacral stage 2 pressure ulcer, and patient has incontinence - cleansed, applied calazime. RLE with skin tears x3: cleansed with NS, applied medihoney gel to all and covered with mepilex border... Recommendation: turn q 2 hours when patient unable to do so, education provided to patient regarding importance of repositioning for pressure relief to prevent further skin breakdown. First step select air mattress overlay to be applied to bed ..."

10. 1708 (5:08 pm) - VS: temp 98.6 TA, bp 102/63

11. 1926 (7:26 pm ) - VS: temp 100.1, c/o lower back pain, medicated with Norco with fair results.

12. 1958 (7:58 pm), "Report taken from [RN #1], patient resting in bed. Patient up to chair, walked from chair to other side of bed. No complaints of pain or discomfort. Patient's daughter wants patient to have Xanax. Patient's Primary Care Physician ordered 0.5 mg Xanax with good results. Foley DC'd 1430 [2:30 pm] at shift change patient still had not voided no bladder distention. Patient has temp. 100, complaining of lower back pain. Medicated with hydrocodone/acetaminophen with fair results. Report given to RN #3."

13. 2247 (10:47 pm), "Obtained report and assumed cares. Pt alert and resting in bed, communicating with staff. Medicated for c/o pain by day shift RN at 1930 [7:30 pm].

CNA [certified nurse assistant] taking VS at 2015 [8:15 pm] and reported to this RN pt has MEWSS of 4: RR mid 20's BP 80's over 30's, Pt confused and able to answer question or track side to side with eyes and temp 103.0.

Call placed at 2033 [8:33 pm] to on call MD regarding above findings. New orders for IV bolus and Tylenol obtained, IV bolus started and daughter present in room. Pt became completely unresponsive.

RAPID RESPONSE called at 2100 [9:00 pm]. RRT [Rapid Response Team] present in room immediately after called. See RRT report sheet for details. On Call MD called and pt transferred to ICU, room 112. ICU nurse present in RRT and report given. Assisted pt to ICU and cares transferred. All pt belongings brought to ICU room."


E. Review of the Mortality Review Tool for the incident dated 07/28/14 for Patient #1, "A MEWS score of 4 was noted (respirations mid 20's, BP 80's/30's, confusion, temp 103.0). This would appear to score higher than a 4, possibly a 5 - 6. No heart rate was noted in the vital signs or on the nursing note for this period of time. The patient was tachycardic upon admission to the ICU in the 120's -140's which would make the MEWS score a 7 without adding in the respiratory rate."


F. On 10/02/14 at 1:05 pm, during interview, RN #2 staff member of the 4th floor/Telemetry day shift, who cared for Patient #1 on 07/26/24, 07/27/14 and 07/28/14, stated that she remembered Patient #1, "because she complained all day about the [nursing] service." The patient reported hurting (pain) so the staff would turn and reposition her. The patient continued to complain about being repositioned. The daughter would calm her down. RN #2 stated, "The patient did not feel like we were meeting her needs." RN #2 stated that she did not report these complaints to management. When questioned about Patient #1's low blood pressure, RN #2 stated that she thought the low blood pressure was from the Xanax. RN #2 stated that the patient was concerned about not having a bowel movement. RN #2 also stated that the patient had requested to be disimpacted. The patient was checked and no stool was removed.

G. Review of the facility "Modified Early Warning Scoring System (MEWSS)" policy effective 07/01/13, revealed the following: "The MEWSS is designed to identify subtle vital sign changes earlier in the patients and the scoring is calculated using each component collected. The MEWSS is a clinical decision support system to assist and alert the clinical team to know when to continue monitoring routine care, to increase monitoring of vital signs, when to elevate their concern and inform others of subtle changes, notify physician, and/or when to call a rapid response ... a score of 6 requires informing the physician and consider calling the Rapid Response Team (RRT)."

H. On 10/02/14 at 6:50 pm, during interview, RN #3, a staff member of the 4th floor/Telemetry night shift, was asked if she remembered taking care of Patient #1 on the evening of 07/28/14. She stated "Yes." RN #3 stated that she remembered the patient had an infection of unknown origin, but she denied remembering any odor or smells coming from the patient's room. RN #3 stated that around 8:15 pm the CNA reported a MEWS of 4 and a blood pressure of 80's over 30's. RN #3 stated that the patient's daughter was called and that the on-call MD was called at 8:33 pm. When asked why she did not call for the Rapid Response Team at this time, she responded, "I discussed the situation with my charge nurse and we decided that we would not call the Rapid Response Team until the patient became unresponsive. At that time the patient was still alert and responsive." The Rapid Response Team was then called at 9:00 pm.

I. On 10/02/14 at 1:40 pm, during interview, the ICU nurse on the night shift stated that she responded to a Rapid Response call about 9:00 pm on 07/28/14. She further stated that the minute she saw the patient she knew that the patient was in trouble. She stated that there was a sickening, sweet smell coming from the room. The ICU nurse stated that the patient appeared dehydrated and that she felt that the Rapid Response Team should have been called sooner.

J. Review of the hospital's Rapid Response Team Policy indicated the following: "The purpose of the Rapid Response Team is to bring critical care expertise to the patient's bedside with the goal of: reduced inpatient mortality, reduced non-ICU/ED arrests and increased recognition of patient deterioration."

K. On 10/03/14 at 08:55 am, during interview, the Interim Director of ICU was asked to explain the MEWSS to the surveyors. She stated that it was a point system based on the patient's condition.

If the patient has a MEWS score of 0 - 3, take routine vital signs every 4 hours and reassess the patient as ordered. For a MEWS score of 4 - 5, implement first line of treatment, take vital signs every hour and reassess every hour until the score decreases; the physician should be notified and the CNA should remain with the patient, and if nothing changes in one hour call the Rapid Response Team.

For a MEWS score of 6+, inform the physician and consider calling the Rapid Response Team. For a MEWS score of 3 on any one item the nurse is to inform the physician and consider calling the Rapid Response Team. In reviewing Patient #1's medical record, the Interim Director of ICU agreed that this patient was not scored properly and that the Rapid Response Team should have been called sooner.

Based on medical record review and staff interviews, a registered nurse failed to assign nurses to the patient who could manage the complexity of Patient #1's care. These deficient nursing practices contributed to the deterioration of Patient #1, requiring the need to transfer the patient to a higher level of care (refer to A-397).

Based on medical record review and staff interviews, a registered nurse failed to assign nursing staff to the patient who could manage the complexity of Patient #1's care. These deficient nursing practices contributed to the deterioration of Patient #1, requiring the need to transfer the patient to a higher level of care. The findings are:

A. Review of Patient #1's medical record revealed that the patient had been a patient at a local rehabilitation hospital recovering from a right total hip replacement.

She had a significant medical history of the following: a cerebrovascular accident, osteoarthritis, a myocardial infarction 10 years ago, cardiac catheterization, hypertension, renal artery stenosis, gastroesophageal reflux disease, right total shoulder replacement, back surgery with a fusion of the lumbar 4 - 5, two knee replacements, and an intramuscular rodding of the left hip.

While at the rehabilitation hospital, she had relentless belching, which prevented the patient from drinking or eating. At one point during the rehabilitation hospital stay, Patient #1 required bowel disimpaction (removal of hard stool). A peripherally inserted central catheter (PICC) was placed on 07/21/14.

Patient #1 was transferred to the hospital on 07/25/14 with a markedly high white blood count and hypotension (low blood pressure).

1. The following was a time line of events that occurred during Patient #1's hospitalization from 07/25/14 - 07/29/14:

a. Patient Care Notes and Clinical Documentation Reports dated 07/25/14 indicated the following:

1. 1530 (3:30 pm) - Patient #1 was transferred from the local rehabilitation hospital to 4th floor/Telemetry with bacteremia (infection in the blood), urinary tract infection (UTI), status post (s/p) right total hip replacement, atrial fibrillation, and an elevated white blood count (WBC) of 31,000; with vital signs (VS) of temperature (temp) 98.5, and blood pressure (bp) 118/69. The last bowel movement (BM) was documented on 07/24/14. Patient was started on the medications Vancomycin and Rocephin (intravenous antibiotics) upon admission.

2. 1830 (6:30 pm) - [Patient #1] Reports pain to the left hip 9 out of 10

3. 1851 (6:51 pm) - RN (registered nurse) calls MD for pain medication

4. 1857 (6:57 pm) - Pain medication given, patient temp
102.5 given ice packs

5. 2000 (8:00 pm) - VS: temp 99.0 AX (axillary), bp 145/50

6. 2011 (8:11 pm) - VS: temp 98.5 AX, bp 118/69

7. 2039 (8:39 pm) - temp 100

8. 2131 (9:31 pm) - bladder scanned; 418 cc of urine present

9. 2345 (11:45 pm) - 16 French Foley catheter (indwelling urinary catheter) inserted - urine output of 150 cc


B. Patient Care Notes and Clinical Documentation Reports dated 07/26/14 indicated the following:

1. 0000 (12:00 am) - VS: temp 98.2 AX, bp 77/36; MEWSS 2. (During Patient #1's hospital stay the Modified Early Warning Scoring System (MEWSS) was used by the nursing staff to assist in identifying "at risk" patients who may display physical signs of deterioration before an adverse event occurs.)

2. 0400 (4:00 am) - VS: temp 98.3 AX, bp 89/45, MEWSS 1, WBC 31.7

3. 0828 (8:28 am) - VS: temp 98.3, bp 90/54, MEWSS 2

4. 1230 (12:30 pm) - Primary care physician rounded, VS: temp 98.5 AX, bp 96/49, MEWSS 1, WBC 31,000, PICC line removed (inserted on 07/21/14)

5. 1602 (4:02 pm) - Pain level 0/10

6. 1655 (4:55 pm) - VS: temp 98.4 AX, bp 86/60, MEWSS 2

7. 2000 (8:00 pm) - VS: temp 100.4, bp 100/45

8. 2007 (8:07 pm) - complains of (c/o) left hip pain 5/10

9. 2034 (8:34 pm) - Nursing Note: "Patient has low BP, not comfortable giving patient Xanax for anxiety with low BP. MD aware, no changes."

10. 2059 (8:59 pm) - 20 gauge (Ga.) angiocatheter (angiocath) to right AC (antecubital) placed

11. 2110 (9:10 pm) - Temp 99.8 axillary (AX), meds given, cool washcloth applied, MD notified and blood cultures ordered.


C. Patient Care Notes and Clinical Documentation Reports dated 07/27/14 indicated the following:

1. 0015 (12:15 am) - Pain 0/10, VS: temp 99.6 AX, bp 118/58, MEWS 1

2. 0400 (4:00 am) - Pain 0/10, VS: temp 98.6 AX, bp 133/72, MEWS 0

3. 0730 (7:30 am) - VS: temp 98.8 tympanic (TA), bp 144/76, MEWS 0, "primary care physician [PCP] rounded, WBC down to 20,000"

4. 0827 (8:27 am) - "... Patient is max assist to bsc [bedside commode]. Patient is hemodynamically stable. Patient's pain managed with PRN hydrocodone. Patient also had slight low grade temperature. Physician notified. Patient turned q [every] 2 hrs through the night ..."

5. 0830 (8:30 am) - "c/o right hip pain 8/10, changed position and pain 2/10, last BM reported on 07/27/14 small and hard, PICC right brachial, 20 Ga. in right antecubital [AC]."

6. 1100 (11:00 am) - VS: temp 97.6 TA, bp 110/61, MEWS 0

7. 1500 (3:00 pm) - VS: temp 99.1 TA, bp 122/81, MEWS 0

8. 1514 (3:14 pm) - PT evaluation completed

9. 1600 (4:00 pm) - 0/10 pain

10. 2026 (8:26 pm) - VS: temp 99.3 TA, bp 107/49, MEWS 1

11. 2059 (8:59 pm) - "20 Ga. angiocatheter to the right AC, infiltrated and removed. Times 6 attempts by 3 different nurses, 22 Ga. angio to right forearm."

12. 2105 (9:05 pm) - "Report taken from [RN #1, day shift nurse], [Patient] complaining of pain and discomfort to right hip. Medicated and repositioned. IV [intravenous] to left AC has infiltrated, IV removed new IV started x 6 attempts [by] three different nurses. New 22 Ga. to right forearm. Pt is complaining of nausea [name of physician] called for Zofran IV given with good results. Pt has complained all day that the service here is terrible ..."



D. Patient Care Notes and Clinical Documentation Reports dated 07/28/14 indicated the following:

1. 0039 (12:39 am) - VS: temp 99.3 TA, bp 125/94, MEWS 1

2. 0349 (3:49 am) - "Assisting patient with turning every 2 hours, midnight temp 99.3, asking for Tylenol and Xanax. At 0300 patient c/o pain 8/10 medication given."

3. 0512 (5:12 am) - VS: bp 111/42, MEWS 0

4. 0758 (7:58 am) - "[Patient] continues to be assisted with reposition at least every 2 hours. All concerns attended to throughout the shift."

5. 0812 (8:12 am) - oxygen saturation (O2 saturation) 99% on 2 Liters.

6. 0825 (8:25 am) - VS: temp 97.6 TA, bp 116/80, MEWS 0

7. 1246 (12:46 pm) - VS: temp 98.6 TA, bp 132/58, MEWS 0. PCP (primary care physician) rounded, WBC 16.8

8. 1430 (2:30 pm) - Foley catheter discontinued, patient medicated at 1421 (2:21 pm) with Xanax per daughter's request.

9. 1500 (3:00 pm), "Braden Score Skin Assessment, Braden Score: 15 Skin Assessment: sacral stage 2 pressure ulcer, and patient has incontinence - cleansed, applied calazime. RLE with skin tears x3: cleansed with NS, applied medihoney gel to all and covered with mepilex border... Recommendation: turn q 2 hours when patient unable to do so, education provided to patient regarding importance of repositioning for pressure relief to prevent further skin breakdown. First step select air mattress overlay to be applied to bed ..."

10. 1708 (5:08 pm) - VS: temp 98.6 TA, bp 102/63

11. 1926 (7:26 pm) - VS: temp 100.1, c/o lower back pain, medicated with Norco with fair results.

12. 1958 (7:58 pm), "Report taken from [RN #1], patient resting in bed. Patient up to chair, walked from chair to other side of bed. No complaints of pain or discomfort. Patient's daughter wants patient to have Xanax. Patient's Primary Care Physician ordered 0.5 mg Xanax with good results. Foley DC'd 1430 [2:30 pm] at shift change patient still had not voided no bladder distention. Patient has temp. 100, complaining of lower back pain. Medicated with hydrocodone/acetaminophen with fair results. Report given to RN #3."

13. 2247 (10:47 pm), "Obtained report and assumed cares. Pt alert and resting in bed, communicating with staff. Medicated for c/o pain by day shift RN at 1930 [7:30 pm].

CNA [certified nurse assistant] taking VS at 2015 [8:15 pm] and reported to this RN pt has MEWSS of 4: RR mid 20's BP 80's over 30's, Pt confused and able to answer question or track side to side with eyes and temp 103.0.

Call placed at 2033 [8:33 pm] to on call MD regarding above findings. New orders for IV bolus and Tylenol obtained, IV bolus started and daughter present in room. Pt became completely unresponsive.

RAPID RESPONSE called at 2100 [9:00 pm]. RRT [Rapid Response Team] present in room immediately after called. See RRT report sheet for details.

On Call MD called and pt transferred to ICU, room 112. ICU nurse present in RRT and report given. Assisted pt to ICU and cares transferred. All pt belongings brought to ICU room."

E. Review of the Mortality Review Tool for the incident dated 07/28/14 for Patient #1, "A MEWS score of 4 was noted (respirations mid 20's, BP 80's/30's, confusion, temp 103.0). This would appear to score higher than a 4, possibly a 5 - 6. No heart rate was noted in the vital signs or on the nursing note for this period of time. The patient was tachycardic upon admission to the ICU in the 120's -140's which would make the MEWS score a 7 without adding in the respiratory rate."

F. On 10/02/14 at 1:05 pm, during interview, RN #2 staff member of the 4th floor/Telemetry day shift, who cared for Patient #1 on 07/26/24, 07/27/14 and 07/28/14, stated that she remembered Patient #1, "because she complained all day about the [nursing] service." The patient reported hurting (pain) so the staff would turn and reposition her. The patient continued to complain about being repositioned. The daughter would calm her down. RN #2 stated, "The patient did not feel like we were meeting her needs." RN #2 stated that she did not report these complaints to management. When questioned about Patient #1's low blood pressure, RN #2 stated that she thought the low blood pressure was from the Xanax. RN #2 stated that the patient was concerned about not having a bowel movement. RN #2 also stated that the patient had requested to be disimpacted. The patient was checked and no stool was removed.

G. Review of the facility "Modified Early Warning Scoring System (MEWSS)" policy effective 07/01/13, revealed the following: "The MEWSS is designed to identify subtle vital sign changes earlier in the patients and the scoring is calculated using each component collected. The MEWSS is a clinical decision support system to assist and alert the clinical team to know when to continue monitoring routine care, to increase monitoring of vital signs, when to elevate their concern and inform others of subtle changes, notify physician, and/or when to call a rapid response... a score of 6 requires informing the physician and consider calling the Rapid Response Team (RRT)."

H. On 10/02/14 at 6:50 pm, during interview, RN #3 staff member of the 4th floor/Telemetry night shift, was asked if she remembered taking care of Patient #1 on the evening of 07/28/14. She stated "Yes." RN #3 stated that she remembered the patient had an infection of unknown origin, but she denied remembering any odor or smells coming from the patient's room. RN #3 stated that around 8:15 pm the CNA reported a MEWS of 4 and a blood pressure of 80's over 30's. RN #3 stated that the patient's daughter was called and that the on-call MD was called at 8:33 pm. When asked why she did not call for the Rapid Response Team at this time, she responded, "I discussed the situation with my charge nurse and we decided that we would not call the Rapid Response Team until the patient became unresponsive. At that time the patient was still alert and responsive." The Rapid Response Team was then called at 9:00 pm.

I. On 10/02/14 at 1:40 pm, during interview, the ICU nurse on the night shift stated that she responded to a Rapid Response call about 9:00 pm on 07/28/14. She further stated that the minute she saw the patient she knew that the patient was in trouble. She stated that there was a sickening, sweet smell coming from the room. The ICU nurse stated that the patient appeared dehydrated and that she felt that the Rapid Response Team should have been called sooner.

J. Review of the hospital's Rapid Response Team Policy indicated the following: "The purpose of the Rapid Response Team is to bring critical care expertise to the patient's bedside with the goal of: reduced inpatient mortality, reduced non-ICU/ED arrests and increased recognition of patient deterioration."

K. On 10/03/14 at 08:55 am, during interview, the Interim Director of ICU was asked to explain the MEWSS to the surveyors. She stated that it was a point system based on the patient's condition. If the patient has a MEWS score of 0 - 3, take routine vital signs every 4 hours and reassess the patient as ordered. For a MEWS score of 4 - 5, implement first line of treatment, take vital signs every hour and reassess every hour until the score decreases; the physician should be notified and the CNA should remain with the patient, and if nothing changes in one hour call the Rapid Response Team. For a MEWS score of 6+, inform the physician and consider calling the Rapid Response Team. For a MEWS score of 3 on any one item the nurse is to inform the physician and consider calling the Rapid Response Team. In reviewing Patient #1's medical record, the Interim Director of ICU agreed that this patient was not scored properly and that the Rapid Response Team should have been called sooner.