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Based on record review and interview, the facility's nursing staff failed to identify the change in the patient's condition for 2 (#4 and #5) of 5 (#1-#5) patient records reviewed. There was no reassessment of the patients deteriorating condition. Also, the facility failed to follow the facility's Rapid Response Team policy and the facility's Reassessment Policy.


This deficient practice had the likelihood to cause injury and/or harm to all patients being cared for in the facility.


Cross refer: A 0392

Based on record review and interview, the facility's nursing staff failed to identify the change in the patient's condition for 2 (#4 and #5) of 5 (#1-#5) patients records reviewed. There was no reassessment of the patients deteriorating condition. Also, the facility failed to follow the facility's Rapid Response Team policy and the facility's Reassessment Policy.


This deficient practice had the likelihood to cause injury and/or harm to all patients being cared for in the facility.


A review of the medical record for Patient #5 revealed that the patient had oxygen saturations that were less than 90 and respiratory rates that were greater than 30. The Rapid response team was not activated per the facility's policy. Patient #5's oxygen saturation was less than 60 for more than 2 hours without rapid intervention to promote a better outcome for the patient whose condition was deteriorating. Further review of the Patient's #5 record revealed no reassessment of the patient's condition when there were vital sign changes and the patient was showing signs of shortness of breath, and agitation which were signs of hypoxia.


Oxygen saturation levels measure the degree to which the haemoglobin contained in the red blood cells (erythrocytes) has bonded with oxygen molecules. Oxygen is taken in by the lungs when we breathe in. A range of 95 - 99% is normal for healthy adults breathing room air which contains 21% oxygen. Anyone who is not achieving the critical blood oxygen saturation level of 90% (SpO2) or of 55-60mmHg (SaO2), requires additional oxygen.


Findings:


Patient #5 was a 59 year old female who was admitted to the hospital with pneumonia. She was a Lufkin State school resident that was non-communicative and non-ambulatory. Patient #5 had profound mental retardation, seizure disorder and a feeding tube. Past medical history included: hyperlipidemia, hypertension, hernia, spastic quadriplegia, hepatitis B, anemia, scoliosis, autism, gastroesophageal reflux disease and pneumonia.


Patient #5 was admitted to the facility on 01/15/2017 at 15:56 (3:56 PM)


A review of the Patient #5's admission assessment report dated 01/15/2017 at 18:30 (6:30 PM), which was the arrival time for the medical surgical unit revealed the following:


A review of the record titled, "Admission Assessment Report" revealed Patient #5's first set of vital signs were dated 01/16//2017 and timed at 04:00 (4:00 AM). Vitals signs were: Temp. 100.2 Pulse 77 Respirations. 20 B/P (blood pressure) 105/55 O2% 94% (4 liters per minute per nasal cannula), which was nine hours and 30 minutes after the admission to the floor per the registered nurse performing the initial assessment.


A review of the record titled, "Vital Sign Report" dated 01/17/2017 at 09:32 (9:32 AM) through 01/18/2017 at 23:59 (11:59 PM) revealed the following:

01/17/2017 9:32- Temp. 99.4 Pulse (marked out) Respirations. (marked out) B/P 89/57 O2% (marked out)

01/17/2017 13:43 (1:43 PM) Temp. 97.8 Pulse 98 Respirations. (blank) B/P 101/66 O2% (blank)

01/17/2017 16:11(4:11 PM) Temp. 98.8 Pulse 77 Respirations. (blank) B/P 101/55 O2% (blank)

01/17/2017 19:12 (7:12 PM) Temp. 100.7 Pulse 74 Respirations. 16 B/P 164/74 O2% 94%

01/18/2017 00:12 AM Temp. 99.6 Pulse 88 Respirations. 16 B/P 135/73 O2% 95%

01/18/2017 6:12 AM Temp. 99.1 Pulse 106 Respirations. 18 B/P 115/63 O2% 93%

01/18/2017 8:00 AM Temp. 97.7 Pulse 106 Respirations. 25 B/P 173/56 O2% 48%

01/18/2017 10:15 AM Temp. (blank) Pulse 100 Respirations. 35 B/P 113/56 O2% 45%


A review of the vital sign record revealed Staff #15 documented the low oxygen saturation of 48% at 8:00 AM, but there was no documented evidence in the record that any other nursing staff members were notified of the low oxygen saturations.


A review of Patient #5's record revealed decrease oxygen saturation of 48% at 8:00 AM and the next set of vitals were not taken until 10:15 AM and the oxygen saturation at that time was 45%.


Hypoxemia (low oxygen in your blood) can cause hypoxia (low oxygen in your tissues) when your blood doesn't carry enough oxygen to your tissues to meet your body's needs. When your body doesn't have enough oxygen, you could get hypoxemia or hypoxia. These are dangerous conditions. Without oxygen, your brain, liver, and other organs can be damaged just minutes after symptoms start. http://www.webmd.com/asthma/guide/hypoxia-hypoxemia#2.


A review of the daily focus assessment report on 01/18/2017 at 8:00 AM noted the following: Staff #9 (primary nurse for the patient) documented, "Patient sleeping, tachypnic (sic), O2 sat mid 50's patient keeps taking her O2 off, RT here to try & give her a breathing treatment will page hospitalist. Will continue to monitor patient complaints or changes in status. Personal needs met."


A review of the daily focus assessment report on 01/18/2017 at 8:09 AM noted the following: Staff #6 (Respiratory Therapist) documented, "nebulizer mask O2% 40, heart rate 90, O2Sat. 50%, Respirations 44 (pretreatment) after treatment labored. Nurse aware of pt. condition and is notifying the DR."


Staff #9 documented on 01/18/2017 at 8:25 AM, "spoke with physician #13 (patient's doctor) he will consult Physician #14 who has seen the patient before."


Staff #9 documented on 01/18/2017 at 10 AM, "stat ABG show 02 sat of 50, patient awake & agitated, state school sitter at bedside... paged Dr. #13, orders are to transfer to PCU, house supervisor notified, he will call me back with a room... RT put patient on nonbreather (sic) at 15 liters."


A review of the daily focus assessment report on 01/18/2017 at 10:15 AM noted the following: Staff #9 documented "Dr. #14 here at 10:10, patient's O2 sat 45, called RR (rapid response) & code at 10:15 to intubate the patient, started bagging with Ambu ...see code charting for meds, staff, etc. Patient was intubated & put on vent with the following settings."


A record review revealed the Rapid Response Team was called at 10:15, arrived at 10:18 AM and the event ended at 10:35 AM. Patient #5 was intubated by Physician #14 (Pulmonologist). Rhythm on arrival tachycardia with a pulse, heart rate 100, B/P 131/56, pulse O2 45%.
01/18/2017 10:30 AM Temp (blank) Pulse 90 Respirations 35 B/P 90/53 O2 90% (intubated)


The Rapid Response and Code Blue event took place 2 hours and 30 minutes after the first documented low reading of an oxygen saturation of 48% at 8:00 AM.


Patient #5 was a Lufkin State School resident that was non-communicative and non-ambulatory. The Lufkin State School required a sitter to be with the patient 24 hours a day when hospitalized. The sitters were trained by the Lufkin State School. The sitters documented anytime a person entered the room and any activity that was performed to the patient including vital signs, medication, and treatments.
A review of the record titled, "Hospital Observations Notes" (Lufkin State School Notes) from 01/15/2017 beginning at 2:15 PM through 01/18/2017 ending at 2:00 PM was documented by DSP #11.


01/18/2017 at 7:05 AM "Aide got vital signs B/P 176/53, Temp 97.7, HR 106, O2 45 Respirations. 30"

01/18/2017 at 8:05 AM "RT into give breathing treatment O2 51"

01/18/2017 at 8:40 AM "RN... into give meds via g-tube"

01/18/2017 at 8:55 AM "RT .... to RN ... that patient #5 may need to move to ICU or PCU due to his sat machine picking up 51..."

01/18/2017 at 9:15 AM "HL (Hospital Liaison) #12 into check on Patient #5. DSP #11 (Direct Support Professional) notified HL #12 that O2 was very low on arrival and rechecked O2. HL#12 asked the nurse was she aware of the low O2 and she told HL #12 that physician #13 had been called and his response."

01/18/2017 at 9:35 AM "HL #12 ask about the ABG (Arterial Blood Gases), RN.... agreed RT... into get ABG from left forearm." (sic)

01/18/2017 at 9:45 AM "Physician #16 into see Patient #5, HL#12 waiting on ABG results, RT John stated her O2 was low, HL #12 stated something needed to be done due to O2 being low."

01/18/2017 at 10:10 AM "Physician #13 and #14 into see Patient #5."

01/18/2017 at 10:13 AM "Physician #14 ask HL#12 what are her Sats and HL #12 told that she was 60 after RT ... placed Patient #5 on high flow at 15 liters. Physician #14 decided to intubate Patient #5 on the floor."

01/18/2017 at 10:45 AM "Patient #5 moved to ICU vitals HR 86 O2 100 B/P 86/56 Respirations 26"


A review of the facility's policy titled, "Rapid Response Team" revealed the following:


"Responsibility of:


Registered Nurses
Licensed Vocational Nurses
Patient Care Techs
Unit Secretaries
Rapid Response Team


PURPOSE:

The role of the Rapid Response Team (RRT) will be to provide early and rapid intervention in order to promote better outcomes for patients whose condition may be deteriorating so as to reduce the number of hospital deaths. In addition, a major focus of this team will be to provide support and education to the staff as needed. The team will consist of the Patient's floor Nurse, Critical Care RN, Critical Care Respiratory Therapist, and the House Supervisor. The ER physician may be called if needed. A Pharmacist will also be considered a member of the team and will be available for consultation via telephone.


A. The RRT will strive to reduce the number of cardiac and/or respiratory arrests, intubations in the hospital, and unnecessary transfer of patients to the critical care setting while promoting a more timely transfer of patients to a higher level of care when indicated.


B. The RRT will be available for all areas.


C. The Critical Care RN will provide clinical expertise, advanced assessment skills, interventions as indicated by current ACLS guidelines, and support for the bedside nurse, patient and patient's family.


D. In the event staff is unable to immediately contact the primary physician, the ER physician will provide the medical care for emergent interventions.

E. The Respiratory Therapist will provide clinical expertise, advanced respiratory assessment skills, interventions as indicated by current ACLS guidelines and current National institute of Health's Asthma guidelines, and support for the bedside nurse patient and patient's family.


F. The Pharmacist will be available via telephone for consulting and recommendations.


G. If the patient is off the floor in a procedure area such as Radiology, GI Lab, Outpatient areas, etc., any staff member may activate the RRT if the patient meets the criteria listed below.


H. The Charge Nurse should be notified of a patient's deteriorating condition, but any patient care RN on the floors may call the RRT if the patient meets the following criteria:


RRT Activation Criteria


1. Staff concerned or worried about patient's presentation or condition


2. Unexplained temperature> 100.4° F or < 96.8° F


3. Acute change in Heart Rate from patient's baseline (e.g. <40 bpm or >130 bpm)


4. Threatened airway or acute change in Respiratory Rate <10 or >30.


5. Acute change in oxygen saturation-level is <90% despite increasing F102


6. Acute change in Systolic Blood Pressure from patient's baseline (e.g. >90

mm/Hg)


7. Acute change in level of consciousness


8. Acute significant bleed


9. New, repeated, or prolonged seizures


10. Physician request


II. PROCEDURE:

A. When a care provider feels that a patient needs immediate or emergency intervention, the RRT will be called by dialing 7999. The person initiating the call will tell the operator to "Call the RRT" and will supply the patient's floor, room number or area.


B. The patient's nurse will also page the attending physician when activating the team.


C. Once the page is received, the RRT will simultaneously go to that floor or area within an estimated arrival time of five minutes.


D. Patient Care Nurse's Recommendations:

1. Provide the situation and background of the patient for the team on the patient's condition. Remain with the patient as primary care provider while the RRT is there.

2. Assist the RRT as needed.


E. Critical Care Nurse Responsibilities:

I, Assist with further assessment of the patient.

2. Assist physician in communicating with the family/patient about the situation.

3. Administer interventions and medications as directed and assist the Primary Care Nurse with documentation as needed.

4. Assist/facilitate with transfer to higher level of care if indicated,


F. ER MD Responsibilities:

1. Assess the patient and recommend treatment as he/she feels the situation demands.

2. Communicate with attending physician.

3. Communicate with patient and family regarding situation and interventions.


G. Respiratory Therapist Responsibilities:

1. Assess and treat within scope of care as outlined by current AHA ACLS Guidelines or Guidelines for the Diagnosis and Management of Asthma as outlined by the National Institute of Health and document as appropriate.

2. Advanced interventions after consultation with the physician.


H. A member(s) of the team will either continue to stay with the patient until stable or assist with the transfer of the patient to a higher level of care.


III. DOCUMENTATION:

A. The Primary Care Nurse will complete documentation regarding the patient's condition and interventions taken in the medical record. The House Supervisor or his/her appointed designee will ensure a Code Critique Form will be completed.

B. The Code Critique Form will be summarized and reported to the Quality Council."



An interview with Staff#17 on 01/25/2017 at 1:30 PM confirmed as she reviewed Patient #5's record with the surveyor that there should have been rapid intervention with the low O2 saturations and changes in the patient's condition.


An interview with Staff#4 (House Supervisor) on 01/25/2017 at 2:00 PM confirmed as she reviewed Patient #5's record that there should have been rapid intervention with low O2 saturations and changes in the patient's condition.


An interview with Complainant #12 by phone on 01/24/2017 at 7:25 PM revealed the following:


"I arrived at the hospital at 9:15 AM to check on the patient. DSP #11, who had been sitting with Patient #5, informed me that patient's oxygen saturations were in 40's/50's, I checked immediately and got a reading of 54%, she told me that the nursing staff first check was at 7:00 AM and the 02 sat was 45%. Also, the respiratory therapist had checked the O2 sat, and it was in the low 50's. I immediately spoke with charge nurse Staff #8 who was unaware of Patient #5's condition. I then spoke to the primary nurse Staff #9. She stated, they called the primary Physician #13 and he stated she breathes like that and he would be calling and consulting Physician #14 (pulmonologist). I requested ABGS immediately and a call be placed to Physician #14 informing the hospital that she was not a DNR and she had already been sitting here for 2 plus hours with barely anything being done for her. At 9:35-ABG were completed by RT and results were again extremely low, I requested they called to Physician ASAP (as soon as possible). Orders were received to transfer patient to PCU unit. Soon after that Physician #13 and #14 arrived around 10:00-10:15 AM. Physician #14 immediately called rapid response team, then code blue, and intubated her where she was then transferred to ICU for further treatment. I feel more could have been done for her prior to my arrival. If I had not arrived when I did, I don't know what could have happened to her. I believe if action would have been taken earlier, intubation could have been prevented."


During the survey on 01/25/2017 at 10:30 AM a visit was made to Patient #5 who was still in ICU on a ventilator. During the tour in ICU, the patient was being weaned off the ventilator. Later in the survey, surveyor was informed the patient had been extubated.


A phone conversation with Complainant #12 on 02/02/2017 at 10:00 AM informed the surveyor that Patient #5 was re-intubated on 01/25/2017 around 7:00 PM and remains on a ventilator. Also, as of today (02/02/2017) Patient #5 had to have a tracheostomy and that her condition was deteriorating.



Patient #4 was an 80 year old female with a past history of coronary disease and stent placement 6 years ago, atrial fibrillation with RVR, CVA, shortness of breath, and increased heart rate. She presented to the emergency room with Atrial Fibrillation with RVR at a heart rate of 150.


A review of the record titled, "Admission Assessment Report" revealed Patient #4's first set of vital signs were at 16:15 (4:15 PM) Temp 98.6 Pulse 115 Respirations 32 B/P 107/73 O2 100%. Patient was admitted to PCU (Progressive Care Unit).


A review of the record titled, "Vital Sign Report" revealed the following:


01/19/2017 00:00 Temp (blank), Pulse 64, B/P 89/44, O2 Sat 94%, Respirations 22


01/19/2017 00:41 Temp (blank), Pulse (Blank), B/P low, O2 Sat 90%, Respirations 29


01/19/2017 01:00 Temp (blank), Pulse (Blank), B/P 82/36, O2 Sat 92%, Respirations 25


01/19/2017 01:30 Temp (blank), Pulse 119, B/P 167/96, O2Sat 86%, Respirations 26


01/19/2017 01:45 Temp (blank), Pulse 124, B/P 141/87, O2Sat 85%, Respirations 25


01/19/2017 01:59 Temp (blank), Pulse 106, B/P 124/72, O2Sat 84%, Respirations 32



A review of the record titled, "Code Blue" for Patient #4 revealed Staff #19 documented the code was called at 0225 (2:25 AM) and the documentation indicated: "Pulseless Ventricular Fibrillation /Ventricular Tachycardia, heart rate 120, B/P 82/36 O2 sat 88%. Patient admitted for atrial fibrillation, Nurse turned Cardizem off d/t bradycardia-patient went into V-Fib. Patient #4 transferred to ICU."



A review of the record titled, "Daily Focus Assessment Report" for Patient #4 revealed Staff #18 documented on 01/19/2017 at 1:30 AM, "No change from previous assessment by the clinician, Pt. denies any complaints at this time, Vital Signs Stable, Call light in reach, Side rails X 2, Bed position low. Will continue to monitor patient for complaints or changes in status. Patient self-turned, and personal needs met."


A review of the Patient's #4 record on 01/19/2017 at 1:30 AM documented heart rate 119, O2 sat 86%, and respirations 26. The Code Blue form indicated Cardizem drip turned off due to bradycardia. There was no evidence in the daily focus assessment to determine what was going on with the patient's condition and the change in vital signs. Also, there was no evidence about the Cardizem drip being turned off because patient was bradycardic. Patient #4's last pulse documented was at 00:00 on 01/19/2017 and the next two vital signs documented at 00:41 and 1:00 AM were left blank. The 1:30 AM documentation showed the patient had a 119 pulse rate.


Patient #4 expired on 01/19/2017 at 6:25 AM.


A review of the facility's policy titled, "Reassessment Policy" revealed the following:

"PURPOSE: To provide an ongoing system to monitor patient's condition.


RESPONSIBILITY OF:

Registered Nurse


PROCEDURE:

All patients shall be reassessed every 24 hours, or sooner if the patient's condition changes. The following is an incomplete list of examples which warrants reassessment: post-operative patients, post cardiac catheterization patients, post patient falls or other incidents for potential injury, patients transferred from other units, patient condition deteriorates or improves, any change in mental, physical, psychosocial or spiritual status, changes in vital signs and before discharge. Documentation of the reassessment is done in the patient's electronic medical record."



An interview with Staff #4 and #17 on 01/25/2017 at 1:30 PM confirmed that Patient #4 had vital signs, medication, and condition changes that were not addressed by the nursing staff.


A review of Patient #4 and #5's record revealed that the reassessment was not performed when the patient's condition was deteriorating.



It was determined that this deficient practice created an Immediate Jeopardy situation and placed patients at risk of potential harm, serious injury, and subsequent death. These failures had the likelihood to affect all patients being cared for at the facility.