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Based on interview and record review, the hospital failed to ensure the nursing staff carried out or clarified the physician's orders for two of seven sampled patients (Patients 1 and 2) as evidenced by:

1. The nursing staff did not perform the EKG for Patient 1 as per the physician's order and did not clarify with the physician when receiving two conflicting physician's orders for Patient 1.

2. The nursing staff did not clarify with the physicians about the PWEP monitoring when the nursing staff could not perform the PWEP measurements for Patients 1 and 2.

These failures created the risk of substandard outcomes for these patients.

Findings:

Review of the hospital's Plan For Provision of Care dated July 2024 showed the RN will assume responsibility and accountability for executing therapeutic and diagnostic regimens prescribed by licensed physician and practitioners who by license are authorized to order these regimens.

1. On 1/6/25, review of Patient 1 closed medical record was initiated. Patient 1 was admitted to the hospital on 11/20/24.

Review of the History and Physical Assessment - Internal Medicine dated 11/20/24 at 1640 hours, showed Patient 1 was admitted for NSTEMI. The Plan section showed to trend EKGs.

Review of the physician's order dated 11/20/24 at 1829 hours, showed to perform an ECG 12 Lead every six hours for two occurrences. The order remained active until it was discontinued on 11/24/24 at 1706 hours.

Review of Patient 1's medical record showed another physician's order for EKG was written. Review of the physician's order dated 11/20/24 at 1909 hours, showed to perform an ECG 12 Lead on Patient 1 once.

Review of the EKG studies performed on Patient 1 were as follows for 11/20-11/21/24:

- 11/20/24 at 1427 hours.

- 11/21/24 at 0732 hours.

An EKG was not performed every six hours for two occurrences after 1829 hours, nor after 1909 hours on 11/20/24. Additionally, the conflicting orders were not clarified by the nursing staff.

2. On 1/6/25, review of Patients 1 and 2's closed medical records was initiated.

a. Patient 1's medical record showed Patient 1 was admitted to the hospital on 11/20/24.

Review of the Inpatient Consult - Cardiothoracic Surgery dated 11/21/24 at 1916 hours, showed MD 1 planned to perform a CABG on 11/23/24.

Review of the Operative Report dated 11/23/24 at 1200 hours, showed MD 1 performed a coronary artery bypass grafting surgery to three vessels for Patient 1. At the conclusion of the surgery, Patient 1 was transferred to the ICU in stable condition and on a ventilator.

Review of the physician's order dated 11/23/24 at 1645 hours, showed the physician ordered to perform PWEP monitoring for Patient 1 on arrival, every two hours for four occurrences, then every four hours if Patient 1 was stable. The order remained active until it was discontinued on 12/1/24 at 2015 hours.

However, review of Patient 1's medical record failed to show documentation of the PWEP
measurements according to the physician's order.

b. Patient 2's medical record showed Patient 2 was admitted to the hospital on 12/16/24, after
arriving to the ED in cardiopulmonary arrest.

Review of the Op Note dated 12/23/24 at 1200 hours, showed MD 1 performed a coronary artery bypass grafting surgery for Patient 2. Patient 2 was moved to the ICU in a stable hemodynamic and ventilatory status.

Review of the physician's order dated 12/23/24 at 1514 hours, showed the physician ordered to perform PWEP monitoring for Patient 2 on arrival, every two 2 hours for four occurrences, then every four hours if Patient 2 was stable. The order remained active until 1/2/25 at 2024 hours as an automatic discontinuation since the patient was discharged.

Review of Patient 2's medical record failed to show documentation of the PWEP measurements according to the physician's order.

On 1/7/24 at 1055 hours, an interview was conducted with the Director of ICU and Director of PI. The Director of ICU stated the PWEP measurements were not within the nursing scope of practice at the hospital and was only done by the physicians. The Director of ICU stated the ICU RN knew not to perform the PWEP measurement and released the order. The Director of ICU stated performing a PWEP measurement on the patient was very risky on a newly received cardiac bypass patient. When asked why the order was not clarified, the Director of ICU stated this was an ongoing issue with MD 1 and the OR for not clarifying the orders. The Director of PI stated that MD 1 stated the order was intended for the physicians or residents to perform the PWEP as necessary. The Director of PI acknowledged the physician's order lacked clarification indicating it was for the physician's exclusive use.

On 1/7/25 at 1650 hours, the above findings were shared and acknowledged by the CNO and Director of PI.