HospitalInspections.org

Based on interview and record review, the hospital failed to assess and evaluate care for two (1 and 2) of 30 sampled patients.

1. For Patient 1, the hospital failed to assess and document care and vital signs (pulse, respirations, blood pressure and oxygen saturation), when Patient 1 was transferred from a procedure unit to his room on a medical/surgical telemetry unit, (telemetry-a process of continuously measuring heart rate and rhythm remotely), which had the potential to result in a delay in recognition of impending deterioration of Patient 1's medical condition, which required Patient 1 to be transferred to an Intensive Care Unit (ICU) and be placed on a ventilator (a machine that breathes for the patient).

2. For Patient 2, the hospital failed to monitor his vital signs and telemetry after he returned from surgery which had the potential to result in a delay in recognition of a change in condition and treatment as he was recovering from major surgery.

Findings:

1. During a review of the clinical record for Patient 1, the "Nursing Procedural Sedation Record", dated 8/13/14, indicated Patient 1 was transferred from a procedure room/unit to his medical/surgical telemetry room at 3:45 PM by a hospital transporter. Patient 1's vital signs were recorded as taken at 3 PM in the procedure room and indicated he was receiving three liters of oxygen. His oxygen saturation (percentage of oxygen [O2] in his blood) was recorded as 94% at 3 PM. The "Nurses Progress Notes", dated 8/13/14, indicated he was returned to his room (on the medical/surgical telemetry unit), from a procedure in the Gastro-Intestinal (GI) laboratory at 4:30 PM (45 minutes after the "Nursing Procedural Sedation Record " indicated he was returned to his room.).

During a concurrent interview and record review for Patient 1, with Clinical Supervisor Registered Nurse (CSRN) 1, on 8/15/14 at 2:10 PM, the physician orders, dated 8/13/14, indicated Patient 1 was to be placed on telemetry to constantly monitor his EKG (electro cardiogram). CSRN 1 was unable to find Patient 1's EKG strips for 8/13/14, the day Patient 1 was sent to ICU. The telemetry log, dated 8/13/14, indicated the section of the form labeled "ALARM LIMITS VERIFIED BY RN [Registered Nurse]" was blank. CSRN 1 stated the alarm limits should be verified and documented by the RN for each shift.

The Interdisciplinary (IDT) note, dated 8/13/14 at 5:30 PM, indicated Licensed Nurse (LN) 1 placed oxygen at 2 liters per minute on Patient 1 because his O2 saturation had dropped to 88% (normal O2 saturation is 96-100%). The patient's physician was notified and ordered a chest x-ray (a specialized picture of the chest to look for internal abnormalities) "stat" (immediately). The next entry indicated the chest x-ray was done at 6:20 PM, (50 minutes after it was ordered). At 6:55 PM the IDT note indicated "Patient 1 was not breathing and was pulseless. There was no documentation of Patient 1's vital signs (including O2 saturation) between the time he returned from his GI procedure at 4:30 PM and 6:55 PM when he was found without respirations or pulse. Patient 1 was transferred to the ICU and placed on a ventilator after resuscitation attempts.

During an interview with LN 1 on 8/22/14 at 3 PM, she stated that she was not responsible for documenting vital signs, "I'm not the person that records the vital signs or checks the monitor settings". When asked if Patient 1's vital signs were stable after return from the GI laboratory, she stated, "The CNA (certified nurse assistant) came in and she took the vital signs. I went to do a discharge in another room and I heard the CNA telling Patient 1 to wake up, I went in and he had no pulse."

During an interview with CSRN 1, on 8/15/14, at 2:10 PM, she was unable to find documentation of Patient 1's vital signs upon transfer back to his medical/surgical telemetry room until he "coded" at 6:55 PM (three hours and 10 minutes later).

During a review of the clinical record for Patient 1, the "Physician's Progress Notes", dated 8/14/14, indicated in part"...CPR [cardiopulmonary resuscitation] was performed for approximately 30 minutes, cardiopulmonary arrest secondary to hypoxemia (lack of oxygen) vs hemorrhage (bleeding) ...CNS [Central Nervous System] depression from sedation (effect of medications given in the GI lab) ... "

2. During an interview with Quality Registered Nurse (QRN) 1, on 8/20/14 at 2 PM, she reviewed the clinical record for Patient 2 and was unable to find documentation of post-operative vital signs for Patient 2. The "Nurses Progress Notes", dated 8/15/14, indicated Patient 2 was returned to his room (on the medical/surgical telemetry unit), at 4:51 PM. The "Cumulative Vitals Report" dated 8/15/14 indicated no vital signs were documented between 4 PM and 9 PM the afternoon of his surgery. QRN 1 stated, "he should have had his vital signs taken frequently after surgery."

The nurse's notes, dated 8/17/14 at 3:57 AM, indicated Patient 2 was in sinus tachycardia (high heart rate) at 114 beats per minute. An order was then received to place Patient 2 on telemetry. The "Physician Orders" dated 8/17/14 indicated to notify the physician if his heart rate goes above 110 or below 50. Patient 2's baseline heart rate (normal heart rate) was between 80-90. The nurse's notes, dated 8/17/14 at 7:15 PM, indicated under "Alarm Settings" High:150 and low 40. This setting was set at 40 points over the physician's order indicating he wanted to be notified of a reading over 110.

The hospital policy and procedure titled "Assessment and Re-assessment of Patients", dated 5/2005, indicated "Reassess patients as needed based on patient's condition... TO INCLUDE... vital signs and pain assessment." The Policy and Procedure titled, "Continuous Monitoring Parameters", dated 2008 indicated in part, "At the start of the shift the licensed staff will verify that alarms are on and set according to physicians orders or unit standard. Licensed nurses will document verification of alarm settings at the beginning of each shift. The following will be documented on the unit specific flow sheet (as applicable)... patient's heart rate, respiratory rate, pulse oximetry, apnea and blood pressure."

Based on interview and record review, the hospital failed to ensure one nurse (1) was assigned patients which she was trained to care for. This failure had the potential for unmet care needs for those patients.

Findings:

During an interview with Licensed Nurse (LN) 2, on 8/20/14, at 8:20 AM, she stated she was a "float" to the Telemetry Unit referred to as 3C, (hospital unit which specializes in cardiac monitoring) who normally works in the Post Partum Unit (hospital unit which cares for women and newborns immediately after birth). She also stated she had five patients assigned to her; four of which were telemetry patients... "I don't have any telemetry (process where heart rate and rhythm are monitored remotely) training... I'm uncomfortable with it (caring for telemetry patients)... It's a bit overwhelming... I don't know how to read the strips (telemetry strips: a graphic tracing of the electrical activity of the heart)."

During a review of the Telemetry Unit "Staffing Report" dated 8/20/14, it indicated LN's assignment included Rooms 27 bed 1, 28 bed 3, 34 bed 2, and 35 bed 3.

During a review of the 3C "Census" dated 8/20/14, it indicated the patients in Rooms 27 bed 1, 28 bed 3, 34 bed 2, and 35 bed 3 were all telemetry patients.

During an interview with the Chief Nursing Officer, on 8/20/14, at 10:35 AM, she stated nursing assignments are done based on the nurses' competencies...if they are not telemetry trained...they should not be assigned to telemetry patients.

During an interview with the Director of Staff Development, on 8/20/14, at 12:45 PM, she reviewed the personnel record for LN 2, and was unable to find documentation of any telemetry training.

The hospital policy and procedure titled "Utilization of Nursing Staff and Staffing", dated 1/2012, indicated in part, "... Assignment of Nursing Personnel... Considerations in Assignment... Patient care responsibilities are assigned to nursing staff based on...staff competency... Competency of assigned personnel in relationship to knowledge and skills required to effectively provide care and utilize current technology..."