HospitalInspections.org

Based on documentation review, a review of 3 medical records, a review of 5 personnel files, interviews with hospital personnel, and observations in the hospital's emergency room, it was determined that in 1 of 3 medical records, medical record #1, a Registered Nurse failed to provide and evaluate the care for each patient appropriately and in accordance with acceptable standards of practice. The hospital failed to ensure that nursing services were provided in a safe and appropriate manner.

Findings included:

Medical records for 3 patients who received care in the Emergency Department (ED) of the hospital were selected and reviewed. The medical record for Patient #1 revealed the following:

Patient #1 was an 80 year-old woman who arrived in the ED at 0531 hours on 04/10/11 after a sudden onset of abdominal pain. A physician assessment revealed a plan to admit Patient #1 to the hospital with nasogastric tube decompression for an apparent small bowel obstruction. The medical record reflected that at 0758 hours, a nasogastric tube was placed by Registered Nurse (RN) #1, and at 0802 hours, Patient #1 "became acutely bradycardic and rapidly progressed into a pulseless electric activity cardiac arrest," per a document titled: "HISTORY AND PHYSICAL" dictation-dated "04/02/2011 5:50 PM" by a treating physician. After 22 minutes of Advanced Cardiac Life Support resuscitative effort, Patient #1 returned to a "perfusable rhythm." Patient #1 was sent for an "emergent non-contrast CT of (his/her) chest, abdomen, and pelvis," which revealed "extensive subcutaneous emphysema, pneumomediastinum, and pneumoperitoneum. There was no clear intra-abdominal source for her pneumoperitoneum. However, (Patient #1) is noted to be severely distended from the pneumoperitoneum with slightly elevated diaphragms." The history and physical documented that the treating physician met with the family of Patient #1 to review the patient's status, CT scan findings, the physician's concerns for Patient #1's extensive pneumoperitoneum, and not being able to discern the cause of that problem.

A document titled: "Physician Clinical report" and electronically signed by a treating physician on "04/01/2011 14:25" contained the following:

"CT chest with SBO (small bowel obstruction) and perforated bowel with R (right) sided PTX (pneumothorax).

The medical record contained information that a chest tube was placed in Patient #1 and that the patient was then taken to surgery for a laparotomy. Patient #1's abdomen was left open due to the development of abdominal compartment syndrome. After surgery, Patient #1 was taken to the intensive care unit of the hospital, where s/he failed to recover neurological function, and where the condition of Patient #1 further deteriorated over the next two days. Patient #1 died on 04/03/11 at 2010 hours with "profound progressive multiple organ dysfunction with hepatic, renal, pulmonary and cardiovascular deterioration" per a document titled: "EXPIRATION SUMMARY" dated 04/03/11 2029. A document titled: "Report of Deceased Patient" listed the cause of death as: "Multiple organ failure" and "Shock after cardiac arrest."

A copy of an incident report regarding an error which allegedly took place during the time of the insertion of a nasogastric tube into Patient #1 was requested. In an interview with the hospital's Nursing Director of Trauma, Emergency services, Critical Care, Oregon Burn Center and Respiratory Therapy on 04/11/11 at 1300 hours, s/he stated that during the "code" resuscitative efforts on 04/01/11, "The physicians were questioning why the patient was in PEA (pulseless electrical activity) and were discussing the possibilities, when (RN #2, who had assisted RN #1 in the insertion of the nasogastric tube) overheard them and wondered if they knew" that RN #1 had mistakenly connected the nasogastric tubing to the wall-mounted oxygen delivery system rather than to suction, and that the oxygen had been administered for 1-2 minutes before this error had been noted, which was immediately prior to the patient's cardiac arrest. The Director of Nursing stated that RN #2 then asked the ED Charge Nurse to step out of the active code activities on Patient #1, and RN #2 shared this information with his/her Charge Nurse. The Charge Nurse then called his/her Nursing Manager to inform him/her of the alleged incident, and then stepped back into the room where Patient #1 was being resuscitated. Upon his/her arrival at the ED, the Nursing Manager asked RN #1 to step out of the code situation, and confronted RN #1 with the allegation of an error in which the nasogastric tube was attached to oxygen rather than to suction for a period of 1 to 2 minutes. RN #1 admitted that the incident had occurred, and also confirmed that s/he had not informed the physicians participating in the ongoing code situation. The Director of Nursing stated that RN #1 then re-entered the code situation and informed the physicians of his/her practice error. The Director of Nursing stated, "But that wasn't (the doctor's) recollection, and (the doctor) is known as a very approachable (guy/gal)." The Director of Nursing stated that after the code activities for Patient #1 had concluded, RN #1 was directed to address each physician individually to discuss his/her patient treatment error, and his/her lack of communication concerning that error.

The Accreditation and Clinical Compliance Officer stated that s/he was unable to display the requested written incident report as this was "protected information," but that the Director of Nursing could read the report aloud. The Director of Nursing proceeded to read the contents of a white sheet of paper aloud. She stated:

"The NG (nasogastric tube) was placed without difficulty. The patient was immediately in pain. Placement of the NG was confirmed. The NG remained in the patient for one minute, and was disconnected from the oxygen when it was noted. The NG tube was removed at the same time. The patient Brady'd down (heart slowed from a normal rhythm to a bradycardia rhythm). The patient was moved to a critical bay. The code was started."

The Director of Nursing added that the incident report had been written by RN #1 on 04/01/11.

The personnel files for 5 RNs whose work assignment included the ED were reviewed. The personnel file for RN #1 contained the following:

A form titled: "Corrective Action," "Final Corrective Action," and dated "May 25, 2011," and signed by the ED Manager, which contained the following information:

"You did not 'Do the Right Thing' " and "You may have put your own interests above the interests of the patient" by not reporting the incident in a timely manner.

The form further described that RN #1 would not be allowed to function in the capacity of a charge nurse in the ED, and that s/he would not be able to mentor new nurses until she was able to "repair the trust" between his/herself and the physicians and staff members of the ED.

The Director of Nursing stated that since the incident, staff of the ED had participated in a "training scenario" regarding inserting nasogastric tubes and attaching the tubing to suction, then visually following the tubing all the way to the suction apparatus before turning the suction on, to prevent a reoccurrence of a similar incident. The Director of Nursing also stated that this had not yet been documented, as the training had not yet been completed with all staff members. The Director of Nursing also stated that the RNs of the ED had participated in a training termed "Critical Conversations," which included case studies in which RNs informed MDs of patient care errors. No documentation to confirm this training was discoverable in the RNs' personnel files or training records. The Director of Nursing stated that RN #1 had been required to read a book titled: "Critical Conversations" and would be submitting a written report about what s/he had learned by reading this book, but at the time of the investigation, this had not yet occurred.

The Director of Nursing stated that this incident had been analyzed for a root cause, and that the information discovered in the hospital's own investigation had been shared with other facilities throughout the hospital's system in order to prevent a similar error from reoccurring. S/he stated that while the information had been disseminated, it was up to individual managers how, or if, to disseminate this information to staff members who provided direct patient care. The Director of Nurses presented two pieces of paper titled: "NG Tube Connected to Oxygen" and dated "August 3, 2011." The papers included the following information:

"What Happened? An elderly female came to the ED with a small bowel obstruction. The nurse placed an NG tube and connected it to a valve and turned the valve on. The patient experienced severe abdominal pain, cardiac tamponade and cardiac arrest. She died several days later. What patient safety lessons do we want to share? CONFIRM NG TUBE CONNECTIONS. TRACE ALL LINES BACK TO THE CONNECTIONS TO CONFIRM THEY ARE CORRECT. REPORT ERRORS PROMPTLY. Humans make errors. Even if you do not know it is pertinent, you must tell a physician about an error promptly so she may use the information to assess the situation."

The Director of Nurses stated that a protocol change regarding NG tubes had been drafted in response to the incident, but had not yet become a protocol at the time of this investigation. The protocol was titled: "Verification of Gastric Tube Placement" and "Last Review Date: 08/11." The bottom of page 2 of 2 contained the following information: "Date: 7/22/2011 Type of Review: Minor Revision: Renumbered Procedure from 912 to 914 for system use. Changed product used from nitrazine to multi-dye pH strips."

The draft protocol did not contain information regarding connecting nasogastric tubing to suction, nor warning staff members not to connect nasogastric tubing to oxygen. This was confirmed with the Director of Nursing.

An observation of patient room #7 in the ED was completed; the Director of Nursing stated that this room was similar to the one in which the NG tube was inserted into Patient #1, and room #7 was the location of the NG insertion review with staff members of the ED. From the foot of the gurney looking toward the head of the gurney, the oxygen apparatus was on the left-hand side, the suction apparatus was on the right-hand side. The oxygen apparatus appeared distinctly different from the suction apparatus.

A significant error in patient care was made by a Registered Nurse working in the hospital, and a delay in communicating critical information related to that error occurred, not in keeping with acceptable standards of nursing practice.