HospitalInspections.org

Based on staff interviews, clinical record review and facility investigation review, nursing staff failed to notify the physician when they identified a significant decline in a patient's condition which caused delay in providing interventions for Patient #1. The administrative staff reported a census of 19 current patients.

Failure to notify the physician of a decline in patient's condition could result in a delay in treatment causing harm to the patients.

Findings include:

Review of Patient #1's clinical chart revealed the patient presented to the CAH Emergency Room (ER) due to a fall at home on 7/12/12. Staff admitted the patient for observation for anemia, nausea/vomiting and status post fall at home.

Review of the Nurse's Notes revealed from 7/12 at 1:10 PM until 7/14 at 4:00 AM the patient was able to communicate with legible writing, had headaches relieved with Tylenol and could move their own feet during staff assisted transfers. On 7/14 at 4:00 AM the patient complained of a headache (not relived with Tylenol), a decline in handwriting (no longer legible) and could not move their own feet during staff assisted transfers. The patient had a fall in the hospital room on 7/14/12 at 7:45 AM, staff reported the fall to the physician, but failed to tell the physician about the decline in the patient's condition including the headache that was not relieved with Tylenol, decline in handwriting legibility, and increase in the level of assistance required during transfer. Staff notified the physician of the patient's increased need to attempt voiding at 12:36 PM, but, again, failed to report the patient's decline in condition. Staff notified the physician of the patient's decline in condition on 7/14/12 at 7:09 PM after a request by family because they identified a significant decline in the patient's condition.

During an interview on 7/25/12 at 7:50 AM, Staff A, Certified Nursing Assistant (CNA) stated she cared for the patient from 7/13 at 7:00 PM until 7/14 at 7:00 AM. The patient communicated by sign language and writing notes on paper, and transferred without difficulty at the beginning of the shift. At 4:00 AM the patient's condition changed. The patient complained of a headache and the headache was not relieved with Tylenol, the patient's handwriting became sloppy and hard to read, and the patient had difficulty moving their feet during transfers. CNA A notified the nurse of the decline in condition and that something was just not right with the patient. At 7:00 AM the patient signed they could see blood. The nurses were completing report just outside the patient's door and were notified the patient reported seeing blood.

During an interview on 7/25/12 at 7:25 AM, Staff B, Registered Nurse (RN) stated she cared for the patient from 7/13 at 11:00 PM until 7/14 at 7:00 AM. RN B said the patient's ability to assist during transfers declined toward the end of the shift. The patient could not move their legs as done during prior transfers. The patient received Tylenol for complaints of a headache, but the Tylenol was not effective. At the end of the shift, the patient had a hard time communicating needs to the staff. The Patient wrote the word blood and I thought the patient wanted a blood sugar check. The patient shook their head no when asked if they wanted a blood sugar check. At the end of my shift, I would notify the physician of any changes that occurred during the physician's rounds, but I did not report the change in transfers to the physician. I do not recall reporting the change with transfers or difficulty communicating to the oncoming nurse.

During an interview on 7/25/12 at 9:00 AM, Staff C CNA stated she cared for the patient on 7/14 at 7:00 AM. When transferring the patient at 7:45 AM using a gait belt, the patient leaned forward and I assisted the patient to the floor. The patient did not hit their head but obtained a bruise on the right hand. The nurse evaluated the patient and reported the fall to the physician. The Patient was alert at this time, but handwriting with communication was very scribbly. The family notified me of a change in the patient's ability to communicate with them (sign and read lips) at about 3:00 PM. I reported the concern to the unit secretary at 4:00 PM to report to the nurse because I could not locate the nurse. I did not notice any decline in the patient's condition from the start of my shift to the end.

During an interview on 7/25/12 at 8:10 AM, Staff D, RN stated he cared for the patient on 7/14 from 7:00 AM until 7:00 PM. Staff B reported the patient had an excruciating headache, Tylenol given for the headache and patient had increased confusion. The patient fell during report and I evaluated the patient at that time. The patient had a bruise on the right hand, but did not hit their head. I notified the physician of the fall and the physician ordered an x-ray of the hand. I did not tell the physician about the patient's headache or increased confusion. The patient's family was in the room from 10:00 AM until the end of the shift. At 5:30 PM, the family reported a change in the patient's ability to communicate. After an evaluation of the patient, I notified the physician and he ordered laboratory tests and a CT scan.

During an interview on 7/24/12 at 1:15 PM, Physician A, Medical Doctor (MD) reported evaluating the patient on 7/14 at 6:29 AM. According to Physician A, staff did not notify him of any change in condition at that time. Physician A stated he did not do a full neurological assessment at this time because the concerns identified for the hospitalization at that time were urinary tract infection, anemia, and dehydration. At the time of the evaluation, he documented the patient was alert with no new concerns. Physician A said if the patient had a change in condition, staff should have notified him of the change so proper tests and treatments could be initiated. Staff did not inform Physician A about the patient's decline in condition until 7/14/12 at 7:09 PM when tests and treatments were completed.

Facility documentation and staff interview showed staff was aware of the Patient's significant decline at approximately 4:00 AM on 7/14/12. However, facility staff failed to tell the physician about the Patient's change in condition for approximately 15 hours, which delayed treatment for the patient.