HospitalInspections.org

Based on medical record reviews, policy reviews, and interviews, the Hospital failed to ensure an organized nursing services that provided care to patients in a manner consistent with hospital policy, standards of care, and physician orders.

The cumulative effects of this deficient practice have the potential to place patients at risk for unmet medical needs resulting in the deterioration of their health, safety and medical condition.


Findings Include:


1. The RN failed to monitor a patient's blood pressure for two hours and 15 minutes on 08/17/21 while the patient was receiving a bolus of 1000 milliliters (ml) of Normal Saline (NS) for a decrease in blood pressure (BP) for one (P3) of two patient records reviewed for monitoring during treatment of low BP from a sample of 10 patients. (Refer to tag A0395)

2. The RN failed to assess and document a patient's orthostatic BP for three days as ordered on 09/16/21 for one (P7) of one patient record reviewed with orders to assess a patient's orthostatic BP from a sample of 10 patients. (Refer to tag A0395)

3. The RN failed to notify the physician of a patient's change in condition as required by hospital policy for two (P1, P9) of four medical records reviewed with the patient experiencing a change in condition from a sample of 10 patients. (Refer to tag A0395)

4. The RN failed to perform and document wound care on 09/10/21 and 09/12/21 as ordered for one (P8) of five patient records reviewed for wound care from a sample of 10 patients. (Refer to tag A0395)

5. The RN failed to document a telephone order to transfer a patient and the cancellation of the transfer order when additional orders were received for treatment of the patient for one (P2) of three patient records reviewed who were transferred to a higher level of care from a sample of 10 patients. (Refer to tag A0395)

6. The RN failed complete wound care as order and failed to change the patient's suprapubic catheter on 09/15/21 as ordered by the physician for one (P8) of one patient record reviewed with orders to change the suprapubic catheter from a sample of 10 patients. (Refer to tag A0395)

7. The RN failed to document the administration of a fleets enema and the results of the enema for one (P6) of one patient record reviewed with orders to administer a fleets enema from a sample of 10 patients. (Refer to tag A0405)

Based on record review and interview the hospital failed to ensure one of ten patients (Patient, P5) was allowed to exercise their rights to be transferred to another hospital as requested and failed to ensure staff acted upon the request. Failure to allow a patient to exercise their rights places patient at risk for dissatisfaction in their care and the potential for poor health outcomes.


Findings Include:


Review of P5's "H&P," located under the "History & [and] Physical" tab, indicated it was completed by Advanced Practice Registered Nurse (APRN) 2 on 09/18/21 and signed by the Medical Director. Review indicated P5 was admitted on 09/17/21 for continued medical management related to a diagnosis of COVID-19 pneumonia with development of acute respiratory failure, ultimately requiring a tracheostomy (is a hole that surgeons make through the front of the neck and into the windpipe (trachea). A tracheostomy tube is placed into the hole to keep it open for breathing) and ECMO (extracorporeal membrane oxygenation whereby blood is pumped outside of the body to a heart-lung machine that removes carbon dioxide and sends oxygen-filled blood back to tissues in the body). P5 was admitted from the acute care hospital for further vent weaning and overall pulmonary management.

Review of the "Nursing Progress Note Page" section of the "24 Hour Care Record-1," indicated on 09/19/21 at 12:10 PM, RN5 documented, "Pt [patient] accuses that [pt] is being held against [pts] will. Pt states it is a violation of rights and that a felony is happening. AMA [against medical advice] papers offered. Educated pt to allow us to provide pt care. Call placed to pts mom. CNO [Chief Nursing Officer] notified." Further documented by RN5 at 12:20 PM indicated, "pt refuses to sign AMA. Demands transfer be put in place. RN educated pt that CM [case manager] can place calls in AM (Monday) pt yelled, pointed finger and hit bed demanding to be transferred now."

The RN failed to act upon a P5's request to be transferred.

There was no documentation that P5's attending physician, the Medical Director, was notified of P5's request to be transferred and no documentation of attempts to arrange a transfer.

In an interview on 09/21/21 at 2:26 PM, RN5 stated APRN2 was notified about P5's request for transfer. RN5 stated APRN2 responded, "there was no reason to transfer to a higher level of care." When asked why the medical record had no documentation of the report by RN5 to APRN2, RN5 stated there is no reason for not documenting the discussion with APRN2 "other than I got busy with another patient, and it never got put on paper." When the surveyor discussed patient rights with RN5, RN5 stated, "at that point I was following doctor's orders." RN5 stated P5 stated he/she was a veteran and was concerned about the bill, and P5 knew if he/she went to the veteran administration hospital, P5's bill would be taken care of.

In an interview on 09/21/21 at 2:43 PM, the Administrator stated he/she came in to help to move P5 to a new room, and P5 "seemed fine." Administrator stated he/she didn't speak with P5 about P5's previous request to be transferred. When asked by the surveyor why Administrator didn't speak with P5 about P5's previous request to be transferred, Administrator stated P5 seemed calm, so he/she didn't speak with P5 about it.

In an interview on 09/22/21 at 1:50 PM, the surveyor discussed with P5 the documented request in P5's medical record to be transferred on 09/19/21. P5 stated, "I requested Friday, Saturday, and Sunday to be transferred." When P5 was asked if he/she felt rights had been denied P5 stated, "yes, my rights were denied. I'm a veteran and was concerned about my medical bills and wanted to be sent to the VA [veteran administration] hospital."

Based on medical record reviews, policy reviews, and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care for six of ten patients (Patient (P)1, P2, P3, P7, P8, and P9) in accordance with physician orders, standards of nursing practice and hospital policy. This failure had the potential to affect the health status, safety, and response to medical interventions for the current 23 inpatients and any future patients admitted to the hospital for services.


Findings Include:


Review of the facility's policy titled "Documentation Requirements of the Medical Record," dated 08/01/21, indicated it was the policy of the hospital to provide guidelines for documentation requirements in patient medical records to include, ". . . 11. The medical record must contain results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. 12. The medical record must contain documentation of complications, hospital acquired infections, and unfavorable reactions to drugs and anesthesia. . . Pertinent progress notes should be recorded at the time of observation, be sufficient to permit continuity of care, and transferability. Progress notes must give a chronological report of the patient's course in the hospital and reflect any change in condition and the results of treatment. . . All orders for treatment should be in writing. A verbal order shall be considered to be in writing, if dictated to a duly authorized person functioning within their sphere of competence and signed by the responsible practitioner. All orders dictated over the telephone should be signed by the appropriately authorized person to whom dictated, noting the name of the practitioner to whom dictated, "slash", and the name of the individual taking the order. The responsible practitioner must then authenticate such orders. . . All medications administered to the patient shall be documented on the Medication Administration Record in accordance with hospital policy and formulary. . .Nurses; notes give a chronological picture of the nursing care and the patient's reaction to it. Nurses' notes should include the manner of admission and of discharge, daily observations about the patient, and a record of medications and treatment given. . . Decubitus ulcers should be described to include size, color, drainage, and location. . ."

Review of the facility's policy titled, "Physician Notification of Change in Condition," revised 01/09/19, indicated, ". . . The physician will be notified immediately of any adverse changes in a patient's condition. Procedure: The attending physician will be notified immediately . . . of any significant change in the patient's condition, including, but not limited to: Change in level of consciousness Excessive Bleeding Significant changes in vital signs Shortness of breath, respiratory depression, cyanosis Excessive pain Critical labs . . . If any change in condition occurs that will necessitate a transfer to a higher level of care, an order must be written or received by the attending physician. Patients can be transferred immediately to a higher level of care with the approval of the Chief Clinical Officer or designee if the patient's physician cannot be immediately reached, and it is felt a higher level of care is immediately necessary to safeguard the patient's health and safety. Responsibility: It is the responsibility of the nurse assigned to the patient to determine that the patient's condition has changed significantly and to notify the patient's attending physician. The nurse or designee shall notify the patient's family or significant other of the condition change and status as soon as possible and document this in the medical record."


Patient 1

Review of P1's History and Physical (H&P), dictated 07/03/21 by Medical Doctor (MD)1, indicated P1 was morbidly obese with a complex medical history who presented for long-term acute care following a prolonged hospitalization for a subtotal colectomy (bowel reception of the large bowel) performed on 03/30/21, a further re-exploration and small bowel resection on 03/31/21, an ileocolonic anastomosis (the joining together of the end of the ileum, or small intestine, to the first part of the large intestine, called the colon) on 04/02/21, a further exploratory laparotomy (a surgical procedure involving small incisions through the abdominal wall to gain access into the abdominal cavity) for revision of an anastomotic leak (a leak of luminal contents from a surgical join) with abdominal wall closure with Phasix (brand name) mesh and wound VAC (vacuum assisted closure) placement on 04/05/21, and had full-thickness skin graft (procedure to provide epidermis, dermis, and subcutaneous tissue with great pliability which is useful for the reconstruction of defects) from a donor site on the left lateral thigh performed on 06/28/21.

Review of documentation of the "Nursing Progress Note Page" located on page seven and eight of the "24-Hour Care Record-1" (a document containing all information related to the nursing care and assessment of the patient for each day) in the hard chart (a paper based medical record system) for P1 revealed urine output had been measured in cubic centimeters (cc) at the beginning of the hospital stay indicating the staff were able to collect and measure urine output. Later urine output documentation was changed to the number of times voided (urinate) per shift. Documentation on 07/21/21 on the output record indicated "incontinent." On 07/22/21, documentation indicated P1 had one urine output on the day shift (7:00 AM to 7:00 PM) and one urine output on the night shift (7:00 PM to 7:00 AM). Normal urinary output for a healthy adult is 400 to 2000 milliliters (ml) daily with a normal intake of about two liters per day. Urine output of 500 ml is generally considered adequate for normal function. Review of nursing documentation on 07/23/21 indicated there was no documentation that P1 had any urine output from 7:00 AM through 9:00 PM.

There was no documentation that the nurse reported the decrease/absence of urinary output to the nurse practitioner or the attending physician. P1 was transferred to an acute care hospital on 07/23/21 at 9:00 PM related to decreasing BP.

Review of P1's "Nursing Progress Note Page" dated 07/23/21 indicated the following documentation by Registered Nurse (RN) 3:

8:20 PM "VS [vital signs] done, pt [patient] lethargy at the moment, no responding to command, can open eyes to touch, labor breathing at the moment, family by the bedside . . ." There was no documentation that the charge nurse and physician were notified of the change in P1's condition.

8:30 PM "Bath given to the pt, still no responding to commands. BP [blood pressure] of 106/51 at the moment."

8:45 PM "BP decreasing at the moment, labor breathing notice, pt no responding to command, charge nurse notified."

There was no documentation that the physician was notified of the change in P1's condition.

9:00 PM "BP dropping and pt unstable, bipap (a device used for the treatment for sleep apnea and other health conditions that impact breathing) implemented and no changes. [Physician (MD) 2] notified, order received to send the pt out."

In an interview on 09/21/21 at 10:12 PM, RN3, when asked by the surveyor why she gave a bath when P1 had labored breathing and was lethargic and didn't notify the physician, she stated the day before he was so sleepy, and he woke up with the bath. When asked if P1 had labored
breathing the day before, she stated "no, he was just sleepy."

In an interview on 09/21/21 at 11:06 AM, Licensed Practical Nurse (LPN) stated "I don't think it was passed on to me that [P1] only voided once, but it would seem unusual to have only one voiding in 12 hours." LPN stated the aides document the voiding on the "24-Hour Care Record-1". LPN stated he/she probably reviewed it. During this interview, after reviewing the notes of 07/23/21 regarding no urinary output, LPN stated "I guess I shouldn't depend so much on the aides telling me." LPN confirmed he/she can't be certain whether P1 voided or not. LPN stated, "I know if [P1] had not voided the entire shift, I would have told the charge nurse." LPN confirmed it would have been his/her responsibility to review aide documentation and note the change in urinary output. After reviewing P1's nursing record, LPN stated there was no documentation the charge nurse was notified P1 had not voided during the shift. LPN stated not voiding should have been reported to the physician.

In an interview on 09/22/21 at 11:20 AM, Administrator stated any change in a patient's condition should be reported to the patient's physician. Administrator confirmed the above-documented findings should have been reported P1's physician.


Patient 2

Review of P2's "Nursing Progress Note Page" section of the "24 Hour Care Record-1" documentation by RN1 on 07/24/21 at 11:00 PM indicated "Unable to obtain blood pressure at this time after several attempts. Pt would possibly benefit in acute setting ICU [intensive care unit] [with] internal pressure monitoring. [MD3] notified of pt condition and lack of ability to obtain BP. Order to send out to acute hospital and notify attending [Medical Director]. Order from [Medical Director] to bolus one-liter NS [normal saline] now." Review of P2's physician orders indicated no documentation by Registered Nurse (RN)1 of the telephone order received from MD3 to transfer P2. Review of RN1's nursing documentation indicated no documentation on 07/24/21 that RN1 informed Medical Director that MD3 had ordered P2 to be transferred.

Review of P2's "24 Hour Care Record-1" dated 07/24/21 indicated P2's blood pressure (BP) was 73/40 at 8:00 AM, 106/57 at 11:00 AM, 102/55 at 2:00 PM, and 81/39 at 9:00 PM. Normal blood pressure is 120/80. Review of P2's "Nursing Progress Note Page" of the "24-Hour Care Record-1" dated 07/24/21 indicated there was no documentation by the nursing staff until 9:30 PM. At 9:30 PM on 07/24/21 RN1 documented "Multiple attempts to obtain blood pressure with several different Dynamaps [automatic blood pressure machine] as well as 3 different manual blood pressure cuffs. Systolic pressure extremely hard to see on spygnometer [sic] cuff. Automatic cuff not working at this time. Blood pressure observed at 2125 [9:25 PM] of 81/39. Levophed (medication used to treat life-threatening low blood pressure that can occur with certain medical conditions or surgical procedures) drip started at 10 mcg. mm [micrograms per millimeter] . . ." At 11:00 PM RN1 documented "Unable to obtain blood pressure at this time after several attempts. . . [MD3] notified of pt. condition and lack of ability to obtain BP. Order to send out to acute hospital and notify attending [Medical Director]. Order from [Medical Director] to bolus 1-liter NS now. . ." RN1 documented at 5:00 AM on 07/25/21 that "Pt maintaining low BP most of evening with Levophed drip running at a hold rate of 19 mcg/mm per [Medical Director]. Pt is continually hemodynamically unstable (abnormal or unstable blood pressure that results in improper circulation and organs of the body do not receive adequate blood flow) since admission and all efforts to stabilize are unsuccessful. 500 ml bolus [name of solution not documented] order by [Medical Director]." Review of documentation by the nursing assuming care of P2 on 07/25/21 at 7:30 A< indicated "hypotensive/tachycardic/afebrile/minimal response to noxious stimuli. BUE [bilateral upper extremity] & [and] BLE [bilateral lower extremity] noted to have cyanotic appearance with sluggish refill. Levophed drip continued. Chest x-ray and labs done. Foley draining scant amount amber urine. Rectal tube draining watery malodorous feces. Watery brown leakage from trach tube/suctioned with similar drainage noted. Skin cool/cold/diaphoretic (clammy) with poor turgor. Pulse thready in BUE/BLE. PCP [primary care physician] notified of assessment findings. "

There was no documentation after this entry on the narrative nursing note until 11:30 AM when "EMS [emergency medical service] activated per PCP r/t [related to] continued decline without meaningful response to interventions."

Review of P2's physician orders dated 07/24/21 showed the following:

4:00 PM Start a Dopamine drip (second line drug for symptomatic slow heart rate and low blood pressure with signs and symptoms of shock) per protocol to keep the systolic blood pressure (SBP) above 90 millimeters mercury (mm Hg).

7:30 PM Stop Dopamine and start Levophed drip per protocol to keep SBP above 90 mm Hg.

10:50 PM Give one-liter Normal Saline (NS) now.

4:45 AM on 07/25/21 Give a bolus of 500 milliliters (ml) NS.

7:15 AM on 07/25/21 Give a bolus of 500 ml NS, get a stat chest x-ray, draw a CBC (complete blood count - blood test used to evaluate overall health and detect a wide range of disorders, including anemia, infection and leukemia), CMP (comprehensive metabolic panel - test that measures 14 different substances in your blood and provides important information about the body's chemical balance and metabolism), ABGs (arterial blood gas - test used to check the function of the patient's lungs and how well they are able to move oxygen into the blood and remove carbon dioxide), and continue Levophed.

7:30 AM Get a KUB (x-ray of kidneys, ureters, and bladder) for high residual from PEG (percutaneous endoscopic gastrostomy - feeding tube used to allow the patient to receive nutrition through the stomach) and transfer to the acute care hospital.

There was no documentation of P2's blood pressure and heart rate after 9:25 PM on 07/24/21 (patient was treated for 14 hours 30 minutes without documentation of vital signs).

In an interview on 09/21/21 at 12:15 PM, RN1 stated when he/she contacted the Medical Director, the Medical Director didn't want P2 transferred and gave orders for treatment. RN1 stated he/she may have written the order wrong, because MD3 wanted RN1 to call Medical Director, and when RN1 did so, Medical Director gave RN1 more orders. RN1 confirmed he/she did not write MD3's telephone order to transfer P2 and did not write Medical Director's order to cancel the transfer order. RN1 offered no explanation for vital signs not being documented while P2 was receiving Levophed.


Patient 3

Review of P3's H&P documented by MD1 on 08/01/21, indicated P3 was admitted on 07/31/21 with diagnoses of infection following a procedure, persistent postprocedural fistula (an abnormal connection between two body parts, such as an organ or blood vessel and another structure), unspecified severe protein-calorie malnutrition, Crohn's disease (A chronic inflammation of the digestive tract that leads to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition), pressure ulcer right heel, pressure ulcer of other site, malaise, and anemia.

Review of "Nursing Progress Note Page" section of the "24 Hour Care Record-1" in the medical record for P3 indicated a note on 08/17/21 by RN4 at 7:00 PM that P3 was noted to be lethargic, had a BP of 85/38, pulse 133, and the rechecked BP was 70/35, pulse 131. RN4 indicated the charge nurse and MD1 were notified. Documentation indicated at 8:00 PM a bolus of Normal Saline (NS) 500 Milliliters (ml) was administered as ordered. At 8:30 PM, RN4 documented P3's BP was 78/41, pulse 125. RN4 notified MD1, and new orders were given. At 9:00 PM, 1000 ml bolus of NS was begun as ordered. At 10:45, PM RN4 documented that the 1000 ml bolus of NS was completed, and P3's BP was 71/41, pulse 124. RN4 documented that RN4 notified MD1, and orders were received to transfer P3 to the acute care hospital.

There was no documentation of P3 being transported and the method of transportation used.

There was no documentation that RN4 assessed P3's BP and pulse from 8:30 PM to 10:45 PM (2 hours 15 minutes) while the bolus NS was being administered to determine whether the blood pressure remained low, dropped lower, or had increased to a normal blood pressure range of 120/80.

In an interview on 09/21/21 at 11:40 AM, RN4 stated P3's BP was in the systolic (the top number, measures the force your heart exerts on the walls of your arteries each time it beats) range of the 70s or 80s while P3 was receiving the bolus NS. RN4 stated two companies were called to transport P3 but would not be available for two to three hours, so the charge nurse told RN4 to call 911, and an ambulance came to transport P3. RN4 stated if the BP had gone down further than what was recorded initially, he/she would have documented it. RN4 confirmed he/she should have documented the BP readings from 8:30 PM to 10:45 PM and P3's transport in the medical record. RN4 stated he/she also had six patients that night which might have prevented documenting the BPs and transport.


Patient 7

Review of P7's medical record indicated an admission date of 09/15/21. Review of P7's physician orders, located under the "Physician Order" tab, indicated an order on 09/16/21 at 3:30 PM to check orthostatic BP (checking the patient's blood pressure sitting and standing to assess for orthostatic hypotension- a condition in which your blood quickly drops when you stand up from a sitting or lying position) every day for three days. Review of the MAR, located under the "Medication" tab, indicated on 09/16/21 at 8:00 PM a BP of 148/64 was documented with no documentation of whether it was taken with P7 lying, sitting, or standing. Review of P7's "24 Hour Patient care Record-1," located under the "Nurses Notes" tab, indicated a BP of 148/64 was documented at 8:00 PM with notation of "orthostatic/standing." There was no documentation of P7's BP while lying and sitting. Review of the MAR for 09/18/21 indicated documentation of "orthostatic BP lying ___ sitting ___ standing ___" with no BP documented on each line. Review of P7's nurses' notes for 09/16/21 and 09/18/21 indicated no documentation of orthostatic blood pressures as ordered and no documentation that the physician was notified that the orthostatic blood pressures were not assessed.

The RN failed to assess and document a P7's orthostatic BP for three days as ordered.

In an interview on 09/21/21 at 12:00 PM, RN5 confirmed P7's orthostatic BP was not assessed as ordered.


Patient 8

Review of P8's physician order on 09/10/21 at 12:10 PM, located under the "Physician Order" tab, indicated, "Dakins [a solution used to clean wounds] soaked kerlix to L [left] heel [triangle sign indicating change] BID [twice a day]. hydrofoam blue [a type of wound dressing] to coccyx." There was no documentation of the frequency ordered for wound care to the coccyx.

Review of P8's admission nursing assessment dated 09/10/21, located under the "Nurses Notes" tab, indicated "quarter size Stage IV decubitus ulcer" and "Stage IV pressure wound L heel - large." Review of P8's nurses notes for 09/10/21 and 09/12/21 indicated there was no documentation that wound care had been performed to P8's decubitus ulcer located on the coccyx or the left heel.

The RN failed to perform and document wound care on 09/10/21 and 09/12/21 as ordered.

Review of P8's "physician order" from Medical Director on 09/13/21 at 11:20 AM indicated "On 9/15/21 [triangle indicating change] patient's SP [suprapubic] catheter [with] same sized catheter or one size larger than currently using. 10 ml balloon. Flush catheter PRN [as needed] clots/clogs per [name of transferring physician] order."

Review of P8's MAR for 09/15/21 and the nurses notes for 09/15/21 indicated there was no documentation that P8's suprapubic catheter had been changed and flushed as ordered.

In an interview on 09/22/21 at 9:40 AM, RN5 stated he/she was sure that he/she looked at P8's heel wound but agreed there is no documentation of the appearance of the heel wound. RN5 stated the admit was a Friday, and the TAR [treatment administration record] starts on Monday (doesn't include the weekend days). After review of the chart, RN5 confirmed there was no documentation that wound care was done on 09/10/21 and 09/12/21 as ordered. RN5 offered no explanation of the reason the wound care was not done. RN5 confirmed there was no documentation that the SP catheter was changed as ordered. RN5 indicated he/she had not been able to reach the nurse who provided P8's care on 09/15/21 to determine if the catheter had been changed and had not been documented.


Patient 9

Review of P9's medical record indicated P9 was admitted on 09/15/21 with diagnoses that included acute-on-chronic respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) with hypoxia (low oxygen level in tissues), acute-on-chronic renal disease, stage 3 to stage 4, now hemodialysis (a process of purifying the blood of a person whose kidneys are not working normally) dependent,

Review of P9's "Nursing Progress Note Page" section of the "24 Hour Care Record-1," dated 09/16/21 at 8:00 PM indicated P9's BP was 76/48. Review of RN6's documentation on 09/16/21 at 7:35 PM indicated, "VS [vital signs] WNL [within normal limits] ([arrow pointing down] BP - normal for pt)." There was no documentation that RN6 notified the physician or charge nurse of P9's low BP. Review of P9's nurses notes of 09/17/21 indicated P9's BP at 8:00 PM was 72/48. Review of RN6's documentation at 7:40 PM indicated "VS WNL except [arrow pointing down] BP r/t [related to] dialysis. Gave pt ½ mug of ice water to drink. . ." There was no documentation that RN6 notified the physician or charge nurse of P9's low BP.

There was no documentation that P9's blood pressure was reassessed by RN6 on 09/16/21 after 8:00 PM and on 09/17/21 after 8:00 PM.

Further review of documentation in "Nursing Progress Note Page" section of the "24 Hour Care Record-1," for P9 indicated BP on 09/16/21 as 117/45, on 09/17/21 at 7:00 AM as 114/46, at 11:00 AM as 133/66, and at 3:00 PM as 151/67.

The RN failed to notify the physician of a P9's change in condition as required by hospital policy.

In an interview on 09/22/21 at 11:20 AM, the Administrator stated according to hospital policy regarding a change in condition, the nurse should have notified the physician or nurse practitioner of P9's low BP.

Based on record review, policy review and interview the hospital failed to ensure the registered nurse (RN) administrated and documented a medication in accordance with physician orders, standards of nursing practice and hospital policy for one of 10 sampled patients, Patient 6, (P6). Failure to administer and document medications in accordance with physician orders, standards of nursing practice and hospital policy has the potential to place patient at risk for poor health outcomes and unmet medical needs.


Findings Include:


Review of the facility's policy titled "Documentation Requirements of the Medical Record," dated 08/01/21 showed, ...Medication Administration Records: All medications administered to the patient shall be documented on the Medication Administration Record in accordance with hospital policy and formulary. Nurses' Notes: Nurses' notes give a chronological picture of the nursing care and the patient's reaction to it ... ...and a record of medications and treatment given.

Review of P6's physician orders, located under the "Physician Orders" tab, indicated an order on 09/14/21 at 9:00 AM from Medical Director to administer a "fleets enema per rectum times one now."

Review of P6's Medication Administration Record (MAR), located under the "Medication" tab, and RN8's documentation, located under the "Nursing Progress Note Page" section of the "24 Hour Care Record-1," indicated there was no documentation that a fleets enema had been administered or if the fleets enema was effective.

Review of documentation on the "Nursing Progress Note Page" by RN8 on 09/14/21 at 9:00 AM indicated "Pt. [P6] alert et [and] awake, groaning et yelling out "I hurt so bad." Pt continues [with] description of being up all-night having bowel movements. [Medical Director] present during assessment. Tylenol provided. Assisted to bedpan. Small soft stool passed."

There was no documentation that a fleets enema had been administered or if the fleets enema was effective.

In an interview on 09/21/21 at 4:15 PM, RN4 presented an "All Device Events Report" (a report of supplies removed) showing that an enema had been signed out for P6 on 09/14/21 at 8:45 AM by RN8. RN4 stated the nurse failed to document the nurse had administered the enema and the results of the enema. When asked by the surveyor how RN4 knew that RN8 had administered the enema, RN4 stated RN4 did not know whether the enema was administered. RN4 stated RN4 could only say that an enema was removed from stock by RN8 at the time the enema was ordered. RN8 was not available to be interviewed.

Based on record review, policy review and interview the hospital failed to ensure all information necessary to monitor the patient's condition was documented in the medical record for eight of ten records reviewed. Failure to ensure all information necessary to monitor the patient's condition is documented in the medical record places patients at risk for unidentified medical needs and harm.

Findings Include:

Review of the facility's policy titled "Documentation Requirements of the Medical Record," dated 08/01/21, indicated it was the policy of the hospital to provide guidelines for documentation requirements in patient medical records to include, ". . . 11. The medical record must contain results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. 12. The medical record must contain documentation of complications, . . . Pertinent progress notes should be recorded at the time of observation, be sufficient to permit continuity of care, and transferability. . . All orders for treatment should be in writing. . .. All medications administered to the patient shall be documented on the Medication Administration Record in accordance with hospital policy and formulary. . .Nurses; notes give a chronological picture of the nursing care and the patient's reaction to it. Nurses' notes should include ...daily observations about the patient, and a record of medications and treatment given. . . Decubitus ulcers should be described to include size, color, drainage, and location. . ."


Patient 1

Review of P1's History and Physical (H&P), dictated 07/03/21 by Medical Doctor (MD)1, indicated P1 was morbidly obese with a complex medical history who presented for long-term acute care following a prolonged hospitalization for a subtotal colectomy (bowel reception of the large bowel) performed on 03/30/21, a further re-exploration and small bowel resection on 03/31/21, an ileocolonic anastomosis (the joining together of the end of the ileum, or small intestine, to the first part of the large intestine, called the colon) on 04/02/21, a further exploratory laparotomy (a surgical procedure involving small incisions through the abdominal wall to gain access into the abdominal cavity) for revision of an anastomotic leak (a leak of luminal contents from a surgical join) with abdominal wall closure with Phasix (brand name) mesh and wound VAC (vacuum assisted closure) placement on 04/05/21, and had full-thickness skin graft (procedure to provide epidermis, dermis, and subcutaneous tissue with great pliability which is useful for the reconstruction of defects) from a donor site on the left lateral thigh performed on 06/28/21.

Review of documentation of the "Nursing Progress Note Page" located on page seven and eight of the "24-Hour Care Record-1" (a document containing all information related to the nursing care and assessment of the patient for each day) in the hard chart (a paper based medical record system) for P1 revealed urine output had been measured in cubic centimeters (cc) at the beginning of the hospital stay indicating the staff were able to collect and measure urine output. Later urine output documentation was changed to the number of times voided (urinate) per shift. Documentation on 07/21/21 on the output record indicated "incontinent." On 07/22/21, documentation indicated P1 had one urine output on the day shift (7:00 AM to 7:00 PM) and one urine output on the night shift (7:00 PM to 7:00 AM). Normal urinary output for a healthy adult is 400 to 2000 milliliters (ml) daily with a normal intake of about two liters per day. Urine output of 500 ml is generally considered adequate for normal function.

Review of nursing documentation indicated there was no documentation that P1 had any urine output on 07/23/21 from 7:00 AM through 9:00 PM.

There was no documentation that the nurse reported the decrease/absence of urinary output to the nurse practitioner or the attending physician.

In an interview on 09/21/21 at 11:06 AM, Licensed Practical Nurse (LPN) stated "I don't think it was passed on to me that [P1] only voided once, but it would seem unusual to have only one voiding in 12 hours." LPN stated the aides document the voiding on the "24-Hour Care Record-1". LPN stated he/she probably reviewed it. During this interview, after reviewing the notes of 07/23/21 regarding no urinary output, LPN stated "I guess I shouldn't depend so much on the aides telling me." LPN confirmed it would have been his/her responsibility to review aide documentation and note the change in urinary output. After reviewing P1's nursing record, LPN stated there was no documentation the charge nurse was notified P1 had not voided during the shift.


Patient 2

Review of P2's "Nursing Progress Note Page" section of the "24 Hour Care Record-1" documentation by RN1 on 07/24/21 at 11:00 PM indicated "Unable to obtain blood pressure at this time after several attempts. Pt would possibly benefit in acute setting ICU [intensive care unit] [with] internal pressure monitoring. [MD3] notified of pt condition and lack of ability to obtain BP. Order to send out to acute hospital and notify attending [Medical Director]. Order from [Medical Director] to bolus one-liter NS [normal saline] now." Review of P2's physician orders indicated no documentation by Registered Nurse (RN)1 of the telephone order received from MD3 to transfer P2. Review of RN1's nursing documentation indicated no documentation on 07/24/21 that RN1 informed Medical Director that MD3 had ordered P2 to be transferred.

Review of P2's "24 Hour Care Record-1" dated 07/24/21 indicated P2's blood pressure (BP) was 73/40 at 8:00 AM, 106/57 at 11:00 AM, 102/55 at 2:00 PM, and 81/39 at 9:00 PM. Normal blood pressure is 120/80. Review of P2's "Nursing Progress Note Page" of the "24-Hour Care Record-1" dated 07/24/21 indicated there was no documentation by the nursing staff until 9:30 PM. At 9:30 PM on 07/24/21 RN1 documented "Multiple attempts to obtain blood pressure with several different Dynamaps [automatic blood pressure machine] as well as 3 different manual blood pressure cuffs. Systolic pressure extremely hard to see on spygnometer [sic] cuff. Automatic cuff not working at this time. Blood pressure observed at 2125 [9:25 PM] of 81/39. Levophed (medication used to treat life-threatening low blood pressure that can occur with certain medical conditions or surgical procedures) drip started at 10 mcg. mm [micrograms per millimeter] . . ." At 11:00 PM RN1 documented "Unable to obtain blood pressure at this time after several attempts. . . [MD3] notified of pt. condition and lack of ability to obtain BP. Order to send out to acute hospital and notify attending [Medical Director]. Order from [Medical Director] to bolus 1-liter NS now. . ." RN1 documented at 5:00 AM on 07/25/21 that "Pt maintaining low BP most of evening with Levophed drip running at a hold rate of 19 mcg/mm per [Medical Director]. Pt is continually hemodynamically unstable (abnormal or unstable blood pressure that results in improper circulation and organs of the body do not receive adequate blood flow) since admission and all efforts to stabilize are unsuccessful. 500 ml bolus [name of solution not documented] order by [Medical Director]." Review of documentation by the nursing assuming care of P2 on 07/25/21 at 7:30 A< indicated "hypotensive/tachycardic/afebrile/minimal response to noxious stimuli. BUE [bilateral upper extremity] & [and] BLE [bilateral lower extremity] noted to have cyanotic appearance with sluggish refill. Levophed drip continued. Chest x-ray and labs done. Foley draining scant amount amber urine. Rectal tube draining watery malodorous feces. Watery brown leakage from trach tube/suctioned with similar drainage noted. Skin cool/cold/diaphoretic (clammy) with poor turgor. Pulse thready in BUE/BLE. PCP [primary care physician] notified of assessment findings. "

There was no documentation after this entry on the narrative nursing note until 11:30 AM when "EMS [emergency medical service] activated per PCP r/t [related to] continued decline without meaningful response to interventions."

There was no documentation of P2's blood pressure and heart rate after 9:25 PM on 07/24/21 (patient was treated for 14 hours 30 minutes without documentation of vital signs).

In an interview on 09/21/21 at 12:15 PM, RN1 stated when he/she contacted the Medical Director, the Medical Director didn't want P2 transferred and gave orders for treatment. RN1 stated he/she may have written the order wrong, because MD3 wanted RN1 to call Medical Director, and when RN1 did so, Medical Director gave RN1 more orders. RN1 confirmed he/she did not write MD3's telephone order to transfer P2 and did not write Medical Director's order to cancel the transfer order. RN1 offered no explanation for vital signs not being documented while P2 was receiving Levophed.


Patient 3

Review of P3's H&P documented by MD1 on 08/01/21, indicated P3 was admitted on 07/31/21 with diagnoses of infection following a procedure, persistent postprocedural fistula (an abnormal connection between two body parts, such as an organ or blood vessel and another structure), unspecified severe protein-calorie malnutrition, Crohn's disease (A chronic inflammation of the digestive tract that leads to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition), pressure ulcer right heel, pressure ulcer of other site, malaise, and anemia.

Review of "Nursing Progress Note Page" section of the "24 Hour Care Record-1" in the medical record for P3 indicated a note on 08/17/21 by RN4 at 7:00 PM that P3 was noted to be lethargic, had a BP of 85/38, pulse 133, and the rechecked BP was 70/35, pulse 131. RN4 indicated the charge nurse and MD1 were notified. Documentation indicated at 8:00 PM a bolus of Normal Saline (NS) 500 Milliliters (ml) was administered as ordered. At 8:30 PM, RN4 documented P3's BP was 78/41, pulse 125. RN4 notified MD1, and new orders were given. At 9:00 PM, 1000 ml bolus of NS was begun as ordered. At 10:45, PM RN4 documented that the 1000 ml bolus of NS was completed, and P3's BP was 71/41, pulse 124. RN4 documented that RN4 notified MD1, and orders were received to transfer P3 to the acute care hospital.

There was no documentation of P3 being transported and the method of transportation used.

There was no documentation that RN4 assessed P3's BP and pulse from 8:30 PM to 10:45 PM (2 hours 15 minutes) while the bolus NS was being administered to determine whether the blood pressure remained low, dropped lower, or had increased to a normal blood pressure range of 120/80.

In an interview on 09/21/21 at 11:40 AM, RN4 stated P3's BP was in the systolic (the top number, measures the force your heart exerts on the walls of your arteries each time it beats) range of the 70s or 80s while P3 was receiving the bolus NS. RN4 stated two companies were called to transport P3 but would not be available for two to three hours, so the charge nurse told RN4 to call 911, and an ambulance came to transport P3. RN4 stated if the BP had gone down further than what was recorded initially, he/she would have documented it. RN4 confirmed he/she should have documented the BP readings from 8:30 PM to 10:45 PM and P3's transport in the medical record. RN4 stated he/she also had six patients that night which might have prevented documenting the BPs and transport.


Patient 5

Review of P5's "H&P," located under the "History & [and] Physical" tab, indicated it was completed by Advanced Practice Registered Nurse (APRN) 2 on 09/18/21 and signed by the Medical Director. Review indicated P5 was admitted on 09/17/21 for continued medical management related to a diagnosis of COVID-19 pneumonia with development of acute respiratory failure, ultimately requiring a tracheostomy (is a hole that surgeons make through the front of the neck and into the windpipe (trachea). A tracheostomy tube is placed into the hole to keep it open for breathing) and ECMO (extracorporeal membrane oxygenation whereby blood is pumped outside of the body to a heart-lung machine that removes carbon dioxide and sends oxygen-filled blood back to tissues in the body). P5 was admitted from the acute care hospital for further vent weaning and overall pulmonary management.

Review of the "Nursing Progress Note Page" section of the "24 Hour Care Record-1," indicated on 09/19/21 at 12:10 PM, RN5 documented, "Pt [patient] accuses that [pt] is being held against [pts] will. Pt states it is a violation of rights and that a felony is happening. AMA [against medical advice] papers offered. Educated pt to allow us to provide pt care. Call placed to pts mom. CNO [Chief Nursing Officer] notified." Further documented by RN5 at 12:20 PM indicated, "pt refuses to sign AMA. Demands transfer be put in place. RN educated pt that CM [case manager] can place calls in AM (Monday) pt yelled, pointed finger and hit bed demanding to be transferred now."
There was no documentation that P5's attending physician, the Medical Director, was notified of P5's request to be transferred and no documentation of attempts to arrange a transfer.

In an interview on 09/21/21 at 2:26 PM, RN5 stated APRN2 was notified about P5's request for transfer. When asked why the medical record had no documentation of the report by RN5 to APRN2, RN5 stated there is no reason for not documenting the discussion with APRN2 "other than I got busy with another patient, and it never got put on paper."



Patient 6

Review of P6's physician orders, located under the "Physician Orders" tab, indicated an order on 09/14/21 at 9:00 AM from Medical Director to administer a "fleets enema per rectum times one now."

Review of P6's Medication Administration Record (MAR), located under the "Medication" tab, and RN8's documentation, located under the "Nursing Progress Note Page" section of the "24 Hour Care Record-1," indicated there was no documentation that a fleets enema had been administered or if the fleets enema was effective.

Review of documentation on the "Nursing Progress Note Page" by RN8 on 09/14/21 at 9:00 AM indicated "Pt. [P6] alert et [and] awake, groaning et yelling out "I hurt so bad." Pt continues [with] description of being up all-night having bowel movements. [Medical Director] present during assessment. Tylenol provided. Assisted to bedpan. Small soft stool passed."

There was no documentation that the fleets enema had been administered or if the fleets enema was effective.

In an interview on 09/21/21 at 4:15 PM, RN4 presented an "All Device Events Report" (a report of supplies removed) showing that an enema had been signed out for P6 on 09/14/21 at 8:45 AM by RN8. RN4 stated the nurse failed to document the nurse had administered the enema and the results of the enema.



Patient 7

Review of P7's medical record indicated an admission date of 09/15/21. Review of P7's physician orders, located under the "Physician Order" tab, indicated an order on 09/16/21 at 3:30 PM to check orthostatic BP (checking the patient's blood pressure sitting and standing to assess for orthostatic hypotension- a condition in which your blood quickly drops when you stand up from a sitting or lying position) every day for three days. Review of the MAR, located under the "Medication" tab, indicated on 09/16/21 at 8:00 PM a BP of 148/64 was documented with no documentation of whether it was taken with P7 lying, sitting, or standing. Review of P7's "24 Hour Patient care Record-1," located under the "Nurses Notes" tab, indicated a BP of 148/64 was documented at 8:00 PM with notation of "orthostatic/standing." There was no documentation of P7's BP while lying and sitting. Review of the MAR for 09/18/21 indicated documentation of "orthostatic BP lying ___ sitting ___ standing ___" with no BP documented on each line. Review of P7's nurses' notes for 09/16/21 and 09/18/21 indicated no documentation of orthostatic blood pressures as ordered and no documentation that the physician was notified that the orthostatic blood pressures were not assessed.

The RN failed to assess and document a P7's orthostatic BP for three days as ordered.

In an interview on 09/21/21 at 12:00 PM, RN5 confirmed P7's orthostatic BP was not assessed as ordered.



Patient 8

Review of P8's physician order on 09/10/21 at 12:10 PM, located under the "Physician Order" tab, indicated, "Dakins [a solution used to clean wounds] soaked kerlix to L [left] heel [triangle sign indicating change] BID [twice a day]. hydrofoam blue [a type of wound dressing] to coccyx." There was no documentation of the frequency ordered for wound care to the coccyx.

Review of P8's admission nursing assessment dated 09/10/21, located under the "Nurses Notes" tab, indicated "quarter size Stage IV decubitus ulcer" and "Stage IV pressure wound L heel - large." Review of P8's nurses notes for 09/10/21 and 09/12/21 indicated there was no documentation that wound care had been performed to P8's decubitus ulcer located on the coccyx or the left heel.

The RN failed to perform and document wound care on 09/10/21 and 09/12/21 as ordered.

Review of P8's "physician order" from Medical Director on 09/13/21 at 11:20 AM indicated "On 9/15/21 [triangle indicating change] patient's SP [suprapubic] catheter [with] same sized catheter or one size larger than currently using. 10 ml balloon. Flush catheter PRN [as needed] clots/clogs per [name of transferring physician] order."

Review of P8's MAR for 09/15/21 and the nurses notes for 09/15/21 indicated there was no documentation that P8's suprapubic catheter had been changed and flushed as ordered.

In an interview on 09/22/21 at 9:40 AM, RN5 stated he/she was sure that he/she looked at P8's heel wound but agreed there is no documentation of the appearance of the heel wound. After review of the chart, RN5 confirmed there was no documentation that wound care was done on 09/10/21 and 09/12/21 as ordered. RN5 confirmed there was no documentation that the SP catheter was changed as ordered.


Patient 9

Review of P9's medical record indicated P9 was admitted on 09/15/21 with diagnoses that included acute-on-chronic respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) with hypoxia (low oxygen level in tissues), acute-on-chronic renal disease, stage 3 to stage 4, now hemodialysis (a process of purifying the blood of a person whose kidneys are not working normally) dependent,

Review of P9's "Nursing Progress Note Page" section of the "24 Hour Care Record-1," dated 09/16/21 at 8:00 PM indicated P9's BP was 76/48. Review of RN6's documentation on 09/16/21 at 7:35 PM indicated, "VS [vital signs] WNL [within normal limits] ([arrow pointing down] BP - normal for pt)." There was no documentation that RN6 notified the physician or charge nurse of P9's low BP. Review of P9's nurses notes of 09/17/21 indicated P9's BP at 8:00 PM was 72/48. Review of RN6's documentation at 7:40 PM indicated "VS WNL except [arrow pointing down] BP r/t [related to] dialysis. Gave pt ½ mug of ice water to drink. . ."

There was no documentation that RN6 notified the physician or charge nurse of P9's low BP.

There was no documentation that P9's blood pressure was reassessed by RN6 on 09/16/21 after 8:00 PM and on 09/17/21 after 8:00 PM.