HospitalInspections.org

Based on policy review, document review, medical record review and staff interview, it was determined nursing failed to:

1. Ensure a registered nurse supervised and evaluated nursing care for each patient on an ongoing basis. (Refer to A0395)

2. Follow physician orders for collection, monitoring, and reporting of intake and output (I&O's), daily weights, and orthostatic blood pressures (BPs) for patients diagnosed with congestive heart failure (CHF). (Refer to A0395)

3. Document I&O's, daily weights and orthostatic BP's as ordered in the patient medical record. (Refer to A0395)

4. Assess patient needs, change in condition, and provide interventions according to standard nursing practice related to collection/monitoring/reporting of intake and output (I&O's), daily weights, and orthostatic blood pressures. (Refer to A0395)

5. Notify the physician of the failure to follow orders to ensure safe / quality patient care was provided. (Refer to A0395)

The cumulative effect of the above findings determined the facility was not in compliance with the Condition of Participation for Nursing Services.

Based on review of facility policy and procedures, medical records, and staff interview, it was determined the facility failed to ensure a registered nurse supervised and evaluated nursing care for each patient on an ongoing basis to include; following physician orders, documenting patients' intake and output (I&O's), daily weights, and orthostatic blood pressures (BP's), assessing patient needs related to these orders, and notifying the physician of these failures in accordance with hospital policy for seven (#1, #2, #4, #5, #7, #8, #9) of nine medical records sampled.

Findings included:

A review of the policy entitled, Initial Patient Assessment and Reassessment, #NS.000-03, revised 08/20, showed ...(2) The assessment of the care or treatment required to meet the needs of the patient is ongoing throughout the patient's hospital stay, with assessment process individualized to meet the needs of the patient population. (3) A Registered Nurse (RN) shall complete a nursing assessment upon admission with completion of that admission data from within the recommended times for each individual unit ...Responsibilities (1) The Director is responsible for ensuring compliance with this policy and procedure ...Procedure ...(2) The assessment is structure to identify facilitating factors and possible barriers to the patient reaching his or her goals including the presenting problems and needs such as symptoms that might be associated with a disease, condition or treatment ...(11) All data collected is recorded in the nursing assessment record and is available to all those disciplines involved in the care of the patients ...based on the outcome of screening data, other disciplines are contacted to perform a more comprehensive assessment of the patient as needed. This data is used by the multidisciplinary team to establish the information necessary to provide the most comprehensive plan of care for the patient ...(13) Each discipline's scope of assessment if defined as ...(a) Registered Nurse: collects and analyzes data about the patient, determines the need for additional data, the patient's healthcare of treatment needs and the care or treatment of the patient ...Nursing Reassessment ...(2) Scope and intensity of re-assessment is determined by patient's (a) Diagnosis ...(e) Response to treatment.

A review of Patient #1's physician history and physical (H&P) documentation dated 10/28/20 at 5:37 PM showed the patient presented to the ED with complaints of shortness of breath (SOB), and cough. The patient was noted to have a history of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and pulmonary hypertension. The physician assessment showed the following; COPD exacerbation, acute on chronic respiratory failure, acute on chronic diastolic and systolic heart failure exacerbation with secondary acute on chronic hypoxic respiratory failure, left ventricular ejection fraction (LVEF) 30 - 35%, severe pulmonary hypertension, interstitial lung disease, rheumatoid arthritis and acute kidney injury (AKI). Notes showed the plan was to monitor I&O's and diurese (make the body excrete more fluids as urine).

A review of physician orders dated 10/28/20 at 4:16 AM showed:
1. Code Status, Full Resuscitation.
2. Intake and Output, continuous order, per unit routine.
3. Notify physician if urine output is less than 30 ml per hour for 2 consecutive hours.
4. Daily orthostatic blood pressure and pulse supine and standing.
5. Daily weight very morning, after emptying the bladder, before and oral intake.
6. Education to be provided to patient/family regarding; weight monitoring, signs/symptoms of fluid overload, and worsening dyspnea (difficult or labored breathing).

A review of Patient #1's pulmonary physician documentation, dated 11/02/20 at 8:07 AM, showed no improvement in oxygenation despite aggressive diuresis, worsening kidney function (creatinine increased from 1.1 to 1.4), with not much improvement in diuresis or oxygen status. Oxygen SpO2 90% despite attempt to aggressively diurese. Given worsening acute on chronic hypoxic respiratory failure, biventricular CHF, the plan is to transfer to ICU with placement of an indwelling catheter for strict monitoring of hourly urine output, goal net negative 1 liter in 24 hours. Prognosis is guarded due to multiorgan failure.

A review of nursing documentation from 10/28/20 to 11/02/20 failed to show accurate measured monitoring of I&O's as ordered by the physician. Daily urinary output failed to show measurements in milliliters (ml's), but rather documented as a number count (i.e., 1 time, 2 times).

Patient #1 had a total of 1,350 ml's of urine voided in the course of six days. The physician order to notify if less than 30 ml's in two consecutive hours was met on 10/29/20. There was no further documentation of urinary output in ml's after 10/29/20. Additionally, there was no nursing documentation that any physicians had been made aware that their orders had not been carried out.

A review of the physician discharge summary documentation dated 11/02/20 at 8:07 AM, showed Patient #1's kidney failure had worsened (creatinine increased from 1.1 to 1.4), with not much improvement in diuresis or oxygen status. The documentation showed Patient #1 had been transferred to a higher level of care (ICU) on 11/02/20 at 8:46 AM and transferred to another facility on 11/02/20 at 2:30 PM

An interview with the Director of QM on 12/07/20 at approximately 11:25 AM, confirmed the above findings in the medical record of Patient #1.

Patient #2 was admitted on 12/02/2020 through the Emergency Room with complaints to include abdominal swelling and difficulty breathing. Assessment in the Emergency room noted diagnoses including Acute Exacerbation of Congestive Heart Failure (CHF). Review of the medical record noted plans for monitoring CHF to include orders written on 12/02/2020 at 1947 hours and again on 12/05/20 at 1105 hours for daily weights to be done every morning after emptying of the bladder. Review of the medical record noted physician orders were not followed when daily weights were not recorded on Patient #2 for at least 2 days; 12/05/2020 and 12/06/2020. It was also noted patient's condition declined requiring him/her to be transferred to the Intensive Care Unit on 12/06/2020 at 1314 hours for BiPap assistance with patient's respiratory status. This was confirmed via interview on 12/07/2020 at 1:25 p.m. with the Manager of Patient Experience, RN, who was assisting with medical record reviews.

Patient #4 was admitted on 11/24/2020 through the Emergency Room with diagnoses to include Acute Exacerbation of Congestive Heart Failure (CHF) and reported complaints of shortness of breath. Review of the medical record noted plans for monitoring CHF to include physician orders on 11/24/2020 at 0615 hours to weigh every morning after emptying bladder "before any PO intake" and orders for continuous monitoring of Intake and Output per unit routine on 11/24/2020 at 0747 hours. Review of the medical record noted physician orders were not followed when daily weights were not recorded on patient #2 for at least 2 days; 11/25/2020 and 11/26/2020. Also noted in medical record reviews, patient was kept NPO (nothing by mouth) for a swallow study which was done on 11/25/2020 at 8:00 a.m. Continued review of medical record, with assistance from the RN Manager of Patient Experience on 12/07/2020 at approximately 2:30 p.m., confirmed physician orders were not followed when noting there were no other recordings of patient's intake on 11/25/2020 after swallow study completed nor on 11/26/2020 prior to discharge.

Patient #5 was admitted on 11/28/20 at 8:41 AM, after being brought from home via EMS with SOB and chest pain. The patient was noted to have significant respiratory distress and not able to speak in full sentences with concerns for possible CHF exacerbation. The patient was admitted to the progressive care unit (PCU) with a diagnosis of CHF.

Physician orders dated 11/28/20 at 9:25 AM showed an order for a Full Code Status Resuscitation and a STAT BP and pulse supine and standing. On 11/28/20 at 4:10 PM there was an order for I&O's, continuous order, per unit routine.

A review of nursing documentation failed to show the STAT BP and pulse order had been carried out by nursing. There was no documentation of any oral intake. The last documented output was on 11/29/20 at midnight. There was no nursing documentation that any physicians had been made aware their orders had not been carried out. The patient was discharged on 11/29/20 at 2:07 PM.

On 12/09/20 at approximately 2:30 PM, the QM Director confirmed the above medical record findings for Patient #5.

Patient #7 was admitted to the facility on 11/28/20 at 8:26 AM with a diagnosis to include CHF and severe pulmonary hypertension with complaints of difficulty breathing accompanied by chest pain.

A review of physician orders dated 11/28/20 at 1:54 PM showed:
1. Code Status, Full Resuscitation.
2. Intake and Output, continuous order, per unit routine.
3. Daily blood pressure and pulse supine and standing.
4. Daily weight very morning, after emptying the bladder, before and oral intake.

A review of nursing documentation revealed physician orders were not followed when daily weights were not recorded on Patient #7 for at least 2 days; 11/29/20 and 11/30/20. Continued review of medical record, with assistance from the RN Director of QM on 12/09/20 at approximately 2:30 PM, confirmed physician orders were not followed when there was no documentation of daily orthostatic blood pressure and pulse supine and standing. A request for nursing documentation of I&O's was requested and none was provided. The patient was discharged on 11/30/20.

Patient #8 presented to the facility on 11/24/20 with complaints of weakness and chest pain. The patient was admitted to the Intensive Care Unit (ICU) on 11/25/20 at 4:17 AM with a diagnosis of CHF exacerbation, acute hypoxic respiratory failure, and possible pneumonia.

Physician orders showed the following with the date and time the order was placed:
1. Code Status, Full Resuscitation. 11/25/20 at 4:17 AM
2. Intake and Output, continuous order, per unit routine. 11/25/20 at 4:17 AM.
3. Intake and Output, STAT Continuous Order11/25/20 at 9:45 AM.
4. Notify physician if urine is less than 30 ml per hour for 2 consecutive hours. 11/25/20 at 2:14 AM and 11/25/20 at 4:17 AM.
5. Daily orthostatic blood pressure and pulse supine and standing. 11/25/20 at 2:14 AM
6. Daily weight very morning, after emptying the bladder, before and oral intake. 11/25/20 at 2:14 AM.

Review of the medical record showed physician orders were not followed when nursing failed to perform and document daily weights on 11/26/20 and 11/29/20, and daily orthostatic blood pressure and pulse supine and standing for the entire length of stay, nine days. Additionally, the order to notify physician urine output if less than 30 ml per hour for 2 consecutive hours was not carried out due to urine measurements being performed at intervals greater than 2 hours from 11/25/20 till discharge on 12/03/20. There was no nursing documentation that any physicians had been made aware of orders not being carried out.

On 12/09/20 at approximately 2:30 PM, the QM Director confirmed the above medical record findings for Patient #8.

Patient #9 presented to the emergency department from home and was admitted on 11/27/20 at 12:44 PM with complaints of dizziness and a hip wound. The patient was noted to have a past medical history significant for CHF, coronary artery disease (CAD), chronic kidney disease (CKD), and hypertension (HTN).

Physician orders showed the following with the date and time the order was placed:
1. Code Status, Full Resuscitation.
2. Intake and Output, continuous order, per unit routine. 11/27/20 at 12:44 PM
3. Intake and Output Routine, every 8 hours. 11/27/20 at 12:43 PM
4. Intake and Output Routine, every 12 hours. 11/27/20 at 12:40 PM
5. Notify physician if urine output is less than 30 ml per hour for 2 consecutive hours. 11/27/20 at 12:40 PM
6. Daily orthostatic blood pressure and pulse supine and standing. 11/27/20 at 12:40 PM
7. Daily weight very morning, after emptying the bladder, before and oral intake. 11/27/20 at 12:40 PM.
8. Routine Daily Weight. 11/27/20 at 12:43 PM

A comprehensive review of the physician orders for Patient #9 failed to reveal any of the above orders had been discontinued. An interview on 12/09/20 at 2:00 PM with the CNO, confirmed there was conflicting orders in the medical record of Patient #9.

A review of Patient #9's nursing documentation failed to show physician orders were carried out related to daily blood pressure and pulse supine and standing, and daily weight every morning, after emptying the bladder, before and oral intake. A review of the collection and monitoring of I&O's and urinary output for Patient #9 showed the urine was collected once on 11/28/20 and three times on 11/29/20. There was no nursing documentation that any physicians had been made aware their orders had not been carried out, including the requirement for nursing to notify the physician if the patient's urine output was less than 30 ml's for 2 consecutive hours.
11/28/20 - 10:00 PM - 50 ml's urine.
11/29/20 - 2:00 AM - 200 ml's urine.
11/29/20 - 3:00 AM - 200 ml's urine.
11/29/20 - 6:00 AM - 300 ml's urine.
11/30/20 - NO I&O's collected

Patient #9 was placed on comfort measures only on 11/30/20 at 10:15 AM per physician order in the medical record.

A review of the physician DC summary dated 11/30/20 at 8:00 PM, showed the patient had not progressed on the admission and the decision was made to place the patient under hospice care.

On 12/09/20 at approximately 2:30 PM, the QM Director confirmed the above medical record findings for Patient #9.