HospitalInspections.org

A. Based on review of Hospital policy, clinical records, staff interview, and observational tour, it was determined, that for 2 of 3 clinical records reviewed for patients (Pts. #1 & 8) with Nasogastric Tubes (NGTs), the Hospital failed to ensure NGT placement was assessed.

Findings include:

1. Hospital policy # N - 3, titled, "Nasogastric Tube Insertion Placement and Anchoring," revision date July 2006, was reviewed on 10/6/11 at 1:25 PM. The policy required, "Checking Tube Placement: A. Attach a syringe to end of nasogastric tube. Place diaphragm stethoscope over upper left quadrant of client's abdomen just below costal margin. Inject 10 - 20 ml. of air while auscultating abdomen... B. Aspirate gently to obtain gastric contents..."

2. On 10/4/11 between 9:30 AM and 11:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 69 year old female, admitted on 8/25/11 at 2:22 PM, with a complaint of lower back pain from a fall. Pt. #1 was admitted to the Intensive Care Unit (ICU) on 8/25/11 at 5:10 PM.

3. A physician's (E #1) note dated 8/29/11 at 5:00 PM, indicated that Pt. #1 had 3 episodes of nausea and vomiting and "insert NGT [Nasogastric Tube] to LIWS [Low Intermittent Wall Suction] - post insertion KUB [abdominal X-ray]". A nursing note on 8/29/11 at 5:27 PM, included, "Patient has #16 NG tube in right nares. Moderate amount coffee ground emesis ..." Neither physician nor nursing notes included documentation that the NGT placement was checked in accordance with policy, or that the NGT tube was set to low intermittent suction.

4. These findings were confirmed by the Vice President of Quality and Compliance on 10/4/11 at approximately 11:30 AM, during an interview.

5. A tour was conducted in the Intensive Care Unit (ICU) on 10/5/11 between 9:30 AM and 10:45 AM. Two patients (Pts. #7 & 8) had NGTs.

6. Pt. #8's clinical record was reviewed during the tour. Pt. #8 was a 67 year old male, admitted on 10/2/11, with diagnoses of Impending Sepsis, Shock, Right Lung Mass, and Dementia. A physician's order dated 9/2/11 at 10:30 PM, required NG tube placement. Nursing notes lacked documentation that the NGT placement was checked in accordance with policy.

7. These findings were confirmed by the Director of Nursing on 10/5/11 at approximately 10:30 AM, during the ICU tour.


B. Based on clinical record review and staff interview, it was determined, that for 2 of 3 clinical records reviewed for patients with NGTs (Pts. #7 & 8), the Hospital failed to ensure proper placement of the NGT occurred in a timely manner.

Findings include:

A tour was conducted in the Intensive Care Unit (ICU) on 10/5/11 between 9:30 AM and 10:45 AM. Two patients (Pts. #7 & 8) had NG tubes:

1. Pt. #7's clinical record was reviewed during the tour. Pt. #7 was a 56 year old female, admitted on 9/30/11, with diagnoses of Acute Renal Failure and Chronic Obstructive Pulmonary Disease. Progress notes dated 10/4/11 at 6:55 PM, indicated that Pt. #7 removed her own endotracheal (breathing) tube and NGT, without physician approval. A physician's order dated 10/4/11 at 8:30 PM, required, "Chest X-ray stat (to check ETT position), KUB (to check NG position).

A KUB report dated 10/5/11 at 2:39 AM, included, "Nasogastric tube has curled upon itself with tip directed cephalad. The nurse was contacted with these findings at the time of interpretation." The record lacked documentation that Pt. #7's NGT was adjusted or replaced.

2. On 10/5/11 at approximately 10:00 AM, an interview was conducted with the Nurse (E #3) who was caring for Pt. #7. E #3 stated that the NG tube had not been adjusted or removed during the night shift and that he removed and placed a new NG tube for Pt. #7 on 10/5/11 at approximately 7:45 AM. Thus, Pt. #7's non-functional NG tube was not removed and properly replaced for more than 5 hours.

3. Pt. #8's clinical record was reviewed during the tour. Pt. #8 was a 67 year old male, admitted on 10/2/11, with diagnoses of Impending Sepsis, Shock, Right Lung Mass, and Dementia. A physician's order dated 10/2/11 at 10:30 PM, required NG tube placement. A registered nurse did not check off and complete the order until 10/3/11 at 6:00 AM, 7 1/2 hours after the order was written.

4. These findings were confirmed by the Director of Nursing on 10/5/11 at approximately 10:30 AM, during the ICU tour.


C. Based on review of Hospital policy, clinical records, and staff interview, it was determined, that for 1 of 3 clinical records reviewed for patients with Nasogastric (NG) Tubes (Pt. #1), the Hospital failed to ensure NG tube care/flushing and output were recorded.

Findings include:

1. On 10/5/11 at approximately 11:25 AM, Facility Policy A-3 titled,"Patient Assessment and Reassessment," revision date February 2010 was reviewed. The policy included,"...a systems reassessment should be completed every shift..."

2. On 10/5/11 at approximately 1:30 PM, Policy C-6 titled, "Charting of Nursing Observation, Activity and Care," revision date March 2007 was reviewed. The Policy included,"...Nurse's documentation should assess the patient's needs....problems...limitations nursing interventions. In the critical care setting every 2 hrs...in the general medical care areas assessment and documentation must occur a minimum of once per shift.

3. On 10/4/11 between 9:30 AM and 11:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 69 year old female, admitted on 8/25/11 at 2:22 PM, with a complaint of Lower Back Pain from a fall. Pt. #1 was admitted to the Intensive Care Unit (ICU) on 8/25/11 at 5:10 PM and discharged on 9/9/11. The ICU utilizes 2 nursing shifts per day (7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM). Pt. #1 had a NGT placed on 8/29/11 at approximately 6:00 PM.

4. The record for Pt. #1 lacked the required every 2 hours documentation of NGT care/flushing and output for 11 of 20 shifts between 8/30/11 and 9/9/11. There was no documentation regarding the NGT care/flushing and output for these shifts.

5. These findings were confirmed by the Chief Nursing Officer on 10/7/11 at approximately 4:30 PM, during an interview.


D. Based on review of Hospital policy, clinical records, and staff interview, it was determined that for 1 of 3 (Pt #10) clinical records reviewed for patients that were receiving enteral nutrition, the Hospital failed to ensure the assessment of the patient was completed as required.

Findings include:

1. The Hospital policy entitled, "Infusion of Enteral Nutrition Policy", revised 07/06, was reviewed on 10/4/11 at approximately 10:15 AM and required "...Once feeding is started, RN must check gastric residual every shift...document on graphic sheet; Intake and output - after each feeding or end of shift..."

2. The clinical record for Pt #10 was reviewed on 10/4/11 between approximately 9:15 AM and 10:30 AM. Pt #10 was a 77 year old male admitted to the Hospital on 8/22/11 with diagnoses of Seizure and Rule out Cerebrovascular Accident (CVA). Pt #10 had a gastric tube for enteral nutrition on admission. The clinical record included the physician's order dated 8/22/11 at 3:30 AM that required, "G-tube feeding- Jevity 20 cc/hr (cubic centimeters per hour)". The clinical record included a nurse's shift assessment dated 8/24/11 at 8:00 AM that lacked an assessment for gastric tube residual. The record lacked documentation of the intake and output assessment from admission (8/22/11 at 11:05 PM) through 8/23/11 at 10:59 PM.

3. The above findings were confirmed with the Director of Nursing during an interview on 10/4/11 at approximately 2:00 PM.

E. Based on review of Hospital policy, clinical records, Hospital procedure, and staff interview, it was determined that for 1 of 3 (Pt #10) clinical records reviewed for patients that required aspiration precautions related to enteral nutrition infusion, the Hospital failed to ensure proper positioning of the patient was maintained.

Findings include:

1. The Hospital policy entitled, "Infusion of Enteral Nutrition Policy", revised 07/06, was reviewed on 10/4/11 at approximately 10:15 AM and required "...RN must verify that Head of Bed (HOB) is elevated at least 45 degrees at all times while feeding is infusing..."

2. The Hospital procedure entitled, "Steps for Prevention of Aspiration in Hospitalized Patients", revised 10/11, was reviewed on 10/11/11 at approximately 1:05 PM and required "...Maintain head of bed greater than 30 degrees..."

3. The clinical record for Pt #10 was reviewed on 10/4/11 between approximately 9:15 AM and 10:30 AM. Pt #10 was a 77 year old male admitted to the Hospital on 8/22/11 with diagnoses of Seizure and Rule out Cerebrovascular Accident (CVA). Pt #10 had a gastric tube for enteral nutrition on admission. The clinical record included the physician's order dated 8/22/11 at 3:30 AM that required, "...Aspiration precautions...G-tube feeding- Jevity 20 cc/hr (cubic centimeters per hour)". The clinical record lacked documentation of aspiration precautions, to include that the HOB was elevated, on 2 nursing assessments for 8/24/11 (12:00 AM and 8:00 AM).

4. The above findings were confirmed with the Director of Nursing during an interview on 10/4/11 at approximately 2:00 PM and on 10/11/11 at approximately 1:10 PM via telephone interview.

F. Based on review of clinical record, and staff interview, it was determined that for 1 of 10 (Pt #10) clinical records reviewed, the Hospital failed to ensure basic patient care needs were met for the patient with urinary incontinence, who required total assist with activities of daily living.

Findings include:

1. The clinical record for Pt #10 was reviewed on 10/4/11 between approximately 9:15 AM and 10:30 AM. Pt #10 was a 77 year old male admitted to the Hospital on 8/22/11 with diagnoses of Seizure and Rule out Cerebrovascular Accident (CVA). The nurse's
"Admission Assessment Report" dated 8/23/11 at 2:44 AM included that Pt #10 required total assist with toileting, incontinence and activity of bedrest.

2. On 10/6/11 at approximately 9:40 AM, an interview was conducted with the 2 East RN (E #6) who cared for Pt #10 on 8/23/11 from 7:00 AM to 7:00 PM. E #6 stated that Pt #10 was incontinent and she needed a urine specimen. She said that she asked the Patient Care Technician (PCT) to obtain the sample by placing a urinal to catch the urine as he was incontinent. E #6 said that Pt #10's daughter came into the room and found that the urinal had spilled onto the patient and the bed. The PCT had not been in Pt #10's room to manage the urine specimen collection. E #6 stated that she and the PCT cleaned Pt #1 after Pt.#10's daughter complained.

3. The above findings were confirmed with the Director of Nursing during an interview on 10/6/11 at approximately 9:45 AM.

(19843)

A. Based on Hospital stated practice, personnel file review, and staff interview, it was determined that, for 3 of 3 Agency Nurses (E #3, 5, & 6), the Hospital failed to ensure Agency Nurses were trained in the operation of wall suctioning equipment for patient use.

Findings include:

1. On 10/6/11 at approximately 4:00 PM, the Hospital policy for use of suction with Nasogastric Tubes (NGTs) was requested. The Chief Nursing Officer (CNO) stated that there was no such policy, and NG Tube suctioning for the whole Hospital is done using Ohmeda wall suction equipment, which the staff was trained to use.

2. Three personnel files of Agency Registered Nurses (E #3, 5, & 6) who worked in ICU were reviewed on 10/5/11 between 3:00 PM and 4:00 PM. None of the 3 Agency Nurses' files included documentation that they were competent using Ohmeda wall suction apparatus.

3. An interview was conducted with the Vice President of Quality and Compliance, Chief Nursing Officer (CNO), Vice President of Patient Care, ICU Nurse Manager, and Director of Education on 10/6/11 at 4:00 PM. The ICU Nurse Manager stated that competency review for Agency Nurses, including NG Tube suctioning proficiency, was not done by the Hospital but by the Agency. The findings were confirmed during the interview by the CNO on 10/6/11 at approximately 4:40 PM.