HospitalInspections.org

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Based on medical record review, document review and interview, in one (1) of thirteen (13) medical records reviewed, the Nursing Department failed to ensure adequate staffing in the Intensive Care Unit to meet the emergency care needs of patients on the unit (Patient #1).

Findings:

See Tag: 0392
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Based on medical record review, document review and interview, in one (1) of thirteen (13) medical records reviewed, the Nursing Department failed to ensure adequate staffing in the Intensive Care Unit to meet the emergency care needs of patients on the unit (Patient #1).

Findings include:

Review of medical record for Patient #1 identified the following information:

On 9/14/2023 at 3:41PM, Patient #1, 64-year-old presented to the Emergency Department (ED) with complaints of abdominal pain, nausea, and vomiting for 2 (two) days. Her past medical history included but was not limited to congestive heart failure, renal failure, stroke, hypertension, gastroesophageal reflux disease and stomach cancer. On 9/15/2023 at 6:33AM, the patient was admitted for persistent intractable right upper quadrant pain, sepsis (bacteria multiplying in the blood), cholelithiasis (gallbladder stones), questionable cholecystitis (swelling of the gallbladder), CHF exacerbation, nausea, and vomiting.

On 9/16/2023 at 9:55AM, Patient #1 underwent a robotic assisted cholecystectomy (surgical removal of the gallbladder) with Jackson Pratt (JP) drain (a surgically placed drain that removes fluid from the surgical site) insertion.

The Registered Nurse (RN) note dated 9/16/2023 at 7:25PM identified that Patient #1 was received in Surgical Intensive Care Unit (SICU) post procedure with continuous norepinephrine and intravenous fluids infusing.

Patient #1's MR revealed that her oxygen needs changed multiple times throughout the admission. The Respiratory Therapist (RT) note dated 9/17/2023 identified that she was placed on 1 (one) liter of oxygen via nasal cannula with a pulse oximetry of 100%. By 9/18/2023 at 8:36 PM, anesthesia note indicated the patient required intubation due to moderate to severe respiratory distress.

The MD note dated 9/19/2023 at 3:23AM revealed that Patient #1 underwent an emergency bronchoscopy for worsening respiratory failure, aspiration, pneumonia, and increased ventilator requirements. The bronchoscope was inserted into the main airway. The findings included thick mucus and secretions primarily in the right upper lobe, and noted complications was brief episode of bradycardia with the heart rate in the 30's (heart rate lower than normal, 60-100 is normal) with no palpable pulse. Two rounds of Cardiopulmonary Resuscitation (CPR) were performed before ROSC with heart rate in the 90's.

The facility policy and procedure (P&P) "Care of Patient Undergoing Bronchoscopy, "last revised 12/31/2023, stated the following: "The Registered Profession Nurse will continuously monitor the patient and intervene with physician for any changes, and monitor and evaluate patient ' s response post-procedure. "In addition to that, the Pre-Procedure, Intra-Procedure, and Post-Procedure interventions require the Registered Nurse to complete them. In particular, the interventions include but not limited to: Two-Identifier Patient ID Verification, Vital Signs and Assessment, Medication Gathering, monitoring of cardio-respiratory rhythm and rate, observe for airway patency, and monitor for signs and symptoms of distress. Post procedural activities include but not limited to assessment and monitoring.

There was no documented evidence that a registered nurse was assigned to care for Patient #1 during bronchoscopy.

The RN note dated 9/19/2023 at 4:39AM revealed that she was informed that the bronchoscopy might be performed during the time she was covering the primary nurse's break. She discussed with the Resident Physician how this would leave the unit unsafely staffed. Per her request, the Resident Physician agreed that the bronchoscopy could be held off.

During interview of Staff F (MD, PGY 1) on 10/18/2023 at 11:00AM, he confirmed that he assisted Staff D during the bronchoscopy. He recalled that the RN was not present during the entire procedure but shared that the 2 (two) medical students and the respiratory therapist were present. He indicated that the RN entered the room just before the patient received CPR to question the procedure.

Per interview of Staff E (MD PYG 2) on 10/19/2023 at 10:19AM, she did not recall having a conversation with the covering RN about holding off on the bronchoscopy due to staffing. She could recall that she informed the covering RN that the patient was going to receive the bronchoscopy emergently, but the RN said she was busy with another patient who was exhibiting behaviors due to alcohol withdrawals.

Per interview of Staff E (MD PYG 2) on 10/19/2023 at 10:19AM, she explained that she called for the emergency bronchoscopy to be performed because of Patient #1's emergent clinical presentation. She shared that Patient #1 was going into respiratory failure, had a newly collapsed lung (seen on chest x-ray), and was tachypneic in the 50's (fast respiratory rate, normal rate 12-20) although she was on the ventilator. She also indicated that she informed the covering RN that the patient was going to receive the bronchoscopy emergently, but the RN said she was busy with another patient who was exhibiting behaviors due to alcohol withdrawals.

During phone interview of Staff H (RN, SICU) on 10/20/2023 at 11:18AM, she confirmed that the RN must be present during bronchoscopies.

During tours of Medical Intensive Care Unit 1&2 and in Surgical Intensive Care Unit on 10/18/2023 between 10:00 AM and 12:30 PM, staffing plans posted on units directs each RN to care for 2 patients.

During interview of Staff C (SICU Head RN) on 10/18/2023 at 11:25AM, she indicated there were communication failure by all parties and that the RN should have been present during the procedure. She acknowledged that the covering RN had 5 (five) ICU patients at the time the bronchoscopy was being performed, and that the other 2 (two) RNs on the unit were not involved with the care of the patient.

During interview of Staff L (Associated Director of Nursing) on 10/20/2023 at 11:17AM, he admitted that at that time of the incident, the covering nurse had 5 (five) ICU patients (2 assigned, 2 she was covering, and 1 new admission). Staff acknowledged that an RN must be present during bronchoscopies and that staffing plan for SICU was not met.

The facility implemented corrective actions prior to the survey. The following problems were identified:

1. Inconsistent communication among the treatment team.
2. Tour 1 SICU RN staff breaktime was not assigned to provide optimal patient care.
3. An emergent bronchoscopy was performed without appropriate support staff.

Actions taken by the facility included:
1. Reinforcement of concise loop communication among the treatment team members.
2. Compliance monitoring by review of pre-procedural notes and consents in EPIC for "all non-emergent bedside procedures ...."
3. Documentation of lunch break time by the charge nurse for the staff.
4. Assignment of staff for planned bedside procedures will be done by the nurse in charge and senior providers.

The facility's corrective actions did not address immediate provision of staff for emergent bedside procedures.