HospitalInspections.org

Based on record review and staff interview, the hospital failed have a Registered Nurse (RN) supervise and evaluate the needs and failed to assess for changes in condition of 1 (Patient #3) of 12 patients surveyed.

The findings include:

Record reveiw of Patient #3's Admission orders, dated 8/8/11, and signed by the physician documented, "Routine post-op vital signs."

The Patient Controlled Analgesia orders, dated 8/8/11, and signed by the physician documented, "Spot check pulse oximetry every four hours and as needed when no basal rate is ordered."

The record documented that Patient #3 arrived on the floor at 11:45 a.m., on 8/8/11. Initial vital signs were obtained at that time. Routine vitals should have been done at 12:15 p.m., 12:45 p.m., 1:45 p.m., 2:45 p.m., 3:45 p.m. and 4:45 p.m. Routine Post-operative vital signs should have included temperature, pulse, respirations, blood pressure and pain scale.

A code blue was called at 4:40 p.m. From 11:45 a.m. to 4:40 p.m. a pain scale was done one time, at 11:49 a.m. The temperature, pulse, respirations and blood pressure are recorded at 12:00 p.m., 12:16 p.m. and 1:00 p.m. There are no vital signs documented from 1:00 p.m. until 4:45 p.m. The medical record shows for 8/8/11 that there is no documentation that an oximetry reading was done from 11:45 a.m. until 8:00 p.m.

An interview was conducted with the Nursing Director of 4th floor North, on 9/22/11, at 3:00 p.m. A document was provided that stated, "Post-operative assessment upon arrival from PACU with vital signs (temperature, pulse, Respirations, blood pressure) and pain level, which is considered the fifth vital sign, as follows: On arrival, and then every 30 minutes times 2, every hour times 4, then every 4 hours for the first 24 hours." The Nursing Director for 4th floor stated, those are 4th floor north routine post-operative vital signs.

Review of the hospital Policy and Procedure Manual for PCA (Patient Controlled Analgesia) was reviewed on 9/21/11. It was found that hospital's policy for monitoring a patient on a PCA pump is to complete an initial assessment which includes:
a. Allergies
b. Level of consciousness
c. Vitals (include an accurate respiratory count, counted for 1 full minute)
d. Pain scale
e. O2 saturation-obtain baseline pulse oximetry reading before starting a PCA

1) Apply continuous pulse oximetry with low saturation limit of 92% or per physicians order for continuous rate PCA's.
2) If needed apply O2 to maintain saturation at 92% or per physician's order.
3) Notify ordering physician of O2 application.

In reviewing the policy for monitoring a PCA patient it was noted that: A RN or LPN will monitor and document at a minimum of every four hours and based on patient's response.

Nursing staff failed to follow the hospital policy for assessing patients with Patient Controlled Analgesia. Nursing staff failed to assess Patient #3's vital signs for 3 hours and 45 minutes. The patient's oxygenation level was not assessed for a period of 8 hours and 15 minutes.