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Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23, NURSING SERVICES, was out of compliance.

A-0395 A registered nurse must supervise and evaluate the nursing care for each patient. The facility's nursing staff failed to notify providers and provide appropriate ongoing evaluations when medical changes in a patient's condition occurred in 4 of 6 medical records reviewed of patients transferred to a higher level of care (Patients #1, #3, #6, and #8). This failure resulted in the delay of medical intervention by the medical physician and led to the progression of acute medical conditions resulting in poor patient outcomes.

Based on interviews and document review the facility's nursing staff failed to notify providers and provide appropriate ongoing evaluations when medical changes in a patient's condition occurred in 4 of 6 medical records reviewed of patients transferred to a higher level of care (Patients #1, #3, #6, and #8).

This failure resulted in delay of medical intervention by the medical physician and led to the progression of acute medical conditions resulting in poor patient outcomes.

FINDINGS:

POLICY

According to Assessment/Reassessment (Nursing), a reassessment occurs for each patient by an RN with any change in condition.

According to Early Recognition Program/Medical Emergency, criteria for early recognition and early intervention include but are not limited to: Acute change in systolic blood pressure (decrease SBP>30 mmHg) - Confirm the abnormal blood pressure with manual BP cuff, MEWS score > 5 or > 2 points above lasts MEWS score. If early intervention criterion is met staff must act upon one or more of the following interventions: Contact Nursing supervisor or nurse manager on call, contact the patient's physician with a report that includes: Situation; Background; Assessment; and Recommendation (SBAR) for additional orders.

1. Nursing staff did not alert medical providers when a change in a patient's condition occurred.

a) A review of Patient #1's medical record revealed s/he was admitted on 02/20/17 status post lumber fusion 5 days prior to admission. Patient #1 had an admission heart rate (HR) of 106 beats per minute and was fully continent of his/her bowel and bladder movements. Eight days later, on 02/28/17 it was documented that Patient #1 was incontinent of urine. Physicians were not notified regarding this change in Patient #1's functional status.

On 03/03/17, Patient #1 had a HR of 125 beats per minute at 6:37 a.m. Twelve hours later, at 6:03 p.m. a Physical Therapist's note stated Patient #1 was incoherent through much of the session and did not respond appropriately to questions. A nurse's note at 8:49 p.m. stated Patient #1 was sent to the emergency room for further evaluation. Patient #1 was admitted to a higher level of care for altered mental status and tachycardia per a nurse's note on 03/03/17 at 10:06 p.m. The last HR recorded in Patient #1's medical record had been 16 hours before s/he was admitted to a higher level of care and was abnormal for Patient #1 at 125 beats per minute. Physician notification was not done regarding Patient #1's tachycardia before his/her transfer to the emergency room.

i) An electronic review of Patient #1's medical record was completed with Nurse Manager #5 on 06/09/17 at 7:43 a.m. Manager #5 explained that Patient #1 had been put on a medication that could have contributed to his/her incontinence. Manager #5 stated the physician should have been notified, as the bladder incontinence was a change in Patient #1's condition. Further, Manager #5 confirmed there were no further nursing assessments regarding Patient #1's rapid HR before his/her transfer to a higher level of care. The first documented notation of physician acknowledgment of the change of condition was in a progress note at 2:33 p.m., 8 hours after the change in vital signs had occurred. Manager #5 stated s/he would have expected to see a reassessment of the patient and physician notification regarding the change in condition.

b) A review of Patient #8's medical record revealed s/he was admitted to the facility on 04/24/17 with myopathy (muscular weakness) secondary to a resection of an ovarian mass complicated by bowel perforation and sepsis (a life threatening infection of the bloodstream). On 04/27/17 at 6:45 p.m., Patient #8 spiked a temperature of 101.9 degrees Fahrenheit. At 6:47 p.m., Tylenol 650 mg was documented as given for aching head pain. No physician notification or treatment was done regarding Patient #8's fever. The next time Patient #8's temperature was taken was 12 hours later on 04/28/17 at 6:34 a.m. and it was still elevated at 101.4 degrees Fahrenheit. Patient #8 was transferred to a higher level of care at 7:48 a.m. for spiking a fever, tachycardia, and increased respiratory rate. All conditions listed in physician discharge summary had been documented in the medical record by facility staff hours before Patient #8's transfer. No physician contact had been done regarding Patient #8's status and change in vital
signs, reassessment of vital signs before his/her transfer to a higher level of care were not present.

i) During an electronic review of Patient #8's medical record with Nurse Manager #5 on 06/07/17 at 2:34 p.m., s/he stated there should have been a physician notification completed for a temperature of 101.9. Physicians should have been notified for temperatures exceeding 100.3 degrees Fahrenheit and additional assessments should have been completed to assess for an infection. Physician notification or additional assessments regarding Patient #8's fever and change in condition were not completed per the medical record.

ii) During an interview on 06/08/17 at 10:05 a.m., Chief Nursing Officer (CNO) #4 stated a physician should have been notified regarding Patient #8's temperature. S/he expected Patient #8's temperature to have been re-assessed prior to when it was reassessed in the morning.

c) A review of Patient #3's medical record revealed s/he was admitted on 04/07/17 with a diagnosis of encephalopathy (brain damage) after bilateral chronic subdural hematoma evacuation. On 04/08/17 at 6:45 a.m., Patient #3's blood pressure (BP) was 139/66 per monitor reading. Less than two hours later, Patient #3's the BP was 91/54 per monitor. No manual BP reading was done. At 3:33 p.m. Patient #3's BP was 108/53; also at this time Patient #3 had a developed a new low-grade temperature at 99.4. Physician notification or intervention were not done for Patient #3's change in condition. Patient #3 was transferred to a higher level of care on 04/10/17 due to being "largely unresponsive" per physician discharge note.

i) During an electronic review of Patient #3's medical record on 06/07/17 at 2:34 p.m., Nurse Manager #5 stated a physician should have been notified regarding Patient #3's change in BP on 04/08/17. Upon review of Patient #3's medical record Nurse Manager #5 was unable to find notification or orders pertaining to Patient #3's change in condition.

ii) During an interview on 06/08/17 at 10:05 a.m., Chief Nursing Officer (CNO) # 4 stated Patient #3's BP of 91/54 on 04/08/17 was a change in condition for the patient. S/he expected to see the BP re-taken within an hour. CNO #4 expected facility staff to follow policy, which did not occur for the change in BP.

d) A review of Patient #6's medical record revealed s/he was admitted on 03/30/17 with newly diagnosed coronary artery disease and congestive heart failure after a four-vessel coronary artery bypass graft done one week prior to admission. Patient #6's admission BP was 110/65 on 03/30/17. On 04/02/17 at 7:14 a.m., Patient #6's BP was 106/57. The next day at 7:29 a.m., Patient #6's BP increased to 148/70. No physician notification, intervention, or reassessment was noted. 23 hours later Patient #6's BP was 89/51 on 04/04/17 at 6:30 a.m. Again, no physician notification, intervention, or reassessment was noted. At 2:21 p.m., Physician #1 was notified regarding Patient #6 complaining of light sensitivity. Patient #6 was transferred to a higher level of care for an Emergency Room evaluation on 04/04/17 at 2:35 p.m. due to hypotension; 8 hours after the Registered Nurse (RN) had become aware Patient #6 was hypotensive.

i) During electronic review of Patient #6's medical record with Administrative Director #3 on 06/07/17 at 2:34 p.m., s/he confirmed no documentation of notification or medical interventions were done for Patient #6's BP of 89/51. Director #3 stated notification for the drop in BP should have happened sooner and the patient should have been reassessed in case an intervention was needed.

ii) During an interview on 06/08/17 at 10:05 a.m. CNO #4 stated a physician should have been notified regarding Patient #6's drop in BP. CNO #4 would have expected a reassessment and physician notification regarding the change in condition.

e) During an interview with RN #6 on 06/07/17 at 10:56 a.m., s/he stated a physician should have been notified for any change in patient's symptoms, an increase in pain or a change in the baseline vital signs assessment. RN #6 stated s/he would assess the patient and then call the physician regarding the findings. Physician notifications should have been documented in the patient's medical record. RN #6 explained there were multiple places the notification could have been documented.

f) During an interview on 06/08/17 at 8:01 a.m., Physician #1 stated s/he expected RNs to notify him/her regarding a drop in BP greater than 20 mmHg. Additionally, s/he expected the RN to notify him/her with any fevers. Physician #1 expected a temperature to have been rechecked within 4-6 hours if Tylenol was given for a fever. S/he expected nurses to assess changes in a patient's condition and use critical thinking to discuss the change with the physician. Physician #1 stated notification to the physician should have always been documented in the medical record, even when the nurse reported the changes in person.

g) During an interview with CNO #4 on 06/08/17 at 10:05 a.m., s/he explained that based on his/her understanding regarding the charts reviewed it seemed the nurses did not receive clear guidelines for when to notify physicians and what constituted a change in patient condition.