HospitalInspections.org

The Oro Valley Hospital failed to require that a Registered Nurse (RN) supervised the nursing care of each patient by:

(A395) 1. failing to require that Registered Nurses supervised and evaluated the care of two (2) patients who developed negative outcomes requiring transfers to the Intensive Care Unit (ICU) (Patient #2, Patient #6);

2. failing to require that an anti-hypertensive drug was administered as ordered to two (2) patients in which the respective diagnoses included Hypertension (Patient #4, Patient #5); and

3. failing to require that a Registered Nurse adhered to the Hospital's policies and procedures when the nurse and patient signed the anesthesia consent prior to the physician providing informed consent.

The cumulative effect of these systemic problems resulted in the inability of the hospital to be in compliance with the federal regulations for NURSING SERVICES which led to actual and increased potential for adverse patient events.

Based on record review, policy and procedure review, Registered Nurse (RN) job description review, and interview, it was determined that the Hospital failed to require that an RN supervised and evaluated the care of each patient as evidenced by the:

1. failure to appropriately assess two (2) of two (2) patients who became hypotensive while under the care of a Registered Nurse (RN); both patients subsequently developed sepsis (Patient #2, and #6), with an outcome of death in one (1) of the two (2) patients (Patient #2); and

2. failure to administer an anti-hypertensive drug as ordered to two (2) of two (2) patients in which the respective diagnoses included Hypertension (Patient #4, and #5), as well as holding additional medications on Pt #5 without explanation.

Findings include:

The Oro Valley Hospital Registered Nurse Job Description revealed: "1. Provides care, evaluates outcomes, consults with interdisciplinary team members as required and adjusts patient care as indicated to ensure optimal care. Effectively identifies predictable problems and plans and provides patient care...Assigns work to subordinate staff, provides direction, and reviews all work, as necessary...2. Evaluates patient histories, assess patients' conditions and develops individual care plans for patients assigned to the unit...5. Communicates with medical/allied health personnel regarding patient's progress, needs...8. Administers medications and blood in accordance with unit policy and physician orders...."

The Oro Valley Hospital policy titled "Interdisciplinary Assessment/Reassessment" (Nursing) revealed: "Patients at Oro Valley Hospital receiving inpatient, outpatient or ED services have an initial assessment and appropriate interdisciplinary follow-up assessments based upon their individual needs including physical, psychological and social/cultural status, and history...." The "Purpose" revealed: "To ensure that all patients receive the appropriate assessment, care and reassessment provided by qualified individuals within the organizational setting. The assessment process is a continuous, collaborative effort with all departments functioning as a team...." The "Guidelines" revealed: "Patient assessment is guided by the data that is collected...B. Information generated via a patient's assessment is integrated with other disciplines to identify and prioritize the patient's needs for care and treatment..." "Reassessment" revealed:...Reassessment is ongoing, interdisciplinary and is done at intervals specified by the departments/ancillary disciplines or is done as needed with changes in the patient's condition...."

1.

- Patient #2

Patient #2 had become ill at work on 3/29/10 with nausea, vomiting, and "left flank pain." Patient #2 was seen in the Emergency Department (ED) at (name) hospital that day with laboratory tests and a computerized tomography (CAT) scan and was discharged home. The next day, 3/30/10, she was seen in Surgeon #1's office where the physician described her as being "ashen," "dehydrated," and in "significant" left upper quadrant pain."

Surgeon #1 ordered Patient #2 as a direct admission to the hospital on 3/30/10 at 8:00 p.m., with orders to be seen by the Hospitalist and to have intravenous (IV) fluids, Dilaudid 0.5 mg for pain, and Zofran 4 mg IV for nausea, among other orders. Patient #2's blood pressure had ranged between 113/76 and 136/88 and her pulse ranged between 63 and 77 over night through 11:00 a.m. on 3/31/10.

Surgeon #1 took Patient #2 to the operating room on 3/31/10 at 1:45 p.m., where she underwent a" laparoscopic exploration, adhesiolysis, reduction and repair of jejunojejunostomy internal hernia, and repair of Peterson defect." Surgery finished at 4:35 p.m. and the patient was taken to the Post Anesthesia Care Unit (PACU) with documentation in the record that the patient "arrived awake."

Patient #2's blood pressure ranged between 120/69 and 141/96 and her pulse ranged between 72 and 87 postoperatively in the PACU. While in the PACU, Patient #2 received IV's of Morphine 2 mg for 3 doses, Demerol 12.5 mg for one dose and Compazine 5 mg for one dose. The patient was transferred to a medical surgical room leaving PACU at 6:17 p.m.

Patient#2 was admitted to the medical surgical room at 6:30 p.m. The record revealed at 6:57 p.m. the patient "woke up in panic - screaming, tossing around - crying out loudly - wanting more pain med." The record revealed the patient was medicated with Dilaudid 1 mg and then Ativan 1 mg at "6:50 p.m." and returned to sleep.

The record revealed the nurse notified Surgeon #1 at 9:05 p.m. that the patient was "unconsolable," and was restless, complaining of pain, had shallow breathing, and "extreme anxiety." Surgeon #1 ordered a bolus of IV fluids, an increase of the Dilaudid from 0.5 mg to 1 to 2 mg IV every 2 hours as needed and Ativan 1 mg "now." The record revealed the patient was medicated with Dilaudid 1 mg and then Ativan 1 mg IV and returned to sleep.

Through the night of 3/31/10 to 4/1/10, Patient #2 had 3 additional doses of Dilaudid, Zofran 4 mg, Valium 5 mg, and one dose of Percocet 1 tablet. The patient's blood pressure ranged between 116/79 and 154/89 and her pulse ranged between 92 and 112. The record revealed Patient #2 had a critical magnesium blood value of 0.9 at 6:18 a.m. (normal range 1.3 to 2.1). Surgeon #1 was notified and ordered IV magnesium 6 gm to be given and a repeat blood magnesium level at 4:00 p.m..

The record revealed that at 7:00 a.m. 4/1/10, Patient #2's blood pressure was 121/84 with a pulse of 116. The record revealed that R.N. #1 provided care for Patient #2 beginning at 7:00 a.m. on 4/1/10. RN #1 documented that the "Patient in extreme pain at start of shift. Crying and rocking back and forth," and that Surgeon #1 was "aware." Surgeon #1 saw the patient at 7:45 a.m. and added Toradol 15 - 30 mg every 6 hours as needed alternating with the Dilaudid. Surgeon #1 ordered the patient to "ambulate in halls (sign equal to or more than) 4 times a day."

RN #1 documented a nursing assessment of the patient at 9:19 a.m. on 4/1/10. RN #1 documented at 11:34 a.m. that Patient #2 "has expressed a great deal of pain this morning. Toradol was given with some effect" and that Patient #2 had also received Dilaudid 1 mg and 2 tablets of Percocet. RN #2 documented that the patient "requested Ativan but I explained to her that I did not want to give it to her at this time as the doctor wants her to be awake enough to ambulate and to participate in her care." RN #1 documented that Patient #2 was resistant to get out of bed or to ambulate as she "just didn't feel well enough." The patient did ambulate "x 1 in hallway."

The hospital's electronic record revealed no assessment at the time of getting the patient to ambulate or any vital signs before or after the ambulation. The record revealed no further nursing assessments or nursing care by RN #2 on 4/1/10.

The electronic record revealed that Patient #2's blood pressure was 87/56 at 1:00 p.m. on 4/1/10, without documentation in the assessment area or the notes, of any nursing reassessment, interventions, and notifying the surgeon that a significant change in the patient's condition had occurred.

A graphic sheet in the record revealed a hand written entry at 2:00 p.m. that the blood pressure was 87/56 with a pulse of 101. There was no documentation in the nursing assessment area or the notes, of any nursing reassessment, interventions, and notifying the surgeon that a significant change in the patient's condition had occurred.

The record revealed that blood was drawn for a complete blood count (CBC) and a Lactic Acid which the laboratory record dated 4/1/10 at 3:25 p.m. The physician orders revealed a "telephone order" from Surgeon #1 for these blood tests with only "4/1" and no year and no time as to when the order was received by RN #1. The results of these blood tests revealed the magnesium was elevated to 2.8 with the CBC within normal limits except for a low white blood count of "2.2" and a high neutrophil count of 81.1.

Hospitalist #1 documented seeing the patient at 3:30 p.m. on 4/1/10. The record revealed no documentation that RN #1 had called the Hospitalist, and Hospitalist #1 did not document that he had been notified regarding Patient #2's continued pain and low blood pressure. Between 8:00 a.m. and 2:30 p.m., RN #1 administered 3 doses of Dilaudid for a total of 3 mg, 3 doses of Toradol for a total of 60 mg, 2 Percocet tablets, and one dose of Ativan 1 mg.

Hospitalist #1 ordered Duragesic Patch 25 mcg/hr every 72 hours, blood pressures every 2 hours x 12 hours, an IV bolus of 500 cc, and blood work for the "AM."

At 4:00 p.m. the graphic sheet in the record revealed a hand written entry that the blood pressure was 86/56 with a pulse of 86. There was no documentation in the nursing assessment area or the notes, of any nursing reassessment, interventions, and notifying the surgeon that the patient's condition continued to decline.

The record revealed that Hospitalist #1 called in an order at 4:40 p.m. for more blood work of a Lactic Acid and CBC to be done immediately (with no results in the record for either of these tests following the ones previously ordered and drawn at 3:25). Hospitalist #1 also ordered a stat abdominal series. The patient left the medical surgical unit to go to x-ray and the radiology department's computer revealed the patient had been in their department for the abdominal series on 4/1/10 at 4:52 p.m. The record contained no documentation by RN #1 that the patient had returned from the radiology department. The radiology department verified that she had been returned to the medical surgical room.

The next entry in the record of Patient #2 revealed the patient was in the pre-operative area of the operating room at 5:50 p.m. The record revealed a progress note by Surgeon #1 at 6:00 p.m. on 4/1/10. Surgeon #1 documented that he was "called due to worsening pain/abnormal labs, generalized abdominal pain, more prominent than expected, requires excess analgesic and narcotic with an episode of hypotension to 80's and now tachycardiac, She continues to make urine, though labs consistent with acute renal failure and lactic acidosis." The record revealed that Patient #2 was in the operating room at 6:41 p.m.

This record was reviewed, on 8/10/10 at 4:30 p.m., with the hospital's Chief of Staff who acknowledged that Surgeon #1 did not have documentation of seeing the patient during the night of 3/31/10, when the patient was in "a lot of postoperative pain (first surgery)." The Chief of Staff also acknowledged that, after 7:45 a.m. on 4/1/10, Surgeon #1 did not see the patient until 6:00 p.m. after it had appeared the patient had been declining and had become "very, very ill." The Chief of Staff, who is an anesthesiologist and an Intensivist, acknowledged that upon reviewing the record, Patient #2 appeared to be in Septic Shock, Hypoperfusion, Renal Failure, with Cardiac problems, and in Multi-Organ Failure by the time of the surgery on 4/1/10.

Patient #2 had an exploratory laparotomy, a small bowel resection with primary anastomosis for an enterotomy of an accidental operative laceration. She was transferred from the operating room to the Intensive Care Unit with an endotracheal tube on a ventilator. She subsequently died on 4/3/10 at 2:30 a.m.

Patient #2's record contained a 3 1/2 page hand written "Late Entry" that was undated and untimed. RN #1 stated, on telephone interview 8/19/10, that she had been "too exhausted to do her documentation" of Patient #2's nursing care on 4/1/10. RN #1 stated it didn't matter that she had not done her documentation that day as "the doctor orders in the chart spoke for the day and for the nursing care she had given." RN #1 stated she was "not sure when she had written the Late Entry, but thought it was probably the next day (after 4/1/10)."

The 3 1/2 page Late Entry was written in a non-sequential manner of an account of RN #1's recollections of the events of Patient #2 on 4/1/10. Events listed in the Late Entry were not congruent with the record such as the only nursing assessment was documented in the record as occurring at 9:19 a.m. while it was listed in the Late Entry as prior to 7:45 a.m.

Other examples were: the record revealed at 9:19 a.m. the patient had taken "only a small amount of clear liquid diet" as she "had no appetite." The Late Entry listed she had taken "50 % of her clear liquid breakfast with meds" given at 10: 20 a.m. and 10:40 a.m. The Late Entry revealed the blood pressures had been "in the low 90's" while Patient #2's record revealed the blood pressures had been above 113/76 until 1:00 p.m. when the blood pressure was recorded as 87/56 and stayed in the 80's after that.

The Late Entry revealed an entry on the third page that RN #1 documented "I called Dr (Surgeon #1) around (time that was not readable)." The time documented by RN #1 appeared to be "1600 (4:00 p.m.)" with heavy marks over it that appeared to be "1100 (11:00 a.m.)."

- Patient # 6

Patient #6 presented to the Emergency Department (ED) on 07-31-10 at 6:00 P.M. The "Brief Assessment" revealed: "watching tv (television) and started shaking very badly, unable to control hands or legs."

At Triage, Patient #6 had a temperature of 102.3 (Fahrenheit), a pulse of 137, respirations of 18, a blood pressure of 118/66, and an blood oxygenation level of 92% on room air.

The primary nursing assessment conducted at 6:00 P.M., revealed: "...Patient with Port-A- Cath in left upper chest with power point through which he is receiving his TPN (Total Parenteral Nutrition)...."

The reassessment conducted at 11:54 P.M. revealed: "patient vomitted (sic) zofran given. ice packs applied to patient to help decrease fever."

The "Emergency Department Report" for Patient #6 revealed: "...The patient has had fever, chills, very shaking chills and fever that began just prior to arrival. States it is quite severe, uncontrollable, currently on TPN, variety of comorbidities (Metastatic Stomach Cancer, Radiation Esophagitis, Radiation Colitis, Total Gastrectomy with Roux-en-Y)...Primary concerns for the patient did include underlying disease including early sepsis. The patient is on TPN with possible line sepsis, although unclear at this time...."

The ED nursing "Disposition" revealed: "Patient left the department at 08-01-2010 01:21 (1:21 A.M.). Patient's disposition is: ADMIT- Telemetry...Vital signs taken at 01:21 were: T (temperature) 100 (degrees Fahrenheit), P: (pulse) 99 and is regular, R: (respirations) 16 and unlabored, BP (blood pressure) 89/048...MD (Hospitalist #2) called for patient low BP 89/48 no orders received for low BP." No new orders were given.

The admission nursing assessment revealed that on 08-01-10, at 2:00 A.M., Patient #6 was admitted to the Telemetry Unit with a pulse of 94, a blood pressure of 80/46, respirations of 18, and a pulse oxygenation level of 98% on 2 L (liters) of oxygen per nasal cannula. The RN documented that Hospitalist #2 was notified of the hypotension, and "no further orders received." No new orders were given.

The "Oro Valley Hospital Graphic/Intake & Output Sheet," dated 08-01-10, revealed that the Patient #6's blood pressure was not taken again until 10:55 A.M. on 08-01-10. A repeat blood pressure was taken, which was 86/50. There was no documentation in the "List Patient Notes" narrative that a physician was notified that the blood pressure remained low subsequent to the 2:00 A.M. blood pressure that had been reported to Hospitalist #2.

Subsequent blood pressure recordings for Patient #6 on 08-01-10 from 3:45 P.M. through 1:30 P.M. on 08-02-10, revealed the following: Patient #6 had a blood pressure on 08-01-10 of 103/57 and a pulse 71 at 3:45 P.M., and a blood pressure of 102/64 and a pulse of 81 at 9:30 P.M. The patient's blood pressure was next documented on the graphic form on 08-02-10, at 6:00 A.M., when the patient had a blood pressure of 102/57, and a pulse of 70. The next blood pressure was taken on 08-02-10 at 1:30 P.M., with a reading of 102/65, and a pulse of 119.

The "List Patient Notes" revealed that at "1524" (3:24 P.M.) on 08-02-10, Patient #6 was found to be pale with rigors (chills) with a heart rate "in the 160's." The physician was called, and an order for an EKG was given.

The "Graphic/Intake & Output Record" revealed that at 3:40 P.M. on 08-02-10, the patient had a blood pressure of 87/52, and a pulse of "111."

The "Graphic/Intake & Output Record" for Patient #6 dated 08-02-10 at 9:00 P.M. revealed a blood pressure of 78/47, a temperature of 98.8, a pulse of 81, and respirations of 20.

Thirty (30) minutes later, at 9:30 P.M. on 08-02-10, the "List Patient Notes" revealed: "(Hospitalist #3) paged and notified that Pt. (Patient) BP (blood pressure) is 78/47 with HR (heart rate) 81. MD notified that Pt has been hypotensive in the 80/50's T/O day (sic). Informed that pt is very diaphoretic and blood sugar is 131...Orders received for 500 cc (cubic centimeters) NS (Normal Saline) bolus over one hour...2230 (10:30 P.M.) BP 76/42...." At 11:45 P.M. the blood pressure had risen to 101/51 subsequent to a second bolus of intravenous fluid "wide open." On 08-03-10 at 12:17 A.M., the blood pressure was 68/34, and Hospitalist #3 again notified. At 12:20 A.M., the manual blood pressure was 72/50, and orders were received to transfer Patient #6 to ICU.

The "Progress Note" dated 08-03-10 revealed: "...The patient did have the Port-A-Cath removed by (Surgeon #2) during the late afternoon and evening hours of August 02, 2010. Throughout the day the patient had experienced some modest hypotension, but during the late evening hours his blood pressure declining to 76/42 mmHg (milligrams of Mercury). The patient received fluid bolus administration and was transferred to the intensive care unit...."

The "Discharge Summary Hospital Course" for Patient #6 revealed: "The patient's blood cultures rapidly turned positive for gram-negative bacilli, that was identified as Enterobacter cloacae...After removal of the port (Port-A-Cath) he had a transient episode of hypotension with a blood pressure in the 70s, prompting his transfer to acute care telemetry...."

2.

- Patient #4

Patient #4 presented to the ED on 08-10-10, and was triaged at 2:27 P.M. The Chief Complaint was Lower Abdominal Pain. The "Brief Assessment" revealed: "Pt sent by (Surgeon #3) for a positive blockage in the duodenum found today from an endoscopy. Pt C/O (complains of) LLQ (left lower quadrant) pain on/off x 2 weeks with vomiting. Last BM (bowel movement) today-Normal. Pt PWD (pink, warm, dry), NAD (no acute distress). Denies pain at this time."

At triage, Patient #4 had a temperature of 98.3, a pulse of 87, respirations of 18, a blood pressure of 141/65, and an oxygen saturation level of 96% on room air.

The "Past Medical History" revealed that Patient #4 had a medical history which included: Hypertension, Hemochromatosis, and Congestive Heart Failure. The medication reconciliation form for Patient #4 revealed that he was prescribed the antihypertensives Benicar 5 milligrams (mg) daily, and Metoprolol ER 50 mg daily, prior to his presentation to the ED.

The "Emergency Department Record" revealed that the "Impression" was Acute Bowel Obstruction and Vomiting. Patient #4 had a nasogastric tube (NG) inserted while in the ED, and was discharged to the Medical-Surgical unit at 4:58 P.M. Upon discharge form the ED, Patient #4 had a blood pressure of 168/64. There was no order for antihypertensive medication at the time the patient was in the ED.

The "History and Physical" revealed that the "Impression" was: "Probable gastric outlet obstruction of undetermined cause...No reported CT (Computerize Axial Tomography) scan available at this time. Highly symptomatic degree of obstruction, however. Moderate volume depletion due to poor oral intake...Essential Hypertension...." The "Plan" revealed: "IV Hydralazine (antihypertensive) as needed for blood pressure...."

The "Consultation Report" "Assessment" for Patient #4, dictated by Surgeon #2 on 08-10-10, revealed: "1. Gastric outlet obstruction, 2. Hemochromatosis, 3. Chronic bronchitis, 4. Hypertension, 5. Nausea and vomiting." The "Plan" revealed: "The patient has a nasogastric tube, and I will continue this on low intermittent suction. I will also start the patient on TPN as he will probably need a surgery with creation of gastrojejunostomy in the near future."

On 08-10-10, the "Routine Admitting Orders" for Patient #4 revealed an order for: "Hydralazine 10 mg IV Q 6 (symbol for hours) prn SBP (systolic blood pressure) >150 or DBP (diastolic blood pressure) >90."

The first blood pressure obtained on the Medical-Surgical Unit for Patient #4's admission, was taken on 08-10-10 at 5:30 P.M., and was 165/78, as recorded on the "Graphic Intake/Output Record." However, the blood pressure was retaken at 6:00 P.M., at which time the blood pressure had decreased to 149/74, which did not require the administration of Hydralazine.

On 08-10-10 at 8:55 P.M., Patient #4 had a blood pressure of 160/73. The MAR revealed that no Hydralazine had been administered as ordered. On 08-11-10 at 9:30 P.M., Patient #4 had a blood pressure of 155/78. No Hydralazine was administered as ordered. On 08-12-10 at 3:55 A.M., the patient had a blood pressure of 153/75. No Hydralazine was administered as ordered. On 08-12-10 at 9:00 P.M., the patient had a blood pressure of 159/74. No Hydralazine was administered as ordered. On 08-13-10 at 3:15 A.M., the patient had a blood pressure of 154/73. No Hydralazine was administered as ordered. On 08-15-10 at 7:55 A.M., the patient had a blood pressure of 167/77. No Hydralazine was administered as ordered. On 08-15-10 at 3:05 P.M., the patient had a blood pressure of 151/76. No Hydralazine was administered as ordered.

- Patient #5

Patient #5 presented to the ED on 08-09-10 at 10:43 P.M. The Chief Complaint was Epigastric Abdominal Pain. The "Brief Assessment" revealed: "Pt. c/o epigastric pain x 2 days progressively getting worse. Positive nausea Negative V/D (vomiting/diarrhea); pt stating pain is a 'cramping' radiating into back negative pulsatile mass noted; Pt A&O (alert and oriented) x3 in NAD, Skin WPD; Pt stating 'I think I have kidney problems'." The "Past Medical History" revealed that Patient #5 had medical conditions that included Congestive Heart Failure and Hypertension.

At the time of Triage, Patient #5 had a temperature of 98.0, a pulse of 94, respirations of 18, a blood pressure of 238/108, and an oxygen saturation level of 93% on room air. The pulse of 94 is noted by the RN to be "Regular."

The ED vital signs flowsheet revealed a blood pressure of 210/107 at 11:30 P.M., a blood pressure of 198/92 at 12:20 A.M., a blood pressure of 200/109 at 1:45 A.M., a blood pressure of 204/94 at 2:51 A.M., a blood pressure of 197/91 at 3:19 A.M., and a blood pressure of 189/92 at 3:34 A.M. Coreg (antihypertensive) 12.5 mg. P.O. was administered at 3:19 A.M.

The "Emergency Department Report" revealed: "...her heart is irregular...She also does have a markedly elevated blood pressure...." The "Impression" revealed: "1. Right upper quadrant pain. 2. Cholelithiasis, possible acute cholecystitis. 3. Hypertension. 4. Congestive heart Failure. 5. Dependent edema. 6. Abnormal EKG. The "Emergency Department Report" "Plan" revealed: Admission...."

Emergency Physician #1 wrote the "Routine Admitting Orders" for Patient #5 on 08-10-10 at 2:15 A.M. for "Hydralazine 10 mg. IV q 8 hrs (hours) prn SBP>180."

The "Graphic/Intake & Output Record" for Patient #5, dated 08-10-10 at 4:15 A.M., revealed the patient had a blood pressure of 189/92. No Hydralazine was given as ordered. On 08-10-10 at 7:00 A.M., the patient's blood pressure was elevated to 210/120, at which time a dose of Hydralazine was first given for the elevated blood pressure.

The "History and Physical" "Past Medical History" revealed: "Certainly complex. Most significant for a history of chronic congestive heart failure due to diastolic dysfunction. She also has a history of chronic insufficiency. She has a history of severe pulmonary hypertension, indeed has a pacemaker and has a history of atrial fibrillation. She has dementia and hypertension as well...." The "Plan" revealed: "Overall, I think we are going to see if we can avoid a surgical intervention here in this patient with complex medical problems including diabetes, atrial fibrillation, chronic renal insufficiency, congestive heart failure and pulmonary hypertension."

On 08-11-10, the physician ordered "Clear liquid + (arrow up depicted) to low fat diet as tolerated. The "Graphic/Intake & Output Record" for 08-11-10 revealed that Patient
#5 ate "100%" of dinner. The "Graphic/Intake & Output Record" for 08-12-10 revealed no oral intake for Patient #5, beginning at 7:00 A.M.

Patient #5's MAR revealed that on 08-12-10 at 8:00 A.M., the 8:00 A.M. scheduled dose of Coreg (antihypertensive) was held. There was no explanation on the MAR or on the narrative notes as to the reason RN #4 held the Coreg. Documentation on the MAR revealed that on 08-12-10 at 9:00 A.M., the oral dose of aspirin and Celebrex were also circled as "held." There was no explanation on the MAR regarding why the aspirin and Celebrex oral medications were not administered as ordered. On 08-12-10 at 9:00 A.M., IV Levofloxacin was administered by RN #4.

On 08-12-10, narrative nursing documentation revealed: "Assumed care of patient this A.M...Pt. was transferred to BSC (bedside commode) this A.M. at approx. (approximately) 0910 (9:10 A.M.) by (RN named). Stated to this nurse that pt. was a difficult transfer to commode, due to left leg weakness. Pt. returned to bed and seen by (Surgeon #4) at 0920 (9:20 A.M.). Nurse in to see pt. at 0925 (9:25 A.M.). Assessment completed. Pt. was noted to have left facial droop, left pupil 3 cm, right pupil 2 cm, slurred speech. Pt unable to lift left arm or squeeze hand. Pt. unable to move left leg or do extension flexion with left foot. Blood pressure was 180/106, heart rate was 86. Recheck of blood pressure was 179/110, heart rate of 91. Pt. unable to follow commands...Pt. to be transferred to ICU...."

The "Discharge Summary" revealed: "...The patient was admitted. We treated her conservatively. (Surgeon #4) saw the patient...We hoped that we might be able to get past this problem with medical management, without surgical intervention. Indeed, she began to improve. On the morning of August 12, 2010, we found the patient with the sudden onset of a rightward gaze and a left-sided paralysis. We got a CAT (Computerized Axial Tomography) scan. We found no bleed. We concluded that she had acute nonhemorrhagic stroke, most likely embolic in nature. She was transferred to the ICU and given TPA (tPA) (Tissue Plasminogen Activator)...She will be discharged to a skilled nursing facility today for comprehensive occupational therapy, and speech therapy, and physical therapy...."

Based on record review, policy and procedure review, and interview, it was determined that the Hospital failed to require that informed consent for anesthesia was obtained in one (1) of one (1) records reviewed for pre-operative care (Patient #3).

Findings include:

The "Oro Valley Hospital Consents" Policy "Purpose" revealed: "To safeguard the right of the patient, in collaboration with his/her physician, to make decisions involving his/her health care, including:...2. Right of the patient to the information necessary to enable him/her to make treatment decisions that reflect his/her wishes...Informed consent is the sole responsibility of the physician and should include evidence in the medical record: a. Procedure b. Benefits of treatment c. Risks and complications...d. Alternatives e. Documentation that the patient understands and agrees to the procedure...Informed consent is the duty and obligation of the physician according to Arizona law. Under the law, nurses are not considered 'competent' to provide informed consent or to assess the patient to determine evidence of informed consent...."

Patient #3, was admitted to surgical services on 08-19-10, for a Cystoscopy and Suprapubic Tube Placement. The History and Physical revealed that Patient #3 had a Chief Complaint of Neurogenic Bladder. The "History of Present Illness" revealed: "The patient is a (year-old-male), history of T3 (thoracic region vertebrae) spinal cord injury for a motor vehicle collision in (year). The patient had been managing his bladder with intermittent catheterizations, but more recently had an indwelling Foley catheter placed due to the presence of a decubitus ulcer. The patient was told to stop CIC (Clean Intermittent Catheterization) due to these ulcers and has subsequently had an in dwelling (sic) urethral catheter in place for approximately 2 months and developed a severe urethral erosion...."

The "Oro Valley Hospital Consent For Anesthesia" for Patient #3 revealed: "I, (name) have been scheduled for 'Cysto (Cystoscopy), suprapubic tube placement' surgery. I understand that anesthesia services are needed so that my doctor can perform the operation or procedure. It has been explained to me that all forms of anesthesia involve some risks and no guarantees or promises can be made concerning the results of my procedure or treatment. ALTHOUGH RARE , SEVERE UNEXPECTED COMPLICATIONS CAN OCCUR WITH EACH TYPE OF ANESTHESIA, INCLUDING THE POSSIBILITY OF INFECTION, BLEEDING, DRUG REACTIONS, BLOOD CLOTS, LOSS OF SENSATION, LOSS OF VISION, LOSS OF LIMB FUNCTION, PARALYSIS, STROKE, BRAIN DAMAGE, HEART ATTACK OR DEATH. I understand that these risks apply to ALL forms of anesthesia and that additional or specific risks have been identified below as they may apply to a specific type of anesthesia. I understand that the type(s) of anesthesia service checked below will be used for my procedure and that the anesthetic technique to be used is determined by many factors including my physical Condition, the type of procedure my doctor is to do, his or her preference, as well as my own desire...."

The consent form contained a field for: "General Anesthesia, Spinal or Epidural Analgesia/Anesthesia, Major/Minor Nerve Block, Intravenous Regional, Monitored Anesthesia Care (With moderate to deep sedation), Monitored Anesthesia Care (without sedation)." Each type of anesthesia listed on the form had an empty field to the left of the descriptor to be marked for the type of anesthesia to be administered. Each anesthesia type had fields in which the Expected Result, Technique, and Risks were revealed.

The form subsequently revealed: "I consent to the anesthesia service checked above and authorize that it be administered by an Anesthesiologist from Oro Valley Anesthesia, PLLC., all of whom are credentialed to provide anesthesia services at this health facility...."

The "Consent For Anesthesia Services" form for Patient #3 revealed a signature consistent with the patient's name. The "Witness Signature" was signed by RN #3. The "Date and Time" field revealed the consent was signed on 08-19-10 at "9:40." There were no markings specifying the type of anesthesia to be administered to Patient #3, and there was no anesthesiologist signature on the form.

The Pre-Operative Charge Nurse (RN #3) acknowledged, during interview conducted on 08-19-10 at 10:30 A.M., that she had asked Patient #3 to sign the anesthesia consent form which contained no notation of the type of anesthesia to be administered, and which had not been signed by the anesthesiologist.