HospitalInspections.org

Based on medical record review, document review and interview, in one (1) of ten (10) medical records reviewed, it was determined the facility failed to (a) ensure the nursing staff implemented a physician's order, (b) notify a provider when a patient's condition began to deteriorate and (c) modify a nursing care plan that reflected the patient's changing needs. This was evident in medical record (MR) #1.


Findings include:

(a) The nursing staff failed to reassess a patient's vital signs every four (4) hours according to a provider's order.

(b) The nursing staff failed to notify a provider in a timely manner when a patient's condition began to deteriorate.

See Tag A 0395.

(c)The nursing staff failed to modify and implement a nursing care plan in a timely manner in to monitor and reassess a patient's condition frequently when the patient began to decompensate.

See Tag A 0396.

Based on medical record review, document review and interview, in one (1) of ten (10) medical records reviewed, it was determined the facility failed to (a) ensure the nursing staff implemented the physician's order to check the patient's vital signs every four (4) hours and (b) notify a provider when a patient's condition began to deteriorate. This was evident in medical record (MR) #1.

Findings include:

Review of MR #1: This 52-year-old patient arrived and was triaged in the Emergency Department (ED) on 6/9/23 at 6:59 PM with a complaint of multiple injection site infections, also with left leg pain, redness and swelling of wounds to the bilateral lower legs. According to patient she has been non-compliant with her medications and has had multiple admissions for skin Cellulitis. However, this time the patient stated, she injects cocaine intravenously (IV) and is concerned that some of her wounds might be getting worse. The patient's previous medical history was significant for Diabetes Mellitus, Obesity, Narcolepsy and Bipolar Disorder.

The patient was alert and oriented to person, place and time, speech was normal, and the patient had multiple abrasions and Cellulitis on both upper and lower extremities. Vital signs at 7:00 PM were temperature 99.1F, pulse 121, respiration 18, B/P 171/99 and oxygen saturation was 99% (room air). Blood work was abnormal for sodium, chloride, lactate, complete blood count and liver enzymes and glucose 620 [normal level 74-106). The patient was diagnosed with Multiple Infected Skin Ulcers, Cellulitis, Sepsis and Hyperglycemia. Urine toxicology was positive for Cocaine and Methadone.

The provider documented an order on 6/9/23 at 10:58 PM for vital signs to be checked every four (4) hours.

The patient's vital signs were monitored every six (6) - eight (8) hours from 6/10/23 - 6/11/23.

On 6/12/23 at 6:00 AM, vital signs were monitored: temperature 98.9F, pulse 99, respiration 16, B/P 175/98 and oxygen saturation was 94%.

On 6/12/23 at 12:05 noon, six (6) hours later, vital signs were monitored: pulse 92, respiration 20, B/P 148/83 and oxygen saturation was 96% on room air. The nursing staff documented throughout the day that the patient was only oriented to self.

There was no documentation of a vital sign assessment at 4:00 PM on 6/12/23.

At 6:36 PM on 6/12/23, nurse documented "patient aberrant behavior continues. Patient continues to require 1:1 for safety. Patient with many attempts to remove medical equipment. Attempts to remove oxygen. Patient inconsolable. Patient only oriented to self at this time. VSS. Will continue to monitor." There was no documentation of a numerical value of the vital signs at that time.

There was no documentation of a vital sign assessment at 8:00 PM on 6/12/23.

At 10:00 PM on 6/12/23, nurse documented the patient's "orientation and mood were not normal, and the speech was garbled and incoherent." The nurse was "unable to assess the patient's level of orientation. The patient was hyperactive, (agitated, impulsive), restless, uncooperative, sexually inappropriate and there was now fecal incontinence." There had been urinary incontinence since 6/10/23. "The patient refused vital signs at this time."

There was no documentation that the provider was notified of these assessments and deterioration of the patient's mental status, behavior and general condition until almost three (3) hours later.

On 6/13/23 at 12:35 AM, nurse documented patient's vital signs: pulse 114 (normal 60-100), respiration 28 (normal 12-20), B/P 213/120 (normal 90-120/50-90).

The nurse practitioner documented that at 12:58 AM "contacted by a nurse because the patient became lethargic, tachypneic (40's), tachycardic (150's), hypertensive (200/120's). A few minutes after she called for an immediate response. Found in severe respiratory distress, unresponsive, diaphoretic. Non-rebreathing mask placed."

At 2:00 AM, 6/13/23, the nurse documented "patient with agonal breathing. Oxygen saturation 80's with 2 liters of oxygen via nasal cannula. Patient unresponsive, diaphoretic, and flushed. Patient was not at baseline behavior from start of shift. Rapid response initiated."

The head CT-Scan performed on 6/13/23 at 9:03 AM showed "Extensive intracranial hemorrhage is present primarily intraventricular. There is blood in the third ventricle and foramen. There is blood in the fourth ventricle and extending in the left and right posterior fossa. There is edema and mass effect in the posterior fossa. Overall, sulci and gyri are effaced."

There was no documentation of every four (4) hours vital sign assessment during the period 6/12/23 at 6:00 AM through 6/13/23 at 12:35 AM when the patient's condition was noted to be critical.

These findings were confirmed with Staff A, Medical Surgical Educator during an interview conducted on 8/16/23 at approximately 3:30PM.

Based on medical record review, document review and interview, in one (1) of ten (10) medical records reviewed, it was determined the facility failed to modify and implement a nursing care plan when there was a change in the patient's condition. This was evident in medical record (MR) #1.

Findings include:

The policy titled "Assessment and Reassessment of Patient," revised 3/2023 states, the frequency of reassessment including education and plan of care should be done "per change in patient condition and following change in level of care. Adult Medical/Surgical without a PCA pump: Every 8 hours and with change in patient condition."

Review of MR #1 identified: the patient was admitted alert and oriented to person, place and time on 6/9/23, with diagnoses of Multiple Infected Skin Ulcers, Cellulitis, Sepsis and Hyperglycemia.
On 6/12/23, the provider documented, patient's diagnosis was Acute Metabolic Encephalopathy. At 6:51 AM a nurse documented "1:1 in place for safety and impulsivity. Continues to climb out of bed." The patient was given Ativan 2mg IV at 8:52 AM and 2:58 PM. At 11:45 AM on 6/12/23, the nurse documented the patient's neurological assessment as oriented to self only.

At 6:36 PM on 6/12/23, nurse documented "patient aberrant behavior continues. Patient continues to require 1:1 for safety. Patient with many attempts to remove medical equipment. Attempts to remove oxygen. Patient inconsolable. Patient only oriented to self at this time. Vital signs stable. Will continue to monitor."

At 10:00 PM on 6/12/23, nurse documented that the patient's orientation and mood were not normal, and the speech was garbled and incoherent. The nurse was unable to assess the patient's level of orientation. The patient was hyperactive, (agitated, impulsive), restless, uncooperative, sexually inappropriate and there was now fecal incontinence. There had been urinary incontinence since 6/10/23. The patient refused vital signs at this time.

There was no documentation in the medical record that the nursing care plan was modified to address the changes in the patient's mental status, behavior, and general medical condition. There were no documentation that neurological and vital signs assessments were completed more frequently.

The patient was found unresponsive, lethargic and in respiratory distress with abnormal vital signs at 12:35 AM on 6/13/23, which required intubation, placement on a ventilator and critical nursing care.

These findings were confirmed with Staff A, Medical Surgical Educator during an interview conducted on 8/16/23 at approximately 3:30PM.