HospitalInspections.org

Based on record review and interview, the facility failed to protect the patient from injury. The facility failed to have a system in place to monitor critically ill patients that required constant monitoring of telemetry for heart rhythms.



Refer to Tag A0144

Based on record review and interview, the facility failed to protect the patient from injury. The facility failed to have a system in place to monitor critically ill patients that required constant monitoring of telemetry for heart rhythms that, if left unattended, could cause injury or death.

Review of Patient #1's Emergency Room (ER)chart revealed she was admitted to the facility on 1/12/22 for acute respiratory distress and overdose of Ambien. The patient also had Diabetes, Hypertension (HTN) and Congestive Heart Failure (CHF). Patient #1 was placed on the ventilator and admitted to ICU. Patient #1 was two doors down from the nurse's station and on telemetry. The telemetry monitor showed the patient's heart rate and rhythm, blood pressure, respiratory rate, and oxygen levels.

Review of Patient #1's Respiratory Therapy (RT) notes dated 1/17/22 at 1715 (5:15PM) revealed Patient #1 was extubated (removal of the endotracheal tube). The patient was placed on O2 per nasal canula at 3 L. Patient #1's Post Extubation Respiratory Rate was at 16 and 97% O2 saturation. There were no other vital signs documented.

Review of Patient #1's Nurses Notes dated 1/17/22 revealed the patients primary nurse (Staff #7) documented, "1715- "Pt S/P extubation at 1715, nursing and RT at bedside. Pt assessed for stridor and instructed to rest vocal cords. Pt. verbalized the need to have a bowel movement. Pt placed on bedpan, given call light and instructed to call for assistance by this writer. Pt. verbalized understanding of instructions given. Pt waited until she was left alone and attempted to walk to the bathroom. Pt was found face down with ICU monitor cords tangled around her, bed rails up and a large amount of BM on the floor. Pt. family made aware by this writer that pt. is very modest with regards to her bowels. Pt encouraged by this writer to have a bowel movement. Pt has a small bowel movement yesterday and another small one this afternoon. Pt given a complete bed bath after bowel movements from this writer. The apprehension about using the bathroom was discussed with patient's family by this writer."

Review of the nursing flowsheet on 1/17/22 at 2027 (8:27PM) Staff # 7 documented, "1715-Nursing care rendered, nursing and RT at bedside. Pt extubated, assessed for stridor , instructed to rest vocal cords. Oxygen applied at 3L. Pt sitting up in bed no acute distress noted, see chart for vitals. 1735-Pt verbalized need to have a bowel movement. Pt placed on bedpan, and given call light and instructed to call for assistance by this writer. Pt verblize understnding of instructions given. Pt waited until she was alone and attempted to use the restroom. 1740- Pt found unresponsive prone on floor with ICU cords and a large amount of BM around her body. 1741-CPR initiatied on floor.1742-Code blue called, see chart. _______ (Staff #12) at bedside. Pt re-intubated, arterial line and central line placed. 1800-Pts Son ______ notified of the above event. 1830-Pts family at bedside."

Review of the code sheet dated 1/17/22 at 1742 (5:42PM) revealed Patient #1 was found unresponsive and in PEA. CPR was initiated at 1742 and continued until 1753 (5:43PM) when a heart rate was established and the patient was placed back on the ventilator.

Review of Patient #1's Nursing Notes revealed that Staff #11 (charge nurse) documented, "18:50 (6:50PM) Pt found, unresponsive, on the floor after having an unwitnessed fall by ______ (Staff #7) RN@ 1740. Unable to palpate pulse, code blue called, CPR initiated. Dr. _____ (Staff #9 MD) and _____ (Staff #12) ACNP at bedside. Pt log rolled onto green lift pad and lifted onto bed with assist x6 staff members after 2 minutes CPR. Pt remained pulseless, CPR resumed, see code sheet. Pt's son, _____ notified of change in condition and fall by _____ (staff #7) RN." (sic)

Review of the physician progress notes dated 1/18/22 stated, "Acute Hypercapnic Respiratory Failure: Suspect some degree of narcosis related to Ambien and opioids. Was extubated 1/17 @1715, however she developed a cardiac arrest after a fall requiring re-intubation. Cont. to wean FiO2 as tolerated. ...Concerned for poor neurological recovery given myoclonus following arrest."

An MRI was performed on 1/26/22. The MRI shows an anoxic brain injury. Anoxic brain injuries are caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation.

An interview was conducted with Staff #7 on 1/26/22 at 2:00PM. Staff #7 stated that she had been taking care of this patient for several days. Staff #7 stated that she had the patient ready for extubation at 10:00AM but there was not a respiratory therapist available to remove the patient from the vent until 17:15. Staff #7 stated she had been talking to the patient and she was following all commands and had not been on any sedative medications. Staff #17 stated the patient was having family come up and she gave Patient #1 a bed bath before extubation. "The patient had a small BM in the bed, and I cleaned her up. It seemed she was a little shy about pooping in front of anyone. After she was extubated, she wanted to get on the toilet and poop, but I told her she could use the bedpan. I didn't want her to get up yet. I had already pulled medication for my other patient so I put her on the bed pan, raised her head, bedrails were up for her to hold onto, gave her the call light and I told her I would be right back and to call if she needed anything. I went into my Covid patients' room and administered his medications. I know I was not gone more than 3-4 minutes. I walked out and looked into ______ (Patient #1) room and she was not in the bed. I ran in and she was lying on the floor with poop everywhere. It was so large." The surveyor asked Staff #7 to clarify what she meant by "large." Staff #7 stated, "The BM was large around like the size of a coke can and also a large amount. I called out for help and another nurse came in. We assessed the patient and realized she was unresponsive and no pulse. He called a code and I initiated CPR. _____ (Staff #9 Intensivist/Pulmonologist and #12 NP) were on the unit and came in and helped with the code." Staff #7 reported that the patient was placed back on the vent and she called the patients family and told them the status of the patient."

The hospital had a centralized telemetry area or Warning Armed Rhythms (W.A.R) room. The W.A.R. room is a 24-hour department staffed with telemetry technicians that are certified and proficient at cardiac rhythm identification. Patients that are placed on telemetry are monitored from this room. A patient's heart rhythm can become lethal. This involves life threatening rhythms that, if left unattended, could cause symptoms that could in turn lead to death. Whenever there is a lethal rhythm this triggers an alarm by the monitoring system, followed by identification by the telemetry technician has life-threatening and not merely an artifact, a nurse is paged and called, alerting her to the emergency.

On 1/26/22 at 1:55PM the surveyor entered the ICU unit and viewed Patient #1 on the ventilator. The surveyor walked up to the nurse's desk and no one was at the desk. The telemetry monitors for each patient were unattended.

During an interview conducted with Staff #7 on 1/26/22 at 2:00PM. Staff #7 was asked if the patients telemetry monitors were disconnected or on the patient. Staff #7 stated they were disconnected and wrapped around her when she fell. Staff #7 was asked why she was not alerted from the WAR room that the patient was disconnected? Staff #7 stated that none of the patients in ICU are monitored by the WAR room. Staff #7 confirmed that the cords to the telemetry monitors do not audibly alarm when they are disconnected. Staff #7 stated she would have not known her patient was off the monitor unless she was watching the monitors. Staff #7 stated that was impossible when you have more than one patient.

An interview was conducted with Staff #10 ICU director, Staff #2 CNO on the ICU at 2:30PM. Staff #10 confirmed that the patients are the only telemetry patients not monitored by the WAR room. Staff #10 stated that the nurses should monitor their patients. Staff #10 stated that they used to have unit clerks that monitored the monitors but were used for other duties and were not available to always monitor the patients. Staff #10 and #2 confirmed they did not have trained monitor technicians to watch the monitoring system for ICU patients. Staff #10 and #2 were unable to give the surveyor a reason on why the audible alarms were not on when a patient was disconnected from telemetry. Staff #10 stated that years ago they tried to move the ICU telemetry to the war room but was told IT could not make it happen. Staff #10 confirmed that there are times a patient's telemetry may not be monitored.
An interview was conducted with Staff #1 CEO on 1/26/22 in the afternoon. Staff #1 was not aware that the ICU telemetry was not being monitored by the WAR room. Staff #1 stated that was not acceptable and would be setting that up immediately.

Based on record review and interview, Nursing failed to assess and reassess Patient #1 for an injury after an unwitnessed fall and failed to complete the Cardiopulmonary Resuscitation Flow Sheet.

Review of Patient #1's Emergency Room (ER)chart revealed she was admitted to the facility on 1/12/22 for acute respiratory distress and overdose of Ambien. The patient also had Diabetes, Hypertension (HTN) and Congestive Heart Failure (CHF). Patient #1 was placed on the ventilator and admitted to ICU. Patient #1 was two doors down from the nurse's station and on telemetry. The telemetry monitor showed the patient's heart rate and rhythm, blood pressure, respiratory rate, and oxygen levels.

Review of Patient #1's Respiratory Therapy (RT) notes dated 1/17/22 at 17:15 (5:15PM) revealed Patient #1 was extubated (removal of the endotracheal tube) at 1715 (5:15PM). The patient was placed on O2 per nasal canula at 3 L. Patient #1's Post Extubation Respiratory Rate was at 16 and 97% O2 saturation. There were no other vital signs documented.

Review of Patient #1's Nurses Notes dated 1/17/22 revealed the patients primary nurse (Staff #7) documented, "1715- "Pt S/P extubation at 1715, nursing and RT at bedside. Pt assessed for stridor and instructed to rest vocal cords. 1735 Pt. verbalized the need to have a bowel movement. Pt placed on bedpan, given call light and instructed to call for assistance by this writer. Pt. verbalized understanding of instructions given. Pt waited until she was left alone and attempted to walk to the bathroom. 1740 Pt was found face down with ICU monitor cords tangled around her, bed rails up and a large amount of BM on the floor. Pt. family made aware by this writer that pt. is very modest with regards to her bowels. Pt encouraged by this writer to have a bowel movement. Pt has a small bowel movement yesterday and another small one this afternoon. Pt given a complete bed bath after bowel movements from this writer. The apprehension about using the bathroom was discussed with patient's family by this writer."

Review of the nursing flowsheet on 1/17/22 at 2027 (8:27PM) Staff # 7 documanted, "1715-Nursing care rendered, nursing and RT at bedside. Pt extubated, assessed for stridor , instruced to rest vocal cords. Oxygen applied at 3L. Pt sitting up in bed no acute distress noted, see chart for vitals. 1735-Pt verbalized need to have a bowel movement. Pt placed on bedpan, and given call light and instructed to call for assistance by this writer. Pt verblize understnding of instructions given. Pt waited until she was alone and attempted to use the restroom. 1740- Pt found unresponsive prone on floor with ICU cords and a large amount of BM around her body. 1741-CPR initiatied on floor.1742-Code blue called, see chart. _______ (Staff #12) at bedside. Pt re-intubated, arterial line and central line placed. 1800-Pts Son ______ notified of the above event. 1830-Pts family at bedside."

Review of the code sheet dated 1/17/22 at 1742 (5:42PM) revealed Patient #1 was found unresponsive and in PEA. CPR was initiated at 1742 and continued until 1753(5:43PM) when a heart rate was established and the patient was placed back on the ventilator.

Review of Patient #1's Nursing Notes revealed that Staff #11 (charge nurse) documented, "18:50 (6:50PM) Pt found, unresponsive, on the floor after having an unwitnessed fall by ______ (Staff #7) RN@ 1740. Unable to palpate pulse, code blue called, CPR initiated. Dr. _____ (Staff #9 MD) and _____ (Staff #12) ACNP at bedside. Pt log rolled onto green lift pad and lifted onto bed with assist x6 staff members after 2 minutes CPR. Pt remained pulseless, CPR resumed, see code sheet. Pt's son, _____ notified of change in condition and fall by _____ (staff #7) RN." (sic)

Review of the physician progress notes dated 1/18/22 stated, "Acute Hypercapnic Respiratory Failure: Suspect some degree of narcosis related to Ambien and opioids. Was extubated 1/17 @1715, however she developed a cardiac arrest after a fall requiring re-intubation. Cont. to wean FiO2 as tolerated. ...Concerned for poor neurological recovery given myoclonus following arrest."

An MRI was performed on 1/26/22. The MRI shows an anoxic brain injury. Anoxic brain injuries are caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation.

Review of patient #1's chart revealed there was no found vital signs documented on 1/17/22 from 1618(4:18PM) to 1851 (6:51PM). There was no found documentation on any head-to-toe assessment for injuries after fall or after resuscitation. The oncoming RN assessed the patient for the shift at 8:00PM.

An interview was conducted with Staff #7 on 1/26/22 at 2:00PM. Staff #7 stated that she had been taking care of this patient for several days. Staff #7 stated that she had the patient ready for extubation at 10:00AM but there was not a respiratory therapist available to remove the patient from the vent until 17:15 (5:15PM). Staff #7 stated she had been talking to the patient and she was following all commands and had not been on any sedative medications. Staff #17 stated the patient was having family come up and she gave Patient #1 a bed bath before extubation. "The patient had a small BM in the bed, and I cleaned her up. It seemed she was a little shy about pooping in front of anyone. After she was extubated, she wanted to get on the toilet and poop, but I told her she could use the bedpan. I didn't want her to get up yet. I had already pulled medication for my other patient so I put her on the bed pan, raised her head, bedrails were up for her to hold onto, gave her the call light and I told her I would be right back and to call if she needed anything. I went into my Covid patients' room and administered his medications. I know I was not gone more than 3-4 minutes. I walked out and looked into ______ (Patient #1) room and she was not in the bed. I ran in and she was lying on the floor with poop everywhere. It was so large." The surveyor asked Staff #7 to clarify what she meant by "large." Staff #7 stated, "The BM was large around like the size of a coke can and also a large amount. I called out for help and another nurse came in. We assessed the patient and realized she was unresponsive and no pulse. He called a code and I initiated CPR. _____ (Staff #9 Intensivist/Pulmonologist and #12 NP) were on the unit and came in and helped with the code." Staff #7 reported that the patient was placed back on the vent and she called the patient's family and told them the status of the patient." Staff #7 was asked if a head-to-toe assessment was performed on the patient after the CPR resuscitation. Staff #7 stated that she did do an assessment. Staff #7 stated, "I was so upset after the incident that I know I should have documented better than I did."

Review of the Cardiopulmonary Resuscitation Flow Sheet (CPR Sheet) dated 1/17/22 revealed a code was initiated in room 414 at 1742 (5:42PM). The recorder failed to fill out the intubation time, size, by whom, and attempts. If it was oral, nasal, cric, or trach placement and who it was confirmed by. The recorder failed to fill out if the family was notified and if attending called. The recorder failed to list the whole names of the team that assisted with the resuscitation. The recorder only wrote in first names with titles. Staff #2 confirmed the findings.