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Based on medical record review, document review, and staff interviews, the acute care hospital's administrative staff failed to ensure the nursing staff assessed 1 of 3 patients selected (Patient #1), documented the focused nursing assessment, and contacted the patient's physician following the patient experiencing a new onset change in their condition.

The cumulative effect of these systemic failures and deficient practices resulted in the acute care hospital staff's inability to ensure the acute care hospital staff provided adequate nursing care to meet patient needs.

Please refer to A-0395.

Based on medical record review, document review, and staff interviews, the acute care hospital's administrative staff failed to ensure the nursing staff assessed 1 of 3 patients selected (Patient #1), documented the focused nursing assessment, and contacted the patient's physician following the patient experiencing a new onset change in their condition. Failure to ensure the nursing staff assessed, documented the assessment, and contacted the patient's physician resulted in the nursing staff failing to report that Patient #1 suffered a stroke for up to 6 hours to Patient #1's physician, potentially resulting in Patient #1's physician lacking the option to order tPA (tissue plasminogen activator, a drug used to break down blood clots) following Patient #1's stroke. The acute care hospital's administrative staff identified an average daily census of 214 inpatients.

Findings include:

1. Review of the policy "Documentation Principles for Electronic Medical Records," effective 1/2019, revealed in part, "... provide principles and guidelines for care related to the patient documentation with an electronic medical record (EMR) system ... The electronic medical record is a secure legal document that summarizes patient care activities within varied patient care settings over a period of time."

"Nursing Shift Assessment includes "Head-to-toe physical assessment including daily cares, ... interventions, ... and appropriate screenings ... The shift assessment is completed ... with any change in nurse caregiver ..."

The policy defined Nursing Re-Assessment or Focused Assessment as "A condensed reassessment of chief complaints and pertinent systems previously noted on a head-to-toe physical assessment that were found to be either outside of normal or a new complaint or observation. For inpatient units, this reassessment is performed by the same nurse who documented the head-to-toe assessment and is also within the same shift.... The pertinent systems or variations from normal parameters will be assessed. The nurse will document changes from the shift assessment ... Documentation that will be included in a note (but not limited to): 1) Significant event note will include: detailed objective account of the event including precipitating factors leading up to event, who was notified (including the time of notification and response of the person notified. Also include how the patient responded to actions that were taken and the end outcome of the event ..."


2. Review of the "Nursing Operations Structure Standards," issued 5/2015, revealed in part, "Physicians shall be notified whenever requested and/or when nursing judgement deems appropriate according to patient condition."


3. Review of Patient #1's medical record revealed:

a. The hospital staff admitted Patient #1 to the hospital on 1/2/21, with right hip pain after Patient #1 fell. The hospital staff diagnosed Patient #1 with a right femoral neck fracture. Patient #1 underwent surgical repair of the hip fracture on 1/3/21. Following the surgery, Patient #1 made slow progress with physical and occupational therapy, due to Patient #1's fatigue, reduced endurance, drowsiness, and pain. The discharge planning staff had recommended that Patient #1 continue their recovery from the hip surgery at a skilled nursing facility.

b. A physician's note on 1/5/21 at 7:08 AM revealed that Hospitalist C (a physician with specialized training in the treatment of hospitalized patients) documented that Patient #1 was alert and oriented to person, place, and time. Patient #1's fatigue was improving without focal (localized) motor or sensory deficits.

c. RN A documented on 1/5/21 at 9:20 AM, during RN A's morning nursing assessment of Patient #1, that Patient #1 was awake and alert, but did not know the time (a sign of confusion).

d. RN B documented on 1/5/21 at 11:15 AM that, following Physical Therapy, Patient #1 was tired. Patient #1's daughter grabbed Patient #1's head and yelled at Patient #1, in an attempt to wake up Patient #1. Following RN B's interaction with Patient #1's daughter, Patient #1's daughter requested the charge nurse assign a different nurse to provide Patient #1's care. RN B's note did not include any information about changes in Patient #1's condition or contact Patient #1's physician, as required by hospital policy.

e. Social Worker D documented on 1/5/21 at 11:44 AM that Social Worker D spoke with Patient #1's daughter about Patient #1's plans to discharge home versus going to a skilled nursing facility for more therapy than Patient #1 could receive at home. Social Worker D began contacting skilled nursing facilities to identify a facility which could assist Patient #1 with regaining their mobility and strength following the hip surgery, with the hope of Patient #1 returning to their home eventually.

f. Occupational Therapy Aide (OTA) E documented on 1/5/21 at 12:10 PM that OTA E attempted to work with Patient #1. Patient #1 did not wake up when OTA E and Patient #1's daughter attempted to wake up Patient #1. Patient #1 did not respond to OTA E when asked questions and would only moan (despite Patient #1 being awake and alert approximately 2 hours earlier).

g. OTA E documented on 1/5/21 at 3:10 PM that OTA E attempted to work with Patient #1 a second time that day. Patient #1 moaned when OTA E attempted to work with Patient #1. Patient #1 was drowsy and would only wake up for brief periods while OTA E worked with Patient #1.

h. Licensed Practical Nurse (LPN) F documented on 1/5/21 at 3:56 PM that Patient #1 was sleeping.

i. LPN F documented on 1/5/21 at 4:10 PM that Patient #1 was drowsy and would only respond when LPN F spoke to Patient #1.

j. LPN F documented on 1/5/21 at 4:58 PM that LPN F checked Patient #1's vital signs. LPN F did not document they assessed Patient #1, or that the nursing staff notified Hospitalist C about Patient #1's condition change.

k. Hospitalist C documented on 1/5/21 at 8:08 PM that at 5:15 PM (6 hours after Patient #1 worked with therapy staff) the nursing staff contacted Hospitalist C regarding a change in Patient #1's condition. After working with therapy staff in the morning, Patient #1 was sleepy and would not respond to the nursing staff. Given the sudden changes in Patient #1's condition and Patient #1's heightened risk of stroke from Patient #1's prior medical conditions and recent hip surgery, Hospitalist C ordered the hospital staff to perform several tests on Patient #1 to determine the cause of the changes in Patient #1's condition, including performing a CT of Patient #1's head. The head CT showed Patient #1 possibly had a stroke.

When Hospitalist C examined Patient #1, Hospitalist C noticed that Patient #1 was drowsy, had slight drooping on the right side of Patient #1's face, and Patient #1 had pronounced weakness of the right side of Patient #1's body. Due to the length of time since Patient #1 began experiencing symptoms, Hospitalist C could not order the nursing staff to administer medication to Patient #1 which would break down any blood clots causing Patient #1's stroke. Hospitalist C discussed Patient #1's poor prognosis with Patient #1's family, and Patient #1's family decided to place Patient #1 in hospice.


4. Review of a photo of Patient #1 taken by Patient #1's daughter, dated 1/5/21 at 11:15 AM, revealed Patient #1 appearing to exhibit right sided facial droopiness (a sign of a potential stroke).


5. During an interview on 5/20/21 at 2:30 PM, RN A revealed that Patient #1 was recovering from surgery to repair a hip fracture. On the morning of 1/5/21, RN A assisted Patient #1 to get out of the bed and work with Physical Therapy to allow Patient #1 to regain their strength to go home. Since Patient #1 was receiving pain medication following the surgery, Patient #1 would occasionally forget things, but RN A did not notice any new changes in Patient #1's mental status. RN A did not identify Patient #1 exhibiting any signs or symptoms of a stroke. RN A handed off Patient #1's care to RN B at 11:00, while Patient #1 was working with the Physical Therapy staff.

6. During an interview on 5/25/21 at 9:30 AM, Physical Therapist G revealed that Patient #1 needed encouragement to perform the physical therapy on the morning of 1/5/21 at 11:04 AM. Patient #1 did not experience any difficulties during the physical therapy session, except Patient #1 was a little sleepier at the end of the physical therapy session. Physical Therapist G had worked with Patient #1 the day prior and did not notice any changes with Patient #1 between 1/5/21 and the day prior.

7. During an interview on 5/21/21 at 11:00 AM, RN B indicated they did not provide any care for Patient #1 on 1/5/21. When RN B assumed care for Patient #1, Patient #1 had worked with physical therapy and occupational therapy. The therapy staff had assisted Patient #1 back to bed after therapy. RN B went to assess Patient #1, as RN B assumed care for Patient #1, and Patient #1's Daughter thought something was wrong with Patient #1 because Patient #1 was sleeping. Patient #1's Daughter became upset towards RN B, and asked about additional testing for Patient #1. RN B denied noticing any changes in Patient #1 when RN B was in the room with Patient #1. RN B did not assess Patient #1, due to Patient #1's Daughter requesting a different nurse provide care to Patient #1. RN B acknowledged they did not document anything besides their interaction with Patient #1's daughter.

8. During an interview on 5/25/21 at 9:00 AM, OTA E indicated that Patient #1 did not participate in therapeutic exercises on 1/5/21 (first attempt was 1 hour after the picture of Patient #1 with right sided facial droop was taken), as Patient #1 would not wake up, despite OTA E and Patient #1's Daughter attempting to wake up Patient #1. Patient #1 would only moan when OTA E or Patient #1's daughter attempted to wake Patient #1. Patient #1's Daughter indicated they had difficulty waking up Patient #1 for a while. OTA E notified RN B (who was assigned to care for Patient #1 but had not assessed Patient #1) and RN B indicated Patient #1's condition was normal for Patient #1.

9. During an interview on 5/25/21 at 11:05 AM, Charge Nurse H revealed they went into Patient #1's room twice briefly on 1/5/21, but could not recall what time they went into Patient #1's room. Patient #1's Daughter indicated Patient #1 was weak and in pain. Charge Nurse H informed Patient #1's Daughter about how the nursing staff assessed Patient #1's pain and the need to carefully administer pain medication to Patient #1, as Patient #1 was falling asleep while Charge Nurse H was talking to Patient #1's Daughter. Charge Nurse H reinforced that the nursing staff did not want to over-sedate Patient #1 with pain medication.

While Charge Nurse H was in Patient #1's room, Charge Nurse H did not notice any signs or symptoms of Patient #1 experiencing a stroke. Patient #1's Daughter left Patient #1's room around lunch, another family member stayed with Patient #1, and when Patient #1's Daughter returned, the nursing staff realized that Patient #1's weakness was not due to tiredness or medication, but a possible stroke. Charge Nurse H also recalled that one of the therapy staff members indicated Patient #1 was weaker on 1/5/21 than the day before, but did not recall the therapy staff member indicating Patient #1 was weaker on 1 side.

(Review of Patient #1's medical record revealed that Charge Nurse H failed to document their observations interactions and assessment of Patient #1 or the time Charge Nurse H assessed Patient #1 and Charge Nurse H's interactions with Patient #1's family) Charge Nurse H acknowledged they failed to document their interactions and assessment of Patient #1.


10. During an interview on 5/24/21 at 8:50 AM, LPN F revealed they assumed Patient #1's care around 12:00 PM on 1/5/21, after Patient #1's Daughter requested a different nurse than RN B. LPN F recalled they assessed Patient #1 (the medical record lacks evidence LPN F assessed Patient #1 when LPN F assumed care for Patient #1). Patient #1's Daughter had left the room, and Patient #1's grand-daughter was in Patient #1's room. LPN F asked Patient #1's grand-daughter if Patient #1's current condition was normal for Patient #1, and Patient #1's grand-daughter did not know. LPN F performed a neurological assessment at an unknown time (which helps to detect changes in a patient's neurological function, such as a stroke), and noticed Patient #1 had some facial droopiness (a sign of a possible stroke).

When Patient #1's Daughter returned to Patient #1's room at an unknown time, Patient #1's Daughter informed LPN F that Patient #1's condition was not normal for Patient #1. LPN F contacted Hospitalist C, who ordered lab testing and a head CT scan. The head CT scan revealed Patient #1 had a stroke. LPN F did not recall the timeframe between Patient #1's Daughter leaving Patient #1's room, Patient #1's Daughter returning to Patient #1's room, and LPN F contacting Hospitalist C. LPN F indicated they documented the events in Patient #1's medical record.

(Patient #1's medical record revealed Patient #1's Daughter was present at 12:10 PM on 1/5/21 according to OTA E's treatment note (1 hour after the picture of Patient #1 with right sided facial droop). OTA E's treatment note at 3:10 PM on 1/5/21 indicated Patient #1's Daughter had returned by that time (4 hours after the picture of Patient #1 with right sided facial droop). Hospitalist C's progress note at 8:08 PM on 1/5/21 indicated LPN F contacted Hospitalist C about Patient #1's condition at 5:15 PM (6 hours after the picture of Patient #1 with right sided facial droop).



11. During an interview on 5/25/21 at 8:38 AM, the Program Manager Risk Management/Patient Safety verified that Patient #1's medical record lacked documentation that RN B or LPN F performed a nursing assessment on Patient #1 and Patient #1's medical record lacked documentation that any nursing staff member notified a physician about Patient #1's new onset of right sided facial droop and right sided weakness.

12. During an interview on 5/25/21 at 3:00 PM, Hospitalist C recalled evaluating Patient #1 for mental status changes late in the afternoon on 1/5/21. The nursing staff told Hospitalist C that Patient #1 exhibited intermittent drowsiness during the day and the nursing staff did not tell Hospitalist C that Patient #1 had new onset right sided facial droopiness and right sided weakness (signs of a possible stroke). When an unknown nurse contacted Hospitalist C at 5:15 PM, that was the first time Hospitalist C received notification about the right sided facial droop and right sided weakness. The nursing staff thought Patient #1's mental status change occurred due to Patient #1's use of pain medications, but Hospitalist C wanted to verify Patient #1 had not experienced a stroke or heart attack.

On 1/5/21 at 5:16 PM (6 hours after the picture of Patient #1 possibly exhibiting signs of a stroke), Hospitalist C ordered the hospital staff to perform a laboratory testing and a head CT on Patient #1 to identify any possible causes for Patient #1's mental status changes. On 1/5/21 at 6:17 PM (7 hours after the picture of Patient #1 possibly exhibiting signs of a stroke), the results of the lab testing suggested Patient #1 had a heart attack, and on 1/5/21 at 8:55 PM (almost 10 hours after the picture of Patient #1 possibly exhibiting the signs of a stroke), the results of the head CT revealed Patient #1 had a stroke. Hospitalist C discussed Patient #1's condition with Patient #1's daughter and possible treatment options after receiving all of Patient #1's test results. Due to Hospitalist C not knowing when Patient #1's symptoms started, Patient #1 was outside the timeframe for the hospital staff to administer medications to break up any clots in Patient #1's brain which could have caused the stroke. Hospitalist C informed Patient #1's Daughter that if the nursing staff had identified Patient #1's stroke symptoms earlier, Hospitalist C could have performed more aggressive treatment of Patient #1's stroke, including medication to break down a possible blood clot and had a neurologist evaluate Patient #1 prior to ordering the medication to break down a possible blood clot. Due to the uncertain time Patient #1's stroke symptoms started and the risks of bleeding following Patient #1's recent hip surgery if the nursing staff administered medication to break down a possible blood clot in Patient #1's brain, Patient #1's Daughter elected to place Patient #1 on hospice care.

Hospitalist C verified that Patient #1 did not exhibit any right sided facial droop or right sided weakness when Hospitalist C examined Patient #1 on the morning of 1/5/21, but noticed both right sided facial droop and right sided weakness when Hospitalist C examined Patient #1 at 5:15 PM on 1/5/21.


13. During an interview on 5/26/21 at 1:32 PM, Patient #1's Daughter verified they first noticed Patient #1's right sided facial drooping was at 11:15 AM on 1/5/21 (the same time as the photo). Patient #1's condition had changed dramatically, and Patient #1's Daughter wanted to take a photo and video to share with Patient #1's other children. Patient #1 kept notes about Patient #1's care during Patient #1's hospitalization, so Patient #1's Daughter could share information with Patient #1's other children.

Patient #1's Daughter recalled notifying RN B about the dramatic change in Patient #1's condition after Physical Therapy worked with Patient #1 on 1/5/21. Patient #1's Daughter specifically remembered asking RN B is Patient #1 had possibly dislodged a blood clot during therapy, which could have caused Patient #1's change in condition. RN B dismissed Patient #1's Daughter's concerns, as Patient #1 did not show any changes in their vital signs. Patient #1's Daughter verified RN B failed to assess Patient #1, despite Patient #1's Daughter informing RN B that Patient #1's Daughter suspected Patient #1 had a stroke.

After Physical Therapist G worked with Patient #1 on the morning of 1/5/21, Physical Therapist G felt something was abnormal with Patient #1 and called for a nurse to assess Patient #1, but a nurse did not respond while Physical Therapist G was in the room. Patient #1's Daughter was concerned about the fact that Patient #1 was not acting normally, but the nursing staff did not assess Patient #1.

Patient #1's Daughter informed LPN F that Patient #1's condition was not normal for Patient #1. LPN F did not assess Patient #1 until around 4:00 PM (around 5 hours after the picture of Patient #1 with right sided facial droop), despite Patient #1's Daughter repeatedly informing LPN F that something was wrong with Patient #1. LPN F dismissed Patient #1's Daughter's concerns as changes in Patient #1's condition due to Patient #1's use of pain medications.

When LPN F finally assessed Patient #1, LPN F identified possible right sided facial droop on Patient #1, but LPN F did not perform any other assessments to determine if Patient #1 was experiencing a stroke. LPN F contacted Hospitalist C regarding a change in Patient #1's condition. Hospitalist C requested the hospital staff perform a head CT on Patient #1. Following the head CT, Hospitalist C informed Patient #1's Daughter that Patient #1 had a stroke, but the stroke was not detected until it was too late for the hospital staff to attempt to treat the stroke. Due to the lack of treatment options, Patient #1's Daughter decided to place Patient #1 in hospice care.