HospitalInspections.org

Complaint TX00159142

Based on interview and record review nursing services failed to supervise / evaluate the care of 1 of 6 patient records reviewed (Patient ID# 1). Patient ID# 1 experienced a change in condition and nursing services failed to notify a physician and failed to document assessment of vital signs / neurological assessments per physician orders.

Findings include:

PATIENT ID# 1

Record review of the physician emergency room notes dated 3/9/12 at 9:19 p.m. stated " Chief Complaint: Altered mental status, weakness left leg, sometime after 5:45 p.m., onset unknown. Patient has no real concerns. Past history includes cerebral vascular accident with left leg weakness, diabetes, hypertension, and dementia. Patient admitted 2/3/12 to 2/6/12 for Right Cerebral Vascular Accident post TPA treatment. (Tissue Plasminogen Activator). Alert and disoriented. Subtle speech changes sisters say at baseline. CT scan of brain shows no acute intracranial abnormality, unchanged from 2/4/12. This seems to be a TIA (transient ischemic attack) due to unsure onset and TIA would not do or consider TPA. Spoke with case management and meet inpatient criteria. Clinical Impression: TIA. "

Record review of a History and Physical dated 3/10/12 stated " Reason for admission: Left leg weakness. This is a 74-year old African-American male with history of hypertension, hyperlipidemia, prior history of CVA (cerebral vascular accident), dementia who presented to the emergency room with sudden onset of left leg weakness, unable to stand and walk... Initial brain CT scan was unremarkable. "

Record review of initial physician orders dated 3/10/12 at 6:36 a.m. stated " Vital signs every 4 hours. " Another physician order dated 3/12/12 at 3:30 p.m. stated " Neurological vital signs every 4 hours. "

Record review of nursing assessments revealed the following:
3/10/12 at 7 a.m. " Initial Nursing Assessment " alert, some confusion and disorientation, not oriented to time, cooperative, clear speech. Unsteady gait.
3/11/12 at 8:09 a.m. " Confusion, disorientation, weakness, alert, not oriented to time, calm, speech clear, extremity movement unequal. "
3/12/12 at 8:00 p.m. " Confused, disoriented, alert, unable to follow directions, calm, speech clear, Extremities equal,
3/13/12 at 8 a.m. " Confusion, disorientation, weakness, alert, not oriented to time, affect appropriate, slurred speech, unequal extremity movements.

The patient developed a change in condition (slurred speech) on 3/13/12 at 8 a.m. and the nursing notes failed to document if a physician was notified.

A Speech Therapist note dated 3/13/12 at 1:41 p.m. stated " It was noted that the patient had slurred speech today, when on Saturday he just had some mild distortions ...Patient also could not move his left arm, which he was able to do on Saturday ...Patient ' s sister stated that she noticed a change since yesterday with the left sided weakness. Nurse was notified to let MD know about patient ' s change in status and that a consult with the neurologist and an MRI may be warranted. She verbalized understanding. A note was also left in the chart for the MD. Consider MRI brain to rule out extension to original CVA. "

Record review of nursing notes 3/13/12 and 3/14/12 revealed no documentation that a physician had been notified regarding the change in the patient ' s condition.

Nursing notes on 3/14/12 failed to document scheduled vital signs at 10 a.m. as ordered by the physician every 4 hours.

A physician progress note 3/14/12 at 10:33 a.m. stated " Last evening increased weakness to left, now with flaccid weakness left arm and leg. Rule out infarct right hemiphresis, will get STAT repeat MRI brain. "

Nursing notes 3/14/12 at 12 p.m. stated " Lethargic, oriented x3, behavior calm but flat, slurred speech, extremity movement unequal. "

A Radiology report dated 3/14/12 at 12:05 p.m. stated " Brain without contrast MRI Impression: Moderate to large acute / sub-acute right territory infarction, new since prior MRI dated 3/10/12. Findings reported to patient ' s nurse at time of dictation to be relayed to referring physician. "

Nursing notes 3/14/12 failed to document scheduled vital signs at 2 p.m. as ordered by the physician every 4 hours.

Nursing notes 3/14/12 failed to document scheduled neurological assessments at 4 p.m. as ordered by the physician every 4 hours.

Nursing notes 3/14/12 documented normal vital signs at 4:37 p.m.

Nursing notes 3/14/12 at 5:35 p.m. stated " Rapid response team called " increase in slurred speech. " The patient was subsequently moved to the intensive care unit.

The patient stabilized and was discharged 3/20/12 to a rehabilitation hospital.

Interview 5/16/12 at 1:20 p.m. with patient care nurse (ID# 53) revealed she was the patient care nurse for patient ID# 1 on 3/13 and 3/14/12. The nurse stated that if the speech therapist notified her of changes in the patient ' s condition she would have notified the physician. The nurse further stated she did not document this information in the patient ' s record.

The Administrative Director (ID# 50) acknowledged 3/16/12 at 1:30 p.m. that the patient care nurse should have documented the patient ' s vital signs / neurological assessments every 4 hours as ordered and should have also documented that a physician was notified when the patient ' s condition changed (slurred speech) on 3/13/12.