HospitalInspections.org

Based on medical record (MR) review and interview, in 4 of 23 MRs, Patient #2, Patient #3 (on 2 different dates of service), and Patient #4 reviewed, there was no documentation that Advance Directive information was obtained when the patient presented to the Emergency Department (ED). This lack of documentation could lead to a patient's wishes concerning their provision of care to not be followed.

Findings include:

-- Per review of Patient #2's MR dated 10/22/18, there was no documentation that her Advance Directive information on admission to the ED had been obtained.

The same lack of documentation was noted in Patient #3's MRs dated 9/8/18 and 9/10/18 and in Patient #4's MR dated 8/10/18.

-- During interview of Staff A, ED Nurse Manager on 2/1/19 at 11:50 am, he/she acknowledged the above findings.

Based on document review and interview, the facility's quality assurance performance improvement (QAPI) program did not ensure adequate review of a patient's (Patient #1) medical record (MR) after it was identified as having quality of care issues. This could lead to other similar adverse events for patients.

Findings include:

-- Review of the nursing peer review dated 8/30/18 and physician peer review dated 8/23/18 regarding Patient's #1's quality of care provided in the emergency department (ED) on 8/10/18 indicated the standard of care was not met.

-- During interview of Staff B, Lead Quality Professional, on 1/31/19 at 3:05 pm, he/she acknowledged that the peer review findings should have been discussed at the Quality Assurance Peer Review Meeting, which was not done.

Based on medical record (MR) review, document review and interview the hospital did not adequately monitor the performance a registered nurse (RN). This could lead to untoward patient outcomes.

Findings include:

-- Per MR review, Patient #1, a 65-year-old male, presented to the emergency department (ED) on 8/10/18. Staff C, ED RN, triaged and provided care to this patient. Please see findings in Tag 0395.

-- Staff A, ED Nurse Manager, completed a review (dated 8/30/18) of the nursing care provided to Patient #1 on 8/10/18. He/she found standard of care was not met. Staff A spoke with the Staff C at the time and educated him/her on advocating for the patient, and in this case the medications administered were not working to appropriately sedate the patient to perform computerized tomography (CT).

-- Per interview of Staff A on 1/31/19 at 11:20 am and 2/1/19 at 2:30 pm, the primary nurse, Staff C, caring for Patient #1 was a low performer and had been placed on a Work Improvement Plan focused on his/her lack of documentation, difficulty prioritizing patients, recognition of critical events and lack of provider notification of urgent patient needs.

Staff C started in the ED on 12/4/17. He/she had a 90-day orientation in the ED which was reviewed and extended for another 45 days. At the time of the extension, Staff C's preceptors were changed to help with the learning process. At the end of the 45-day extension, Staff A met with Staff C and placed him/her on a Work Improvement Plan listing expectations and goals. Staff A and the ED Educator did random checks of Staff C's documentation and relied on Charge Nurses to report specific events involving Staff C but did not meet with him/her at regular intervals.

-- Per interview of Staff D, ED Charge Nurse on 2/1/19 at 1:30 pm, he/she does not oversee staff on a Work Improvement Plan, that is done by the ED Educator and/or Nurse Manager.

-- Staff A was unable to provide the Work Improvement Plan that Staff C was following.

-- Review of the hospital's policy and procedure (P&P) titled "Employee Performance and Coaching Tools," last revised 4/2014, indicated implementing a successful "Work Improvement Plan" (a tool for alerting an employee that certain areas of their work require improvement in order to be successful) allowing a department manager/supervisor to develop steps to aid the employee in attaining specific goals. The Work Plan should clearly identify the issue(s), goal(s), action step(s) and follow up. Follow up is key to ensuring the employee is on the right track. For example, a manager/supervisor may institute formal progress meetings (weekly, bi-weekly) until the plan is successfully completed and beyond.

-- During interview of Staff A on 1/31/19 at 11:20 am and 2/1/19 at 2:30 pm, he/she acknowledged the above findings.

Based on medical record (MR) review, document review and interview nursing staff failed to provide appropriate care to a patient (Patient #1) in accordance with accepted standards of nursing practice. Specifically, in one (1) of 23 MRs reviewed, nursing staff failed to document a complete neurological assessment, an ongoing assessment of the patient's condition and care needs (e.g., facilitating laboratory, diagnostic and radiological testing), provider communication and response to interventions. This could lead to untoward patient outcomes.

Findings include:

-- Review of Patient #1's MR revealed he was a 65-year-old male that presented to the emergency department (ED) on 8/10/18 at 7:01 am. Chief complaint was documented as alcohol intoxication. (Patient #1 was found lying on grass, neighbor called police department). The patient was not answering questions or being cooperative. He was triaged at 7:11 am as a level 2 (on a scale of 1 - 5, level 1 - requires immediate life saving measures, level 2 - condition that has potential to threaten life or limb and requires rapid medical intervention, level 3-5 less severe.) Patients rectal temperature (T) - 91.3 Fahrenheit (F [normal rectal T 99.1-99.6 F]).

Physician documented that the patient had decreased mental status, found unresponsive, head injury, alert but confused, lethargic, unequal pupils, disoriented, laceration and contusion to face. Patient has mild mental retardation. At 7:23 am the physician ordered a STAT (emergent) computerized tomography (CT) of the head.

At approximately 7:30 am nursing documented Patient #1 was uncooperative and irritable. Patient in fetal position. Patient noted with right eye hematoma (collection of blood under the skin) and dried blood on hands and face. Neurological assessment indicated, he was agitated and appeared asleep. The Glasgow Coma Scale (GCS [a neurological scale which aims to give a reliable and objective way of recording the conscious state of a person for initial as well as subsequent assessment]) was 14 (eye response 4 - eyes open spontaneously, verbal response 4 - confused and motor response 6 - obeys commands. Normal GCS is 15).

There is no documented evidence that Patient #1's mental status was reassessed from 7:27 am until 1:00 pm. Additionally, there were no vital signs from 7:27 am until 2:50 pm with the exception of a rectal temperature of 95.9 (F) at 10:24 am.

-- During interview of Staff A, ED Nurse Manager, on 1/31/19 at 10:20 am and 11:20 am, He/she was working on the day of Patient #1's ED visit. Patient #1 had come in that morning with history of alcohol abuse and had pending labs and CT. Staff A returned to the ED around 1:00 pm and saw Patient #1 was still there so he/she asked what the plan of care for Patient #1 was. Staff A then talked with the provider about sedating the patient with Ketamine for the CT scan. At that time Patient #1 had a seizure, was respiratory compromised and required intubation.

-- Nursing documentation revealed that at 1:00 pm, patient noted to be having seizure-like activity and a bout of incontinence. Patient's pupils pinpoint and fixed. Rapid intubation was initiated at 1:26 pm.

CT was completed at 1:55 pm, 7 hours after Patient #1 presented to the ED with a head injury and unequal pupils. There was no documentation that nursing facilitated diagnostic testing or had ongoing communication with the ED provider.

-- At 3:00 pm Neurology consult documentation indicated, reviewed images, patient has acute intracranial bleed with high blood pressure, unstable. Possible worsening of bleeding need for acute life-saving craniotomy (brain surgery). Orders were obtained. Patient was transferred to a higher level of care.

-- Review of the hospital's policy and procedure (P&P) titled "Emergency Department Triage Policy," last revised 7/31/18, indicated patients should be triaged according to the Emergency Severity Index (ESI) with a ESI level of 1 - 5. Patients noted as a level 2 (condition that has potential to threaten life or limb and requires rapid medical intervention) should have a focused reassessment and V/S documented at least every hour until stable.

-- Review of the hospital's P&P titled "Bair Hugger/Bair PAWS Patient Warming System," last revised 11/17/15, indicated patients who are hypothermic (temperature less than 96.8) should be rewarmed with the Bair Hugger. The patient's temperature should be monitored every 15 minutes.

There was no documented evidence that Patient #1's temperature was taken every 15 minutes.

-- During interview of Staff C, RN ED (provided triage and was primary nurse for Patient #1), on 1/31/19 at 2:30 pm, indicated being unable to remember the patient. If a patient had a change in condition, he/she would notify provider and document the same.

Nursing staff did not adequately document Patient #1's condition. The MR lacked documentation of patient reassessments, vitals signs, facilitation of diagnostic testing, communication with the ED provider, and response to interventions after his initial triage and assessment upon arrival to the ED. The patient's temperature was documented at 10:24 am. The next assessment documented was at 1:37 pm which described seizure-like activity at 1:00 pm.

-- During interview of Staff A, ED Nurse Manager on 1/31/19 at 11:20 am, he/she acknowledged the above findings.

Based on medical record (MR) review, document review and interview, 1 of 23 MRs reviewed (Patient #5), lacked documentation of patient notification and treatment for abnormal laboratory results. This could lead to untoward patient outcomes.

Findings include:

-- Per review of Patient #5's MR, dated 12/2/18, a blood culture specimen collected on 12/2/18 at 6:00 am, during an emergency department (ED) visit, contained a preliminary report of a positive blood culture with gram negative rods. The laboratory documented a registered nurse (RN) was notified of the preliminary results on 12/3/18 at 1:30 am. The preliminary report was reviewed by an ED physician on 12/3/18 at 1:36 pm who advised waiting for the final culture results. A final blood culture report/result dated 12/4/18 at 7:48 am identified a positive blood culture with gram negative rods, however, there is no documentation in the MR that the patient was notified and/or treated for the positive blood culture.

-- Review of the hospital's policy and procedure (P&P) titled "Emergency Department Call Backs," last revised 9/2018, indicated to assure timely review of abnormal labs and radiology results not resulted at the time of the patient's discharge from the ED the patient will be contacted for appropriate evaluation, change in treatment and follow up if indicated. Labs not resulted at the time of the patients visit such as culture results should be available to be reviewed in the "Positive Microbiology" report. The report should be generated by the laboratory at 8:00 am everyday. If the culture is positive the patient's chart should be reviewed for treatment accuracy (i.e., appropriate antibiotic therapy, specialty follow-up, etc.). If no action is required for treatment changes the midlevel provider should document as such. If the positive culture chart review indicates a treatment change the midlevel provider should complete the ED call back form and instruct the charge nurse to contact the patient regarding the changes. Contacting the patient should be attempted via phone a max of 2 times with documentation indicating if a message was left for the patient to return the call, no answer unable to leave message or no contact. If contact is not achieved a letter should be sent to the patient's address. A copy of the letter should be filed in the final MR.

-- During interview of Staff A, ED Nurse Manager on 2/1/19 at 11:50 am, the charge nurse would document patient notification of an abnormal laboratory result in the follow-up assessment, the only proof of patient notification would be a written letter if the charge nurse was unable to reach the patient by telephone. He/she acknowledged the above finding.