HospitalInspections.org

Based on medical record review, document review, and interview, in one (1) of 12 medical records reviewed, nursing staff failed to identify and evaluate the needs of a patient experiencing diarrhea, dizziness, and unstable pulse and ensure that care was provided as per facility's policy (Patient #1).

Findings Include:

Review of the facility's policies and procedures revealed the following:

The "Vital Signs Assessment and Reassessment" Policy last reviewed 2/2019 states: "Reassess the patient at a minimal frequency of every shift, or more frequently, based on his/her care needs.

The policy titled: "Vital Signs" last reviewed 7/2017 states: "Vital signs are monitored routinely, according to physician orders and assessed patient needs."

Review of the medical record of Patient #1 revealed a 79-year-old female who was admitted to inpatient psychiatry on 9/7/19 due to major cognitive disorder, secondary to Alzheimer's disease.

From 9/8/19 to 9/14/19, nursing staff documented acute changes in the patient's condition as follows:

On 9/8/19, at 1:53 PM, positive loose stool noted;
On 9/9/19 at 8:00 AM, patient's pulse was 112 beats per minute (bpm) (normal pulse: 60-100 bpm).
On 9/10/19 at 8:02 AM, the patient complained of loose stools.
On 9/10/19 at 7:08 PM, the patient complained of loose watery stools. Nurse noted "Unable to tell how many times she moved her bowel ...latest bowel movement at about 6:40 PM, stool noted to be loose, medium in quantity."
On 9/11/19 at 5:18 PM, the patient had small amount of loose stool
On 9/11/19 at 8:36 PM, an elevated pulse of 118 bpm noted
On 9/12/19 at 7:00 PM, the patient's pulse remained elevated at 105 bpm
On 9/12/19 at 11:19 PM, the patient complained of being lightheaded
On 9/12/19 at 7:30 PM. Vitals were as follows: BP 106/52 (normal 90/60 mm Hg to 130/80 mm Hg) , P 81, R 18 (normal respiration at rest is 12 to 20 breaths per minute), T 98.2 Fahrenheit (normal range from 97.8°F to 99°F) and Fingerstick 166 milligrams per deciliter (mg/dl) (normal range 70-100 mg/dl)." The nurse also documented that the patient was unsteady on her feet and needed to be monitored for oral and fluid intake.
On 9/13/19 at 2:01 PM RN documented that the patient was complaining of dizziness.
On 9/13/19, at 5:47 PM, the patient had two episodes of diarrhea.
On 9/14/19 at 6:00 AM, pulse of 148 bpm.
On 9/14/19 at 7 AM, the patient had a cardiac event, she was resuscitated and transferred to the intensive care unit.

There was no documented evidence in the medical record of nursing reassessment of this patient who experienced diarrhea for over seven (7) days while in the inpatient psychiatric unit. The frequency of the patient's diarrhea and the amount of fluid intake were not tracked and documented.
There was no documented evidence that the patient refusal to drink fluids noted by a nurse on 9/13/19 at 3:22 PM was brought to the attention of a physician.
In addition, nursing documentation of elevated heart rate of 112 bpm on 9/9/19 at 8:00 AM, 118 bpm on 9/11/19 at 8:36 PM, and 148 bpm on 9/14/19 at 6:00 AM were not reported to the physician.

During interview on 11/26/19 at 2:36 PM, the Assistant Director of Nursing for Psychiatry, stated that the expectation is for any change in the status of a patient be reported to the provider. If there is resistance, nursing should then escalate to the charge nurse/Head Nurse. She acknowledged that the escalation policy was not followed. She also acknowledged that nursing staff did not appropriately follow nursing judgement in monitoring vital signs and the patient's oral intake.