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Based on the nature of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.13, PATIENT RIGHTS, was out of compliance. The hospital failed to protect and promote patient rights by failing to ensure that 3 distinct standards under the Condition were carried out per the regulations.

Cross-reference:

A-0131: §482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient's rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate.

The facility failed to ensure patients with limited English proficiency were given the opportunity to understand and make informed decisions regarding their care, plan, treatment, health status, and were able to communicate their needs and refuse treatment.
This failure had the potential to affect all patients who were not English proficient.

A-0144: §482.13(c)(2) The patient has the right to receive care in a safe setting.

The facility failed to ensure physicians were promptly notified when orders were unable to be carried out by staff. In 1 of 11 medical records reviewed (Patient #8), there was no documentation showing the physician was notified or aware an Arterial Blood Gas (ABG) was not obtained by respiratory staff. In addition, staff leadership responsible for the review of the care of patients who were transferred out to acute care settings, failed to ensure reviews were conducted in a timely manner and that the reviews reflected a complete review of patient's medical record and that the care provided to patients was actually evaluated.
This failure had the potential to affect all patients.

A-0168: §482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under §481.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law.

Based on interview and document review, the facility failed to ensure a new order was obtained from a physician, or other Licensed Independent Practitioner (LIP), for a patient who was placed in restraints after an initial restraint episode ended.
This failure had the potential to affect all patients who were in any restraint device while in the facility.

Based on observations, interviews, and document reviews, the facility failed to ensure patients with limited English proficiency were given the opportunity to understand and make informed decisions regarding their care, plan, treatment, health status, and were able to communicate their needs and refuse treatment.

These failures denied the patient's right to understand and actively participate in their care, which resulted in missed opportunities to collect physical assessment information and identify patient care needs.

Policy

Facility policy, Communication with Limited English-Proficient Persons, stated the facility will provide over-the-phone interpretive service through Telelanguage service. The policy also stated an interpreter would be obtained if needed to ensure effective communication with patients.

The facility provided document, Languages Interpreted and Translated by Language Line Solutions, listed all available languages interpreted by the language service the facility contracted with.

FINDINGS:

1. The facility denied the patient and the family the right to make informed decisions by failing to collect physical assessment information and communicate patient health status for patients with limited English language proficiency.

a) During an observation of Registered Nurse (RN) #1 on 10/21/15 at 8:55 a.m., s/he responded to a call light that signaled from Patient #11's room. RN #1 stated the patient was non-English speaking. RN #1 stated s/he was told another individual at the facility tried to use the interpreter phone with Patient #11 previously. S/he stated the patient didn't like using the language phone, and pushed the phone away. RN #1 used hand gestures to communicate with Patient #11 during the observation, but was unable to determine why the patient rang his/her call light or identify any patient care needs. Patient #11 was speaking to RN #1 in a language other than English. RN #1 stated s/he believed Patient #11 wanted company, and s/he would perform a physical assessment on Patient #11 at that time.

During this same observation at 9:00 a.m., RN #1 performed a neurological assessment on Patient #11 at the bedside. During the observation, Patient #11's lower extremities were not assessed for strength, nor were any questions, including the neurological orientation assessment questions of person, place, or time, asked of the patient by RN #1. No family members were present at the facility during the neurological or other physical assessments, nor was the translation phone located on Patient #11's bedside table utilized to collect or relay information during the assessments.

An interview with RN #1 during the observation revealed s/he didn't assess the patient's lower extremities because s/he was familiar with the patient's baseline lower extremity strength. RN #1 stated s/he didn't ask the patient any assessment questions, including the neurological orientation assessment questions of person, place, and time because s/he asked the patient's family the orientation questions when s/he worked with the patient and family the week prior. RN #1 stated this meant the family previously confirmed Patient #11 was oriented to person, place, and time. RN #1 stated s/he was not going to assess the patient's pupils because the patient was anxious and she would assess them at a later time.

b) Medical record review confirmed RN #1 documented an assessment on 10/21/15 at 8:45 a.m. for Patient #11, which included s/he was independently oriented to person, place, and time, and the patient's family confirmed his/her orientation status due to a language barrier. RN #1 charted the patient didn't have a deterioration of mental status, and Patient #11's left leg and left foot had moderate extremity strength, and the patient's right leg and right foot had weak extremity strength, despite not using the interpreter language phone, and no family being present in the room during the time of the assessment. The patient's pupil assessment was never documented by RN #1.

c) An interview on 10/21/15 at 2:50 p.m. with RN #1 revealed that s/he was unable to independently assess Patient #11's orientation level because s/he was non-English speaking, which was why RN #1 previously relied on family to assess that information. When RN #1 was asked if Patient #11's previous nursing assessment conducted by the family specifically included if the patient knew who s/he was, where s/he was, or what day or time it was, RN #1 stated s/he only asked the family if they noticed any changes in his/her behavior, and did not ask the specific neurological orientation assessment questions of person, place, or time.

RN #1 stated that because s/he did not speak Patient #11's native language, s/he could not confirm what the family previously asked the patient. RN #1 confirmed s/he was told Patient #11 pushed the translation phone away when it was offered to him/her the prior week, but stated s/he wasn't present to witness the phone being offered and declined by the patient. RN #1 stated she never provided translation phone education to Patient #11 or his/her family. RN #1 stated she didn't remember receiving any training on the facility's policy for communicating with patients that had limited English proficiency, nor had s/he ever looked up the policy. RN #1 stated she received education on how to use the language line when s/he first oriented to the facility as a new employee but the use of the language line had not been brought forward by any staff or leadership since that time. RN #1 stated she was not aware that any staff member or staff leadership tracked or in any way monitored the use of the language line for patients who were non- English speaking. RN #1 stated no one in the facility asked him/her if s/he used the language line or if s/he experienced barriers when communicating with non- English speaking patients.
d) An interview with Patient #11's family member on 10/22/15 at 8:00 p.m. confirmed that the family had only been asked 2 times about Patient #11's neurological status. This meant the family was only asked by the facility twice to ask the patient specifically about the patient's ability to state his/her name, where s/he was located, and if s/he knew the date in time. Generally, the family member was asked by the facility if s/he believed the patient was "in a good mood" and if the patient recognized visitors.

e) Review of Patient #11's medical record from 10/05/15 through 10/21/15 revealed only 2 nursing assessments that documented the use of the interpreter phone, despite nursing assessments being completed twice daily (1 nursing assessment per 12 hour shift worked).

f) Review of the facility provided document, Languages Interpreted and Translated by Language Line Solutions, listed all available languages interpreted by the language service the facility contracts with. The document confirmed Patient #11's primary language was offered for interpreter services.

g) On 10/21/15 at 5:23 p.m., an interview was conducted with Employee #2, the Senior Director of Clinical Operations, who stated s/he was not aware of staff being audited or monitored to ensure the use of the language line for non-English speaking patients when needed. S/he stated that patients' family members were not trained or educated to conduct nursing assessments. S/he stated it would be appropriate for an RN to document "unable to assess" when conducting patient assessments, when necessary, and this would have been the appropriate documentation for RN #1 to use for the areas of the assessment of Patient #11 that s/he was unable to obtain.

h) An interview on 10/27/2015 at 2:31 p.m. with the Interim Chief Clinical Officer (CCO) confirmed the language line the facility contracts with had interpreters for all the languages listed on the Language Line Solutions document provided by the facility. The CCO stated the language line did cover all the languages listed but each language might not be available at all times, especially the more "unique" languages.

2. The facility denied the patient and family the right to make informed decisions by failing to communicate and involve patients with limited English language proficiency in their patient care, provide an opportunity to communicate their patient needs, and request or refuse treatment.

a) Observation on 10/22/15 at 8:44 p.m. revealed the interpreter telephone on the floor, in the corner of Patient #11's room. Further, the facility's Interim Resource Nurse Manager (Nurse Manager) was observed communicating with the patient in English, without the use of the interpreter phone or family present in the room. The patient was asked by the Nurse Manager if s/he was "okay," if s/he wanted to go to sleep, was tired, wanted the lights turned out, and wanted the bed raised or lowered.

b) An interview with the Nurse Manager on 10/27/15 at 9:22 a.m. revealed s/he did not use the interpreter language telephone when s/he was observed on 10/22/15 because s/he was told by an RN previously that the patient did not like to use the language telephone. Further, s/he stated that staff told him/her the patient's primary language was not an available language on the interpreter language phone. The Nurse Manager stated s/he had not viewed a list of languages offered by the language service, nor had s/he received any training by the facility regarding use of the language phone.

c) An interview with the CCO on 10/27/15 at 1:07 p.m. revealed the Nurse Manager would need to be educated on the use of the interpreter language telephone because s/he wasn't following the expectation the facility had for communicating with patients with limited English proficiency. The CCO was also unsure of any specific training facility staff ever received regarding the use of the interpreter phone.

d) An interview with RN #10 on 10/22/15 at 7:45 p.m. revealed s/he had not received any specific training on the interpreter language phone, nor could s/he recall being trained on any specific policies related to patients with limited English language proficiency. S/he had not reviewed any such policies his/herself.

Based on interviews and document review, the facility failed to ensure physicians were promptly notified when orders were unable to be carried out by staff. In 1 of 11 medical records reviewed (Patient #8), there was no documentation showing the physician was notified or aware an Arterial Blood Gas (ABG) was not obtained by respiratory staff. In addition, staff leadership responsible for review of the care of patients who were transferred out to acute care settings, failed to ensure reviews were conducted in a timely manner and that the reviews reflected a complete review of patient's medical record and that the care was actually evaluated.

These failures created the potential for negative patient outcomes due to inadequate or incorrect care and treatment related to the lack of physician ordered laboratory results. In addition, these failures created the potential for negative outcomes for patients due to inadequate or incomplete reviews and evaluations of the care provided.

FINDINGS:

1. Patient #8's medical record lacked evidence showing respiratory staff notified the physician in charge of Patient #8's care that an ordered ABG was unable to be obtained.

a) On 10/21/15, a review of Patient #8's medical record was conducted. The record review revealed the patient was transferred to a short term acute care hospital on 10/01/15. According to the Transfer Summary dated 10/01/15, Patient #8 was transferred for evaluation of metabolic acidosis (a blood condition in which the bicarbonate concentration is below normal) after s/he was found unresponsive and evaluated by the facility's rapid response team. Patient #8's ABG showed a pH of 6.9 with a calculated bicarbonate of 9.81. The bicarbonate level was critically low based on the facility's reference range of 22 to 26. Patient #8 was administered sodium bicarbonate, then a repeated ABG was performed which revealed an increased pH of 7.186. This pH was below the 7.20 critical low value listed on the facility's ISTAT Assay Reference Sheet.

i) Review of the change of condition dated 10/01/15 at 12:17 p.m., showed at 10:00 a.m., Patient #8's Registered Nurse (RN) reported to Medical Doctor (MD) #14 a critical low CO2 (bicarbonate level) of 11 millimoles per liter (mmol/l). MD #14 ordered intravenous (IV) fluids, a nephrologist evaluation, and an ABG. According to the physician orders dated 10/01/15, MD #14 entered the ABG electronically at 10:46 a.m.

ii) Review of respiratory therapy notes dated 10/01/15 at 3:49 p.m., revealed Respiratory Therapist (RT) #15, along with two other RTs, were unable to obtain an ABG after 4 attempts. There was no evidence in RT #15's documentation showing MD #14 was notified the ABG was not obtained.

iii) Review of the Rapid Response Team Record dated 10/01/15 revealed at 9:30 p.m., Patient #8's heart rate was in the 40s, oxygen saturation was in the 50-60% range, and the patient had acute mental status changes. Patient #8 was administered sodium bicarbonate during the rapid response.

The change of condition documented by respiratory therapy staff around the same time of the rapid response revealed a venous blood gas was drawn and required sodium bicarbonate to be administered.

The Rapid Response Team was called approximately 10 1/2 hours after Patient #8's critical low CO2 was reported to the attending physician earlier the same morning. There was no evidence in Patient #8's medical record showing the attending physician was notified the ABG ordered the morning of 10/01/15 was not collected.

b) On 10/22/15 at 12:48 p.m., an interview was conducted with RT #9 who stated if an ABG was unable to be collected, s/he would notify the physician. However, RT #9 stated s/he would not document the physician notification in the medical record.

RT #9 stated physicians would order an ABG to evaluate the patient's pH if the patient's CO2 was low. S/he stated a pH below 7.35 was considered acidotic. RT #9 then stated if a patient became acidotic, the acidosis may lead to patient distress. S/he further stated if the acidosis was metabolic, the patient may need bicarbonate to normalize the pH.

c) On 10/22/15 at 1:30 p.m., an interview was conducted with the Director of Respiratory (Employee #16) who stated RTs were expected to notify the physician if an ABG was unable to be collected. Employee #16 stated documentation about ABG attempts and physician notification should be found in the respiratory care assessment, the ABG order comments, or in "change of condition" notes.

Although, there was evidence documented under the respiratory care assessment about the multiple attempts to collect Patient #8's ABG ordered the morning of 10/01/15, there was no documention showing the physician was notified the lab was not obtained.

Employee #16 stated if the patient's acidosis was metabolic, physicians were responsible for managing treatment. Employee #16 further stated if an ABG was unable to be obtained, there were other alternatives that could be done to evaluate the patient's condition, including a venous blood gas.

d) On 10/23/15 at 1:25 p.m., an interview was conducted with MD #14 who stated s/he expected staff to notify him/her if they are unable to carry out an order.

A review of Patient #8's medical record was conducted. MD #14 who stated s/he remembered Patient #8 was acidotic and ordered an ABG to determine if the acidosis was respiratory or metabolic, and the severity of the acidosis. MD #14 stated if s/he would have been notified, a venous blood gas could have been ordered to determine the patient's pH. MD #14 stated s/he expected the RT to notify him/her, and the notification should have been documented.

MD #14 stated if s/he had the results of the ABG ordered for Patient #8 the morning of 10/01/15, s/he may have ordered ordered additional diagnostics and/or changed medical treatment. MD #14 further stated depending on the results of the ABG ordered, the patient may have transferred earlier in the day. MD #14 then stated, it is safer to transfer a patient out when they are stable versus immediately after a rapid response.

e) On 10/27/15 at 10:55 a.m., a review of Patient #8's Return to Acute Transfer Review form and Rapid Response Record quality review form, was conducted. The facility review date documented on both forms was 10/20/15; approximately 2 1/2 weeks after the event occurred. Both quality review documents lacked evidence that the facility identified the ABG test ordered by the physician the same morning of Patient #8's rapid response on 10/01/15 was not completed.

2. Review of the facility documents used to record, track, and evaluate the care provided to patients who were transferred out of the facility to an acute care setting were found to have incomplete and inaccurate information and were reviewed by facility leadership, up to 6 weeks after the transfer occurred (Patient #5). These documents were completed by and used by staff leadership to ensure quality care was provided to patients.

a) From 10/21/15 through 10/27/15 the following facility documents were reviewed; Readmission to Short Term Acute Care (STAC) Worksheet, and the Return to Acute's (RTA) Transfer Review. The purpose of both documents was to gather information regarding those patients who were transferred out of the facility to an acute care setting and to enable the facility to understand the care provided and if the transfer out could have been avoided or if the transfer out should have been done sooner. Both documents contained information that would eventually be reported to the quality department of the facility.

The STAC Worksheet, developed and completed by the Quality Manager, did not indicate when patient medical records were reviewed in order to understand the facility's timely review and possible response to any issues that might be discovered from medical record reviews for these transferred patients.

b) On 10/21/15 at 6:20 p.m., an interview with Employee #2, the Senior Director of Clinical Operations and Employee #17, the facility's Quality Manager was conducted. Both staff members confirmed the comment on the STAC stating there was prompt notification of the MD of the labs for Patient #8 was referring to the labs that were drawn at the time of a rapid response and not the ABGs ordered earlier on the morning of 10/01/15. The STAC contained no documention in the "reason for readmission section" or the "comment" section that the facility was aware of the missing ABG value from the morning of 10/01/15. The Quality Manager stated s/he was responsible for completing the STAC Worksheet in order to track these transfers out of the facility. The Quality Manager stated s/he was unaware of the missing ABGs from the morning on 10/01/15.

c) On 10/27/15 at 10:55 a.m., an interview was conducted with Employee #2 to review the documents titled, Return To Acutes (RTA) Review. There were five reviews completed by staff regarding transfers out of the facility which occurred from 08/18/15 to 10/01/15. All 5 of the reviews were dated and signed by the reviewers on 10/20/15, with the exception of one that was signed as reviewed on 10/30/15 (a date that had not yet occurred). Each of the reviews was signed by two individuals; Employee #2 (Senior Director of Clinical Operations) for example, and the facility's Medical Director.

d) Review of the STAC Worksheet revealed documentation for Patient #8 which stated the patient was transferred to a higher level of care on 10/01/15, that the transfer was "unavoidable," and there was prompt notification of the MD of lab values. Review of the RTA Transfer Review for this patient contained additional documentation about the patient's condition and care.

The RTA for Patient #8 was reviewed with Employee #2. The RTA reflected the patient was transferred to an acute care setting after a rapid response that occurred on 10/01/15 and the reason for the transfer was metabolic acidosis. Employee #2 stated s/he completed the RTA review form for this patient on 10/20/15, reviewed the document with the Medical Director, and they both signed the document.

In the section of the review titled, "Opportunities for Improvement," Employee #2 documented that the transfer could not have been prevented. Then Employee #2 checked the statement that indicated the patient's signs and symptoms could have been detected earlier and that resources were not available to manage the patient's change in condition safely or effectively. Employee #2 did not list the resources that were not available as required on the form. During this interview Employee #2 could not state which resources were not available for the care of Patient #8.

Under the "reviewer's evaluation of the case" section, Employee #2 checked the section which stated the case was managed appropriately but was lacking documentation. The documentation that was missing from the review was not stated on the document. Employee #2 stated at the time of this interview, that the missing documentation was the lack of the ABG's ordered by the Medical Director on 10/01/15, as Patient #8 was his/her patient. Employee #2 went on to say that s/he did not write this information on the review document but on 10/20/15 s/he told the Medical Director of missing labs. Employee #2 stated s/he did not tell the Medical Director which labs were missing at the time of the review, but just that "labs were missing."

It was shared with Employee #2 that during an interview with the Medical Director on 10/23/15 at 1:25 p.m., the Medical Director stated s/he signed the RTA review for Patient #8 but was not informed at the time of the review on 10/20/15 that there were missing labs or that the missing lab was the ABG s/he had ordered the morning of 10/01/15 for this patient.

Employee #2 went on to state that obtaining a blood gas earlier on 10/02/15 could have changed the course of treatment for Patient #8.

e) A second RTA review was conducted with Employee #2 during the interview on 10/27/15 at 10:55 a.m., for Patient #5. This RTA was completed by Employee #2 on 10/20/15 and was signed on this date by Employee #2 and the Medical Director. The review revealed the patient was transferred to an acute care facility on 09/10/15 due to findings from a CT scan.

In the section of the review titled, "Opportunities for Improvement," Employee #2 documented that the transfer could not have been prevented. Then Employee #2 then checked the statement that indicated the patient's signs and symptoms could have been detected earlier and that resources were not available to manage the patient's change in condition safely or effectively. Employee #2 listed the lack of CT availability as the resource not available.

Under the "reviewer's evaluation of the case" section, Employee #2 checked the section which stated "questionable quality related to physician approach."

Employee #2 stated s/he was concerned when s/he reviewed the patient's medical record that "stuff" could have been done sooner. Employee #2 stated there would be further review of the patient's care with MD's #4, #13, and #14. S/he stated review of the physician's care had not yet begun, but s/he wanted "further review of the physicians." Employee #2 confirmed that the transfer out of Patient #5 occurred on 09/10/15 and the review of this transfer and his/her concerns about the care provided occurred on 10/20/15, 6 weeks after the transfer.

It was reviewed with Employee #2 that the transfer for Patient #12 was on 08/18/15 and the RTA review was conducted on 10/20/15, 9 weeks after the transfer. Likewise, the transfer for patient #5 was on 09/10/15 and the RTA review was conducted on 10/20/15, 6 weeks after the transfer. Employee #2 then stated it was not appropriate for RTAs to "sit for the length of time we see" before they were reviewed.

Employee #2 stated the current survey prompted review of the RTAs listed on the STAC Worksheet because facility leadership realized the STAC Worksheet "was not telling the whole story." Employee #2 stated s/he first saw the RTA Transfer Review document on 10/19/15 or 10/20/15 as it was suggested by the Director of Quality Assurance Operations, Employee #18, as a possible tool to use to review RTAs. Employee #2 stated "it would be difficult" for someone to read the RTA Transfer Reviews dated 10/20/15 and understand "the story told by these documents" as the reviews had sections that were incomplete and some sections that had contradictory information documented. Employee #2 stated the Quality Manager and The Resource Chief Clinical Officer were responsible for the RTA reviews both for timeliness and for quality of the reviews.

Employee #2 stated the STAC Worksheet developed by the Quality Manager was more a tracking worksheet for these events and did not reflect a thorough review of the transfers.

f) On 10/27/15 at 9:57 a.m., an interview was condcuted with Employee #12, the facility's Resource Chief Clinical Officer who stated Return to Acutes (RTAs) was a "big" category for patient medial record review. Employee #12 stated s/he had been involved in review of the RTAs since the end of September, 2015, along with the Quality Manager, by using the STAC Worksheet.

Upon review of the RTA for Patient #8, dated 10/20/15, Employee #12 stated there were conflicting statements documented on the form, and in reviewing this document, it was not stated, for example, which lab was missing for the patient. Employee #12 stated the facility needed to ensure the RTAs reviews were conducted in an appropriate time frame and that reviewing these cases 6 to 9 weeks after a transfer did not ensure safe care was being provided to patients. Employee #12 stated part of her job role was to help train the Quality Manager, Employee #10. Employee #12 then stated s/he was not part of the RTA review for the most recent transfers out, meaning since s/he began in the facility at the end of September, 2015, by completion and use of the RTA Transfer Review forms that were completed on 10/20/15.

Based on interview and document review, the facility failed to ensure a new order was obtained from a physician, or other Licensed Independent Practitioner (LIP), for a patient who was placed in restraints after an initial restraint episode ended.

This failure created the potential for an unsafe patient care environment in which the responsible attending physician or LIP was not aware of the patient's medical needs and current health status.

FINDINGS:

According to the policy, Physical Restraints (Violent and Non-Violent Behavior) and Seclusion, "as needed" restraint use was prohibited. Whenever a patient's restraints were removed, the restraint episode ended and a new order was required. The policy stated after the application of restraints, the physician must be notified as soon as possible to obtain a telephone order and to communicate the patient's condition.

1. The facility failed to obtain an additional restraint order for a patient that was subsequently placed in restraints after the initial restraint episode ended.

a) Review of Patient #11's medical record revealed the patient was initially placed in restraints on 10/5/15 at 7:00 p.m. and remained in restraints until 10/6/15 at 1:00 p.m. when the restraints were discontinued by the Registered Nurse (RN) taking care of the patient.

The patient was subsequently placed in restraints a second time on 10/09/15 at 8:00 p.m. until 10/10/15 at 12:00 a.m., when the restraints were discontinued by the RN taking care of the patient.

No order by a physician or LIP was found in the patient's medical record for the subsequent use of restraints on 10/09/15.

b) An interview with RN #5 on 10/27/15 at 8:16 a.m. revealed s/he was unable to locate a physician or LIP order for the 10/09/15 restraint use after s/he reviewed the medical record for Patient #11. RN #5 stated a new order must be obtained by a physician if the restraints were off 1 hour or more, and the medical record should have contained an additional physician order for the 10/09/15 restraint date.

c) An interview with the Interim Resource Nurse Manager (Nurse Manager) on 10/27/15 at 9:26 a.m. confirmed if a restraint was discontinued, a new physician order would need to be obtained. The Nurse Manager confirmed there should have been a new physician order obtained for Patient #11 related to the 10/09/15 use of patient restraints.

Based on interviews and document review, the facility failed to ensure the re-assessment of a patient, after a significant change in condition, was conducted and documented in the medical record. In 1 of 11 medical records reviewed (Patient #5), required nursing re-assessments were not found documented in the patient's medical record.

This failure created the potential for negative patient outcomes as the patient's status after a significant change in condition, was not documented in the medical record through a Registered Nurse re-assessment.

FINDINGS:

POLICY

According to the policy, Assessment/Re-Assessment - Interdisciplinary Patient, the rationale for the policy was to establish a comprehensive information base for decision making about each patient's care and to assure the care provided to each patient was based on an assessment of the patient's needs.

In addition to a Registered Nurse conducted assessment each shift, re-assessment of patients will be conducted to evaluate the patient's response to care, treatment, and services or in response to a significant change in status or condition. All nursing assessments are recorded in the patient medical record by a licensed nurse.

1. In 1 of 11 medical records reviewed (Patient #5), lack of documentation of a patient re-assessment was noted.

a) On 10/19/15, review of the medical record for Patient #5 was conducted. The record revealed the patient was in a motor vehicle accident in which s/he suffered a shear head injury with hemorrhage, contusions, subarachnoid hemorrhage, occipital condylar fracture, vertebral artery dissection bilaterally, bilateral pulmonary contusions, and liver laceration. The patient had a craniectomy for increased intracranial pressure. Initial care was provided to the patient at an acute care hospital until the patient was transferred to the facility for treatment and rehabilitation. The patient was admitted to the facility on 07/22/15.

A Primary Care Progress Note written by Medical Doctor (MD) #14, dated 09/10/15, stated the patient had been having some jerking movements of his/her extremities over the last few days, but not definite seizures.

The transfer summary, dated 09/10/15, stated while at the facility the patient was started on a neurologic stimulation program, remained minimally responsive, opened his/her eyes to noxious stimuli, but was otherwise unresponsive with flaccid extremities. The patient was placed on a trach collar and received regular and as needed suctioning. On the morning of 09/10/15, MD #13 saw the patient and ordered a head Computed Tomography (CT) scan, which indicated severe hydrocephalus. The patient was then transferred back to the acute care hospital.

b) Review of the medical record nursing notes and assessments for Patient #5 was conducted.

i) Review of the nursing notes in the patient's medical record revealed a head-to-toe assessment was conducted on 09/09/15, at 8:40 a.m., by Registered Nurse (RN) #6.

A nursing note, dated 09/09/15 at 10:00 a.m., by RN #6 revealed s/he documented a change of condition at this time for Patient #5, that was reported to MD #4. The change of condition was documented as increased seizure-like activity, increased emesis, and increased tachycardia. RN #6 noted s/he spoke with MD #4 and requested baclofen for possible muscle spasms. RN #6 also documented "seizures/spasms" as a description of the patient's episodes. The note stated s/he also received an order from MD #4 to turn off the patient's tube feed for 1 hour to see if this would alleviate the emesis.

RN #6 documented the patient's response to both the baclofen and the hold on tube feeding. The nurse further documented that the patient became tachycardic again with a heart rate of 120-130.

The medical record contained a note written by RN #6 documenting that s/he spoke with the charge nurse, RN #5, about his/her concerns about Patient #5's status the morning of 09/09/15. RN #5 then called and spoke with MD #4 about the patient's condition and received an order for ativan, which was administered to the patient.

After the change in condition dated 09/09/15 at 10:00 a.m., there was no documentation noted in the patient's medical record of an RN re-assessment of the patient.

ii) Review of the nursing notes in the patient's medical record revealed a head-to-toe assessment was conducted on 09/10/15, at 9:00 a.m., by RN #6.

A nursing note dated 09/10/15 at 7:11 p.m., by RN #6, stated on the afternoon of 09/10/15, the patient experienced 2 episodes of projectile vomiting while on the way to obtain a CT scan. There was no documented re-assessment of the patient by nursing staff found in the medical record to address the patent's status following the projectile vomiting.

c) On 10/27/15 at 7:30 a.m., an interview was conducted with RN #5, who stated not all documented changes in conditions for patients would require an assessment or focused re-assessment of the patient by an RN. S/he reviewed the medical record for Patient #5 and stated that on 09/09/15, the documentation of "increased seizure-like activity" by RN #6 should have been followed by a re-assessment of the patient's neurological status. RN #5 stated likewise on 09/10/15, the note by RN #6 that described projectile vomiting on the afternoon of 09/10/15 should have been followed by an RN re-assessment of the patient, and this would have included a re-assessment of the patient's neurological status and possibly the patient's gastrointestinal status. RN #5 confirmed there was no documented re-assessment of the patient by an RN on these dates in the patient's medical record.

d) On 10/27/15 at 9:22 a.m., an interview was conducted with RN #11, the Interim Nurse Manager, who stated changes in a patient's condition would require documentation in the medical record of the change, documentation that the patient's physician was notified, and documentation of follow-up care provided by nursing staff. RN #11 stated if there was a significant change in condition noted by an RN, the expectation was that the RN would conduct and document a focused re-assessment of the patient. RN #11 stated for a patient with seizure-like activity, s/he would expect the patient's RN to assess or to re-assess the patient's neurological status and document the assessment in the medical record.

e) On 10/27/15 at 9:57 a.m., an interview was conducted with Employee #12, the Interim Resource Chief Clinical Officer, who stated for a patient with increased emesis and projectile vomiting, a change in condition should be documented by nursing staff, along with a documented assessment or re-assessment of the patient's status by an RN. S/he stated a neurological assessment would be appropriate for a patient with worsening nausea and vomiting, for example. Employee #12 stated there was no specific time frame stated for the re-assessment of a patient, but a re-assessment should be conducted and documented as soon as possible by nursing staff.