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Based on interview and record review, the facility failed to ensure the development of a nursing care plan to provide care and services for 1 of 5 patients with a respiratory distress diagnosis that was prescribed oxygen therapy. (Patient #1). The facility failed to develop a plan of care that addressed the need for oxygen, the need to measure oxygen saturation before and after the increases in oxygen were made; and physician notification when the oxygen consumption exceeded the order and/or the oxygen saturation dropped below the prescribed parameters.

Findings:

Review of Emergency Center Record revealed Patient #1 presented to the facility's Emergency Department via ambulance on 8/21/13 at approximately 6:30pm with "increased heart rate and palpitations, shortness of breath, and left arm numbness/tingling." Differential diagnosis documentation included pulmonary embolus. Triage note documented patient's oxygen saturation at 95% with oxygen being delivered via a nasal cannula and without documentation of oxygen concentration on the entry.

History and Physical (H&P), dated 8/21/13 at 10:54pm, documentation included, but not limited to, the following: ... presents with shortness of breath for the last 5 days.. started seeing gradual increase in her work of breathing, and shortness of breath. .. becomes extremely short of breath with any kind of physical exertion..increased respiratory effort.. normally regains breath by resting..lower extremity pain in calves bilaterally, left worse that then right.. claims when short of breath, becomes diaphoretic.. also left shoulder pain, radiating to fingers on her left. H&P documents patient receiving 2 liters/minute of oxygen via a nasal cannula with an oxygen saturation of 94% on 8/21/13 at 9:15pm. H&P documents patient's respiratory assessment as follows: Lungs are clear to auscultation, breath sounds equal. Physical exam done right after returning from using the restroom and patient was tachypneic with a respiratory rate approaching 25 and became diaphoretic and clammy .... Took patient approximately 3 minutes after returning from the rest room to catch her breath. H&P documented a working medical diagnosis to be (1) Deep vein thrombosis of lower limb, acute (2) Acute respiratory distress (3) Acute pulmonary embolus.

In telephone interview conducted with Patient #1's spouse on 9/11/13 at approximately 6:00pm he stated he observed the patient ambulated to the bathroom while in the Emergency Department without oxygen in place although wheelchair and portable oxygen was requested by the patient. Stated the patient became very short of breath and clammy as a result; and it took a while for her to recover her breathing to a normal pattern and both he and his wife were upset by the incident.

Physician admission orders, dated 8/21/13 at 9:50pm include oxygen at 2-4 liters/minute via nasal cannula to keep oxygen saturation greater or equal to 92%. Diagnosis is documented as "likely pulmonary embolus/respiratory distress."

Electronic medical record (EMR) review, in the presence of facility Quality Improvement Director, was conducted on 9/13/13. Emergency Department (ED) record documents an entry, dated 8/21/13 at 10:45pm that "report given to nurse on 2A, patient to go upstairs after ultrasound." The EMR documented an oxygen saturation of 90% (outside parameters) on 8/22/13 at 0020, but failed to indicate whether patient was receiving the oxygen as prescribed as there is not documentation of oxygen delivery amount. This finding was confirmed by the QI Director. The ED record documented that on 8/22/13 at 0059, the patient was ready for transport to Unit 2A after speaking with the Registered Nurse. The last recorded oxygen saturation for the patient in the ED was on 8/22/13 at 0020 which documented a 90% oxygen saturation (outside the physician prescribed parameters); failed to indicate if patient was receiving the prescribed oxygen; and failed to indicate additional assessments conducted .

Further EMR review revealed a nursing assessment was conducted on 8/22/13 at 1:28am with patient's oxygen saturation noted to be at 93%, without documentation of amount of oxygen being delivered or documentation of delivery method. EMR documented the amount of oxygen being delivered had increased from 3 liters on 8/21/13 at 10:15pm to 4 liters on 8/22/13 at 3:14am. The increase in oxygen failed to include an assessment to include measurement of the patient's oxygen saturation. EMR nursing documentation by the Registered Nurse entered on 8/22/13 at 7:52am, but performed on 8/22/13 at 3:00am, documented "patient alert and oriented x 4; 5 liters nasal cannula, seems slightly short of breath, complaining of pain to legs, pulses present. Patient told it is important to use call bell before ambulating to the bathroom, patient understood, will continue to monitor patient's shortness of breath." The EMR documented oxygen being delivered at 5 liters on 8/22/13 at 4:39am (noted again to be outside the parameters of the prescribed physician's orders); and failed to include an assessment to include measurement of the patient's oxygen saturation. This finding was confirmed by the QI Director who stated "would expect to have an oxygen saturation assessment with the increases in oxygen being delivered. "

Nursing admission assessment, dated 8/22/13 at 1:29am, documented weakness and shortness of breath; and documented active diagnoses to include Acute Pulmonary Embolus and Acute Respiratory Distress.

EMR review, in presence of QI Director, revealed 2 nursing goals, dated 8/22/13 at 1:39am, were documented for the patient. Nursing Goal #1 was documented as "pain level less than 5" without documented interventions; and Nursing Goal #2 was documented as "no falls this shift" with interventions documented to be "bed locked and in lowest position, call light in reach, side rail up x 3." Patient's admitting diagnosis of likely pulmonary embolus/respiratory distress was not addressed in the nursing goals. QI Director stated nursing goals are taken from the physician's History and Physical; and could offer no explanation as to why the patient's respiratory problems with an admitting diagnosis of Acute Pulmonary Embolus and Acute Respiratory Distress were not addressed as a Nursing Goal with documented interventions. In interview conducted with Unit 5A Charge Nurse on 9/13/13 at approximately 10:30am, she also stated the nursing goals are initiated from the patient's History and Physical.

EMR nursing documentation entered on 8/22/13 at 7:55am, but performed on 8/22/13 at 6:25am included "called to patient's bathroom by Patient Care Assistant. Patient found seated on floor in front of toilet. Noted to be short of breath, but alert and able to speak ... observed to experience increasing shortness of breath and increasing paleness.. code blue called.. became apneic prior to arrival of the code team.. CPR started and patient moved from bathroom to floor of the room."

EMR nursing documentation entered on 8/22/13 at 8:00am, but performed on 8/22/13 at 6:30am included "PCA stated she went to help patient to bathroom and patient was found in bathroom on the floor. Patient very pale, breathing heavily, no oxygen attached. Oxygen tank brought in and attached to patient immediately. Code called. Resuscitation attempted for 30 minutes. Time of death 6:55am. "

Further EMR review failed to demonstrate whether patient was being assisted to bathroom with oxygen being maintained prior to the respiratory arrest.

Interviews conducted on 9/13/13 from approximately 9:30am until 11:00am with Unit 5A Charge Nurse, Unit 5A Registered Nurse and Unit 5A Licensed Practical Nurse revealed an oxygen saturation should be obtained when increasing and/or decreasing oxygen levels. Charge Nurse stated shortness of breath alone would not necessarily indicate the need for an oxygen increase as could be related to anxiety versus oxygen deprivation.

Review of facility's P&P titled "Assessment and Plan of Care" with a revision date of 3/2012 documented "the goal of assessment is to determine the care, treatment and services that will meet the patient's initial and continuing needs ..... to provide an organized plan for utilizing the Nursing Process ... the Registered Nurse is responsible for assess the patient and developing the plan of care; and coordinate the implementation of the plan of care. Documented "assure the plan of care is kept current, or revised, based on ongoing assessments and the patient's responses to interventions."

Interview with facility's Chief Nursing Officer on 9/13/13 at approximately 11:00am revealed the facility is in process of meetings to address Care Plans in the hospital; and provided supporting documentation. However, the facility's current process of identifying nursing goals was not demonstrated for Patient #1 as the H&P clearly identified the diagnoses to be respiratory problems with documentation of likely pulmonary embolus and respiratory distress.