HospitalInspections.org

Based on record review and staff interviews, it has been determined that the hospital failed to ensure that the patient has the right to receive care in a safe setting related to ongoing monitoring. (ID# 1)

Findings are as follows:

Patient ID #1 was admitted to the hospital on 3/13/2020 for a tonsillectomy, and admitted to the nursing care unit at 11:20AM, for ongoing observation. While on the nursing care unit for approximately 16 hours, the patient had his/her vital signs including temperature, and blood pressure checked one time. Patient ID# 1 was found unresponsive on 3/14/2020 at 4:00AM.

During an interview on 7/20/2020 at approximately 2:00PM, with the accepting unit, nurse B, on first shift he stated the physician had ordered compression boots, continuous pulse oximetry and humidified oxygen. The patient was medically stable upon arrival to this unit. Nurse B stated he did not enter any nursing notes or documentation because there were no changes in the patient which warranted a note. He was unable to provide evidence that the patients temperature or blood pressure had been monitored during that shift.

During a phone interview on 7/20/2020 at approximately 1:00PM, with unit nurse, staff A who was present on the 3/13/2020 at 7PM through 3/14/2020, 7AM shift, she stated that the patient was "fine, alert oriented and talkative". She stated she was frequently in the patient's room because Patient ID#1 used her call light frequently just to talk. Nurse A stated, because the patient refused to wear the continuous pulse oximetry monitor, she would frequently go in and check the oxygen level, approximately every hour. Staff A could not provide evidence she had checked the patients' blood pressure or temperature every 4 hours.

Although the hospital stated there is no written policy relative to the ongoing monitoring of the post-surgical patient, during an interview with the Interim Director of Nursing on 7/20/2020, at approximately 12:30PM, she stated her expectation would be for post-operative patients, to have their vital signs taken every 4 hours.

During an interview with the surgeon on 7/20/2020 at approximately 12:30PM, he stated, he was not satisfied with the monitoring of his patient. Additionally, he stated, the nurses should have informed him of the patient's noncompliance with the use of the continuous pulse oximeter and oxygen.

During a second phone interview with the surgeon on 7/24/2020 at 10:15AM, he stated his expectation was that all vital signs be done every 4 hours.

(Refer to A-395)

Based on record review and staff interview it has been determined that the hospital failed to evaluate the care for 1 of 5 sample patient's (ID # 1) on an ongoing basis, following a surgical procedure, in accordance with accepted standards of nursing practice.

Findings are as follows:

According to Brunner & Suddworths Textbook of Medical Surgical Nursing, Volume 1 10th Edition, page 443 under; "The Hospitalized Post-Operative Patient" states in part ..."for post-operative patients admitted to medical-surgical/telemetry units from post anesthesia care units states vital signs are taken every 15 minutes for 1 hour, every 30 minutes for 2 hours. Thereafter they are measured less frequently if they remain stable. The temperature is monitored every 4 hours for the first 24 hours."

Review of the medical record for patient ID#1 reveals she was admitted to the hospital on 3/13/2020 for a surgical removal of his/her tonsils. The patient was alert, oriented and independent with all care needs.

Patient ID#1 had a tonsillectomy on 3/13/2020, without complications, and was transferred to the post anesthesia care unit (PACU) for recovery. At 11:00AM the patient was stable and certified as ready for discharge to the care unit for ongoing observation. The patient arrived on the care unit at 11:20AM.
Review of the patient's vital signs taken after transfer to the care unit on 3/13/2020 from approximately 11:20AM through 3/14/2020 at 4:00AM, reveals the patients' blood pressure was taken one time, on 3/13/2020, at 10:15PM, approximately 10 hours and 55 minutes after her transfer. Additionally, the patient's temperature, pulse and respirations were documented as completed one time on 3/14/2020 at 1:19AM approximately 12 hours after his/her transfer.

During an interview on 7/20/2020 at approximately 2:00PM, with the accepting unit, nurse B, on first shift he stated the physician had ordered compression boots, continuous pulse oximetry and humidified oxygen. The patient was medically stable upon arrival to this unit. Nurse B stated he did not enter any nursing notes/documentation because there were no changes in the patient which warranted a note. Nurse B could not provide evidence that the patients blood pressure or temperature had been checked.

Review of the second shift nursing notes dated 3/13/2020 through 3/14/2020 at 3:20AM indicated the patient was alert and oriented with no overt concerns. Medicated for pain as ordered by the physician. Notes do indicate the patient was noncompliant throughout the evening and night with use of the compression boots, continuous pulse oximetry and oxygen face mask ordered by the physician.

During a phone interview on 7/20/2020 at approximately 1:00PM, with unit nurse, staff A who was present from 3/13/20 7PM through 3/14/20 7AM , stated that the patient was "fine, alert oriented and talkative". She stated she was frequently in the patient's room, because Patient ID#1 used the call light frequently just to talk. Nurse A stated, because the patient refused to wear the pulse oximetry monitor, she would frequently go in and check the patient's oxygen level, approximately every hour, but did not take all of his/her vital signs.

The last time the patient was checked at approximately 3:20AM, patient ID#1 was alert, oriented and the oxygen level was 94% on room air. Nurse B states she called respiratory for a moist mist mask to be administered to the patient, when respiratory therapy came into the room at approximately 4:00AM the patient was unresponsive in her bed.

Although the hospital stated there is no written policy relative to the ongoing monitoring of the post-surgical patient, during an interview with the Interim Director of Nursing, she stated her expectation would be for post-operative patients, to have their vital signs taken every 4 hours.

During an interview with the surgeon on 7/20/2020 at approximately 12:30PM, he stated, he was not satisfied with the monitoring of his patient. Additionally, he stated, the nurses should have informed him of the patient's noncompliance with the use of the continuous pulse oximeter and oxygen.
(Refer to A-0144)

Based on record review and staff interview it has been determined that the hospital has failed to administer medications in accordance with Federal and State laws, per the orders of the practitioner for 2 of 7 sample records (ID#'s 1 and 5) reviewed for medication administration following a surgical procedure.

Findings are as follows:

Review of the medical record for patient ID#1 reveals s/he was admitted on 3/13/2020 for a tonsillectomy. A physician's order dated 3/13/2020 indicates the patient can be administered the following medications for pain treatment:

Hydromorphone 1mg intravenous every 2 hours as needed, for pain of less than 7 on a scale of 10.

Additionally, there was a second order for pain treatment as follows:

Hydromorphone 2mg intravenous every 2 hours as needed, for pain of 7 or above on a scale of 10.

Review of the administration record for patient ID# 1, reveals on 3/13/2020, Hydromorphone 0.25mg intravenous was administered at 10:41AM.

Additionally, on 3/13/2020, at 11:00AM, ID# 1, was administered Hydromorphone 0.5mg intravenous.

2. Review of the medical record for patient ID#5 reveals s/he was admitted for a left neck dissection.
A physician order dated 7/15/2020 for pain treatment was written as follows:

Hydromorphone 1mg intravenous every 2 hours as needed, for pain of less than 7 on a scale of 10.

Additionally, there was a second order for Hydromorphone 2mg intravenous every 2 hours as needed, for pain of 7 or above on a scale of 10.

Review of the administration record for patient ID# 5, reveals on 7/15/2020, Hydromorphone 0.5mg intravenous was administered at 5:00PM.

During an interview with the PACU clinical manager (staff C), on 7/20/20 at approximately 2:00PM, regarding the administration of medications in the PACU, he reveals it is common practice in the PACU to administer the narcotics with caution due to concern a naive patient may have a poor reaction to the drug. He stated, by administering a lower dosage we see the patient's response to the medication. Staff C was able to provide a reference sheet used by the PACU nurses to adjust the dosage safely. He stated that this reference sheet only and is not part of the medical record or hospital policy. Additionally, he acknowledged this practice is not following the physicians written order.