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Based on interview and record review, the facility failed to ensure, for 1 of 33 sampled patients, Patient 80, that the patient's representative was informed of his health status, by failing to notify Patient 80's representative when the patient had a life threatening medical emergency. This failure had the potential to result in the patient's representative not having the information needed to make treatment decisions.

Findings:

Complaint #CA00168717

Review on 3/18/10, of Patient 80's record, documented that the patient was 80 years of age, admitted to the facility on 6/17/08 with a diagnosis of hematuria (blood in the urine). The patient was treated for a urinary tract infection and had a high INR (a blood test to check the ability of the blood to clot. A high INR indicates the patient has a high risk of bleeding). Patient 80 had been on a blood thinner (Coumadin) at home.

Review of the nurses flowsheet notes dated 6/18/08 (the date was written on the nursing flowsheet before midnight) at 3:30 AM, the nurse documented that the patient was found unresponsive and slumped over in bed. The patient had no respirations (breathing), with a faint pulse, and no blood pressure. The Code Blue team (emergency response team) was called.

Review of the Patient Resuscitation Record dated 6/18/08 (according to other records in the patient record, the date should have been 6/19/08) at 3:32 AM, showed that the patient was slumped across bed with no respirations and a faint pulse. The vital signs (blood pressure, pulse, respirations) were recorded at 3:30 AM as blood pressure 0, pulse 0, and respirations were left blank. At. 3:40 AM the vital signs were: blood pressure 110/70 (normal 90-120/60-80), pulse 70 (normal 60-100), respirations 18 (normal 12-18). The patient outcome of the Code Blue was "Palpable (able to feel) pulse restored."

There was no documentation found in the record that the patient's family was notified of Patient 80's medical emergency until after a second Code Blue was called on 6/19/08 at 5:45 AM and the patient died at 6:30 AM.

In an interview on 3/23/10 at 10:00 AM with the Administrative Staff RN C, she stated that the physician should have called the family after the 3:30 AM Code Blue. She further stated that there was "no excuse for that."

Based on interview, and record review, it was determined that the hospital failed to ensure that nursing was organized and that the delivery of nursing care was supervised by failing to:

1. Ensure that a registered nurse evaluated the nursing care requirements for 3 of 33 sampled patients.

For Patient 80, the registered nurse failed to advocate for the safety of the patient when the patient had a medical emergency. This failure resulted in the patient not having closer cardiac and respiratory monitoring to be able to respond faster to the patient's change in condition. (Refer to A 0395)

For Patient 64, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care of the patient's nutritional status by failing to ensure that the chain of command was followed for the patient with a very low nutritional intake. They also failed to ensure that nursing supervised and evaluated the nursing care by providing assessments and documentation for the care of a pressure ulcer and excoriated skin. This failure had the potential to cause further skin problems, malnutrition, lethargy, and even death. (Refer to A 0395)

For any patient who had intensive care unit admission orders, the facility failed to provide registered nursing supervision of the patient's status and care by having a medication room that was away from the patient care unit (Refer to A 0395)

For Patient 62, the facility failed to reassess the patient for over-sedation or the effectiveness of the medication in a timely manner after a pain medication was administered. This failure had the potential to result in the patient being over sedated or not having their pain effectively managed to relieve suffering. (Refer to A 0395)

For Patient 62, the facility failed to assess the patient for location and level of pain prior to the administration of a pain medication. This failure had the potential to result in Patient 62 receiving unnecessary pain medication. (Refer to A 0395)

2. Ensure adequate numbers of licensed registered nurses were available to provide nursing care to all patients by failing to make adjustments for nursing staff absenteeism during lunch and breaks, resulting in the potential for patients not having their care needs met. (Refer to A 0392)

The facility also failed to ensure that they had the nursing staff necessary to ensure that continuous telemetry (heart) monitoring was being done for all patients that required the monitoring. This failure had the potential to cause a delay in recognition and treatment of abnormal heart rhythms up to and including heart rhythms that can cause death for all patient who require telemetry monitoring. (Refer to A-392)

3. Ensure that each patient had a care plan that addressed the patient's care needs and that the care plan was kept current for 4 of 39 sampled patients (Patients 64, 78, 81, and 23). The failures were as follows:

For Patient 64, the facility nursing staff failed to develop a care plan to direct how to care for the patient when she refused cares, medication and food. The failure had the potential to result in the patient developing complications such as malnutrition or worsening of the symptoms that the medication was treating. (Refer to A 0396)

For Patient 64, the nursing staff failed to ensure the care plan had goals for the use of restraints, with the potential of the patient being restrained longer than necessary. (Refer to A 0396)

For Patient 78, the nursing staff failed to develop a care plan for skin breakdown prevention with the potential for the patient to develop pressure sores. (Refer to A 0396)

For patient 81, the nursing staff failed to develop a care plan for the use of restraints, with the potential of the patient being put in unnecessary restraints or being in restraints longer than necessary. (Refer to A 0396)

For Patient 23, the nursing staff failed to keep the plan of care current by re-assessing the patient's respiratory status, when the patient developed early signs of respiratory distress. This failure had the potential for the patient's respiratory status to deteriorate further and result in the need for a higher level of care. (Refer to A-396)

4. Ensure that Emergency Department (ED) required the equivalent competencies for RNs as those required in the Intensive Care Unit (ICU) to ensure that ED nurses were competent to care for ICU patients. This failure had the potential for critically ill patients to not receive the care necessary to promote their physical well-being. This failure had the potential for continuous powerful intravenous (IV) medications to be given incorrectly which could lead to the patient becoming more ill and could even cause the patient ' s death. (Refer to (A-397)

5. Ensure that the PACU nurses monitored the medication refrigerator in order to maintain medications within the required temperature parameters. This created the risk of PACU patients receiving frozen or inactive medications. (Refer to A-404)

The cumulative effect of these systemic problems resulted in the facility's failure to deliver patient care in a safe manner and in compliance with the Condition of Participation for Nursing Services.

Based on interview and record review, the facility failed to ensure that a registered nurse evaluated the nursing care requirements for 3 of 33 sampled patients.

For Patient 80, the registered nurse failed to advocate for the safety of the patient when the patient had a medical emergency. This failure resulted in the patient not having closer cardiac and respiratory monitoring to be able to respond faster to the patient's change in condition.

For Patient 64, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care of the patient's nutritional status by failing to ensure that the chain of command was followed for the patient with a very low nutritional intake. They also failed to ensure that nursing supervised and evaluated the nursing care by providing assessments and documentation for the care of a pressure ulcer and excoriated skin. This failure had the potential to cause further skin problems, malnutrition, lethargy, and even death.

For any patient who had intensive care unit admission orders, the facility failed to provide registered nursing supervision of the patient's status and care by having a medication room that was away from the patient care unit.

For Patient 62, the facility failed to reassess the patient for over-sedation or the effectiveness of the medication in a timely manner after a pain medication was administered. This failure had the potential to result in the patient being over sedated or not having their pain effectively managed to relieve suffering.

For Patient 62, the facility failed to assess the patient for location and level of pain prior to the administration of a pain medication. This failure had the potential to result in Patient 62 receiving unnecessary pain medication.

The facility failed to ensure that a wound care nurse was available to evaluate and institute nursing interventions for one patient who was admitted with a stage III pressure ulcer, resulting in substandard wound care management for that patient.


Findings:

1. Complaint #CA00168717

Review on 3/18/10, of Patient 80's record, showed that rhe patient was 80 years of age, admitted to the facility on 6/17/08 with a diagnosis of hematuria (blood in the urine). The patient was treated for a urinary tract infection and had a high INR (a blood test to check the ability of the blood to clot-a high INR indicates the patient has a high risk of bleeding). Patient 80 had been on a blood thinner (Coumadin) at home.

Review of the nurses flowsheet notes dated 6/18/08 (the date was written on the nursing flowsheet before midnight) at 3:30 AM, the nurse documented that the patient was found unresponsive and slumped over in bed. The patient had no respirations (breathing), with a faint pulse, and no blood pressure. The Code Blue team (emergency response team) was called.

Review of the Patient Resuscitation Record dated 6/18/08 (according to other records in the patient record, the date should have been 6/19/08) at 3:32 AM, showed that the patient was slumped across bed with no respirations and a faint pulse. The vital signs (blood pressure, pulse, respirations) were recorded at 3:30 AM as blood pressure 0, pulse 0, and respirations were left blank. At. 3:40 AM the vital signs were: blood pressure 110/70 (normal 90-120/60-80), pulse 70 (normal 60-100), respirations 18 (normal 12-18). The patient outcome of the Code Blue was "Palpable (able to feel) pulse restored."

There was no documentation found in the record that Patient 80 was placed on cardiac and respiratory monitoring after the medical emergency. The community standard is to closely monitor a patient that had an episode of instability (the Code Blue), to be able to respond quickly to a change in the cardiac rhythm or any respiratory changes.

A review of the facility policy titled, Escalation Policy-Methodology for Resolving Questions Concerning Medical Care" dated 12/09, revealed that "Any member of the health care team who has a concern regarding patient safety is obliged to escalate (take up the chain of command) the issue until the concern is resolved."

Review of the second Patient Resuscitation Record dated 6/19/08 at 5:46 AM, showed that Patient 80 was unresponsive and was in cardiac arrest. The patient died at 6:30 AM.

In an interview on 3/23/10 at 3:00 PM with the Director of Quality, he agreed that if Patient 80 was placed on cardiac and respiratory monitoring after the first emergency, a cardiac rhythm disturbance or a decrease in breathing, leading to loss of consciousness and no vital signs may have been discovered earlier and allowed for a quicker response to the patient's change of condition.a

2 (a.) A review of the medical record for Patient 64 revealed that she was admitted to the facility on 2/19/10 with a chief complaint of confusion and agitation. Her medical history included dementia and diabetes mellitus.

A review of the patient's dietary intake was as follows:
(patient had 0 intake for other meals that are not noted)

2/21/10, 6 PM - 85%
2/22/10, 7:50 AM - 5%, 6 PM - 100%
2/23/10, 8 AM -95%, 1 PM - 100%
2/24/10, 12:30 PM - 50%, 6 PM - 90%
2/25/10, 2:25 PM - 70%
2/26/10, 0%
2/27/10, 0%
2/28/10, 12:30 PM - 98%, 6 PM - 50%
3/1/10, 9:30 AM 60%
3/2/10, 0%
3/3/10, 0%
3/4/10, 7:30 PM - 100%
3/5/10, 0%
3/6/10, 0%
3/7/10, 6 PM - 5%
3/8/10, 0%
3/9/10, 0%
3/10/10, 0%
3/11/10, 0%
3/12/10, 0%
3/13/10, glycotrol (tube feeding) given, not documented how much
3/14/10, 0%
3/15/10, 8 PM - 100%

A review of the weights documented for Patient 64 were as follows:

No admission weight was documented
3/4/10, 115 pounds
3/5/10, 119 pounds
No further weights were documented at the review date of 3/16/10

A review of the Registered Dietitian (RD) notes revealed that the patient was seen on 2/24/10 and assessed as a "moderate risk" for dietary problems. The patient was seen again on 3/4/10, 3/8/10, 3/10/10, and 3/14/10. On 3/10/10 and 3/14/10, there were notes from the RD regarding a tube feeding that the RD documented the patient was receiving. On 3/14/10 the RD documented that a discussion was held with the Registered Nurse (RN) regarding weight orders. There was no other documented discussion with nursing regarding this patient's nutritional status.

A review of the nurse's narrative notes from admission until review on 3/16/10 revealed no discussion with the RD or with the physician regarding a plan for the patient's nutritional needs. There were notes describing a nasogastric (feeding tube) being placed and a smaller feeding tube being placed; however, the patient pulled out these tubes. A nurses documentation on 3/10/10 at 11:23 PM revealed, "tried to insert ng tube (feeding tube through the nose) pt (patient) agitated and said 'it hurt'. also noticed blood from her nostril"

The documentation on the patient's dietary intake revealed that the patient received nutrition through the tube on one day, 3/13/10.

The medical record review of the nutritional intake, RD notes, and weights was confirmed by Administrative Staff RN A on 3/16/10 at 11:30 AM.

An interview was conducted with the charge nurse (Staff RN A) on the unit that the patient was placed on 3/15/10 at 3 :30 PM. Staff RN A stated that the patient often refuses cares, medications, and food. She stated that the physician for the patient did not want another feeding tube placed. She stated that the plan for the patient was to send her home on hospice care; however, the family had not agreed to hospice at this time.

4 (a). The clinical record for Patient 62 was reviewed on 3/18/10 at 8:50 AM with the Clinical Director of Maternal and Child Department (CDMC). The clinical record indicated that Patient 62 was a 6year old male admitted to the facility, on 2/27/10 with a diagnosis of status post appendectomy for perforated (ruptured) appendicitis.

Review of the "Pediatric Hospital Admission History and Physical" dated 2/27/10, indicated that patient 62 had a laparoscopic appendectomy at another facility on 2/25/10.

Review of the physician's orders for Patient 62 indicated that the patient had an order for Tylenol with Codeine 120-12mg (milligrams)/5 ml (milliliters) oral elixir with an administration dose of dose12mg=5ml, to be taken by mouth every four hours as need for mild pain (a pain scale of 1-3), or moderate pain (a pain scale of 1-4).

During an interview with the CDMC on 3/18/10 at 9:15 AM, the CDMC stated that the licensed staff had used the FLACC with Patient 62 because of his medical history of autism. ( The FLACC [Face, Legs, Activity, Cry, Consolability] scale is a behavioral pain scale used with non-verbal patients unable to verbally report pain, total pain score total is between 0 and 10. This pain scale is used for pediatric patients, cognitively impaired patients, and those unable to verbally report pain.)

Review of Patient 62's "Flow sheet Data" reports, that documented the patient's pain assessments, and review of Patient 62's Medication Administration Records (MARs) dated 2/28/10 to 3/17/10 revealed the following information.

On 2/28/10 at 1828 (6:28 PM), Patient 62's pain level was assessed at 5 on a 0-10 score. There was no documentation of the location or the source of the patient's pain. Patient 62 was medicated with 5 ml of Tylenol with Codeine at 6:28 PM. The patient was not reassessed for over-sedation or the effectiveness of the medication until 2008 (8:08 PM), which is does not met the time frame of 30 to 60 minutes.

On 3/1/10 at 9:32 AM Patient 62's pain level was assessed at 4 on a 0-10 pain score, the patient was medicated with Tylenol with Codeine at 9:32 AM in the morning, and was not reassessed for the effectiveness of the medication. There is no documented evidence that Patient 62 was reassessed for over-sedation or the effectiveness of the medication.

On 3/2/10 at 12:35 AM, Patient 62's pain level was assessed at 5 on a 0-10 pain score, the patient was medicated with Tylenol with Codeine at 12:41 AM. There is no documented evidence that Patient 62 was reassessed for over sedation or the effectiveness of the medication.

On 3/2/10 at 1359 (1:59 PM), Patient 62's pain level was assessed at 5 on a 0-10 score. There was no documentation of the location or the source of the patient's pain. Patient 62 was medicated with 5 ml of Tylenol with Codeine at 1:59 PM. There is no documented evidence that Patient 62 was reassessed for over-sedation or the effectiveness of the medication.

On 3/12/10 at 2136 (9:36 PM), Patient 62's pain level was assessed at 5 on a 0-10 pain score. There was no documentation of the location or the source of the patient's pain.
Patient 62 was medicated with 5ml of Tylenol with Codeine at 9.36 PM. There is no documented evidence that Patient 62 was reassessed for over sedation or the effectiveness of the medication.

On 3/4/10 at 12:00 PM, Patient 62's pain level was assessed at 0 (having no pain) on a 0-10 pain score, and the MAR indicates that the patient was medicated with 5 ml of Tylenol with Codeine at 12:00 PM even though the patient had been assessed as having 0 (no) pain. There is no documented evidence that Patient 62 was reassessed for over sedation after the medication was administered.


Review of the facility policy and procedure titled, " Pain Assessment Documentation " dated 08/08 indicated the following:

" 2. Comprehensive pain assessments will include patient ' s acceptable pain level, current pain level, source, location and intervention " .


Review of the facility policy and procedure titled, "Pain Management" dated 12/09, indicated the following:

"3. Patients will be assessed and reassessed at appropriate interval for the prevention and management of opioid induced side effects which may include, but not limited to:"

"4. Alteration of mental status, respiratory depression, nausea, vomiting, purities and constipation."

"6. Patients will have their pain assessed and /or self-reported:
6.1 On admission
6.2 At the time routine vital signs are taken
6.3 Prior to the initiation of patient controlled analgesia
6.4 Following an intervention (30-60 minutes is suggested)
6.5 Until an acceptable level of pain is achieved, as defined by the patient, or the patient requests that there will be no further intervention."

During an interview with the CDMC on 3/18/10 at 10:30 AM, the CDMC verified that licensed staff had not reassessed Patient 62 for over sedation or the effectiveness of the Tylenol with Codeine each time the medication was administered. During the interview the CDMC stated that the licensed staff had not managed Patient 62's pain in accordance to the facility's policy in-order to evaluate the effectiveness of the intervention of the administration of medication.




4 (b). Review ofPatient 62's physician's orders indicated that the patient had an order for Tylenol with Codeine 120-12mg (milligrams)/5 ml (milliliters) oral elixir with an administration dose of dose12mg=5ml, to be taken by mouth every four hours as need for mild pain (a pain scale of 1-3), or moderate pain (a pain scale of 1-4).

During an interview with the CDMC on 3/18/10 at 9:15 AM, the CDMC stated that the licensed staff had used the FLACC with Patient 62 because of his medical history of autism. ( The FLACC [Face, Legs, Activity, Cry, Consolability] scale is a behavioral pain scale used with non-verbal patients unable to verbally report pain, total pain score total is between 0 and 10. This pain scale is used for pediatric patients, cognitively impaired patients, and those unable to verbally report pain.)

Review of Patient 62's clinical record indicated that Patient 62 had been administered 5 ml of Tylenol with Codeine on the following dates and times without having been assessed for level, and location of pain, prior to or after the administration of the medication.

3/2/10 at 10:14 PM,
3/3/10 at 5:53AM and 3:33 PM
3/6/10 at 12:00 PM,
3/7/10 at 10:38 PM,
3/8/10 at 8:03 PM,
3/09/10 at 2:35 AM and 6:05 AM

There was no documented evidence in the clinical record that indicated that Patient 62 had been assessed for level, and location of pain, prior to or after the administration of the medication on the above listed dates and times.

Review of the facility policy and procedure titled, "Pain Management" dated 12/09, indicated the following:

"4. Pain will be assessed prior to the initiation of any pain management intervention."

During an interview with the CDMC on 3/18/10 at 10:30 AM, the CDMC verified that the clinical record indicated that Patient 62 been administered Tylenol with codeine without first having been assessed for level, and location of pain, prior to or after the administration of the medication. During the interview the CDMC stated that the licensed staff had not managed Patient 62 ' s pain in accordance to the facility ' s policy in-order to evaluate the effectiveness of the intervention of the administration of medication and to ensure that the patient did not receive unnecessary medications.

5. On 3/23/10 the medical record of Patient 21 was reviewed. According to the admission assessments, the patient was admitted with a stage III sacral ulcer, and also had a stage III sacral ulcer upon discharge. He arrived on the hospital floor on 12/23 at 4:14 PM, and a non-powered mattress was ordered for him and a Mepelex foam dressing was put in place. The nurse measured the wound on 12/23 and a wound care consultation was ordered. The wound was measured again on 12/28, but not thereafter.

During an interview with Risk Management Staff 1 on 3/23/10 at 10:20 AM, she stated that mattresses were selected by the nursing staff according to a mattress selection algorithm.

During a second interview with Risk Management Staff 1 at 10:55, she stated that the documentation indicated that the patient was placed on a non powered redistribution mattress initially, which she stated was the Accumax, the facility ' s regular mattress. She stated that was not the correct mattress for a patient with a grade III pressure ulcer. She concurred that the first time the correct mattress was documented as in use was on 12/30/09, a week after Patient 21's arrival at the facility.

RN 23, a wound care consultant, was interviewed on 3/23/10 at 11:15 AM, and she stated that the correct mattress choice for a patient with a stage III ulcer would have been a low airloss mattress. RN 23 was also asked to review the wound care policy for the correct dressing. She stated that according to the policy, Mepelex dressing was for a stage II, not a stage III wound.