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Based on record review, policy review and staff interview it was determined the registered nurse failed to supervise and evaluate care related to changes in condition for two (#8, #10) of ten sampled patients.

Findings included:

1. Patient #8 was admitted to the facility on 12/19/15. The History and Physical dated 12/20/15 at 7:31 p.m. documented a past medical history that included coronary bypass graft, ischemic cardiomyopathy and a cardiac pacemaker.

Patient #8 had a urological procedure on 12/23/15. The Post Anesthesia Care Unit Record (PACU) dated 12/23/16 revealed the patient arrived in PACU at 12:17 p.m. and return to the nursing unit at 12:54 p.m. Vital signs in the PACU noted an oxygen saturations of 87%, 84%, 86% and 93% with oxygen via nasal cannula at 3L/min (Liters per minute). The next entry in the record was dated 12/23/15 at 2:00 p.m. by the Certified Nursing Assistant (CNA) that the patient was resting comfortably. The vital signs on the medical surgical nursing unit were documented at 5:36 p.m., more than 5 hours following the return from PACU.

Patient #8 had a second surgery to repair injuries sustained on 12/23/15 when the patient re-fractured the left ankle. The last vital signs documented by the PACU RN were dated 12/24/15 at 6:20 a.m. The patient left the PACU and return to nursing unit sometime between 6:41 a.m. when the PACU RN signed a final note and 6:55 a.m. when the RN on the nursing unit signed a note indicating the bedside shift report was conducted.

A detailed review of the record failed to reveal any evidence of any further assessment of Patient #8 until 12/24/15 at 8:17 a.m., over an hour following the return from PACU.

The review of the facility policy Care of the Post-Operative Patient, policy #620015.002, last review/revise date 11/2015 indicated when the patient arrives on the nursing unit from surgery, vital signs will be taken every 15 minutes times 4, then every 30 minutes times 2, then every hour times one and then every 4 hours for the next 48 hours. The policy did not include any reference to performing a nursing assessment of post-operative patients returning to the general nursing unit.

An interview was conducted at the time of the record review with the Manager of Quality and Patient Safety on 2/16/16 at approximately 3:15 p.m. She confirmed the finding vital signs were not taken on Patient #8 in compliance with facility policy on 12/23/15 or 12/24/15.

2. Patient #10 was admitted on 2/9/16 with a diagnosis of rule out osteomyelitis (infection of the bone) of the foot. The History and Physical dated 2/9/16 at 7:40 p.m. and signed by the attending physician indicated a past medical history that included coronary artery disease, coronary artery bypass graft and hypertension. Vital signs on admission were within normal limits. The oxygen saturation was 98% on room air. The Physical Examination included the heart rate and rhythm were regular with no murmurs. The patient had a toe amputation on 2/11/16.

The History and Physical dated 2/9/16 at 7:40 p.m. and signed by the attending physician, the pre-operative nursing assessment dated 2/11/16 from 3:34 p.m. until 7:15 p.m. and signed by the Registered Nurse (RN) and the anesthesia record dated 2/11/16 from 7:15 p.m. until 8:15 p.m. and signed by the anesthesiologist all included documentation Patient #10 had a regular heart rate and rhythm.

The Post Anesthesia Care Unit Record (PACU) signed by the Registered Nurse (RN) indicated the patient arrived from the operating room on 2/11/16 at 8:14 p.m. A cardiac monitor rhythm strip identified Patient #10 and was dated 2/12/16 at 8:16 p.m. It included a hand written notation "A fib". The rhythm strip displayed an abnormal rhythm with an irregular heart rate.

A detailed review of the record failed to reveal any evidence the PACU RN recognized Patient #10's heart rhythm as a change in condition. There was no evidence any physician was notified Patient #10 had developed a new onset of atrial fibrillation.

An interview was conducted at the time of the record review with the Manager of Quality and Patient Safety on 2/16/16 at approximately 1:00 p.m. She confirmed the findings Patient #10 developed atrial fibrillation at the time of transfer to the PACU. She confirmed the finding a new onset of atrial fibrillation was a serious change in the heart rhythm. She confirmed the finding the PACU RN did not notify any physician of the change in the patient's condition.

The Discharge and Transfer Information documented Patient #10 arrived in PACU on 2/11/16 at 8:14 p.m. and departed to the Medical Surgical room at 9:03 p.m. on 2/11/16. The final vital signs documented in PACU were taken at 8:45 p.m. The heart rate was 88 and the blood pressure was 140/88. The next entry in the record was dated 2/11/16 at 9:26 p.m. and signed by the CNA on the Med/Surg nursing unit. The patient's oxygen saturation was 86% and the blood pressure was 67/42. Between 9:26 p.m. and 9:49 p.m. the oxygen saturation was recorded as 89% at 9:31 p.m., 78% at 9:44 p.m., 80% at 9:45 p.m. and then 100% at 9:49 p.m. (normal per facility is 92-100%). On 2/11/16 at 11:02 p.m. the level was 88%. It was 87% at 11:22 p.m., 76% at 11:25 p.m. and was 69% at 11:26 p.m. The review of the record failed to reveal vital signs were taken at the time the patient arrived on the nursing unit, every 15 minutes for an hour and then every 30 minutes for an hour.

Review of all Physician Progress Notes failed to reveal documentation of any concerns related to Patient #10's significant changes in the oxygen saturation level. The Progress Notes did contain documentation of Patient #10's oxygen saturation levels and oxygen flow rate. The Progress Note dated 2/15/16 at 8:49 a.m. and signed by the attending physician included oxygen saturation 92% with oxygen at 4L/min by nasal cannula The Progress Note dated 2/14/16 at 12:07 p.m. and signed by the attending physician included oxygen saturation 94% with oxygen at 4L/min by nasal cannula. The Progress Note dated 2/13/16 at 10:29 a.m. and signed by the attending physician included oxygen saturation 94% with oxygen at 2L/min by nasal cannula. The Progress Note dated 2/12/16 at 9:13 a.m., the first post-operative day, included oxygen saturation 90% on room air.

The review of the facility policy Care of the Post-Operative Patient, policy #620015.003, last review/revise date 1/2016 revealed the policy indicated when the patient arrives on the nursing unit from surgery, vital signs will be taken every 15 minutes times 4, then every 30 minutes times 2, then every hour and then every 4 hours for the next 48 hours.

An interview was conducted at the time of the record review with the Manager of Quality and Patient Safety on 2/16/16 at approximately 3:15 p.m. She confirmed the finding vital signs were not taken on Patient #10 in accordance with facility policy.

An interview was conducted with the attending physician for Patient #10 on 2/16/16 at approximately 4:00 p.m. He confirmed the finding he had seen the patient daily following the surgery. He stated he had not been notified by the nursing staff of any significant changes in Patient #10's condition.