HospitalInspections.org

Based on record review and interview the facility failed to use a hospital wide approach to the quality assessment and improvement of its performance as follow: the removal of the remote telemetry pack and failure of tech to report the offline monitor, the lack of follow through with application of telemetry pack by the registered nurse, and failure to assess and closely monitor the patient for further needs secondary to self extubation in 1 of 8 sample patients (SP#1).


Findings include:
Record review of sample patient #1 revealed an admission date of 3/17/13 and a chief complaint of shortness of breath. Sample patient #1 was diagnosed with a malignant mass of the esophagus and hypopharyngeal with metatstasis to the lung. The patient underwent a percutaneous gastrostomy on 3/18/13 and a tracheostomy on 3/19/13. The patient was awake and alert .On 04/9/2013 at 21:30PM the PCT disconnected the telemetry pack without an order while preparing for transfer from the Telemetry Unit to the Medical- Surgical Unit. The telemetry technician did not notify the telemetry charge nurse that the telemetry pack was off line. The telemetry technician then overrode the alarms to turn off the monitor. The receiving registered nurse applied the telemetry pack but did not activate the pack or call the monitoring room to confirm the placement.
Documentation revealed that sample patient #1 on 04/10/2013 at 01:00am the patient self-extubated himself with a hand mitten in place on his right hand. Further review revealed that on 4/10/13 sample patient #1 was found with the tracheostomy pulled out at 1:16 a.m., the respiratory therapist reinserted the tracheostomy. The nurse progress note revealed a late entry into the record on 4/10/13 at 6:14 a.m. which stated that at 1:16am the mitten to right hand was in place. The cannula was then replaced and the mitten remained on the right hand. At 04:16am on 04/10/2013 the patient was found self extubated again and a Code blue was called. The Patient (SP#1) expired. On 4/10/13 at 4:17 a.m. the respiratory therapist documented "treatment was not given, patient expired."

The physician also documented on the Discharge Note dated (DD) 04/10/2013 "This is a patient with a tracheostomy from 3/20/13, on a T-piece, was in his room and self extubated. Nurses went to the scene and this patient with a tracheostomy site was self extubated. Cardiac arrest was called. ER (Emergency Room) doctor assisted with the attempted resuscitation. The patient through exhaustive CPR (cardio pulmonary resuscitation) despite all medical regimens, despite all aggressive resuscitative measures, despite the assistance of all consultants, the patient expired."

Interview on 5/2/13 at 8:30 a.m. with the registered nurse who was caring for sample patient #1 from 9:30 p.m. on 4/9/13 until his expiration on 4/10/13 stated that sample patient was transferred to her with a mitten in place to his right hand and that he was unable to use his left hand because it was contracted. The registered nurse then stated she was not given a reason for the right mitten placement. The registered nurse stated she found sample patient #1 extubated at 1:16 a.m. and tried to reinsert the cannula but had no success so she contacted the respiratory therapist to reinsert the cannula. The registered nurse stated that the right mitten was in place when she found the cannula out. The registered nurse stated that at 4:17 a.m. sample patient #1 was found self extubated again and a code blue was called but the patient expired. The registered nurse stated that she did not call the physician after the first extubation or make any adjustments to the patient's care.

Interview with the Risk Manager on 05/01/2013 at 09:15am confirmed that sample patient (#1) was offline (not monitored) from 9:30pm until expiration 4:16am

Interview with the Risk Manager on 5/1/13 at 2:20 p.m. confirmed that the registered nurse failed to further assess and make necessary care plan changes to sample patient #1.

Review of the policy titled: Telemetry Monitoring revealed in section ( C) notification of Telemetry rhythm abnormalities/ monitoring issues: staff monitoring telemetry- identifies a tracing that require assessment then notifies the responsible staff by utilizing the unit paging system.

At of time of the exit conference on 5/1/13 at 6:30 p.m. the facility failed to provide evidence of a hospital wide assessment and performance improvement plan after the incident of sample patients (SP#1) regarding: the removal of the remote telemetry pack without a doctor's order; and failure of tech to report the offline monitor; the lack of follow through with application of telemetry pack by the registered nurse; and failure to assess and closely monitor the patient for further needs.

Based on interview and record review the facility was determined to be out of compliance with 42 CFR 482.23 Conditions of Participation for Nursing Services.

The facility's failure to: provide revised nursing care plans and assessments as the needs of sample patient #1 changed, and to develop written standards of nursing practice and policies and procedures related to the use of unsecured hand mittens to define and describe the scope and conduct of patient care to be provided by the nursing staff for 1 of 8 sample patients(#1).
(Refer to A-396)

The facility failed ensure that the registered nurse supervised and evaluate the nursing care for 1 of 8 sample patients(#1). (Refer to A-395)

The facility's failure to: administer medications as ordered by the physician in 1 of 8 sample patients(#1).(Refer to A-0405)


And related A-309.

Based on interview and record review the facility failed ensure that the registered nurse supervised and evaluate the nursing care for 1 of 8 sample patients(#1).

Findings include:

Record review of sample patient #1 revealed an admission date of 3/17/13 and a chief complaint of shortness of breath. Sample patient #1 was diagnosed with a malignant mass of the esophagus and hypopharyngeal with metatstasis to the lung. The patient underwent a percutaneous gastrostomy on 3/18/13 and a tracheostomy on 3/19/13. The patient was awake and alert .On 04/9/2013 at 21:30PM the PCT disconnected the telemetry pack without an order while preparing for transfer from the Telemetry Unit to the Medical- Surgical Unit. The telemetry technician did not notify the telemetry charge nurse that the telemetry pack was off line. The telemetry technician then overrode the alarms to turn off the monitor. The receiving registered nurse applied the telemetry pack but did not activate the pack or call the monitoring room to confirm the placement.
Documentation revealed that sample patient #1 had a right hand mitten on at 12 a.m. on 4/10/13. On 04/10/2013 at 01:00am the patient self-extubated himself with a hand mitten in place on his right hand. Further review revealed that on 4/10/13 sample patient #1 was found with the tracheostomy pulled out at 1:16 a.m. and the respiratory therapist reinserted the tracheostomy. The nurse progress note had a late entry into the record on 4/10/13 at 6:14 a.m. which revealed that the mitten to right hand was in place at 1:16 a.m. . The cannula was then replaced and the mitten remained on the right hand. At 04:16am on 04/10/2013 the patient was found self extubated again and a Code blue was called. The Patient (SP#1) expired. On 4/10/13 at 4:17 a.m. the respiratory therapist documented "treatment was not given, patient expired."

Interview on 5/2/13 at 8:30 a.m. with the registered nurse who was caring for sample patient #1 from 9:30 p.m. on 4/9/13 until his expiration on 4/10/13 stated that sample patient was transferred to her with a mitten in place to his right hand and that he was unable to use his left hand because it was contracted. The registered nurse then stated she was not given a reason for the right mitten placement. The registered nurse stated she found sample patient #1 extubated at 1:16 a.m. and tried to reinsert the cannula but had no success so she contacted the respiratory therapist to reinsert the cannula. The registered nurse stated that the right mitten was in place when she found the cannula out. The registered nurse stated that at 4:17 a.m. sample patient #1 was found self extubated again and a code blue was called but the patient expired. The registered nurse stated that she did not call the physician after the first extubation or make any adjustments to the patient's care.

Interview with the Risk Manager on 05/01/2013 at 09:15am confirmed that sample patient(#1) was offline (not monitored) from 9:30pm until expiration 4:16am.
Interview with the Risk Manager on 5/1/13 at 2:20 p.m. also confirmed that the registered nurse failed to further assess and make necessary care plan changes to sample patient #1.

Based on interview and record review the facility failed: to ensure the process of assessment, planning, intervention and evaluation was completed and documented; to provide revised nursing care plans and assessments as the needs of sample patient #1 changed, and to develop written standards of nursing practice policies and procedures related to the use of unsecured hand mittens by the nursing staff for 1 of 8 sample patients (SP #1).


Findings Include:
Record review of sample patient #1 revealed an admission date of 3/17/13 and a chief complaint of shortness of breath. Sample patient #1 was diagnosed with a malignant mass of the esophagus and hypopharyngeal with metatstasis to the lung. The patient underwent a percutaneous gastrostomy on 3/18/13 and a tracheostomy on 3/19/13. The patient was awake and alert .On 04/9/2013 at 21:30PM the PCT disconnected the telemetry pack without an order while preparing for transfer from the Telemetry Unit to the Medical- Surgical Unit. The telemetry technician did not notify the telemetry charge nurse that the telemetry pack was off line. The telemetry technician then overrode the alarms to turn off the monitor. The receiving registered nurse applied the telemetry pack but did not activate the pack or call the monitoring room to confirm the placement.
Documentation revealed that sample patient #1 had a right hand mitten on at 12 a.m. on 4/10/13. On 04/10/2013 at 01:00am the patient self-extubated himself with a hand mitten in place on his right hand. Further review revealed that on 4/10/13 sample patient #1 was found with the tracheostomy pulled out at 1:16 a.m. and the respiratory therapist reinserted the tracheostomy. The nurse progress note dated 4/10/13 had a late entry into the record on 4/10/13 at 6:14 a.m. which revealed that the mitten to right hand was in place at 1:16am . The cannula was then replaced and the mitten remained on the right hand. At 04:16am on 04/10/2013 the patient was found self extubated again and a Code blue was called. The Patient (SP#1) expired. On 4/10/13 at 4:17 a.m. the respiratory therapist documented "treatment was not given, patient expired."

The physician also documented on the Discharge Note dated (DD) 04/10/2013 "This is a patient with a tracheostomy from 3/20/13, on a T-piece, was in his room and self extubated. Nurses went to the scene and this patient with a tracheostomy site was self extubated. Cardiac arrest was called. ER (Emergency Room) doctor assisted with the attempted resuscitation. The patient through exhaustive CPR (cardio pulmonary resuscitation) despite all medical regimens, despite all aggressive resuscitative measures, despite the assistance of all consultants, the patient expired."


Interview on 5/2/13 at 8:30 a.m. with the registered nurse who was caring for sample patient #1 from 9:30 p.m. on 4/9/13 until his expiration on 4/10/13 stated that sample patient was transferred to her with a mitten in place to his right hand and that he was unable to use his left hand because it was contracted. The registered nurse then stated she was not given a reason for the right mitten placement. The registered nurse stated she found sample patient #1 extubated at 1:16 a.m. and tried to reinsert the cannula but had no success so she contacted the respiratory therapist to reinsert the cannula. The registered nurse stated that the right mitten was in place when she found the cannula out. The registered nurse stated that at 4:17 a.m. sample patient #1 was found self extubated again and a code blue was called but the patient expired. The registered nurse stated that she did not call the physician after the first extubation or make any adjustments to the patient's care.

Interview with the Risk Manager on 5/1/13 at 2:20 p.m. confirmed that the registered nurse failed to further assess and make necessary care plan changes to sample patient #1. The Risk Manager also confirmed that there was no policy on unsecured mittens.

Review of the facility's policy titled: Assessment of Patients revealed (#7) the reassessment process takes place throughout the patient's hospitalization/ visits. Each discipline determines the need and frequency for re-assessment based upon but not limit to: changes in the patient condition.

There were no documented assessments or changes made to sample patient#1 plan of care (care plan) found between the first extubation and the second extubation.

Based on record review and interview the facility failed to administer the medications (Ativan and Vancomycin) as ordered by the physician in 1 of 8 sampled patients (#1).

The findings include:

Record review of sample patient #1 revealed a patient admitted on 3/17/13 for shortness of breath. Sample patient #1 was diagnosed with a malignant mass of the esophagus and hypopharyngeal with metatstasis to the lung. The patient underwent a percutaneous gastrostomy on 3/18/13 and a tracheostomy on 3/19/13. On 3/19/13 at 10:55 p.m. the psychiatrist completed his evaluation for anxiety and ordered Ativan 0.5 milligrams by mouth twice daily. Further review revealed the medication was not placed in the electronic order system and therefore sample patient #1 did not receive the medication from 3/19/13 through his discharge on 4/10/13.

Record review of sample patient #1 revealed that on 4/19/13 at 2:29 p.m. the physician ordered the sample patient to receive Vancomycin 1000 milligrams intravenously(IV) every 12 hours with the next dose for 4/10/13 at 3:00 a.m. Review of the record for sample patient #1 revealed that he did not receive the Vancomycin at 3:00 a.m. as ordered. Furthermore sample patient #1 did not receive the Vancomycin prior to his expiration at 4:16 am.

Interview on 5/1/13 at 10:44am with the Risk Manager and the Peer Review Coordinator confirmed that the Ativan and Vancomycin were not given. Furthermore the Peer Review Coordinator stated the Ativan was never entered in to the electronic ordering system.

Interview on 5/1/13 with the Associate Director of the Emergency Department (ED) and Intensive Care Unit(ICU) revealed that sample patient #1 was taken to the operating room on 3/20/13 and then to the Intensive Care Unit post-operative(after surgery). The Associate Director of the ED and ICU reviewed sample patient #1's record and stated that the order for the Ativan was written at 10:55 p.m. and was never "profiled" in the computer system; therefore the pharmacy never received the order. On 3/20/13 sample patient #1 went to the operating room for a scheduled procedure and then to the Intensive Care Unit for care.

The Director of the ED and ICU stated that when a patient is transferred to the ICU from another unit all medications are discontinued and must be re-ordered by the physician. The Director of the ED and ICU also confirmed that the Ativan was never re-ordered. Furthermore, the pharmacist would not know to question the medication and it ' s re-ordering because the original order was never sent to the pharmacy.