HospitalInspections.org

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Based on record review and interview, the facility staff failed to demonstrate that quality data collected was analyzed and trended to accomplish performance improvement.

Failure to do so created risk that changes implemented to address performance improvement would not be adequate to assure quality patient care.

Findings included:

Item #1 - Medication Errors

1. On 06/26/19 at 10:30 AM, the investigator interviewed the Director of Pharmacy (Staff #8) about departmental quality assurance and performance improvement processes. He identified that the pharmacy staff organized data about medication errors obtained from unusual incident reports submitted by staff members. He acknowledged that the data was not analyzed to identify a specific goal(s) for clinical improvement and that strategies to address those goals were not implemented. Quality problems were handled on a case-by-case basis, including when there were commonalities in the types of problems (i.e. anticoagulation, intravenous fluids).

2. Record review of quality information related to medication errors showed that the data was organized around 9 data points but there were not established benchmark goals for focus on clinical improvement.

Item #2 - Patient Falls

1.On 06/26/19 at 2:15 PM, the investigator interviewed the Director of Acute Care and Intensive Care Services (Staff 2) about quality assurance and performance improvement processes related to patient falls: a facility identified priority to "decrease". She stated that the facility staff identified an increasing number of inpatient falls occurred since the year 2016 and the trend continued to progress. She acknowledged that the data was not analyzed to identify a specific goal(s) for clinical improvement and that strategies to address those goals were not implemented. Additionally, she stated the facility addressed patient fall problems on a case-by-case basis and she could not identify risk patterns.

2. Record review of quality data about inpatient falls showed that the total number of inpatient falls increased from 2016 to 2018; almost doubled. Additionally, the number of falls in the first quarter of 2019 showed that the total number of falls were projected to increase again from 2018 to 2019, if the first quarter trend was annualized through end of 2019.
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Based on record review and interview, the facility failed to demonstrate that there was adequate organization about staff functions associated with roles in emergency responses, including documentation of medication administration and other responses.

Failure to do so creates risk that emergency care will not be documented/administered adequately for accurate and timely continuity of patient care which may result in patient harm.

Findings included:

1. a. Record review of facility policy titled "Code Blue," reviewed 09/19/18), showed guidelines to responses and support to a patient in respiratory or cardiac arrest. It did not include information about direct care staff duties. It did state that all RN team members will be able to accurately record the information "required" during resuscitation but it did not define what was "required".

b. Record review of facility policy titled, "Code Blue: Clinical Work Instructions," reviewed 01/24/19, listed the titles of the roles of seven Code Blue team Members but it did not provide staff with information about what duties were associated with those roles.

c. Based on written communication on 06/06/19 at 1:05 PM from the Director of Quality and Risk Management (Staff #3) to the investigator, she stated that there was not a facility policy that addressed staff responsibilities related to administration of emergency medications, including documentation.

2. Review of the medical record of Patient #1 showed the following:

a. On 05/15/19 at 8:35 PM, a Code Blue was called to resuscitate Patient #1 who had suddenly become unresponsive and who then she proceeded to not have a pulse. The Cardiac Arrest Sheet showed that that the ED MD and staff arrived at 8:37 PM. Between 8:40 PM and 9:06 PM, the patient was administered 9 doses of epinephrine 1 milligram and 1 dose of naloxone 0.4 milligram (emergency drugs). However, the routes of administration were not recorded.

b. At 8:39 PM, an entry on the Cardiac Arrest Sheet noted indicated the patient had an intra-osseous needle placed into the right shin for administration of intravenous products.

c. The record did not indicate that the patient received manual chest compressions.

d. The record did not indicate that the patient received manual ventilations but noted at 8:54 PM that an airway (type not noted) was placed in the patient. Information about the airway management from a provider note showed that it took a few attempts to intubate the patient due to problems with emesis. The Cardiac Arrest Sheet record did not show that she vomited/required suctioning to maintain a clear airway.

3. a. On 05/29/19 at 2:45 PM, the investigator interviewed the assigned charge nurse (Staff #4) at the time that a Code Blue was called on Patient #1. She was stated that she responsible for making sure staff efforts were coordinated. She stated that the patient received timely and effective chest compressions by the floor staff and that respiratory therapy staff was responsible to manage the patient's respirations. She thought staff performed those activities effectively; even though they were not recorded as occurring on the Cardiac Arrest Sheet.

b. On 05/29/19 at 2:30 PM, the investigator interviewed the nurse (Staff # 5) who cared for Patient #1 at the time that the Code Blue was called. She recalled that at least 10 staff members responded to the Code Blue even though the Cardiac Arrest record did not indicate that. She also recalled that the patient had received intravenous medications through 2 intraosseous lines (even though only 1 line was recorded as placed). She stated that during the prior Rapid Response event, attempts to obtain peripheral IV access had not been successful.

c. On 05/31/19 at 10:35 AM, the investigator interviewed another nurse (Staff #6). She stated that the patient was became suddenly unresponsive when she was present. Upon Code Blue initiation (most Code Team members already present per prior Rapid Response activation), she stated that she attempted to make her Cardiac Arrest Sheet documentation of care complete.

d. On 05/29/19 at 12:00, the investigator interviewed the Nursing Director on the Acute Care and Intensive Care Unit (Staff #2) about the Code Blue event. When asked if she had reviewed the Cardiac Arrest Sheet completed by staff members caring for Patient #1, she stated that she had not. She stated that she had not identified of any omissions in staff processes for emergency care.
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Based on record review and interview, the facility staff failed to demonstrate that the plan of care was implemented and revised to address ongoing care needs for pain management (1) for 1 of 1 patients, application of devices to prevent blood clots (2) for 2 of 2 patients and planning for potential needs for intravenous access based on patient status (3).

Failure to do so created risk that patient's plan of care would not be individualized per changes in health status and may result in patient harm.

Findings included:

Item #1 - Pain Management

1. a. Record review of facility policy titled, "Plan of Care Policy," revised 09/21/17, stated that the hospital provides continuity of care through individualized plans that are regularly reviewed and updated. It stated that they were reviewed and updated at least every shift as nursing problems and patient issues were identified.

b. Record review of facility policy titled, "Pain Management Policy," approved 12/13/17, stated it was the hospital policy to accurately assess each patient's pain level and to treat it appropriately to ensure optimal comfort. It also included the following:

-assessments would include the patient's comfort goal.

-pain scale included a 0-10 numeric pain distress scale, including completion 1 hour after an intervention was completed (i.e. medication administration).

-unexpected intense pain with altered vital signs will be immediately evaluated and a new diagnosis would be considered, including but not limited to deep vein thrombosis. It stated to notify the physician of changes in patient condition.

2. On 05/30/19 at 1:45 PM, the investigator observed patient rooms on the Acute Care Unit. In the rooms there was a large white board posted on the walls with a "Pain Intensity Rating Scale" on it. The scale included the following rating on it: 6-severe, dreadful; 8 horrible, very severe; 10 worst possible, agonizing.

3. Record review of the medical record of Patient #1 showed the following:

a. On 05/05/19 the patient was evaluated in the Emergency Department for severe back pain (10/10 in triage), leg numbness and weakness. She was admitted to the hospital and required a walker to ambulate upon hospital admission. Urine screening in the Emergency Department indicated that she had not been taking opioid pain medications to manage pain. On 05/09/19, the patient had a multi-level spine surgery. The patient identified her goal for pain management was a level of 4 of 10.

b. Postoperatively, a physician ordered an oral pain medication prescribed every 3 hours for "severe pain" which she began receiving on 05/10/19 at 11:37 AM (after receiving 5 doses of intravenous pain medication for severe pain). She received it regularly every 3 hours until 05/15/19 at 8:56 PM. There were a total of 58 pain ratings recorded by nursing staff during that time period.

c. Of the 58 pain ratings, 32 (55%) of them were 7 -10 of 10, indicating more than severe (dreadful) to worst possible (agonizing) pain level at the time it was recorded.

d. A sample of post-medication administration readings between 05/10/19 and 05/15/19 indicated that of 17 recorded pain ratings after the administration of pain medication, 10 ratings (59%) showed the patient had the same or more pain after the administration of pain medications, usually within 1 to 1.5 hours.

e. Review of nursing record entries during that time period did not indicate that the nursing staff addressed a concern about pain management to the physicians. However, on 05/14/19 there was one new order added for a muscle relaxer to the patient's pain medication regime.

f. Review of the patient's nursing plan of care showed that staff were to complete pain assessments. However, the patient's plan was not individualized to address the patient's ongoing severe pain level.

3. On 06/26/19 at 3:30 PM, the investigator observed the Director of Quality (Staff #3) ask the the Director of Acute Care and Intensive Care (Staff #2) about nursing care plans.Staff #2 stated that it was an expectation that nurses modified nursing care plans to individualize them to patient's needs and problems.

4. On 05/30/19 at 2:15 PM, the investigator interviewed a certified physicians assistant (Staff #7). He stated that it was not his routine to read the nursing documentation and he was not aware of any "alerts" on her care. He recalled that she was withdrawn and she reported she could not move due to pain. It was his impression that she was refusing treatment. The patient's pain rating just prior to his bedside visit was 9 of 10; very severe pain. He did not think he initiated a discussion with team members about adjusting the plan for how to manage the patient's pain subsequent to the patient's hospital visit.

Item #2 - Prevention of Patient Blood Clots

1. a. Record review of the medical record of Patient #1 indicated that the patient had a physician order post-operatively for "continuous" sequential compression device (SCD) stockings on 05/09/19 at 12:32 PM. The order did not designate removal for out of bed activity (which is required per equipment set-up).

b. The record showed that they were applied on 05/09/19 at 5:43 PM. There were 2 entries on 05/11/19 (at 9:00 AM and 1:30 PM) that the stocking were applied and 2 entries on 05/11/19 (at 1:15 AM and 5:00 AM) that they were "refused". There were no other entries related to SCD application from 05/09/19 to 05/15/19.

c. 1. From the date of surgery on 05/09/19 to 05/15/19, the patient was in and out of bed on multiple occasions to use the bathroom or participate in physical therapy, among other activities. The record did not include information about use of the SCDs ordered to prevent the occurrence of blood clots except for the above entries.

c. 2. The same medical record entry pattern was observed for Patient #2 who had an order for application of SCDs after surgery on 04/30/19 for the application of SCDs after surgery. There was 1 entry on 05/01/19, 05/02/19 and 05/03/19 (respectively) that SCDs were "off for activity" but no entries about re-application per physician order.

d. The use of SCDs was not included in the plan of care for Patient #1 and #2.

2. This finding of ommissions was verified and acknowledged by the Director of Quality (Staff Member #3) on 06/26/19 at 11:00 AM.

Item #3 - Access for Treatment via Intravenous Adminisitration

1. Review of facility policy titled, "Intravenous (IV) Therapy Administration," revised 05/11, stated under the section about intravenous therapy maintenance that the IV site condition be recorded, at least 2 times per shift. The policy did not identify whether or not there was a need to maintain IV access during a patient's hospitalization.

2. Record review of the medical record showed the following:

a. Patient #1 was admitted to the hospital subsequent to an Emergency Department visit on 05/05/19 for increased low back pain after physical activity. Her functional status required use of a walker due to pain, weakness and numbness symptoms. On 05/06/19 she received an evaluation by a spine surgeon who identified the need for surgical treatment.

b. On 05/09/19, the day of surgery, the orthopedic surgery team assumed care as the primary team from the hospitalist team. At 1:53 PM post-operative orders indicated that the patient was to have intravenous (IV) fluids discontinued in the morning if the patient could manage oral intake but to leave a saline lock (an IV access line flushed with normal saline twice a day for future use).

c. On 05/15/19 at 9:00 AM, a RN (Staff #1) recorded that the patient's intravenous access line was discontinued. The record stated "patient refused". There was no documentation of the IV site condition, including indicating suspected tissue injury or infection. There was no indication that a hospital provider was notified of the situation or that plans were adjusted accordingly. The patient had reported to a provider one hour earlier that she was in extreme pain, could not move and was teary about her condition.

d. Later that day at 8:35 PM, Patient #1 had a cardiopulmonary arrest and a Code Blue emergency response was called. The patient did not have IV access for immediate medication administration. IV lines were placed by staff during the emergency response but determined not to be adequate for intravenous use. To obtain immediate access for emergency drug administration, staff obtained supplies from the Emergency Department to place 2 lines into each of the patient's shin bones (considered an adequate method; comparable to IV). The patient did not resuscitate from continued Code Blue efforts and the patient was declared deceased at 9:08 PM.

3. On 05/30/19 at 3:40 PM, the investigator interviewed the Nursing Director of Acute Care and the Intensive Care Unit (Staff #2). She acknowledged that the RN (Staff #1) discontinued the patient's IV line. The RN indicated to Staff #2 that the IV line "bothered" the patient (not recorded in the medical record). The Nursing Director acknowledged that there was not an order for the RN to remove the IV line. She also said that the RN should have contacted the provider about the IV status to obtain orders accordingly, including discussion about possible need for IV replacement per the patient's surgical recovery status.
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