HospitalInspections.org

Based on policy review, medical record review, incident log review, physician and staff interviews, the facility staff failed to supervise and assess a patient with a change in condition for 1 of 8 sampled patients (Patient #5).

Findings included:

Review of policy titled,"Change in Physical Status" issued May 2014 and reviewed January 2018, revealed "...All physical complaints or observations that could indicate medical/surgical conditions shall be regarded as symptoms of a physical condition/change in physical status until ruled out by a physician. The Registered Nurse (RN) Change in Physical Status Note shall be used by RNs to document acute changes in an individual's physical condition...The Chief Nursing Officer shall ensure that all nursing staff is trained to monitor individuals' physical/medical status, identify changes in status and report these changes to the appropriate persons..."

Review of the RN Change in Physical Status Note revealed (purpose is to) "document assessment of an individual's physical status change in the SBAR format. Use this form to document any physical status changes including those evaluated/treated within the hospital as well as those associated with transfer to an Emergency Department or other hospital for medical/surgical care."
Further review of RN Change in Physical Status Note revealed sections to document (SBAR format) Situation (Individual's physical complaint and/or observations), Background (Individual's report and record review of symptoms), Allergies, Assessment Data (temperature, respiration rate, blood pressure, pain rating, oxygen saturation, lung sounds, abdominal exam, neurological checks and focused physical assessment and findings revealed through inspection/observation/listening and touch, and Recommendation/Request.

Review of Patient #5's closed medical record revealed a 56-year old male admitted on 11/15/2018 with a diagnosis of Psychosis and Suicide Ideation (thoughts of killing self). Patient #5's (Pt #5) medical history revealed Bipolar Disorder, recent lithium toxicity, Morbid Obesity and generalized pain. Review of a Comprehensive Nursing Assessment signed by Registered Nurse #1 (RN#1) on 11/15/2018 at 0900 revealed Pt #5's pulse 101, respiration rate 18, oxygen saturation 97%. Review of Pt #5's vital sign sheet dated 11/19/2018 at 0600 revealed pulse 102 (high), respirations 16 and oxygen saturation 83% (low). Further review of Pt #5's vital sign sheet revealed on 11/19/2018 at 1053 (4 hours and 53 minutes after prior vital signs recorded), pulse 110 (high), respirations 20 and oxygen saturation 97%. Review of 11/19/2018 8am-4pm nurse progress note revealed "Pt on O2 at 2 liters per minute. No respiratory distress at this time. V/S (vital signs) BP 113/72, pulse 110, respirations 20, O2 sat 97%, temperature 97.4. Denies SI & HI (suicide ideation & homicide ideation). Pt is safe on the unit." Review of nursing notes revealed no documentation that the nurse assessed the patient's lung sounds or evaluated the patient for the decrease in his oxygen saturation. There was no time recorded when the oxygen was applied or the response until 1053 (four hours and 53 minutes after the low oxygen saturation level was obtained. Review of 11/19/2018 4pm-12am Nursing Flow Sheet/Progress Record for Pt #5 revealed progress note was blank and signed by RN #3. Review of 11/20/2018 12am-8am Nursing Flow Sheet/Progress Record for Pt #5 revealed Pt slept at short intervals with O2 concentrator at 2 liters per minute; (Pt #5) agitated and disorganized, (named) antipsychotic and (named) pain medication given.

Review of November 2018 Incident Report log did not reveal an entry of incident for Pt #5.

Interview with Medical Doctor #2 (MD #2) on 01/17/2019 at 1335 revealed Pt #5 was known to MD #2 from a previous admission to the facility during October 2018. MD #2 examined the on 11/15/2018. MD #2 reported the patient was walking, talking and recognized MD #2 during the visit. MD #2 reported being consulted again on 11/20/2018 and examined Pt #5 in his room. MD #2 reported upon arrival Pt #5 was lying naked in the bed, visibly in pain, and on supplemental oxygen. MD #2 denied Pt #5 had been on supplemental oxygen previously. MD #2 reported the patient looked psychotic and repeated "I'm dying" throughout the examination. MD #2 reported Pt #5 had decreased breath sounds in his left lung. MD #2 reported Pt #5 was sent to the emergency department via EMS (emergency ambulance transport) for hypoxia (decreased oxygen reaching the body tissue) and severe back pain on 11/20/2018 at 1020. Pt #5 was admitted to the hospital 11/20/2018.

Telephone interview on 01/17/2019 at 1545 with RN #3 revealed she was the assigned nurse for Pt #5 on 11/17/2018 and 11/18/2018. RN #3 reported Pt #5 was on one-to-one observation each shift due to confusion and disorientation. RN #3 reported Pt #5 was given tramadol for lower back pain. RN #3 reported on 11/18/2018 Pt #5 stated he fell, but stated he could not remember when and why he had not reported it to a nurse. RN #3 reported on 11/19/2018, she was notified by MHT #7 that Pt #5's oxygen saturation was in the 80s (low). RN #3 reported notifying the physician and receiving an order for supplemental oxygen at 2 liters per minute via nasal cannula. RN #3 reported applying the oxygen and re-checking Pt #5's oxygen saturation level again thirty minutes later. RN #3 reported she mentioned to the on-coming nurse that Pt #5 needed a medical consult, but did not personally request the consult.
RN #3 stated she was not aware of the Change in Physical Status policy and did not use the Change of Status form.

Interview with the interim Director of Nursing (DON) on 01/17/2019 at 1425 revealed there were no respiratory problems documented on the 11/15/2018 admission assessment for Pt #5. The DON revealed on 11/19/2018 at 0600 Pt #5's recorded vital signs were pulse 102, blood pressure 100/59, respiration rate 16 and oxygen saturation 83%. The DON stated that such significant change in condition would warrant either a medical consult or possibly a request to send Pt #5 to the emergency room for evaluation. The DON stated she would expect that the House Supervisor would have been notified and she would expect to see documentation of oxygen saturation and lung sounds on a RN Change of Status Form. The DON stated the policy was to use a RN Change of Status Form when there is a change in a patient's condition to guide the nurse on obtaining assessment data and systematically communicating information to the doctor. The DON reported there was not a RN Change of Status Form in Pt #5's medical record. The DON stated best practice would have been for the nurse to complete a physical assessment, document in the progress notes, complete the RN Change of Status form and notify the doctor. Interview revealed the nurse failed to follow hospital policy and failed to document a physical assessment of the patient when there was a change in condition.

NC00145774 and NC00146173