HospitalInspections.org

Based on the survey findings, it was determined the Condition of Participation for Nursing Services, 42 CFR 482.23, was not met. The facility failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care for one (1) of ten (10) sampled patients (Patient #2), and failed to ensure a physician's order was obtained prior to the insertion of a nasogastric (NG) tube for Patient #2. In addition, the facility failed to ensure staff assessed and took appropriate action when Patient #2 experienced a change in condition following the insertion of the NG tube and the administration of an oral contrast solution through the NG tube. Based on medical record review, facility staff was preparing Patient #2 for discharge from the facility on 04/19/13 and at 10:00 AM, the patient began to complain of abdominal pain and distension. Facility staff notified Patient #2's primary physician of the patient's complaints and orders were obtained for Morphine (a potent opiate narcotic used to treat moderate to severe pain) on an "as needed" basis for pain and for a Computed Tomography (CT) scan of the patient's abdomen and pelvis. According to the documentation and interviews, Patient #2 received the ordered pain medication, became very lethargic/sleepy, and was not awake/alert enough to drink the oral contrast required for the CT scan. The medical record and interviews confirmed on 04/19/13, at 8:30 PM facility staff inserted an NG tube in order to administer the oral contrast; however, a review of documentation revealed facility staff failed to obtain a physician's order for the NG tube.

A review of the medical record and interview revealed RN #2 inserted the NG tube, and RN #1 administered the oral contrast solution through the NG tube. Interview with RN #1 revealed she had administered almost one-half of the first bottle of contrast solution (which contained 450 milliliters of contrast and approximately 300 milliliters of water) and Patient #2's lung sounds changed from slight wheezing to "wet" and audible "rattling" was noted. However, the interview revealed RN #1 failed to complete an assessment of Patient #2's condition and the patient's physician was not notified of the change in the patient's condition. According to interviews and medical record, RN #1 continued to administer the oral contrast solution and had completely administered the entire bottle at 9:28 PM when Patient #2 "began to turn blue," had trouble breathing, became unresponsive, and failed to have a heart rate or respirations. RN #1 stated a "code" (generally used to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention) was initiated at 9:30 PM. Interviews revealed a white substance was expelled from the patient's mouth when chest compressions were initiated during the "code." The medical record revealed Patient #2 was placed on a ventilator at 9:45 PM following the "code" and expired on 04/25/13, when the ventilator was discontinued. Review of Patient #2's chest x-rays from 04/19/13, revealed at 1:16 PM the patient's right lung was clear and the left lung had small effusion (fluid around lung); and at 11:11 PM the patient's right lung had basilar (lower segment) pneumonia and the left lung had upper lobe pneumonia.

Based on the findings, Immediate Jeopardy was identified on 05/09/13. The facility was out of compliance with the Conditions of Participation at 42 CFR 482.23 Nursing Services (A0385) and the associated Standard at Nursing Services, Registered Nurse Supervision (A0395).

Refer to 42 CFR 482.23, A0395.

Based on interview, medical record review, and review of facility policies, it was determined the facility failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care for one (1) of ten (10) sampled patients (Patient #2). The facility failed to ensure a physician's order was obtained prior to the insertion of a nasogastric tube for Patient #2. In addition, the facility failed to ensure staff assessed residents and took appropriate action when a patient experienced a change in condition. On 04/19/13, at 10:00 AM, facility staff was preparing to discharge Patient #2 from the facility when the patient began to experience abdominal pain and distension. Patient #2's primary physician (Physician #1) was notified of the patient's condition and at 5:10 PM an order was obtained for staff to administer Morphine (a narcotic used to treat moderate to severe pain) on an as needed basis for complaints of pain and also requested a Computed Tomography (CT) scan of the patient's abdomen and pelvis. According to interview with RN #1, Patient #2 received the Morphine as ordered, became very lethargic/sleepy, and was not awake/alert enough to drink the oral contrast required for the CT scan. The medical record and interviews revealed on 04/19/13, at 8:30 PM, a nasogastric (NG) tube was inserted and the oral contrast was administered via the NG tube. However, based on interview and a review of the medical record, staff failed to obtain a physician's order for the NG tube. Interview with RN #1 revealed she had administered approximately one-half of the oral contrast that was required for the CT scan through the NG tube and Patient #2's lung sounds changed from slight wheezing to "wet" and staff could hear "rattling" in the patient's lungs. The interview revealed facility staff failed to thoroughly assess the patient following the change in condition after the administration of one-half of the oral contrast through the NG tube, and failed to notify the physician of the patient's change in condition. According to interview and record review, after the nurse had completely administered the bottle of oral contrast at 9:28 PM, Patient #2's skin color turned "blue," the patient experienced difficulty breathing and became unresponsive with no respirations or heart rate noted. RN #1 stated a "code" (generally used to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention) was announced and initiated at 9:30 PM. Interviews revealed a white substance was expelled from the patient's mouth with the initial chest compressions during the "code." Continued review of the medical record revealed Patient #2 was placed on a ventilator following the "code" and expired on 04/25/13, after he/she was removed from the ventilator. A review of Patient #2's chest x-rays from 04/19/13 revealed at 1:16 PM the patient's right lung was clear and the left lung had small effusion (fluid around lung); and at 11:11 PM the patient's right lung had basilar (lower segment) pneumonia and the left lung had upper lobe pneumonia.

The findings include:

Review of the facility's policy entitled "NG Tube Insertion" dated 02/20/07, revealed a physician's order was required for the insertion of an NG tube and an RN should perform the procedure. The policy revealed the RN should confirm placement of the NG tube by auscultation (to utilize a stethoscope to listen for a sound made by air blown through the tube) and aspiration of stomach contents.

Review of the facility's policy entitled "Patient Assessment/Reassessment: Nursing, Nutrition, Social Services, Behavioral Health" revised 05/21/12, revealed an RN was responsible to complete the initial shift assessment of a patient and reassessments should occur "as needed" by the RN to determine the patient's response to care. The policy revealed the patient's diagnosis and treatment setting, along with the patient's response to treatment, would determine the scope and intensity of the reassessment. According to the policy, reassessments would be of sufficient scope to identify potential or actual changes in the patient's condition. Further review revealed nurses were responsible to reassess a patient as major clinical changes, either positive or negative, occurred; and when a patient completed treatment or developed a negative outcome from a treatment.

Review of Patient #2's medical record revealed the facility admitted the patient on 04/16/13, with diagnoses of Urinary Tract Infection (UTI) and Dehydration. The medical record revealed the patient was treated with intravenous (IV) fluids and IV antibiotics and on 04/19/13 Physician #1 gave orders to discharge the patient home. However, prior to discharge on 04/19/13, Patient #2 experienced a change of condition and was noted to have abdominal pain and distension. Physician #1 was notified and new orders were obtained.

Further review of the medical record revealed on 04/19/13, at 5:10 PM, physician's orders were obtained for staff to administer 2 milligrams (mg) of Morphine intravenously (IV) every four hours as needed for pain; 400 mg of Cipro (an antibiotic) IV every twelve hours; and 500 mg of Flagyl (antibiotic used to treat infections in the stomach) IV every twelve hours. In addition, Physician #1 requested a CT scan with contrast be obtained of the patient's abdomen and pelvis.

Review of nurse's notes in Patient #2's medical record revealed on 04/19/13, at 8:30 PM facility staff inserted an NG tube and verified placement of the tube by auscultation.

Interviews on 05/08/13, at 12:00 PM with RN #1 revealed on the evening of 04/19/13, following the administration of the Morphine, Patient #2 was not alert enough to physically drink the oral contrast required for the CT scan. RN #1 stated she was unable to contact Physician #2, who was responsible for the patient's care on the weekend, to obtain an order for the NG tube, and she continued with the procedure. The interview revealed RN #2 inserted the NG tube while RN #1 held the patient's hands to prevent the patient from pulling out the NG tube. RN #1 stated she checked placement of the NG tube by auscultation to determine proper placement; however, according to RN #1, she did not hear air and the NG tube was advanced further. RN #1 stated at that time she verified placement of the NG tube by auscultation; however, RN #1 stated she did not check placement of the NG tube by aspirating the patient's stomach contents.

Interview on 05/09/13, at 11:10 AM with RN #2 confirmed she inserted Patient #2's NG tube on 04/19/13. RN #2 stated she observed RN #1 verify placement of the NG tube by auscultation and stated she did not observe RN #1 aspirate the patient's stomach contents. RN #2 further stated she had not obtained a physician's order for the insertion of Patient #2's NG tube.

Interview on 05/08/13, at 5:10 PM with Physician #2, responsible for the care of Patient #2 on the weekend, revealed he did not give an order for the insertion of an NG tube for Patient #2 in order for staff to administer the oral contrast solution required for the CT scan. Physician #2 stated, "I probably would not have ordered it (NG tube) just because [Patient #2] was sedated."

Review of Patient #2's nurse's note dated 04/19/13, at 9:00 PM revealed the oral contrast for the CT scan was administered through the patient's NG tube "per family request." The note further stated "pt (patient) is not tolerating it very well sounds wet placement checked again good air sounds was going to stop and give pt a break family asked me to continue because she was afraid [Patient #2] would pull ng (nasogastric) tube out if we did not continue giving contrast." On 04/19/13, at 9:28 PM the nurse's note revealed Patient #2 "began to turn blue," was having difficulty breathing, and became unresponsive. At that time, based on documentation, facility staff announced a "code" for Patient #2.

Interviews with Patient Care Assistant (PCA) #1 on 05/08/13 at 10:05 AM, and with RN #1 on 05/08/13 at 12:00 PM and on 05/09/13, at 12:55 PM revealed on 04/19/13, after RN #2 inserted the NG tube, RN #1 administered the oral contrast solution to Patient #2 through the NG tube. RN #1 stated she thinned the 450 milliliters (ml) of oral contrast with approximately 300 ml of water (total of 750 ml) to make administration through the NG tube easier. RN #1 reported Patient #2 audibly started to "rattle" halfway through the administration of the oral contrast solution. The RN stated the patient's lungs sounded "wet" and she wanted to "wait" to complete the administration of the oral contrast; however, the patient's family insisted the contrast be given. RN #1 stated she proceeded after she verified the NG tube placement again and administered the remaining contents of the oral contrast. RN #1 stated after completion of the first bottle of contrast, Patient #2 "coughed up contrast;" the RN and PCA changed the patient's gown, and the patient stopped breathing and had no pulse. PCA #1 confirmed RN #1's statement but described the audible lung sounds as the patient began to "gurgle."

Review of Patient #2's "CODE 1 RECORD" dated 04/19/13, revealed the "code" began at 9:30 PM; Emergency Room (ER) Physician #1 intubated the patient at 9:35 PM; and the "code" ended at 9:45 PM.

Interviews on 05/07/13 at 9:50 AM with Respiratory Therapist (RT) #1, on 05/09/13 at 7:05 AM with RN #4, and on 05/09/13 at 7:25 AM with RN #5 revealed they had responded to the "code" announced for Patient #2 on 04/19/13. According to RT #1, RN #4, and RN#5, the patient was unresponsive and a white substance was expelled from Patient #2's mouth and onto the bed during chest compressions.

Interviews on 05/08/13 at 10:15 AM with RT #2 and at 4:00 PM with ER Physician #1 revealed they responded to the "code" called for Patient #2 on 04/19/13. The interviews revealed upon their arrival to the bedside of Patient #2, they observed a white substance in the patient's mouth. ER Physician #1 stated he had to suction the white substance from the patient's mouth to visualize the trachea prior to intubation. The interview revealed the same white substance came out of the endotracheal tube (a tube placed into the windpipe/trachea to maintain an airway) following intubation.

Interviews on 05/09/13 at 6:55 AM with RN #3 and at 11:25 AM with RN #6 revealed they were present during Patient #2's "code" on 04/19/13, and remained with the patient until he/she was transported and admitted to the Critical Care Unit (CCU). RN #6 reported upon admission to the CCU Patient #2's NG tube was removed because she was unable to verify placement of the NG tube with auscultation. The interviews revealed RN #3 inserted an Oral Gastric (OG) tube prior to obtaining the second chest x-ray on 04/19/13 at 11:00 PM.

Review of Patient #2's chest x-ray reports revealed on 04/19/13 at 1:16 PM, before the administration of the contrast solution, there was small effusion in the left lung and the right lung was clear. The chest x-ray report for Patient #2 on 04/19/13 at 11:11 PM (2 hours after the administration of the contrast solution) revealed there was right basilar pneumonia and chronic change versus left upper lobe pneumonia. A review of the report of a chest x-ray obtained on 04/20/13 revealed, "Right basilar consolidation (thick viscous fluid) and left upper lobe consolidation stable."

Interview conducted on 05/08/13, at 4:35 PM, with Radiologist #1 while reviewing Patient #2's chest x-rays electronically from 04/19/13, revealed the first chest x-ray obtained at 1:16 PM was read at 2:56 PM which showed nothing. Then the patient's second chest x-ray obtained at 11:11 PM on 04/19/13, showed an NG tube in the stomach and pneumonia bilaterally. Radiologist #1 stated the consolidation on Patient #2's chest x-rays could be oral contrast. The interview revealed the change in Patient #2's chest x-rays was likely caused by aspiration of a substance.

Review of Patient #2's Intake and Output sheet revealed the patient had no oral intake after 2:00 PM on 04/19/13, prior to the NG tube insertion, until in the CCU on 04/20/13 at 1:56 AM and received fluids via the OG tube.

Review of Pulmonologist #1's consultation dated 04/22/13, revealed Patient #2 was admitted for a UTI and three days later seemed stable and was preparing for discharge. However, according to the consultation report, the patient began having abdominal symptoms requiring x-rays. The consultation revealed the chest x-ray on 04/19/13 at approximately 3:00 PM indicated Patient #2's chest was "clear." However, the chest x-ray for Patient #2 on 04/19/13, at 11:00 PM showed right lower lobe and left upper lobe infiltrate (appearance of any abnormal substance that has accumulated in the lungs).

Review of Cardiologist #1's consultation dated 04/20/13, revealed Patient #2 developed abdominal pain on 04/19/13, the day the patient was to be discharged. The review revealed an NG tube was inserted to administer oral contrast; however, the NG tube's placement was not verified by x-ray, but the nurse that administered the oral contrast clinically felt the NG tube to be correctly placed in the patient's stomach. The consultation revealed the contrast was administered and according to the patient's family, the patient immediately sounded like the patient was drowning and developed acute cardiorespiratory arrest. The consultation stated, "Endotracheal tube was placed and they suctioned a large volume of whitish material, presumably the barium contrast." The consultation also revealed, "I do not think this is an infectious issue," and "I think it is a chemical pneumonitis."

Interview on 05/08/13, at 4:20 PM with Cardiologist #1 revealed Patient #2 was transferred to his care in the Critical Care Unit (CCU) following the "code." The Cardiologist stated he obtained a history of the events from the nurses that assisted with the "code" and the patient's family member that was also in attendance. According to Cardiologist #1, the report from the nurses and family member was that there were copious amounts of contrast in the endotracheal tube. The Cardiologist stated the chest x-ray obtained after Patient #2 was being transported to the CCU "clearly showed extensive bilateral pneumonia which wasn't there prior" to the NG tube being placed.

Interviews on 05/08/13, at 12:25 PM with the Director of 3 North (unit where Patient #2 had initially been admitted) and at 2:05 PM with the Director of Risk Management revealed the facility was still in the review process of the incident on 04/19/13 that involved Patient #2. The Director of 3 North revealed RN #1 had been interviewed about the incident. The Director of Risk Management revealed the facility had 45 days to complete the analysis of alleged adverse events.

Interview on 05/09/13, at 1:30 PM with the Chief Nursing Officer (CNO) revealed he was aware of the alleged adverse event involving Patient #2 and a "root cause analysis" meeting had been scheduled. The CNO stated Pulmonologist #1 revealed Patient #2's x-ray on 04/19/13, at 11:11 PM revealed the NG tube was in the stomach. However, the CNO was unaware the tube visualized in the x-ray on 04/19/13 at 11:11 PM was the OG tube that had been inserted in the CCU following the incident. The interview also revealed the facility had not previously been aware RN #1 had not obtained a physician's order for the NG tube. The CNO stated after the "root cause analysis" was completed the facility would educate/re-educate staff and revise any needed policies.

Interview on 05/09/13, at 3:10 PM with the Medical Director revealed it was common practice to auscultate for air and aspirate stomach contents to verify NG tube placement prior to utilization of the tube. The interview revealed that during administration of oral contrast via an NG tube, if the patient experienced a change in condition such as "wet" lung sounds, the nurse should assess the patient, verify NG tube placement if questionable, and notify the patient's physician of the change in condition.

Based on interview, medical record review, and review of facility policies, it was determined the facility failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care for one (1) of ten (10) sampled patients (Patient #2). The facility failed to ensure a physician's order was obtained prior to the insertion of a nasogastric tube for Patient #2. In addition, the facility failed to ensure staff assessed residents and took appropriate action when a patient experienced a change in condition. On 04/19/13, at 10:00 AM, facility staff was preparing to discharge Patient #2 from the facility when the patient began to experience abdominal pain and distension. Patient #2's primary physician (Physician #1) was notified of the patient's condition and at 5:10 PM an order was obtained for staff to administer Morphine (a narcotic used to treat moderate to severe pain) on an as needed basis for complaints of pain and also requested a Computed Tomography (CT) scan of the patient's abdomen and pelvis. According to interview with RN #1, Patient #2 received the Morphine as ordered, became very lethargic/sleepy, and was not awake/alert enough to drink the oral contrast required for the CT scan. The medical record and interviews revealed on 04/19/13, at 8:30 PM, a nasogastric (NG) tube was inserted and the oral contrast was administered via the NG tube. However, based on interview and a review of the medical record, staff failed to obtain a physician's order for the NG tube. Interview with RN #1 revealed she had administered approximately one-half of the oral contrast that was required for the CT scan through the NG tube and Patient #2's lung sounds changed from slight wheezing to "wet" and staff could hear "rattling" in the patient's lungs. The interview revealed facility staff failed to thoroughly assess the patient following the change in condition after the administration of one-half of the oral contrast through the NG tube, and failed to notify the physician of the patient's change in condition. According to interview and record review, after the nurse had completely administered the bottle of oral contrast at 9:28 PM, Patient #2's skin color turned "blue," the patient experienced difficulty breathing and became unresponsive with no respirations or heart rate noted. RN #1 stated a "code" (generally used to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention) was announced and initiated at 9:30 PM. Interviews revealed a white substance was expelled from the patient's mouth with the initial chest compressions during the "code." Continued review of the medical record revealed Patient #2 was placed on a ventilator following the "code" and expired on 04/25/13, after he/she was removed from the ventilator. A review of Patient #2's chest x-rays from 04/19/13 revealed at 1:16 PM the patient's right lung was clear and the left lung had small effusion (fluid around lung); and at 11:11 PM the patient's right lung had basilar (lower segment) pneumonia and the left lung had upper lobe pneumonia.

The findings include:

Review of the facility's policy entitled "NG Tube Insertion" dated 02/20/07, revealed a physician's order was required for the insertion of an NG tube and an RN should perform the procedure. The policy revealed the RN should confirm placement of the NG tube by auscultation (to utilize a stethoscope to listen for a sound made by air blown through the tube) and aspiration of stomach contents.

Review of the facility's policy entitled "Patient Assessment/Reassessment: Nursing, Nutrition, Social Services, Behavioral Health" revised 05/21/12, revealed an RN was responsible to complete the initial shift assessment of a patient and reassessments should occur "as needed" by the RN to determine the patient's response to care. The policy revealed the patient's diagnosis and treatment setting, along with the patient's response to treatment, would determine the scope and intensity of the reassessment. According to the policy, reassessments would be of sufficient scope to identify potential or actual changes in the patient's condition. Further review revealed nurses were responsible to reassess a patient as major clinical changes, either positive or negative, occurred; and when a patient completed treatment or developed a negative outcome from a treatment.

Review of Patient #2's medical record revealed the facility admitted the patient on 04/16/13, with diagnoses of Urinary Tract Infection (UTI) and Dehydration. The medical record revealed the patient was treated with intravenous (IV) fluids and IV antibiotics and on 04/19/13 Physician #1 gave orders to discharge the patient home. However, prior to discharge on 04/19/13, Patient #2 experienced a change of condition and was noted to have abdominal pain and distension. Physician #1 was notified and new orders were obtained.

Further review of the medical record revealed on 04/19/13, at 5:10 PM, physician's orders were obtained for staff to administer 2 milligrams (mg) of Morphine intravenously (IV) every four hours as needed for pain; 400 mg of Cipro (an antibiotic) IV every twelve hours; and 500 mg of Flagyl (antibiotic used to treat infections in the stomach) IV every twelve hours. In addition, Physician #1 requested a CT scan with contrast be obtained of the patient's abdomen and pelvis.

Review of nurse's notes in Patient #2's medical record revealed on 04/19/13, at 8:30 PM facility staff inserted an NG tube and verified placement of the tube by auscultation.

Interviews on 05/08/13, at 12:00 PM with RN #1 revealed on the evening of 04/19/13, following the administration of the Morphine, Patient #2 was not alert enough to physically drink the oral contrast required for the CT scan. RN #1 stated she was unable to contact Physician #2, who was responsible for the patient's care on the weekend, to obtain an order for the NG tube, and she continued with the procedure. The interview revealed RN #2 inserted the NG tube while RN #1 held the patient's hands to prevent the patient from pulling out the NG tube. RN #1 stated she checked placement of the NG tube by auscultation to determine proper placement; however, according to RN #1, she did not hear air and the NG tube was advanced further. RN #1 stated at that time she verified placement of the NG tube by auscultation; however, RN #1 stated she did not check placement of the NG tube by aspirating the patient's stomach contents.

Interview on 05/09/13, at 11:10 AM with RN #2 confirmed she inserted Patient #2's NG tube on 04/19/13. RN #2 stated she observed RN #1 verify placement of the NG tube by auscultation and stated she did not observe RN #1 aspirate the patient's stomach contents. RN #2 further stated she had not obtained a physician's order for the insertion of Patient #2's NG tube.

Interview on 05/08/13, at 5:10 PM with Physician #2, responsible for the care of Patient #2 on the weekend, revealed he did not give an order for the insertion of an NG tube for Patient #2 in order for staff to administer the oral contrast solution required for the CT scan. Physician #2 stated, "I probably would not have ordered it (NG tube) just because [Patient #2] was sedated."

Review of Patient #2's nurse's note dated 04/19/13, at 9:00 PM revealed the oral contrast for the CT scan was administered through the patient's NG tube "per family request." The note further stated "pt (patient) is not tolerating it very well sounds wet placement checked again good air sounds was going to stop and give pt a break family asked me to continue because she was afraid [Patient #2] would pull ng (nasogastric) tube out if we did not continue giving contrast." On 04/19/13, at 9:28 PM the nurse's note revealed Patient #2 "began to turn blue," was having difficulty breathing, and became unresponsive. At that time, based on documentation, facility staff announced a "code" for Patient #2.

Interviews with Patient Care Assistant (PCA) #1 on 05/08/13 at 10:05 AM, and with RN #1 on 05/08/13 at 12:00 PM and on 05/09/13, at 12:55 PM revealed on 04/19/13, after RN #2 inserted the NG tube, RN #1 admi