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Based on facility policy and procedure review, medical record review, and staff interview, nursing staff failed to identify and report and change in patient condition, resulting in an unsafe transfer for 1 of 2 patients reviewed (Patient #4).

Findings include:

Review on 04/03/18 of a facility policy entitled "Patient Assessment and Reassessment," last reviewed 07/2017, revealed that patients should be reassessed when there is a "significant" change in condition. Review revealed that information for reassessment should be gathered from patients, families, other health care professionals, and physician input.

Further review revealed a policy entitled "Chain of Command," last reviewed 09/2012. Review revealed, "Duty of Care owed by Nurse/Physician...In general, a physician or professional nurse has the duty to exercise the degree of care and skill ordinarily employed, under the same or similar circumstances, by members of her/his profession in good standings...and to use reasonable care and diligence, along with the exercise of professional judgment in providing care to our patients." Further review revealed, "The chain of command procedure is initiated at any time an issue exists that has the potential for adverse effect on a patient..." Further review revealed the protocol for nursing staff to escalate concerns when a care issue exists that may adversely affect the patient: first contact the physician for clarification, then contact the nursing director or nursing supervisor; if resolution is not reached, the issue may be escalated to the Chief Nursing Officer or the Administrator on call, followed by the Chief of Service or the Chief of Staff.

Review on 04/03/2018 of a closed medical record for Patient #4 revealed a 72 year old female with an extensive medical history who was admitted on 09/01/2017 after a fall that resulted in a left femur fracture. The patient had surgery to repair the fracture on 09/03/2017 and developed complications on 09/05/2017 including respiratory distress and hypotension. A chest x-ray showed a small bowel obstruction [SBO], which was treated with a nasogastric (NG) tube to suction. Review of nursing documentation revealed that the output from the nasogastric tube was described as brown or green on 09/05/2017-09/07/2017. Review revealed on 09/08/2017 at 0000 the NG output was documented by RN #1 as red and brown. Review revealed no documentation that the physician was notified of the change in character of the output. Review of nursing documentation by RN #2 revealed on 09/08/2017 at 1135, the output was "Red; Brown; Coffee Ground [a description that is indicative of blood in the gastrointestinal system]." The output was described as "Red; Brown; Coffee Ground" again at 1336 with the notation, "NGT with very thick return. Requires constant flush to thin fluids..." Review revealed on 09/08/2017 the patient was accepted for transfer to a long term acute care hospital. Review revealed at 1500 RN #2 questioned Case Manager (CM) #1 whether the transfer was appropriate due to "copious amount of return from NGT;" CM #1 explained that the accepting facility is qualified for this type of patient care. Review revealed at 1600 RN #2 documented, "Discuss with MD [MD #1] that pt doesn't seem ready for transfer secondary to SBO." Review revealed at 1710 RN #2 documented, "Discussed amount of fluid from NGT and blood tinged suctioning of pt. MD [MD #2] states pt not a surgical candidate" Review failed to reveal documentation that RN #1 or RN #2 notified a physician of the change in character of the patient's NG tube output. Review revealed MD #1 signed the transfer authorization at 1600; RN #2 signed as a witness at 1615. Review revealed MD #2, the surgeon who was managing the small bowel obstruction and the NG tube, saw the patient around 1700. The patient was transferred via advanced life support transport to the outside facility at 1747. Review revealed an autopsy report which stated the patient's time of death was 1911 on 09/08/2017. Review revealed the following diagnoses were included on the autopsy report: "Gastric ulcers, stomach, numerous, up to .5cm, hemorrhagic bases with focal adherent thrombus; Acute gastritis; Gastrointestinal hemorrhage, stomach through small intestine."

Request for interview on 04/04/2018 revealed that RN #1 no longer worked at the facility and was not available for interview.

Interview on 04/05/2018 at 1055 with RN #2 revealed the nurse recalled patient #4. Interview revealed the nurse recalled that she had spoken to "every physician on the case" regarding concerns about transferring Patient #4, including MD #1 and MD #2. Interview revealed that RN #2 was concerned that Patient #4 was "a very sick lady...stable, yes. She was just very sick." Interview revealed the nurse specifically recalled the conversation with MD #2. Interview revealed, "I asked had he seen the output, he said yes. We discussed the amount ...that was pretty much the discussion." Interview revealed the documentation referring to "blood tinged suctioning" referred to suctioning in the patient's mouth, not the NG tube output. Interview confirmed there was no documentation of specific discussion of the coffee ground character of the output; interview revealed, "It's not there...if it's not in those notes, that's it." Interview revealed after speaking with MD #2, RN #2 felt like her concerns were heard. "I felt better after I spoke with [MD #2]. I felt comfortable that he was not concerned."

Interview on 04/05/2018 at 1030 with MD #2 revealed he was the surgeon who was managing Patient #4's small bowel obstruction. Interview revealed MD #2 saw the patient in the morning and in the afternoon on the day of her transfer and felt she was ready for transfer to a long term acute care facility. Interview revealed, "We had no indication, no nurses notified me of blood in the NG tube." Interview confirmed that discussion of "blood tinged suctioning" referred to suctioning of mucous from the patient's mouth, but MD #2 had "absolutely no concerns about blood from the belly." Interview revealed MD #2 saw "nothing remarkable" about the NG tube output or volume. Interview revealed, "I was not informed, I never suspected." Interview revealed if MD #2 had known about the coffee ground character of the NG tube output, "of course I would have stopped the transfer."

Interview on 04/04/2018 at 1300 with MD #1 revealed the physician was a hospitalist who recalled caring for Patient #4. Interview revealed that although RN #1 stated she had brought her concerns to MD #1, "I don't have a specific recollection of her speaking to me." Interview revealed, "I was never notified of coffee ground output from the NG tube...if we suspected acute GI (gastrointestinal bleed) we never would have put her in an ambulance." Interview revealed, "I did not see any red [NG tube output]...I did not know about that prior to my review of the chart [after Patient #4 was transferred]." Interview revealed that because her other medical issues had stabilized, "all doctors involved agreed she was stable for transfer." Interview revealed, "In retrospect, I wish we had kept her."