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Tag No.: C0296
Based on record reviews, staff interviews and review of facility policies and procedures, the Critical Access Hospital (CAH) failed to ensure a Registered Nurse (RN) updated the physician for 1 of 42 (Patient 9) sampled patients with a medical change of condition-respiratory distress. This failure has the potential to effect all patients with a change of condition.
Findings are:
A. A review of Patient 9's medical record revealed, that Patient 9 was admitted 12/12/16 at 1055 with complaints of shortness of breath related to COPD (Chronic Obstructive Pulmonary Disease-A chronic disease that makes it heard to breathe.) exacerbation (worsening) and pneumonia (infection in the lungs).
A review of the vital signs (VS) and nursing assessments of Patient 9's respiratory status during the 12/12/16-12/14/16 hospital stay revealed:
12/12/16 at 11:15 AM-VS 37.4 C (99.3F), Pulse (P) 113, Blood Pressure (BP) 186/94, Respirations (R) 24 and labored, Oximetry (Ox) 98% on 4 liters of oxygen per Nasal Cannula (4l/nc)
12/12/16 at 1640 (4:40 PM)- VS 37.0 (98.6), P 117, BP 156/76, R 32 and labored, Ox 87% on 4l/nc
12/12/16 at 1931 (7:31 PM)- VS BP153/65, P110, R 24, Ox 91% on 4l/nc
12/13/16 at 4:12 AM- VS 36.7 (98.0), BP 157/77, P112, R 24, Ox 88% on 4l/nc
12/13/16 at 7:30 AM- VS 37.0 (98.6), P 117, BP 158/78, R28 and labored, Ox 87% on 4l/nc
12/13/16 at 1617 (4:17 PM)- VS 37.2 (98.9), P112, BP 149/57, R 24 and labored, Ox 88% on 4l/nc
12/13/16 at 1943 (7:43 PM)- VS 37.5 (99.5), P122, BP150/77, R 24 dyspnea (difficult breathing)-grunting-stridor (noisy breathing that occurs due to obstructed air flow through a narrowed airway.) -tripod position (leaning forward, hands on knees to enhance breathing)-use of accessory muscles (use of other muscles to help breathing such as abdominal, rib cage muscles, back muscles).
12/13/16 at 2338 (11:38 PM) -VS P 128, R 28 dypnea, tripod position, use of accessory muscles
12/14/16 at 0100- VS 37.6 (99.6), P120, BP 145/74, R24 dyspnea, tachypnea (rapid breathing)
12/14/16 at 6:08 AM- VS 37.0 (98.6), P 126, BP 183/90, R 36 Dyspnea, gasping, grunting, tachypnea, use of accessory muscles), Ox 68% on 4l/nc [nasal cannula placed in mouth and Ox increased to 82% after 2 minutes]
12/14/16 at 9:30 AM- 37.0 (98.6), P118, BP 155/79, R 34 dypnea, grunting, stridor, tripod position, use of accessory muscles, Ox 83% at 4l/nc.
The medical record reviewed that the RN Z caring for Patient 9 DID NOT NOTIFY THE PHYSICIAN OF THE PATIENT'S DECLINING RESPIRATORY CONDITION THROUGHOUT THE NIGHT.
The patient was transferred to (Hospital B-a hospital of a higher level of care) at 9:30 AM on 12/14/16, accompanied by a Registered Nurse (RN) D and Respiratory Therapist (RT) P in the ambulance.
B. A review of the History and Physical completed by Doctor (Dr R) on 12/12/16 at 12:19 PM revealed:
HISTORY:
-Constitutional- Weakness, fatigue, decreased activity, no fever, no chills
-Respiratory- Short of breath, cough, sputum production, wheezing
PHYSICAL EXAMINATION:
-General- Alert and oriented, mild distress
-Respiratory- Symmetrical chest wall expansion, no chest wall tenderness, rales (abnormal rattling sound in lungs) can be heard in the right lower lobe. Has wheezing throughout all lung fields. Does appear tachypneic.
-Integumentry (skin)- Warm, dry, pink, intact.
Admitting Diagnosis: COPD exacerbations, pneumonia
C. A review of the Discharge Summary completed by Dr R on 12/14/16 at 1736 (5:36 PM) revealed:
PHYSICAL EXAMINATION:
-"Obvious respiratory distress at this point in time. Patient is purplish hue (Discoloration of skin resulting from inadequate oxygenation of the blood or poor circulation) to the SKIN. BiPAP (a machine to help RESPIRATIONS by use of mechanical pressure support of ventilation) in place. CARDIO tachycardic (fast heart rate) no murmurs rubs or gallops. LUNGS grossly decreased breath sounds throughout with HARDLY any air movement. Tachypneic. There is ACCESSORY MUSCLE use. Extremities no clubbing cyanosis, 1+edema bilaterally."
PLAN:
"Transfer to the ICU at (Hospital B-higher level of care hospital) for continued care. Condition guarded. Follow-up is with definitive care at (Hospital B).
D. A review of ABG'S (arterial blood gases) revealed:
12/14/16 12/13/16 Normal Values
Base Excess Art 8.1 High 4.2 [-5.0-5.0]
pH Art 7.31 Low 7.37 Low [7.38-7.43]
pCO2 Art 78 CRITICAL 56 High [31-45] mmHG
pO2 Art 45 Low 46 Low [84-100] mmHG
HCO3 Art 38.6 High 31.5 High [21.0-27.0] mmHg
TCO2 Art 41.0 High 33.3 High [22.0-28.0] mEq/L
O2 Sat Art 82 Low 85 Low [92-98]
Amount of O2 4 L
ABG's measure the bodies ability to compensate for its respiratory status.
pH-Measures the blood level of acid to base in the blood. If pH falls below 7.35 it's acidic and if above 7.45 is alkalotic. Respiratory acidosis occurs when there is to much Carbon Dioxide (CO2) build up in the body and your lungs can't compensate.
pCO2- Measures the Carbon Dioxide build up in the body. .
pO2- Measure the Oxygen level in the arterial blood. A low level of pO2 indicates the lungs inability to pull oxygen into the blood stream.
HCO3- Measures the kidneys attempt to correct the acidosis/alkalosis balance in the blood stream.
TCO2-Measues the total carbon dioxide in the blood stream.
O2 Sat Art- Measures the percent of Hemoglobin binding (the red blood cells in the blood that carries oxygen) sites in the blood that are carrying oxygen.
E. Review of the policy Lippincott Procedures-Assessment revised 8/12/16 related to Physician Notification of change in condition revealed , "Document significant normal and abnormal findings in an objective, organized manner, according to the order of information collected. Record the date, time, and the name of the practitioner you notified of any abnormal results and the interventions prescribed. Document the patient's responses to those interventions, as indicated. Also record any patient teaching provided and the patient's understanding of that teaching."
F. An interview with the Director of Skilled Service, Acute Services and Emergency Services, on 3/15/17 at 4:15 PM, verified that Patient 9's declining condition on 12/13/16 19:43 (7:43PM)-12/14/16 (9:30 AM) should have been reported to the practitioner on call.
G. An interview on 3/16/17 at 9:22 AM with RN D that accompanied Patient 9 in the ambulance to Hospital B on 12/14/16. "I remember the transfer, we were going to use the BiPap, but when I called respiratory they said, "It was a delicate unit and we don't ususally transport with it." "So (RT P) put a non rebreather mask on (gender) and we left. (Gender) oxygen saturations stayed in the low 90's with it on transport."
H. An interview with the Respiratory Therapist (RT P) on 3/16/17 at 9:30 AM revealed, "I remember (Patient 9). I remember it was a quick deal. By the time we could get the ABG's back the transfer team came. We just got (the patient) loaded and took (gender) to (Hospital B) ICU (intensive care unit). I rode with the nurse with (Patient 9) in the ambulance to monitor (the patient). (The patient) tolerated the transfer, we didn't put (gender) on the BiPap because we just loaded the patient and got (gender) there. (The patient) needed to get going, and like I said, I rode along and monitored the respiratory status."
Tag No.: C0302
Based on staff interview, record review and review of the Medical Staff Rules and Regulations, the Critical Access Hospital (CAH) failed to have discharge orders for 6 of 6 (Patient's 26, 27, 28, 29, 30 and 31) surgical patient's medical records. This failed practice had the potential to affect all surgical patients of the CAH. The CAH provided 266 outpatient minor procedures including colonoscopies (a test that allows the doctor to look at the inner lining of the large intestine), cystoscopies (a procedure allowing the doctor to examine the lining of your bladder), and EGD's (esophagogastroduedenoscopy-a procedure allowing the doctor to examine the lining of the esophagus, stomach and duodenum); and 344 outpatient surgeries in the 2016 for a total of 610 outpatient procedures/surgeries.
Findings are:
A. Review of Patient 26's outpatient surgical record admitted on 12/20/16 revealed the patient had a laparoscopic cholecystectomy (removal of the gallbladder). The medical record indicated that Patient 26 was dismissed on 12/20/16 at 5:10 PM. The medical record for Patient 26 lacked a physician order for discharge.
B. Review of Patient 27's outpatient surgical record admitted on 1/6/17 revealed the patient had insertion of bilateral myringotomy and tubes (insertion of tubes in the ears to prevent the accumulations of fluids behind the eardrum). The medical record indicated that Patient 27 was dismissed on 1/6/17 at 8:15 AM. The medical record for Patient 27 lacked a physician order for discharge.
C. Review of Patient 28's outpatient surgical record admitted on 12/7/16 revealed the patient had cystocele repair (repair of a dropped bladder). The medical record indicated that Patient 28 was dismissed on 12/7/16 at 8:05 PM The medical record for Patient 28 lacked a physician order for discharge.
D. Review of Patient 29's outpatient surgical record admitted on 12/15/16 revealed the patient had a left ankle arthroscopy (ankle surgery through a scope). The medical record indicated that Patient 29 was dismissed on 12/15/16 at 1:30 PM. The medical record for Patient 29 lacked a physician order for discharge.
E. Review of Patient 30's outpatient surgical record admitted on 11/29/16 revealed the patient had a laparoscopic cholecystectomy (removal of the gallbladder). The medical record indicated that Patient 30 was dismissed on 11/29/16 at 5 PM. The medical record for Patient 30 lacked a physician order for discharge.
F. Review of Patient 31's outpatient surgical record admitted on 1/5/17 revealed the patient had a partial toe amputation (removal of part of the toe). The medical record indicated that Patient 31 was dismissed on 1/5/17 at 9:55 AM. The medical record for Patient 31 lacked a physician order for discharge.
G. An interview with the Quality Assurance Director and the Medical Records Director on 3/14/17 at 11:15 AM revealed that they had reviewed the surgical records (Patient 26, 27, 28, 29, 30 and 31) and verified that the records lacked a discharge order. They indicated that when the CAH changed electronic medical records vendors the dismissal orders were accidentally left off.
H. Review of the CAH Medical Staff Rules and Regulations dated May 18, 2015 revealed, "Discharge Orders- Patients shall be discharged only on an order of the attending practitioner, or his/her designee. A discharge order must contain the date and type of discharge and any special travel requirements or instructions for the patient."
Tag No.: C0388
Based on record review and staff interview the facility failed to develop and initiate a standardized, comprehensive, and reproducible assessment of each Resident's functional capacity for 5 of 5 Swing Bed record reviews (Patients 32, 33, 34, 35, 36). This has the potential to affect all Swing Bed Residents due to failure to identify a need which, if addressed, would allow the resident to achieve their highest level of functioning. The total Swing Bed sample was 5. The Swing Bed census at the time of entrance on 2/27/17 was 1. Findings are:
A. Electronic Medical Record (EMR) reviews revealed Resident 32 (Swing Bed stay 2/14/17 -3/1/17), Resident 33 (Swing Bed stay 9/21/16 - 10/3/16), Resident 34 (Swing Bed stay 11/21/16 - 2/16/17), Resident 35 (Swing Bed stay 12/15/16 - 12/28/16), and Resident 36 (Swing Bed stay 10/24/16 - 10/27/16) failed to have a standardized reproducible comprehensive assessment of the Resident's functional capacity initiated on admission.
B. Interview with the Registered Nurse (RN) A, the Director of Skilled Services and Social Worker (SW) B on 3/13/17 at 4:00 PM confirmed the facility does not have a standardized reproducible comprehensive assessment currently in use. SW B stated that they have not had one since implementing a new EMR system in November of 2015.
C. Interview with RN A on 3/16/17 at 10:45 AM revealed that the facility has no policy for completion of a Comprehensive Assessment "because we were not doing it."
Tag No.: C0389
Based on record review and staff interview the facility failed to develop and complete a standardized, comprehensive, and reproducible assessment of each Residents functional capacity for 2 of 5 Swing Bed Residents ( #32 and #34) who had been in the facility 14 days or longer. This has the potential to affect all Swing Bed Residents who are in the facility longer than 14 calendar days. Failure to complete the required assessment of the patients functional capacity could lead to failure due to identify a need, which if addressed, would allow the Resident to achieve their highest level of functioning. The total Swing Bed sample was 5. The Swing Bed census at the time of entrance on 2/27/17 was 1. Findings are:
A. Electronic Medical Record (EMR) reviews revealed Resident 32 (Swing Bed stay 2/14/17 -3/1/17) and Resident 34 (Swing Bed stay 11/21/16 - 2/16/17) failed to have a standardized reproducible comprehensive assessment of the Resident's functional capacity initiated on admission and completed by the 14th calendar day.
B. Interview with the Registered Nurse (RN) A, the Director of Skilled Services and Social Worker (SW) B on 3/13/17 at 4:00 PM confirmed the facility does not have a standardized reproducible comprehensive assessment currently in use. SW B stated that they have not had one since implementing a new EMR system in November of 2015.
C. Interview with RN A on 3/16/17 at 10:45 AM revealed that the facility has no policy for completion of a Comprehensive Assessment "because we were not doing it."
Tag No.: C0395
Based on record reviews and staff interviews the facility failed to develop a process/policy to ensure the completion of the Comprehensive Care Plan (CCP) with the Interdisciplinary Team. 1 of 1 Residents( #34) who had been in the facility 21 days or longer failed to have a CCP developed. This has the potential to affect all Residents who have a length of stay 21 days or longer. Failure to develop a CCP with Interdisciplinary Team input could result in failure to identify a Resident need which, if addressed, could allow the Resident to reach their highest functional capacity. The Swing Bed sample size was 5. The Swing Bed Census was 1 at the time of entrance on 2/27/17.
Findings are:
A. Electronic Medical Record (EMR) review on 3/14/17 revealed Resident 34 was admitted to a Swing Bed on 11/21/16. The History and Physical dated 11/22/16 identified the Resident was admitted after an acute hospital stay in which the Resident was diagnosed with a Small Bowel Obstruction. The Resident had surgery for the obstruction and was diagnosed with chronic duodenal ileus, a lack of movement of food/fluids/secretions through the digestive tract. The Resident was also diagnosed with urothelial (urinary system) terminal cancer. The Resident was admitted with Total Parenteral Nutrition (all nutrition through an intravenous line), a tube in the stomach to drain secretions, and a urostomy (an external artificial opening into the urinary system for drainage). The EMR failed to contain a Comprehensive Assessment of the Residents functional status. The only care plan in the record was developed by nursing on 11//22/17 and included chronic pain, alteration in bowel function, and fall risk. During the stay the Resident was evaluated for Hospice Services. The record contained weekly Interdisciplinary Team Notes by Social Work, Nursing, Physical and Occupational Therapy, Pharmacy, Registered Dietician and Chaplain however the Team Notes were never organized into a CCP in the EMR. The Resident Discharged on 2/16/17 (87 day Swing Bed Stay) to home with family and Home Health services.
B. Staff interview with Registered Nurse (RN) A, the Director of Skilled Care on 3/14/17 at 10 AM confirmed a CCP was not developed for Resident 34. Additional interview with RN A on 3/16/17 at 10:45 AM confirmed the facility does not have a policy or procedure developed to ensure each Swing Bed Resident in the facility 21 days or longer has a CCP developed.
C. Staff Interview with Social Worker B on 3/14/17 at 10:10 AM revealed the Interdisciplinary Team meeting notes are not incorporated into a Comprehensive Care Plan.
Tag No.: C0396
Based on record reviews and staff interviews the facility failed to develop a Comprehensive Care Plan (CCP) with the Interdisciplinary Team for 1 of 1 Residents( #34) who had been in the facility 21 days or longer. This has the potential to affect all Residents who have a length of stay 21 days or longer. Failure to develop a CCP with Interdisciplinary Team input could result in failure to identify a Resident need which, if addressed, could allow the Resident to reach their highest functional capacity. The Swing Bed sample size was 5. The Swing Bed Census was 1 at the time of entrance on 2/27/17. Findings are:
A. Electronic Medical Record (EMR) review on 3/14/17 revealed Resident 34 was admitted to a Swing Bed on 11/21/16. The History and Physical dated 11/22/16 identified the Resident was admitted after an acute hospital stay in which the Resident was diagnosed with a Small Bowel Obstruction. The Resident had surgery for the obstruction and was diagnosed with chronic duodenal ileus, a lack of movement of food/fluids/secretions through the digestive tract. The Resident was also diagnosed with urothelial (urinary system) terminal cancer. The Resident was admitted with Total Parenteral Nutrition (all nutrition through an intravenous line), a tube in the stomach to drain secretions, and a urostomy (an external artificial opening into the urinary system for drainage). The EMR failed to contain a Comprehensive Assessment of the Residents functional status. The only care plan in the record was developed by nursing on 11//22/17 and included chronic pain, alteration in bowel function, and fall risk. During the stay the Resident was evaluated for Hospice Services. The record contained Interdisciplinary Team Notes by Social Work, Nursing, Physical and Occupational Therapy, Pharmacy, Registered Dietician and Chaplain however the Team Notes were never organized into a CCP in the EMR. The Resident Discharged on 2/16/17 (87 day Swing Bed Stay) to home with family and Home Health services.
B. Staff interview with Registered Nurse (RN) A, the Director of Skilled Care on 3/14/17 at 10 AM confirmed a CCP was not developed for Resident 34.
C. Staff Interview with Social Worker B on 3/14/17 at 10:10 AM revealed the Interdisciplinary Team meeting notes are not incorporated into a Comprehensive Care Plan.