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Based on medical record review, document review and interview, in one (1) of 10 medical records reviewed, it was determined the nursing staff failed to document a change in a patient's condition after the patient vomited a coffee ground substance. This was evident for Patient #1.

Findings include:

Review of the Medical Record for Patient #1 identified the following: the patient was admitted to the facility on 10/1/18 with a perforated sigmoid (bowel) colon and underwent a bowel resection and placement of a Hartman's colostomy on 10/2/18. The patient's previous medical history included a Myocardial Infarction (heart attack) with the placement of three (3) stents, End Stage Renal Disease for which he was receiving hemodialysis three (3) times per week, Chronic Obstructive Pulmonary Disease, Hypertension and Diabetes Mellitus.

On 10/6/18 at 6:05 AM, a nurse documented that the patient was given juice because his blood sugar was 72.
At 11:22 AM a surgeon documented that the patient had bilious emesis that morning.
At 2:10 PM a gastroenterologist documented that the patient had coffee ground emesis.
At 5:56 PM a resident documented that the vomiting started after the patient drank apple juice and again in the afternoon, and that it was dark in color.

There was no documented evidence that a member of the nursing staff documented the change in the patient's condition and reassessed the patient.

The policy titled "Assessment/Reassessment Parameters" which was last reviewed 2/18 states: each patient is reassessed as necessary based on his or her plan of care or changes in his or her condition.

These findings were shared with Staff A, the Director of Nursing, on 1/9/19 at 3:40 PM.

Based on medical record review, document review and interview, in one (1) of 10 medical records reviewed, it was determined the nursing staff failed to provide discharge teaching and instructions to a patient and family members regarding the care of a colostomy. This was evident for Patient #1.

Findings include:

Review of Medical Record # 1 identified the following: this 68 year old patient underwent a resection of the bowel and a Hartman's colostomy on 10/2/18. The patient was alert and oriented to person, place, time and situation throughout his hospitalization and was independent with his activities of daily living. The patient was discharged from the facility to a rehabilitation facility on 10/11/18. There was no documented evidence that the staff educated and instructed the patient and his family members regarding the care of the colostomy.

During an interview conducted on 1/9/19 at 3:45 PM, Staff A, the Director of Nursing stated the patient was given written instructions for the care of his colostomy. There was no documentation to support this and there was no evidence that the patient and his family were given the opportunity to demonstrate their understanding of the care of the colostomy.

The policy titled "Patient/Family Education" which was last revised 12/18 states: "the goal of patient education is to improve health outcomes by promoting recovery, speeding return to function, promoting healthy behavior and appropriately involving the patient in his/her care and care decisions. The patient and, if appropriate, the family/significant other/caregiver, will receive education that is sensitive to the needs and learning ability of each individual. With any education provided, the nurse will ask the patient or family member to explain or teach back, in their own words, what they need to know or do regarding a learned task."

This finding was shared with Staff A, the Director of Nursing on 1/9/19 at 3:45 PM.

Based on medical record review, document review, and interview, in one (1) of 10 medical records reviewed, it was determined the facility failed to (a) transport and perform a stat blood test in a timely manner, (b) conduct a cardiology consultation and (c) reassess a patient who presented with an emergency medical condition. This was evident for Patient #1.

Findings include:

Review of Medical Record for Patient #1 identified the following:
Patient #1 presented to the emergency department (ED) on 10/24/18 at 11:18 AM via an ambulance, with a complaint of shortness of breath and leg swelling which was new for him. The patient's previous medical history included a Myocardial Infarction (heart attack), Coronary Artery Disease with the placement of three (3) stents, COPD, End Stage Renal Disease for which he was receiving hemodialysis three (3) times per week, Hypertension and Diabetes Mellitus. The patient was triaged at 11:42 AM with a complaint of shortness of breath. Vital signs were Temperature 97.2 F (normal range 97 F - 98.6 F), Heart Rate 79 (normal range 60 - 100), Respiration 18 (normal range 12-20), Blood Pressure 196/81 (normal 120/80) and the Oxygen Saturation 96% (normal 94% -100 %) on room air. The pain score was 0 (no pain).

The ED physician, Staff B, examined the patient at 11:20 AM and documented that the patient was alert and oriented, that he was moving all of his extremities which had 1+ edema and that he looked chronically ill. The ED physician ordered multiple diagnostic tests which included stat Troponin I Quantitative, which was entered into the medical record and collected at 11:24 AM. The specimen was received in the lab at 12:18 PM, almost one (1) hour after the specimen was drawn and a critical value result was reported to a nurse and a doctor at 1:20 PM.
The ED physician documented the following: Diagnostics reviewed. Troponin elevated at 0.07 (normal range 0.00 - 0.03), D-Dimer elevated at 2301 (normal range 0-230). BNP is elevated >5000 (>600 suggest moderate heart failure).
At 2:00 PM, a nurse documented that an admission assessment was going to be initiated when the patient complained of difficulty breathing. Oxygen desaturated to 70% and continued to drop. ED MD called and attempted intubation and that the daughter stated patient is DNR/DNI. The patient was pronounced dead at 2:14 PM by the ED MD.


An ECG performed at 12:04 PM revealed abnormal results. During an interview conducted on 1/8/19 at 11:30 AM, Staff B stated that he was concerned about the patient's elevated Troponin, BNP and D-Dimer and that when he discussed the patient's condition with the cardiologist, the cardiologist stated that he would come to see the patient.

There was no documentation in the medical record that a cardiologist conducted a consultation.

The facility's bylaw states, "if in the opinion of the ED physician, the "on call physician or LIP's presence is necessary to evaluate or treat a patient in the ED, the "on call" physician or LIP must be present in the ED within 60 minutes from the time of the telephone call."


Staff B, the ED physician wrote an order at 11:24 AM for the patient's vital signs to be checked every 2 hours.
There was no documented evidence in the medical record that the vital signs were reassessed throughout the patient's stay in the ED.

The policy titled "Vital Signs Monitoring for ED Patients" which was last revised 7/18 states: the "vital signs should be taken more frequently when the patient is clinically unstable and at the discretion of the practitioner."