HospitalInspections.org

I. Based on policy review, medical record review and staff interview, the Critical Access Hospital (CAH) staff failed to communicate significant changes in arterial blood pressure to the physician and transport vehicle staff for 1 of 17 closed medical records (Patient #1). The CAH had an average daily census on the medical/surgical nursing unit of approximately 8 patients a day and approximately 24 patients a year receiving ICF level of care services a year.

Failure to communicate changes in condition to the physician and the transport vehicle staff could potentially interrupt continuity of care and cause delays in treatment for life threatening conditions.

Failure to reassess declining blood pressure could potentially lead to insufficient perfusion and oxygenation of tissues and decreased cardiac output.

Findings included:
1. Review of Critical Access Hospital (CAH) policy titled "Assessment and Reassessment of Patients" (Revision date 2/20/09) revealed: ..."The scope and intensity of any further assessments are determined by the patient's diagnosis and patient's response to previous treatment...."
..." Any significant change in the patient's condition necessitates an immediate reassessment with changes in the plan of care reflecting the change in condition..."

2. On 2/22/10, the Vice President (VP) of Patient Services presented the survey team with copies of nursing practices contained in a Clinical Nursing Skills and Technique manual. The VP of Patient Services reported that while they did not have an " actual policy " she expected the med/surg staff members to refer to these documents for guidance in nursing practices. She continued stating, " I am working on a draft policy."

3. Review of the Clinical Nursing Skills and Technique documents revealed the following, in part:

a. "...Transferring clients:.....Evaluation: During, final assessments compare data with previous findings. Rationale: Determines if client's condition is changing..."
...Unexpected outcomes: Client's physical status deteriorates during preparation. Related interventions: Call physician immediately..."

b. "...Assessing arterial [BP]:...
..."Evaluation: Compare BP reading with client's previous baseline and usual BP for client's age. Rationale: Allows nurse to assess for change in condition...
Recording and Reporting: Report abnormal findings to nurse in charge or physician...
Unexpected outcomes: A difference of more than 20 mm Hg systolic or diastolic between BP measurements on upper extremities. Related interventions: Report abnormal findings to nurse in charge or physician..."

4. Review of Patient #1's Emergency Department's medical record revealed:

a. An Emergency Nursing record dated 12/17/09 documented the patient arrived to the [ER] at Midnight complaining of shortness of breath and worsening cough throughout day. The patient was subsequently admitted and treated in the [ER].

b. An Emergency Department Note dated 12/17/09 documented the following past medical history, in part: Severe Aortic stenosis, Secondary hypertension and Congestive Heart failure.

c. A vitals flow-sheet documented Patient #1's BP as follows:
i. 12/17/09 at Midnight: BP 163/102.
ii. 12/18/09 at 12:51 AM: BP 169/83.
iii. 12/18/09 at 1:11 AM: BP 170/77.
iv. 12/18/09 at 1:30 AM: BP 169/82.
v. 12/18/09 at 1:51 AM: BP 187/73.
vi. 12/18/09 at 2:25 AM: BP 167/74.

d. On 12/18/09 at 2:25 AM, Patient #1 transferred from the Emergency Department to Medical/Surgical nursing unit for ICF level of care.

5). Review of Patient #1's ICF/Acute medical record revealed:

a. A Patient Progress note documented Patient #1's BP as follows:
i. 12/18/09 at 2:30 AM: BP 155/74.
ii. 12/18/09 at 7:45 AM: BP 101/51.
iii. 2/18/09 at 9:25 AM: BP 80/50.

b. The medical record lacked physician notification of significant declines in blood pressure and communication of blood pressure findings to transport vehicle staff.

6. On 12/18/09 at 9:30 AM, Patient #1 transferred to the University of Iowa Hospital and Clinics (UIHC) via ambulance. The patient became unresponsive during the transfer and was pronounced expired upon arrival to UIHC.

7. During an interview on 2/16/10, at 12:50 PM Physician A, (Family Practice Medical Physician) reported Patient #1 had been a patient of his for approximately 10 years. Physician A stated, "I saw [Patient #1] on 12/18/09 at approximately 7:30 AM when I came to make rounds. The change from ICF level of care to Acute was made by me that morning." Physician A reported the patient was awake, alert and talking. When asked if CAH staff had notified him of significant changes in Patient #1's BP Physician A reported the following information:

"The nurse (RN L) that took the BP of 80/50 at 9:25 AM didn't report it to me. If I had been aware, I might have delayed the transfer, gone back to look at [Patient #1] and started Dopamine. (Dopamine is a vasopressor medication that would act immediately on constricting blood vessels making the heartbeat stronger and raising the BP). "The BP of 155/74 referenced in my H and P would have been taken at 2:30 AM. This is not an unreasonable BP for him; in fact it would be an average normal BP for him."


Physician A reported the following, in regards to his conversation with RN L, about Patient #1 ' s BP. "In retrospect, it would have been good if [RN L] had called me and let me know. The decisions were all reasonable and in my opinion, the outcome would not have been any different. I could never have predicted that [Patient #1] would have died on the way to Iowa City. If [he/she] had a normal heart, [he/she] might be alive now. I don't think the vasopressors started here would have mattered."


8. During an interview on 2/16/10 at 2:55 PM, RN L, (Primary/discharge nurse for Patient #1 on 12/18/09) reported that vital signs included temperature, blood pressure, pulse, and respirations. RN L stated, "If there were a change in vitals, I contact the physician. It would be my practice to call the physician to inform [the physician] about the patient. If I took a set of vitals and they were way off, I would wait and take another set in 10-15 minutes." RN L reported that she took and recorded Patient #1 ' s BP of 101/51 on 12/18/09 at 7:45 AM. Additionally, RN L stated that she did not retake Patient #1 ' s BP as required in CAH policy " Assessment and Reassessment of Patients. " RN L further stated, "The BP of 80/50 was taken at 9:25 AM when the patient was being transferred. I didn't tell the doctor [Physician A] because I wanted to wait before I called the doctor. The patient did not look like [his/her] blood pressure was 80/50 and so I wanted to redo it again to make sure it was accurate. I felt comfortable with that because [Patient #1] did not look like [he/she] had a low BP, I felt like it was a machine error. I know now it was not an error." RN L reported that when she returned to the patient's room, the paramedics were in the room. RN L stated, "They were loading [Patient #1] on the gurney so I told the paramedics the BP and they said they would check it when they got in the rig." She stated, "I felt like it was a machine error. I know now it was not an error." RN L discharged/transferred Patient #1 at 9:30 AM on 12/18/09. RN L reported the paramedics "called her from the rig on their cell phone at 9:45 AM" and stated, "The patient ' s BP was 80/D [a method of obtaining a BP using a Doppler ultrasound, resulting in only a systolic BP reading]. RN L contacted Physician A immediately, obtained an order for a Dopamine drip, then relayed the order to the EMS staff. RN L stated, "I told [Physician A], [Patient #1's] BP was low when I checked it at 9:25 AM and I had told the paramedics to retake it. Looking back now before [Patient #1] left I should have taken a follow-up BP. Per policy, I should have taken another BP."

9. During an interview on 2/16/10 at 3:42 PM, Paramedic D, EMS Operation Supervisor/Paramedic reported he accompanied Patient #1 to UIHC and was taking caring of Patient #1 during the transport. He stated, "When I first saw the patient, [he/she] was alert, awake and said [he/she] felt better. [Patient #1] only complained of a cough and being thirsty. RN L gave a report to Paramedic D about Patient #1's condition." Paramedic D did not remember RN L telling him that the patient's blood pressure was low and he needed to take a follow up blood pressure. Paramedic D stated, "Approximately 10 minutes after leaving Henry County Health Center when I took [Patient #1's] BP at 9:45 AM, I called [RN L] because the blood pressure was low enough I thought [Patient #1] should be treated. I'm almost certain that [RN L] told me then that [Patient #1's] BP was low when she took it. After starting the Dopamine, and attempting to increase the dosage, [Patient #1's] BP did not rise." EMS staff contacted the Johnson County Ambulance Service (JCAS) at approximately 10:17 AM when Patient #1 became "harder to arouse and then was unresponsive" to assist with driving the ambulance to UIHC. When HCHC called JCAS, the ambulance was approximately 4-5 miles from UIHC. After assessing Patient #1, Paramedic D determined that he needed to intubate Patient #1 (manually placing a tube in the trachea to allow staff to breath for the patient). The driver of the ambulance, Paramedic E pulled over and assisted Paramedic D by performing chest compressions. JCAS arrived at the HCHC ambulance while "[Paramedic E] and I were doing chest compressions and ventilation." Paramedic D stated, "The patient, from the time [he/she] arrested until they called it (declared the patient expired) at the UIHC never regained consciousness or a pulse."

10. Review of the EMS Report dated 12/18/09 revealed the following information, in part:
"En route: 9:45 AM: Patient found to have absent radial pulses with no audible blood pressure. Cardiac monitor applied shows sinus rhythm. Assess at 80/D. Med/Surg RN contacted concerning blood pressure and she said similar blood pressures had been obtained prior to departure. HCHC contacts [Physician A] for orders and relays orders to begin infusion of Dopamine 5mcg/kg/min (micrograms per kilogram per minute)."

11. During an interview on 2/18/10 at 8:35 AM, Paramedic E, EMS/Paramedic specialist, reported that he accompanied Patient #1 to UIHC, and drove the ambulance. Paramedic E stated, "I would expect a nurse to inform the ambulance or paramedic staff if there were changes in vitals. Obviously if a patient's BP is low it should be passed on. That information about this patient's BP is significant enough that it should have been relayed to us. "

12. During an interview on 2/22/10 at 8:30 AM, Paramedic A, EMS/Paramedic-Training Coordinator with EMS reported the department with a patient needing transfer to another facility notifies EMS staff by phone. Paramedic A stated, "They would tell where the patient is and a brief rundown of the patient. Typically, with a vast majority of transfers, the nurse goes to the room with us. They always talk to us before we leave. We would expect a verbal report. The expectation would be a verbal report of the patient's condition or any changes in vitals before I left. I would think that would be pretty standard."

13. During an interview on 2/16/10 at 4:20 PM, RN H, RN/ER stated, "If the patient's BP decreased, I would retake it to verify the findings. I would let my physician know right away."

II Based on policy review, medical record review and staff interview, the Critical Access Hospital (CAH) staff failed notify the physician of significant changes in body temperature and follow up assessment for 1 of 17 closed medical records (Patient #1).

Failure to notify the physician of changes in body temperature could potentially interrupt the detection and monitoring of an abnormal process going on within the body.

Findings included:

1. Review of the policy "Assessment and Reassessment of Patients" Revised 2/20/09, revealed:
..."The scope and intensity of any further assessments are determined by the patient's diagnosis and patient's response to previous treatment... Any significant change in the patient's condition necessitates an immediate reassessment with changes in the plan of care reflecting the change in condition..."

2. On 2/22/10, the VP of Patient Services presented the survey team with copies of nursing practices, contained in Clinical Nursing Skills and Technique manual. The VP reported the hospital did not have an "actual policy" but the information contained in the manual would, provide guidance to med/surg nursing staff on nursing practices. She stated the CAH was developing a "draft policy" addressing nursing assessment of patients.

Review of the Clinical Nursing Skills and Technique manual revealed the following information, in part: " ...Measuring body temperature: If client has fever, temperature should be taken approximately 30 minutes after administering antipyretics, and every 4 hours until temperature stabilizes... Recording and Reporting: Report abnormal findings to nurse in charge or physician."

3. Review of Patient #1's medical record revealed A History and Physical dated 12/18/09 that revealed, "...History of Present Illness: Patient with multiple severe medical problems who was in [his/her] usual health until yesterday afternoon. [He/she] began feeling poorly with chills. [He/she] states that [he/she] was cold all evening... [He/she] had a fever initially, but seemed to go away by the time [he-she] was evaluated in the emergency room and they felt [he/she] likely had bronchitis. [He/she] was given a dose of Rocephin (an antibiotic) and Zithromax (an antibiotic) and placed on ICF since [he/she] didn't feel [he/she] would care for [him/herself] at home. [He/she] had one episode of emesis since coming to the hospital. [He/she] continues to feel cold. Reports mild shortness of breath, complains of marked malaise, weakness and nausea. This morning [his/her] temperature is elevated and [he/she] continues to have rigors....Past medical history: Notable for Type II diabetes which has been long standing.... [he/she] has diabetic nephropathy and developed end stage renal disease in 1998, [he/she] underwent deceased donor kidney transplant in May of 2006....[He/she] had multiple episodes of infection including sepsis, discitis and right knee septic arthritis during [his/her] time on dialysis...[he/she] has a history of pancytopenia since November 2009...."

4. Review of the discharge summary for the ICF stay, dated 12/18/09 revealed the following, in part " ...Principal Diagnosis: Pneumonia..."Secondary Diagnosis: Pancytopenia, Aortic Stenosis, Chronic kidney disease. Clinical Resume: ...Patient is a 75 year old [person] who has multiple medical problems including long standing kidney disease status post kidney transplant approximately three years ago, who has had problems with pancytopenic for the last month requiring red blood cell transfusion. [He/she] presented to the emergency room in the evening complaining of shortness of breath and chills. [He/she] was evaluated in the emergency room and given a dose of Ceftriaxone and Zithromax. [He/she] elected to stay in the hospital. [He/she] was brought to floor about 2:30 AM. This morning [he/she] developed a fever, worsening oxygenation, [he/she] was placed on IV Zosyn, treated with nebulized bronchodilators and [his/her] FiO2 increased. [His/her] care was discussed with the UIHC and it was felt [he/she] would benefit from transfer to a tertiary center with the availability of infectious disease, hematology consultants, and cardiology consultants as well. Patient was agreeable to transfer ... A transfer summary documented a physician's order for transfer via ambulance on 12/18/09 to the University of Iowa Hospital and Clinic...."

5. Emergency Nursing Record notes, dated 12/17/09, documented a tympanic temperature, taken at Midnight of 98.8 degrees.

6. Patient Progress notes dated 12/18/09, "Vital signs" documented tympanic temperatures as follows:
a. 12/18/09 at 2:30 AM: 101.4 degrees.
b. 2/18/09 at 7:45 AM: 102.7 degrees.
i. The medical record lacked physician notification and/or a follow up assessment related to the elevated temperature.
c. 12/18/09 at 9:25 AM: 102.9 degrees.
i.The patient was discharged/transferred at 9:30 AM.

7. Review of the EMS Report dated 12/18/09 revealed:
" ...Physical exam: Patient skin noted pale and hot. Patient is febrile per HCHC staff. Skin turgor very poor. Patient does complain of being thirsty..."

8. During an interview on 2/16/10 at 12:50 PM, Physician A reported the CAH staff did not report the elevated temperature at the time the staff took the temperatures.

9. During an interview on 2/17/10 at 8:30 AM, RN I, RN on the Medical/Surgical nursing unit stated, "At 2:30 AM when [Patient #1's] temperature was 101.4 degrees, I called the ER physician. I am not sure why I called the ER doc. I should have called the primary physician. My normal protocol would be to contact [Physician A]. I understand the ER physician's do not assume care for patients once they leave the ER. I did not take the temp again after 2:30 AM (12/18/09). I should have taken another temperature, yes. I did not document anything in the nurse's notes about an elevated temperature after 2:30 AM. When there is a change in vitals, it would be policy to recheck them, and notify the primary doctor. "

10. During an interview on 2/22/10, at 10:22 AM RN B, RN on the Med/Surg nursing unit reported vital signs included temperature, pulse, respirations, blood pressure and oxygen saturations. Staff B stated, "I would review vitals from the previous shift to determine elevations or declines in the patient's vitals. If there were, I would notify the doctor and document the findings in the patient's record." RN B indicated if a patient had a temperature greater than 100.4 degrees, she would "call the doctor and let him know." RN B stated, "The doctor should know if there's a temp."

11. During an interview on 2/22/10, at 10:40 AM, RN C, RN on the Med/Surg nursing unit reported if a patient had an elevated temperature, they would call the physician. RN C stated, "It's something you're trained to do."

12. During an interview on 2/17/10 at 9:02 AM, RN J, RN on the Med/Surg nursing unit reported staff need to report elevations in temperature to the physician. RN J stated, "It would be standard nursing practice and I think it's a policy that any change in patient condition you would notify the physician."


III. Based on medical record review and staff interview, the Critical Access Hospital (CAH) staff failed to monitor urinary output after administration of intravenous diuretics for 1 of 17 closed medical records (Patient #1).

Failure to monitor urinary output could potentially lead to vascular, cellular, or intracellular dehydration and life threatening electrolyte imbalances.

Findings included:

1. An Emergency Department Note dated 12/17/09 revealed:
"HPI: [He/she] states that [he/she] does not seem to be having much trouble with extra fluid as [he/she] sometimes does after a transfusion. By this, [he/she] means excess peripheral edema. [He/she] always has trace to 1+ pedal edema per [his/her] report..."
"Past Medical History: ...End stage renal disease with a history of renal transplant in 2006, immunosuppressants on hemodialysis... Congestive heart failure with ejection fraction of 45% on echocardiogram in June of 2009... Physical exam: Musculoskeletal shows 1 to 2+ pretibial and pedal edema bilaterally..."
"Emergency department course: Patient was given 100 milligrams (mg) of Lasix intravenously (IV)..."

2. Review of an Emergency Department Nursing Record dated 12/18/09, revealed nursing staff administered IV Lasix to Patient #1 at 12:22 AM . The medical record lacked documentation of urinary output.

3. Review of an Emergency Nursing Record, dated 12/17/09, revealed CAH staff transferred the patient from the ER to Med/Surg for ICF level of care at 2:25 AM on 12/18/09.

4. Review of ICF Patient Progress notes, dated 12/18/09, revealed the medical record lacked documentation of urinary output from the time staff admitted Patient #1 to ICF until discharge/transfer at 9:30 AM.

The CAH staff administered 100 mg of IV Lasix (a diuretic) on12/18/09 at 12:22 AM then failed to monitor the patient's urine output the entire 9 hours and 10 minutes that [he/she] was in their care following the administration of the IV Lasix.

5. Review of the EMS Report dated 12/18/09 at 9:43 AM revealed:
"Physical exam: Skin turgor very poor. Patient does complain of being thirsty... HPI: Patient also shows signs of kidney failure..."

6. During an interview on 2/16/10 at 4:20 PM, RN H, RN/ER reported she provided care to Patient #1 while in the ER, and administered the intravenous diuretic.RN H stated, "[Patient #1]was up to the bathroom on [his/her] own. We did not measure urine output."

7. During an interview on 2/18/10, at 12:00 PM , the VP of Patient Services stated the CAH lacked a policy for monitoring urinary output, and said that nursing normally monitors urinary output following administration of IV diuretics. She stated, "You would not need a physician's order for [monitoring urinary output]."

8. During an interview on 2/22/10, at 10:22 AM, RN B, RN on the Med/Surg nursing unit reported nursing measures for patient's who received intravenous diuretics included "daily weights, watching vitals because the BP can drop with that, and of course measuring their urine output." RN B stated, "If they are, up on their own [we use] a measuring device (hat) to measure urine. The urine would be monitored because you want to see how they are diuresing. That would be a standard of nursing practice, you don't need a physician's order for that. "

9. During an interview on 2/22/10, at 10:40 AM RN C, RN on the Medi/Surg nursing unit reported if patients receive diuretics, staff monitor the patient's weight daily and staff place a measuring hat in the commode. RN C stated, "We would do that to see how the diuretic is working and how much fluid they are getting rid of. We would be checking to make sure their blood pressure wasn't dropping like a rock. If that did happen, we would call the physician, I think nurses are trained to do that. "

10. On 2/23/10, prior to exit the VP of Patient Services confirmed findings of the investigation.

























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