HospitalInspections.org

Based on review of records and interviews, the hospital failed to provide appropriate nursing services for 1 of 1 patient (Patient #1) who expired at the hospital on 01/15/12 in that the Registered Nurse did not evaluate Patient #1 after at least three episodes of nausea and vomiting and one episode of breathing problems from 01/14/12 through 01/15/12.

Findings included:

The hospital's "Admission/Registration Face Sheet" dated 01/20/12 reflected Patient #1's admission date of 01/11/12 with admission diagnoses that included Congestive Heart Failure and Chest Pain.

The nursing notes signed by Personnel #7 on 01/15/12 at 6:52 AM reflected on the night of 01/14/12 at 8 PM Patient #1 was "nauseated and spitting up clear phlegm." At 9 PM Patient #1 was "nauseated again." At 9:30 PM the patient "vomited large amount of emesis onto bed and side of bed to the floor" which was "red colored with food fragments." At 10:30 PM the patient experienced breathing problems.

The physician provided "Death Summary" dated 01/15/12 at 9:52 AM reflected "during intubation ..... he [Patient #1] had copious GI [gastrointestinal] contents in his oropharynx [area of the throat that is at the back of the mouth] and airway consistent with aspiration leading to pulmonary [lung] collapse."

The "Standards of Nursing Assessment" Policy revised 09/11 reflected "Reassessment... any patient who is observed by any nurse to have a change in condition will receive prompt intervention and documentation to reflect this change in status. The nurse will document which provider was notified and any intervention taken after notification."

On 01/25/12 at 11:45 AM Personnel #9, the unit RN Manager, was interviewed. Personnel #9 verbalized the expectation for nursing staff to do report at the bedside. Personnel #9 denied Patient #1 had been evaluated for a change of condition when he experienced nausea and vomiting.

On 01/25/12 at 3:50 PM Personnel #9 stated that Patient #1's care was "not the care expected."

Cross refer to A0395.

Based on records review and interviews, the hospital failed to ensure 1 of 1 patient (Patient #1) in the hospital's intensive care unit was evaluated by an RN (Registered Nurse) after at least three episodes of nausea and vomiting and one episode of breathing problems from 01/14/12 through 01/15/12. Patient #1 went into cardiac arrest, was intubated and found with large amounts of gastrointestinal contents in the back of his throat and airway. The patient died.

Findings included:

The hospital document titled "Admission/Registration Face Sheet " dated 01/20/12 reflected Patient #1's admission date of 01/11/12 with admission diagnoses that included Congestive Heart Failure and Chest Pain.

The "Hospital Encounter Summary Report" dated 01/20/12 reflected Patient #1's additional diagnoses included Coronary Artery Disease, Ventricular Tachycardia, Reticulosarcoma, Unspecified Site, Depression, Sinusitis, Cellulitis of Right Leg, Constipation, Hyperlipidemia, Paroxysmal Atrial Fibrillation.

The "Problem List as of 1/15/12" reflected additional diagnoses that included Lymphoma, Lymph Edema, Chronic Kidney Disease, Pulmonary Nodule, Diabetes Mellitus, Type 2, Thrombus, Lower Limb Amputation, Implantable Cardiac Defibrillator In Place, Sleep Apnea, Osteoarthritis, Depression, and Hyperlipidemia.

The Hospital "All Notes" dated 01/13/12 reflected plans to move Patient #1 to the intensive care unit "for closer monitoring."

The nursing notes signed by Personnel #7 on 01/15/12 at 6:52 AM reflected on the night of 01/14/12 at 8 PM Patient #1 was "nauseated and spitting up clear phlegm." At 9 PM Patient #1 was "nauseated again." At 9:30 PM the patient "vomited large amount of emesis onto bed and side of bed to the floor" which was "red colored with food fragments." At 10:30 PM the patient experienced breathing problems. There was no documented evidence that the RN did an assessment of the patient and/or informed a physician of the patient's status.

The "Standards of Nursing Assessment" Policy revised 09/11 reflected "Reassessment... any patient who is observed by any nurse to have a change in condition will receive prompt intervention and documentation to reflect this change in status. The nurse will document which provider was notified and any intervention taken after notification."

The nursing notes documented nausea and vomiting again on 01/15/12 at 4 AM; at 6 AM Patient #1 was documented "spitting up phlegm continuously."

The physician's "Death Summary" dated 01/15/12 at 9:52 AM reflected "during intubation ..... he [Patient #1] had copious GI [gastrointestinal] contents in his oropharynx [area of the throat that is at the back of the mouth] and airway consistent with aspiration leading to pulmonary [lung] collapse."

On 01/20/12 at or around 11 AM Personnel #1 was interviewed. Personnel #1 stated that a face to face patient evaluation during shift report "did not happen."

On 01/24/12 at 8:55 AM Personnel #7 was interviewed on the phone. Personnel #7 stated at the beginning of her shift on 01/14/12 Patient #1 was "nauseated" and she administered medication first by mouth and then by intravenous mode "due to the nausea." Personnel #7 stated she interrupted the morning shift report on 01/15/12 at about 7:10 AM to assist Patient #1 because he wanted "water and the pink spit bucket [emesis basin] closer by." Personnel #7 stated that a face to face patient evaluation did not take place during report.

On 01/25/12 at 11:45 AM Personnel #9, the unit RN Manager, was interviewed. Personnel #9 verbalized the expectation for nursing staff to do report at the bedside. Personnel #9 denied Patient #1 had been evaluated for a change of condition when he experienced nausea and vomiting.

On 01/25/12 at 3:50 PM Personnel #10 was asked to provide chart documentation of further assessment and nursing interventions which addressed Patient #1's nausea, vomiting and/or aspiration. Personnel #10 stated he could not find any in the chart.

On 01/25/12 at 3:50 PM Personnel #9 stated that Patient #1's care was "not the care expected."

Based on interviews and records review, the hospital failed to ensure nursing staff kept a current nursing care plan for 1 of 1 patient (Patient #1) in the hospital's intensive care unit. Patient #1 had at least three episodes of nausea and vomiting, and one episode of breathing difficulties from 01/14/12 through 01/15/12. Patient #1 went into cardiac arrest, was intubated and found with large amounts of gastrointestinal contents in the back of his throat and airway. The patient died.

Findings included:

The hospital document titled "Admission/Registration Face Sheet" dated 01/20/12 reflected Patient #1's admission date of 01/11/12 with admission diagnoses that included Congestive Heart Failure and Chest Pain.

The "Hospital Encounter Summary Report" dated 01/20/12 reflected additional diagnoses included Coronary Artery Disease, Ventricular Tachycardia, Reticulosarcoma, Unspecified Site, Depression, Sinusitis, Cellulitis of Right Leg, Constipation, Hyperlipidemia, Paroxysmal Atrial Fibrillation.

The "Problem List as of 1/15/12" reflected additional diagnoses that included Lymphoma, Lymph Edema, Chronic Kidney Disease, Pulmonary Nodule, Diabetes Mellitus, Type 2, Thrombus, Lower Limb Amputation, Implantable Cardiac Defibrillator In Place, Sleep Apnea, Osteoarthritis, Depression, and Hyperlipidemia.

The Hospital "All Notes" dated 01/13/12 reflected plans to move Patient #1 to an intensive care unit "for closer monitoring."

The nursing notes signed by Personnel #7 on 01/15/12 at 6:52 AM reflected on the night of 01/14/12 at 8 PM Patient #1 was "nauseated and spitting up clear phlegm." At 9 PM Patient #1 was "nauseated again." At 9:30 PM the patient "vomited large amount of emesis onto bed and side of bed to the floor" which was "red colored with food fragments." At 10:30 PM the patient experienced breathing problems. The nursing notes documented nausea and vomiting again 01/15/12 at 4 AM; at 6 AM Patient #1 was documented "spitting up phlegm continuously." The nursing care plan of the patient failed to address the patient's change of status.

The hospital "Nursing Documentation" Policy #NSG 13-08, revised 05/09, reflected "Plan of Care Needs...additional needs will be added by registered nurse...during the patient's clinical course."

The physician's "Death Summary" dated 01/15/12 at 9:52 AM reflected "during intubation...he [Patient #1] had copious GI [gastrointestinal] contents in his oropharynx [area of the throat that is at the back of the mouth] and airway consistent with aspiration leading to pulmonary [lung] collapse."

On 01/25/12 at 11:45 AM Personnel #9, the unit RN Manager, was interviewed. Personnel #9 denied Patient #1 had a care plan addressing nausea, vomiting and/or aspiration.