HospitalInspections.org

Based on review of policies/procedures, medical record, and interview with staff, it was determined the hospital failed to require a registered nurse (RN)assesses and evaluated the nursing care for patient (pt.) #1, as evidenced by:

1. documentation in the medical record did not include an assessment by the evening RN, after administering medications; and
2. the nursing staff did not reassess the patient after a change in condition warranting a transfer to a higher level of care.

Findings include:

The hospital's policy titled, Assessment / Re-Assessment, Interdisciplinary, required: "...To provide all patients with an appropriate assessment (including initial/screening and reassessment) provided by qualified individuals within the organizational setting...Each patient is to be reassessed according to the guidelines established by the clinical discipline. Further assessment and reassessment will be based on a collaborative effort as warranted by the patient's condition...Reassessment is based on the patient's diagnosis, the care setting...the patient's response to any previous care. Reassessment be at specified / regular intervals related to:...the patient's response to treatment...Significant change in the patient's condition...."

1. Pt. #1 was admitted to the long term care hospital's intensive care unit (ICU) on 02/17/09, from another acute care hospital.

On 02/20/10, at 1745 hours, the pt. received Fentanyl 0.25 mcg IV and Xanax 0.25 mg per PEG tube. Nursing documentation indicated the pt. complained of pain "all over" and rated the severity of the pain as an 8 with a pain scale of 0-10 (10 being the worst pain and 0 no pain).

The day shift RN did not reassess the pt. after the medications were given at 1745 hours.

The day shift RN documented the patient had spiked a fever at 1800 hours, of 101.5 and physician # 2 was notified. Nursing received an order to obtain urine, sputum and blood cultures, draw an arterial blood gas (ABG) immediately (STAT) and IV antibiotic orders were received. The nursing staff did not reassess the patient after administration of Tylenol for a fever at 1845.

The Chief Clinical Officer was interviewed on 02/25/10 at 1430 hours, and confirmed it is the hospital's expectation that nursing is to reassess patients after as needed (prn) medications are administered.

2. The night shift nurse coming on shift for 02/20/10, at 1900 hours, to assume care of the patient did not document an assessment / reassessment of the patient as required by facility policy.

The following is the only documentation by the night shift nursing staff, a Licensed Practical Nurse (LPN) caring for the patient:

"1930...recvd (received) pt (patient)...cont (continued)-labored breathing. HR (heart rate) (elevated)--will monitor...2100...Dr (#2) notified in building--to pt room. Dr assesses pt orders Nitro (nitroglycerin) SL (sublingual) STAT- will monitor...2120...Dr orders Nitro IV...100mg Lasix IVP (intravenous push) BP (blood pressure) 88/48 Dr. (#2) at bedside--will (check)...2140...heparin drip ordered but held per Dr. d/t (due to) (decrease) BP--Bolus 5000 Heparin given...Dr (#2) calls Hosp for transport to ICU...2210...Transport arrives X2--pt transferred to (name of hospital)...2130...report given to (name of other hospital)...2230...family (wife) notified of transport...."

The RN assigned to this patient did not assess or reassess the patient when the patient's condition changed. Nursing did not conduct/document a physical assessment for Pt #1.

The CCO confirmed on 02/26/10, at 0955 hours, that the RN assigned to care for the patient did not document an assessment or reassessment for Pt. #1 whose condition changed warranting transfer to a higher level of care.