HospitalInspections.org

Based on policy review, record review and staff interview it was determined the facility failed to ensure the registered nurse supervised and evaluated nursing care for one (#5) of 10 sampled patients to ensure the patient needs were met.

Findings included:

The "Plan for Patient Assessment and Reassessment", policy number PC509, reviewed 12/2016 defined the practice of nursing as a registered professional nurse as, "the performance of those acts requiring substantial specialized knowledge, judgement and nursing skill based upon applied principles of psychological, biological, physical and social sciences which shall include, but not be limited to the observation, assessment, nursing diagnosis, planning intervention and evaluation of health care...".

The Intraoperative Nursing Record for Patient #5 dated 6/19/17 revealed the patient left the Operating Room to the Post Anesthesia Care Unit (PACU) at 10:30 a.m. The blood pressure reading documented at the time was within normal limits at 138/56.

The Vital Sign Flowsheet for Patient #5 dated 6/19/17 revealed the first blood pressure reading documented in PACU at 10:40 a.m. was abnormally low at 40/25. A recheck at 10:42 a.m. was 74/43. Patient #5's oxygen saturation was 100% with supplemental oxygen through a simple mask at 10 liters per minute (10L/min). The respiratory rate was 17 breaths per minute.

The Vital Sign Flowsheet at 11:20 a.m. reported Patient #5's vital signs as blood pressure 102/52, oxygen saturation 100% with supplemental oxygen through a simple mask at 10L/min and respirations at 7 breaths per minute. At 11:30 a.m. Patient #5 was reported to be on room air (no supplemental oxygen), oxygen saturation 98%, respirations 18, blood pressure 51/29. Vital signs documented at 11:42 a.m., 11:45 a.m. and 11:48 a.m. revealed Patient #5's respiratory rate at 21-22 breaths per minute, blood pressure 50's-60's over 29-39 and oxygen saturation 99% - 96%. Patient #5 continued on room air with no supplemental oxygen. Vital signs at 12:00 noon and 12:06 p.m. reported Patient #5's respirations at 26 and 27 breaths per minute, blood pressure 52/23 and 47/20 and oxygen saturation at 100% with no supplemental oxygen. Patient #5's blood pressure continued in the 40's over 20's. Respirations were documented at 12:09 p.m. as 26 breaths per minute, at 12:15 p.m. as 28 breaths per minute and at 12:20 p.m. at 29 breaths per minute. No supplemental oxygen was provided. At 12:30 p.m. Patient #5's heart rate was 100, blood pressure was 47/22 and oxygen saturation was 92% on 3L/min of supplemental oxygen via nasal cannula.

The review of the PACU record revealed Patient #5 was under the care of a Registered Nurse (RN) throughout the stay in the PACU. The record failed to reveal any evidence of any discussion by the nurse with the anesthesiologist or the attending surgeon regarding the patient's continuing respiratory distress as evidenced by the elevated respiratory rate between 11:42 p.m. 12:30 p.m., a period of approximately 45 minutes.

An interview and record review was conducted with the Director of Perianesthesia Services on 8/8/17 at 10:30 a.m. The Director confirmed the finding the RN failed to appropriately evaluate the overall clinical condition of Patient #5. The IN failed to take appropriate nursing action based on the the symptoms of respiratory distress as evidenced by the patient's elevated respiratory rate, despite the oxygen saturation readings being within normal limits.