HospitalInspections.org

Based on policy review, clinical record review and interviews the facility failed to evaluate changes in vital signs for one patient (#1) of seven patients' records reviewed who received a caesarian section delivery.

The facility census was 86.

Findings included:

1. Review of the facility policy titled, "Patient Care Guidelines for Nursing Practice" initiated 12/89, revised 1/03 showed the following directions:
-Policy: Patients can expect to receive nursing care, which promotes, maintains, and supports the physiological, psychological and emotional needs of the patient during the healing process. The Nursing Process is utilized by Registered and Licensed Practical Nurses in providing care to patients.
Standard II: Assessment/Data Collection: The nurse will:
B. Recognize subtle changes in the patient's physical and mental condition, initiating action based on findings.
C. Communicate pertinent findings to other members of the health care team.
G. Assess vital signs: Recheck of blood pressures with a reading of 20 mm (millimeters of mercury) higher or lower than previous reading.

Review of the Merck Manual, Nineteenth Edition, (a medical reference book) defines Hypertension (high blood pressure) as a sustained blood pressure of 140/90 and tachycardia (fast heart rate) as a heart rate of 100 beats per minute or greater.

1. Review of the clinical record and the operation report on 02/16/12 for Patient #1 showed the patient was admitted on 02/10/12 at 11:23 PM, for spontaneous rupture of membranes (membranes - the amniotic sac, which is a bag of fluid inside a woman's uterus where the unborn baby develops and grows). The physician performed a Cesarean Section (the baby is delivered through an incision made in the mother's abdomen and uterus) procedure 02/10/12.

2. Review of Patient #1's vital sign records for 02/11/12 through 02/12/12 showed the patient's blood pressure (B/P) baseline (what is normal for the patient) of 110/64 and heart rate (HR) baseline of 91 beats per minute. The B/P and HR gradually became elevated over the course of the patient's hospitalization with the highest B/P of 158/85 and the highest HR of 125.
-Patient #1's B/P and HR over the course of the hospitalization showed the following information:
-02/11/12
5:30 AM, B/P 110/64 and HR 91;
5:45 AM, B/P 133/81 and HR 96;
6:00 AM, B/P 126/86 and HR 96;
6:15 AM, B/P 117/75 and HR 93;
6:30 AM, B/P 108/75 and HR 91;
6:45 AM, B/P 116/69 and HR 89;
7:35 AM, B/P 120/76 and HR 90;
10:39 AM, B/P 133/99 and HR 96;
3:17 PM, B/P 128/66 and HR 125;
7:00 PM, B/P 125/68 and HR 125; and
11:04 PM, B/P 144/69 and HR 125.

-02/12/12
2:56 AM, B/P 144/71 and HR 125;
7:10 AM, B/P 135/70 and HR 120;
11:50 AM, B/P 158/85 and HR 104;
2:29 PM, B/P 158/85 and HR 104; and
2:34 PM, B/P 158/85 and HR 104.

On 02/12/12 at 2:34 PM, the nursing discharge summary for Patient #1 showed the following information:
-The patient was "Stable";
- Blood Pressure 158/85; Pulse 104; Respirations 16; and Temperature 97.4; and
-The facility discharged the patient to home.

During an interview on 02/16/12 at 3:47 PM, Staff J, the physician for Patient #1 stated that:
-When beginning the C-Section (a surgical procedure in which one or more incisions are made through a mother's abdomen and uterus to deliver one or more babies) Patient #1 appeared normal. As the procedure continued Patient #1 began to have slurred speech and looked under the influence of unknown drugs. Patient #1 would not stay alert when aroused even with sternal rubs (the breast bone, the long flat bone in the upper middle of the front of the chest, is rubbed vigorously with the knuckles of a closed fist to create pain).
-He did not check Patient #1's vital signs before discharging the Patient #1;
-While looking at the vital sign sheet for Patient #1 he stated had he looked at the vital signs prior to discharging Patient #1 the vital signs would have caught his attention indicating he was not aware of the vital signs;
-Patient #1 was discharge with a prescription of 24 Percocet (a prescription pain narcotic);
-The coroner reported to him the preliminary autopsy report showed the cause of death for Patient #1 was a drug overdose. The final autopsy report is pending toxicology (is a branch of biology, chemistry, and medicine concerned with the study of the adverse effects of chemicals on living organisms) results.

During an interview on 02/17/12 at 4:55 PM, Staff I, RN, Obstetrics (OB) Shift Manager, stated that her expectation of nursing staff is when a patient has an elevated heart rate the heart rate will be monitored to see if it drops. If the heart rate stays high for hours the physician should be notified. If a B/P is elevated it is the expectation the nurse would recheck the B/P and notify the physician if the elevated B/P is sustained.

Based on the interview on 02/17/12 at 4:55 PM, with Staff I, RN, Obstetrics (OB) Shift Manager, the facility should have notified the physician of Patient #1's elevated and sustained blood pressures and heart rates on 02/11/12 and 02/12/12. Patient #1's clinical record showed:
-An elevated HR ranging from 104 to 125 beats per minute;
-The elevated HR was sustained for a period of 23 hours with 16 of those hours having a HR between 120 - 125 beats per minute;
-The facility discharged Patient #1 with a HR of 104;
-An elevated B/P (as compared to the patient's baseline B/P) of 158/85 was rechecked three times and was sustained over 2.5 hours and the facility discharged Patient #1 with a B/P of 158/85;
-There is no documentation the facility notified the physician of the elevated and sustained blood pressures or heart rates.

Based on interview, clinical record review, policy review and review of discharge community resource lists, the facility failed to provide a discharge planning evaluation that included a referral to post-hospital services in one (#1) of nineteen patients reviewed for discharge planning. Specifically, the hospital failed to provide individualized discharge planning for one patient who may have benefited from Drug and Alcohol Rehabilitation Services.

The facility census was 86.

Findings included:

1. Review of the facility policy titled, "Discharge Planning" initiated 01/97, revised 12/08, showed the following direction:
-Policy: Patients discharged from the acute-care hospital will be evaluated regarding discharge planning needs and assisted with specific discharge plans.
-Patients discharged from the acute-care hospital to post-acute organizations, facilities, and agencies will be evaluated regarding discharge planning needs and assisted with specific discharge plans. Discharge planning will include post discharge needs and the availability of post discharge care to provide for these needs.
-Patients and significant others will be given choices of organizations, facilities and agencies related to discharge needs. Care Manager will contact the chosen organization, facility or agency to facilitate the beginning or continuation of services and document the interaction on the medical record.
-The Care Managers will serve as Discharge Planning Coordinators.
Discharge planning evaluations and assessments will be initiated at or before the time of admission for patients in the acute-care hospital. Patient specific needs will be reassessed throughout the entire hospitalization. This assessment will include a method to determine the psycho-social needs of the patient; a method of providing appropriate social work interventions, including discharge planning and counseling; and a mechanism for referrals to community agencies when appropriate.
-Discharge plans will be documented in the patient's medical record. The plans will be discussed thoroughly with the patient, significant other, and the physician. The patient and/or significant others will be given choices, and ultimately make a knowledgeable decision regarding their discharge planning needs, placements and services.
-Procedure: Section II, Discharge Planning Roles, Section A - Care Managers: The Care Managers are responsible for coordinating aftercare and documenting all arrangements in the patient's medical record.
A1. Participating in early identification of patients requiring assistance with post-hospital care;
A2. Conducting a psycho-social assessment of patients identified as possessing post-hospital care needs;
A3. Coordinating the agreed upon post-hospital plan;
A4. Providing education to patients and families in appropriate areas;
A6. Coordinating the community support system for the purposes of enabling the patient to either return home, relocate, or transfer to another health care facility;
A7. The Care Management Team will complete a pre admission and/or admission review. This information will be utilized in beginning the hospital's discharge planning process. A number of special needs may be identified and documented in the patient's medical record. Reassessment of the patient's discharge planning needs will be completed and documented as needed throughout the patient's hospitalization.

Review of the facility policy titled, "Patient Care Guidelines for Nursing Practice" initiated 12/89, revised 1/03 showed the following directions:
-Standard VII: Discharge Planning: The health care providers begin to assess for discharge needs upon admission. Data is gathered from professionals in other disciplines (social services, case managers, Physical Therapy, Occupational health), as well as nursing. Emphasis is placed upon planning for needs that will exist after discharge, which are related to:
A. Physical and other therapeutic needs with focus on medications, treatment, appointments with physician and other therapist.

2. Review of the clinical record on 02/16/12 for Patient #1 showed the patient was admitted on 02/10/12 at 11:23 PM, for spontaneous rupture of membranes (membranes - the amniotic sac, which is a bag of fluid inside a woman's uterus where the unborn baby develops and grows). The record showed a drug screen dated on 02/11/12 at 1:28 AM, for Patient #1 showed Benzodiazepines (tranquilizers), Opiates (narcotic pain medication) and Oxycodone (narcotic pain medication) present.

Review of medications administered after admission and prior to the C-Section showed no administration of Benzodiazepines or Opiates.

Further review of the nursing notes showed prior to admission the patient took Tylenol #3 (a prescription pain killer with Codeine which is a narcotic) taken on 02/10/12 at 9:00 AM and Phenergan 25 mg (to prevent vomiting) taken on 02/10/12 at 5:00 PM.

Review of the Cesarean Section (C-Section. the baby is delivered through an incision made in the mother's abdomen and uterus) report dated 02/10/12 (physician's date) showed an IV (intravascular line) inserted at 12:02 AM and the surgeon, Staff J, arrived at 1:00 AM.

Review of the record showed on 02/11/12 at 1:25 AM, the physician ordered IV medications to prevent nausea and vomiting, to decrease acid production and an antibiotic.

Review of the operation report for Patient #1 showed:
"Date of C-Section procedure 02/10/12;
-Spontaneous rupture of membranes (membranes - the amniotic sac, which is a bag of fluid inside a woman's uterus where the unborn baby develops and grows.)
-Term pregnancy (most full term babies are delivered sometime between 38 and 42 weeks of pregnancy);
-Spontaneous Labor (a labor beginning and progressing without mechanical or pharmacologic stimulation);
-Substance Dependency (when a person has developed a tolerance for a particular substance, needing increased amounts to experience the effects, and has withdrawal symptoms when not using the substance for a period of time);
-Borderline Personality Disorder (a psychological condition marked by a prolonged disturbance of personality function, characterized by depth and variability of moods);
-Manic Depressive (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks);
Patient #1 had been scheduled for a primary elective cesarean section. However, she presented to labor and delivery with a spontaneous rupture of membranes, contracting sporadically; and
-The physician documented that Patient #1 received a spinal anesthesia
(used to control pain to the lower half of the body by injecting a medication into the fluid surrounding the spinal cord) for the Cesarean procedure."

Review of Staff W, CRNA, nursing notes dated 02/11/12 showed:
"At 3:42 AM, trying to keep Patient #1 in conversation to keep patient aroused, patient has slurred speech;
-At 4:15 AM, Patient #1 is leaning to side and slobbering into oxygen mask;
At 4:30 AM, Patient #1, becoming slightly more aroused, talking without having to be talked to first;
-At 5:00 AM, asked Patient #1 when was the last time she took Tylenol #3; Patient #1 stated she was in the ER the other day for back pain due to Scolliosis (an abnormal curving of the spine) and the doctor gave me 15 pills of Tylenol #3 (controlled substance pain medication) and the other doctor gave me 5 pills. Patient #1 stated she took two pills of Tylenol #3 every 3-4 hours until the pain got worse then she was taking two pills of Tylenol #3 every two hours. Patient #1 stated her last pill was taken yesterday morning and stated the only pill she took tonight was one half pill of Phenergan (used to relieve nausea) to help her rest and for nausea. Patient #1 denied taking Percocet/Oxycodone (controlled substance pain medication)."

Review of the physician progress dated 02/11/12, (time is not documented showed:
"Recovering from overdose of unknown mix of drugs;
-Psyche issues (psychiatric issues);
-Still slurring speech but awake alert & (and) insistent, if unrealistic, on wanting to go home."

Review of the nursing notes dated 02/11/12 at 11:38 AM, showed:
"The surgeon, Staff J, for Patient #1, returned to the room of Patient #1 and found the patient remained groggy and continually repeated the same questions over and over. Patient #1 was instructed per physician in front of the nurse and Patient #1's mother that Patient #1 would receive no narcotics until the patient was appropriately alert and awake."

Review of the assessment and discharge planning dated 02/11/12 at 7:45 PM, showed the following discharge planning for Patient #1 by Staff H, Care Manager, Social Worker:
"Called to OB (Obstetrics, the area of the facility providing medical care during pregnancy and childbirth), this AM (morning) to find out condition of Patient #1 and baby and nursing reported that Patient #1 was so "high" from her own pain meds that she would not be able to answer any questions. Worker waited until later to interview Patient #1 due to her inability to answer questions;
-Both the mother and father of Patient #1 were present and reported they have both tried to get Patient #1 to stop taking pain medication and reported she does not make good decisions for herself;
-Patient #1 denied she had a substance abuse history;
-Patient #1 denied she drank, but old records showed Patient #1 had a history of alcohol abuse;
-Patient #1 requested to go AMA (leave the hospital against medical advice) to smoke and get pain medications;
-Worker (Social Worker) explained Patient #1 just had a C-Section and she would not get a prescription for pain medications if she left AMA;
-Worker explained to patient that baby would not be ready for discharge by the time she would be ready due to the baby being under the influence of drugs and going through withdrawal at the hospital until he was medically stable, and:
-Worker hotlined (call made to the state protective child services) that mother and baby both tested positive for narcotics."

Review of the nursing notes dated 02/12/12 at 12:05 AM, showed:
"Morphine given IVP (intravenous) for complaints of severe pain. Called CRNA, Staff W, to see if Patient #1 could have Percocet and he stated not until patient was past the 24 hour mark (after C-Section). Patient #1 stated I'm hurting so bad and I need a cigarette. Patient #1 still unable to get a ride out of here."

Review of the nursing notes dated 02/12/12 at 12:47 AM, showed:
"Patient #1 sitting at bedside and requesting more pain medication. Patient #1 instructed on anesthesia order to only give Morphine for the first 24 hours. Patient verbalizes understanding that she can have a Percocet at 3:00 AM. Patient #1 verbalized understanding that no other medications (except morphine) can be given until 3:00 AM for her safety. Patient #1 agreed to stay overnight, but plans to go AMA tomorrow if she is not discharged."

Review of this discharge planning dated 02/11/12 at 7:45 PM, showed Staff H, Care Manager, Social Worker, failed to include a discharge community referral for drug abuse and addiction.

Review of nursing discharge planning dated 02/12/12 at 2:29 PM, for Patient #1 failed to include a community referral for drug abuse and addiction.

Review of the facility's community resource lists included a document titled, "Drug Abuse & Addiction Information & Treatment." This community resource document showed 19 community resources for alcohol and addiction treatment. The facility failed to include drug abuse and addiction resources as part of the discharge planning for Patient #1.

3. During an interview on 02/16/12, at approximately 2:00 PM, Staff H, Social Worker, stated the facility assigned her to the Emergency Department (ED) to cases where patients were frequently visiting the ED. Staff H stated Patient #1 visited the ED frequently with complaints of pain and requested pain medication. Staff H stated she had counseled Patient #1 about obtaining a primary care physician to address her medical needs. Staff H stated Patient #1 was seeking pain medication frequently through the ED.

During an interview on 02/17/12, at approximately 2:00 PM, Staff B, RN, Administrative Director, stated the staff probably did not make a referral for drug abuse for Patient #1 due to the fact Patient #1 is seen frequently in the emergency room and drug abuse has been addressed often with Patient #1.

4. Review of the facility document titled, "Root Cause Analysis Tool" (a preliminary facility investigation) regarding Patient #1 showed the following:
"Date of the event: 02/13/12;
-Type of event: Death in hospitality room;
-Patient #1 was admitted on Friday, 02/10/12, in labor and high on drugs. She had a C-Section at 2:40 AM due to baby in distress;
-Patient #1 was discharged the afternoon on 02/12/12 after a C-Section on 02/11/12;
-Patient #1 returned to the hospital the evening of 02/12/12 as a visitor and was placed in the hospitality room to be close to her child;
-The father of Patient #1 found Patient #1 dead in the hospitality room (a guest room at the hospital) on 02/13/12 at approximately 10:00 AM."

5. During a phone interview on 03/05/12, approximately 11:14 AM, physician "U", Phelps County Coroner, stated that:
-The preliminary cause of death for Patient #1 is drug overdose; and
-Patient #1's body was sent to another acute care facility for autopsy.