HospitalInspections.org

Based on interview and document review, the facility failed to adequately monitor 1 (#13) of 1 ventilator patients in the Emergency Department (ED) resulting in patient harm. Findings include:

Patient #13 was a 54 year-old ventilator patient, presented to the ED on 9/5/15 at approximately 1818 from the Extended Care Facility for mental status changes. The "Emergency Center Attending Progress Notes" dated 9/5/15 at 2033, documented that the patient was a chronic vent (ventilator) dependent patient, awake, alert and able to give history. The patient was found to have a urinary tract infection, the case was discussed with the PCP (primary care physician) with plans for admission and observation. The progress notes documented that the vent disconnected accidently and right soft wrist restraint was placed to protect the connection, on 9/5/15 at 2131.

The patient was admitted to "Inpatient Status" on 9/5/15 at 2310 per "CPOE (computerized physician order entry) Orders Report" but remained in the ED Bay #3 awaiting for an inpatient bed in the "PCU" (progressive care unit). The nursing "Daily Focus Assessment Report" and nursing "Progress Notes Report" documented "hourly rounds". The facility Director of Nursing, staff #D provided documentation requirements for PCU level of care on 10/7/15 at approximately 0900. The documentation requirements provided was "Documentation Guidelines/Daily Assessment, EMR" (electronic medical record) undated, documented "Hourly Rounding should be completed per protocol and documented on the ADL's (activities of daily living) tab."

On 9/6/15 at 1136, the nursing "Progress Notes Report" documented "Respiratory at bedside. The patients (sic) inner cannula came out of the trach per respiratory. Dr XYZ was alerted. A new size 6 cuffed trach is at the bedside." The physician note dated 9/6/15 at 1140 documented "Called to bedside for partial trach removal. When arrived to bedside trach completely removed. Patient sats (oxygen saturation percentage) 98% in NAD (no acute distress). No blood or trauma noted at site... Trach replaced without complications. Ventilator replaced... Pulse Ox 100%. Patient tolerated without difficulty. Will continue to monitor."

Phone interview with Nurse #O, on 10/7/15 at approximately 1330, revealed that there were issues with the patient's trach and portable ventilators which were changed. She stated that she checked on the patient prior to break at approximately 1230 on 9/6/15, and the patient was stable. She gave report to the relief nurse at approximately 1235.

Interview with the relief Nurse #J, on 10/7/15 at approximately 1000, revealed that he came on duty on 9/6/15 at 1100 to provide relief for staff in the ED to take breaks. He stated that he was scheduled to relieve Nurse #O and got report from the nurse at approximately 1235-1240. He stated that he had three patients to attend to, one of which had an urgent need. He stated when he went in to check on patient #13, (on 9/6/15) at approximately 1253, "the tube was disconnected and the monitor looked like the patient was in asystole (no heart beat). A code was called and the patient was resuscitated." When queried if he heard any alarms go off, he stated, "no."

The patient was transferred to the Intensive Care Unit on 9/6/15 at approximately 2045 and hospitalization continued through 10/5/15. The patient was transferred back to the Extended Care Facility on 10/5/15. The "Discharge Instructions and Physician Orders" dated 10/5/15, documented "Hospital Problems: Anoxic Brain Injury, Splenic Laceration, Chronic Respiratory Failure..."