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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES was out of compliance.

A-0395 RN SUPERVISION OF NURSING CARE A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and document review, the facility failed to ensure the nursing care provided met the continuous care needs of patients and was in accordance with facility protocol, policy, and national guidelines. Specifically, the facility failed to ensure registered nurses (RNs) assessed detox patients on Clinical Institute Withdrawal Assessment (CIWA) protocols (clinical assessment used to diagnose the severity of alcohol withdrawal) and ensure patients were assessed after medication was administered in three of four medical records reviewed (Patient #2, #3, and #4). Additionally, nursing staff failed to identify and respond to changes in the patient's condition, implement timely interventions, and inform medical providers when the patient's condition worsened in one of four medical records reviewed (Patient #3).

Based on interviews and document review, the facility failed to ensure the nursing care provided met the continuous care needs of patients and was in accordance with facility protocol, policy, and national guidelines. Specifically, the facility failed to ensure registered nurses (RNs) assessed detox patients on Clinical Institute Withdrawal Assessment (CIWA) protocols (clinical assessment used to diagnose the severity of alcohol withdrawal) and ensure patients were assessed after medication was administered in three of four medical records reviewed (Patient #2, #3, and #4). Additionally, nursing staff failed to identify and respond to changes in the patient's condition, implement timely interventions, and inform medical providers when the patient's condition worsened in one of four medical records reviewed (Patient #3).

Findings include:

Facility policies:

The Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy read, reassessment of the hospitalized patient is a continuous, ongoing process based upon department-specific assessment parameters as well as in response to changes in diagnosis, treatments, procedures, and the plan of care. Patient condition and ongoing changes in status warrant more frequent reassessment and documentation of specific system changes as determined by the caregiver. A registered nurse (RN) supervises and evaluates the nursing care for each patient.

The Medication Administration policy read, before the administration of any medication, the health care professional administering the medication will ensure the following information: the indications for which they are prescribed, the clinical situations in which they are administered, and the needs of the patient receiving the medication.

Facility order sets:

The Provider Order Set: Alcohol Withdrawal CIWA Less Than 19 read, CIWA nursing assessments should be completed as follows: For CIWA greater than 19, every 30 minutes times 2, then every 2 hours. For CIWA between 8-19, every 2 hours times 2 then every 4 hours. For CIWA less than 8, every 4 hours. Always check CIWA within 1 hour after medications. Notify the provider if CIWA does not decrease by at least 3 points after medication administration. The provider should be notified if the CIWA score is greater than 19, if there is any seizure activity, and/or if there is new onset delirium and/or hallucinations.

The Provider Order Set: Alcohol Withdrawal Intensive Care Unit (ICU) read, the following interventions were to be provided only within the ICU and the Alcohol Withdrawal CIWA Less Than 19 order set and the Alcohol Withdrawal ICU order set must be used in conjunction with one another for CIWA scores greater than 19. CIWA nursing assessments should be completed as follows: For CIWA greater than 19, every 30 minutes times 2, then every 2 hours for patients not receiving a sedating infusion. For patients sedated with dexmedetomidine (a medication used to sedate non-intubated patients and reduce the severity of alcohol withdrawal), concurrent administration of intravenous (IV) lorazepam (a medication used to treat alcohol withdrawal) was to occur for the prevention of alcohol withdrawal seizures. Additionally, for patients receiving dexmedetomidine infusions nursing staff were to reassess the patient's CIWA score every hour.

References:

The Elsevier Clinical Skills - Alcohol Withdrawal reference, provided by the facility, read, delirium tremens (DTs) is a potentially fatal condition occurring 24 to 72 hours after cessation or reduction of prolonged and heavy alcohol use. Reassess signs and symptoms of alcohol withdrawal symptoms (AWS) including assessing for DTs using standardized assessment tools such as CIWA. Assess the patient's response to medications and other treatments or interventions. Monitor the patient's vital signs, orientation, sleep, and emotional status, including suicidal thoughts. Monitor a patient receiving pharmacotherapy for signs of oversedation and respiratory depression. Continue to reassess the patient's condition until an assessment is no longer clinically indicated per the organization's practice regarding alcohol withdrawal.

1. The facility failed to ensure nurses identified and responded to changes in the patient's condition, implemented timely interventions, informed medical providers when the patient's condition worsened, and conducted CIWA assessments for patients who were undergoing alcohol detoxification per facility protocol, policy, and national guidelines.

a. A review of Patient #3's medical record revealed on 2/5/24 at 6:14 p.m., Patient #3 was admitted for alcohol withdrawal and pancreatitis (inflammation of the pancreas). Further record review revealed the provider had ordered CIWA assessments to be completed and for Patient #3 to receive nothing by mouth (NPO).

i. A review of the CIWA flowsheet for Patient #3 revealed on 2/5/24 at 6:02 p.m. Patient #3's CIWA score was 7.

Patient #3's next CIWA assessment was performed five hours and 42 minutes later at 11:44 p.m.

This was in contrast to the Alcohol Withdrawal CIWA Less Than 19 Provider Order Set which read, for CIWA scores less than 8 the patient should be assessed every 4 hours.

ii. On 2/6/24 at 3:46 a.m., RN #6 completed a CIWA assessment for Patient #3. Patient #3's CIWA score at the time was 15. At 3:53 a.m. RN #6 administered a one milligram (mg) tablet of lorazepam to Patient #3.

The administration of the lorazepam tablet contradicted the NPO order entered on 2/5/24 at 6:14 p.m. Furthermore, there was no indication Patient #3 had been reevaluated within one hour of receiving the medication to assess its effectiveness.

Further review of Patient #3's medical record revealed at 5:35 a.m., one hour and 49 minutes after Patient #3 had been administered lorazepam, RN #7 conducted a CIWA assessment. Patient #3's CIWA score was 14, despite having a continued elevated score, no additional medication had been administered to the patient. Additionally, no communication had been initiated with Patient #3's medical provider regarding an elevated CIWA score greater than 11 or that Patient #3's CIWA score had not decreased by at least three points. Lastly, there was no evidence Patient #3 had been administered medication for alcohol withdrawal when their CIWA score was 14.

At 6:02 a.m., twenty-three minutes after Patient #3 had a CIWA score of 14, RN #7 and a phlebotomist entered Patient #3's room and found the patient unresponsive. At 6:03 a.m. a code blue (a code used to indicate a patient requiring resuscitation) was called and CPR (cardiopulmonary resuscitation) was initiated. CPR was terminated at 6:23 a.m. and the patient subsequently died.

These events were in contrast to the Alcohol Withdrawal CIWA Less Than 19 Provider Order Set which read, always check CIWA within one hour after medications have been administered. Notify the provider if the CIWA score does not decrease by at least three points after medication administration or if there are additional concerns. In addition, notify the medical provider for CIWA scores greater than 11.

iii. A review of the safety event for Patient #3 revealed Patient #3's death was unexpected.

On 4/15/24 at 3:48 p.m., an interview was conducted with patient safety program manager (PSPM) #5. PSPM #5 stated they had interviewed nursing staff and the medical provider (Provider #3) who had cared for Patient #3 on the morning of 2/6/24. However, this interview was in contrast to an interview conducted on 4/16/24 at 9:30 a.m. with Provider #3. During the interview Provider #3 stated they had not spoken to PSPM #5 or quality and patient safety leadership after Patient #3 had expired.

PSPM #5 stated they had reviewed Patient #3's medical record on 2/7/24 and a critical event analysis (CEA) had been performed on 2/12/24. PSPM #5 stated after interviews, medical record review, and the CEA were conducted no inconsistencies or concerns in the care provided to Patient #3 had been identified.

This was in contrast to Patient #3's medical record review which had identified, nursing staff failed to identify and respond to changes in Patient #3's condition and implement timely medical interventions. Additionally, nursing staff failed to inform Patient #3's medical provider Patient #3's medical condition worsened, and the patient expired.

Additionally, on 4/10/24 at 3:49 p.m., 4/11/24 at 3:58 p.m., and 4/15/24 at 5:00 p.m. surveyors requested evidence of the corrective actions and preventive measures implemented by the facility after the facility investigated and evaluated the care provided to Patient #3. However, the facility was unable to provide this evidence.

b. A review of Patient #2's medical record revealed on 3/30/24 at 11:16 p.m. Patient #2 was directly admitted to the ICU for acute alcohol withdrawal and management of alcohol withdrawal symptoms.

Patient #2's medication administration record revealed on 3/31/24 at 12:37 a.m. a dexmedetomidine continuous infusion was initiated and the continuous infusion was not discontinued until 4/3/24 at 2:15 a.m. Review of the CIWA assessments for Patient #3 revealed nursing staff had not performed hourly CIWA assessments in accordance with the Provider Order Set: Alcohol Withdrawal Intensive Care Unit while Patient #2 received the dexmedetomidine continuous infusion. Examples included:

i. On 3/31/24 between 12:30 a.m. and 12:00 p.m. (a duration of 11 hours and 30 minutes), nursing staff performed six CIWA assessments for Patient #2. The CIWA assessments were performed at,12:30 a.m., 1:57 a.m., 4:00 a.m., 6:00 a.m., 10:00 a.m., and 12:00 p.m.

Additionally, from 2:18 p.m. to 11:00 p.m. (a duration of 8 hours and 42 minutes), four CIWA assessments were performed for Patient #2. The CIWA assessments were performed at 2:18 p.m., 6:00 p.m., 8:58 p.m. and 11:00 p.m.

ii. On 4/1/24 between 4:00 a.m. and 10:00 p.m. (a duration of 18 hours), there were six CIWA assessments performed for Patient #2. The CIWA assessments were performed at, 4:00 a.m., 9:40 a.m., 3:00 p.m., 6:00 p.m., 8:00 p.m., and 10:00 p.m.

iii. On 4/2/24 between 2:00 a.m. and 7:00 p.m. (a duration of 17 hours), nursing staff performed six CIWA assessments for Patient #2. The CIWA assessments were performed at, 2:00 a.m., 6:00 a.m., 11:00 a.m., 6:00 p.m., 6:36 p.m., and 7:00 p.m.

c. Review of Patient #4's medical record revealed Patient #4 was directly admitted to the ICU on 3/11/24 at 11:55 p.m. after the patient had a witnessed alcohol withdrawal seizure.

According to Patient #4's medication administration record on 3/12/24 at 12:14 a.m. Patient #4 was placed on a dexmedetomidine continuous infusion. The continuous dexmedetomidine infusion was not stopped until 3/22/24 at 5:46 p.m.

Upon review of the CIWA assessments performed for Patient #4, hourly CIWA assessments had not been performed while Patient #2 was administered the dexmedetomidine. Additionally, Patient #2's medical record showed no evidence of CIWA assessments being performed prior to 3/22/24.

The events for Patient #2 and Patient #4 were in contrast to the Provider Order Set: Alcohol Withdrawal Intensive Care Unit (ICU) which read, nursing staff were to perform CIWA assessments every hour for patients receiving dexmedetomidine in the ICU.

Additionally, these events were in contrast to the Elsevier Clinical Skills - Alcohol Withdrawal reference and the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, the medical condition of alcohol withdrawal patients and their response to medical treatment should have been assessed until no longer clinically indicated.

d. On 4/10/23 at 2:25 p.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated it was important to follow CIWA protocol to prevent seizures and possible death. RN #2 stated it was important to reassess patients after medication administration to ensure the medication was working to treat the patient's symptoms. RN #2 further stated if the medication was not effective, they would notify the provider.

e. On 4/11/24 at 4:56 p.m., an interview was conducted with RN #1. RN #1 stated lorazepam was often used to treat withdrawal symptoms. RN #1 further stated the patient needed to be assessed one hour after medication administration. RN #1 stated if a CIWA patient was not assessed or treated with medication, there was a risk that the patient would have a seizure or possible death.

f. On 4/16/23 at 9:15 a.m., an interview was conducted with Provider #3. Provider #3 stated it was important to reassess a patient after medication administration to ensure the medication was working and to ensure the patient was not going through alcohol withdrawal. Provider #3 stated they expected to be notified when CIWA scores increased for patients with a prior history of alcohol withdrawal. Provider #3 stated they relied on the nursing staff to notify them when alcohol withdrawal patients exhibited changes in behavior and began experiencing alcohol withdrawal symptoms regardless of whether or not medication had been administered to the patient. Additionally, Provider #3 stated alcohol withdrawal could have been deadly for patients.