HospitalInspections.org

Based on document review and interview, the facility failed to ensure adequate numbers of licensed nursing staff for 11 of 42 shifts (see tag 392) and failed to supervise and evaluate care provided related to response to alarms (see tag 395).

Findings include:

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that Nursing Services were provided in a safe manner.

Based on document review and interview, the hospital nursing staff failed to ensure adequate numbers of licensed nursing staff necessary for the provision of care to patients, for 11 shifts of 42 shifts (day shifts for: 9/5/2021, 9/12/2021 & 9/17/2021 and evening shifts for: 9/6/2021, 9/8/2021, 9/9/2021, 9/14/2021, 9/15/2021, 9/16/2021, 9/17/2021 & 9/18/2021).

Findings include:

1. Review of established hospital policy titled: "Scope of Care, 5 West (Oncology/Medical/Telemetry)", policy number - none listed, indicated on page 1, under C. Staffing Plan: 1. Pattern (staffing adjustment variances), "The general nurse-patient ratio is 1:5 on 7-3, 3-11 and 1:6 on 11-7 shifts, but may vary to a higher nurse-patient ratio based on acuity". Last reviewed 2019.

2. Review of staffing pattern worksheet and 5 West "Assignment Sheets", for weeks of September 5 - 11/2021 and September 9 - 12, 2021; indicated the following:
A. Days shifts: 9/5/2021, census = 29 patients; Nurses = 5 (ratio > 1:5)
9/12/2021, census = 30 patients; Nurses = 6 (with one as orientee; ratio > 1:5)
9/17/2021, census = 30 patients; Nurses = 5 (ratio > 1:5)
B. Evening shifts: 9/6/2021, census = 31 patients; Nurses = 5 (ratio > 1:5)
9/8/2021, census = 30 patients; Nurses = 5 (ratio > 1:5)
9/9/2021, census = 30 patients; Nurses = 5 (ratio > 1:5)
9/14/2021, census = 31 patients; Nurses = 5.5 (ratio > 1:5)
9/15/2021, census = 30 patients: Nurses = 5.5 (ratio > 1:5)
9/16/2021, census = 28 patients; Nurses = 5 (ratio > 1:5)
9/17/2021, census = 30 patients; Nurses = 5 (ratio > 1:5)
9/18/2021, census = 28 patients; Nurses = 5 (ratio > 1:5)
C. 5 West "Assignment Sheets", lacked documentation for patient(s) acuity level; for staffing.

3. In interview on 10/26/2021, at approximately 3:30 pm, with A # 2 (Director - Patient Care Services), the following was confirmed:
A. Some shifts not at set ratios for census/number of patients..
B. Some shifts are short.
C. No acuity of patients on staffing assignments sheets, for 5 West.

Based on document review and interview, the Registered Nurse failed to supervise and evaluate care provided to each patient, and follow P&Ps (Policy & Procedure) for Telemetry Monitoring and Clinical Alarm Safety for 1 of 10 MRs (Medical Records) reviewed. (Patient # 3).

Findings include:

1. Review of established hospital policy titled: Telemetry Monitoring (and Alarm Safety)", policy number: PCS-T, on page 3, under Monitor Alarms, "Arrhythmia alarms are reviewed within one (1) minute of the alarm", "Alarms will be reviewed/discarded at least at the end of of each 8 hour shift". Last reviewed 2019.

2. Review of established hospital policy titled: "Clinical Alarm Safety", policy number - none listed, on page 1, under Medical Equipment/Device Alarms:, 8.0, "The hospital staff member... assigned to or treating the patient must immediately respond to medical equipment alarms". Last revised 3/2019.

3. Review of Patient # 3's MR, indicated the following:
A. Patient admitted on 9/9/2021, to 5 West (Medical/Oncology/Telemetry unit), to room 502; for complaints of abdominal pain and shortness of breath. Patient's orders, from ED (Emergency Department) Physician, included telemetry monitoring.
B. Code blue documentation on 9/12/2021 at 9:02 am, reflected team was called to assist a code blue called for patient # 3. Patient unresponsive; cardiac rhythm "Asystole", CPR (Cardiopulmonary resuscitation) was initiated. Emergency medications were given, chest compressions; Endotracheal intubation by ED Physician (at 9:10 am); cardiac rhythm "PEA" (Pulseless electrical activity) at 9:10 am; code interventions completed at 9:20 am; patient with "palpable pulse"; intubated, supplemental oxygen and ambued (for ventilation).
1. "Patient aspirated on eggs".
2. ED Physician noted: Upon arrival patient in "asystole with chest compressions in progress". Patient airway obstructed with food particles"; "Per nursing report patient had been eating breakfast when they noticed that" patient was "asystole" on the monitor.
C. Patient's MR lacked telemetry monitor strips for prior to code (8:38 am) and during code blue.
D. Patient transferred to ICU (Intensive Care Unit), on 9/12/2021, after code blue.
E. Patient with additional code blue event; note on 9/22/2021 at 10:04 pm; patient unresponsive; code interventions completed. Patient's family decision for then DNR (Do not resuscitate), and patient expired at 10:49 pm.
F. MD # 31 (Family Medicine) discharge - death summary; reflected diagnoses that included "Anoxic encephalopathy"; two days after admission, patient had episode of asystole on the monitor while eating breakfast; code blue was called.

4. Review of Telemetry monitoring alarm logs for Patient # 3; in room 502, for am of 9/12/2021, indicated the following:
A. A red alarm sound played at 8:35 am.
B. A red alarm sound played at 8:38 am; heart rate "48".
1. Continued on alarm log: red alarm sound played; for heart rate "34", "26" then to "asystole".
2. Continued on alarm log: red alarm sound played; with noted to yellow alarm sound at 9:01 am.

5. In interview on 10/25/2021 at approximately 3:45 pm, with N # 20 (RN - Registered Nurse - 5 West), indicated the following:
A. Unit was short staffed on 9/12/2021; staff were rounding on patients, no one at the nurses station.
B. N # 20 and N # 22 (RN - 5 West) into nurses station to grab something and noticed alarm sound and red alarm for patient # 3; strips started running at 8:38 am. To patient's room, found patient and code blue called.

6. In interview on 10/25/2021 at approximately 10:05 am and on 10/26/2021 at approximately 4:00 pm, with A # 1 (Director Quality/Risk), confirmed the following
A. Patient # 3's monitor alarms, for red were not responded to for (=/>) 22 minutes. Was not noted immediately.
One or two staff members in and out of nurses station, who did not notice; where other alarms going off at the time.
B. Patient did code; patient did expire on 9/22/2021, evening shift.
C. Do not have telemetry monitor techs (technicians) for telemetry unit(s); each nurse is responsible for their own patients. No specific staff member assigned to watch tele-monitors.

Based on document review and interview, the hospital's nursing staff failed to follow P&P (Policy & Procedure) for Telemetry Monitoring documentation; for accurate results/recordings; for 5 of 10 MRs (Medical Records) reviewed. (Patients # 1, # 3, # 4, # 6 and # 10).

Findings include:

1. Review of established hospital policy titled: "Telemetry Monitoring (and Alarm Safety)", policy number PCS-T, on page 1, last paragraph, "A six second rhythm strip of the patient's monitor pattern will be documented at the beginning of the shift on a monitor strip sheet ..., every eight hours (7am, 3pm, 11pm) and prn" (as needed); "Any significant change of rhythm will be documented as it occurs", and on page 3, under ECG (Electrocardiogram) Monitoring Strips Documentation, second sentence, "ECG monitoring strips are documented on admission, and at least every 8 hours and with any change in the patient's condition or cardiac rhythm". Last reviewed 2019.

2. Review of MRs for patients # 1, # 3, # 4, # 6 and # 10, reflected the following:
A. Patient # 1's MR lacked monitoring strips for days/shifts: 9/11/2021 for all 3 shifts: 9/13/2021 for day & evening shift; 9/14/2021 for day & evening shift and 9/15/2021 for all 3 shifts.
B. Patient # 3's MR lacked monitoring strips for patient's change in cardiac rhythm/condition: code blue event (prior to 8:38 am {asystole}, during code blue and after code stopped at 9:20 am).
C. Patient # 4's MR lacked monitoring strips days/shifts: 9/16/2021 for night shift; 9/17/2021 for evening shift; 9/18/2021 for evening & night shift and 9/19/2021 for day & evening shift.
D. Patient # 6's MR lacked monitoring strips for days/shifts: 10/4/2021 for all 3 shifts; 10/20/2021 for day & night shift; 10/21/2021 for evening & night shift; 10/22/2021 for evening & night shift and 10/24/2021 for night shift.
E. Patient # 10's MR lacked monitoring strips for days/shifts: 10/19/2021 for all 3 shifts; 10/20/2021 for day & night shift; 10/21/2021 for evening and night shift; 10/22/2021 for evening & night shift; 10/23/2021 for night shift and 10/24/2021 for night shift.

3. In interview on 10/26/2021, at approximately 2:23 pm, with A # 7 (Nursing Quality), the following was confirmed:
A. That the above patient's MRs had consistently lacked documentation - entries for required telemetry monitoring strips.
B. Policy was not followed for monitoring strip documentation by nursing staff; for each shift, and for a change in a patient's cardiac rhythm (patient # 3).