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Based on record review it was determined the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care of 1 in 10 sampled patients (P1, P2, P3, P4, P5, P6, P7, P8, P9, and P10). The registered nurse failed to ensure oxygen delivery to P4 per physician order.

Findings include:

According to hospital records, on 3/25/2011 P4 was admitted with ADL mobility dysfunction with history of esophageal dysmotility status post laparoscopic fundoplication complicated by cardiac arrest. CPR was performed, s/he had a transvenous pacemaker placed and s/he was transferred to the ICU. S/he was stabilized and transferred back out to a nursing floor. S\he had acute renal failure secondary to hypotension but it was being resolved with fluids. The patient was taken back to surgery for completion of the distal myotomy. S/he was on TPN but was weaned to solid foods. S/he also had a gastric tube in place. The patient was being seen by physical therapy (PT) and occupational therapy (OT) and so s/he was transferred to the Rehabilitation Unit on 3/22/2011.

Despite the patient's multiple medical comorbidities, the physicians ordered 3 hours/day of physical therapy, occupational therapy and speech therapy to get her/him to an independent level. The patient was motivated to make good gains toward independence.

Record review of the patient revealed that on 4/10/2011 at 2245 hours, s/he experienced a change in mentation, with an increase in hypoxia and decrease in breath sounds. The Rapid Response Team (RRT) was summoned, a Code Blue was called. A responding physician documented that the patient appeared to have aspirated again since the chest x-rays revealed increased consolidation. The patient's SpO2 decreased from 96% down to 88% during this episode. The patient's son was notified of the event and he came in to the hospital to be with the patient. The patient's condition improved and by 2400 hours the SpO2 had increased to "high 90s" per RN documentation.

After assessing the patient, the physician determined that the patient should be transferred back to the Coronary Care Unit (CCU) the following morning. The son elected to stay with the patient. At 0047 hours the RN documented a SpO2 of 96% on 2 liters per minute (lpm). The next nursing entry occurred at 0355 hours when the SpO2 was noted to be 72%. The respiratory therapist documented the oxygen had become disconnected. Oxygen was reconnected and at 0402 hours the patient's SpO2 was up to 98%. By 0703 hours the nurse documented "Patient checked frequently and on oximetry. Kept at 90(%) and tube feeding remains off."

At 0735 hours, stat arterial blood gases (ABGs) and a chest x-ray were ordered and the results were called to physicians. The patient was placed on BiPap and transferred to CCU.

Record review revealed a lack of documentation that the patient's condition was monitored after the Code Blue, between 0047 hours and 0355 hours when the SpO2 dropped to 72%. The nurse failed to supervise and evaluate the nursing care of this patient as his/her condition warranted.