HospitalInspections.org

Based on policy review, medical record review and staff interview the hospital's nursing staff failed to supervise and evaluate nursing care by failing to assess vital signs per policy and failing to notify a physician of a held medication for 1 of 5 sampled patients (#4).

The findings include:

Review of current hospital policy entitled "Vital Signs" dated 10/01/2008 revealed, "Vital signs...include temperature, pulse, respirations, blood pressure, oxygen saturation levels and pain scoring....Frequency for obtaining, documenting and reporting vital signs are:...MSP (Medical/Surgical/Pediatric Unit) as listed below:...Telemetry (use of heart monitor) - every 4 hours....Routine - every 8 hours....Vital signs must be obtained more frequently if the patient's condition, regimen or procedure dictates...."

Closed medical record review for Patient #4 revealed an 88 year old female that was admitted to the MSP unit on 11/22/2009 with dementia for respite care while her primary care giver was hospitalized at another facility. Record review revealed the patient was referred to the hospital for respite care from a community hospice agency. Record review revealed a physician's order dated 11/22/2009 for "Do Not Resuscitate". Record review revealed the patient had an EKG (electrocardiogram) on 11/23/2009 that showed atrial fibrillation (an irregular heart rhythm). Record review revealed a physician's order dated 11/23/2009 at 1500 for telemetry monitoring (continuous heart monitoring) for 24 hours. Record review revealed the patient was on the heart monitor from 11/23/2009 at 1829 until she expired on 11/24/2009 at 1832. Record review revealed the last assessment of vital signs was documented on 11/24/2009 at 0702 (11 hours and 30 minutes before the patient's death). Further record review revealed the patient's blood pressure (BP) at 0702 was 85/48 (low) and her pulse was 42 (low). Review of nurse's note on 11/24/2009 at 0825 revealed, "...(Physician) notified of patients status being unresponsive. (Low) B/P and (low) heart rate...." Review of nurse's note at 1055 revealed the patient's heart rate was 39 per the telemetry monitor. Record review revealed no further documentation of vital signs.

Further record review revealed the nurse reported a high blood Potassium level of 6.9 mmol/L (millimoles per liter) to the physician on 11/24/2010 at 0825. Record review revealed a physician's order at 0830 to administer a Kayexalate enema to the patient. Record review revealed the patient's blood Potassium level was 8.0 mmol/L at 1655, at which time the laboratory notified the MSP Unit's charge nurse of the high level. Record review revealed Patient #4's nurse administered the Kayexalate enema at 1700 (8 1/2 hours after the physician ordered it). Record review revealed no documentation of the reason the nurse did not administer the medication when ordered or documentation that the nurse told the physician the medication was not given.

Interview on 01/05/2009 at 1700 with the patient's physician revealed the patient's blood Potassium was high on the morning of 11/24/2009, so he wanted the nurse to give the patient a Kayexalate enema. Interview revealed the purpose of the Kayexalate enema was to decrease the patient's blood Potassium level. Interview revealed, "She (the nurse) did not tell me she didn't give the enema in the morning. I had her give it in the afternoon when I found out."

Interview on 01/06/2010 at 0915 with the nurse that was assigned to Patient #4 from 0700-1900 on 11/24/2009 revealed vital signs must be assessed and documented every 4 hours for all patients that are on the heart monitor. Interview revealed, "I was going in often to check her (Patient #4) and was taking her blood pressure. It should be documented." Interview revealed the nurse usually documents vital signs on the flow sheet or in the nurse's notes. Interview confirmed the last available documentation that the nurse assessed the patient's heart rate was on 11/24/2009 at 1055 (7 hours and 37 minutes before the patient's death). Further interview confirmed the last available documentation that the nurse assessed the patient's temperature, respirations and blood pressure was on 11/24/2009 at 0702 (11 hours and 30 minutes before the patient's death). Interview revealed the nurse did not give the Kayexalate enema immediately when ordered by the physician because the patient's pulse and blood pressure were low and she was afraid the pulse and blood pressure would drop even more due to a vagal response that an enema might cause. Interview revealed the nurse thought she told the physician she did not give the enema. Interview confirmed there was no available documentation that she notified the physician of her decision to withhold the medication.

Interview on 01/06/2009 at 0920 with the Chief Nursing Officer (CNO) confirmed there was no available documentation the nurse assessed Patient #4's vital signs every 4 hours while the patient was on the heart monitor per policy. Further interview confirmed there was no available documentation that the nurse notified the physician of her decision to withhold the medication.


NC00060867