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The Condition of Participation for Nursing Services has not been met. Based on review of clinical records, review of hospital policies/procedures, review of hospital documentation and interviews with hospital personnel, it was identified that the hospital failed to ensure that nursing staff consistently assessed, monitored, and/or documented the care of one patient (Patient #4) who had a chest tube inserted that required suction and experienced worsening subcutaneous emphysema. In an expansion of the sample, 9 of 13 additional records of patient's with chest tubes were reviewed and failed to ensure that nursing staff consistently assessed, monitored, and/or documented care and management of the chest tube and the required suction.

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Based on review of clinical records, review of hospital policies/procedures, review of hospital documentation and interviews with hospital personnel for 1 (Patient #4) of 14 patients who had a chest tube inserted and experienced worsening subcutaneous emphysema, the hospital failed to ensure that nursing staff monitored and managed the chest tube and drainage system according to physician orders and/or hospital policy and/or the chest drainage unit manufacturer information. The findings include:


Patient #4 was admitted as an out-patient to the hospital on 4/9/14 for a planned lung biopsy via interventional radiology which was completed with no complications identified. A postoperative chest X-ray dated 4/9/14 at 10:00 AM identified evidence of a 5-10 % pneumothorax. A follow-up chest X-ray dated 4/9/14 at 11:02 AM identified a worsening left sided pneumothorax at 30% and identified that a chest tube was to be inserted. A thoracic surgeon (MD #16) was consulted and urgently inserted a chest tube at 1:05 PM. MD #16's operative report dated 4/9/14 documented that on insertion of the chest tube there was near complete re-expansion of the lung with immediate relief of shortness of breath and immediate improvement in oxygen saturation levels. A moderate air leak at the insertion site was noted. A post insertion chest X-ray dated 4/9/14 at 1:14 PM identified that the left surgical chest drain was in good position and there was a reduction in size of the pneumothorax. Nursing post-operative notes identified that crepitus (crackling feel under the skin) was noted.


Patient #4 was subsequently admitted for in-patient treatment of the pneumothorax and was identified with a history of mild chronic obstructive pulmonary disease. An admission order dated 4/9/14 at 1:55 PM directed: chest tube, empty and measure every 4 hours, suction 10 cm, left, when suction was being used, and the orange float must appear in the suction indicator window, which indicates suction was operative. Review of manufacturer information for the chest drainage unit directed to monitor the collection chamber and to increase source suction until the orange float appears in the suction indicator window.


An interview with RN #11 on 3/7/16 at 3:30 PM was conducted and included a clinical record review. A review of Patient #4's nursing admission assessment documentation dated 4/9/14 at 7:10 PM identified chest tube in left pleural space, bright red draining area marked, and the dressing was dry and intact. However, documentation failed to identify the amount of chest tube suction that was in use and failed to identify that the orange float appeared in the suction indicator window (indicating proper suction) per physician order. In addition, nursing documentation failed to include an assessment of Patient #4 for the presence of crepitus/subcutaneous emphysema, as previously identified. RN #11 was unable to identify why this documentation was not included in the clinical record.


Nurses notes dated 4/10/14 at 5:38 AM identified Patient #4 experienced dyspnea on exertion. An additional nurses note at 7:26 AM identified dyspnea on exertion, diminished breath sounds, chest tube suction was set at 10 cm, and that there was no subcutaneous emphysema and no air leak. However, 32 minutes later, a chest X-ray was obtained (7:58 AM) that demonstrated extensive subcutaneous emphysema from the neck and across the left chest and that the pneumothorax had increased in prominence.


Review of nursing documentation by RN #13 on 4/10/14 at 8:11 AM and interview with RN #13 on 3/3/16 at 2:30 PM indicated that RN #13 notified Physician Assistant (PA) #7 of Patient #4's change in condition as noted in the chest X-ray and there was a question of chest tube leakage. The note indicated that the chest tube suction was to be increased to 20 cm.


Review of nursing notes with RN #200 on 5/5/16 identified that there was a discrepancy between the nursing assessment of no subcutaneous emphysema and the chest X-ray that identified extensive subcutaneous emphysema during the same time frame, and could not identify why there was a discrepancy.


A physician progress note dated 4/10/14 at 8:30 AM identified that Patient #4 was experiencing an increase of the pneumothorax with an air leak and that the chest tube to low continuous wall suction was increased from 10 centimeters (cm) to 20 cm. Although RN #13 and PA #7 each documented that the chest tube suction was to be increased to 20 cm, PA#6 entered the order for the chest tube suction to be increased 20 cm on 4/10/14 at 10:06 PM.


Review of nursing notes with RN #200 on 5/5/16 failed to identify the amount of suction used between 4/10/14 at 8:30 AM through midnight on 4/10/14. RN #200 identified that based on documentation, the chest tube suction remained at 10 cm until 4/11/14 at 7:15 PM, despite PA #4's order on 4/10/14 to increase the suction to 20 cm. In addition, nursing documentation in this same time frame failed to include an assessment of Patient #4 ' s of the extensive subcutaneous emphysema.


On 4/11/14 at 2:50 AM a nursing note identified that Patient #4 experienced crepitus of the left upper chest. Interview with RN #12 on 3/7/16 at 2:45 PM identified that a chest tube assessment (for functioning) was not completed or documented at that time.


A nurse's note dated 4/11/14 at 7:20 AM identified that Patient #4 complained of chest discomfort and dyspnea, and the wall suction was found to have an air leak. Scattered wheezing was identified and Patient #4's a blood oxygenation level was within defined limits at 94. A physician progress dated 4/11/14 at 7:45 AM identified Patient #4's subcutaneous emphysema was more extensive and a pneumomediastinum (air in the mediastinum) was noted.


Review of the progress note dated 4/11/14 at 7:45 AM and interview with PA #5 on 3/3/16 identified that, although all the chest tube tubing was connected to the collection chamber, the orange float was not visible (indicating no suction). At that time, PA #5 found the wall suction was turned off and did not know how long the suction was off. PA #5 identified that once the wall suction was turned on, a large amount of air was audibly expelled.


Review of a nurse's note dated 4/11/14 at 9:30 AM and interview with RN #14 on 3/7/16 at 3:10 PM identified that the wall suction was "hissing." The entire wall suction was changed out and the wall suction setup was switched from the left side outlet to the right side outlet.


Between 9:00 AM and 4:00 PM on 4/11/14 Patient #4 was seen and treated by multiple physicians/PA's whose notes identified that crepitus was severe and spanned from the patient ' s neck to the genitalia. At 4:20 PM a Surgical PA identified that the suction system was replaced. A physician progress note dated 4/11/14 at 5:30 PM identified the extensive subcutaneous emphysema was due to the faulty suction and the patient was transferred to the ICU for additional care. Between 12:01 AM to 5:55 PM, nursing documentation failed to identify the amount of wall suction that was used. At 5:55 PM, nursing documentation identified that the chest tube suction remained at 10 cm, when the order (4/10/14) directed suction to be 20 cm. On 4/11/14 at 7:15 PM (approximately 36 hours later) nursing documentation identified that the chest tube suction was increased from 10 cm to 20 cm.


Between 4/10/14 and 4/12/14, multiple chest X-rays were obtained and there was no indication that the chest tube was in the wrong position. In addition, vital signs were obtained frequently throughout the admission and with each change in condition, and treatments were initiated as needed.


On 4/12/14 a nurses note at 7:30 AM identified that the suction container orange ball was continually dropping with movement. A thoracic surgeon note dated 4/12/14 at 9:00 AM identified that Patient #4 has crepitus from the left jaw to the thighs and across the chest and the extensive subcutaneous emphysema was due to a lack of suction for several hours. A nurse's note at 5:35 PM identified the subcutaneous emphysema extended to the patient ' s knees. A second opinion was obtained and Patient #4 returned to the operating room for a new chest tube placement. The new chest tube required a suction of 40 cm, remained in place until removal on 4/19/14, and the patient's condition had notably improved. On 4/21/14 Patient #4 was discharged home.


The hospital's chest tube insertion policy directed to check the functioning of the chest tube and the drainage system (including suction) with vital signs and changes in the patient's condition. Subcutaneous emphysema is an unexpected outcome for a patient with a chest tube. Documentation of goal/outcome evaluation will be assessed and documented at least once every shift.



b. In an expansion of the sample, 13 additional patient records were reviewed (Patients #37 - #49) for chest tube management (with drainage system) during their admissions between 2015 and 2016. Review of each of the clinical records including nursing documentation failed to consistently document that the orange float appeared in the suction indicator window (indicating proper suction) per physician order. There were no noted adverse medical problems as a result of the lack of documented suction amount.



c. Review of the clinical records of 4 (Patients #37, #45, #46, #47) of 13 patients with a chest tube and drainage system between 2015 and 2016 identified that nursing documentation failed to consistently reflect the change in chest tube suction amount as per physician order. There were no noted adverse medical problems as a result of the failure to document the increase the suction amount.


d. Review of clinical records of 9 (Patients #37, #38, #39, #41, #43, #45, #46, #47, #49) of 13 patients with a chest tube and drainage system between 2015 and 2016 identified that the assessments of the chest tube and drainage systems were not documented consistently on each shift and with a patient's change in condition, per chest tube clinical skills policy and manufacturer guidelines. There were no noted adverse medical problems as a result of the lack of documented assessments.

Interviews with RN #200 and the Regional Director of Quality and Safety on 5/5/16 identified that the hospital had just changed the vendor for the computerized patient records within the past week. The old computerized medical record had some challenges for nursing documentation and the hospital's switch to a new computerized system would allow for better nursing documentation.