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Based on document review, staff interview and in (one) 1 of 15 medical records reviewed, it was determined the medical staff did not follow the facility's policy for management of sepsis and did not identify, care and treat a patient in a timely manner (Patient #1).

Findings include:

Patient #1's medical record identified; This ninety-four year old patient presented to the Emergency Department (ED) on December 16, 2015 because he had fallen at home and had sustained a right fractured hip. The patient had a previous medical history of Hypertension and Dementia. The ED doctor documented that the patient was alert and oriented to person and fully oriented. The patient underwent a Right Hip Arthroplasty that day, during which he had an interval of a rapid heart rate and low blood pressure. The patient's condition improved and stabilized until December 28, 2015, when at 8:00 PM a nurse's documentation revealed; the "Patient's family states patient doesn't look right. Patient lethargic, barely opening eyes."
A physician was called and an intravenous fluid of 0.45% NS was started at 45 cc/hr (centimeter/hour).
The medical record also revealed patient's white cell count (WBC) at 7:00 AM was 18.1 K/mm 3 (normal range 4.0 - 10.0) and it rose to 19.8 at 1:00 PM that day.


A review of Performance Improvement Risk Management document dated December 31, 2015, noted a physician documented that she "was first notified by patient's nurse around 10:00 PM that he was having difficulty breathing despite nebulization; that she thought that he was retaining fluid in his lungs and that he had bilateral peripheral edema. She expressed that the daughter was at bedside and concerned about her father's condition. She explained that she had attempted to call the primary medical doctor (PMD) 3 times without any response and therefore was now requesting my assistance."

The medical record revealed this physician's note at 11:17 PM that night stated; the patient had possible Aspiration and Sepsis which was most likely secondary to Aspiration Pneumonia. This assessment revealed the patient was in acute distress, lethargic and non-verbal. This physician also documented that the patient had an acute hypoxic respiratory distress secondary to fluid overload. The abdomen was distended and there was 3+ lower extremity pitting edema. The ejection fraction was 35%. The blood urea and nitrogen levels (BUN) at 11:00 PM was 45 (normal is 8 - 20) and the creatinine was 2.3 (normal is 0.7 - 1.3). Lasix stat was given at this point. The oxygen saturation was 91% (normal 96-100%) on a non-rebreathing mask at 10:59 PM and the heart rate had increased from 105 beats per minute at 5:52 PM (normal range is 60 - 100), to 195 beats per minute at 10:59 PM that night. In addition, this physician documented that a Foley Catheter was inserted and that more than 600 cc of brown-burgundy colored urine drained after its insertion. Antibiotics were ordered and given after midnight and the patient died at 5:20 AM that morning, 5 hours after the antibiotics were administered and 9 hours after the family identified the change in the patient's condition.


The facility's policy titled "Adult Non-Invasive or Invasive Sepsis, (Early, Severe and Shock), Management Of," which was last revised in February 2015, stated "In the worse cases, infection leads to a life-threatening drop in blood pressure, called septic shock. This can quickly lead to the failure of several organs -- lungs, kidneys and liver -- causing death. Therefore, rapid response in the identification, care and treatment of the patient with early sepsis is essential."

On December 28, 2015, the patient's white cell count (WBC) elevated at 7:00 AM and was 18.1 K/mm 3 (normal range 4.0 - 10.0) and it rose to 19.8 at 1:00 PM that day. There is no documentation that the medical staff identified and treat the patient's elevated WBC at 7:00 AM on December 28, 2015 until midnight when antibiotics were administered, after the patient's condition had decompensated. In addition, there was no documentation that a physician examined the patient and revised the care plan until 2 hours after the patient's condition had decompensated.

The findings were shared with Staff A, the Risk Manager, during an interview on February 22, 2016 at 12:00 PM.

Based on document review and staff interview and in (one) 1 of 15 medical records reviewed, it was determined the nursing staff did not perform ongoing assessment and reassessment when a change in a patient's condition was identified. (Patient #1).

Findings include:

On December 28, 2015 at 8:00 PM a nurse's documentation in the medical record for Patient #1 revealed; the "Patient's family states patient doesn't look right. Patient lethargic, barely opening eyes."

The doctor's note at 11:17 PM stated the patient was in acute distress, lethargic and non-verbal. The physician also noted that the patient had an acute hypoxic respiratory distress secondary to fluid overload. The abdomen was distended and there was 3+ lower extremity pitting edema. In addition, this physician documented that a Foley Catheter was inserted and that more than 600 cc of brown-burgundy colored urine drained after its insertion.

There was no documentation of a nursing assessment/reassessment at 8:00 PM when the change in the patient's condition was identified. The oxygen saturation and heart rate were documented at 10:59 PM, 3 hours after the change in the patient's condition. At this point the oxygen saturation was 91% and the heart rate had increased from 105 at 5:52 PM to 195 at 10:59 PM. In addition, the record does not indicate when oxygen therapy was initiated and the patient's response to its administration.

The facility's policy titled "Patient Assessment," which was last revised in November 2014, states "Assessment is systematic and ongoing and is performed by the Registered Professional Nurse. Ongoing assessment/reassessment alerts the Registered Professional Nurse to changes, improvement and deterioration in the patient's status. Changes in the patient's condition may necessitate changes in the treatment, nursing interventions and plan of care and/or care provided by other health care professionals."

The findings were shared with Staff A, the Risk Manager, during an interview on February 22, 2016 at 12:00 PM.

Based on document review, staff interview and in (one) 1 of 15 medical records reviewed, it was determined the nursing staff did not revise and update, a nursing care plan for a patient when his condition deteriorated (Patient #1).

Findings include:

Review of the medical record identified; Patient #1 was alert and oriented to self upon admission on December 16, 2015. On December 28, 2015 at 8:00 PM, he became "lethargic, barely opening eyes."

There was no documented evidence of a revision in the patient's nursing care plan. In addition, the patient's status was changed to "Do Not Resuscitate/Do Not Intubate (DNR/DNI)" at approximately 11:00 PM that night but there was no documented evidence in the medical record of any change in the nursing care plan.

The facility's policy titled "Patient Assessment," which was last revised in November 2014, states; "Assessment is systematic and ongoing and is performed by the Registered Professional Nurse. Ongoing assessment/reassessment alerts the Registered Professional Nurse to changes, improvement and deterioration in the patient's status. Changes in the patient's condition may necessitate changes in the treatment, nursing interventions and plan of care and/or care provided by other health care professionals."

The findings were shared with Staff A, the Risk Manager, during an interview on February 22, 2016 at 12:00 PM who acknowledged the findings.