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Based on interview, clinical record and facility document review, the facility failed to develop and maintain an effective, on-going, data-driven quality assessment and performance improvement program related to the New Vision program for medical stabilization services for alcohol and drug detoxification. The facility:

Failed to implement and monitor indicators related to an adverse event following the death of a patient (#5) who expired within approximately fifteen hours of admission to the New Vision program. The patient had an abnormal electrocardiogram with shortness of breath on admission and the Registered Nurse failed to report the information to the physician. Interview with the Risk Manager on 6/14/12 revealed no investigation had been conducted. There was no rationale as to why an investigation was not performed. (Refer to A0257)

Failed to implement and monitor indicators related to patient safety concerns to ensure physician orders for assessments were implemented as ordered. Interview with the Chief Nursing Officer on 6/15/12 revealed the electronic system was not showing the complete physician orders for the New Vision program for assessment of the Withdrawal symptoms resulting in nursing not being aware of the assessment needed to be conducted every four hours for twenty four hours for five of five New Vision patients. (Refer to A0267)

Failed to ensure the admitting physician, who did not know the new patient, was aware of the patient's medical history, status on admission and home medications that included Lisinopril, Coreg, Aspirin, Ventolin, Phenergan and Amox-clav for patient #5. (Refer to A0267)

Review of Quality Assessment and Performance Improvement Plan dated and meeting minutes from initiation of the program in 11/11 to 6/12 and interview with the Vice President of Quality on 6/15/12 revealed the New Vision Program for Medical Stabilization for alcohol and drug detoxification was not uded in the plan. (Refer to A0286)

The cumulative effect of the facility's failure to analyze and implement a plan of action following an adverse patient event and failure to include a new specialized program in the Quality Assessment Performance Improvement program resulted in the determination that the Condition of Participation for Quality Assessment Performance Improvement is not in compliance.

Based on record and facility document review and staff interview it was determined the facility failed to initiate tracking of indicators following an adverse incident (#5) and for patients (#6, #7, #8, #9) in the New Vision Program, which was a new program for medical stabilization for alcohol and drug detoxification. This resulted in continued lack of nursing assessment of the Withdrawal Severity Nursing Assessment per physician orders for five of five patients and failure to inform the physician of abnormal test result and changes in condition for one (#5) of five patients in the New Vision Program. This practice places patients at risk of a delay in treatment and prevention of injury related to withdrawal symptoms in the New Vision patients.

Findings include:

1. Patient #5 was admitted on 5/14/12 at 3:52 p.m. with an admitting diagnosis of acute alcohol withdrawal.

Review of nursing documentation dated 5/14/12 at 4:31 p.m. revealed the patient's vital signs were within normal limits except for a blood pressure of 175/104 and an oxygen saturation level of 93%. Review of the "Admission Assessment" completed by the registered nurse (RN) on 5/14/12 at 5:36 p.m. revealed the following assessments were not Within Defined Parameters (WDP): Neurological, ears, eyes, nose and throat (EENT), cardiovascular and gastrointestinal(GI)/nutrition. The patient currently had no pain. The neurological evaluation revealed the patient was alert, awake and oriented. His speech was soft. His left and right hand grips were weak. He had distant and recent past memory impairment. The behavior was anxious and cooperative. There were no tremors noted. The EENT evaluation revealed bilateral vision impairment and was hard of hearing in the left ear. The patient stated that he "needs glasses and hearing aide". The cardiovascular evaluation revealed the bilateral post tibia pulses were weak and he denied chest pain. The respiratory evaluation revealed the respirations were shallow. The breath sounds evaluation revealed the left lower and posterior lungs were diminished with a comment of "history of left lung tumor removal". The GI/nutrition evaluation revealed the abdomen was obese.

Review of the New Vision Standing Admission Orders, dated 5/14/12 at 5:40 p.m., revealed the orders were received as telephone orders from the physician to the RN. The orders included to admit to inpatient status, vital signs every 4 hours for twenty four hours, then every 4 hours while awake, call the physician if the blood pressure was less than 90/60 or greater than 160/100, and to complete the withdrawal severity nursing assessment every 4 hours for 24 hours then every 4 hours while awake. The standing orders instructed for an electrocardiogram (EKG) on admission if age 50 or older and if history of hypertension or cardiac disease, or as needed for symptoms of chest pain, shortness of breath or palpitations and call the physician. An EKG was performed on 5/14/12 since the patient was older than 50 years. The computerized documented time of the EKG was 4:36 p.m. The EKG machine generated an unconfirmed interpretation of "possible anterior infarct (heart attack), age undetermined, Abnormal ECG".
There was no documentation revealing the physician was notified of the abnormal EKG.

Review of the "Admission History" dated 5/14/12 at 6:09 p.m. completed by the RN revealed the admission diagnosis was Acute Alcohol Withdrawal. The documentation noted the patient was currently complaining of shortness of breath. The cardiovascular history revealed hypertension and anticoagulant therapy. The respiratory history noted the patient had asthma and shortness of breath. The home medication inventory receipt dated 5/14/12 (no time) was completed by the same RN. The form revealed the patient's current home medications were: Lisinopril, Coreg, amox-clav, aspirin, ventolin inhaler and Phenergan syrup. There was no evidence of what the medications were used for, the dosage, frequency, or when the last does was taken.

The patient's vital signs at 8:45 p.m. were within normal limits except for the blood pressure of 175/111.

The RN note at 8:06 p.m. revealed the patient was alert and oriented to person, place and time. There were no tremors noted. The physician was notified and received new order.
There was no evidence of new orders from the physician being obtained or written.

A " Withdrawal Severity Nursing Assessment" was completed by the Licensed Practical Nurse (LPN) on 5/14/12 and documented at 11:21 p.m. The assessment revealed hypertension at 151-175. A shift evaluation completed by the LPN at 11:26 p.m. revealed all systems were WDP except respiratory. An entry from respiratory therapy at 9:41 p.m. revealed the patient was receiving oxygen therapy at 3 liters per nasal cannula with a pulse oximetry reading at 97%.

Review of the nursing
documentation revealed no evidence the admitting physician was notified of the abnormal EKG, the high blood pressure,or abnormal findings on the initial assessment. There was no physician order for oxygen in the clinical record.

At 11:00 p.m. the patient received Trazodone 50 mg by mouth for insomnia and Seroquel 50 mg by mouth for anxiety.

LPN documentation dated 5/15/12 at 1:00 a.m., for the New Visions Withdrawal Severity, revealed the patient's heart rate was increased at 101-130, blood pressure 150 and below, mild sweating, and the patient was oriented to person, place and time. The vital signs at 1:07 a.m. were pulse 111 and blood pressure 124/81.

Review of the MAR revealed the patient did not receive the scheduled Ativan 1 mg by mouth on 5/15/12 at 1:57 a.m. because he was lethargic. There was no documentation of notifying the physician of the lethargy as ordered by the physician.

Nursing documentation at 3:55 a.m. noted the patient had removed his intravenous line.
The vital signs at 5:35 a.m. were pulse 112, respirations 20 and blood pressure 195/103.

Nursing documentation at 8:21 a.m., by the day shift RN, revealed "at approximately 7:10 a.m., went to the patient's room for bedside report with night shift nurse and patient was sleeping in bed naked. Prior to report, night shift nurse informed me that she just put the patient back in bed due to patient being found sleeping in the floor naked and was very confused. According to report patient has been doing this, in various occasions during the night. After finishing report for my other patients, at approximately 7:35 a.m. went back to patient's room and patient was out of the bed and appeared to be sleep walking, snoring with eyes closed. Tried to reorient patient and patient seemed to be still asleep. Put patient back in bed. Comfort measures provided...When I came back to the room to move the patient at approximately 7:40 a.m. the patient was found on the floor unresponsive. Assessed the patient and patient was not breathing and had no pulse. Code blue was called and started cardiopulmonary resuscitation (CPR) immediately. Unable to resuscitate patient after CPR."

Physician progress note for 5/15/12 at 8:00 a.m. code blue note revealed "arrived to find patient intubated with CPR in progress. According to nursing staff patient has been confused, lying in floor, curled up in corner, sleeping. Staff had talked to patient within 3 minutes prior to finding him unresponsive. Advanced cardiac life support (ACLS) protocol undertaken by resident staff, patient remained asystole and unresponsive to all interventions".

Review of the discharge summery dictated by the admitting physician on 5/15/12 at 12:41 p.m. revealed "the patient had a history of chronic alcoholism who presents with acute alcohol withdrawals. He was admitted and started on the usual withdrawal protocol. The patient was remarkably confused on admit suggestive of acute delirium tremors. He was placed in a quiet room, found to be walking with his eyes closed and had to be redirected. He was found not to be breathing, had no pulse, code blue was called and CPR was started. The patient expired. The documentation noted the patient had underlying heavy alcohol use suggestive of likely sudden death episode likely hypertensive.

An interview conducted with the Chief Nursing Officer (CNO) on 6/14/2012 at approximately 4:50 p.m. confirmed the above findings.

An interview with patient #5's physician was conducted on 6/15/2012 at approximately 10:30 a.m. The physician stated he did recall the patient. He stated he did not recall being notified of the results of the EKG that indicated a possible Anterior Infarct. He stated he did not recall being notified at any time of the patient's elevated blood pressure readings.

Review of nursing documentation did not reveal evidence of the nurse assessing the patient every four hours as ordered. The was no evidence of the admitting physician being notified of an abnormal EKG, Increased blood pressure, shortness of breath, the admitting history, use of oxygen via nasal cannula or home medications. The home medications included medications that may be used for high blood pressure, cardiac problem, nausea, anticoagulation therapy, and an antibiotic. There was no documentation by nursing that the patient had become confused or had a change in behavior, other than the lethargy, during the night.

The patient may have experienced harm by the nurse not assessing, evaluating, implementing physician orders and notifying the physician of a patient's changes in condition and needs.

2. Patient #6 was admitted to the Medical Stabilization Unit at 5:06 p.m. on 6/11/12 for medical stabilization of acute withdrawal from drugs. Review of the Withdrawal Severity Nursing Assessments revealed the assessment was not performed every 4 hours for 24 hours and then every 4 hours while awake as ordered by the physician. The Withdrawal Severity Nursing Assessment was documented on 6/11/2012 at 8:00 p.m., on 6/12/2012 at 12:31 a.m., 8:00 a.m., 4:00 p.m. and 8:00 p.m. The assessment was not done every four hours as ordered by the physician. The assessment was performed on 6/13/2012 at 12:00 p.m. and 8:00 p.m. There was no evidence of the assessment being performed every four hours while awake or note if the patient was asleep.

Patient #6's New Vision Standing Orders showed the physician signed the admission orders on the day of the patient's admission, 6/11/2012 at 5:40 p.m. There was a progress note dated on 6/13/2012 (no time noted). Review of the record failed to reveal documentation that the nursing staff had notified the chain of command that the patient had not been seen by her physician since arriving at the hospital for a period of over 24 hours.

An interview was conducted on 6/14/12 at 11:15 a.m. with the New Vision patient. On entrance to the patient's room, the patient was observed to be sitting on her bed working on a laptop computer. She stated that she had just seen her physician for the first time this morning 6/14/2012, on her 4th hospital day.

An interview with the CNO and Vice President of Quality/Risk Management conducted on 6/14/2012 at approximately 11:40 a.m. confirmed the above findings.

3. Patient #7 was admitted to the Medical Stabilization Unit on 6/10/12 at 2:50 p.m. for medical stabilization for acute alcohol withdrawal. Review of physician orders dated 6/10/2012 at 4:40 p.m. indicated the patient was to be assessed every four hour for twenty four hours then every four hours while awake.
The Withdrawal Severity Nursing Assessment was not performed every 4 hours for 24 hours as ordered by the physician. The Withdrawal Severity Nursing Assessment was documented on 6/10/2012 at 4:00 p.m. and 8:01 p.m. On 6/11/2012 at 8:00 a.m.,12:00 p.m. and 4:00 p.m.

4. Patient #8 was admitted to the Medical Stabilization Unit on 6/9/2012 at 1:01 p.m. for medical stabilization for acute alcohol withdrawal. The Withdrawal Severity Nursing Assessment was not performed every 4 hours for 24 hours and then every 4 hours while awake as ordered by the physician on 6/9/2012 at 2:15 p.m. The Withdrawal Severity Nursing Assessment was documented on 6/9/2012 at 2:00 p.m. and 6:00 p.m. and on 6/10/2012 at 8:00 a.m. The assessment was not performed every four hours for twenty four hours. On 6/11/12 at 8:00 a.m., 12:00 p.m. and 4:00 p.m. On 6/12/2012 at 8:00 a.m., 12:00 p.m., 4:00 p.m. and 9:00 p.m. On 6/13/12 at 8:15 a.m., 11:04 a.m. and 8:00 p.m. There was no evidence of the patient being assessed every four hours while awake or if the patient was asleep.

5. Patient #9 was admitted to the Medical Stabilization Unit of the facility on 6/4/2012 at 7:28 p.m. for medical stabilization of acute opiate (narcotic) withdrawal. The Withdrawal Severity Nursing Assessment was not performed every 4 hours for 24 hours and then every 4 hours while awake as ordered by the physician on 6/4/2012 at 9:10 p.m. The Withdrawal Severity Nursing Assessment was documented on 6/4/2012 at 8:53 p.m. On 6/5/2012 at 12:00 a.m., 6:00 a.m., 8:59 a.m., 1:00 p.m., 5:00 p.m. and 8:00 p.m. The assessment was not performed every four hours. on 6/6/12 at 8:00 a.m., 4:00 p.m. 8:00 p.m. The assessment was not performed every four hours while awake or noted if the patient was asleep.

6. An interview with the Chief Nursing Officer (CNO) was conducted on 6/14/2012 at approximately 4:50 p.m. while reviewing the electronic medical record for Patient #5. The CNO confirmed the computer screen the nurses used to view the physician's order for the Withdrawal Severity Nursing Assessment only permitted part of the order to appear. Instead of seeing the actual order to perform the assessment every 4 hours for 24 hours, the computer screen shows "every 4 hours x 2". The CNO confirmed this would affect the nursing implementation of physician orders for the Withdrawal Severity Nursing Assessment for every patient admitted to the Medical Stabilization Unit since the inception of the program in November 2011. The CNO stated the facility admitted an average of 20-30 patients per month to the Medical Stabilization Unit.

An interview with the Nurse Manager of the Medical Stabilization Unit was conducted on 6/15/2012 at approximately 4:40 p.m. The Nurse Manager was questioned during the interview regarding what had been done to correct the problem with the computer screen displaying only a portion of the physicians orders for the Withdrawal Severity Nursing Assessment. The Nurse Manager stated that she had emailed her contact that day in Health Information Technology and was awaiting a response.

The lack of nursing assessments, providing care as ordered by the physician and notifying the physician of changes in the patient's condition places current and future patients in the New Vision program a risk for harm.

A review of the facility's Quality Assurance Performance Improvement documentation from 11/11 to 6/12 failed to reveal any integration of the New Vision Medical Stabilization Services with the Quality Assurance performance Improvement Plan.

An interview was conducted on 6/14 and 6/15/12 with the Chief Nursing Officer, Risk Manager and Vice President of the Quality Assurance. The participants were questioned concerning the Quality Assurance program for the New Vision Services. They responded the only they were tracking was based upon how many patients had been admitted since the program opened. There had not been any tracking or trending of the services to ascertain how the program was functioning.

Based on record and facility documents review and staff interview it was determined that the facility failed to conduct a thorough review following the death of 1 (#5) of 10 sampled patients within 15 hours of admission to the the facility. This practice does not ensure identification of problems related to patient care and implementation of corrective action.

Findings include:

Patient #5 was admitted to the New Vision program for medical stabilization for alcohol detoxification on 5/14/12 at 4:31 p.m. The patient was found on 5/15/12 at 7:40 a.m. in the patient's room on the floor unresponsive. Resuscitation efforts were not successful a.m.

Review of facility documentation revealed the New Vision program was initiated in 11/11 and had not been integrated in the facility's Quality Assurance Performance Improvement plan.

An Interview was conducted with the Risk manager on 6/14/12 at approximately 3:00 p.m. The interview confirmed the adverse patient event had not been investigated.

31098


Based on record review, policy review and staff interview, the nursing staff :

failed to identify and notify the physician of an abnormal EKG obtained on patient (#5) on admission (possible Anterior Infarct age undetermined) and failed to notify to physician (of a patient who the physician did not know) of the medical history, high blood pressure, and home medications that included Lisinopril, Coreg, Aspirin, Phenergan, Ventolin and Amox-clav. the patient was admitted to the New Vision Program for acute alcohol detoxification. The patient was found on the floor without a heart rate or respirations and subsequently expired approximately fifteen hours after admission. (refer to A0395)



failed to provide physician ordered patient assessment for patients in the New Vision Program for alcohol and drug detoxification for 5 (#5, #6, #7, #8, #9) of 5 sampled patients in the program. (Refer to A0395)

failed to notify the physician of changes in a patient's (#5) condition that included neurological, respiratory, and vital signs that were not within defined parameters for patients in the New Vision Program for alcohol and drug detoxification. (Refer to A0395)

failed to follow accepted standard of practice in the administration of medications for one (#2) patient of ten sampled patients with a known allergy over a six day period. (Refer to A0405)


The cumulative effect of the failure of the nursing staff to assess, implement physician orders, notify the physician of changes in condition, failure to inform the physician of new admission needs and failure to ensure medications with known allergies are not administered to the patient has resulted in the determination that the Condition of Participation for Nursing Services is out of compliance.

Based on clinical record review, staff interview and policy review it was determined the Registered Nurse failed to supervise and evaluate care for five (#5, #6, #7, #8, #9) of five New Vision patients of ten sampled patients related to informing the physician of critical values, changes in the patient's condition, assess patient's per physician orders, and verify and inform the physician of the patient's home medications needs and prior medical history. This practice may have lead to the potential delay in treatment that may result in the death or injury to a patient seeking care in the New Vision program.

Findings include:

A review of the facility's policy, "Care of the patient for Medical Stabilization in New Vision Service: Withdrawal Severity Nursing Assessment" policy #Gen 065, dated 11/2011, paragraph 1) indicated "patients receiving medical stabilization with the New Vision Service will receive a nursing assessment every (4) hours for the initial twenty-four hours of admission and every (4) hours while awake thereafter, for signs and symptoms of impending or active withdrawal.

Review of the Medical Staff Bylaws Page 5. 2. Frequency of Physician Visits indicated "The patient shall be seen by a physician every day".

1. Patient #5's face sheet and registration form dated 5/14/12 at 3:52 p.m. noted the patient's admitting diagnosis was "acute alcohol withdrawal".

Review of nursing documentation dated 5/14/12 at 4:31 p.m. revealed the patient's vital signs were within normal limits except for a blood pressure of 175/104 and an oxygen saturation level of 93%. Review of the "Admission Assessment" completed by the registered nurse (RN) on 5/14/12 at 5:36 p.m. revealed the following assessments were not Within Defined Parameters (WDP): Neurological, ears, eyes, nose and throat (EENT), cardiovascular and gastrointestinal(GI)/nutrition. The patient currently had no pain. The neurological evaluation revealed the patient was alert, awake and oriented. His speech was soft. His left and right hand grips were weak. He had distant and recent past memory impairment. The behavior was anxious and cooperative. There were no tremors noted. The EENT evaluation revealed bilateral vision impairment and was hard of hearing in the left ear. The patient stated that he "needs glasses and hearing aide". The cardiovascular evaluation revealed the bilateral post tibia pulses were weak and he denied chest pain. The respiratory evaluation revealed the respirations were shallow and unlabored. The breath sounds evaluation revealed the left lower and posterior lungs were diminished with a comment of "history of left lung tumor removal". The GI/nutrition evaluation revealed the abdomen was obese. The patient stated that he always had a large abdomen.

Review of the New Vision Standing Admission Orders, dated 5/14/12 at 5:40 p.m., revealed the orders were received as telephone orders from the physician to the RN. The orders included to admit to inpatient status, vital signs every 4 hours for twenty four hours, then every 4 hours while awake, call the physician if the blood pressure was less than 90/60 or greater than 160/100, and to complete the withdrawal severity nursing assessment every 4 hours for 24 hours then every 4 hours while awake. The standing orders instructed for an electrocardiogram (EKG) on admission if age 50 or older and if history of hypertension or cardiac disease, or as needed for symptoms of chest pain, shortness of breath or palpitations and call the physician. An EKG was performed on 5/14/12 since the patient was older than 50 years. The computerized documented time of the EKG was 4:36 p.m. The EKG machine generated unconfirmed interpretation was "possible anterior infarct (heart attack), age undetermined, Abnormal ECG".
There was no documentation revealing the physician was notified of the abnormal EKG.

Review of the "Admission History" dated 5/14/12 at 6:09 p.m. completed by the RN revealed the patient arrived from home accompanied by family. The admission diagnosis was listed as "Acute Alcohol Withdrawal". The documentation noted the patient was currently complaining of shortness of breath. The cardiovascular history revealed hypertension and anticoagulant therapy. The respiratory history noted the patient had asthma and shortness of breath. The home medication inventory receipt dated 5/14/12 (no time) was completed by the same RN who completed the Admission Assessment and history. The form revealed the patient's current home medications were: Lisinopril, Coreg, amox-clav, aspirin, ventolin inhaler and Phenergan syrup. There was no evidence of what the medications were used for, the dosage, frequency, or when the last does was taken.

The patient's vital signs at 8:45 p.m. were within normal limits except for the blood pressure of 175/111.

The RN note at 8:06 p.m. revealed the patient was alert and oriented to person, place and time. There were no tremors noted. The physician was notified and received new order.
There was no evidence of new orders from the physician being obtained or written.

A " Withdrawal Severity Nursing Assessment" was completed by the Licensed Practical Nurse (LPN) on 5/14/12 and documented at 11:21 p.m. The assessment revealed hypertension at 151-175. A shift evaluation completed by the LPN at 11:26 p.m. revealed all systems were WDP except respiratory. An entry from respiratory therapy at 9:41 p.m. revealed the patient was receiving oxygen therapy at 3 liters per nasal cannula with a pulse oximetry reading at 97%.

Review of the nursing
documentation revealed no evidence the admitting physician was notified of the abnormal EKG, the high blood pressure,or abnormal findings on the initial assessment. There was no physician order for oxygen in the clinical record.

Review of the standing admission physician telephone orders for medications included catapress TTS 0.1 milligrams (mg) patch; apply to skin every 7 days, Ativan 1 mg intramuscularly (IM) now and at 9:30 p.m. Catapress 0.1 mg by mouth every 4 hours as needed (hold for blood pressure < 90/60). Ativan Taper day 1-Ativan 1 mg by mouth every 4 hours, day 2-Ativan 1 mg by mouth every 6 hours x 4 doses, and day 3-Ativan 1 mg by mouth every 8 hours as needed for withdrawal symptoms. If the patient becomes drowsy notify the physician.

Review of the Medication Administration Record (MAR) dated 5/14/12 at 7:51 p.m. revealed the patient received Ativan 1 mg IM and the other 1 mg IM at 9:30 p.m. The patient also received Ativan 1 mg by mouth at 7:14 p.m. and 10:59 p.m. At 11:00 p.m. the patient received Trazodone 50 mg by mouth for insomnia and Seroquel 50 mg by mouth for anxiety.

LPN documentation dated 5/15/12 at 1:00 a.m., for the New Visions Withdrawal Severity, revealed the patient's heart rate was increased at 101-130, blood pressure 150 and below, mild sweating, and the patient was oriented to person, place and time. The vital signs at 1:07 a.m. were pulse 111 and blood pressure 124/81.

Review of the MAR revealed the patient did not receive the scheduled Ativan 1 mg by mouth on 5/15/12 at 1:57 a.m. because he was lethargic. There was no documentation of notifying the physician of the lethargy as ordered by the physician.

Nursing documentation at 3:55 a.m. noted the patient had removed his intravenous line.
The vital signs at 5:35 a.m. were pulse 112, respirations 20 and blood pressure 195/103.

Nursing documentation at 8:21 a.m., by the day shift RN, revealed "at approximately 7:10 a.m., went to the patient's room for bedside report with night shift nurse and patient was sleeping in bed naked. Prior to report, night shift nurse informed me that she just put the patient back in bed due to patient being found sleeping in the floor naked and was very confused. According to report patient has been doing this, in various occasions during the night. After finishing report for my other patients, at approximately 7:35 a.m. went back to patient's room and patient was out of the bed and appeared to be sleep walking, snoring with eyes closed. Tried to reorient patient and patient seemed to be still asleep. Put patient back in bed. Comfort measures provided...When I came back to the room to move the patient at approximately 7:40 a.m. the patient was found on the floor unresponsive. Assessed the patient and patient was not breathing and had no pulse. Code blue was called and started cardiopulmonary resuscitation (CPR) immediately. Unable to resuscitate patient after CPR."

Physician progress note for 5/15/12 at 8:00 a.m. code blue note revealed "arrived to find patient intubated with CPR in progress. According to nursing staff patient has been confused, lying in floor, curled up in corner, sleeping. Staff had talked to patient within 3 minutes prior to finding him unresponsive. Advanced cardiac life support (ACLS) protocol undertaken by resident staff, patient remained asystole and unresponsive to all interventions".

Review of the discharge summery dictated by the admitting physician on 5/15/12 at 12:41 p.m. revealed "the patient had a history of chronic alcoholism who presents with acute alcohol withdrawals. He was admitted and started on the usual withdrawal protocol. The patient was remarkably confused on admit suggestive of acute delirium tremors. He was placed in a quiet room, found to be walking with his eyes closed and had to be redirected. He was found not to be breathing, had no pulse, code blue was called and CPR was started. The patient expired. The documentation noted the patient had underlying heavy alcohol use suggestive of likely sudden death episode likely hypertensive.

An interview conducted with the Chief Nursing Officer (CNO) on 6/14/2012 at approximately 4:50 p.m. confirmed the above findings.

An interview with patient #5's physician was conducted on 6/15/2012 at approximately 10:30 a.m. The physician stated he did recall the patient. He stated he did not recall being notified of the results of the EKG that indicated a possible Anterior Infarct. He stated he did not recall being notified at any time of the patient's elevated blood pressure readings.

Review of nursing documentation did not reveal evidence of the nurse assessing the patient every four hours as ordered. There was no evidence of the admitting physician being notified of an abnormal EKG, Increased blood pressure, shortness of breath, the admitting history, use of oxygen via nasal cannula or home medications. The home medications included medications that may be used for high blood pressure, cardiac problem, nausea, anticoagulation therapy, and an antibiotic. There was no documentation by nursing that the patient had become confused or had a change in behavior, other than the lethargy, during the night.

The patient may have experienced harm by the nurse not assessing, evaluating, implementing physician orders and notifying the physician of a change in a patient's condition or the patient's needs.

2. Patient #6 was admitted to the Medical Stabilization Unit at 5:06 p.m. on 6/11/12 for medical stabilization of acute withdrawal from drugs. Review of the Withdrawal Severity Nursing Assessments revealed the assessment was not performed every 4 hours for 24 hours and then every 4 hours while awake as ordered by the physician. The Withdrawal Severity Nursing Assessment was documented on 6/11/2012 at 8:00 p.m., on 6/12/2012 at 12:31 a.m., 8:00 a.m., 4:00 p.m. and 8:00 p.m. The assessment was not done every four hours as ordered by the physician. The assessment was performed on 6/13/2012 at 12:00 p.m. and 8:00 p.m. There was no evidence of the assessment being performed every four hours while awake or if the patient was asleep.

Patient #6's New Vision Standing Orders showed the physician signed the admission orders on the day of the patient's admission, 6/11/2012 at 5:40 p.m. There was a progress note dated on 6/13/2012 (no time noted). Review of the record failed to reveal documentation that the nursing staff had notified the chain of command that the patient had not been seen by her physician since arriving at the hospital for a period of over 24 hours.

An interview was conducted on 6/14/12 at 11:15 a.m. with the New Vision patient. On entrance to the patient's room, the patient was observed to be sitting on her bed working on a laptop computer. She stated that she had just seen her physician for the first time this morning 6/14/2012, on her 4th hospital day.

An interview with the CNO and Vice President of Quality/Risk Management conducted on 6/14/2012 at approximately 11:40 a.m. confirmed the above findings.

3. Patient #7 was admitted to the Medical Stabilization Unit on 6/10/12 at 2:50 p.m. for medical stabilization for acute alcohol withdrawal. Review of physician orders dated 6/10/2012 at 4:40 p.m. indicated the patient was to be assessed every four hour for twenty four hours then every four hours while awake.
The Withdrawal Severity Nursing Assessment was not performed every 4 hours for 24 hours as ordered by the physician. The Withdrawal Severity Nursing Assessment was documented on 6/10/2012 at 4:00 p.m. and 8:01 p.m. and on 6/11/2012 at 8:00 a.m.,12:00 p.m. and 4:00 p.m.

4. Patient #8 was admitted to the Medical Stabilization Unit on 6/9/2012 at 1:01 p.m. for medical stabilization for acute alcohol withdrawal. The Withdrawal Severity Nursing Assessment was not performed every 4 hours for 24 hours and then every 4 hours while awake as ordered by the physician on 6/9/2012 at 2:15 p.m. The Withdrawal Severity Nursing Assessment was documented on 6/9/2012 at 2:00 p.m. and 6:00 p.m. On 6/10/2012 at 8:00 a.m. The assessment was not performed every four hours for twenty four hours. The assessment was documented on 6/11/12 at 8:00 a.m., 12:00 p.m. and 4:00 p.m. On 6/12/2012 at 8:00 a.m., 12:00 p.m., 4:00 p.m. and 9:00 p.m. and on 6/13/12 at 8:15 a.m., 11:04 a.m. and 8:00 p.m. There was no evidence of the patient being assessed every four hours while awake or if the patient was asleep.

5. Patient #9 was admitted to the Medical Stabilization Unit of the facility on 6/4/2012 at 7:28 p.m. for medical stabilization of acute opiate (narcotic) withdrawal. The Withdrawal Severity Nursing Assessment was not performed every 4 hours for 24 hours and then every 4 hours while awake as ordered by the physician on 6/4/2012 at 9:10 p.m. The Withdrawal Severity Nursing Assessment was documented on 6/4/2012 at 8:53 p.m. and on 6/5/2012 at 12:00 a.m., 6:00 a.m., 8:59 a.m., 1:00 p.m., 5:00 p.m. and 8:00 p.m. The assessment was not documented every four hours. on 6/6/12 at 8:00 a.m., 4:00 p.m. 8:00 p.m. The assessment was not performed every four hours while awake or noted if the patient was asleep.

An interview with the Chief Nursing Officer (CNO) was conducted on 6/14/2012 at approximately 4:50 p.m. while reviewing the electronic medical record for Patient #5. The CNO confirmed the computer screen the nurses used to view the physician's order for the Withdrawal Severity Nursing Assessment only permitted part of the order to appear. Instead of seeing the actual order to perform the assessment every 4 hours for 24 hours, the computer screen shows "every 4 hours x 2". The CNO confirmed this would affect the nursing implementation of physician orders for the Withdrawal Severity Nursing Assessment for every patient admitted to the Medical Stabilization Unit since the inception of the program in November 2011. The CNO stated the facility admitted an average of 20-30 patients per month to the Medical Stabilization Unit.

An interview with the Nurse Manager of the Medical Stabilization Unit was conducted on 6/15/2012 at approximately 4:40 p.m. The Nurse Manager was questioned during the interview regarding what had been done to correct the problem with the computer screen displaying only a portion of the physicians orders for the Withdrawal Severity Nursing Assessment. The Nurse Manager stated that she had emailed her contact that day in Health Information Technology and was awaiting a response.

The lack of nursing assessments, providing care as ordered by the physician, and notifying the physician of changes in the patient's condition placed current and future patients in the New Vision program a risk for harm.

Based on record review, interview and policy review it was determined the nursing staff failed to follow accepted standard of practice for administration of medication for 1 (#2) of 10 sampled patients by administering medication with known allergies. The practice may cause harm to patients and lead to a prolonged hospital stay.

Findings include:

Patient #2's admission physician orders dated 5/23/12 at 8:30 a.m. revealed allergies to Iodine, Codeine and Aspirin. A review of the History and Physical dictated on 5/23/12 at 10:40 a.m. revealed allergies to codeine, aspirin, and Iodine. It noted the medications would give the patient "a rash". A review of the Nursing Admission Assessment, completed on 5/23/12 at 11:23 a.m. revealed the patient was allergic to Iodine-causes Hives, Codeine-causes Dyspnea and Aspirin-causes Nausea.
Review of the Pulmonology/Critical care consultation dictated on 5/25/12 at 1:17 p.m. revealed the patient was allergic to codeine, aspirin and iodine. A review of the physician orders dated 5/31/12 at 10:15 p.m. revealed an order for aspirin 325 milligrams (mg) crushed now and then every 24 hours. A review of the Cardiology Consultation dictated 6/1/12 at 9:08 a.m. revealed allergies to codeine, aspirin and Iodine. They all cause a rash.

Review of the Medication Administration Record (MAR), revealed the patient received Aspirin on 5/31/12, 6/1/12, 6/2/12, 6/4/12, and on 6/5/12.

Review of nursing notes documentation dated 5/25/12 at 1:41 a.m. revealed urinary catheter was inserted using an aseptic technique.

A review of the urinary insertion catheter kit used by the Intensive Care Unit (ICU) revealed the contents included povidone-Iodine solution. The patient was allergic to Iodine.

A telephone interview was conducted with patient #2 on 6/13/12 at 4:45 p.m. The interview revealed she had a "severe" vaginal area rash.

A review of the Nursing documentation from 5/31/12 to 6/5/12 did not reveal any communication with the physician concerning the patient being allergic to the aspirin or Iodine.

An interview with the Chief Nursing Officer on 6/14/12 at approximately 4:30 p.m. revealed "if a medication is profiled as an allergy, then nursing would not be able to give the medication".

A review of the facility policy "administration of medications", policy #MED 005, reviewed 9/11, revealed on page 1 of 2, paragraph 4,"know the desired effects, toxic effects, side effects and contraindications of drug being administered " .