HospitalInspections.org

Based on record reviews and interviews, it was determined the Registered Nurse (RN) failed to review and revise the plan of care based on the assessed needs of 1 of 10 sampled patients (Patient #4).

The findings include:

1) The facility policy for reassessment of a patient is as follows: Reassessments occur in the Telemetry Unit as the patient condition warrants and every 4 hours and the Plan of Care is reviewed and updated as applicable by an RN, at least every 24 hours.

The Director of the Medical Surgical/Telemetry Unit 2 East stated at 1120 hours on 2/25/14 the RN assessments are documented electronically every four hours and as needed. The plan of care is updated every day.

Patient #4 was admitted to the facility on 1/22/14 with complaints of abdominal and left flank pain. The patient had an Upper Endoscopy and a Colonoscopy on 1/23/14. There is an order by the physician at 1048 hours to notify the provider if Oxygen Saturation less than 92%.

Review of the plan of care dated 1/23/14 at 1049 hours reveals the nurse was to notify if any of the following occur: respiratory distress, desaturation, chest pain, hypotension, persistent hemoptysis, abdominal pain, excessive distension or rectal bleeding.

The patient's Oxygen Saturation was recorded approximately every 4 hours 1/22/14 through 1023 hours on 1/24/14 is 93% - 98% on room air. A nurse documented on 1/24/14 at 0409 hours on 1/24/14 Oxygen is being delivered per Nasal Cannula. There was no Liter flow documented for the Oxygen.

On 1/26/14 at 0750 hours the RN documented the patient's Oxygen Saturation was 78 % on room air. The patient is receiving Oxygen at 2 Liters per minute via a Nasal Cannula. At 0800 the patient's Oxygen Saturation is recorded at 78%. The nurse documents the patient's Oxygen Saturation increased to 96% with 2 Liters of Oxygen. The nurse documents the patient was advised that she needed to wear it (Oxygen).

The PCP visits at 1133 hours on 1/26/14 and documents the patient's Oxygen Saturation is 93- 97 %. The clinical record lacked documentation to support a physician was made aware of the change in the patient's condition.

At 1304 hours on 1/26/14 the Oxygen Saturation is 79%. The nurse writes the patient took the Oxygen off and was educated again. The patient's Oxygen saturation recorded at 2354 hours on 1/26/14 reveals the Oxygen Saturation is 92% on 2 Liters of Oxygen.

The PCP writes in a 1/27/14 progress note Oxygen hourly and no shortness of breath (SOB).

At the time of the survey the medical record lacked documentation of Oxygen Saturation measurements 1/27/14 through 1637 hours on 1/28/14. The clinical record lacked documentation to support the PCP was aware of the desaturation without the administration of Oxygen.

On 1/28/14 at 1820 hours the nurse documented Oxygen Saturation decreased to 83%, heart rate 119 and patient SOB. A Rapid Response was called 1820 - 1840 hours.

On 1/28/14 at 1840 hours the physician writes "here to see the patient. Patient just developed SOB. The patient is transferred to Intensive Care Unit (ICU). Pulmonary Embolus (PE) should be ruled out".

The findings were verified by the Director and Nurse Manager of the Medical/Surgical/ Telemetry Unit on 2/26/14 at 1400 hours.

The RN failed to review and revise the plan of care based on the assessed needs of the patient (alteration in the patient's respiratory status) after 1/23/14, in accordance with the Standard of Care: Assessment, Problem Identification, Outcome Identification and Planning and facility policy.