HospitalInspections.org

Based on medical record (MR) review and interview, in 1 MR (Patient #4) of 4 MRs reviewed, the medical care provided was inconsistent with generally acceptable standards of professional practice. Specifically, the MR lacked documentation that a practitioner physically assessed the patient who was experiencing an elevated heart rate (HR), elevated respirations, and pain (possible gastrointestinal discomfort) over a prolonged period of time. This lack of documentation and physical assessment could affect the quality of care provided to patients.

Findings include:

-- Per MR review, Patient #4 was admitted on 8/10/2024 after presenting to the emergency department with shortness of breath. Past medical history included Trisomy 7 (a chromosomal condition where a person has three copies of chromosome 7 instead of two), congenital glaucoma, seizure disorder, intellectual disability, nonverbal at baseline, and chronic upper and lower extremity contractures. Admission diagnoses included shortness of breath, aspiration pneumonia and dysphagia (difficulty swallowing). On 8/13/2024 a Rapid Response was called for the patient being unresponsive. After assessment and interventions, the patient was stabilized and transferred to the intermediate medical care unit (IMCU). After a 10-day stay in IMCU, the patient was transferred to a medical/surgical unit on 8/23/2024. This same day the patient had percutaneous endoscopic gastrostomy (PEG) tube placement (a feeding tube surgically placed into the stomach through the abdomen). Tube feedings were started, and the patient seemed to be tolerating them.

On 8/25/2024 at 12:00 pm, nursing documented HR = 134, respirations = 25, blood pressure (BP) = 90/54, oxygen saturation (SpO2) = 100%.

On 8/25/2024 at 1:14 pm, provider documented patient with past medical history significant for Trisomy/Epilepsy, admitted with recurrent aspiration pneumonia, weight loss and poor PO (by mouth) intake. Due to malnourished state and concern for nutritional status, patient underwent PEG tube placement 8/23/2024. Patient examined at bedside, resting in bed comfortably, tolerating tube feedings, hypoglycemia resolved. No fever or chills. Vital signs, lab work reviewed, case discussed with primary nurse.

On 8/25/2024 the following vital signs and pain assessments were documented by nursing:
- 2:00 pm - HR = 120, respirations = 22, SpO2 = 100%.
- 3:00 pm - HR = 124, respirations = 24, SpO2 = 57%.
- 4:00 pm - HR = 113, respirations = 17, BP =106/79, SpO2 = no documentation.
- 5:00 pm - HR = 98, respirations = 23, SpO2 = no documentation.
- 6:00 pm - HR = 112, respirations = 23, SpO2 = no documentation.
- 7:04 pm - medicated with Tylenol, patient yelling out which indicative of pain/repositioned, continued to moan.
- 7:07 pm - SpO2 = 100 % on room air, patient at rest.
- 7:20 pm - shift assessment (in part). Sinus tachycardia (heart is beating faster than normal). Abdomen; flat, gastrostomy tube, bowel sounds (all quadrants) active, abdominal tenderness, soft, passing flatus (gas). Respirations; regular, unlabored. Bilateral breath sounds diminished. Comfort; pain medication, repositioned
- 7:44 pm - pain level = 6, no location documented.
- 11:03 pm - order for tramadol (a pain medication) 50 mg tablet every 6 hours as needed for moderate pain and morphine sulfate 2 mg injection every 4 hours as needed for severe pain.
- 11:10 pm - pain level = 7, no location documented.
- 11:14 pm - HR = 124, respirations = 24, SpO2 = 57%.
- 11:15 pm - HR = 131, respirations = 36, SpO2 = not documented.
- 11:16 pm - HR = 142, respirations = 49. Patient moaning out since writer arrival on floor, Tylenol given without effect. HR reaching 150 with MD (physician) updated and new order for Lopressor (a medication to lower HR and BP), IV obtained, patient continues to moan out with large loose stool times 2 during this time frame. Positive results noted following Lopressor. HR low 100's with patient napping for short interval only, patient then waking up and again thrashing in bed turning sideways so they are flat which writer explained is not safe due to continuous tube feeding (TF). Patient continues with moaning and yelling out. HR now in high 120's low 130's. MD again updated with new orders obtained. Writer administering Tramadol (a pain medication). If patient continues to present as though they are in pain, writer will give PRN (as needed) Morphine.

-- Per MR review on 8/26/2024 the following vital signs and pain assessments were documented by nursing:
- 12:02 am - SpO2 = 100%, several different areas with probes placed for accuracy, digits cold with cyanosis.
- 12:04 am - BP 166/125, moved (BP cuff) from left arm to right arm for confirmation. BP remaining elevated arm without movement.
- 12:11 am - pain level = 8, pain severe. No location of pain documented.
- 12:26 am - HR = 137, respirations = 45, BP = 71/55, SpO2 = 77%.
- 1:00 am - pain level = 7, no location documented.
- 1:06 am - PRN medication given with patient still moaning out, TF held due to possible gastrointestinal discomfort. HR remains elevated up to 140 (medical aware). PRN Clonidine given for elevated BP with BP down to a systolic of 95. Questioning if patient with abdominal discomfort without residual when assessed, abdomen rounded and firm presenting as did with assessment on 8/24. Patient is reacting with palpation of abdomen, at this time will place Lopressor on hold as per conversation with charge nurse. At 1:30 patient with large BM with HR converting to high 110's eyes closed sleeping quietly at this time. TF remains on hold will restart at 2:00 am.
- 1:59 am - compressions initiated and ongoing.
- 3:31 am - at 1:59 am writer walking into patient's room to restart TF, alarm sounding at time of entering room, patient with oxygen off. Wall monitor showing HR of 0-36 back to 0 due to this writer feeling for carotid pulse, no palpable pulse therefore chest compressions started, and Code Blue initiated. Continuing compressions until relieved by responders to Code Blue.

From 8/25/2024 at approximately 1:00 pm until the time of the Code Blue (8/26/2024 at 2:00 am) the MR revealed the patient's HR was in the 120's - 140's, (normal is 60 -100 beats/minute), respirations were 20 - 60 (normal is 12 - 20 breaths/minute), and the patient was moaning in pain (location of pain not specified, possible gastrointestinal discomfort). Nursing documented provider notification with administration of medication interventions, however, there was no documentation that a provider physically assessed the patient from approximately 1:00 pm on 8/25/2024 until Code Blue was called 13 hours later.

-- During interview of Staff A, on 11/20/2024 at 2:00 pm, they acknowledged the above findings.