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Based on document reviews and interviews, nursing staff failed to ensure patients' physicians were notified of abnormal assessment findings, in order for the provider to evaluate the patient's treatment plan, in 2 out of 10 medical records reviewed (Patients #2 and #3)

Findings include:

Facility policy:

The Initial Assessment and Reassessment policy read, nurses shall use their clinical resources (preceptors, charge nurses, rapid response team) to evaluate assessment findings to ensure essential changes are communicated in a timely way. The provider is to be notified if condition does not improve after nursing/provider ordered intervention. Nurses shall document reassessment, intervention, and communication in the EMR (electronic medical record).

1. Nursing staff did not report abnormal assessment findings to the providers in charge of the patients' care.

a. Review of Patient #2's medical record revealed on 1/25/19, the patient presented to the emergency department for a large black tarry stool which tested hemoccult positive (a test that detects the presence of blood in stool). On 1/26/19, Patient #2 had an upper gastrointestinal (GI) endoscopy (a nonsurgical procedure used to examine a person's digestive tract) with an intervention to stop his bleeding. Patient #2 was admitted to the Internal Medicine/Oncology unit.

Review of the nursing head-to-toe assessments, showed nursing staff documented Patient #2 did not have bowel movements for two days after the intervention.

Review of the Intake and Output (I and O) Flowsheets revealed, on 1/28/19 at 7:34 a.m., RN #1 documented the patient was incontinent of a large, black, tarry, loose stool.

On 1/28/19 at 1:21 p.m., Patient #2's Gastroenterologist (a medical practitioner qualified to diagnose and treat disorders of the stomach and intestines) documented in a physician progress note, the patient had no melena (dark tarry stool with or without visible blood) overnight. There was no evidence in the provider's progress note, which showed she was notified of the patient's stool or was aware of the patient's abnormal stool characteristics.

On 1/28/19 at 2:30 p.m., Patient #2's in-patient physician documented rounds with nursing staff were conducted. However, there was no evidence in the progress note which showed the physician was aware of the black, tarry, loose stool documented at 7:34 a.m.

Further review of the Patient #2's I and O Flowsheets showed the patient continued to have large, black, tarry, loose stools on 1/28/19 at 9:08 p.m., 1/29/19 at 2:19 a.m., and on 1/29/19 at 5:02 a.m.

Review of the Head-To-Toe Flowsheets revealed on 1/28/19 at 9:08 p.m., Patient #2's nurse documented the patient had gastrointestinal (GI) symptoms which included, incontinence, diarrhea and bleeding. On 1/29/19 at 8:21 a.m., nursing staff documented the same GI symptoms. Patient #2 was discharged at 2:35 p.m.

On 1/29/19 at 12:51 p.m., Patient #2's physician documented a discharge summary with recommendations for the patient's primary care provider to monitor for recurrence of melena. There was no evidence the patient's physician was aware Patient #2 had black, tarry, loose stools on 1/28/19 and 1/29/19. Additionally, there was no documentation in the patient's medical record, including the discharge summary, which showed nursing staff notified the inpatient physician or which showed Patient #2's provider was aware the patient had abnormal GI symptoms prior to discharge.

b. Review of Patient #3's medical record revealed on 1/24/19, the patient presented to the hospital for abnormal labs, and falls. According to the emergency department provider notes, dated 1/24/19, the patient's family reported the patient had black stools, weakness and was pale prior to arrival.

Review of the History and Physical, documented on 1/24/19, showed Patient #3's blood loss anemia (a condition in which the blood does not have enough healthy red blood cells) was presumed to be an upper GI bleed with black tarry stools and a decrease in an hemoglobin and hematocrit (blood tests used to check for anemia). Patient #3 was admitted to the Internal Medicine/Oncology unit.

On 1/25/19, Patient #3 had an upper endoscopy with an intervention to stop the bleeding.

Review of the I and Flowsheets showed nursing staff documented the patient went from scant, brown stool on 1/26/19 at 8:00 a.m. to charcoal colored stool on 1/27/19 at 3:00 a.m. Further review showed the nursing staff documented Patient #3 had charcoal colored stools at 5:45 a.m., 8:10 a.m., and at 10:36 a.m. At the 8:10, the patient's CNA documented Patient #3 was incontinent four times. Patient #3 was discharged the same day, at 1:21 p.m.

There was no evidence in Patient #3's medical record which showed nursing staff updated the patient's physician with the change in stool characteristics and increase in frequency.

c. On 7/26/19 at 7:31 a.m., an inpatient physician (Physician #4) was interviewed. Physician #4 stated if a patient had a black stool for the first time, it was good if nursing staff notified the provider. She said the provider should be called if any dark stools. The notification would allow the provider to evaluate the black stools and review any tests. Physician #4 stated black stool could indicate old blood or medication that caused the color of the stool to change. Physician #4 then stated it was the responsibility of the physician to make the call and determine if there was a concern. Additionally, Physician #4 said if a patient had a change in stool assessments particular, the physician should be notified. She said it was important for the physician to know so they could talk with the patient's nurse and ask about other possible changes like smell and if the patient had any complaints.

d. On 7/25/19 at 2:15 p.m., an interview was conducted with RN #1 who provided care to Patient #2 on 1/28/19.

RN #1 stated for a patient admitted with a GI bleed, she would monitor for the patient's stools and make sure the stools were not getting worse or more frequent. She said after a patient had a GI intervention, hopefully, there would be a decrease in the amount of stools that had been occurring and she would not want to see anymore blood.

RN #1 said either black or melena stool could indicate a GI bleed. RN #1 stated if the patient had a black or melena stool, she would do an assessment, obtain vital signs, and call the provider with the information.

A review of Patient #2's medical record was conducted. She reviewed the patient's I and Os. RN #1 said the patient's black tarry stools could be normal after an intervention because the blood still needs to come out. She said she would look at the patient's blood counts to see if the patient lost any blood. She said if any doubt, then she would call the provider to determine if there was a concern. RN #1 stated because Patient #2's bowel pattern slowed down, then increased in the amount of occurrences, the provider should have been notified. She said this was one of her first patients after she completed her new nurse graduation program.

e. On 7/29/19 at 10:05 a.m., an interview was conducted with RN #3 who provided Patient #3 care on 1/27/19. RN #3 stated she had been a nurse for about a year and finished her training in December 2018.

RN #3 stated for a GI bleed patient, she would closely monitor the patient's intake and output, focus on their GI physical assessment, review labs, monitor their hemoglobin and hematocrit, and if there were any changes, she said she would notify the physician. RN #3 said she would document the notification in a note and include the change in condition, physician orders received or if she needed to continue to monitor the patient. RN #3 said the content of the note would depend on what the physician would say.

RN #3 stated a change in a GI assessment would be an increase in frequency or amount of bowel movements, a change in color, any pain the patient reported, or any nausea or cramping.

When asked about color, RN #3 said if the patient's stool was black, tarry or bright red, that was considered a change. She said the color of the stool could be dependent on the location of the bleed and severity.

She said the physician would be notified because the change may need to be treated.

RN #3 reviewed Patient #3's I and Os for 1/26/19 and 1/27/19. She stated she did not remember the patient, but it looked like she documented one stool at 10:36 a.m. on 1/27/19. She said the earlier I and O documentation was done by the certified nurse assistant. RN #3 stated the CNA documented the patient had four incontinent bowel movements. RN #3 then said that she would consider increase frequency in bowel movements a change in the patient's assessment.

RN #3 stated the descriptor she used, charcoal, was considered a darker color, not a healthy brown. She said if the patient's stool went from brown to charcoal, she would consider that a change in the patient's assessment. RN #3 stated she did not remember if she notified the physician.

RN #3 stated she could not find anything documented in the medical record. She said if the change was something the doctor was not concerned about, she usually did not write a note, unless the provider required an order.

RN #3 said she documented more now than when she was a new grad.

f. On 7/29/19 at 11:04 a.m., an interview was conducted with unit manager (Manager #7) for Internal Medicine/Oncology floor. Manager #7 stated with any patient change of condition or new condition, nursing staff should update the patient's physician. She said during the day shift, DELTA rounds occurred which were face to face updates with the patient care team. She said DELTA rounds included the physician, the nurse and the patient. She said during the rounds, events which occurred over night would be discussed. Manager #7 stated for other times, nursing staff could page or call the physician. She said then a note should be documented and the patient should be reassessed.

When asked where in there record would the discussion at DELTA rounds be found, Manager #7 said results should be reflected in the physician's notes. She said their note should reflect any changes or continuation of the patient's active problems and anything which was identified during the rounds. Manager #7 said nursing staff did not have to document the DELTA rounds.

Manager #7 said if a patient had a true change on bowel movements, including a change from brown color to charcoal, she expected documentation by the physician or nurse about the change. Manager #7 stated it was the physician's decision to determine if an assessment was a change, normal, or not normal. She said nursing staff should notify the physician about the changed assessment findings.

Based on document reviews and interviews, the facility failed to ensure nursing staff documented vital signs 15 minutes after the start of a blood transfusion in 3 of 3 patient records reviewed for blood transfusions (Patients #1, #2, and #3).

Findings include:

Facility policy:

The Blood Transfusion Administration and Transfusion Reaction policy read, 15 minutes after the start of a transfusion, the patient's temperature, pulse, respiration rate and blood pressure, was required to be documented in the electronic medical record (EMR).

1. Nursing staff did document the patients' vital signs, to include temperature, pulse, respiration and blood pressure,15 minutes after blood transfusions were initiated.

a. Review of Patient #1's medical record revealed, on 2/15/19 at 9:36 p.m., nursing staff started a blood transfusion. Vitals signs were documented at 10:00 p.m., 24 minutes after the blood transfusion was initiated. This was in contrast to policy.

b. Review of Patient #2's medical record revealed on 1/25/19, the patient was administered two units of blood. On the second transfusion, nursing staff started the blood transfusion at 4:56 p.m. The next set of vital signs were documented at 5:07 p.m., however, there was no evidence of a temperature or respiratory rate (RR) assessment as required per policy.

On 1/26/19 at 7:07 a.m., a third blood transfusion was started. Vitals signs were recorded in the EMR 24 minutes after the transfusion was initiated.

Review of Patient #2's second admission from 2/2/19 through 2/9/19, revealed on 2/3/19 at 10:13 a.m., nursing staff started a blood transfusion. The 15 minute vitals signs, recorded at 10:30 a.m., did not include the patient's temperature. Nursing staff did not record a temperature in the blood administration flowsheet until 1:58 p.m., 3 hours 45 minutes after the patient's blood transfusion was started.

c. Review of Patient #3's medical record, including blood administration flowsheets, revealed, on 1/30/19 at 2:13 p.m., nursing staff initiated a blood transfusion. According to the blood administration flowsheet, at 2:25 p.m., nursing staff documented the patient's blood pressure and heart rate. However, the patient's temperature was not recorded until 2:56 p.m., which was 41 minutes after the start of the transfusion.

On 1/30/19, at 4:39 p.m., the patient was administered a second transfusion. Vitals signs were not documented until 22 minutes after nursing staff started the blood transfusion. A third transfusion was initiated at 8:30 p.m. There was no evidence the patient's vital signs were taken 15 minutes after the start of the blood transfusion according to policy. The next documented set of vital signs were done at 9:05 p.m., 35 minutes after the start of the transfusion.

d. On 7/25/19 at 2:54 p.m., an interview was conducted with RN #5 who worked on the progressive care unit. RN #5 stated patient vital signs were required to be taken at the beginning of the blood transfusion, 15 minutes after the blood transfusion started and at the end of the blood transfusion. She said for the first 15 minutes, nursing staff did not leave the room to ensure the patient was safe. She said staying in the room was the policy.

RN #5 stated the vitals signs included the patient's temperature, heart rate, blood pressure, oxygen saturation and their respiratory rate. She said the vital signs needed to be documented in the blood administration flowsheet.

e. On 7/29/19 at 11:04 a.m., an interview was conducted with unit manager (Manager #7) for Internal Medicine/Oncology floor. She stated nursing staff were expected to assess patient's vital signs 15 minutes from the start of the blood transfusion. She said the vital sign assessment required temperature, respiratory rate, heart rate, blood pressure and oxygen saturation. Manager #7 said the purpose of the 15 minute vital signs were to see if there was a blood transfusion reaction happening. She said nursing staff should specifically look at temperature, blood pressure and the patient's respiratory rate. Manager #7 if there is a 2 degree increase in temperature, then there could be a concern for transfusion reaction. She said other signs of reaction could include shortness of breath, back pain and a decrease in blood pressure at the 15 minute mark.

Manager #7 stated nursing staff did not leave the room the first 15 minutes and there were computers in the room for the staff to use. She said the vital sign documentation was required by policy.

Manager #7 said laboratory staff would send her emails regarding blood transfusion audits to ensure appropriate documentation and assessments patients during blood administration. She said her process was to review the chart identified in the audit, review the patient's vital signs and make sure the transfusion was stopped within four hours. She said she would forward any concerns to the staff involved in the audit via email.

Manager #7 stated staff were trained through annual electronic learning modules. She said the last education occurred in November 2018. She said there had not been any blood transfusion education done at the staff meetings.

Upon exit, Manager #7 was unable to find her emails regarding laboratory audits and follow up for blood transfusions done January and February of 2019.

f. On 7/29/19 at 11:46 a.m., an interview was conducted with the manager of the progressive care unit (Manager #8). She said during blood transfusions, nursing staff should be assessing patient vital signs prior to the start of the transfusion, 15 minutes after the transfusion was initiated, and at the end of the transfusion. Manager #8 said all of the vital signs should be documented in the electronic medical record.

Manager #8 said vitals signs that should be assessed included the patient's temperature, pulse, respiration rate and blood pressure. She said the purpose of monitoring the patient's vital signs at 15 minutes after the start of the transfusion, was to assess for transfusion reactions. She said an increase temperature was the most common sign of a blood transfusion reaction.

Manager #8 stated laboratory staff did send emails regarding any fallouts from staff compliance during blood transfusions. She said she would follow up with nursing staff who were involved via email or one on one conversations.

Manager #8 said there were computers in the patient rooms. She said the only thing she could think of as to why 15 minute vitals signs were not documented in the required time frame, was because the way flowsheets were set up in the electronic medical record.

Manager #8 stated the last education done for blood transfusions was in November 2018. She said documentation in the medical record painted a patient's whole story. She said when she did chart review, if documentation was not there, there was no proof the intervention was done.