HospitalInspections.org

Based on records reviewed and interviews the Hospital failed to ensure for one patient (Patient #1) of ten sampled patients a well-organized nursing service responsible for the Patient's nursing care and Quality Assessment and Performance Improvement (QAPI) activities following the Patient's death.

Findings included:

1.) The Hospital report, dated 4/30/2020, indicated that a Patient died after a nasogastric feeding tube was inserted into the Patient's left lung instead of the Patient's stomach as intended, in error.

The Hospital policy titled Assessment and reassessment of Patients and Documentation, dated 3/29/19, indicated that assessment activities may vary between settings as defined by Hospital leaders, level of care, policies and procedures. The Assessment and reassessment of Patients and Documentation indicated that a significant change in patient's condition would trigger a reassessment.

The Surveyor Interviewed the Risk Manager at 10:00 A.M. on 9/17/2020. The Risk Manager said that the Nurse Manager told her that the frequency for nursing to obtain Patient #1's vital signs was "routine" and with the shift assessment or if there were specific physician orders.

The Surveyor interviewed the Nurse Manager and Associate Nurse Manager at 11:30 A.M. on 9/17/2020. The Nurse Manager said that she conducted the investigation for the nursing care provided to Patient #1. The Nurse Manager said that usually vital signs (patient temperature, heart rate and breathing rate) were obtained every eight hours or with a change in the Patient's condition. The Nurse Manager said that the frequency of vital signs did not change if the patient received oxygen therapy. The Nurse Manager said that it would have been nice to see a full set of vital signs (regarding Patient #1).

The Physician transfer orders, dated 4/2/2020, indicated no documentation for nursing to obtain vital signs.

The Hospital provided no documentation to indicate assessment activities as defined by Hospital leaders for Patient #1's Patient Care Unit.

The Hospital policy titled Assessment and reassessment of Patients and Documentation indicated no documentation of who would provide a reassessment of a patient that demonstrated a significant change in condition.

2.) The Hospital policy titled Oxygen Administration and Discontinuation, dated 10/2007, indicated a physician or licensed independent practitioner's (MD/LIP) order would be obtained prior to the initiation of oxygen therapy. The policy indicated that a nurse would notify an MD/LIP if the Patient's oxygen level measurement was 90% or less.

Patient #'1 medical record Oxygen Therapy flow-sheet, dated 4/2/2020 through 4/4/2020, indicated Patient #1 was treated with oxygen therapy.

Review of Patient #1's transfer orders dated 4/2/2020, indicated no documentation or an order to administer oxygen to Patient #1.

Patient #'1 medical record Oxygen Therapy flow-sheet, indicated at 8:36 A.M. on 4/4/2020, Patient #1's oxygen level was 87% and the nurse increased the oxygen liters/minute from three liters/minute to five liters/minute. The Oxygen Therapy flow-sheet indicated no documentation to indicate that the nurse notified a Provider per Hospital policy or notified the Rapid Response Team (RRT).

The Nurse Manager said that oxygen therapy was considered a medication and that she did not recall if the investigation identified that Patient #1 was transferred from the Intensive Care Unit to the Patient Care Unit without a physician order. The Nurse Manager said that this was an oversight of the handoff (nurse to nurse report) process.

3.) The Nurse Manager said that the Hospital had a robust Rapid Response Team that would respond anytime. The Nurse Manager said that the nurse did not notify a physician or notify the Rapid Response Team when Patient #1 had a decrease in oxygen level.

Patient #1's medical record Neurological Assessment flow-sheet indicated, at 4:00 P.M. on 4/3/2020, Patient #1 was oriented to person, place and situation. The Neurologic Assessment flow-sheet indicated, at 3:00 A.M. on 4/4/2020, Patient #1 was oriented to person and disoriented to time and situation. Patient #'1 medical record indicated no documentation a Provider was notified of a possible change in condition.

4.) The Nurse Manager said that she conducted the nursing care review for the Hospital internal investigation regarding Patient #1.

The Hospital internal investigation of nursing care provided failed to provide a thorough investigation, implement and monitor corrective actions. The Hospital internal investigation of nursing care failed to:

A.) Identify that Patient #1 did not have vital signs obtained on the night shift prior to Patient #1's death.

B.) Identify that the Patient Care Unit had no documentation to indicate assessment activities as defined by Hospital leaders.

C.) Identify that the day shift nurse did not notify a physician or call the RRT on at 8:30 A.M. when Patient #1's oxygen saturation decrease or that the night nurse on 4/3/3030 did not escalate concerns about a change in Patient #1's neurologic status, and

D.) Identify that Patient #1 was admitted to the Patient Care Unit without a physician order for oxygen according to Hospital policy.

The Associate Nurse Manager said that this was an opportunity for improvement.