HospitalInspections.org

Based on document review and interview, the facility failed to ensure a registered nurse supervised and evaluated the care provided to 1 of 10 patients (patient #9). See tag 0395.

The cumulative effect of this systemic problem resulted in the hospital's inability to ensure that Nursing Services were provided in a safe manner.

Based on document review and interview, the RN (Registered Nurse) failed to supervise and evaluate the care planned and provided for each patient, for 1 of 10 MRs (Medical record) reviewed. (MR # 9).

Findings include:

1. Review of established policy titled: "Admitting/Reassessing a Patient Policy", PolicyStat ID: 11758775, on page 1 & page 2, under Statement of Policy, "determining scope reassessment for needs of patient"; f., "standards of care", on page 5; "reassessed to evaluate condition and care provided". Last revised 5/2022.

2. Review of established policy titled: "Central Monitoring Room - Remote Telemetry Monitoring of the Patient", PolicyStat ID: 10286867, on page 4, under Ongoing Remote Telemetry Process, 3. "The RN" (Registered Nurse) "is responsible for notifying the patient's physician(s) of any changes in patient condition and/or changes in rhythm/heart rate". Last revised 12/2021.

3. Review of established job description for "Registered Nurse", # 501064, on page 1 under Job Summary, "The Registered Nurse (RN) is responsible for providing total comprehensive nursing to patients", and on page 3 under Essential Functions, "Communicates timely changes in patient's ongoing reassessment to providers", and "by documenting interventions, and responses to care in the electronic medical record in a timely manner". Version date: 4/10/2019.

4. Review of MT's - Cardiac Daily Log sheets for Telemetry monitors, included the following:
A. Patients on portable telemetry; Telemetry units, that included 2 North, for 1/18/2023 and 1/19/2023 am.
Total 3 entries by MT # 23, related to Patient # 9, in room # 223.
1. Time: 2:57 am, patient's rhythm - Brady (bradycardic) 37 to Asystole; AS # 3 (Agency Nurse - 2 North staff), notified. AS # 3's comments: he/she is 'ok'.
2. Time: 3:12 am, alarms ringing; patient's rhythm - Asystole; AS # 3 notified. AS # 3's comments: Patient pulling leads off; put monitor on stand by.
3. Time: 3:48 am. MT noted Code Blue. Patient was on Stand by.

5. Review of MR for patient # 9, indicated the following:
A. Patient admitted to AH # 60 (Acute Care Hospital) on 1/18/2023; diagnosis: Acute Kidney Injury, with complaints of weakness, shortness of breath and low oxygen saturation. Patient admitted to 2 North unit. Order for Telemetry monitoring.
B. Telemetry monitor strips for patient's hospital stay on 2 North; prior to Code Blue, reflected patient's rhythm of bradycardia/HR 38 at 2:57 am. Monitor strip noted as Stand by, lead off at 3:12 am. Monitor strip noted as Stand by, lead off, no data at 3:48 am.
C. MD (Doctor Of Medicine) # 33 (Hospitalist), note on 1/19/2023 at 4:09 am, reflected Code Blue called; appeared to be PEA (pulseless electrical activity); ACLS (Advanced Cardiovascular Life Support) provided. Patient transferred to ICU (Intensive Care Unit). Note at 4:37 am, reflected diffuse EKG (electrocardiogram) changes. Note at 4:50 am, reflected brady (bradycardia) down, brief CPR (cardiopulmonary resuscitation).
D. MD # 35 (Cardiology) progress note on 1/19/2023 at 7:42 am, reflected patient admitted with acute respiratory failure and acute renal failure. Patient coded; ACLS protocol was followed. Patient was down for 40 minutes with PEA arrest. EKG (electrocardiogram) showed inferior STEMI (ST Elevation Myocardial Infarction); patient had a longer downtime.
E. MR documentation lacked nurse narrative note(s) for patient status changes, and action of call to MD # 33 for Bi-Pap (Bilevel positive airway pressure), call to Respiratory therapy, and for Bi-Pap on stand by at 12:00 am; MR documentation lacked nurse narrative note(s) for patient's rhythm changes and decision to have patient's telemetry monitor on stand by, and MR lacked narrative nurse notes that reflected patient's status/changes prior to Code Blue at 3:48 am.

6. In interview with administrative staff member A # 2 (RN, 2 North Unit Manager), on 2/22/2023, at approximately 1:41 pm, confirmed the following:
A. No nurse narrative note by AS # 3 (Agency Nurse - 2 North staff), when got BiPap order for patient; patient's restlessness, or concerning telemetry on stand by; after calls from MT (Monitor Technician) for low heart rate in 30's.
B. Policies not followed for nursing reassessment.

7. In interview administrative staff member A # 3 (Chief Nursing Officer), on 2/22/2023, at approximately 1:40 pm, confirmed that no narrative nurse note by AS # 3; prior to patient coding, with status changes; call to Physician, previous to coding. Policies not followed.

8. In interview with administrative staff member A # 8 (Intensive Care Unit - Manager), on 2/22/2023 at approximately 1:36 pm, confirmed the following:
A. Recalled patient's case from January. Not known exactly how long patient was without a pulse; what rhythm; but could be/likely is close to > 36 minutes; before found and code blue called.
B. No narrative note on for call to physician with patient status changes; telemetry on stand by; after calls from MT for rhythm changes.

Based on document review and interview, the hospital staff failed to ensure the MR (Medical record) contained accurate and complete documentation for course of treatment for 1 of 10 MR's reviewed (MR # 9).

Findings include:

1. Review of established hospital policy titled: "Charting by Exception Documentation Procedure", PolicyStat ID: 11387678, on page 1, under Procedure Statement, G. "Assessments not included in the pre-established WDL" (within defined limits) "parameters are also documented within the electronic patient record". Last reviewed 5/5/2022.

2. Review of established policy titled: "Admitting/Reassessing a Patient Policy", PolicyStat ID: 11758775, indicated on page 7 under d., 1. "documentation of time of patient reassessment shall be documented to accurately reflect reassessments completed". Last revised 5/2022.

3. Review of established policy titled: "Code Blue Policy", PolicyStat ID: 11029797, on page 5 under B. Primary Nurse of Patient, 4. "Documents what led up to event as a significant note in the electronic medical record". Last revised 5/2022.

4. Review of established policy titled: "Incident Reporting and Investigation Policy", PolicyStat ID: 10844041, on page 2, under PROCEDURE, D., "The facts surrounding the incident must be documented in the medical record to assure continuum of care". Last reviewed 1/2022.

5. Review of MR for patient # 9, indicated the following:
A. Patient admitted to AH # 60 (Acute Care Hospital) on 1/18/2023; diagnosis: Acute Kidney Injury, with complaints of weakness, shortness of breath and low oxygen saturation. Patient admitted to 2 North unit. Order for Telemetry monitoring.
B. Telemetry monitor strips for patient's hospital stay on 2 North; prior to Code Blue, reflected patient's rhythm of bradycardia/HR 38 at 2:57 am. Monitor strip noted as Stand by, lead off at 3:12 am. Monitor strip noted as Stand by, lead off, no data at 3:48 am.
C. MD (Doctor Of Medicine) # 33 (Hospitalist), note on 1/19/2023 at 4:09 am, reflected Code Blue called; appeared to be PEA (pulseless electrical activity); ACLS (Advanced Cardiovascular Life Support) provided. Patient transferred to ICU (Intensive Care Unit). Note at 4:37 am, reflected diffuse EKG (electrocardiogram) changes. Note at 4:50 am, reflected brady (bradycardia) down, brief CPR (cardiopulmonary resuscitation).
D. MD # 35 (Cardiology) progress note on 1/19/2023 at 7:42 am, reflected patient admitted with acute respiratory failure and acute renal failure. Patient coded; ACLS protocol was followed. Patient was down for 40 minutes with PEA arrest. EKG (electrocardiogram) showed inferior STEMI (ST Elevation Myocardial Infarction); patient had a longer downtime.
E. MR documentation lacked an accurate and complete nurse narrative note(s) for patient status changes; action of call to MD # 33 for Bi-Pap (Bilevel positive airway pressure), call to Respiratory therapy, and for Bi-Pap on stand by at 12:00 am; for patient's rhythm changes and decision to have patient's telemetry monitor on stand by; for patient's status/changes prior to Code Blue at 3:48 am.

6. In interview with administrative staff member A # 1 (Director Of Nursing), on 2/22/2023, at approximately 1:42 pm, confirmed that no narrative nurse note by AS # 3 (Agency Nurse - 2 North staff), prior to patient coding on 1/19/2023. Policies not followed.

7. In interview with administrative staff member A # 2 (RN, 2 North Unit Manager), on 2/22/2023, at approximately 1:41 pm, confirmed the following:
A. No nurse narrative note by AS # 3, when got BiPap order for patient; patient's restlessness, or concerning telemetry on stand by; after calls from MT for low heart rate in 30's.
B. Policies not followed for incident reporting and nursing reassessment.

8. In interview administrative staff member A # 3 (Chief Nursing Officer), on 2/22/2023, at approximately 1:40 pm, confirmed that no narrative nurse note by AS # 3; prior to patient coding, with status changes; call to Physician, previous to coding. Policies not followed.