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Based on record review, physician and staff interview, the Hospital failed to report to the Department, in a timely manner, a serious reportable event for one of one Patient's which occurred in January 2010 until April 2010. During the course of the survey, it was discovered the Patient developed a significant pressure sore which had not been reported to the Department for the same Patient.

The findings are as follow:

The Patient was scheduled for same day surgery and admitted to the Observation Unit.

The Patient was admitted to the Observation Unit from the Post Anesthesia Care Unit (PACU) following a laparoscopic ventral hernia repair and Chronic Ambulatory Peritoneal Dialysis (CAPD) catheter insertion in January 2010. The Patient had a change in level of consciousness. The Patient was administered the medication Narcan without an adequate response.

Two hours following the administration of the medication Narcan, the Medical Emergency Response Team (MET) was called. The Patient's medical condition quickly deteriorated and the Patient was transferred into the Intensive Care Unit.

Review of the Hospital's Root Cause Analysis dated 03/22/10 indicated the Patient became unresponsive and failed to adequately respond to the administration of Narcan given to counter the effects of sedation.

Review of the Hospital's Root Cause Analysis dated 03/22/10 indicated a blood glucose level drawn at approximately 4:30 AM was unrecordable between zero and two. The normal range for the blood glucose is between 70 to 110. The laboratory technician did not report the critical value to the ordering physician. The laboratory technician did not retest the critical value for another two and one half hours at 6:57 AM. The Patient's critical value was recorded as less than ten.

The Hospital's VP of Quality and Director of Safety said in interview on the days of survey that reports of negative patient outcomes were referred to the Quality Department monthly. The serious reportable event was not reported to the Department in a timely manner.

Although, a comprehensive Root Cause Analysis was conducted at the time of survey, the Hospital did not ensure a timely investigation in order to effectively implement measures to improve the quality of patient care.

The Hospital failed to investigate and report to the Department a serious reportable event for which the Patient was permanently disabled in a comatose state.

During the course of the survey, it was discovered the Patient developed a health associated pressure ulcer defined as a serious reportable event in February 2010. The Hospital did not report the Patient's health associated pressure ulcer to the Department; as required nor was there evidence the Patient's pressure ulcer development had been investigated by the Hospital's Quality Department.

There was no Quality Tracking Tool filed for the Patient's sacral pressure ulcer which developed during the course of hospitalization.

The VP of Quality informed the Surveyor on the first day of survey that the Patient developed a sacral pressure ulcer which deteriorated and required surgical debridement on 03/18/10.

Refer to A-Tag 0144, A-Tag 0288, A-Tag 0395, A-Tag 0449, A-Tag 508 and A-Tag 0582.

Based on medical record review, physician and staff interview, the Hospital did not ensure the medical staff was accountable to the governing body for the quality of care provided to one of one Patient's hospitalized in January 2010.

The findings are as follow:

The Patient was admitted to the Observation Unit from the Post Anesthesia Care Unit (PACU) following a laparoscopic ventral hernia repair and Chronic Ambulatory Peritoneal Dialysis (CAPD) catheter insertion. The Patient had a change in level of consciousness. The Patient was administered the medication Narcan without an adequate response.

As reported and review of the medical record indicated the Patient had an extensive complicated medical history excluding the Patient from admission to the Observation Unit post-operatively as per Hospital Policy.

It was reported, the Patient became unresponsive on 01/26/10 at 2 AM and the Crisis Nurse and Intern were called to the Observation Unit. RN #1, who was assigned to the Patient had never administered Narcan, so the Crisis Nurse administered the medication. RN #1 said the Intern notified the Resident Physician who also evaluated the Patient.

Both RN #1 and the Crisis Nurse said the Patient's level of consciousness did not return to the Patient's baseline. Both said the Patient was unable to speak or voice any complaints. RN #1 said neither the Intern nor the Resident returned to re-evaluate the Patient after the administration of the Narcan.

Review of the Physician's Orders indicated RN #1 documented a verbal order was obtained for both the Narcan and Ativan medications at 2 AM. The Intern/Resident signed the medication orders at 3:45 AM. The medication Ativan was documented as administered at 2:40 AM. There was no documentation and RN #1 said the Resident did not evaluate the Patient at the time of the Patient's seizure.

There was no documentation for the Patient's Glasgow Scale. There was no clear documentation for the description of the Patient's involuntary movement nor documentation for the specific time of the seizure-like activity or how long the seizure-like activity lasted.

Review of the Interns Progress Note dated 01/26/10 at 2:20 AM indicated the Intern was summoned to the bedside to evaluate the Patient's unresponsiveness. The Intern indicated after the administration of Narcan 0.1 milligrams, the Patient woke up vigorously. The Intern's Note conflicted with the statements made by Registered Nurse #1 and the Crisis Nurse.

The Intern was interviewed in person on 04/12/10 at 3 PM. The Intern said the Patient was somnolent and difficult to arouse. The Intern said the Resident was called who also evaluated the Patient. The Intern said the Patient was given the medication Narcan, woke up and became alert. The Intern said the Patient was evaluated again for spastic seizure and given Ativan The Intern said after the administration of the mediation Ativan there were no other calls until 4 AM when the MET team was called. The Intern said the Patient at that time was hypotensive and the oxygen levels were low. The Intern said the team was initially suspicious that the Patient had too much narcotic medication in PACU.

Resident #2 was interviewed in person on 04/12/10 at 2:30 PM. Resident #2 said the Intern and Resident #1 described the events leading to the MET team response. The Patient had a seizure and was medicated but the specifics of the sequencing of the medication administration were not clear. Resident #2 said the Patient's pupils were dilated and fixed. Resident #2 said while the Patient was being evaluated by the MET team, the Patient stopped breathing. Resident #2 who attempted to intubate the Patient was unsuccessful. Resident #2 said the Respiratory Therapist intubated the Patient. Resident #2 said the Patient was taken for an immediate Computerized Tomography (CT) of the Head and blood work including a blood glucose level. Resident #2 said there was no return call from the laboratory for the Patient's blood glucose level which was not registering during the initial and a repeated test by the technician. Resident #2 said the Patient was admitted into the Intensive Care Unit. Resident #2 said the Chief Resident for the Surgical Services responded to the MET Team.

There was no documentation that the Chief Resident had been notified by either the Intern or the Resident prior to the MET Call.

Review of the MET Emergency Team Response Resident Documentation dated 01/26/10 at 4:30 AM indicated the Patient became unresponsive. The Patient's pupils were equal, dilated and nonreactive to light. The Report indicated the Patient's respiratory (word unknown) decreased and the Patient destated (low oxygen levels). The Patient's vital signs were recorded as a temperature of 97 degrees Fahrenheit, blood pressure of 81/74, heart rate of 38 beats per minute, respirations 8 breaths per minute with an oxygen saturation level of 80%. Resident #1 indicated the Patient was unresponsive with possible brain damage. There was no documentation any medications were administered for the management of the Patient's low heart rate or blood pressure.

The VP of Quality, the Director of Patient Safety and the VP of Critical Care were interviewed on the days of survey. All reported the MET team should have been called at 2 AM and the Patient should have been transferred to a higher level of care from the Observation Unit.

The Surgeon was interviewed in person on 04/12/10 at 4:30 PM. The Surgeon said the Patient tolerated the two surgical procedures on 01/25/10. The Surgeon said given the Patient's complicated medical history; a request was made to have the Patient co-managed by the medical service. The Surgeon said the Patient was evaluated prior to surgery but not followed by the Hospitalist Service post-operatively. The Surgeon said the request for the Patient to be followed was not communicated.

Refer to A-Tag 021,A-Tag 0144, A-Tag 0288, A-Tag 0395, A-Tag 0449, A-Tag 0508 and A-Tag 0582

Based on record review, physician and staff interview, one of one Patient's admitted to the Observation Unit from the Post Anesthesia Care Unit (PACU) following a laparoscopic ventral hernia repair and Chronic Ambulatory Peritoneal Dialysis (CAPD) catheter insertion in January 2010 had a change in level of consciousness. The Patient was administered the medication Narcan without an adequate response.

The findings are as follow:

The Patient was scheduled for same day surgery and admitted to the Observation Unit.

Review of the Hospital's Policy for Admission Criteria for the Observation Unit indicated the unit would be a non-teaching unit and patients would be provided with services by the Hospitalist. The Policy indicated patients eligible for placement onto the Observation Unit included: medical necessity as determined by the severity of presenting illness, planned medical treatment and expected resolution in 24 hours that include the following categories: vomiting and dehydration, low risk chest pain, syncope/pre-syncope, asthma, flank pain(pyelonephritis), abdominal pain with unknown etiology and elder risk. Patients to be excluded from admission to the Observation Unit included: patients with clinical vital signs indicative of cardiovascular, respiratory or neurological instability, active chest pain associated with cardiac symptoms or anginal equivalent, a Glasgow coma score less than or equal to 12, fecal impaction, chronic pain, acute peritonitis, requirement for more assistance by staff for activities of daily living than the staff can provide and patients with significant co-morbidities that may complicate care.

As reported and review of the medical record indicated the Patient had an extensive complicated medical history excluding the Patient from admission to the Observation Unit post-operatively as per Hospital Policy.

Registered Nurse (RN) #1 was interviewed in person on 04/13/10 at 7 AM . RN #1 said the Patient was admitted from PACU and required narcotic pain administration of an approximate total of 16 milligrams of Morphine, 200 micrograms of Fentanyl and 10 milligrams of Hydralazine. RN #1 said after arrival to the Observation Unit, Morphine 2 milligrams was given by intravenous push at 6:40 PM. and the Patient continued to have pain. RN #1 said Zofran 4 milligrams was given at 8 PM for nausea. RN #1 said the Patient had ambulated with assistance. RN #1 said the Patient had eaten dinner. It was not clear what the Patient had consumed. RN #1 said the Patient's spouse reminded the nurse to check the Patient's capillary blood sugar because the Patient's blood glucose would often drop significantly during the night. RN #1 said the Patient was not provided intravenous fluid support.

Review of the Patient's medical record indicated on 01/26/10 at 12 AM, the Patient's vital signs were recorded as a blood pressure of 150/50, heart rate of 54 beats per minute, respirations 12 breaths per minute with an oxygen saturation level of 100% on one liter of oxygen delivered by nasal cannula.

Continued review indicated on 01/26/10 at 1:52 AM, the Patient's capillary blood glucose was recorded as 133 (normal range for most patients ranges between 70 to 110).

It was reported and a Nursing Note dated 01/26/10 at 2:47 PM indicated the Patient's vital signs on 01/26/10 at 1:52 AM were recorded as a blood pressure of 155/50, heart rate 54 beats per minute and oxygen saturation level of 86% on room air. However, the Patient's vital signs were not recorded electronically in the vital sign section of the Patient's medical record.

It was reported, the Patient became unresponsive on 01/26/10 at 2 AM and the Crisis Nurse and Intern were called to the Observation Unit. RN #1, who was assigned to the Patient had never administered Narcan, so the Crisis Nurse administered the medication. RN #1 said the Intern notified the Resident Physician who also evaluated the Patient.

The Crisis Nurse was interviewed in person on 04/13/10 at 7:30 AM. Crisis Nurse said the Patient was unresponsive on 01/26/10 at 2 AM. The Crisis Nurse said Narcan 0.1 milligrams was given as ordered by the Surgical Resident. The Crisis Nurse said the Patient had been given a large amount of narcotic in the PACU. The Crisis Nurse said the Patient startled after the administration of the medication Narcan with no purposeful movement. The Crisis Nurse said the Patient was assessed for approximately an hour. The Crisis Nurse said the expectation was that the Patient would wake up but the Patient did not. The Crisis Nurse said Ativan was also administered. The Crisis Nurse said the staff which consisted of two registered nurses on the Unit were comfortable keeping the Patient on the Observation Unit. The Crisis Nurse said Ativan was also administered approximately one hour and twenty minutes later for seizure-like activity.

Both RN #1 and the Crisis Nurse said the Patient's level of consciousness did not return to the Patient's baseline. Both said the Patient was unable to speak or voice any complaints. RN #1 said neither the Intern nor the Resident returned to re-evaluate the Patient after the administration of the Narcan.

There was no documentation for the Patient's Glasgow Scale. There was no clear documentation for the description of the Patient's involuntary movement nor documentation for the specific time of the seizure-like activity or how long the seizure-like activity lasted.

Review of the Physician's Orders indicated RN #1 documented a verbal order was obtained for both the Narcan and Ativan medications at 2 AM. The Intern/Resident signed the medication orders at 3:45 AM. The medication Ativan was documented as administered at 2:40 AM. There was no documentation and RN #1 said the Resident did not evaluate the Patient at the time of the Patient's seizure.

Review of the Interns Progress Note dated 01/26/10 at 2:20 AM indicated the Intern was summoned to the bedside to evaluate the Patient's unresponsiveness. The Intern indicated after the administration of Narcan 0.1 milligrams, the Patient woke up vigorously. The Intern's Note conflicted with the statements made by Registered Nurse #1 and the Crisis Nurse.

The Intern was interviewed in person on 04/12/10 at 3 PM. The Intern said the Patient was somnolent and difficult to arouse. The Intern said the Resident was called who also evaluated the Patient. The Intern said the Patient was given the medication Narcan, woke up and became alert. The Intern said the Patient was evaluated again for spastic seizure and given Ativan The Intern said after the administration of the mediation Ativan there were no other calls until 4 AM when the MET team was called. The Intern said the Patient at that time was hypotensive and the oxygen levels were low. The Intern said the team was initially suspicious that the Patient had too much narcotic medication in PACU.

There was no documentation for the observations nor nursing measures made by the Crisis Nurse. The Crisis Nurse said the Patient later destated (lowered oxygen levels) and the MET Response Team was called.

There was no further documentation by RN #1 for the Patient's response to either the Narcan or the Ativan medication administration. RN #1 did not notify the Nursing Supervisor for the Patient's change in condition nor immediately notify the MET Response Team.

The Director of Patient Safety accompanied the Surveyor on two days of survey. The Director of Patient Safety said the MET Team responded to a call at 4 AM. The Director of Patient Safety said Resident #2 responded to the call, along with an RN from the Critical Care Area and a Respiratory Therapist.

Resident #2 was interviewed in person on 04/12/10 at 2:30 PM. Resident #2 said the Intern and Resident #1 described the events leading to the MET team response. The Patient had a seizure and was medicated but the specifics of the sequencing of the medication administration were not clear. Resident #2 said the Patient's pupils were dilated and fixed. Resident #2 said while the Patient was being evaluated by the MET team, the Patient stopped breathing. Resident #2 who attempted to intubate the Patient was unsuccessful. Resident #2 said the Respiratory Therapist intubated the Patient. Resident #2 said the Patient was taken for an immediate Computerized Tomography (CT) of the Head and blood work including a blood glucose level. Resident #2 said there was no return call from the laboratory for the Patient's blood glucose level which was not registering during the initial and a repeated test by the technician. Resident #2 said the Patient was admitted into the Intensive Care Unit. Resident #2 said the Chief Resident for the Surgical Services responded to the MET Team.

There was no documentation that the Chief Resident had been notified by either the Intern or the Resident prior to the MET Call.

Review of the medical record indicated there were no electronic recordings of the Patient's vital signs on 01/26/10 between the hours of 2 AM and 4 AM.

Review of the Nursing Progress Note at 4:47 AM (which documented the events prior to the MET Team response) indicated the Patient appeared to be having seizures and Ativan was given and the Patient settled down for a little while. The RN (#1) indicated on return to check (time unknown) the Patient's heart rate decreased from 49 to 46 beats per minute and the oxygen saturation level was in the low 80's.

Review of the MET Emergency Team Response Resident Documentation dated 01/26/10 at 4:30 AM indicated the Patient became unresponsive. The Patient's pupils were equal, dilated and nonreactive to light. The Report indicated the Patient's respiratory (word unknown) decreased and the Patient destated (low oxygen levels). The Patient's vital signs were recorded as a temperature of 97 degrees Fahrenheit, blood pressure of 81/74, heart rate of 38 beats per minute, respirations 8 breaths per minute with an oxygen saturation level of 80%. Resident #1 indicated the Patient was unresponsive with possible brain damage. There was no documentation any medications were administerted for the management of the Patient's low heart rate or blood pressure.

The VP of Quality, the Director of Patient Safety and the VP of Critical Care were interviewed on the days of survey. All reported the MET team should have been called at 2 AM and the Patient should have been transferred to a higher level of care from the Observation Unit.

The Surgeon was interviewed in person on 04/12/10 at 4:30 PM. The Surgeon said the Patient tolerated the two surgical procedures on 01/25/10. The Surgeon said given the Patient's complicated medical history; a request was made to have the Patient co-managed by the medical service. The Surgeon said the Patient was evaluated prior to surgery but not followed by the Hospitalist Service post-operatively. The Surgeon said the request for the Patient to be followed was not communicated.

Based on record review, physician and staff interview, the Hospital failed to adequately track and analyze one of one Patient's who had a change in condition and mental status post-operatively in January 2010. The Hospital further failed to report that the same Patient developed a health associated pressure sore in the sacral area in February 2010.

The findings are as follow:

Refer to A-021, A-049, A-0144. A-0395, A-0449, A-0508 and A-0582

It was reported to the Department on 04/02/10 that a serious reportable event occurred on 01/26/10 at 2 AM. It was reported a Patient had a change in medical condition on 01/26/10 at 2 AM while on an Observation Unit. It was reported and medical record review indicated the Patient was post-operative for two surgical procedures: a ventral hernia repair and insertion of a Peritoneal Catheter for dialysis was completed on 01/25/10 at 3 PM.

Review of the Hospital's Admission Criteria for the Observation Unit indicated the Patient did not meet safe criteria for admission to the Observation Unit secondary to the Patient's complicated medical history.

The VP of Quality, the Director of Patient Safety and the VP of Critical Care were interviewed on the days of survey. All reported the MET team should have been called at 2 AM and the Patient should have been transferred to a higher level of care from the Observation Unit.

Review of the Hospital's Root Cause Analysis dated 03/22/10 indicated the Patient became unresponsive and failed to adequately respond to the administration of Narcan given to counter the effects of sedation.

Review of the Hospital's Root Cause Analysis dated 03/22/10 indicated a blood glucose level drawn at approximately 4:30 AM and unrecordable between zero and two. The normal range for the blood glucose is between 70 to 110. The laboratory technician failed to report the critical value to the ordering physician and a retest of the critical value was not obtained for an additional two and one half hours at 6:57 AM.

The Hospital's VP of Quality and Director of Safety said in interview on the days of survey that reports of negative patient outcomes were referred to the Quality Department monthly. The serious reportable event was not reported to the Department in a timely manner.

Although, a comprehensive Root Cause Analysis was conducted at the time of survey, the Hospital did not ensure a timely investigation in order to effectively implement measures to improve quality of patient care.

During the course of the survey, the Surveyor was informed by the VP of Quality that the Patient developed a sacral pressure ulcer which deteriorated and required surgical debridement on 03/18/10.

The Hospital did not report the Patient's development of a significant pressure sore to the Department as required for a serious reportable event.

There was no evidence the Hospital had taken appropriate measures to adequately track the incidents of health associated pressure ulcers.

Review of the Hospital's Policy for Wound and Skin Care Standard indicated the policy was to provide a standardized approach to wound and skin care management. Utilizing current standards of practice and products to optimize healing of wounds and to prevent the development of pressure ulcer. The Policy's Objective was to prevent skin breakdown by utilizing resources that are available through the multiple disciplines of the Hospital. The Policy indicated patients would not develop nosocomial (health associated) pressure ulcers. The Policy indicated patients would be assessed on admission, identified as at risk of developing pressure ulcers and wounds would be staged and interventions would be provided. The Policy indicated current standards would be implemented based on drainage and necrosis, wound treatment would be documented and assessed and nosocomial wounds would be reported using the Quality Tracking Tool. The Policy indicated based on the presence of necrotic tissue and amount of drainage an appropriate dressing would be applied to promote a moist environment, control of exudate and to protect the wound until a wound consult could be obtained.

Review of the Critical Care Nursing Note dated 02/03/10 indicated the Patient's coccyx was reddened. It was not clear as to the nursing measures implemented to prevent further skin breakdown.

There was no documentation of preventative treatment for the Patient's reddened coccyx.

Review of the Critical Care Nursing Note dated 02/12/10 at 6:55 AM indicated the Patient had a small deep purple area described as somewhat open to the coccyx. The Critical Care Nursing Note dated 02/12/10 indicated the effected area was dry and without drainage.

On 02/13/10, the Patient was transferred to a Step Down Unit.

Review of a Nursing Note dated 02/13/10 at 2 PM indicated the Patient had an open area on the sacrum which was treated with Critic Aid Paste. There was no staging or measurement of the Patient's pressure sore.

On 02/16/10, Registered Nurse #2 documented the Patient's sacral pressure sore was necrotic.

Registered Nurse #2 was interviewed in person on 04/13/10 at 2:15 PM. Registered Nurse #2 said the Patient's pressure sore was superficial, the size of a nickle or a quarter. Registered Nurse #2 denied having any training in the management of pressure ulcers, staging or measurement of pressure ulcer.

Review of the Nurse Note dated 02/28/10 at 5:17 PM indicated the Patient's sacral pressure sore was identified as necrotic/black measuring 8.0 centimeters by 4.3 centimeters. There was no measurement of depth.

Registered Nurse #3 was interviewed in person 04/13/10 at 3:30 PM. Registered Nurse #3 said the Patient's pressure sore on the bottom was purple and not open the size of a silver dollar and not necrotic. Registered Nurse #3 documented the nursing assessment of the Patient's sacral pressure sore on 02/28/10.

There was no documentation that the Wound Care Consultant had been notified of the Patient's sacral wound as per Policy as an appropriate resource.

There was no evidence of documentation that a physician was notified of the Patient's pressure sore.

Review of the Physician Progress Note dated 03/04/10 indicated the Patient had a sacral wound a Stage II/III.

The Wound Care Consultant was interviewed in person on 04/13/10 at 9:15 AM. The Wound Care Consultant said the Patient had been followed by the wound care team for a foot wound during the course of hospitalization. The Wound Care Consultant said the nursing staff did not inform the wound consultant team that the Patient had developed a sacral pressure sore. The Wound Care Consultant said the nursing staff were responsible for measuring the patient's pressure sores and filing a Quality Tracking Tool.

There was no Quality Tracking Tool filed for the Patient's sacral pressure ulcer.

Approximately 22 days following the development of the Patient's sacral pressure sore, the Wound Care Consultant was notified. Review of the Wound Care Consultant's Progress Note (#2) dated 03/05/10 indicated a new referral for wound assessment of a Sacral Wound was made. The Patient's sacral pressure ulcer measured 7 centimeters in length, by 6 centimeters in width, by unable to determine in depth (UTD). The Wound Care Consultant indicated the base of the wound was 100% black necrotic (with an entry for the word necrotic written as an error) with a few open areas along the edge. The wound had surrounding erythremia and physician was in to see the wound. The Wound Care Consultant indicated the wound would need debridement. The Wound Care Consultant indicated the Patient's surrounding area/perineum was red and fungal looking. Baza Clear AF was applied and the Patient was having loose stools. The Wound Care Consultant indicated Critic Aid Paste was applied to the open areas and Vaseline Gauze and dressing were applied to the Sacral Wound.

Review of the Wound Care Consultant (#3) Progress Note dated 03/07/10 indicated in a follow-up assessment, the Sacral Wound Pressure Sore eschar was soft but adherent. The Sacral Wound measured 8 centimeters by 7 centimeters by UTD with no surrounding erythema and no drainage noted. Wound Care Consultant (#3) indicated the wound may be superficial but not fully able to determine at this time. The Wound Care Consultant indicated the dressing should be changed daily at 9 AM. Critic Aid Paste should be applied to the entire area of eschar and cover with a double layer of Xeroform gauze. The Wound Care Consultant indicated both will act as an occlusive dressing and aide in autolytic debridement of the eschar.

Review of the Wound Assessment Nursing Documentation between the dates of 03/07/10 to 03/18/10 indicated the treatments were done as ordered to the Patient's Sacral Wound.

There was no further measurement provided to the Surveyor for the measurement of the Patient's Sacral Wound until the Patient's discharge.

At the time of discharge to a skilled nursing facility, the Discharge summary dated 04/02/10 indicated the Patient's Sacral Pressure Sore measured 9.5 centimeters by 11 centimeters and 1.5 centimeters in depth, with soft brown necrosis to the bone.

Based on record review and staff interview, the medical record lacked an appropriate nursing assessment following a change in condition for one of one Patient's with a change in mental status and seizure like activity in January 2020. There was a lack of nursing documentation for the appropriate nursing interventions to prevent the development of a sacral pressure sore on or about February 12, 2010 for the same Patient.

The findings are as follow:

Refer to A-0144 and A-0288.

It was reported, the Patient became unresponsive on 01/26/10 at 2 AM and the Crisis Nurse and Intern were called to the Observation Unit. RN #1, who was assigned to the Patient had never administered Narcan, so the Crisis Nurse administered the medication. RN #1 said the Intern notified the Resident Physician who also evaluated the Patient.

The Crisis Nurse was interviewed in person on 04/13/10 at 7:30 AM. Crisis Nurse said the Patient was unresponsive on 01/26/10 at 2 AM. The Crisis Nurse said Narcan 0.1 milligrams was given as ordered by the Surgical Resident. The Crisis Nurse said the Patient had been given a large amount of narcotic in the PACU. The Crisis Nurse said the Patient startled after the administration of the medication Narcan with no purposeful movement. The Crisis Nurse said the Patient was assessed for approximately an hour. The Crisis Nurse said the expectation was that the Patient would wake up but the Patient did not. The Crisis Nurse said Ativan was also administered. The Crisis Nurse said the staff which consisted of two registered nurses on the Unit were comfortable keeping the Patient on the Observation Unit. The Crisis Nurse said Ativan was also administered approximately one hour and twenty minutes later for seizure-like activity.

Both RN #1 and the Crisis Nurse said the Patient's level of consciousness did not return to the Patient's baseline. Both said the Patient was unable to speak or voice any complaints. RN #1 said neither the Intern nor the Resident returned to re-evaluate the Patient after the administration of the Narcan.

There was no documentation for the Patient's Glasgow Scale. There was no clear documentation for the description of the Patient's involuntary movement nor documentation for the specific time of the seizure-like activity or how long the seizure-like activity lasted.

During the course of the survey, the Surveyor was informed by the VP of Quality that the Patient developed a sacral pressure ulcer which deteriorated and required surgical debridement on 03/18/10.

Review of the Hospital's Policy for Wound and Skin Care Standard indicated the policy was to provide a standardized approach to wound and skin care management. Utilizing current standards of practice and products to optimize healing of wounds and to prevent the development of pressure uclers. The Policy's Objective was to prevent skin breakdown by utilizing resources that are available through the multiple disciplines of the Hospital. The Policy indicated patients would not develop nosocomial (health associated) pressure ulcers. The Policy indicated patients would be assessed on admission, identified as at risk of developing pressure ulcers and wounds would be staged and interventions would be provided. The Policy indicated current standards would be implemented based on drainage and necrosis, wound treatment would be documented and assessed and nosocomial wounds would be reported using the Quality Tracking Tool. The Policy indicated based on the presence of necrotic tissue and amount of drainage an appropriate dressing would be applied to promote a moist environment, control of exudate and to protect the wound until a wound consult could be obtained.

Review of the Critical Care Nursing Note dated 02/03/10 indicated the Patient's coccyx was reddened. It was not clear as to the nursing measures implemented to prevent further skin breakdown.

There was no documentation of preventative treatment for the Patient's reddened coccyx.

Review of the Critical Care Nursing Note dated 02/12/10 at 6:55 AM indicated the Patient had a small deep purple area described as somewhat open to the coccyx. The Critical Care Nursing Note dated 02/12/10 indicated the effected area was dry and without drainage.

On 02/13/10, the Patient was transferred to a Step Down Unit.

Review of a Nursing Note dated 02/13/10 at 2 PM indicated the Patient had an open area on the sacrum which was treated with Critic Aid Paste. There was no staging or measurement of the Patient's pressure sore.

On 02/16/10, Registered Nurse #2 documented the Patient's sacral pressure sore was necrotic.

Registered Nurse #2 was interviewed in person on 04/13/10 at 2:15 PM. Registered Nurse #2 said the Patient's pressure sore was superficial, the size of a nickle or a quarter. Registered Nurse #2 denied having any training in the management of pressure ulcers, staging or sizing pressure ulcer.

Review of the Nurse Note dated 02/28/10 at 5:17 PM indicated the Patient's sacral pressure sore was identified as necrotic/black measuring 8.0 centimeters by 4.3 centimeters.

Registered Nurse #3 was interviewed in person 04/13/10 at 3:30 PM. Registered Nurse #3 said the Patient's pressure sore on the bottom was purple and not open, the size of a silver dollar and not necrotic. Registered Nurse #3 documented the nursing assessment of the Patient's sacral pressure sore on 02/28/10.

There was no documentation that the Wound Care Consultant had been notified of the Patient's sacral wound. There was no evidence of documentation that a physician was notified of the Patient's pressure sore.

Review of the Physician Progress Note dated 03/04/10 indicated the Patient had a sacral wound a Stage II/III.

The Wound Care Consultant was interviewed in person on 04/13/10 at 9:15 AM. The Wound Care Consultant said the Patient had been followed by the wound care team for a foot wound during the course of hospitalization. The Wound Care Consultant said the nursing staff did not inform the wound care team, the Patient had a sacral pressure sore until 03/05/10. The Wound Care Consultant said the nursing staff were responsible for measuring the patient's pressure sores and filing a Quality Tracking Tool.

There was no Quality Tracking Tool filed for the Patient's sacral pressure ulcer.

A tour of the Hospital was made and there were no reports of patient's with pressure sore located on the Step Down Unit identified by the staff or the Nurse Manager.

Review of the Wound Care Consultant Progress Note (#2) dated 03/05/10 indicated a new referral for wound assessment of a Sacral Wound was made. The Patient's Sacral Wound measured 7 centimeters in length by 6 centimeters by unable to determine in depth (UTD). The Wound Care Consultant indicated the base of the wound was 100% black necrotic (with an entry for the word necrotic written as an error) with a few open areas along the edge. The wound had surrounding erythemia and physician in to see the wound. The Wound Care Consultant indicated the wound would need debridement. The Wound Care Consultant indicated the Patient's surrounding area/ perineum was red and fungal looking. Baza Clear AF was applied and the Patient was having loose stools. The Wound Care Consultant indicated Critic Aid Paste was applied to the open areas and Vaseline Gauze and dressing were applied.

Review of the Wound Care Consultant (#3) Progress Note dated 03/07/10 indicated in a follow-up assessment the Sacral Wound Pressure Sore eschar was soft but adherent. The Sacral Wound measured 8 centimeters by 7 centimeters by UTD with no surrounding erythema and no drainage noted. Wound Care Consultant (33) indicated the wound may be superficial but not fully able to determine at this time. The Wound Care Consultant indicated dressing should be changed daily at 9 AM. Critic Aid Past should be applied to the entire area of eschar and cover with a double layer of Xeroform gauze both will act as an occlusive dressing and aide in autolytic debridement of the eschar.

Review of the Wound Assessment Nursing Documentation between the dates of 03/07/10 to 03/18/10 indicated the treatments were done as ordered to the Patient's Sacral Wound.

There was no further measurement provided to the Surveyor for the measurement of the Patient's Sacral Wound until the Patient's discharge.

The nursing staff did not meet their responsibilities in adequately identifying a Patient with a pressure sore nor notify the Wound Care Consultant of the development of the Patient's sacral pressure sore in a timely manner.

The Wound Care Consultants did not meet their responsibilities by inquiring as to the Patient's overall skin condition while treating the Patient's foot wound(s) which the Patient had on admission to the Hospital.

On 04/02/10, the Patient was transferred to a skilled nursing facility.

Based on record review, physician and staff interview, one of one Patient had a change in level of consciousness.The Patient was administered the medication Narcan without an adequate response.There was a lack of nursing documentation following the administration of the medication Narcan and a lack of documentation for the Patient's seizure-like activity.

The findings are as follow:

Refer to A Tag 0144, A-0288, and A-0395.

The Patient was scheduled for same day surgery and admitted to the Observation Unit.

Registered Nurse (RN) was interviewed in person on 04/13/10 at 7 AM . RN #1 said the Patient was admitted form the PACU and required narcotic pain administration of an approximate total of 16 milligrams of Morphine, 200 micrograms of Fentanyl and 10 milligrams of Hydralazine. RN #1 said after arrival to the Observation Unit, Morphine 2 milligrams was given by intravenous push at 6:40 PM. and the Patient continued to have pain. RN #1 said Zofran 4 milligrams was given at 8 PM for nausea. RN #1 said the Patient had ambulated with assistance. RN #1 said the Patient had eaten dinner. It was not clear what the Patient had consumed. RN #1 said the Patient's spouse reminded the nurse to check the Patient's capillary blood sugar because the Patient's blood glucose would often drop significantly during the night. RN #1 said the Patient was not provided intravenous fluid support.

Review of the Patient's medical record indicated on 01/26/10 at 12 AM the Patient's vital signs were recorded as a blood pressure of 150/50, heart rate of 54 beats per minute, respirations 12 breaths per minute with an oxygen saturation level of 100% on one liter of oxygen delivered by nasal cannula.

Continued review indicated on 01/26/10 at 1:52 AM, the Patient's capillary blood glucose was recorded as 133 (normal range for most patients ranges between 70 to 110).

It was reported the Patient's vital signs on 01/26/10 at 1:52 AM were recorded as a blood pressure of 155/50, heart rate 54 beats per minute and oxygen saturation level of 86% on room air. However, the Patient's vital signs were not recorded electronically in the section for vital signs in the medical record.

It was reported, the Patient became unresponsive on 01/26/10 at 2 AM and the Crisis Nurse and Intern were called to the Observation Unit. RN #1, who was assigned to the Patient had never administered Narcan, so the Crisis Nurse administered the medication. RN #1 said the Intern notified the Resident Physician who also evaluated the Patient.

Crisis Nurse was interviewed in person on 04/13/10 at 7:30 AM. Crisis Nurse said the Patient was unresponsive on 01/26/10 at 2 AM. Crisis Nurse said Narcan 01. milligrams was given as ordered by the Surgical Resident. The Crisis Nurse said the Patient had been given a large amount of narcotic in the PACU. The Crisis Nurse said the Patient startled after the administration of the medication Narcan with no purposeful movement. The Crisis Nurse said the Patient was assessed for approximately an hour. The Crisis Nurse said the expectation was that the Patient would wake up but the Patient did not. The Crisis Nurse said Ativan was also administered. The Crisis Nurse said the staff which consisted of two registered nurses on the Unit were comfortable keeping the Patient on the Observation Unit.The Crisis Nurse said Ativan was also administered approximately one hour and twenty minutes later for seizure-like activity.

Both RN #1 and the Crisis Nurse said the Patient's level of consciousness did not return to the Patient's baseline. Both said the Patient was unable to speak or voice any complaints. RN #1 said neither the Intern nor the Resident returned to re-evaluate the Patient after the administration of the Narcan.

There was no documentation for the Patient's Glasgow Scale. There was no clear documentation for the description of the Patient's involuntary movement nor documentation for the specific time of the seizure-like activity or how long the activity lasted.

There was no documentation for the observations nor nursing measures made by the Crisis Nurse. The Crisis Nurse said the Patient later destated (lowered oxygen levels) and the MET Response was called.

There was no further documentation by RN #1 for the Patient's response to either the Narcan or the Ativan medication administration. RN #1 did not notify the Nursing Supervisor for the Patient's change in condition nor immediately notify the MET Response Team.

The Director of Patient Safety accompanied the Surveyor on two days of survey. The Director of Patient Safety said the MET Team responded to a call at 4 AM. The Director of Patient Safety said Resident #2 responded to the call, along with an RN from the Critical Care Area and a Respiratory Therapist.

Review of the medical record indicated there was no electronic recording of the Patient's vital signs on 01/26/10 between the hours of 2 AM and 4 AM.

On 04/02/10, the Patient was transferred to a skilled nursing facility.

Based on record review, physician and staff interview, one of one Patient's admitted to the Observation Unit from the Post Anesthesia Care Unit (PACU) following a laparoscopic ventral hernia repair and Chronic Ambulatory Peritoneal Dialysis (CAPD) catheter insertion in January 2010 had a change in level of consciousness. The Patient was administered the medication Narcan without an adequate response.

The findings are as follow:

Refer to A-Tag A 021, A-049, A- 0144, A-0288, A-0395 and A0449.

It was reported, the Patient became unresponsive on 01/26/10 at 2 AM and the Crisis Nurse and Intern were called to the Observation Unit. RN #1, who was assigned to the Patient had never administered Narcan, so the Crisis Nurse administered the medication. RN #1 said the Intern notified the Resident Physician who also evaluated the Patient.

The Crisis Nurse was interviewed in person on 04/13/10 at 7:30 AM. Crisis Nurse said the Patient was unresponsive on 01/26/10 at 2 AM. The Crisis Nurse said Narcan 01. milligrams was given as ordered by the Surgical Resident. The Crisis Nurse said the Patient had been given a large amount of narcotic in the PACU. The Crisis Nurse said the Patient startled after the administration of the medication Narcan with no purposeful movement. The Crisis Nurse said the Patient was assessed for approximately an hour. The Crisis Nurse said the expectation was that the Patient would wake up but the Patient did not. The Crisis Nurse said Ativan was also administered. The Crisis Nurse said the staff which consisted of two registered nurses on the Unit were comfortable keeping the Patient on the Observation Unit. The Crisis Nurse said Ativan was also administered approximately one hour and twenty minutes later for seizure-like activity.

Both RN #1 and the Crisis Nurse said the Patient's level of consciousness did not return to the Patient's baseline. Both said the Patient was unable to speak or voice any complaints. RN #1 said neither the Intern nor the Resident returned to re-evaluate the Patient after the administration of the Narcan.

Review of the Physician's Orders indicated RN #1 documented a verbal order was obtained for both the Narcan and Ativan medications at 2 AM. The Intern/Resident signed the medication orders at 3:45 AM. The medication Ativan was documented as administered at 2:40 AM. There was no documentation and RN #1 said the Resident did not evaluate the Patient at the time of the Patient's seizure.

Review of the Interns Progress Note dated 01/26/10 at 2:20 AM indicated the Intern was summoned to the bedside to evaluate the Patient's unresponsiveness. The Intern indicated after the administration of Narcan 0.1 milligrams, the Patient woke up vigorously. The Intern's Note contradicted with the statements of both the Crisis Nurse and RN #1.

The Intern was interviewed in person on 04/12/10 at 3 PM. The Intern said the Patient was somnolent and difficult to arouse. The Intern said the Resident was called who also evaluated the Patient. The Intern said the Patient was given the medication Narcan, woke up and became alert. The Intern said the Patient was evaluated again for spastic seizure and given Ativan The Intern said after the administration of the mediation Ativan there were no other calls until 4 AM when the MET team was called. The Intern said the Patient at that time was hypotensive and the oxygen levels were low. The Intern said the team was initially suspicious that the Patient had too much narcotic medication in PACU.

There was no further documentation by RN #1 for the Patient's response to either the Narcan or the Ativan medication administration. RN #1 did not notify the Nursing Supervisor for the Patient's change in condition nor immediately notify the MET Response Team.

Review of the Hospital's Root Cause Analysis dated 03/22/10 indicated the Patient became unresponsive and failed to adequately respond to the administration of Narcan given to counter the effects of sedation.

The Hospital's VP of Quality and Director of Safety said in interview on the days of survey that reports of negative patient outcomes were referred to the Quality Department monthly. The serious reportable event was not reported to the Department in a timely manner.

Based on record review and staff interview, the Hospital's laboratory failed to immediate report a critical value for one of one Patient's with a blood glucose level which registered zero in January 2010.

The findings are as follow:

The Hospital's VP of Quality and Director of Safety said in interview on the days of survey that reports of negative patient outcomes were referred to the Quality Department monthly. The Hospital's VP of Quality said while the MET team was evaluating the Patient for an episode of respiratory failure, a blood glucose level was drawn and the laboratory technician was not able to obtain a recordable reading and repeated the Patient's blood glucose level which was recorded as zero to two. The Hospital's VP of Quality said the laboratory technician did not notify the ordering physician for the very low critical value report for the Patient's glucose. The Hospital's VP of Quality said corrective action was taken with the laboratory.

Review of the Hospital's Root Cause Analysis dated 03/22/10 indicated a blood glucose level drawn during a MET team response at approximately 4:30 AM was reported to be unrecordable between zero and two. The normal range for the blood glucose is between 70 to 110. As reported, the laboratory technician did not report the initial blood glucose value drawn on 01/26/10 at 4:30 AM. However, the laboratory technician delayed the repeat of the critical blood glucose value another two hours and twenty minutes and retested the value on 01/26/10 at 6:57 AM. The laboratory technician did not immediately report the initial blood glucose value to the ordering physician.

There was no immediate physician notification by the laboratory technician for a critical blood glucose value drawn on 01/26/10 at 4:30 AM.

Resident #2 said there was no return call from the laboratory for the Patient's blood glucose level which was not registering during the initial and a repeated test by the technician.