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Based on review of Patients #1 and Patient #2's clinical records and the Standards of Emergency Nursing Practice Policy and interviews with the Emergency Department (ED) Executive Director, ED Nurse #1 and Respiratory Therapist (RT) #2, the Hospital failed to ensure that: 1) 1 of 14 sampled patients (Patient #1) with a cardiac history and on oxygen therapy, was placed on cardiac and/or pulse oximetry monitoring while in the ED and 2) oxygen therapy orders were obtained when oxygen therapy was implemented and/or changed to maintain adequate oxygen saturation levels (SpO2 level, indication of the level of oxygen in the blood) for 1 of 14 sampled patients (Patient #2).

Findings include:

PATIENT #1:

The Patient Summary Report, dated 8/7/12 at 12:38 P.M., indicated that Patient #1 presented to the ED with 6 days of vomiting, increased weakness,fatigue, abdominal bloating and discomfort.

The ED Record, dated 8/7/12, indicated that Patient #1's medical history included colon cancer, cardiac arrhythmia (irregular heart beat), Congestive Heart Failure (accumulation of fluid around the heart), a heart attack and Chronic Obstructive Pulmonary Disease (a progressive disease in which the lungs cannot fully expand/contract restricting air flow) with home oxygen therapy.

The Policy/Procedure titled Standards of Emergency Nursing Practice and Plan of Care Guidelines, effective 3/25/09, indicated that the nurse shall triage patients entering the ED and implement a plan of care based on assessment data, nursing diagnosis and medical diagnosis.

The Physician Orders, dated 8/7/12, indicated that cardiac/pulse oximetry monitoring were not ordered.

The Patient Summary Report, dated 8/7/12, indicated that nursing staff did not implement cardiac and/or pulse oximetry monitoring.

The Surveyor interviewed ED Nurse #1 on 9/17/12 at 10:30 A.M. ED Nurse #1 said that he was assigned to Patient #1 during the evening shift on 8/7/12, and Patient #1 was not on cardiac and/or pulse oximetry monitoring because his/her presenting symptoms were not cardiac or respiratory in nature.

The Surveyor interviewed the ED Executive Director with the ED Clinical Manager and the Patient Safety Director present on 9/19/12 at 10:30 A.M. The ED Executive Director said that Patient #1 should have been on cardiac and pulse oximetry monitoring based on the Patient's medical history.

The Patient Summary Report, dated 8/7/12 at 9:00 P.M., indicated that Patient #1's oxygen had been connected to medical air (consists of nitrogen and oxygen, used for certain nebulizer treatments or power pneumatic devices) instead of oxygen. The Patient Summary Report indicated that Patient #1 was cyanotic, breathing heavy and his/her SpO2 level was 41% (normal range is 92-100%).

The Patient Summary Report, dated 8/7/12 at 9:00 P.M., indicated that Patient #1 was administered 100% oxygen and given intravenous fluids. The Patient Summary Report indicated that Patient #1 became more alert as his/her SpO2 level improved to 92%.

The Hospital failed to ensure that Patient #1 was adequately monitored while in the ED.

PATIENT #2:

Please refer to A-0397 for further patient information.

A) The ED Physician Record, dated 8/6/12, indicated that Patient #2 presented to the ED after experiencing several days of shortness of breath and forgetfulness.

The Patient Summary Report, dated 8/6/12 at 11:43 A.M., indicated that Patient #2 was started on oxygen at 10 liters via face mask.

The Physician Orders, dated 8/6/12, did not include an order for oxygen administration.

B) The ED Physician Record, dated 8/6/12, indicated that diagnostic testing was performed that included blood testing, a chest x-ray and an electrocardiogram (ECG, record of heart activity). The ED Physician Record indicated that Patient #2 had congestive heart failure (fluid around the heart), a possible pleural effusion (fluid around the lungs) and an abnormal ECG.

The History and Physical, dated 8/6/12, indicated that Patient #2 was admitted to the Step-Down Unit.

The Admission Physician Orders, dated 8/6/12, did not include an order for oxygen administration.

The Daily Flow Sheet, dated 8/6/12 at 10:00 P.M., indicated that Patient #2 was administered oxygen 4 liters via nasal cannula.

The Daily Flow Sheet, dated 8/7/12 at 1:05 A.M. and 1:13 A.M., indicated that Patient #2 was administered oxygen 8 liters via an pendant oximyzer (an oxygen conserver that accumulates and stores oxygen, usually wasted during exhalation in a reservoir, and returns the oxygen to the patient thus maintaining adequate oxygen saturation at lower levels of oxygen flow).

The Daily Flow Sheet, dated 8/7/12 at 3:07 A.M., indicated that Patient #2 was administered oxygen at 15 liters via a face mask.

The Daily flow Sheet, dated 8/7/12 at 8:06 A.M., indicated that Patient #2 was receiving 75% oxygen via mask at 15 liters.

The Daily Flow Sheet, dated 8/7/12 at 5:15 P.M. indicated that Patient #2 was administered 75% oxygen via BIPAP (bilevel positive airway pressure, a machine that provides various levels of air pressure).

The Inpatient Transfer Report, dated 8/7/12 at 6:45 P.M., indicated that Patient #2 was transferred to the Critical Care Unit for acute respiratory failure.

The Physician Orders, dated 8/7/12, included oxygen via BIPAP with face mask to titrate SpO2 to 92%.

The Surveyor interviewed the Respiratory Therapist (RT) #2 on 9/13/12 at 9:25 A.M. and the Executive Director of the ED. RT #2 and the Executive Director said that a physician order was required to administer oxygen.

The Hospital failed to ensure that oxygen was administered under a physician order.

Based on observation of the medical air and oxygen flow meters, review of Patient #2's clinical record and interviews with the Float Nurse, the Step-Down Charge Nurse and Nursing Assistant (NA) #2, the Hospital failed to ensure that staff trained/qualified to manage oxygen therapy, such as licensed nurse or respiratory therapists, correctly reconnected the oxygen tubing for 1 of 14 sampled patients (Patient #2).

Findings include:

Please refer to A-0395 for Patient #1's medical information.

The Daily Flow Sheet, dated 8/7/12 at 8:06 A.M., indicated that Patient #2 was receiving 75% oxygen via mask at 15 liters with an SpO2 level of 94%.

The Surveyor interviewed the Float Nurse,assigned to Patient #2 during the day shift on 8/7/12, on 9/13/12 at 12:10 P.M. The Float Nurse said she had worked on the Step-Down Unit previously and that on 8/7/12, she was assigned to Patient #2. The Float Nurse said that Patient #2 was on cardiac and pulse oximetry monitoring and during the morning, the SpO2 levels were stable unless he/she removed the oxygen mask. The Float Nurse said that just prior to lunch, she went on break.

The Surveyor interviewed the Charge Nurse on 9/13/12 at 11:50 A.M. The Charge Nurse said that Patient #2 was receiving humidified oxygen via a face mask (oxygen via a bottle containing water to moisturize the oxygen during administration) and had been noncompliant throughout the morning with keeping the oxygen mask on. The Charge Nurse said that while the Float Nurse was on break, Patient #2 was eating lunch and had removed his/her oxygen mask to eat, which caused his/her SpO2 level to drop. The Charge Nurse said she removed Patient #2's mask, disconnected the aerosol bottle from the oxygen flow meter and connected oxygen tubing to the oxygen flow meter. The Charge Nurse said she then applied oxygen to Patient #2 via a pendent oximyzer to maintain Patient #2's SpO2 levels while he/she was eating. The Charge Nurse said that she reported the change to the Respiratory Therapist (RT) on the Unit and told the RT that she would switch Patient #2 back to a mask once he/she was finished with eating.

The Float Nurse said that when she returned from lunch, Patient #2 was still on the pendant oximyzer. The Float Nurse said that Patient #2 was assisted to the commode. The Float Nurse said that Patient #2's SpO2 level was low (unsure of specific %) and she had Nursing Assistant (NA) #2, who was in the room at that time, hand her Patient #2's oxygen mask. The Float Nurse said that NA #2 asked her if she should re-connect the aerosol bottle to the flow meter and the Float Nurse told her yes. The Float Nurse said she did not tell NA #2 which flow meter to connect the aerosol bottle to.

The Surveyor interviewed NA #2 on 9/17/12 at 9:05 A.M. NA #2 said that when the Float Nurse called for her to assist with Patient #2, she observed on the monitor that Patient #2's SpO2 level was low (unsure of the %). NA #2 said she told the Float Nurse that they needed to reapply Patient #2's oxygen mask.

NA #2 said she took it upon herself to re-connect the aerosol bottle to the flow meter. NA #2 said there were 2 flow meters located on the wall over Patient #2's bed and she asked the Float Nurse which flow meter to hook the aerosol bottle up to. NA #2 said the Float Nurse told her that she did not know. NA #2 said no one else was in the room to ask, so she connected the aerosol bottle up to one of the flow meters.

NA #2 said that she had not received training regarding connecting oxygen tubing and this was the first time she had done so.

The Float Nurse said that several minutes after NA #2 connected the aerosol bottle to the flow meter, Patient #2 slumped over and his/her SpO2 levels dropped to the 40's - 50's %. The Float Nurse said that she told NA #2 to get the Charge Nurse.

The Charge Nurse said that when she entered Patient #2's room, she observed that Patient #'s aerosol bottle was connected to the medical air flow meter and not to the oxygen flow meter. The Charge Nurse said she switched the aerosol bottle to the oxygen flow meter and Patient #2's SpO2 level immediately improved to 90%. The Charge Nurse said that she notified the physician and Respiratory Therapy.

The Inpatient Transfer Report, dated 8/7/12 at 6:45 P.M., indicated that Patient #2 was transferred to the Critical Care Unit because he/she was not maintaining his/her SpO2 levels within acceptable parameters and testing determined he/she was in acute hypercapneic respiratory failure (occurs when there is inadequate exchange of gas in the respiratory system. A rise in the arterial carbon dioxide is known as hypercapnia).

The Surveyor interviewed Hospitalist #1 on 9/17/12 at 12:30 P.M. Hospitalist #1 said that Patient #2 was very sick and decompensated and not compliant with oxygen therapy. Hospitalist #1 said that on 8/23/12, Patient #2 was transferred to another Hospital for further care and treatment.

The Hospital failed to ensure that qualified staff manipulated oxygen administration for Patient #2.