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Based on review of medical records, facility policy and procedures, and staff interview, the facility failed to ensure a registered nurse supervised and evaluated nursing care for two (#1, #10) of 10 sampled patients. The facility failed to provide medication administration for elevated blood pressure in accordance with physician orders for Patient #1 and failed to provide treatment in accordance with policies and procedures for the insertion of a Dobhoff feeding tube for Patient #10.

Findings included:

1. Review of the physician history & physical (H&P) dated 10/27/2017 at 9:27 AM showed the patient was admitted to the facility for an acute skin rash, opiate withdrawal, and hypertension (HTN). Review of the physician plan on the H&P revealed the patient would be admitted for management of symptoms related to opiate withdrawal, which included medication to control his blood pressure.

Review of the physician orders dated 10/27/17 at 2:25 PM showed the medication Clonidine 0.2 mg was ordered every 3 hours as needed to keep systolic blood pressure (SBP) less than 170. The SBP is the first number also referred to as the top number in a blood pressure (BP) reading. Review of the admission vital signs (VS) on 10/27/17 at 9:28 AM, revealed a BP of 218/141. Normal blood pressure is between 120/80 - 140/90. The American Heart Association (AHA) considers a blood pressure reading above 180/110 a "hypertensive crisis" and emergency treatment should be sought.

Review of nursing documentation from admission on 10/27/17, at 9:28 AM through 10/29/17 at 8:30 PM, showed the following VS:
10/27/17 at 9:28 AM - 218/141
10/27/17 at 11:08 AM - 206/120
10/27/17 at 12:17 PM - 192/122
10/27/17 at 12:37 PM - 196/120
10/27/17 at 1:37 PM - 220/134
10/27/17 at 2:01 PM - 201/122
10/27/17 at 2:33 PM - 204/104
10/27/17 at 3:38 PM - 199/117 (clonidine given at 4:52 PM)
10/28/17 at 6:57 AM - 171/110
10/28/17 at 8:06 AM - 190/120 (clonidine given at 8:12 AM)

10/28/17 at 10:24 AM - 174/109
10/28/17 at 11:25 AM 184/104 (clonidine given at 11:36 AM)
10/29/17 at 4:32 AM 171/123 (clonidine given at 4:36 AM)
10/29/17 at 2:23 PM 188/122
10/29/17 at 5:29 PM 210/111
10/29/17 at 6:38 PM 199/115
10/29/17 at 7:37 PM 198/122
10/29/17 at 8:30 PM 200/115
10/29/17 at 10:14 PM 198/125
10/29/17 at 11:45 PM 183/110
10/30/17 at 1:35 AM 181/109 - No further readings were taken on this day.
10/31/17 at 8:52 AM 201/116 - Patient's medical record shows a discharge on 10/30/17 at 2:20 AM

Review of the nursing medication administration record (MAR) showed the blood pressure medication Clonidine was only administered 4 of the 22 times the SBP was greater than 170. Clonidine 0.2 mg was administered as follows:
10/27/17 at 4:52 PM
10/28/17 at 8:12 AM
10/28/17 at 11:36 AM
10/29/17 at 4:36 AM

Review of nursing documentation from the time the physician ordered the clonidine on 10/27/17 at 2:25 PM, until the patient left against medical advice (AMA) on 10/30/17 at 2:20 AM, no documentation or evidence could be found to indicate that the physician was notified of Patient #1's critically high blood pressure readings over the course of the patient's four day hospital stay.

On 12/07/17 at 2:15 PM, an interview conducted with the Risk Management Coordinator confirmed the above findings in the medical record of Patient #1.

2. Review of the physician history & physical (H&P) for Patient #10 revealed the patient was admitted on 09/06/2017 for cardiac surgery. Review of the H&P documentation dated 09/07/17 showed the patient was admitted to the cardiovascular intensive care unit (CVICU) post surgery.

An interview conducted with the Director of Patient Safety on 12/07/17 at approximately 9:35 AM, revealed that on 09/15/17 Patient #10's physician ordered a Dobhoff feeding tube to be placed by nursing staff for nutritional purposes. RN #A attempted to place the feeding tube, however, two Registered Nurses (RN's) could not verify placement via auscultation with a stethoscope and therefore removed the feeding tube. RN #A attempted to insert another Dobhoff tube, and once again, placement could not be verified. An x-ray of the chest and abdomen was obtained. The Advanced Nurse Practitioner (ARNP) read the x-ray and told RN #A to advance the tube. A second x-ray was obtained after the RN advanced the Dobhoff feeding tube and the ARNP read the x-ray and told RN #A the tube was okay to be used for tube feedings. The Dobhoff tube feedings were not started on the day shift by RN #A, however, when the night shift RN #B came on, the day shift nurse told RN #B that the feeding tube was in place and the feedings could be started. RN #B gave the patient a bolus tube feeding of 150 cc's and the patient subsequently developed significant abdominal pain and had to be given pain medication (Dilaudid) for the pain by RN #B.

Definition of Dobhoff feeding tube- a small-lumen feeding tube that can be advanced into the duodenum (https://medical-dictionary.thefreedictionary.com)

On 09/16/17 at 3:33 AM a CAT (CT) scan was obtained that showed the Dobhoff feeding tube was seen through the trachea, the left main stem bronchus and into the lingual division of the left upper lobe. Additional findings included; a small left apical pneumothorax, bilateral pleural effussioins with comprehensive atelectic changes, and a small mediastinal and extensive subcutaneous emphysematous changes in the left anterior chest.

On 09/16/17, at 6:01 AM a chest x-ray showed the Dobhoff tube had been removed. There was a small (15%) left pneumothorax, a moderate to large left pleural fluid collection, and a left hemothorax that could not be excluded.

Review of the physician progress noted dated 09/17/17 at 9:16 AM showed the patient had a chest tube in the pleural space that was draining cream-colored drainage.

Continued review of physician progress notes revealed the patient's respiratory status continued to deteriorate and the patient required ventilator assistance.

Review of the facility policy entitled. "Enteral Nutrition Therapy/Tube Feeding," #FNS-800.11/C5, revised 01/15, showed that before initiation of feeding, NG Feeding Tubes require a chest x-ray for placement verification; Post-pyloric tube placements require a KUB. Tube feedings can be initiated after receiving placement verification from the Radiologist.

Review of the policy entitled, "Feeding Tube Insertion, Small Bore," #ADMIN II.PC-F.004, reviewed 09/2015, showed Scope: Critical Care RN with competency. Policy: This procedure is only performed with a specific physician order by Critical Care RNs trained in small bore feeding tube placement. Training includes review of policy and procedures and placement of one tube under supervision of a Critical Care RN already trained in this procedure. Step 12 in the procedure states leave guidewire in place and obtain KUB to verify proper placement.

On 12/14/17 at approximately 12:22 PM, Quality Management (QM) staff confirmed RN #A did not have a competency for insertion of a Dobhoff feeding tube.

An interview conducted on 12/07/17 at approximately 10:00 AM with the VP of QM/Risk Management and the Director of Patient Safety, confirmed the above findings in the medical record of Patient #10.