HospitalInspections.org

Based on medical record review and staff interviews, the facility failed to assess/evaluate 2 of 10 Pts. sampled when changes of condition occurred (Pts. #1 and #9). This has the potential to affect all pts. hospitalized.

Findings include:

1.) Per medical record review of Pt. #1 beginning at 11:43 a.m. on 11/4/13, the following was noted:

Per nursing note at 11:30 p.m. on 5/28/13: Slight expiratory wheeze were noted in Pt. #1's lower lobe of the right lung.

Nursing note at 5:45 p.m. on 5/29/13 states that Pt. #1 complained felt " flushed and weird " . Temp checked and 99 degrees. An assessment was not documented as being done and no probe questions were documented to describe what Pt. #1 meant by feeling "weird."

Nursing note at 4:00 p.m. on 5/30/13 states temp. 101.3 Vicodin given. There is no notification to the physician of the elevated temperature. Per e-mail from Quality Compliance Staff A at 8:43 a.m. on 11/8/13 Physician orders include that the physician is to be notified of temperatures above 101.

Nursing note at 2:10 a.m. on 5/31/13 states that pt. #1 complained of shortness of breath and pointed to upper abdomen indicating increased pressure. Ativan given for increased anxiety and ease of breathing.

Nursing note at 7:30 a.m. on 5/31/13 states that Pt. #1 complained was a bit short of breath, but less so after burping.

Nursing note at 11:00 a.m. on 5/31/13 states, " Pt. continues to c/o (Complain) SOB (shortness of breath), lobes have crackles. " Abdomen distended and feels bloated. The physician was notified. Per review of physician notes of 5/31/13 physician examined Pt. #1 noting crackles in lungs and shortness of breath.

Per physician orders at 11:45 a.m. on 5/31/13 a stat chest x-ray was ordered.

Per review of Chest x-ray results, x-ray revealed: mild interstitial opacities with some Kerley B lines in right cotophrenic angle most consistent with mild edema. Heart size mildly enlarged. No pneumothorax. Impression: Mild pulmonary edema, enlarged cardiac silhouette, and atherosclerotic calcifications within the aorta (heart).

Respiratory Therapy note at 4:50 p.m. on 5/31/13 states Pt. #1 has inspiratory crackles in right lower lung.

Nursing note at 4:00 a.m. on 6/1/13 states that Pt. #1 turned on call light and complained of acute SOB, #1 diaphoretic, and Pt #1 using IS (Incentive Spirometer) without improvement. Expiratory wheezes were noted in both lungs. Oxygen applied and Pt. #1 indicated feeling less SOB with oxygen on, but still "not perfect."

The next nursing note was at 6:00 a.m. 6/1/13 and states that the physician was paged and evaluated Pt. #1.

Per review of physician progress note on 6/1/13 aware of SOB and wheezing per nursing notification. Noted slight expiratory wheezing. Had no infiltrates per 5/31/13 chest x-ray.

Per review of 6/1/13 physician orders, Albuterol nebulizers were ordered every 4 hours as needed and Lasix 60 mg was ordered to be given orally one time.

Nursing note at 2:20 p.m. on 6/1/13 states that Pt. #1's respirations become labored with activity and respiratory rate increases. Pt. reports SOB with activity.

The last nursing note in the record was documented by RN D at 3:35 p.m. on 6/3/13 and is labeled as "Discharge Note." The note states that daughter and son-in-law were there, the physician was there earlier and will discharge today. D documents that discharge instructions and medication list was discussed with Pt. #1 and family. D documented that left knee was clean and dry. No other assessment was documented and no complaints from Pt. #1 or family were documented.


Per face to face interview with Medical-surgical Supervisor C beginning at 9:15 a.m. on 11/5/13, C said that a female came to the nursing station on the day Pt. #1 was discharged and said to C, "Are you sure she's (Pt. #1) ready to go home or something like that." Per C the female said that Pt. #1 said was feeling a little SOB. C stated that C told RN D to go and assess Pt. #1-thinks was around 2:45 p.m. on 6/3/13.


Per face to face interview with Dr. E at 10:10 a.m. on 11/5/13, allegations of the complaint from Pt. #1's family were reviewed. Dr. E reviewed portions of Pt. #1's medical record (nursing and physician documentation). When Surveyor mentioned that could not find documentation of an assessment by RN D after 10:00 a.m. on 6/3/13 Dr. E said, "Yes she (RN D) did'nt document an assessment after that." Dr. E said that RN D never called E to report anything about Pt. #1 on 6/3/13 and added, "She (D) should have assessed the Pt (Pt. #1) and she should have called me. I would have come."

Per face to face interview with RN D beginning at 11:50 a.m. on 11/5/13, D said that on the day Pt. #1 was discharged #1's daughter approached D stating that #1 was SOB. Per D Pt. #1 "Was never short of breath." Per D Pt. #1 was not visually SOB. Per D, D did not document an assessment after Supervisor C asked D to assess Pt. #1 prior to discharge. RN D said asked Pt. #1 questions, but does not recall if did a physical assessment of Pt. #1 prior to discharge on 6/3/13 after daughter reported Pt. #1 SOB.

Discharge record review says Pt. #1 discharged at 3:35 p.m. on 6/3/13.

Further review of Pt. #1's record reveals the following:

A 6/3/13 5:00 p.m. clinic note in Pt. #1's medical record reveals that Pt. #1's daughter called the clinic attached to the hospital at that time and spoke with a medical assistant to report that Pt. #1 had been discharged from the Swing Bed of the hospital at 3:00 p.m. with chest pain, back pain, and shortness of breath which was reported to a nurse who put on an oxygen monitor and said oxygen was over 90, so Pt. #1 was fine. During the conversation Pt. #1 complained that pain was getting much worse. Unidentified MA (Medical Assistant) recommended call ambulance.

At 5:30 p.m. on 6/3/13 Pt. #1's daughter returned call to clinic MA who had spoken with at 5:00 p.m. to report that an ambulance had been called. During conversation ambulance arrived to transport Pt. #1.

Review of the 6/3/13 ambulance report reveals onset of chest pain and SOB was at 2:00 p.m. on 6/3/13.

Pt. #1 arrived into the hospital ED via ambulance at 5:46 p.m. on 6/3/13. MD notified of arrival at 5:48 p.m. and began exam at 5:56 p.m. on 6/3/13. Emergency Department Cardiac Nursing Flow sheet shows that an EKG was initiated upon arrival at 5:46 p.m. Under additional nursing assessment notes on the cardiac flow sheet, it states that pain in upper abdomen moved into chest today and short of breath. Cardiac (heart) monitor shows sinus rhythm with multiple PVCs (Premature ventricular contractions). Pain in chest started at 3:00 p.m. Family reports color change in pt. #1's face and reported Pt. #1 not feeling well at 3:00 p.m.

The ED physician exam reveals: Pt. #1 complained had 3 hour history of chest pain. Pt. #1 was transferred home today and at about 3:00 p.m. #1 began experiencing chest pressure that radiated to the back, but not arms or neck. Pt. describes pain as pressure that started in abdomen and moved to chest. EKG reveals inverted T-waves in V 5-6 and compared to preoperative EKG from 5/20/13, these findings "Are very suspicious for an evolving anteroseptal infarct." (heart attack). Pt. #1 transported to another hospital via ambulance at 8:00 p.m. on 6/3/13.

Per review of transfer hospital records Pt. #1 transferred to other hospital on 6/3/13-Pt. #1 expired (Died) on 6/4/13 with diagnoses including: Cardiogenic shock, Hypoxia, and Congestive Heart Failure after acute myocardial infarction (heart attack) with severe systemic cardiomyopathy (deterioration of the function of the hear muscle). Echocardiogram had revealed dilated left heart ventricle with severely impaired ventricular function, suggesting a multivessel infarct or a stress cardiomyopathy.

Per daily exit interview beginning at 1:45 p.m. on 11/5/13, Chief Nursing Office B said that RN D should have done a heart and lung assessment on Pt. #1 after #1's daughter brought up concern and added, "Not documented, not done."


2.) Review of Pt. #9's medical record beginning at 11:43 a.m. on 11/5/13 reveals that a nursing note at 4:30 p.m. on 5/30/13 documents Pt. #9 has an elevated temperature of 101.4 degrees. No assessment, interventions, or physician notification was done until the next nursing note at 6:00 p.m. when #9's temperature rose to 102.8 degrees.


Per exit interview beginning at 4:00 p.m. on 11/14/13, Chief Nursing Officer B stated that facility protocol is to intervene and to notify physicians when pt. temperatures are above 101 degrees.