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Based on interview, record review, and policy review, the Hospital failed to ensure that a registered nurse (RN) (Staff D) reassessed one of ten patients reviewed (Patient 1) based on the patient's needs and change in condition. This deficient practice has the potential to cause a worsening of condition which could lead to patient harm or death.

Findings Include:

Document review of the Hospital's policy titled, "Change in Patient Condition," dated 03/14/18, showed staff should consider calling in the Rapid Response Team (RRT) when a family member feels there has been a change in the patient's condition and an additional assessment is warranted.

Review of Patient 1's discharged medical record showed the following:

- Admission to this Hospital on 06/21/18 for rehabilitation after being treated at Hospital BB's emergency department (ED) for frequent falls at home and a left rib fracture.

- On 06/25/18 at 7:05 PM, Staff D, RN documented the patient was cooperative and anxious.

- On 06/25/18 at 7:05 PM, Staff D, RN documented that the patient's appetite was "good" but failed to show what percent of her meal she consumed.

- On 06/25/18 at 7:14 PM, Staff D, RN documented that Patient 1's family member (F1) reported that his mother had a decreased level of consciousness and he wanted his mother transferred.


During an interview on 08/01/18 at 12:32 PM, via telephone, F1 stated that on 06/25/18 he had expressed concerns about his mother's increased confusion and told Staff D, RN that Patient 1 was having trouble breathing and he wanted her transferred to a higher level of care.

During an interview on 08/01/18 at 9:30 AM, in the boardroom, Staff D, RN, stated when he assessed Patient 1 in the morning she appeared to be alert and oriented, but after she came back from her cardiologist appointment she was "a little off" compared to how she was earlier. Staff D stated that he did reassess Patient 1 by asking her orientation type questions and although she answered slowly she did respond with the correct answers. Staff D stated that F1's concern was with the patients increased confusion only, so he did not feel it was necessary to assess her oxygen level since he did not believe she was having difficulty breathing and did not consider reassessing her blood sugar.

During an interview on 08/01/18 10:45 AM, in the boardroom Staff C, Physician, stated that nursing staff called him and told him of F1's concerns about Patient 1's increased confusion and he directed nursing staff (Staff D, RN) to send her to Hospital BB.

- During an interview on 08/01/18 at 2:15 PM, in the boardroom Staff G, Director of Quality, stated that Staff D, RN should have considered checking Patient 1's blood sugar and oxygen level due to her change in condition.

Review of Investigation Notes provided by Staff G showed additional feedback and education was provided to the Staff D, RN regarding conducting a thorough assessment at the time of a change in patient condition even if this is from the family's perspective.

According to WebMD, the symptoms of high blood sugar may include trouble concentrating or fatigue, and low blood sugar symptoms may include confusion and irritability.

According to the WebMD, the symptoms of hypoxia (low oxygen levels) include an increase in confusion, rapid breathing, or shortness of breath.

The medical record lacked documentation Staff D, RN performed a thorough assessment of Patient 1 after he himself indicated that the patient's condition had changed from earlier in the day and when F1 expressed a concern that Patient 1 had a decreased level of consciousness. The record lacked documentation that Staff D obtained a current set of vital signs including an oxygen level and a blood sugar and further, the record lacked documentation that Staff D called the RRT to assess the patient's condition.

During an interview on 08/01/18 at 12:32 PM, via telephone, F1 stated that on 06/25/18 when the paramedic's arrived at 7:45 PM, Staff D had not obtained a current set of vital signs on his mother, but when Patient 1 was in the ambulance and the paramedic placed a pulse and oxygen monitor on her, the oxygen saturation showed she was at 85% (normal 92-100%) on room air.

Review of Patient 1's discharged medical record from Hospital BB showed on 06/25/18 at 8:16 PM that the patient's oxygen saturation was 90%. An x-ray of her chest showed poor inspiration and dense atelectasis (the collapse or closure of a lung resulting in reduced or absent gas exchange). The admitting physician's documentation showed Patient 1 was hypoxic on presentation to the emergency department and showed it was reported to the attending physician that Patient 1 had an oxygen saturation in the 80's upon admission to the emergency department.