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Based on clinical record and policy review and staff interviews it was determined the nursing staff failed to ensure 1 (#4) of 11 sampled patients was assessed, monitored, and treated and physician orders were implemented for an Intensive Care Unit patient. The nursing staff failed to ensure that the medications were administered as ordered by the physician for 1 (#2) of 11 sampled patients.

The nursing staff and telemetry technician did not ensure the telemetry monitor alarms were audible and monitored to alert the staff to changes in a patient's heart rate or a lethal rhythm. This practice caused a delay in treatment and possible death of a patient in the Intensive Care Unit on a telemetry monitor. Refer to A0395

Physician orders for the insertion of a nasogastric tube was delayed for two days despite documentation of continued symptoms. Orders for cardiac enzymes for a patient experiencing chest discomfort was not implemented, the physician ordered monitoring of a patient's intake/output that was not performed. Refer to A0395

A patient did not receive Insulin as ordered by the physician despite two nurses checking the dose. Refer to A0404

Due to the lack of assessment, monitoring, implementation of physician orders, error in medication administration and the extent of an adverse outcome, the Condition of Participation for Nursing Services was found to be out of compliance.

Based on clinical record, document and policy review and staff interview it was determined the facility failed to ensure a Registered Nurse supervised and evaluated the nursing care and implemented physician orders for 1 (#4) of 11 sampled patients, causing an Intensive Care Unit patient's lethal cardiac rhythm to be missed by the nursing staff potentially resulting in death. This practice does not provide for patient safety and achievement of patient goals.

Findings include:

1. Patient #4's physician post-operative orders dated 2/9/11 at 1:15 p.m. revealed an order for "Intake and Output". A review of the Graphic/Intake/Output Record from 2/9/11 through 2/21/11 revealed the patient was admitted with a urinary catheter. From 2/9/11 to 2/21/11 there were thirty-seven 37 nursing shifts. Out of thirty-seven 37 shifts there were twenty-one 21 shifts missing the intake and output and thirty-seven 37 of 37 missing the twenty-four hour totals documentation ordered by the physician. The patient had a nasogastric (NG) tube inserted on 2/18/11. The NG tube output was documented only on 3 shifts from 2/18/11 to 2/21/11.

A review of the facility 's policy, "Nursing Service General", policy # NS-196, reviewed/revised 1/09, revealed the purpose of the policy is to (1) keep an accurate, pertinent and permanent written record of the patient's hospital stay, and (2) to provide written communication concerning the patient for all members of the health care team involved in the care of the patient. The policy stated this was completed each shift and as required by all appropriate nursing personnel. A review of the section titled, A) Graphic, Vital signs, #7, " Intake/Output is recorded in the cc's in appropriate date and time column with the 24 hour totals recorded under the "24 hour total" , by the 11-7 shift. "

2. Patient #4's physician's progress notes revealed an entry dated 2/11/11 at 8:30 a.m. (Post-Operative day #2) by the Advanced Registered Nurse Practitioner (ARNP). The patient's heart rate was sinus tachycardia with a rate of 100-120 beats per minute. The patient complained the nebulizer treatments were elevating his heart rate. The patient stated he had chest discomfort following the treatments the night before. The ARNP noted that Intravenous (IV) Lopressor was given at 6:00 a.m. that morning. The ARNP ordered Cardiac Enzymes times 2, an electrocardiogram (EKG) and repeat Lopressor IV this am. Review of the clinical record and interview with the Director of Quality on 8/30/11 at approximately 4:00 p.m. confirmed the cardiac enzymes were never completed and a cardiologist was not consulted for the chest pain.

3. Patient #4's physician orders dated 2/16/11 revealed an order for "If hiccups or burping persist, or patient vomits, insert nasogastric tube (NG) to intermittent suction." The order was noted on 2/16/11 at 5:42 p.m. by nursing and a 24 hour chart check also was completed. The patient continued to experience burping, nausea and vomiting, per physician and nursing documentation. On 2/18/11 at 1:00 p.m., the NG tube was inserted by the charge nurse, 2 days after the physician had ordered the NG tube.
A review of the facility's policy "Gastro-Intestinal Decompression (Insertion and Removal of Nasogastric Tube)", policy# 003-NS-204, reviewed/revised 1/09, revealed the NG tube was to be initiated upon physician orders. Nursing was to maintain integrity of suction unit and nasogastric tube, Observe and note stomach contents.

4. Patient #4's Interdisciplinary patient notes dated 2/24/11 at 1:30 a.m. revealed the patient was ambulated from the bed to the chair, the patient's heart rate was elevated to 124 and the patient complained of abdominal and epigastric pain. The patient was placed back in bed, an EKG was performed and pacer pads were placed on the patient. At 3:44 a.m. the cardiologist was paged regarding critical laboratory results. The cardiologist returned the call at 3:50 a.m. He was informed of the cardiac enzymes being elevated. At 6:00 a.m. the patient was out of bed to use the urinal and experienced shortness of breath and chest pain. The pain subsided with the application of oxygen and rest. A review of the Critical Care Nursing notes dated 2/25/11 at 7:30 a.m. revealed a nursing assessment was completed. At 8:15 a.m. the patient was assisted to the side of the bed in preparation for breakfast. At 9:10 a.m., the patient's family member went to the nursing station and stated "help, he's unresponsive". A nurse went into the room and the patient was unresponsive with absent respirations. The "code blue" button was pressed. At 9:29 a.m. the patient was pronounced deceased by the physician.

A review of the telemetry monitoring event report for 2/25/11 at 6:04 a.m. revealed the patient's heart rate was 149 beats per minute and he was experiencing a lethal rhythm.
A review of the discharge summary dictated on 3/4/11 at 1:09 p.m. revealed the following documentation, "In the middle of the night, the patient developed acute onset of anterior chest pain. Cardiac enzymes were done which showed moderate elevation of troponin and severe elevations of CPK. An electrocardiogram confirmed the presence of an acute anteroseptal myocardial infarction."
An interview was conducted with the Director of Risk Management and the Director of Quality on 8/30/11 at 4:00 p.m. The interviews revealed the monitor technician was not paying attention to the monitors. The telemetry monitors' alarms at the bedside and at the main monitor viewing station were turned down. The patient's nurse was in another patient's room and did not hear the alarms.
A telephone interview with the cardiologist was conducted on 8/30/11 at approximately 2:20 p.m. The physician was questioned on his input concerning the patient. He acknowledged the patient had suffered an acute myocardial infarction during the night. The physician stated the patient had been in ventricular fibrillation for at least 20 minutes.
A review of the facility's policy "Provision of Patient Care," reviewed/revised 2/2011, Intensive Care Unit, leadership responsibilities, revealed " the registered nurse is accountable for the complete and total care of the patient assigned to the patient care team and for the documentation and execution of the care ordered by the Physician."

The interviews and review of the clinical record revealed cardiac laboratory studies were not done as ordered by the physician when the patient complained of chest pain. The intake and output was not monitored as ordered by the physician. The nursing staff and telemetry technician did not ensure the telemetry monitor alarms were audible and monitored to alert the staff to changes in a patient's heart rate or rhythm. This practice caused a delay in treatment and possible death of a patient in the Intensive Care Unit on a telemetry monitor.

Based on clinical record review, staff interview and policy review it was determined the nursing staff failed to administered medications as ordered by the physician for 1 (#2) of 11 sample patients. This practice may cause a delay in discharge and does not ensure effective medication therapy.

Findings include:


Patient #2's physician's order dated 1/6/11 revealed the blood sugar level was to be checked before meals and every evening. Review of the Insulin sliding scale revealed if the blood sugar was 151-200 give 6 units of regular Insulin, 201-250 give 8 units, 251-300 give 10 units, 301-350 give 12 units, 351-400 give 14 units and if greater than 400 call for further orders
Review of the Medication Administration Record (MAR) dated 1/6/11 revealed that patient's blood sugar at 5:27 p.m. was 321. The documentation showed 6 units of regular insulin was administered. The dose was checked by second nurse . The physician's order indicated 12 units should have been given.
A review of the facility's policy for "Nursing/Administration of Medications," policy #NC- 242, reviewed/revised 4/10, revealed ' administration of medications are performed by authorized personnel only." Further review of the policy revealed "the following medication and medication orders will be checked prior to administration and documented by two nurses, or a nurse and a physician in the Medication Administration Record. ( Insulin, Pain Control Administrator/Epidural's)"

An interview was conducted with the Director of Quality on 8/30/11 at approximately 4:00 p.m., after review of the documentation she confirmed the findings.

Based on clinical record review, staff interview and policy review it was determined the nursing staff failed to administered medications as ordered by the physician for 1 (#2) of 11 sample patients. This practice may cause a delay in discharge and does not ensure effective medication therapy.

Findings include:


Patient #2's physician's order dated 1/6/11 revealed the blood sugar level was to be checked before meals and every evening. Review of the Insulin sliding scale revealed if the blood sugar was 151-200 give 6 units of regular Insulin, 201-250 give 8 units, 251-300 give 10 units, 301-350 give 12 units, 351-400 give 14 units and if greater than 400 call for further orders
Review of the Medication Administration Record (MAR) dated 1/6/11 revealed that patient's blood sugar at 5:27 p.m. was 321. The documentation showed 6 units of regular insulin was administered. The dose was checked by second nurse . The physician's order indicated 12 units should have been given.
A review of the facility's policy for "Nursing/Administration of Medications," policy #NC- 242, reviewed/revised 4/10, revealed ' administration of medications are performed by authorized personnel only." Further review of the policy revealed "the following medication and medication orders will be checked prior to administration and documented by two nurses, or a nurse and a physician in the Medication Administration Record. ( Insulin, Pain Control Administrator/Epidural's)"

An interview was conducted with the Director of Quality on 8/30/11 at approximately 4:00 p.m., after review of the documentation she confirmed the findings.