HospitalInspections.org

Based on interview and record review, the hospital's Quality Assessment and Performance Improvement program did not address the prevention and reduction of medical errors in a timely manner for non-compliance of nursing staff to place a physician's ordered cardiac monitor on a patient, non-compliance with hospital policy for physician notification of critical lab results, non-compliance with hospital policy for obtaining vital signs on a patient in the Emergency Department (ED) with certain acuity levels, non-compliance with ED directives for nursing hand-off report between shifts and physician monitoring of patient cardiac status for 1 of 10 sampled patients (#1).

Findings:

Cross Reference A286. Based on interview, record review and a review of hospital documentation, the hospital failed to ensure that performance improvement activities involved the prompt implementation of preventative actions to address failures in nursing compliance with physician orders for cardiac monitor placement, compliance with hospital policy for physician notification of critical lab results, compliance with hospital policy on the performance of vital signs on patients in the ED with certain acuity levels, compliance with ED directives on nursing hand-off reports between shifts and physician monitoring of patient cardiac status for patient (#1).

Based on interview, record review and a review of hospital documentation, the hospital failed to ensure that Performance Improvement activities involved the prompt implementation of preventative actions to address nursing non-compliance with physician orders for cardiac monitor placement, non-compliance with hospital policy for physician notification of critical lab results, non-compliance with hospital policy on the performance of vital signs on patients in the Emergency Department (ED) with certain acuity levels, non-compliance with ED directives on nursing hand-off reports between shifts and physician monitoring of patient cardiac status for 1 of 10 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. The patient was triaged in the ED on 2/08/18 at 5:02 PM. The patient's vital signs were taken at at 5:02 PM on 2/08/18.

The tracking acuity was designated at 5:02 PM on 2/08/18 as "ES1 2 (Emergency Severity Index)."

The hospital's "Patient Assessments in the Emergency Department" policy revealed that under the classification of ES1 2 , vital signs were required to be performed at least every hour. Since the patient had vital signs assessment at 5:02 PM, the next assessment would be needed by 6:02 PM. There were no other documented vital signs in patient #1's medical record. The nurse did not obtain vital signs at least every hour.

Documentation revealed that the patient was seen by physician I on 2/08/18 at 5:52 PM. Physician orders of 2/08/18 at 5:53 PM read, "Cardiac Monitor ED."

The initial nursing assessment, performed on 2/08/18 at 6 PM by RN A, read, "Cardiac monitor: limits set and alarms on." This was the last mention in the patient's record regarding cardiac monitoring or telemetry. However, during an interview of Risk Manager J on 3/29/18 at 1:03 PM, she stated that this was a portable vital signs monitor, and not a cardiac monitor. The nurse did not follow the physician's order for the placement of a cardiac monitor.

On 3/30/18 at approximately 3:47 PM, physician I stated that he was not aware that the cardiac monitor had not been placed on patient #1.

Patient#1's "Orders" indicated that results were viewable at 6:17 PM on 2/08/18 for a "Basic Metabolic Panel i-STAT POC (point of care)." The results indicated a critically low potassium level. A review of facility policy "Communicating Critical Values" revealed the requirement that critical results be reported to the caregiver within 15 to 30 minutes of receiving the results. During an interview of Risk Manager J on 3/29/18 at 3:07 PM, she stated that they had discovered per conversations with RN A that she the physician was never informed of this specific result. The failure of the nurse to report the critical potassium result violated the "Communicating Critical Lab Values" policy.

A nurse's note by RN A at 6:30 PM on 2/08/18 read: "Alert and calm."

A review of nursing documentation revealed that a shift handoff from RN A to RN B took place at approximately 7:08 PM to 7:10 PM. During an interview of ED Director D on 3/29/18 at approximately 4:45 PM, she stated that their investigation had revealed that the hand-off report took place at the nurses' station and not at the patient's bedside, as is expected.

A nurse's note at 7:31 PM by RN B on 2/08/18 indicated that between 7:15 PM and 7:31 PM on 2/08/18, the following was written, "That was the time patient assessed to be unresponsive, stiff and cold."

RN B's note at 7:30 PM on 2/08/18 addressed events in the evening of 2/08/18. The note read, "Patient noted covered with blanket, facing wall. I call patient by name, no response. I touched patient she felt stiff, tried sternal rub, patient remains unresponsive. Pt's skin felt cold. Called made to doctors, [Physician I] responded, [Assistant Nurse Manager G] was also aware. Patient transferred to room 58, code blue initiated."

Physician I's entry at 7:18 PM on 2/08/18 read, "found pt covered up and unresponsive. Subsequently, code was called. Pt put in room 58. Pt unresponsive; CPR and bagging performed. I was called by overhead to pt room." Physician I's note of 2/08/18 at 7:39 PM read, "Pt continued to have no pulse. Pt in asystole; no pulse found. CPR was stopped 7:39 PM."

RN A failed to perform the following activities which were required by hospital policy or ED expectations: (1) apply a cardiac monitor as ordered (2) perform vital signs at a minimum of each hour (3) perform a shift handoff in the presence of the patient and (4) report the results of a critical potassium level which had been indicated through Istat to the physician. RN A and RN B failed to perform a shift hand-off report in the presence of the patient.

On 3/30/18 at approximately 3:47 PM, physician I stated that he did not have any discussions with nurses regarding new vital signs. He stated that he was not aware that the cardiac monitor had not been placed on patient #1. He stated that he had not issued any directives to nurses regarding monitoring activity for the patient. He stated he had not examined the patient at any other time except for his documented interaction at 5:52 PM on 2/08/18.

The patient did not receive medical supervision regarding her cardiac status by confirming placement of the cardiac monitor as ordered for patient #1, classified as ES1 2.

Based on interview, record review and a review of hospital documentation, the hospital failed to ensure that the organized nursing services properly supervised the nursing care of a patient who required cardiac monitor placement, hourly vital signs, a shift handoff in the presence of the patient, and reporting to the physician of critical potassium levels for 1 of 10 sampled patients (#1).

Findings:

Cross Reference A395. A review of the medical record of patient #1 was performed. The patient was triaged in the Emergency Department (ED) on 2/08/18 at 5:02 PM.

During the patient's stay in the ED, registered nurse (RN) A failed to perform the following tasks required by either hospital policy or ED expectations: (1) apply a cardiac monitor as ordered (2) perform vital signs at a minimum of one each hour as required by hospital policy (3) perform a shift hand-off report in the presence of the patient as required by established expectations in the ED (4) report the results of a critical potassium level which had been indicated through i-STAT to the physician as required by hospital policy. "i-STAT is a hand held blood analyzer that provides lab results within minutes." (pointofcare.abbott).

Based on interview, record review and a review of hospital documentation, the hospital failed to ensure that a registered nurse (RN) properly supervised the nursing care of a patient who required cardiac monitor placement, hourly vital signs, a shift hand-off report in the presence of the patient, and reporting to the physician of critical potassium levels for 1 of 10 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. The patient was triaged in the Emergency Department (ED) on 2/08/18 at 5:02 PM. The chief complaint at 5:04 PM on 2/08/18 was "Body cramps since last night/Hypokalemia." The Chief Complaint Comments at this same time read, "Hx (history) of hypokalemia. Sent from work with tremors." The patient's vital signs at 5:02 PM on 2/08/18 were: "Temperature oral: 98.2 DegF (degrees Fahrenheit). Heart Rate 90 bpm (beats per minute). Respiratory Rate Spontaneous: 18 br/min (breaths per minute). Systolic Blood Pressure NBP (Non-invasive Blood Pressure) 89 mmHg (milliliters of mercury) (low). Diastolic Blood Pressure NBP: 52 mmHg. ...O2 (oxygen) saturation: 96%." There were no other documented vital signs in the medical record.

The tracking acuity was designated at 5:02 PM on 2/08/18 as "ES1 2 (Emergency Severity Index). Emergency Severity Index (ESI) is a five level instrumental tool for use in ED triage of patient acuity. The hospital policy "Patient Assessments in the Emergency Department" read, "Assessment and reassessment is based on the Emergency Severity Index (ESI) levels for triage as follows: Level 1 and Level 2: Vital signs and head to toe assessment of the critical patient range from minimum of every 1 hour to continuous heart, blood pressure and oxygen saturation monitoring, based on patient's condition....Level 2 - High-risk situation to include patients that are confused/lethargic/disoriented, suicidal, or have homicidal ideations or severe pain/distress." Thus, the patient required, at a minimum, vital sign assessments at least once an hour. Since the patient had a vital signs assessment at 5:02 PM, the next one would be needed by 6:02 PM. The patient was last seen by a nurse at 6:30 PM. The nurse did not take patient#1's vital signs to assess the patient as indicated by the ES1.

On 3/30/18 at 1:24 PM, the ED Director confirmed that no additional collection of vital signs had been performed, as required by this policy.

The section of patient #1's medical record titled "location information" revealed that the patient had been taken into the ED and assigned to location G25 at 5:48 PM on 2/08/18.

Medical record documentation revealed that the patient was seen by ED physician I on 2/08/18 at 5:52 PM while the patient was in hallway location G25. Observation of this location while on a tour of the ED on 3/29/18 at approximately 4:35 PM revealed that it was directly across from a staffed nurses' station. At 5:52 PM on 2/08/18, Physician I wrote, "The patient presents with muscle cramping. ...with PM Hx (past medical history) of HTN (hypertension) and seizures presents to the ED c/o (complains of) generalized muscle cramping due to low Potassium. Pt (patient) states that she frequently has these cramps with low Potassium levels. She confirms taking Potassium supplements, but is not on seizure medication. She states that she can feel when her potassium is low, and that she believes it is low right now. The onset was chronic." Physician I's physical exam entries at this time included the following: "Last admitted: 12/21/17. Diagnosed with: hypocalcemia and hypokalemia [low calcium and low potassium]."

Physician I ordered a Comprehensive Metabolic Panel, which includes testing for potassium, on 2/08/18 at 5:53 PM. This order required blood to be analyzed by the laboratory, which was outside of the ED. Physician I's orders of 2/08/18 at 5:53 PM read, "Cardiac Monitor ED."

The initial nursing assessment was performed on 2/08/18 at 6 PM by RN A, fifty-eight (58) minutes after the patient was triaged. The assessment included the following diagnoses from prior admissions: depression, eating disorder, heart murmur, hypocalcemia, panic attack, and seizure. It also read, "Cardiac monitor: limits set and alarms on." This was the last mention in the record regarding cardiac monitoring or telemetry. On 3/29/18 at 1:03 PM, risk manager J stated that a portable vital signs monitor was placed on the patient and not a cardiac monitor. Thus, this record entry was not accurate. On 3/30/18 at approximately 3:47 PM, physician I stated that he was not aware that the cardiac monitor had not been placed on the patient as ordered.

A request was made for any hospital policy concerning cardiac monitor placement in the ED. On 3/30/18, risk manager J she stated that the expectation is for nurses to follow physician orders. The nurse did not follow physician I's orders for the placement of a cardiac monitor.

Patient #1's "Orders" in the medical record indicated that results were viewable at 6:17 PM for a "Basic Metabolic Panel i-STAT POC (point of care)." On 3/29/18 at 2:46 PM, ED director D stated that an order for the Basic Metabolic Panel i-STAT POC would have verbally been given to the nurse by the physician. She stated that the test involves obtaining a small blood sample which, in turn, is deposited onto a cartridge and placed into a machine for analysis. She stated that the results for this type of testing would be available in approximately three to five minutes. "i-STAT is a hand held blood analyzer that provides lab results within minutes." (pointofcare.abbott).

The hospital policy "Communicating Critical Values" read, "Point of Care Testing Critical Values: Point of Care testing personnel shall notify the licensed caregiver of critical values derived using point of care devices within 15 minutes of obtaining results. The licensed caregiver shall notify the physician/designee within 15 to 30 minutes of receiving critical value results unless orders or protocols are in place for treatment."

Potassium levels less than (<) 3.0 mmol/L (millimoles per liter) are associated with marked neuromuscular symptoms and are evidence of a critical degree of intracellular depletion. Potassium levels <2.5 mmol/L are potentially life-threatening.

On 3/29/18 at 11:30 AM, risk manager J stated the reference range for potassium tested with i-STAT is 3.5 to 4.9 mmol/L.

RN A's note at 6:30 PM, entered at 8:01 PM on 2/08/18 read, "STAT (urgent) chem (chemistry) 8 result was 2. [Physician I] made aware will await further orders. Pt (patient) in hallway stretcher. Given warm blanket since pt stated she was cold, pt grabbed blanket and covered herself up. Will continue to monitor." Although the nurse did not specify which component in the i-STAT analyzer was associated with the result of "2", a review of the printed laboratory work which showed all of the i-STAT results revealed that only Potassium was associated with a finding of "2." A "C" was printed to the left of this initial, indicating "critical". Regarding this entry's mention of physician notification, the record revealed that the nurse edited it on 2/10/18, two days later, to remove a mention of physician notification. The part regarding the patient's location and her being given a blanket remained.

"Potassium is a mineral (electrolyte) in the body. Almost 98% of potassium is found inside the cells. Small changes in the level of potassium that is present outside the cells can have severe effects on the heart, nerves, and muscles.
Potassium is important to maintain several bodily functions: Muscles need potassium to contract. The heart muscle needs potassium to beat properly and regulate blood pressure...." (emedicinehealth.com).

On 3/29/18 at 3:07 PM, risk manager J stated they discovered per conversations with RN A that she had actually intended to inform the physician of the results but had been called away to help another patient. She stated that the physician was never informed of this specific result. The failure of the nurse to report the critically low potassium result violated the "Communicating Critical Lab Values" policy.

RN A nurse's note at 6:30 PM on 2/08/18 read, "Alert and calm." This was the last entry in the record until approximately 7:15 PM on 2/08/18 which specifically mentioned staff in the presence of the patient, forty-five minutes later.

RN A nurse's note at 7:08 PM on 2/08/18 read, "Report to [RN B] to assume care at this time." RN B's note at 7:30 PM on 2/08/18 read, "Approximately 7:10 PM after receiving report from [RN A]. ..." This indicated the two nurses did a patient hand-off report within 7:08 PM and 7:10 PM on 2/08/18. During a telephone interview of RN B, she confirmed that the hand-off report took place at the nurses' station. On 3/29/18 at approximately 4:45 PM, ED director D stated their investigation revealed that the hand-off report from RN A to RN B took place at the nurses' station. She stated the hospital's expectation was that hand-off report take place at the patient's bedside. Thus, the two nurses did not comply with this directive.

On 3/29/18 at 12:06 PM, Director of Laboratory Services L confirmed that on 2/08/18, labs other than i-STAT labs had been ordered at 5:53 PM. She stated that a critical value for potassium was discovered by a laboratory technician (lab tech) and called to an ED nurse at 7:15 PM. The lab tech then hit the transmit button at 7:16 PM and the results appeared in the record at 7:18 PM. The laboratory report on 2/08/18 at 7:15 PM read, "Results phoned and read back confirmed."

An entry by physician I at 7:08 PM on 2/08/18 discussed events concerning lab results which took place at 7:15 PM or later on 2/08/18. It read, "[RN B] informed at 7:08 PM (actually 7:15 PM) by lab that potassium is 1.8. At that time, asked [RN B] to redraw blood to confirm critical results. ..."

During a telephone interview of RN B, on 3/30/18 at approximately 4:28 PM, she stated that before she could commence with the ordered lab draw, she needed to assist a patient she had seen walking to the bathroom. She stated that this took a few minutes to perform. Once completed, she went to patient #1 and found that the patient had her head and body covered by a blanket and found the patient unresponsive.

A nurse's note at 7:31 PM by RN B on 2/08/18 was retrospective to events that could only have taken place at 7:15 PM onward, since that was the time in which the lab had called her. It read: "Prior to checking on patient Lab called, reported patient's potassium level 1.8 and CO2 (carbon dioxide) > (greater than) 50. [Physician I] made aware of lab results, requested to repeat patient's potassium level. That was the time patient assessed to be unresponsive, stiff and cold." The nurse received the results from the lab, notified the physician, and then discovered the patient to be unresponsive.

A nurse's note at 7:30 PM on 2/08/18 by RN B addressed events in the evening of 2/08/18. The entry read, "I went to do my initial assessment on patient in H25. Patient noted covered with blanket, facing wall. I called patient by name, no response. I touched patient, she felt stiff, tried sternal rub, patient remains unresponsive. Pt's skin felt cold. Call made to doctors, [Physician I] responded, [Assistant Nurse Manager G] was also aware. Patient transferred to room 58, code blue initiated."

A nurse's note by Assistant Nurse Manager G on 2/08/18 at 7:17 PM read, "Primary RN/[RN B] noted assessing pt currently in HW (hallway) 25, pt noted nonverbal/unresponsive/cool to touch/mottled, no pulse noted. CPR (cardiopulmonary resuscitation) initiated, code blue initiated. Pt moved to 58, [Physician I] present, respiratory therapist and pharmacist at bedside."

Physician I's entry at 7:18 PM on 2/08/18 read, "Rechecked chemistry. Upon RN exam, found pt covered up and unresponsive. Subsequently, code was called. Pt put in room 58. Pt unresponsive; CPR and bagging performed. I was called by overhead to pt room." A note by physician I of 2/08/18 at 7:39 PM read, "Pt continued to have no pulse. Pt in asystole; no pulse found. CPR was stopped 7:39 PM."

RN A failed to perform the following activities which were required by hospital policy or ED expectations: (1) apply a cardiac monitor as ordered (2) perform vital signs at a minimum of each hour (3) perform a shift hand-off report in the presence of the patient and (4) report the results of a critical potassium level which had been indicated through i-STAT to the physician. RN A and RN B failed to perform a shift hand-off report in the presence of the patient. The patient was not assessed timely and physician orders were not carried out for patient #1.

Based on interview and record review, the hospital failed to ensure that emergency needs of patients who had cardiac monitoring needs were met in accordance with acceptable standards of practice for 1 of 10 sampled patients (#1).

Findings:

Cross Reference A1111. A review of the medical record of patient #1 was performed. The patient was triaged in the Emergency Department (ED) on 2/08/18 at 5:02 PM. The ED physician ordered the placement of a cardiac monitor on 2/08/18 at 5:53 PM. There was no evidence in the record that the cardiac monitor was placed on the patient from the time it was ordered to the point at which an unsuccessful cardiopulmonary resuscitation (CPR) code was called at approximately 7:18 PM on 2/08/18.

There was no evidence that during the time period between the order for the cardiac monitor and the code, that the ED physician sought to confirm the placement of the cardiac monitor.

The physician did not confirm placement of the cardiac monitor, and the patient did not receive any medical supervision regarding her cardiac status prior to the patient receiving CPR.

Based on interview and record review, the facility failed to ensure that emergency services involving cardiac monitoring were supervised by Emergency Department medical staff for 1 of 10 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. The patient was triaged in the Emergency Department (ED) on 2/8/18 at 5:02 PM. The chief complaint at 5:04 PM on 2/08/18 was "Body cramps since last night/Hypokalemia." The Chief Complaint Comments at this same time read, "Hx (history) of hypokalemia. Sent from work with tremors." The patient's vital signs at 5:02 PM on 2/08/18 were, "Temperature oral: 98.2 DegF (degrees Fahrenheit). Heart Rate 90 bpm (beats per minute). Respiratory Rate Spontaneous: 18 br/min (breaths per minute). Systolic Blood Pressure NBP (Noninvasive Blood Pressure) 89 mmHg (milliliters of mercury) (low). Diastolic Blood Pressure NBP: 52 mmHg (low) O2 (oxygen) saturation: 96%."

At 5:52 PM on 2/08/18, physician I wrote, "The patient presents with muscle cramping....with PM Hx (past medical history) of HTN (hypertension) and seizures presents to the ED c/o (complains of) generalized muscle cramping due to low Potassium." The physician's physical exam entries at this time included the following: "General: Alert, anxious, S/P (status post) IV (intravenous) insertion, pt became increasingly agitated and anxious....Pupils are equal, round and reactive to light, vision unchanged....Cardiovascular: Regular rate and rhythm. No murmur. Normal peripheral perfusion. No edema...Lungs are clear to auscultation (bilaterally), respirations are non-labored, breathe sounds are equal. Symmetrical chest wall expansion.... Musculoskeletal: Normal ROM, generalized tenderness to palpation of arms and legs....Neurological: Alert and oriented to person, place, time and situation. No focal neurological deficit observed, CN (cranial nerves) II - XII intact, normal sensory observed, normal speech observed. Psychiatric: Cooperative, appropriate mood & affect....Last admitted: 12/21/17. Diagnosed with: hypocalcemia and hypokalemia."

Physician orders of 2/08/18 at 5:53 PM read, "Cardiac Monitor ED."

The initial nursing assessment was performed on 2/08/18 at 6 PM by registered nurse (RN) A. It read, "Cardiac monitor: limits set and alarms on." This was the last mention in the record regarding cardiac monitoring or telemetry. However, during an interview of Risk Manager E on 3/29/18 at 1:03 PM, she stated that this was a portable vital signs monitor, not a cardiac monitor. Thus, this record entry is not accurate.

A nurse's note by RN A at 6:30 PM on 2/08/18 read, "Alert and calm."

A nurse's note at 7:08 PM on 2/08/18 by RN A read, "Report to [RN B] ....to assume care at this time." A nurse's note at 7:30 PM on 2/08/18 by RN B read, "Approximately 7:10 PM after receiving report from (RN A) ...." Thus, the two respective nurse entries reflected a patient hand-off time within the time range of 7:08 PM and 7:10 PM on 2/08/18.

A nurse's note at 7:30 PM on 2/08/18 by RN B read, "Approximately 7:10 PM after receiving report from [RN A]. ...I went to do my initial assessment on patient in H25. Patient noted covered with blanket, facing wall. I call[ed] patient by name, no response. I touched patient she felt stiff, tried sternal rub, patient remains unresponsive. Pt's [patient's] skin felt cold. Call made to doctors, [physician I] responded, [RN G], ANM (assistant nurse manager) was also aware. Patient transferred to room 58, code blue initiated."

A nurse's note by RN G, Assistant Nurse Manager, on 2/08/18 at 7:17 PM read, "Primary RN [RN B] noted assessing pt currently in HW (hallway) 25, pt noted nonverbal/unresponsive/cool to touch/mottled, no pulse noted. CPR (cardiopulmonary resuscitation) initiated, code blue initiated. Pt moved to 58, [physician I] present, respiratory therapist and pharmacist at bedside."

A physician entry at 7:18 PM on 2/08/18 read, "Upon RN exam, found pt covered up and unresponsive. Subsequently, code was called. Pt put in room 58. Pt unresponsive; CPR and bagging performed. I was called by overhead to pt room." Physician I's note of 2/08/18 at 7:39 PM read, Pt continued to have no pulse. Pt in asystole; no pulse found. CPR was stopped 7:39 PM."

During an interview of physician I on 3/30/18 at approximately 3:47 PM, he stated that he did not have any discussions with nurses regarding new vital signs. He stated that he was not aware that the cardiac monitor had not been placed. He stated that he had not issued any directives to nurses along the lines of an increase in monitoring activity with the patient. He stated that he had not examined the patient at any other time than his documented interaction at 5:52 PM on 2/08/18.

The physician did not follow-up with patient #1's cardiac status after ordering the placement of the cardiac monitor for a patient with a chief complaint of body cramps and a history of hypokalemia and anorexia.