HospitalInspections.org

Based on interview and record review, the facility failed to:
A. Accurately perform and document nursing assessments
B. Communicate and intervene on abnormal/critical patient vital signs
in two (2) of ten (10) patient medical records (Patient ID# 1 and # 8) according to established nursing standards and facility policy on the medical surgical unit.

Findings include:

Review of the facility policy titled: "Nature and Scope of Service 3rd Floor Medical Surgical Telemetry" (no date) revealed "Objective/Goals: ... Provide quality patient care based upon the nursing process with continuous evaluation reassessment of intervention and priorities in accordance with standards of nursing practice."

Review of the facility policy titled: "Electronic Nursing Documentation and Intervention Documentation Frequency," last reviewed 11/7/2021, "Physical reassessments are completed each shift or change in caregiver by Licensed Personnel. All patients must be reassessed when a significant change in the patient's condition occurs...". "Documentation of vital signs and nursing interventions constitutes a component of reassessment of the patient." "Nursing Interventions: Monitoring patient response to therapeutic interventions to ensure patient safety and provide best outcome in a consistent and efficient manner requires adequate descriptive documentation addressing the patient's response to intervention."

Review of the facility policy titled: "Rapid Response Team", last reviewed 6/30/22 revealed "Criteria Guidelines for Initiating RRT (Rapid Response Team):
1. Any or all of the criteria meets the guidelines for initiating RRT. The key to using the guidelines properly is identification of sudden acute change:
a. Acute change in heart rate < 40 or > 130
b. Acute change in systolic blood pressure < 90 mm Hg ....
e. Acute vital sign change or decrease in level of consciousness.
f. Changes in patient condition that, in the judgement of the accountable nurse, may be life-threatening but with which, he/she desires expert clinical opinion.


A. Medical Record review of Patient ID #1 chart with Staff ID #64, RN clinical manager, on 10/11/2022 at 1:35 p.m. revealed Documentation of nursing assessment performed by RN staff ID #66 on 7/2/22 at 8:00 p.m. stated "WDL" (Within defined limits). WDL is stated to include "no difficulty swallowing and normal gaiting." Patient ID #1 had a prior history of stroke with deficits including dysphagia (impaired swallowing and had a feeding tube as a result) and had left hemiplegia and was bedbound. She had been assessed by nurses on all prior shifts to be "confused, disoriented to time and place, weakness." This WDL assessment description was inaccurate and was inconsistent with patient's assessment previously.

B. Medical Record review of Patient ID #1 chart with Staff ID # 64, RN clinical manager, on 10/11/2022 at 12:35 p.m. revealed patient had 20 systolic blood pressures 169-229 over the course of all shifts between 06/30/22 08:00 a.m. - 07/02/22 07:10 a.m. (normal systolic range 90-140 mm Hg). There were occasional treatments with blood pressure lowering medications (hydralazine and labetolol) however inconsistent reassessments of response to treatments and lack of physician/provider notification or documentation of the response to notifications. Over the course of 7/2/22 night shift until the morning of 7/3/22, patient #1 had significant decline in blood pressure from her hospital baseline:
7/2/22 20:40 HR 56, 57; SBP 120
7/2/22 23:44 HR 57, 56; SBP 124
7/3/22 05:15 HR 52, 55; SBP 94

On 7/3/22 05:14 a.m., her blood pressure was 94/43 and her heart rate 55. On 7/3/22 05:27 a.m., a rapid response team was paged. There was a failure to recognize significant changes in patient's status over the course of the evening/night shift.

Medical Record review of Patient ID #8 chart with Staff ID #64, RN clinical manager, on 10/11/2022 at 1:05 p.m. revealed patient #8 had been admitted as a transfer from a skilled nursing facility with positive blood cultures for possible sepsis. On 06/22/21 at 04:21 a.m., she had a BP 76/41 (critically low) which was relayed via PerfectServe electronic messaging portal to the hospitalist (Physician ID # 73). At 06:41, after the nurse repeated vital signs with a critically low blood pressure in 70s/40s, she messaged the provider again. Physician ID # 73 stated, "Will pass off to the day team, need to have a discussion with family on goals of care." There was no activation of rapid response team per policy and no documentation of further escalation for stabilization and treatment of the patient. The patient did not have a Do Not Resuscitate Order until 6/22/21 afternoon.

Interview with Staff ID #64, Unit manager on 10/11/2022 at 12:40 p.m. validated that there was inadequate documentation for the course of nursing care and abnormal vital signs. She stated the nurse should have documented physician response.

Interview with Staff ID #51, RN Director of Quality, on 10/11/2022 at 2:10 p.m. revealed Staff ID #66 "should have documented more" in patient ID #1 chart. In addition, she stated "WDL should not have been used." She confirmed that both patients met criteria for rapid response activation to facilitate timely assessments and skilled interventions. She confirmed that critically high and low vital signs far outside established normal parameters meet criteria for escalation in care/treatment. She stated there is a "2 tier approach" which is to be utilized for nurses who feel there has been a lack of response from the physician/provider regarding patient's clinical changes. She described first engaging administration through charge nurse and house supervisor. She described medical aspects of care could be escalated as needed to the chief medical officer. There was no evidence of escalation to clinical, nursing or administration for either Patient ID #1 or 8.