HospitalInspections.org

Based on observation, interview, and record review, the facility failed to provide safe nursing services that meet patients' needs.

(1) The facility failed to implement an effective process to make safe patient assignments on the COVID ICU/IMU unit during this period of nursing staff shortage.

- During the night shift on 8/9/2021, two (2) RNs were assigned to ICU patients; these RNs did not have the experience or training to provide care for these ICU patients. Due to patient assignments, two (2) agency nurses walked off the job and one (1) agency nurse was asked to leave due to his reaction upon receiving patient assignment.

The facility had knowledge they would be receiving only one (1) ICU nurse from the contract staffing agency at 5:09 PM and did not start making staffing adjustments until contract staff arrived and questioned administration regarding the assignments. There was a total of nine (9 ) patients on ventilators that night.

Cross refer : Tag A-0397


(2) The facility failed to ensure that Nursing Services supervised and evaluated the care of 19 of 19 patients placed on cardiac monitoring on the the COVID ICU/IMU unit [Patient IDs 13, 15, 19, 20, 22, 26, 37, 38, 39, and 40 through 49 ].

-On 8/17/2021, it was determined that the staff monitoring the central cardiac monitor at the nurses' station on the COVID ICU/IMU unit was not trained to perform this function. The facility Chief Nursing Officer stated she thought she was trained for this role.

Failure to recognize serious cardiac arrhythmias could cause delay in treatment and lead to serious patient harm and injury.

Cross refer : Tag A-0395

Based on observation, interview, and record review, the facility failed to ensure that Nursing Services supervised and evaluated the care of 19 of 19 patients placed on cardiac monitoring on the COVID ICU/IMU unit [Patient IDs 13, 15, 19, 20, 22, 26, 37, 38, 39, 40 through 49 ].

On 8/17/2021, it was determined that the staff monitoring the central cardiac monitor at the nurses' station on the COVID ICU/IMU unit was not trained to perform this function. The facility Chief Nursing Officer stated she thought she was trained for this role.

Failure to recognize serious cardiac arrhythmias could cause delay in treatment and lead to serious patient harm and injury.

Findings included:

Record review of facility policy titled: "Telemetry-Floor Patient: Department- Critical Care Unit," last review date was 2/2019, showed: a licensed nurse or telemetry technician who has completed the basic electrocardiogram course will be assigned to observe telemetry twenty-four hours a day.


Record review of facility policy titled: "Department Staffing Guidelines," dated 04/2021, showed: ICU has one (1) telemetry tech assigned 24/7.

Observation on 8/17/2021 at 10:00 AM on the COVID ICU/IMU unit showed Staff # O observing the central cardiac monitors at the nurses' station. Staff O said that on this date "all of the patients" in the unit were on cardiac monitoring. Staff # O said that three (3) patients were on ventilators (Patient IDs # 13, 15, 19).

Record review of the patient census, dated 8/17/2021, showed 19 current patients on the 400 and 500 hallways, which comprised the COVID ICU/IMU unit.

Continued interview with Staff O, she said her title was "Unit Secretary." When asked if she was also a telemetry tech, she said "not really, I was signed up for the EKG training last year but was not able to attend."


During an interview on 8/17/2021 at 12:30 PM with Charge nurse, RN # M, when asked who was responsible for the cardiac monitoring at the station, she answered: "Staff O". The charge nurse went on to say that Staff O listened for alarms and knew if the vital signs or oxygen levels were not normal and let the nurses know. Charge nurse #M said Staff O "doesn't interpret cardiac rhythms."


Earlier observation on 8/17/2021 at 9:45 AM on the 300 hallway, ICU (non-COVID) showed Staff N observing the cardiac monitors at the nurse's station. During an interview at the time of observation, Staff N stated she was the "unit secretary and also the telemetry tech." Staff N said, the current ICU patient census was 10; six (6) patients were on cardiac monitoring. Staff N confirmed she had EKG interpretation training.


Record review on 8/17/2021 at 11:15 AM of Staff N & Staff O's personnel & training files showed the following:

-Staff N (ICU-non COVID) : "Telemetry Tech" job description & performance evaluation, signed/ undated, showed : Job Summary included : the telemetry tech is responsible to provide continual surveillance of the central telemetry monitor to identify changes in the patient's cardiac rhythm and to notify appropriate medical and nursing personnel.. Position requirements included: successful completion of EKG interpretation class. Staff N's file showed successful completion (2016) of EKG class that included interpretation of 10 cardiac rhythms including potential lethal arrhythmias. Staff N's file also contained a job description for "unit secretary."

-Staff O (COVID ICU/IMU): "Unit Secretary" job description & performance evaluation, signed 6/28/2020. The job summary did not require surveillance of central telemetry monitor or identification of changes in patients' rhythm. Continued review of Staff O's training file showed documentation of a "2019 skills fair. The following skill was marked as "NA" ('not applicable' per HR Director): EKG rhythm identification.


On 8/17/2021 at 11:15 AM, Staff N & Staff O personnel files were reviewed; the training information was verified by HR Director # X.

During an interview in 8/17/2021 at 4:30 PM with facility CNO (Staff B), she stated, she thought Staff O had telemetry tech training. She said she would expect her to have the telemetry tech training.

Based on interview and record review, the facility failed to have an effective process in place to make safe patient assignments on the COVID ICU/IMU unit during this period of nursing staff shortage.

During the night shift on 8/9/2021, two (2) RNs were assigned to COVID ICU patients, these RNs did not have the experience or training to provide care for these patients. Due to patient assignments, two (2) agency nurses walked off the job and one (1) agency nurse was asked to leave due to his reaction upon receiving patient assignment.

The facility had knowledge they would be receiving only one (1) ICU nurse from the contract staffing agency at 5:09 PM and did not start making staffing adjustments until contract staff arrived and questioned administration regarding the assignments.

Findings include:

Record review of facility policy titled: SCOPE OF PRACTICE, department Critical Care Unit, dated 02/19 showed the following information:

E. Staffing for 1:1 patient care will be coordinated between the nursing Director, Critical Care Unit or designee and the Charge Nurse.

F. The following general criteria will be utilized for classifying patients requiring 1:1 nursing care. They are generally those patients who require more than routine critical care nursing and have one or more of the following care or safety needs:

1. Hemodynamically unable with potent vasopressors or antihypertensives. Continuous nursing observation required because of life support such as, but not limited to, ventilators or ventricular support systems

G. The patient to nurse ratio is 2:1, in the event that there is deficiency in the amount of staff required to care for the patients, all attempts shall be made to replace the deficiency with a qualified staff member. The unit manager maintains ultimate responsibility for providing adequate staffing and shall provide patient care in the event that a qualified nurse is available.

Record review of nurse staffing assignments for the night shift of 8/9/2021 (7:00 PM - 7:00 AM) for station 4/5 COVID ICU/IMU unit showed the following information:

Census 23

13 ICU (9 vents), 10 IMU

RN (P) assigned to IMU patient (ID 14) and ICU patient (ID 17) both patients on ventilators.

RN (Q) with no documented patient assignment, with the words 2 vents written alongside of name.

RN (R) assigned to IMU patient (ID 22), ICU patient (ID 27), IMU patient (ID 30) and IMU patient (ID 31).


Record review of HR file of contract staff RN (ID P) showed no documented ICU/IMU training or experience.

Record review of HR file of contract staff RN (ID Q) showed no documented ICU/IMU training or experience.

Record review of HR file of contract staff RN (ID R) showed no documented ICU/IMU training or experience.


Interview of staffing coordinator (ID T) on 8/17/21 at 11:50 AM, she stated that the census determines what type of nurses and how many nurses are requested. When requesting nurses from the different contract staff agencies, ICU nurses are always requested. She stated that she received final confirmation from the staffing agency on 8/9/21 around 2:00 PM and continued to contact all other resources but no one else was available. She stated that she communicated what staff was available to the CNO around 5:00PM. At that point the CNO (ID B), facility administrator (ID A) and the DON (ID C) came to her office to look at and discuss the schedule.

Review of Text message from staffing agency to staffing coordinator (ID T) on 8/9/21 at 2:02PM showed the following information:

Nurses available for Monday 8/9/21
7:00PM
Staff (ID V) ICU
Staff (ID J) IMU
Staff (ID P) IMU/ER
Staff (ID Q) IMU
Staff (ID R) med/tele
Staff (ID W) med/tele

Review of text message on 8/9/21 from staffing coordinator (ID T) to CNO (ID B) at 5:09PM it stated, "we have 9 vents on COVID and 4 in regular ICU and 1 ICU nurse."

Interview with DON on 8/11/21 at 3:03 PM, she stated that on 8/9/21 PM shift, there were nurses from the agency that came in and left after around 45 minutes to an hour of being here. She confirmed that the nurses had been given their patient assignments but were not happy with the assignments. She stated that they came in and reviewed the board and were not happy with the assignments and the nurse supervisor tried to rearrange patient assignments but two of the nurses walked out (ID Q and R) and one was asked to leave (ID P). She said that the patients on ventilators and critical intravenous (IV) drips would be assigned to the ICU nurses. Patient that were on drips and on high flow bipap could be managed by the IMU nurses. The patient classification of IMU/ ICU comes from MD (ID U) or from the emergency department when they are admitted.

Interview with CNO (ID B) on 8/11/21 at 3:41 PM, she stated that the night on 8/9/21 was a very bad night. We had nurses walk off the job, a nurse called in and we were scrambling assignments and the assignments were not settled until around 10:00 PM. We had requested nine (ICU) nurses and four (4) IMU nurses. We expect for them to give us all the ICU nurses they have. It wasn't until 6:20 PM that we were notified of the nurses that would be coming in for the 7:00 PM shift. We were not happy with the nurses that we were given to work with, but this was the best we could do. Contract staff RN (ID P) reached out to the nursing manger yelling and screaming about the assignment given because they are not an ICU nurse and stated they were leaving. Contract staff RNs (ID Q and R) were yelling as well because of the assignments they were given, and just left. She went on to say that she was going to be reporting contract staff RNs (ID P and Q) to the State Board of Nursing. She also stated that the nursing supervisor took care ICU patients. We were able to secure another ICU nurse to come in but that was not until around 10:00 PM, this is when the assignments were settled. This happens every night. It is a struggle to get staff. During discussion at the exit conference on 8/17/21 at 4:30PM it was asked if there was an established time that you are informed on the staffing available for the upcoming shift and plan accordingly, she stated no.

Review of facility document titled: Requirements for staffing requests (undated):

COVID UNIT:
RN ICU Days 7a-7p
RN ICU Nights 7p-7a

Responsibilities not limited to:
-2-3 years' experience I see you in all settings dash medical, surgical, pulmonary, cardiovascular, renal, and post-cath

-Ventilation/ hi-flow/continuous bipap/C pap

-Hypothermia /hyperthermia

-sepsis

-DKA

-Drips-over than 2

-tracheostomy care, suctioning

-unstable hemodynamics

-post-surgical procedures that are unstable

-ability to perform in high intensity areas, COVID patients, fast pace, critical thinking

-assists in bedside procedures with MD

-assist in Emergency Management situations, code in rapid response


Credentials and Requirement pre-hire:

-RN, ACLS, BCLS

-Attestation letter regarding employee health-requirements including COVID vaccine, TB testing, hepatitis, drug screen, fit testing, fire safety, infectious, exposure control, and hazardous waste management

-background checks


Review of medical record for ventilator patient (ID 8) for the night shift of 8/9/21 revealed no nursing documentation.

Review of medical record for ventilator patient (ID 19) for the night shift of 8/9/21 revealed no nursing documentation until 2:15 AM on 8/10/21.

Interview with CNO (ID B) on 8/17/21 at 4:20 PM she stated that the nursing supervisor (ID S) was the nurse who cared for patient (ID 8) on the night shift of 8/9/21. She stated that he did do an assessment of the patient but that it is not documented until 8/10/21 at 7:05 AM. She stated that this is a limitation of the medical record software. There is not a way to document it as a late entry.

Record review of facility policy titled: Hospital Plan for the Provision of Nursing Care, dated 04/19 showed the following:


IV. STAFFING PLAN

The adequacy of staffing in terms of both numbers of qualified staff and the mix of staff is assessed on an ongoing basis through comparisons of actual staffing levels and projected staffing needs. This is based on the patient census determination of staff mix and specific patient assignments based on an acuity system. Alterations are made in staffing for each shift based on assessed patient care or service needs and, on the mix, and competencies of the assigned staff.

Record review of facility policy titled: Nursing Process: Documentation, dated 4/19 showed the following information:

e. The plan of care will be reviewed, revised, and updated every 24 hours by a registered nurse after assessing the patient and reviewing the 24-hour nursing documentation of the patient's progress.

4. Re-assessment of patient status relative to each identified problem each shift and review of assessment data to determine if other problems are present which require nursing actions.

Based on interviews and record review, the facility failed to ensure a complete medical record was maintained that described patients' response to interventions and medications. This deficient practice affected all patients who had been placed on cardiac monitoring and had been discharged.

-The facility failed to implement a policy that required printing and scanning of EKG strips (routine & emergent situations) to become a permanent part of the patient's medical record.

The facility IT system network administrator confirmed the facility's cardiac monitoring system did not interface with the electronic medical record. After a patient was discharged, all cardiac monitoring data was lost and was irretrievable.

[Citing Patient IDs# 1, 2, 3, 4, 5, 7, 8]

Findings included:

Record review of the American College of Cardiology "Standards for Inpatient Electrocardiographic Monitoring," dated 10/04/2017, stated: "proper documentation of ECG monitoring is necessary and will vary based on the ability to interface with current electronic medical records systems. If no mechanism is available to transfer ECG strips to the electronic medical records, it is critical that paper ECG strips be printed and maintained in a paper chart and scanned into the electronic record. For ST-segment and QTc monitoring, relevant parameters should be documented at baseline and then at least every 8- 12 hours."
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Record review was performed on 8/13/2021 of seven (7) "Cardiopulmonary Resuscitation Records" (Patient ID # 1, 2, 3, 4, 5, 7, 8). It was noted there were no EKG strips provided to aid in determining patients' condition and compliance with ACLS protocols prior to and during resuscitation efforts.

On 8/17/2021 while on-site visit, the EKG strips were requested for the seven (7) patients (listed above).

During an interview on 8/17/2021 at 10:45 AM with Staff B, CNO, she stated she was unsure how the EKG strips / monitoring data was stored. She said she would check with the IT director.

During a telephone interview on 8/17/2021 at 10:50 AM, IT Systems Network Administrator ID # I, he said:

-the current cardiac monitoring system was not interfaced with the electronic medical record;

-if patients were currently placed on cardiac monitoring: -all the data could be viewed or printed for any portion of their admission;

-once patients were taken off the cardiac monitoring system ('like at discharge')- none of the cardiac monitoring data was available or retrievable--not stored.

During separate interviews on 8/17/2021 between 9:40 AM and 10 AM, with Staff N (ICU-telemetry tech ) and Staff O (COVID ICU/IMU unit secretary)--each said there was no required routine printing of any EKG strips to maintain for the patient's medical record.

The facility was unable to provide the requested cardiac monitoring strips for Patient IDs# 1, 2, 3, 4, 5, 7, 8, as this data was not stored.