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Based on observation, interview, and record review, the hospital failed to ensure two of six sampled patients (Patients 1 and 2) received care in a safe setting as evidenced by:

1. For Patient 1, Patient 1's temperature was not rechecked after administering acetaminophen (a medication used to treat pain and reduce fever) as per the hospital's P&P. In addition, Patient 1's provider was not notified when Patient 1's oxygen saturation level was below 93% as per the physician's order.

2. For Patient 2, the Anesthesiologist did not perform lung auscultation to verify the anesthesia airway placement.

These failures had the potential to result in the unsafe care and poor clinical outcomes for the patients.

Findings:

1. On 12/3/24, Patient 1's medical record was reviewed with the Accreditation Program Manager.

Patient 1's medical record showed Patient 1 was admitted to the hospital on 9/13/2024.

a. Review of hospital's P&P titled Range Orders and Multiple PRN Medication Order of Use dated October 2023 showed to reassess the patient when the drug approximately reaches peak effect: 45-75 minutes after PO/Rectal administration.

Review of Patient 1's Flowsheet History from 9/22/24 at 0000 hours to 9/23/24 at 0700 hours, showed on 9/22/24 at 0433 hours, Patient 1 had a temperature of 100.9 °F (normal body temperature: 97 °F to 99 °F).

Review of Patient 1's MAR dated 9/22/24, showed 650 mg suppository acetaminophen was administered rectally to Patient 1 at 0444 hours for fever.

Review of Patient 1's Flowsheet History from 9/22/24 at 0000 hours to 9/23/24 at 0700 hours, showed Patient 1's body's temperature was not rechecked until 9/22/24 at 0755 hours, or approximately three hours later.

On 12/3/24 at 1244 hours, an interview and concurrent record review was conducted with the Accreditation Program Manager. The Accreditation Program Manager acknowledged Patient 1's body's temperature was not rechecked after the administration of acetaminophen as per the hospital's P&P.

b. Review of the physician's order dated 9/14/24 at 1613 hours, showed the order for notification parameters for surgical vitals. The nurse would notify the provider of significant changes to vital signs or other clinical deterioration. Provider to indicate below if they would like to be notified OUTSIDE of this usual routine. The order indicated that the provider wanted to be notified if Patient 1's oxygen saturation level dropped below 93%.

Review of Patient 1's Flowsheet History from 9/22/24 at 0000 hours to 9/23/24 at 0700 hours, showed the following:

- On 9/22/24 at 0035 hours, Patient 1's oxygen saturation level was 91%.
- On 9/22/24 at 0433 hours Patient 1's oxygen saturation level was 90%.
- On 9/22/24 at 1617 hours Patient 1's oxygen saturation level was 89%.
- On 9/22/24 at 1916 hours Patient 1's oxygen saturation level was 92%.
- On 9/22/24 at 2106 hours Patient 1's oxygen saturation level was 90%.

On 12/3/24 at 1244 hours, an interview and concurrent record review was conducted was conducted with the Accreditation Program Manager. The Accreditation Program Manager acknowledged Patient 1's provider was not notified of the low oxygen saturation levels as ordered.

On 12/4/24 at 1308 hours, the Director of Risk Management and Accreditation Program Manager were notified of the above findings.


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2. On 12/4/24 at 1050 hours, during an observation of the surgical area with the Accreditation Program Manager, Patient 2 was observed transferring to OR 3. The Anesthesiologist was observed to performing airway placement with a video laryngoscope. The Anesthesiologist was observed not auscultating the patient's bilateral lungs after the airway placement.

On 12/4/24, Patient 2's medical record was reviewed. Patient 2's medical record showed Patient 2 had an outpatient surgical procedure.

Review of the Anesthesia Airway Placement dated 12/4/24 at 1111 hours, showed the airway type used for Patient 2 was endotracheal. The Anesthesia Airway Placement also showed the tube placement was verified by bilateral chest rise, carbon dioxide detection, video laryngoscope, and equal bilateral breath sounds.

On 12/4/24 at 1308 hours, the Director of Risk Management, Accreditation Program Manager, and Executive Director of Surgical Services confirmed the Anesthesiologist did not auscultate Patient 2's lung sounds.

Based on interview and record review, the hospital failed to ensure the nursing staff monitored and assessed the patient's status and response to restraints for one of six sampled patients (Patient 3) as per the hospital's P&P. This failure posed the risk of substandard outcomes to the patient.

Findings:

Review of the hospital's P&P titled Restraint for Non-Violent/Non-Self-Destructive Behavior dated May 2022 showed to ensure the well-being of the patient and the continued needs for restraints, an ongoing process including assessment, intervention, evaluation, and re-intervention will be carried out. The RN assesses on initiation and reassesses the patient's status and response to restraints at intervals not greater than two hours. The RN:

* Assesses neurologic: level of consciousness, orientation, and emotional status to determine if the clinical justification continues or there is potential for reduction or early termination of restraint.
* Assesses proper application of restraints.
* Assesses circulation, joint mobility, and sensation of affected limb, if applicable.
* Assesses skin integrity under the restraint.
* Assesses physical needs, exercise, elimination, nutrition, and hydration.
* Provides range of motion
* Repositions to prevent pressure ulcers.
* The RN or other member of the health care team meets the physical needs identified.

On 12/3/24, Patient 3's closed medical record was reviewed with the Accreditation Program Manager.

Patient 3's closed medical record showed Patient 3 was admitted to the hospital on 8/29/24 and discharged on 10/5/24.

Review of the physician's order dated 9/1/24 at 0641 hours, showed to apply non-violent soft restraints to the waist, right and left upper extremities.

Review of the Flowsheet dated 9/1/24, showed the restraints were initiated for Patient 3 at 0641 hours; and the restraint type, current mental status, response to restraints, peripheral neurovascular, skin, hydration, nutrition, elimination, range of motion, repositioning, and signs of injury were assessed for the patient on 9/1/24 at 0641 hours. Further review of Patient 3's medical record failed to show the monitoring and assessment until the restraint was discontinued at 1112 hours (for four hours and 31 minutes).

On 12/3/24 at 1400 hours, the Accreditation Program Manager verified the above findings.