HospitalInspections.org

Based on medical record review, policy and procedures review, video footage review, and staff interviews, the nursing staff failed to clarify and maintain Continuous Pulse Oximetry for one (1) of 11 patients sampled (Patient #1).

Findings Included:

A review of the "Cardiac/Respiratory and Pulse Oximetry Monitoring on Acute Care Units" Policy last updated 04/01/2016 shows under policy statement: "The physician or licensed independent practitioner is required to write an order for patient monitoring which must include: the type of monitoring (cardiac/respiratory and/or pulse oximetry), rationale/ risk for placement on monitor, and frequency of use (i.e.continuous or intermittent, pulse ox checks with vital signs), circumstances under which patient can be temporarily off the monitor ..."

Further review under Procedure showed Guidelines for Patients Requiring Cardiac, Respiratory, and/or Pulse Oximetry Monitoring as: "7. Patients on supplemental oxygen if their condition warrants monitoring. 8. Patients at risk for decreased oxygen saturation, arrhythmia, or hemodynamic instability."

Further review under Procedure showed Orders for monitors must include: "1. Type of monitoring and 3. Frequency of monitoring (i.e.continuous, continuous during sleep, etc.) and circumstances under which patient can temporarily be taken off the monitor."

According to the History and Physical dated 12/05/2023, at 22:17 (10:17 PM) Patient #1 was a 7 (seven) month old infant who presented to the emergency department with cough and fevers x (times) 2 (two) days. The Patient was admitted to a short-stay observation unit with diagnoses of Acute Hypoxic Respiratory Failure and Bronchiolitis related to RSV (Respiratory Syncytial Virus) and RLL (right lower lobe) Pneumonia. The assessment/plan showed the patient was "clinically stable on 2 Liters Nasal Cannula." The patient requires admission for supplemental oxygen and antibiotics to maintain Sp02 > 92%..." The patient was also on maintenance intravenous fluid (mIVF) and Continuous Pulse Oximetry monitoring.

According to the physician's orders dated 12/04/2023 at 21:30 (9:30 PM) Patient #1 was ordered to "Monitor Pulse Oximetry Continuous (Continuous Pulse Ox) and Provide supplemental oxygen via nasal cannula if pulse Ox < = 92% STAT [immediate]." No documentation of circumstances under which the patient can temporarily be taken off the monitor. Additionally, there was no documentation of nursing staff notifying the physician for clarification of orders.

A review of the Vital Sign Flowsheet dated 12/05/2023 showed between the hours of 11:58 (11:58 AM) to 18:11 (6:11 PM) there are no documented vital signs or pulse oximetry noted on the flowsheet.

During a review of the Video footage from the 4 Main Observation unit on 12/12/2023 at 11:35 AM the surveyor observed on l2/05/2023 at 1:54 PM that Mother and Patient #1 were viewed walking off 4 Main unit. The Pulse Ox leads are seen dangling and not connected to a monitor. Mother and Patient #1 returned to 4 Main from FIC (Financial Information Center) at 2:45 PM. Patient #1 was off Continuous Pulse Oximetry monitoring for 50 minutes.

At 3:25 PM, Mother and Patient #1 are observed leaving 4 Main with Pulse Oximetry leads dangling and not connected to a monitor, got on the elevator, headed to the 1st (first) floor east lobby then exited the building and entered a car at 3:42 PM. Before leaving the facility Patient #1 was off continuous monitoring for approximately 2 hours and 45 minutes.

On 12/12/2023 at approximately 1:30 PM, the surveyors conducted a TEAMS (Microsoft application used to communicate using, chat, video, and screen sharing) interview with Employee #27 Acute Care Float Pool RN. Employee #27 was confirmed as being the primary bedside nurse for Patient #1 on 12/05/2023 from the hours of 7:00 AM to 7:00 PM. The surveyor was queried related to the Continuous Pulse Oximetry order for Patient #1. Employee #27 acknowledged the order for Continuous Pulse Oximetry and stated, "the baby [Patient #1] was not on Continuous Pulse Oximetry, it was discussed during rounds that the baby was stable and wasn't connected to anything." The surveyor queried if a discontinuation order was placed for the Continuous Pulse Oximetry. Employee #27 confirmed no new order was placed. The surveyor asked Employee #27 if Patient #1 should have been able to leave the unit. Employee #27 replied, "no that's why I stayed with the baby while mom went down to FIC with the Social Worker (SW)."

On 12/13/2023 at approximately 10:40 AM the surveyors conducted a face-to-face interview with Employee #7 Executive Nursing Director of 4 Main Medical/Surgical Nursing Unit. Employee #7 confirmed the physician orders showed the following: "Continuous Pulse Oximetry 12/04/2023 at 21:30 (9:30 PM) to 12/06/2023 at 18:13 (6:13 PM)."