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Based on record review, document review, policy review, observations and staff interviews it was determined the facility failed to ensure:
1. The nursing staff had the necessary knowledge and skills to meet the needs of the patients for 3 (#1, #3, #7) of 10 sampled patients (refer to A0395)
2. The nursing staff reported concerning physician behavior through the chain of command resulting in the Medical Director being unaware of the quality of medical services concerns affecting patient health and safety for 2 (#5, #7) of 10 sampled patients, (refer to A0347)
3. Appropriate nursing supervision and oversight was provided to one nursing staff member following her failure to provide nursing care and services determined to have directly resulted in the death of one (#4) of ten sampled patients. (refer to A0386)

Based on record review, document review, physician interviews and staff interviews, the facility failed to ensure the medical director and the administration for the facility were notified of concerns with the quality of care and failed to ensure the quality of medical care concerns were reviewed and addressed in compliance with facility bylaws for 2 ( #5, #7) of 10 sampled patients.

Findings included:

1. Patient #5 was admitted on 1/13/16 for treatment of respiratory failure. The record included documentation Patient #5 had a gastric feeding tube in place at the time of her admission. Patient #5 was transferred to an acute care facility on 2/5/16.

The Physician Order dated 2/3/16 at 5:03 p.m. and signed by the nurse practitioner included an order to perform a CT scan of the abdomen for abdominal pain and retained residual gastric tube feeding fluids. Additional orders dated 2/3/16 at 10:35 p.m. and signed by the nurse practitioner were received to stop administering the tube feedings and to perform an abdominal x-ray. The abdominal x-ray was performed and reported by the radiologist on 2/4/16 at 9:33 a.m. as showing an ileus (the intestines were not working). An order to perform an abdominal CT scan was entered by the radiologist on 2/4/16 at 2:55 p.m. The results of the CT scan included Patient #5 had free air in her abdomen related to her gastric feeding tube. The documentation dated 2/4/16 at 5:03 p.m. and signed by the radiologist indicated he had received no response to his page for the physician and reported the CT results to the Intensive Care Unit (ICU) Registered Nurse (RN). The nurses notes dated 2/4/16 at 5:48 p.m. indicated the physician responded to the RN's call regarding the abnormal CT scan with an order to obtain a gastroenterology (GI) consultation for Patient #4. The consultation note dated 2/5/16 at 6:01 p.m. and signed by the gastroenterologist indicated Patient #5 needed to be transferred to an acute care facility immediately. The nurses notes dated 2/5/16 at 7:51 p.m. indicated that Patient #5 was transferred to an acute care facility for treatment of her free air in the abdomen, indicating over 24 hours had elapsed from the time the condition was first identified until the patient was transferred.

The review of the facility Medical Staff Bylaws on 3/3/16 included documentation routine consultations by specialists may be performed within 3 days of the specialist being notified.

An interview was conducted with the Medical Director of the facility on 3/2/16 at 9:35 a.m. regarding the sequence of events in the care of Patient #5. The medical director confirmed free air in the abdomen is a medical emergency that requires immediate transfer to a higher level of care. He confirmed the finding the delay in the transfer of Patient #5 for over 24 hours was an event that should have been reviewed to determine whether or not the actions of the attending physician in ordering a routine GI consultation were appropriate under the circumstances. The Medical Director indicated he had not been aware with the concerns regarding the quality of the care of Patient #5 until notified by the surveyor.

2. Patient #7 was admitted on 1/15/16 at 6:15 p.m. with a medical history that included respiratory failure, bradycardia and sleep apnea. The patient was transferred from an acute care facility following a Aortic Abdominal Aneurysm repair. The patient completed an advanced directive on admission indicating he did not want his life prolonged by artificial means in the event he had no chance of recovery (DNR-Do Not Resuscitate).

The Medication Administration Record (MAR) dated 1/16/16 at 12:34 a.m. indicated the patient was medicated for back pain at a level of 8 (0-10 with 10 being the worst)with Dilaudid 0.5 mg (milligrams) IVP (Intravenous Push).

Nursing documentation dated 1/16/16 at 12:58 a.m., approximately twenty minutes after receiving the pain medication, noted a heart rate of 48, respiratory rate was 8 and a blood pressure of 88/41.

Respiratory Therapy (RT) documentation dated 1/16/16 at 12:55 a.m. revealed RT was called to the room. The documentation revealed the patient's oxygen saturation was 84%, the HR (Heart Rate) was 32 and the patient had received Dilaudid. The oxygen was increased to 10 Liters per minute (L/min) as ordered by the House Officer (physician) as the patient was a DNR. The oxygen saturation increased level increased to 93% and the heart rate was still in the low 40s.

Nursing documentation dated 1/16/16 at 1:49 a.m. revealed the patient was found unresponsive. The Rapid Response Team (RRT), House Officer and House Supervisor were called to the bedside.

The physician documentation dated 1/16/16 at 1:26 a.m. and signed by the House Officer revealed he was called to the bedside for bradycardia, the patient had received pain medication, was a DNR and failed to respond to non-invasive Advanced Cardiac Life Support (ACLS). The patient was pronounced dead at 1:24 a.m. on 1/16/16, less than twelve hours after admission.

Interviews with the nurse that cared for the patient and the RN nursing supervisor on the 7P-7A shift on 3/2/16 at 8:25 a.m. and 8:40 a.m. respectively revealed they informed the House Officer the patient had received pain medication twenty minutes prior to the bradycardia and decreased respiration. The RN supervisor indicated she asked the physician if he wanted to administer a medication to reverse the effects of the pain medication. The RN indicated the physician responded that medication was not appropriate, and it was not given. The RN supervisor indicated she did not inform her chain of command of any of her concerns related to the physician's failure to administer an antidote to the pain medication.

An interview with the physician who was the House Officer providing the care on 3/2/16 at 2:10 p.m. revealed he was not informed the patient had received pain medication twenty minutes prior. The physician indicated had he been aware, the treatment options may have been different.

The Medical Director for the facility was interviewed on 3/2/16 at 9:20 a.m. and informed regarding the details of the care of Patient #7. He indicated the record should have been reviewed for quality of medical care concerns. He indicated 100% of all patient deaths occurring within 24 hours require review by the Morbidity and Mortality Committee. He indicated he was unaware of any concerns related to the quality of medical care for Patient #7 until notified by the surveyor.

An interview with the Risk Manager conducted on 3/2/16 at approximately 10:00 a.m. confirmed the finding the record of Patient #7 had not been reviewed by any physician or committee prior to the survey.

Based on record review, staff interview and document review it was determined the facility failed to ensure nursing leadership discharged their responsibility to counsel and discipline the nursing employee whose failure to meet the needs of Patient #4 directly contributed to the patient's death.

Findings included:

The record for Patient #4 included documentation a Licensed Practical Nurse (LPN), a nursing assistant and a respiratory therapist were involved in providing personal care and changing the bed linen on 1/17/16 at 11:10 p.m. Patient #4 was alert and oriented and on a ventilator. The patient was pronounced dead on 1/17/16 at 11:40 p.m. after failing to respond to resuscitative efforts.

An interview with the Risk Manager was conducted on 3/1/16 at approximately 2:40 p.m. The Risk Manager indicated an investigation into the events surrounding the death of Patient #4 revealed the LPN failed to respond appropriately and in a timely manner to the ventilator alarms indicating the ventilator was not functioning properly at the time the LPN was at the bedside. The Risk Manager indicated the plan of corrective action included disciplinary counseling for the LPN.

The review of the personnel file for the LPN conducted on 3/2/16 failed to reveal any evidence of disciplinary counseling or any documentation related to the events of the death of Patient #4. The Risk Manager confirmed the finding at the time of the review of the file.

Based on staff interview and review of policy, procedures and clinical records it was determined the Registered Nurse failed to evaluate and supervise nursing care related to assessment, medication administration, implementing physician orders in a timely manner and ensuring care is provided in a safe manner to 3 (#1, #3, #7) of 10 sampled patients. This practice caused harm to patients requiring transfer to a higher level of care and additional care and treatment.

Findings Included:

1. Patient # 1 was admitted on 2/11/16 from an acute care facility. Review of nursing documentation from admission to 3/2/16 revealed the patient was able to take oral nutrition and had a urinary catheter.

Review of the intake and output documentation revealed on 2/28/16 640 IV and no documentation of oral intake. The output documentation revealed the patient was incontinent. Documentation revealed the patient had a urinary catheter.

Physician order dated 2/28/16 at 4:00 p.m. and acknowledge at 4:57 p.m. by the registered nurse revealed an order for D5W intravenous fluid at 100 milliliters over hour. Review of physician progress note dated 2/28/16 revealed the Sodium level was 152 (137-145).

On 2/29/16 intake was documented as IV 400 and no oral intake. The output was 1500. The total amount of IV fluid does not equal the correct amount had the IV fluid been implemented when ordered by the physician. Review of the MAR revealed the D5W was started on 2/29/16 at 9:00 p.m., over twenty four hours after the physician ordered the fluid. Physician progress note dated 2/29/16 at 10:31 a.m. revealed the hypernatremia (increased sodium) was likely secondary to volume depletion and the patient was on D5W at 100ml/hr.

On 3/1/16 the IVF intake was 1000 of IVF and 750 output. Nursing documentation dated 3/1/16 at 10:24 a.m. noted the patient was transferred to the Progressive Care Unit (PCU) due to a change in mental status. Nephrologist documentation dated 3/1/16 revealed the patient appeared clinically dehydrated. The increased sodium was now corrected on D5W.

Review of the nursing documentation and MAR revealed incomplete documentation of the patient's intake and output and a delay in implementing physician's orders for IVF in a clinically dehydrated patient that required transfer to a higher level of care (PCU).

Physician and nursing documentation dated 2/29/16 revealed the patient had twitching of an upper extremity. Physician order dated 2/29/16 at 5:02 p.m. revealed an order for fosphenytoin (anti seizure medication) 1000 milligrams (mg) intravenous piggy back (IVPB). A phenytoin level was ordered on 2/29/16 for 3/1/16. The patient was then to receive phenytoin 100 mg every eight hours IV.

Review of laboratory result dated 3/1/16 reveal a phenytoin level of 12.9 (10-20). Review of physician orders dated 3/1/16 revealed another level was to be obtained on 3/2/16.

Review of the MAR dated 3/2/6 noted the phenytoin was administered at 6:30 a.m. IV. Nursing documentation revealed the phenytoin level was obtained a 6:48 a.m. There was no documentation from where the level was obtained.
Review of laboratory results revealed the phenytoin level was critical at 148.6 (10-20). The physician was notified at 12:18 p.m. and ordered a STAT repeat. Physician documentation dated 3/2/16 indicated the patient was still not responsive, acute encephalopathy and recommend an MRI.
Documentation revealed the patient was transferred to an acute care facility for the MRI prior to the repeat Diantin level being obtained.

Review of a Change in Condition dated 3/2/16 at 3:52 p.m. indicated the patient started seizing during the MRI and was admitted to the acute care facility.

Interview with the nephrologist caring for the patient on 3/3/16 at 2:35 p.m. revealed a patient may require hemodialysis since phenytoin can accumulate quickly in renal patients.

Interview with the nephrologist and Risk Manager/Director of Quality Management on 3/3/16 at approximately 2:45 p.m. reveal the laboratory result from the acute care facility for the phentyoin level was 2.0 and the patient had been in status epliectius (continues seizures). The interview revealed the registered nurse should have obtained the level prior to the infusing of the medication. The registered nurse should not have obtained the specimen from the same line the medication was infusing. This practice lead to a false critical high level, the holding of dose of the medication and the patient developing status epileptic.

2. Patient #7 was admitted on 1/15/16 at 6:15 p.m. with a medical history that included status post respiratory failure, bradycardia and sleep apnea. The patient was transferred from an acute care facility following a Aortic Abdominal Anyuerism repair. The patient completed a DNR (Do Not Resuscitate) form on admission.

The initial nursing assessment dated 1/15/16 at 7:00 p.m. noted the patient was alert and oriented. The respiratory assessment described labored breathing with the use of accessory muscle. The lung sounds were decreased in the Right Middle Lobe, Left Lower Lobe and Right Lower Lobe. The heart rate was described as regular. The skin was documented as not intact. There was no documentation of surgical or other wounds. The blood pressure was 103/58, heart rate 73 and respiratory rate 20. There was no documentation by the Registered Nurse (RN) if the patient was on oxygen at the time of admission or if the oxygen saturation level was assessed on admission in a patient with labored respirations.

Respiratory Therapy documentation dated 1/15/16 at 9:7 p.m. revealed the patient was on a nasal cannula at 4L (liters) with a heart rate per telemetry of 73 in NSR.

Review of the Medication Administration Record (MAR) dated 1/16/16 at 12:34 a.m. indicated the patient was medicated for back pain at a level of 8 (0-10 with 10 being the worst)with Dilaudid 0.5 mg (milligrams) IVP (Intravenous Push). There was no documentation of where the back pain was, type of pain or if the pain was a new onset.

Nursing documentation dated 1/16/16 at 12:58 a.m., approximately twenty minutes after receiving the pain medication, noted a heart rate of 48, respiratory rate was 8 and a blood pressure of 88/41.

Respiratory Therapy (RT) documentation dated 1/16/16 at 12:55 a.m. revealed RT was called to the room. The documentation revealed the patient's oxygen saturation was 84%, the HR (Heart Rate) was 32 and the patient had received Dilauded. The oxygen was increased to 10L as ordered by the House Officer (physician) as the patient was a DNR. The oxygen saturation increased level increased to 93% and the heart rate was still in the low 40s.

Nursing documentation dated 1/16/16 at 1:49 a.m. revealed the patient was found unresponsive. The Rapid Response Team (RRT), House Officer and House Supervisor were called to the bedside.

House Officer documentation dated 1/16/16 at 1:26 a.m. revealed he was called to the bedside for bradycardia, the patient had received pain medication, was a DNR and failed to respond to non-invasive Advanced Cardiac Life Support (ACLS). The patient was pronounced dead at 1:24 a.m. on 1/16/16 less that twelve hours after admission.

Interview with the Risk Manager on 3/1/16 at approximately 9:40 am revealed the telemetry logs for that day could not be located. The logs would show what time the nurse station was called, overhead page and supervisor called.

Review of the clinical record with the Risk Manager/Director of Quality Management (RM/DQM) revealed no evidence of when the telemetry monitor called the nurses' station or overhead paged the nurse for a change in the patient's cardiac rhythm.

Interview with the nurse that cared for the patient and the house supervisor on the 7P-7A shift on 3/2/16 at 8:25 a.m. and 8:40 a.m. respectively revealed they informed the House Officer the patient had received pain medication twenty minutes prior to the bradycardia and decreased respiration.

Interview with the House Officer who provided the care on 3/2/16 at 2:10 p.m. revealed he was not informed the patient had received pain medication twenty minutes prior. Had he been aware, the treatment options may have been different.

Review of the clinical record did not reveal evidence the House Officer was notified of the time the pain medication was given.

The Risk Manager confirmed the findings during the record review on 3/1/16.

The record review and interviews revealed no evidence of an initial assessment of the skin not being intact, oxygen saturation level in a patient with labored breaths, documentation of the patient's status when found unresponsive or when the nurse was first notified by telemetry when the patient experienced a change in the cardiac rhythm.

3. Patient #3 was admitted on 2/26/16 from an acute care facility. The medical history included heart failure and status post a left hip fracture repair.

Initial nursing assessment dated 2/26/16 at 8:45 p.m. noted the patient was on a pureed diet, needed assistance with feeding and had a urinary catheter.

Physician orders dated 2/29/16 instructed to monitor the intake and output every 24. Review of nursing documentation for intake and output revealed on 2/28/16 the twenty four hour total was 200 IV intake and no output or oral intake was noted. On 2/29/16 the oral intake was 100 and the IV intake was 200. There was no documentation of an output on a patient with a urinary catheter. On 3/1/16 the patient had 1000 output and no evidence of intake being documented. Observation of the patient on 3/2/16 at approximately 10:20 a.m. revealed the patient had a urinary catheter in place.

Review of the Medication Administration Record (MAR) and physician order dated 2/29/16 instructed to administered DIgoxin elixir via the feeding tube.
Digoxin feeding tube. Review of the MAR revealed the Digoxin was administered via feeding tube on 2/29/16 and 3/1/16. Observation of the patient and interview with a family member on 3/2/16 at approximately 10:20 a.m. did not reveal the presence of a feeding tube.

Interview with the Risk Manager and confirmed by the Registered Nurse on 3/3/16 at approximately 9:30 a.m. confirmed the patient did not have a feeding tube.

The findings were confirmed with the RM/DQM on 3/2/16 during record review.

Review of policy and procedure " Administration of Medication " #H-MM 05-001 PRO effective 2/15 indicated the 7 rights of medication administration must be adhered for each medication administered. Right # indicated the medication must be administered via the correct route.

The review of the policy, clinical record and interviews revealed physician orders for intake and output were not implemented. A medication was ordered and documented as given via a feeding tube for several days. The policy and procedure for safe medication administration was not followed.