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Based on observation, staff interview, medical record review, review of staff schedules and personnel files, the hospital failed to ensure a registered nurse was available to provide the necessary assessments (refer to A393) and supervision (A395) for patients in the cardiopulmonary outpatient rehabilitation program. The cumulative effect of these systemic problems resulted in the cardiopulmonary outpatient rehabilitation program's failure to provide effective nursing evaluation and oversight of nursing care.

Based on observation, staff interview, review of staff schedules and personnel files, the hospital failed to ensure an RN was available to supervise the LPN during cardiac and pulmonary therapeutic exercise sessions for 7 of 14 sample patients (#1, #3, #4, #5, #6, #7, #8). The findings were:

Observation on 1/25/12 from 8 AM through 11:15 AM and again from 12:30 PM to 1:15 PM revealed an LPN was working in the cardiac and pulmonary outpatient rehabilitation unit without supervision by an RN. During the four hours of observation the LPN assessed and monitored patients without RN supervision. The following concerns were identified:
a. Review of section 3, Standards of Nursing Practice for the Licensed Practical Nurse, page 3-8, revised in July 2011, showed the LPN must "Function under the direction of a licensed physician, advanced practice registered nurse, dentist, or registered professional nurse..." Interview on 1/25/12 at 1:50 PM with the LPN on duty revealed she reported directly to and was supervised by the registered respiratory therapist (RRT) who managed the cardiac and pulmonary rehabilitation outpatient services. In addition, review of the LPN's personnel file showed she was directly supervised by the RRT.
b. Interview with the cardiopulmonary services manager on 1/25/12 at 8:20 AM revealed patients participate in the therapeutic exercise program on Mondays, Wednesdays, and Fridays. Review of the December 2011 schedule showed no evidence an RN was scheduled or present while patients were receiving services for 9 out of 13 days of scheduled therapeutic exercise. Review of the January 2012 schedule through 1/25/12 showed an RN was not scheduled or present to supervise the LPN on 9 of 11 days when patients were present for their treatment. Interview with the cardiopulmonary services manager on 1/26/12 at 1:50 PM verified the schedule reviewed was accurate and no RN, physician or advanced practice RN was present during rehabilitation therapeutic exercise sessions as identified.

Based on staff interview, medical record review, and review of patient event reports and staff schedules, the hospital failed to ensure an RN was available during cardiac or pulmonary rehabilitation therapeutic exercise sessions for 3 of 14 sample patients (#4, #12, #13) who experienced an untoward event during their rehabilitation session. The findings were:

1. Review of the outpatient medical record for patient #4 showed s/he had a three vessel coronary artery bypass graft performed on 11/17/11. Review of the face sheet showed the patient was admitted to cardiac rehabilitation on 12/5/11 and was classified as high risk. Further review revealed s/he was scheduled for cardiac rehabilitation three times per week. Review of the 12/12/11 progress notes and patient event report revealed the patient experienced a change in his/her cardiac rhythm, from a normal sinus rhythm to bigeminal rhythm with occasional premature ventricular contractions after s/he had just walked on the treadmill for ten minutes. Further review of these progress notes showed the patient reported s/he had shortness of breath and chest pain equivalent to 2 - 3 on an anginal scale of 1 - 4. Review of the progress notes and the schedule, showed there was no RN, physician, or advanced practice RN (APRN) present to assess the patient. The LPN scheduled was not allowed, by her scope of practice, to assess the patient's condition. Fifteen minutes after the episode, the patient was transferred to the emergency department for assessment.

2. Review of the outpatient record for patient #12 showed s/he was admitted to the cardiac rehabilitation program on 7/20/11 after having a three vessel coronary artery bypass graft and aortic valve replacement on 6/29/11. Review of the face sheet showed the patient was classified as high risk upon admission. Review of the patient event report and progress notes for 7/25/11 revealed the patient had a "slightly irregular" cardiac rhythm, possibly atrial fibrillation, at the beginning of the therapeutic exercise rehabilitation session at 7:58 AM. Continued review showed the patient's heart rate became "very irregular" when s/he started exercising on the treadmill. Exercise was stopped but there was no RN, physician, or APRN present to assess the patient's condition. A physician notification was completed and faxed to the patient's physician. Further review of the progress notes showed the patient already had an appointment with the physician at 10:30 AM that day so s/he was sent home at 8:20 AM with an "irregular rhythm with no p-waves, an occasional premature ventricular contraction, and a wide QRS complex [abnormal]" to await for his/her physician's appointment two hours later.

3. Review of the outpatient record for patient #13 showed s/he was admitted to the cardiac rehabilitation program on 10/14/11 after having a three vessel coronary artery bypass graft
on 9/16/11. Review of the face sheet showed the patient was classified as high risk upon admission. Review of the patient event report and progress notes for 10/19/11 showed the patient had an elevated blood pressure (B/P) reading of 183/111 upon arrival. After some rest the patient's B/P decreased to 155/99 but later increased again to 171/100. Review of the schedule for 10/19/11 showed there was no RN, phsician or APRN present to assess the patient's condition. The cardiac rehabilitation staff included an LPN and an RT. The triage nurse at the VA (Veteran's Administration) center was contacted and the patient was then allowed to leave the cardiac rehabilitation area to go home to await for a call from the VA without an RN assessment of his/her condition.

4. Interview with the manager of cardiac and pulmonary rehabilitation and with the quality improvement director on 1/26/12 at 1:50 PM confirmed there was no RN in the cardiopulmonary outpatient area during the patient events on the above mentioned dates. Therefore, these patients received no onsite, real time nursing assessment.

Based on review of the organizational chart, facility documentation, job descriptions, and staff interview, the facility failed to assign the responsibility of outpatient services to one designated individual (refer to A1079). The cumulative effect of this systemic problem resulted in the hospital's inability to ensure the provision of quality health care in a safe environment in the cardiopulmonary outpatient rehabilitation department.

Based on review of the organizational chart, facility documentation, and job descriptions, and staff interview, the facility failed to assign the responsibility of outpatient services to one designated individual. The findings were:

Review of a list provided by the facility revealed clinical outpatient services included: cardiac rehabilitation, pulmonary rehabilitation, and rehabilitation services physical/occupational/speech therapy). Review of the facility organizational chart (dated 3/7/11) revealed one person was not assigned responsibility for the various outpatient services. During an interview on 1/26/12 at 1:50 PM, the director of quality confirmed that all outpatient services were not the responsibility of one designated staff person.