HospitalInspections.org

.
Based on medical record review, document review, and interview, in one (1) of seven (7) medical records reviewed, nursing staff failed to adequately monitor a patient with an abnormal level of oxygen saturation and confer with the physician regarding the patient's care.

Findings include:

A review of the medical record for Patient #1 identified that the patient was evaluated in the Emergency Department (ED) on 3/13/2024 at 06:54 AM after an unwitnessed fall incident at the Assisted Living Facility. ED triage vital signs were Blood Pressure 114/54 (normal blood pressure 90/60 mm/Hg - 120/80 mm/Hg), Heart Rate 114 (normal heart rate 60- 100 beats per minute), Respiration Rate 20 (normal respiration rate 12-18 breaths per minute), Oxygen level/saturation [SPO2] 98 % (normal SpO2 95 -100%), and Temperature 97.6 degrees Fahrenheit (normal range 97.8 F - 99.1 F.

ED physician noted the patient's past medical history included advanced Alzheimer's disease and a new onset difficulty swallowing. The patient was admitted to an inpatient unit with orders that included cardiac monitoring, NPO except for medications, code status: Do Not intubate (DNI), and Do Not Resuscitate (DNR).

On 3/14/2024 at approximately 09:52 AM, the physician ordered a Pureed Diet (Dysphagia Puree Diet) and thin liquids based on the speech pathologist's evaluation and recommendations.

On 03/14/2024 at 1:39 PM, the nurse documented that the patient's oxygen level dropped while eating, and the physician was notified.

On 3/14/24 at 2:34 PM, the physician documented the following: the patient was suspected of having choked on liquids and apple sauce as her oxygen saturation level dropped to 85% on room air. The nurse suctioned the patient orally, and the patient was placed on supplemental oxygen. The physician ordered a chest x-ray, aspiration precautions, and nothing by mouth. A repeat chest x-ray at 5:07 PM revealed no acute findings.

On 03/14/2024, the patient's oxygen saturation levels were entered in the medical record as follows:
01:37 PM- SPO2 85 % on room air.
01:39 PM- SPO2 91 % nasal canula at 2 Liters per minute (LPM).
03:58 PM- SPO2 91 %.
07:45 PM- SPO2 91 %.
09:00 PM- SPO2 92 % on nasal canula at 3 LPM.
11:00 PM- SPO2 91% on nasal canula at 3 LPM.
11:32 PM- SPO2 91 %, Blood Pressure 153/71, Heart Rate 77.

There was no documentation found that the patient's persistent abnormal levels of oxygen were reported to the physician after the physician's last documented assessment of the patient on 3/14/2024 at 2:34 PM.

On 03/15/2024, at 01:30 AM, the patient's nurse entered a note, "Received a call from Cardiac Monitoring Unit (CMU) regarding pt [Patient] telemetry having pauses greater than 20 seconds. Telemetry also showed a lead-off. Upon entering the room and replacing loose lead, the patient appeared to have extreme agonal breathing. RRT [Rapid Response Team] called at approximately 01:25 [AM] ...As staff began to arrive, pt [Patient] took a last breath, and RRT was canceled." The patient was pronounced dead on 03/15/2024 at 01:27 AM.

On 5/21/2024 at 01:29 PM, during an interview with Staff I (the patient's nurse), she stated that she could not recall the patient. However, she stated that if a patient's oxygen saturation is between 80-92 %, she would place the patient on low-flow oxygen via nasal cannula and then notify the doctor, and if the patient's oxygen levels do not improve significantly, she will continue communicating with the physician.

There was no documentation found of continued communication with the physician for approximately eleven hours from 2:34 PM on 3/14/2024 PM to 1:25 AM on 3/15/2024 when the nurse found the patient with agonal breathing.
.

.
Based on medical record review, document review, and interview, in one (1) of seven (7) medical records reviewed, the facility failed to document information that supports the patient's diagnosis. Specifically, nursing staff did not document cardiac strips in accordance with the facility's policy for 'Cardiac Monitoring.'

Findings include:

The facility's policy for 'Cardiac Monitoring,' dated 9/20/2023, states, "Tele Tech will obtain a 6-second (minimum) cardiac strip to check the clarity of the strip, confirm accurate placement of leads, and obtain a baseline. A six-second (minimum) cardiac strip should be placed in the patient's chart at the following times by the TeleTech and confirmed by the RN [Registered Nurse] (RN will acknowledge by documenting Last Name and First Initial) in the comments section prior to electronically saving the strip to EMR [Electronic Medical Record]).
- On initiation of telemetry monitoring for baseline.
- Prior to the beginning of each shift.
- Whenever there is a transfer to a different level of care.
- When there is an alteration in the patient's cardiac rhythm or pattern."

A review of the medical record for Patient #1 identified an 81-year-old female patient who was admitted to the facility on 03/14/2024 for an evaluation and observation post-fall at an Assisted Living facility.

On 03/15/2024, at 1:30 AM, the patient's nurse entered a note: "Received call from Cardiac Monitoring Unit (CMU) regarding Pt [Patient] telemetry having pauses greater than 20 seconds. Telemetry also showed a lead was off. Upon entering the room and replacing the loose lead, the patient appeared to be having extreme agonal breathing. RRT [Rapid Response Team] called at approximately 01:25 AM."

On 03/15/2024, at 1:27 AM, the patient was pronounced dead.

There was no documentation found in the patient's medical record and the CMU EKG log of the patient's abnormal cardiac rhythm or pattern before the patient's cardiac arrest and death.

On 05/21/2024 at 1:29 PM, during an interview with Staff Q (7 South Nurse Manager), she stated that patients' EKG strips can be entered into the medical record by either a unit nurse or an EKG Monitoring Technician at a remote location.

On 05/21/2024 at 2:30 PM, during an interview with Staff J (EKG Monitoring Technician), he stated, "Any abnormalities on EKG should be recorded, and if the patient expires, the last strip is documented." Staff J reported that he did not document the patient's EKG strip when there was an alteration in the patient's cardiac rhythm.