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Based on review of policies and procedures, medical record and staff interview, it was determined that a registered nurse supervising patient care failed to ensure:

1. nursing staff notify a physician when the electronic medical record (EMR) issued a sepsis alert for 1 of 1 patient (Patient # 1) per facility's unwritten process/protocol generated in their EMR; and

2. nursing staff monitor a patient's vital signs when titrating an antiarrhythmic drip, or when patient's status requires more frequent monitoring per facility policy. (Patient # 1)

Failure to notify the physician of the sepsis alert poses a potential risk and jeopardizes the health and safety of the patient if medical interventions by the physician were warranted and not implemented. Failure to monitor a patient's vital signs when titrating an antiarrhythmic drip, or when patient's status requires more frequent monitoring, poses a potential risk to health and safety of the patient if critical vital sign changes are not identified that require medical intervention.

Findings include:

1. The policy titled "Level of Care and Monitoring Routines-Adults" indicates that for Progressive Care Monitoring Routines the following tasks must be completed every four hours: full assessment, cardiac rhythm interpretation, vital signs including blood pressure, heart rate, and respiration rate, temperature, oxygen saturation, pain assessment, central venous pressure, urine output, and IV sites checked. Intake and output (I & O) is totaled every 12 hours, and weights are taken every morning. Within this policy is a flow chart "Nurse to Provider Communication Tool" to aid nurses in determining if an issue is emergent, urgent, or nor-urgent. An Urgent concern is described as vital signs outside parameters, an acute change in condition (new or worsening stroke symptoms, new chest pain, arrhythmias, or increasing oxygen requirements), or if the issue poses a risk to the patient. For an Emergent concern, the main criteria is whether or not the patient needs to have a Rapid Response (RR) or Code Blue called. Both Emergent and Urgent concerns indicate a call to the provider.

Documentation related to a Sepsis Protocol and Sepsis Alert that is generated via their EMR was requested. No Sepsis protocol or documented process related to a Sepsis Alert via EMR was provided.

A copy of the Sepsis Clinical Pathway order set was provided for review, however the Pathway was never initiated.

Patient #1's medical record revealed the following:

On 11/10/2017 at 0300 hours patient's B/P was 94/51, pulse was 65. RN #11 documented patient was experiencing atypical pain, nausea, diaphoresis and cardiac rhythm of atrial fibrillation. "...Notified NP of status change. Orders received...."

On 11/10/2017 at 0300, RN #11 received an order to decrease Amiodarone IV drip.

On 11/10/2017 at 0400, patient's B/P was 79/50 with a pulse of 62. There was no documentation that the physician was notified.

On 11/10/2017 at 0500, patient's B/P was 96/49, pulse was 70, respirations were 32, and oxygen level was 88% on 4L nasal cannula. Subsequently the oxygen level was increased to 6L via nasal cannula and the O2 increased to 92%.

On 11/10/2017 at 0511 hours, RN #11 documentation revealed: "...Notification to NP of status change. Orders received...."

There is no documentation by RN #11 regarding the specifics of patient's #1 status change and what was communicated to the physician. Physician order received to adjust patient's pacemaker to 70 beats per minute. There is no documentation that RN #11 completed this order.

On 11/10/2017 at 0515 hours, the electronic medical record issued a Sepsis Alert for the following reasons; WBC 20.4; Respiration rate 32; Creatinine level 1.6 within 72 hours from 0.9.

On 11/10/2017 at 0525 hours, RN #11 acknowledged the Sepsis Alert. There is no documentation that RN #11 notified the physician of the Sepsis Alert.

On 11/10/2017 at 0732, RN #12 documentation revealed: "...Pt. cold, clammy, diaphoretic. NP in the unit and informed her. Charge Nurse informed...." Patient's B/P at this time was 66/51, pulse was 70, respirations were 25.

On 11/10/2017 at 0740 hours 5% Albumin 250mg drip initiated. No prior intervention for patient's decreased blood pressure documented.

On 11/10/2017 at 0756 hours patient was transferred to ICU. Patient coded at 0758 hours.

No Rapid Response call was initiated. No IV fluid bolus was given to address the low B/P prior to the initiation of Albumin at 0740 hours. No new antibiotics were initiated. No Blood cultures were ordered after the Sepsis Alert was acknowledged by RN # 11. There was no documentation available related to the patient being seen by a Respiratory therapist when Oxygen saturations dropped and respiratory rates increased.

RN #3 confirmed, in an interview conducted on 7/1/2019 at 1230 hours, that RN #11 did not notify the physician of the sepsis alert. In the same interview, RN #3 identified that when the electronic medical record issues a sepsis alert the RN should immediately notify the physician.

2. Policy titled, "Level of Care and Monitoring Routines - Adults" revealed: "...Patients with vasoactive or antiarrhythmic drips will have their BP assessed and documented at least every 15 minutes while initiating and titrating until stable, and then every 30-60 minutes as their condition warrants...Exceptions to Monitoring Routines:...Patient status or treatments require more frequent monitoring...."

On 11/10/2017 at 0300 hours patient # 1's B/P was 94/51, pulse was 65. RN #11 documented patient was experiencing atypical pain, nausea, diaphoresis and cardiac rhythm of atrial fibrillation. "...Notified NP of status change. Orders received...."

RN #11 received an order to decrease Amiodarone IV drip on 11/10/2017 at 0300 hours.

On 11/10/2017, the next set of vital signs was not assessed until 0400 hours. Patient's B/P was 79/50 with a pulse of 62. There was no documentation that the physician was notified.

On 11/10/2017, the next set of vital signs was not assessed until 0500 hours. Patient's B/P was 96/49, pulse was 70, respirations were 32, and oxygen level was 88% on 4L nasal cannula. Subsequently the oxygen level was increased to 6L via nasal cannula and the O2 increased to 92%.

On 11/10/2017, the next set of vital signs was not assessed until 0732 hours. RN #12 documentation revealed: "...Pt. cold, clammy, diaphoretic. NP in the unit and informed her. Charge Nurse informed...." Patient's B/P at this time was 66/51, pulse was 70, respirations were 25.

RN #3 confirmed, in an interview conducted on 7/1/2019 at 1230 hours, that patient #1 was on an Amiodarone drip; RN #11 titrated the drip rate down as ordered; and vital signs should have been taken more frequently due to patient's status.