HospitalInspections.org

Based on record review, policy review, and interviews it was determined the hospital failed to evaluate the care of a patient on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy for 1 patient with a change in condition in a survey sample of 30 patients. (Patient identifier is Patient #28.)

Refer to tag 395.

Based on record review, policy review, and interviews it was determined the hospital failed to evaluate the care of a patient on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy for 1 patient with a change in condition in a survey sample of 30 patients. (Patient identifier is Patient #28.)

Findings include:

Review on 11/8/19 of the Facility's "Change of Condition" policy effective 2/6/19, revealed "The goal of the RRT [Rapid Response Team] is to provide early and rapid intervention in order to prevent adverse events, promote better outcomes to reduce the frequency of sending patients to a higher level of care. Any staff or family member may call an RRT when the patient's condition needs immediate evaluation by the additional support of the RRT. I. Criteria to consider in calling the RRT may include but are not limited to: ...3. Acute change in heart rate from baseline 4. Acute change in systolic blood pressure from baseline... 7. Acute change in level of consciousness... 10. Failure of patient to respond to treatment for an acute problem/symptom..."

Review on 11/8/19 of Patient #28's medical record revealed Patient #28 was admitted on 5/24/19 at 5:32 p.m. for a left quad tendon rupture and a BKA (below knee amputation). Patient #28's diagnoses include diabetes and a history a Cardiac Artery Bypass Graft (CABG).

Review on 11/8/19 of Patient #28's medical record revealed after admission on 5/24/19 at 8:12 p.m. Patient #28's blood pressure was 121/73. On 5/25/19 at 9:26 pm Patient #28's blood pressure was 121/62. On 5/26/19 at 2:02 p.m. Patient #28's blood pressure was 81/49. This change in blood pressure showed a change in condition but the facility's rapid response team was not activated. Further review of the medical record revealed no other monitoring of vitals were done on 5/26/19 until 6:42 p.m. when the patient's blood pressure was 86/49. The RRT was not activated at that time. From the first signs of the change of condition until eight hours later the facility never activated its RRT per hospital's Change in Condition policy to provide care and service to Resident #28.

Review on 11/8/19 of Patient #28's medical record revealed a note written by Staff C (Registered Nurse) at 10:15 p.m. on 5/26/19 that stated a LNA (Licensed Nursing Assistant) arrived on shift and found Patient #28 at "diaphoretic and lethargic, bp [blood pressure] 86/49 L [left],could not obtain on RT [right], HR [heart rate] 104 regular BG [blood sugar] 187, resp [respiratory] 12. Pt [patient] placed in trendleberg [sic] position and manual bp's done 102/60 L and 104/60 on rt, pt remained diaphoretic and lethargic pt could respond to RN [registered nurse (RN)] questions with stimulation Pt fell in and out of sleep during assessment and re-assessments. Concerned that narcotics maybe building up in system."

Review on 11/8/19 of Patient #28's medical record revealed no other monitoring and no phone calls to the physician had been completed. Review of the medical record reveals that no monitoring was completed since Patient #28 was placed in the trendelenburg position with the bp of 102/60. There were no other vital signs taken for the next five hours or since Patient #28 change of condition until patient was found unresponsive on 5/27/19 at 3:30 a.m..

Review on 11/8/19 of Patient #28's medication administration revealed that Patient #28 received 15 mg (milligrams) of oxycodone on 5/25/19 at 3:13 a.m. and 10 mg on 5/25/19 at 4:33 p.m.. Patient #28 did not received any other narcotics during his stay.

Interview on 11/8/19 at approximately 11:10 a.m. with Staff B (Chief Nursing Officer) confirmed the above findings.

Review on 11/8/19 of Patient #28's medical record revealed a late entry written at 8:13 a.m. on 5/27/19 for a Code Blue on 5/27/19 by Staff F (RN). "Nursing stat [immediately] called at 0330 [3:30 a.m.]... patient unresponsive with no carotid pulse. Nursing started CPR [Cardiopulmonary resuscitation], 911 was called. RN placed a 22 gauged IV [intravenous] placed in the right forearm. CPR continued until paramedics arrived at 0350 [3:50 a.m.]. Provider notified of condition. Patient pronounced at 0413 [4:13 a.m.] by paramedics and RN. Provider notified..."

Review on 11/8/19 of Patient #28's physician discharge summary written on 5/27/19 by Staff D (Physician) revealed that Staff D was informed about 4:30 a.m. and that Patient #28 was found unresponsive around 3:15 a.m. CPR was initiated, paramedics arrived, and ACLS (Advance Cardiac Life Support) protocols implemented and Patient #28 was pronounced dead at 4:15 a.m." Staff D noted that "The evening before he didn't require any pain medication, but he had slightly low blood pressure 80s systolic that seems to improve with Trendelenburg to 110 systolic." and "The EKG [electrocardiogram] trace showed V-Fib [Ventricular fibrillation]. Medical examiner informed."

Interview on 11/8/19 at approximately 1:30 p.m. with Staff D revealed that the EKG trace was from the paramedics and not the facility and was left on Patient #28's bed. Staff D also indicated that if a call to Staff D was made closer to the original change of condition on 5/26/19 then monitoring, diagnostic testing and IV fluids would have been initiated or performed.

Review on 12/2/19 of the "Change of Condition/Nursing STAT" training revealed that all employees were trained except two per diem nurses.

Interview on 12/2/19 at approximately with Staff B revealed that training of the two per diem nurses will occur upon their next schedule day prior to patient contact.

Interview on 12/20/19 at approximately 10:00 a.m. by telephone with Staff B revealed that one of the two per diem nurses above had actually been trained on 11/29/19. The other per diem had not worked since 11/8/19 and was not currently on the schedule to work.

Based on record review and interview with staff it was determined that the facility failed to maintain accurate records for 2 patients in a final surveyor sample of 30 patients. (Patient identifiers are, #8 and #10.)

Findings include:

Patient #8
Review on 11/8/19 of the medical record for Patient #8 revealed a Do Not Resuscitate (DNR) order dated 11/5/19. Patient #10's Medication Administration Record (MAR) revealed a DNR order dated 11/5/19. On 11/6/19, Patient #8's "History and Physical" revealed Patient #8 as a full code.

Interview on 11/8/19 at approximately 1:15 p.m. with Staff A (Registered Nurse) confirmed that the Patient #8's "History and Physical" does not match. Staff A revealed Patient #8 wishes are to be DNR.

Patient #10
Review on 11/8/19 of the medical record for Patient #10 revealed a Do Not Resuscitate (DNR) order dated 11/5/19. Patient #10's MAR revealed a DNR order dated 11/5/19. On 11/6/19, Patient #10's "History and Physical" revealed Patient #10 as a full code.

Interview on 11/8/19 at approximately 1:15 p.m. with Staff A confirmed that the Patient #10's "History and Physical" does not match. Staff A revealed Patient #10 wishes are to be DNR.

Interview on 11/8/19 at approximately 1:15 p.m. with Staff A indicated that staff would look at the MAR for the appropriate code order.

Interview on 11/8/19 at approximately 1:30 p.m. with Staff B (Chief Nursing Officer) indicated that staff would look at the MAR to determine the patient's code status.

Review of the hospital's policy titled "Do not Resuscitate", dated 3/7/18, revealed the following: "All orders for DNR must be in the medical record authenticated by the physician." The policy does not indicate where in the medical record that DNR must be located or where staff would look to confirm code status when a code is initiated.

Based on record review, policies, and interview it was determined that the hospital failed to ensure that all MD (Medical Doctor) verbal telephone orders are signed by the MDs within 48 hours for 1 of 30 medial records. (Patient identifier is #7).

Findings include:
Review on 11/8/19 of the "Medical Staff Bylaws" effective 2/6/19 revealed at 2.2.8 "Verbal Orders or Telephonic Orders...All verbal or telephonic orders must be authenticated within forty eight (48) hours..."

Patient #7
Review on 11/8/19 of Patient #7's medical record revealed that several dialysis orders that were written in the medical record had not been signed. These dates are as follows: 10/26/19 at 6:30 a.m., 10/26/19 at 8:00 a.m., 10/29/09 with no time associated with it, 10/31/19 at 6:47 p.m., 11/3/19 at 12:15 p.m. and 11/5/19 at 11:40 a.m. that were not signed by the MD as of 11/8/19 approximately 1:00 p.m.

Interview on 11/8/19 with Staff A (Registered Nurse) and Staff B (Chief Nursing Officer) at approximately 1:00 p.m. confirmed these above telephone orders had not been signed by the MD.

Based on observation, facility policy, and interview, it was determined the hospital failed to adhere to professional standards of cleaning and disinfecting 3 of 5 point of care glucose meters.

Findings include:

Observation on 11/6/19 on the "North" hallway at approximately 9:00 a.m. revealed 1of 2 Accu-chek Inform II blood glucose meters (BGM) had a brownish-red substance on the back side of the meter.

Interview with Staff B (Chief Nursing Officer) confirmed this finding at 9:15 a.m. Staff B revealed that the glucose meter is used for multiple patients. Staff B was able to clean the substance off of the BGM with a bleach wipe during finding.

Observation on 11/7/19 on the "East" hallway at approximately 10:30 a.m. revealed 1 of 1 Accu-chek Inform II BGM had a brownish-red substance on the back side of the meter.

Interview with Staff E (Rehabilitation Nurse Technician) confirmed this finding. Staff E revealed the glucose meter is used for multiple patients. Staff E was able to clean the substance off of the BGM with a bleach wipe during finding.

Observation on 11/8/19 on the "Main" nursing station at approximately 9:45 a.m. revealed 1 of 2 Accu-chek Inform II BGM's had a brownish-red substance on the back side of the meter.

Interview with Staff B (Chief Nursing Officer) confirmed this finding at 10:00 a.m. Staff B revealed the glucose meter is used for multiple patients. Staff B indicated that it could be the new lotion that staff uses. The lotion bottle had the same color substance on the tip of the bottle which was nearby the BGM on the "East" hallway and the "Main" nursing station.

Review on 11/8/19 of the facility policy titled "Disinfection and Sterilization" with an effective date of 5/7/19 states "All shared equipment that touches patients must be disinfected between patient contacts."

Review on 11/18/19 of the Accu-chek Inform II BGM Quick Reference Guide under "Important Safety Information" states "For multiple patient use, the meter should be cleaned and disinfected between each patient use following standard precautions and the cleaning and disinfecting procedures found in the [BGM name omitted] Operators's Manual."

Review on 11/15/19 of the CDC website for Infection Prevention during Blood Glucose Monitoring and Insulin Administration (https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html) revealed "Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared."