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Based on findings from document review and interview, the facility's quality assurance performance improvement (QAPI) program lacked documentation of a thorough investigation of an adverse event and implementation and monitoring of corrective actions. This could lead to other similar adverse events.

Findings include:

See citation A385 regarding this adverse event.

-- Review of the hospital investigation, dated 5/5/2016, revealed the hospital identified risk reduction strategies and measures of effectiveness, however, the following were not implemented:
1. a written provider handoff tool had not been developed
2. a critical value nursing log (to monitor significant changes in testing results) had not been monitored for compliance
3. Nursing shift to shift report (known as the "Situation, Background, Assessment, and Recommendation (SBAR)"), had not been changed to reflect diagnostic testing and had not been monitored for compliance

The investigation did not identify that nursing did not follow the chain of command or activate the Rapid Response Team (RRT) (a team of clinicians who respond to a patient's bedside to provide clinical expertise, advanced assessment skills, support for the bedside nurse and aids in the facilitation of a more timely transfer to a higher level of care when needed) in response to the patient's worsening condition.

-- During interview of Staff A (Director of Quality Improvement) on 9/23/16 at 8:45 am, he/she acknowledged the above findings.

Based on findings from medical record (MR) review and interview, timely physician evaluation of a patient (Patient #1), with a change in condition was not done. This type of lapse could negatively impact patient care.

Findings include:

-- Per MR review, on 4/26/16 at 3:52 pm, Patient #1 was admitted to an inpatient unit after evaluation in the emergency department (ED) for shortness of breath (SOB). He had been discharged from the facility on 4/18/16 (8 days earlier) after being treated for a pulmonary embolism (PE) and was on Xarelto (blood thinner) at home.

On 4/27/16 at 7:15 am Patient #1 complained to nursing staff of abdominal pain and SOB. Nursing staff paged the hospitalist at 7:30 am regarding Patient #1's complaints. Nursing staff made multiple contacts with the hospitalist (Staff B) throughout the day, however, Staff B did not evaluate the patient until 4:00 pm (8 hours later.) Upon evaluation, the CT scan was ordered. The CT scan was completed at 6:45 pm. There was no evidence that the positive findings were communicated to the hospitalist.

On 4/28/16 at 6:05 am Patient #1 became unresponsive. A code was initiated. Patient #1 expired at 6:40 am.

-- During interview of Staff C, (Director of Hospitalists) on 9/22/16 at 10:00 am, he/she revealed the expectation for a hospitalist to respond for a bedside evaluation for a change in a patient's condition identified by nursing is within 30 minutes. Additionally, if a hospitalist is unable to see a patient they could notify him/her for assistance.

-- During interview of Staff D, (Registered Nurse) on 9/22/16 at 2:05 pm, he/she revealed Staff B had been called a number of times regarding the patient's change in condition (i.e., increasing SOB, abdominal pain, abdominal distention). However, Staff B did not evaluate the patient until 4/27/16 at 4:00 pm.

Based on findings from document review, medical record (MR) review and interview, nursing staff failed to act timely to address a patient's (Patient #1) changing condition. Specifically, nursing did not follow the facility's chain of command to ensure a timely evaluation of Patient #1 by a provider or activate the Rapid Response Team (RRT) (a team of clinicians who respond to a patient's bedside to provide clinical expertise, advanced assessment skills, support for the bedside nurse and aids in the facilitation of a more timely transfer to a higher level of care when needed) to provide assistance. These failures could potentially lead to patient harm.

Findings include:

-- Review of the facility's policy and procedure (P&P) titled "Chain of Command," dated 8/2016, indicated in the event a patient's condition requires physician intervention the Registered Nurse (RN) shall notify the attending physician or his designee. If the provider does not respond within the appropriate time frame (maximum 30 minutes) even after repeated calls, the RN will proceed to the following steps:
1. Notify Nurse Manager/Supervisor
2. The Nurse Manager/Supervisor (or designee) shall:
a. determine the urgency of the required response and notify either the emergency department physician directly, call for a RRT or call a Code Blue for a critical situation.
b. In an urgent situation call the Physician Department Chair and/or Department Medical Director.
3. If unresolved at 2.b., the Nurse Manager/Supervisor (or designee) shall notify the President of the Medical Staff and the Administrator on call in his/her absence.
4. The RN must document all of the above steps taken, and complete an incident report.

-- Review of the facility's P&P titled "Rapid Response Team," last revised 2/2015, indicated a Rapid Response Team (RRT)'s purpose is to improve recognition and response to changes in a patient's condition. Activation of the RRT can be done by nursing staff or patient's family members.

-- Per MR review, on 4/26/16 at 3:52 pm, Patient #1 was admitted to an inpatient unit after evaluation in the emergency department (ED) for shortness of breath (SOB). He had been discharged from the facility on 4/18/16 (8 days earlier) after being treated for a pulmonary embolism (PE) and was on Xarelto (blood thinner) at home.

On 4/27/16, throughout the day, Patient #1 had multiple complaints (e.g., SOB, chest pain, abdominal pain) and nursing documented significant change in Patient #1's condition. Nursing staff made multiple contacts with the Hospitalist (Staff B) however, he/she did not evaluate the patient until 4:00 pm.

-- During interview of Staff D, (Registered Nurse) on 9/22/16 at 2:05 pm, he/she revealed Staff B had been called a number of times during the day regarding the patient's change in condition (i.e., increasing SOB, abdominal pain, abdominal distention). Additionally, he/she had discussed his/her concerns with the changes in the patient's condition with Staff E (Charge Nurse) multiple times during the day but the RRT was not activated.

-- During interview of Staff E, (Charge Nurse) on 9/23/16 at 9:45 am, he/she revealed Staff B was alerted during the morning doctors meeting on 4/27/16 at 9:45 am, something wasn't right about the patient. The patient was complaining of SOB, epigastric and abdominal pain. His hemoglobin (HGB) and hematocrit (HCT) had dropped since admission to 8.4 (range=12.8-17.0) and 26.9 (range=38.0-48.0) respectively. He/she expressed concern over a possible new PE and questioned if a CT scan should be ordered. Staff B stated the patient was very anxious, already on Xarelto, and he/she would see him. Additionally, he/she revealed Patient #1's condition was discussed a number of times during the day with Staff D (Registered Nurse), both were concerned over changes in the patient's condition.

Nursing staff did not follow the chain of command or initiate a rapid response even though Patient #1's condition was worsening.

On 4/28/16 at 6:05 am, Patient #1 became unresponsive. A code was initiated. Patient #1 expired at 6:40 am.

Based on findings from document review, observation, medical record (MR) review and interview in 1 of 6 MRs (Patient #2), fall risk interventions and skin breakdown prevention interventions were not documented in the electronic health record (EHR).

Findings include:

-- Review of the facility's policy and procedure (P&P) titled "Falls Management Program," dated 11/2014, indicated every patient should be assessed for risk to fall and ability to transfer upon admission to a nursing unit, transfer to another unit ... Patients will be assessed for risk to fall according to the Hendrich II Fall Risk Model. Patients will be identified as at risk by scoring a 5 or greater. Document fall prevention strategies on the "document interventions" section in the EHR. Document implementation of fall prevention strategies.

-- Per observation on 9/23/16 at 9:00 am of Patient #2, fall prevention interventions were in place e.g., a bed/chair alarm and yellow blanket placed on patient's bed as a visual indicator.

-- Per review of Patient # 2's MR, she was identified as a fall risk with a score of "9" on the Hendrich II Fall Risk Model. However, her MR lacked documentation of implementation of these interventions from 9/17/16 to 9/22/16. During interview of Staff F, (Registered Nurse), on 9/23/16 at 9:30 am, it was found when a patient is transferred from one unit to another, (in this case Intensive Care Unit to Medical/Surgical Unit) the fall interventions were not transferring over in the EHR.

-- Review of the facility's P&P titled "Skin Care," dated 4/2014, indicated every patient is assessed for potential skin risk upon admission, transfer to another unit, daily and change in patient condition using the Braden scale. A score of 18 or less is considered at risk and should result in the in the pressure ulcer prevention intervention being added to their care plan automatically. This intervention should be completed every shift. Pressure ulcer prevention intervention is automatically added to the care plan based on the Braden risk assessment and edited/dated to reflect care instructions and documented daily. Interventions are to be documented every shift.

-- Per observation on 9/23/16 at 9:00 am of Patient #2, skin breakdown prevention interventions were in place e.g., turning and positioning every 2 hours, heel elevation and alternating pressure mattress pump.

-- Per review of Patient #2's MR, she was identified as a high skin risk with scores of "11" and "13"on the Braden scale. However, her MR lacked documentation of implementation of these interventions from 9/17/16 to 9/22/16. During interview of Staff F on 9/23/16 at 9:30 am, it was found that when a patient changes from Medical/Surgical status to Swing Bed status these skin breakdown prevention interventions were not transferring over in the EHR.
Nursing staff was not aware the fall and skin interventions did not automatically carry over in the EHR (e.g., when a patient was transferred from one unit to another and/or a patient's status changed from inpatient to swing bed status) until identified during this survey.

Based on findings from observation, interview and document review, the facility did not have a consistent process for cleaning a patient's skin prior to skin puncture with a lancet (for blood sugar monitoring). This practice could lead to potential patient infection.

Findings include:

-- Per observation on 9/22/16 at 11:30 am, Staff G, (Registered Nurse), cleansed Patient #3's finger with a wet paper towel and dried the finger prior to puncturing with a lancet for a glucose fingerstick test. During interview Staff G indicated this was hospital policy and procedure (P&P).

-- Per observation on 9/22/16 at 11:45 am, Staff H, (Registered Nurse) cleansed Patient #4's finger with soap and water on a paper towel and dried the finger prior to puncturing with a lancet for a glucose fingerstick test. During interview Staff H indicated this was hospital P&P.

-- Review of the manufacturer's instructions for the Accu-Chek Inform II (the blood glucose monitoring system device), dated 2013, indicated prior to testing, ask the patient to wash hands with soap and water, then let dry. If patient is unable to wash hands, wipe with alcohol, then let dry.

-- Review of the facility's P&P titled "Blood Glucose and Glucometer Management, Maintenance and Quality Control," dated 7/2014, indicated to cleanse the puncture site with a damp cloth/paper towel. Allow the site to dry completely before puncturing.

-- Review of the "Accu-check Inform II System Glucose Meter Competency 2016," (a clinical checklist used for staff orientation and annual competency), dated 6/2016, indicated to cleanse the puncture site with soap and water and allow to dry.

-- Review of the "Blood Glucose Monitoring," (clinical skills information available to staff at all times), undated, indicated to cleanse a puncture site with an antiseptic swab and allow it to dry completely.

-- During interview of Staff I (Infection Preventionist) on 9/23/16 at 9:00 am, he/she was not aware of the practice of using a wet paper towel or using soap and water to cleanse a patient's skin prior to puncture. Staff should use an alcohol prep pad, it is more readily available than soap and water.

-- During interview of Staff A (Director of Quality Improvement) on 9/23/16 at 2:15 pm, he/she acknowledged the above findings.