HospitalInspections.org

Based on interview, record review and policy and procedure review the facility failed to supervise the nursing care for each patient on an ongoing basis within professional standards of practice and hospital policy for 1 out of 3 patients reviewed for a change in condition. ( Patient #4)

Findings include:

Record review documented that Patient #4 was admitted to the facility with the following diagnoses: NSTEMI (non ST elevation myocardial infarction), Right sided chest pain, nusea and vomiting, anemia, Coronary artery disease, hypertension and hyperlipidemia.

Review of the physician history and physical dated 2/26/2023 reads, "discussed advanced directives with patient and she is a full code."


Review of the" UF Emergency medicine- Emergency intervention Note" dated 2/26/2023 at 2258 ( 10:58 PM) reads, " [Patient #4's name] is a 75 year old female currently admitted to the [Physician's name] awaiting inpatient placement from the ED (emergency department), the working diagnosis clinical impression is NSTEMI ,the ED staff was requested to urgently assess this patient due to bradycardia, hypotension, respiratory failure and unresponsiveness. ED rapid assessment and key findings: General: pale unresponsive, airway breathing circulation: GCS 3 without spontaneous respirations, heart bradycardic and neuro GCS ( Glasgow coma scale) 3 .... ED decision making: patient is a 75 year old female presenting in ED for airway management when i arrived patient was unresponsive hypotensive. I intubated patient ,started patient on levophed as well as epinephrine. Outcome and disposition: Results of emergent intervention: Patient blood pressure stabilized. Airway was protected."

Review of the document titled " Code blue/respiratory arrest flowsheet" Page #3 reads, " 2302 ( 11:02 PM): rhythm blank pulse compressions Resp ( respirations) assisted Epinephrine 1 amp response/treatment: CPR in progress, 2304(11:04 PM) rhythm documented 0, 2305(11:05 PM): rhythm blank, pulse compressions, Resp: assisted , epinephrine 1 amp,2306(11:06 PM) 1 amp sodium bicarbonate, 2307(11:07 PM): rhythm PEA( pulseless electrical activity), 2308( 11:08 PM): 1 amp epinephrine, 2309( 11:09 PM) : rhythm SB ( sinus bradycardia) pulse compressions, resp assisted response/treatment: brief pulse then lost, CPR ( cardiopulmonary resuscitation) resumed, 2310( 11:10 PM) : 3 amp epinephrine, 2311( 11:11 PM): rhythm: NSR( normal sinus rhtym) pulse spontaneous Resp assisted B/P 123/59 Response/treatment: sinus rhythm at 70 and 2316( 11:16 PM) : Levo ( levophed) increased to 1."

Review of the medical record there is no further documentation in the clinical record from nursing.
Review of the medical record there are no nursing notes within the medical record documenting post code and intervention assessments or vital signs from 11:16 PM until Patient #4's death.
Review of the medical record there is no third code blue form documentation.
Review of the medical record there are no telemetry or cardiac monitor strips in the medical record.
Review of the medical record there is no documentation in the nursing progress notes related to patient death and time of death.

During a telephone interview on 9/15/2023 at 3:39 PM Staff A, Registered Nurse ( RN) stated, " I really have no idea what time that was or what time they pronounced her ( Patient #4) dead. It was not my responsibility to do any of that because I wasn't there. The cath lab nurses should have done that. They were with her not me. I should have written a note about her drips and done another assessment after she coded, but a lot was going on so I didn't. I did not do any other documentation on her. We should document that we have titrated drips, we should have pulled telemetry strips for the chart. Really the patient should have been in ICU ( intensive care unit) not the ED. That's what really should have happened. We had enough staff but really that's where she belonged, ever since the time she got intubated. I did not do any assessment of her cardiac, respiratory or neurologic status after her code. It was an acute change, yes we should reassess a patient after changes but really I was busy. "

During a telephone interview with the ED Director on 9/15/2023 at 4:10 PM stated, " We should follow policy and procedure for reassessing patients. I did not find any reassessments of patient ( Patient #4). I did not find additional code blue documentation. We should have documentation of all things that we do. Charge nurses do not document assessments for the primary nurse assigned to an ED patient. They will sometimes document on the , but they are not responsible for any other documentation. We should have titration of drips documented, we should reassess patients, do a focused assessment with changes in condition. We should have telemetry strips in documentation, I couldn't say if the patient was reassessed after the codes because it is not documented. We do not have documentation of blood pressures in the chart, we should. It is my expectation that assessments are completed and that we document in the patients record."


Review of the policy and procedure titled, "Daily patient assessment, intervention, reassessment and plan of care using electronic documentation" last revision date 5/9/2023 reads, " Standard/purpose: The nurse will complete the daily assessments/ reassessments(head to toe) plan of care at least once each shift. Additional periodic assessments and reassessments are to be done as the patient's condition warrants. The scope and intensity of any further reassessments are based on patients conditions i.e. response to care, treatment services, significant change in condition and patients plan of care."


Review of the policy and procedure titled " Provision and documentation of Nursing Care" last revision date of 3/10/2023 reads, " Standard/purpose: Nursing documentation in the medical record is maintained in a systematic, hospital approved manner. Information about the patient, his/her illness and his/her progress is gathered and documented reflecting the patient's plan of care and care that is given. II. The RN is accountable for all required documentation as outlined in theis policy by the completion of each shift or as otherwise specified in this policy. V. Implementatin and ongoing assessment/monitoring: a. nursing interventions: i. Patient care is provided in accordance with physician orders, the plan of care, and nursing interventions. B. Any system assessment that does not meet WDL ( within defined limits) criteria must be reviewed, include documentation for areas with exceptions. D. Ongoing documentation: 1. The RN is responsible for completing and documenting each physical assessment.

Based on interview, record review and policy and procedure review the facility failed to document nursing notes and assessments, vital signs and code blue documentation according to professional standards of practice and hospital policy for 1 out of 3 patients reviewed for a change in condition and code blue documentation. ( Patient #4)

Findings include:

Record review documented that Patient #4 was admitted to the facility with the following diagnoses: NSTEMI (non ST elevation myocardial infarction), Right sided chest pain, nusea and vomiting, anemia, Coronary artery disease, hypertension and hyperlipidemia.

Review of the physician history and physical dated 2/26/2023 reads, "discussed advanced directives with patient and she is a full code."


Review of the" UF Emergency medicine- Emergency intervention Note" dated 2/26/2023 at 2258 ( 10:58 PM) reads, " [Patient #4's name] is a 75 year old female currently admitted to the [Physician's name] awaiting inpatient placement from the ED (emergency department), the working diagnosis clinical impression is NSTEMI ,the ED staff was requested to urgently assess this patient due to bradycardia, hypotension, respiratory failure and unresponsiveness. ED rapid assessment and key findings: General: pale unresponsive, airway breathing circulation: GCS 3 without spontaneous respirations, heart bradycardic and neuro GCS ( Glasgow coma scale) 3 .... ED decision making: patient is a 75 year old female presenting in ED for airway management when i arrived patient was unresponsive hypotensive. I intubated patient ,started patient on levophed as well as epinephrine. Outcome and disposition: Results of emergent intervention: Patient blood pressure stabilized. Airway was protected."

Review of the document titled " Code blue/respiratory arrest flowsheet" Page #3 reads, " 2302 ( 11:02 PM): rhythm blank pulse compressions Resp ( respirations) assisted Epinephrine 1 amp response/treatment: CPR in progress, 2304(11:04 PM) rhythm documented 0, 2305(11:05 PM): rhythm blank, pulse compressions, Resp: assisted , epinephrine 1 amp,2306(11:06 PM) 1 amp sodium bicarbonate, 2307(11:07 PM): rhythm PEA( pulseless electrical activity), 2308( 11:08 PM): 1 amp epinephrine, 2309( 11:09 PM) : rhythm SB ( sinus bradycardia) pulse compressions, resp assisted response/treatment: brief pulse then lost, CPR ( cardiopulmonary resuscitation) resumed, 2310( 11:10 PM) : 3 amp epinephrine, 2311( 11:11 PM): rhythm: NSR( normal sinus rhtym) pulse spontaneous Resp assisted B/P 123/59 Response/treatment: sinus rhythm at 70 and 2316( 11:16 PM) : Levo ( levophed) increased to 1."

Review of the medical record there is no further documentation in the clinical record from nursing.
Review of the medical record there are no nursing notes within the medical record documenting post code and intervention assessments or vital signs from 11:16 PM until Patient #4's death.
Review of the medical record there is no third code blue form documentation.
Review of the medical record there are no telemetry or cardiac monitor strips in the medical record.
Review of the medical record there is no documentation in the nursing progress notes related to patient death and time of death.

During a telephone interview on 9/15/2023 at 3:39 PM Staff A, Registered Nurse ( RN) stated, " I really have no idea what time that was or what time they pronounced her ( Patient #4) dead. It was not my responsibility to do any of that because I wasn't there. The cath lab nurses should have done that. They were with her not me. I should have written a note about her drips and done another assessment after she coded, but a lot was going on so I didn't. I did not do any other documentation on her. We should document that we have titrated drips, we should have pulled telemetry strips for the chart. Really the patient should have been in ICU ( intensive care unit) not the ED. That's what really should have happened. We had enough staff but really that's where she belonged, ever since the time she got intubated. I did not do any assessment of her cardiac, respiratory or neurologic status after her code. It was an acute change, yes we should reassess a patient after changes but really I was busy. "

During a telephone interview with the ED Director on 9/15/2023 at 4:10 PM stated, " We should follow policy and procedure for reassessing patients. I did not find any reassessments of patient ( Patient #4). I did not find additional code blue documentation. We should have documentation of all things that we do. Charge nurses do not document assessments for the primary nurse assigned to an ED patient. They will sometimes document on the , but they are not responsible for any other documentation. We should have titration of drips documented, we should reassess patients, do a focused assessment with changes in condition. We should have telemetry strips in documentation, I couldn't say if the patient was reassessed after the codes because it is not documented. We do not have documentation of blood pressures in the chart, we should. It is my expectation that assessments are completed and that we document in the patients record."


Review of the policy and procedure titled, "Daily patient assessment, intervention, reassessment and plan of care using electronic documentation" last revision date 5/9/2023 reads, " Standard/purpose: The nurse will complete the daily assessments/ reassessments(head to toe) plan of care at least once each shift. Additional periodic assessments and reassessments are to be done as the patient's condition warrants. The scope and intensity of any further reassessments are based on patients conditions i.e. response to care, treatment services, significant change in condition and patients plan of care."


Review of the policy and procedure titled " Provision and documentation of Nursing Care" last revision date of 3/10/2023 reads, " Standard/purpose: Nursing documentation in the medical record is maintained in a systematic, hospital approved manner. Information about the patient, his/her illness and his/her progress is gathered and documented reflecting the patient's plan of care and care that is given. II. The RN is accountable for all required documentation as outlined in theis policy by the completion of each shift or as otherwise specified in this policy. V. Implementatin and ongoing assessment/monitoring: a. nursing interventions: i. Patient care is provided in accordance with physician orders, the plan of care, and nursing interventions. B. Any system assessment that does not meet WDL ( within defined limits) criteria must be reviewed, include documentation for areas with exceptions. D. Ongoing documentation: 1. The RN is responsible for completing and documenting each physical assessment.