HospitalInspections.org

Based on policy review, medical record review, and interview, the hospital failed to assess and monitor 1 of 3 (Patient #1) sampled patients following surgery.

The findings included:

1. Review of the hospital policy, "Vital Signs Policy," revealed, " ...PURPOSE: To monitor patient's vital signs, which include temperature, pulse, respirations, blood pressure, pain score, and MEWS [Modified Early Warning Score with a primary purpose to prevent delay in intervention or transfer of critically ill patients] on a routine basis ...PROCEDURE/SPECIAL INSTRUCTIONS ...Frequency of vital signs will be determined by unit requirements and the condition of the patient, physician orders or at least once per shift ...Post Procedure patient vital signs will be obtained every 30 minutes for 2 hours or based on Physician orders ..."

2. Medical record review for Patient #1 revealed an admission date of 8/2/2021 with diagnoses which included Hypertension, Diabetes, Atrial Fibrillation, Coronary Artery Disease, Chronic Pain, and Gastroesophageal Reflux Disease. Patient #1 had receeived hospice care but revoked hospice election for hospitalization and surgical intervention.

Patient #1 had a fall on 8/2/2021 and sustained a left intertrochanteric femur fracture. Patient #1 underwent a left hip intertrochanteric fracture open reduction internal fixation with intramedullary nail on 8/3/2021 at 4:00 PM.

Patient #1 tolerated the procedure and was taken to the post-anesthesia care unit (PACU) on 8/3/2021 at approximately 5:00 PM.
Patient #1's vital signs at 5:00 PM were: temperature 97.8 degrees Fahrenheit, heart rate 65, blood pressure 141/46, and oxygen saturation level 100% on 8 liters of oxygen via simple facemask.
Patient #1's vital signs at 5:15 PM were: heart rate 63, blood pressure 148/50, and oxygen saturation level 100% on 6 liters of oxygen via simple facemask.
Patient #1's vital signs at 5:30 PM were: heart rate 65, blood pressure 134/50, and oxygen saturation level 94% on 2 liters of oxygen via nasal cannula.
Patient #1 was transferred from PACU to a medical/surgical floor on 8/3/2021 at 5:50 PM.

A physician's order dated 8/3/2021 at 3:49 PM revealed, " ...Post op Adult ...Vital Signs ...per unit policy ..."

Patient #1's blood pressure was taken on 8/3/2021 at 6:34 PM and was 134/50.

Patient #1's vital signs were taken on 8/3/2021 at 8:00 PM and were: temperature 98.3 degrees Fahrenheit, heart rate 70, blood pressure 112/41, and oxygen saturation level 95% on 2 liters via nasal cannula. There was not a full set of vital signs documented for Patient #1 from the time of arrival on the medical/surgical floor (8/3/2021 at 5:50 PM) during the day shift (7:00 AM-7:00 PM). Patient #1 was on the medical/surgical floor 2 hours and 10 minutes before a full set of vital signs were taken.

Patient #1's heart rate was documented on 8/3/2021 at 11:22 PM as 68.

Patient #1's heart rate was documented on 8/4/2021 at 2:40 AM as 52.

Patient #1's heart rate was documented on 8/4/2021 at 4:29 AM as 50.

Patient #1's vital signs were taken on 8/4/2021 at 7:00 AM and were: heart rate 43, blood pressure 97/42, and oxygen saturation level 93% (no documentation of oxygen therapy received, and no temperature was documented). There was not a full set of vital signs documented for Patient #1 from 8/3/2021 at 8:00 PM to 8/4/2021 at 7:00 AM (11 hours). There was no documentation for Patient #1 for MEWS according to hospital policy after arrival on the medical/surgical floor.

The flowsheet dated 8/4/2021 at 10:03 AM revealed, " ...Rapid response (a team of providers called to the bedside to immediately assess and treat the patient with the goal of preventing intensive care unit transfer, cardiac arrest, or death) call followed by code blue (emergency code used to describe the critical status of a patient)..."

A nursing note dated 8/4/2021 at 10:41 AM revealed, "...Pt family called for help. Rapid response was called. BP [blood pressure] was 70/30, HR [heart rate] 48, 96% O2 [oxygen]. Pt was placed in trandelenburg [sic] at 1007 [10:07 AM]. At 1011 [10:11 AM] BP was 67/27, HR 46, 95% O2. Blood sugar was checked. Level was 188. Vitals were retaken. 72/39 [blood pressure], HR 39, 93% O2 ..."

The Discharge Summary by Physician #1 dated 8/4/2021 at 10:55 AM revealed, " ...Given the patient's age and comorbidities, the patient was high risk for cardiac complications from surgery ...Immediately postoperatively, per family, the patient was alert and oriented, having regular conversations. The patient's [family member] arrived at the hospital this morning to visit her, [sic] and noticed that the patient was unresponsive. She was breathing and had a strong pulse, however, she notified nursing out of concern for the change in [Patient #1]'s mental status ...She was noted upon evaluation to be hypotensive, with a blood pressure of 70/30, and bradycardic with a heart rate of 45. Oxygen saturations were 93 to 96% on 2 L [liters] nasal cannula. Blood glucose levels 188. It is unclear how long the patient was in this state ...The patient initially showed some improvement with transcutaneous pacing, however, patient did not have a palpable pulse ...Echocardiogram confirmed lack of cardiac activity. She was pronounced dead at 10:50 AM."

3. In a telephone interview on 2/9/2022 at 10:22 AM, Family Member #1 stated she came to Patient #1's room on the morning of 8/4/2021 and found the patient unresponsive with skin cold to the touch. Family Member #1 stated she saw Patient #1 on 8/3/2021 after surgery, and the patient was awake and alert with good vital signs. Family Member #1 stated she asked staff about Patient #1's vital signs, but staff could not tell her what the vital signs were. Family Member #1 stated she was told Patient #1 was bradycardic (heart rate below 60) by the staff, but they could not tell her what the vitals were or when they were taken last.

In an interview on 2/9/2022 at 11:00 AM, the Chief Nursing Officer (CNO) stated a post-operative patient should have a full set of vital signs taken every 30 minutes for 2 hours after the patient arrived on the floor from PACU. The CNO stated she was unsure what the vital signs requirements were for the medical/surgical unit Patient #1 was transferred to.

In a telephone interview on 2/10/2022 at 8:06 AM, Nurse #1 confirmed she provided care for Patient #1 on the night shift (7:00 PM-7:00 AM) on 8/3/2021. Nurse #1 stated nursing staff was supposed to get vital signs on post-operative patients every hour for 3 hours when patients arrived on the floor from PACU. Nurse #1 stated nursing staff was to get vital signs on each patient at least every 4 hours. Nurse #1 stated getting vital signs every 4 hours was standard for the medical/surgical unit where Patient #1 was transferred to.

In a telephone interview on 2/10/2022 at 8:58 AM, Nurse #2 confirmed she provided care for Patient #1 on the day shift (7:00 AM-7:00 PM) on 8/3/2021 when Patient #1 arrived on the floor from PACU. Nurse #2 stated nursing staff should get vital signs on each patient every 4 hours for the medical/surgical unit. Nurse #2 stated nursing staff should get vital signs on patient transferred from PACU when the patient arrived on the floor.

In a telephone interview on 2/10/2022 at 9:19 AM, Nurse #3 confirmed she provided care for Patient #1 on the day shift (7:00 AM-7:00 PM) on 8/4/2021. Nurse #3 stated she got report from the night shift nurse (Nurse #1) and was told that Patient #1 had been drowsy since Nurse #1 had given the patient pain medication (Nurse #1 administered Dilaudid 1 milligram intravenous push on 8/3/2021 at 8:22 PM). Nurse #3 stated she had gotten vital signs on Patient #1 and went to call the physician, but the family came into the room and pushed the button to call for a Rapid Response (vital signs were taken on 8/4/2021 at 7:00 AM, and the Rapid Response was called on 8/4/2021 at 10:03 AM).

Based on policy review, medical record review, and interview, the hospital failed to notify a physician for changes in a patient's vital signs following surgery for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital policy, "Vital Signs Policy," revealed, "...PURPOSE: To monitor patient's vital signs, which include temperature, pulse, respirations, blood pressure, pain score, and MEWS [Modified Early Warning System] on a routine basis...PROCEDURE/SPECIAL INSTRUCTIONS...Frequency of vital signs will be determined by unit requirements and the condition of the patient, physician orders or at least once per shift...Post Procedure patient vital signs will be obtained every 30 minutes for 2 hours or based on Physician orders..."

2. Medical record review for Patient #1 revealed an admission date of 8/2/2021 with diagnoses which included Hypertension, Diabetes, Atrial Fibrillation, Coronary Artery Disease, Chronic Pain, and Gastroesophageal Reflux Disease. Patient #1 had been on hospice but revoked hospice election for hospitalization and surgical intervention.

Patient #1 had a fall on 8/2/2021 and sustained a fractured femur which required surgery to repair the fracture on 8/3/2021 at 4:00 PM.

Patient #1 tolerated the procedure and was taken to the post-anesthesia care unit (PACU) on 8/3/2021 at approximately 5:00 PM. Patient #1's vital signs at 5:00 PM were: temperature 97.8 degrees Fahrenheit, heart rate 65, blood pressure 141/46, and oxygen saturation level 100% on 8 liters of oxygen via simple facemask. Patient #1's vital signs at 5:15 PM were: heart rate 63, blood pressure 148/50, and oxygen saturation level 100% on 6 liters of oxygen via simple facemask. Patient #1's vital signs at 5:30 PM were: heart rate 65, blood pressure 134/50, and oxygen saturation level 94% on 2 liters of oxygen via nasal cannula. Patient #1 was transferred from PACU to a medical/surgical floor on 8/3/2021 at 5:50 PM.

A physician's order dated 8/3/2021 at 3:49 PM revealed, "...Post op Adult...Vital Signs...per unit policy..."

Patient #1's blood pressure was taken on 8/3/2021 at 6:34 PM and was 134/50.

Patient #1's vital signs were taken on 8/3/2021 at 8:00 PM and were: temperature 98.3 degrees Fahrenheit, heart rate 70, blood pressure 112/41, and oxygen saturation level 95% on 2 liters via nasal cannula.

Patient #1's heart rate was documented on 8/3/2021 at 11:22 PM as 68.

Patient #1's heart rate was documented on 8/4/2021 at 2:40 AM as 52.

Patient #1's heart rate was documented on 8/4/2021 at 4:29 AM as 50.

Patient #1's vital signs were taken on 8/4/2021 at 7:00 AM and were: heart rate 43, blood pressure 97/42, and oxygen saturation level 93% (no documentation of oxygen therapy received, and no temperature was documented).

Patient #1's heart rate was documented on 8/4/2021 at 7:59 AM as 42.

A PostOp Note by Anesthesiologist #1 dated 8/4/2021 at 9:00 AM revealed, "...Pain Scale: 0...PostOp Observations: None...Satisfied With Anesthesia Care: Yes...Comments: Pt [patient] somnolent..."

Patient #1's heart rate was documented on 8/4/2021 at 9:09 AM as 42.

Patient #1's heart rate was documented on 8/4/2021 at 9:10 AM as 45.

Patient #1's blood pressure was documented on 8/4/2021 at 10:00 AM as 72/39.

Patient #1's heart rate was documented on 8/4/2021 at 10:03 AM as 47.

The flowsheet dated 8/4/2021 at 10:03 AM revealed, "...Rapid response (a team of providers called to the bedside to immediately assess and treat the patient with the goal of preventing intensive care unit transfer, cardiac arrest, or death) call followed by code blue (emergency code used to describe the critical status of a patient)..."

A nursing note dated 8/4/2021 at 10:41 AM revealed, "...Pt family called for help. Rapid response was called. BP [blood pressure] was 70/30, HR [heart rate] 48. 96% O2 [oxygen]. Pt was placed in trandelenburg [sic] at 1007 [10:07 AM]. At 1011 [10:11 AM] BP was 67/27, HR 46, 95% O2. Blood sugar was checked. Level was 188. Vitals were retaken. 72/39 [blood pressure], HR 39, 93% O2..."

The Discharge Summary by Physician #1 dated 8/4/2021 at 10:55 AM revealed, "...Given the patient's age and comorbidities, the patient was high risk for cardiac complications from surgery...Immediately postoperatively, per family, the patient was alert and oriented, having regular conversations. The patient's [family member] arrived at the hospital this morning to visit her, [sic] and noticed that the patient was unresponsive. She was breathing and had a strong pulse, however, she notified nursing out of concern for the change in [Patient #1]'s mental status...She was noted upon evaluation to be hypotensive, with a blood pressure of 70/30, and bradycardic with a heart rate of 45. Oxygen saturations were 93 to 96% on 2 L [liters] nasal cannula. Blood glucose levels 188. It is unclear how long the patient was in this state...The patient initially showed some improvement with transcutaneous pacing, however, patient did not have a palpable pulse...Echocardiogram confirmed lack of cardiac activity. She was pronounced dead at 10:50 AM."

A progress note by Physician #2 dated 8/4/2021 at 10:56 AM revealed, "...Patient seen on rounds today. Not oriented, moaning in bed but moving grossly...Vitals & [and] Measurements [no vital signs documented]...Patient doing well..."

There was no documentation a physician had been notified about the change in Patient #1's vital signs by nursing staff until after the Rapid Response was called by Family Member #1 on 8/4/2021 at 10:03 AM.

3. In a telephone interview on 2/9/2022 at 10:22 AM, Family Member #1 stated she came to Patient #1's room on the morning of 8/4/2021 and found the patient unresponsive with skin cold to the touch. Family Member #1 stated she saw Patient #1 on 8/3/2021 after surgery, and the patient was awake and alert with good vital signs. Family Member #1 stated she asked staff about Patient #1's vital signs, but staff could not tell her what the vital signs were. Family Member #1 stated she was told Patient #1 was bradycardic by the staff, but they could not tell her what the vitals were or when they were taken last. Family Member #1 stated she hit the "Code Blue" button on the wall to call someone to help. Family Member #1 stated she was told that Physician #2 had seen Patient #1 earlier that morning, but Physician #2 was not told that there had been a change in the vital signs.

In an interview on 2/9/2022 at 11:00 AM, the Chief Nursing Officer (CNO) stated a post-operative patient should have a full set of vital signs taken every 30 minutes for 2 hours after the patient arrived on the floor from PACU. The CNO stated she was unsure what the vital signs requirements were for the medical/surgical unit Patient #1 was transferred to. The CNO stated nursing staff should notify the physician whenever the vital signs were outside the established parameters or any time there was a change in the vital signs from the patient's baseline.

In an interview on 2/9/2022 at 12:56 PM, Anesthesiologist #1 stated she saw Patient #1 on the morning of 8/4/2022. Anesthesiologist #1 stated she did not recall any issues or anything unusual going on with Patient #1 that morning. Anesthesiologist #1 stated nursing staff did not voice any concerns to her about Patient #1's vital signs.

In a telephone interview on 2/10/2022 at 8:06 AM, Nurse #1 confirmed she provided care for Patient #1 on the night shift (7:00 PM-7:00 AM) on 8/3/2021. Nurse #1 stated nursing staff was supposed to get vital signs on post-operative patients every hour for 3 hours when patients arrived on the floor from PACU. Nurse #1 stated nursing staff was to get vital signs on each patient at least every 4 hours. Nurse #1 stated getting vital signs every 4 hours was standard for the medical/surgical unit where Patient #1 was transferred to. Nurse #1 stated a nurse should notify the physician, either the hospitalist or surgeon, if a patient's vital signs deviated from their baseline.

In a telephone interview on 2/10/2022 at 8:58 AM, Nurse #2 confirmed she provided care for Patient #1 on the day shift (7:00 AM-7:00 PM) on 8/3/2021 when Patient #1 arrived on the floor from PACU. Nurse #2 stated nursing staff should get vital signs on each patient every 4 hours for the medical/surgical unit. Nurse #2 stated nursing staff should get vital signs on patient transferred from PACU when the patient arrived on the floor. Nurse #2 stated the nurse should notify the surgeon or hospitalist if the vital signs were outside the normal range.

In a telephone interview on 2/10/2022 at 9:19 AM, Nurse #3 confirmed she provided care for Patient #1 on the day shift (7:00 AM-7:00 PM) on 8/4/2021. Nurse #3 stated she got report from the night shift nurse (Nurse #1) and was told that Patient #1 had been drowsy since Nurse #1 had given the patient pain medication (Nurse #1 administered Dilaudid 1 milligram intravenous push on 8/3/2021 at 8:22 PM). Nurse #3 stated she asked the Anesthesiologist about Patient #1 being drowsy, and the Anesthesiologist told her it was perfectly normal and would wear off. Nurse #3 stated she had gotten vital signs on Patient #1 and went to call the physician, but the family came into the room and pushed the button to call for a Rapid Response (vital signs were taken on 8/4/2021 at 7:00 AM, and the Rapid Response was called on 8/4/2021 at 10:03 AM).

In a telephone interview on 2/10/2022 at 9:49 AM, Physician #2 stated he saw Patient #1 on 8/4/2021 at some time between 7:30 AM and 8:00 AM. Physician #2 stated he did not enter his note until he got back to his office and had been notified by the primary team that Patient #1 had passed away (Physician #2's note was entered on 8/4/2021 at 10:56 AM). Physician #2 stated Patient #1 was drowsy but awake when he saw the patient. Physician #2 stated nursing staff did not say anything to him about any concerns or problems with Patient #1's vital signs.