HospitalInspections.org

Bringing transparency to federal inspections

11500 BROOKSHIRE AVENUE

DOWNEY, CA 90241

RN SUPERVISION OF NURSING CARE

Tag No.: A0395

Based on observation, interview, and record review:
1. The facility failed to ensure all patients on telemetry (area of a hospital where special machines are used to help staff closely monitor patients, especially for changes in the rate and rhythm of the heart) unit had continuous observation of their cardiac monitoring creating potential for missing abnormal heart rate and rhythm causing decline and potential death.

2. The facilitiy failed to ensure patients on telemetry unit were assessed on an ongoing basis by the licensed nursing staff for two of 32 sampled patients (Patients 210 and 308). During transport outside the telemetry unit, Patients 210 and 308 were not provided with continuous cardiac monitoring as ordered and according to their policy and procedure. The registered nurses (RNs) were unaware of the specific criteria for assessment and documentation of telemetry patients prior to transport outside of the unit per policy and procedure. This failure created potential for missing abnormal heart rate and rhythm causing decline and potential death.

3. The facility failed to ensure Patient 201 on intensive care unit (ICU) was provided with diet as ordered for three days creating potential for not meeting the nutritional needs of the patient.

Findings:

1. Review of the job description dated 2016, indicated, the Monitor Technician continuously monitors cardiac rhythms at central nursing station.

The monitor technician is also responsible for:
* "performs clerical & receptionist duties, including processing and filing forms and medical records."
* "Answers telephone and coordinates telephone communication in and out of the nursing unit."
* "Pages physicians and transfers phone calls to the nursing staff."
* "Responsible for maintaining supplies at a level necessary for proper functioning of the nursing unit."
* "Covers the nursing station at all times, answering call lights and maintaining organization of the nursing station."
* "Contacts attending physician and families, if instructed to do so."
* "Maintains display (patient assignment) boards."
* "Other duties assigned."

During an observation and interview with monitor technician (MT 2) sitting in the DOU (direct observation unit) 2 east nursing station on 6/2/16 beginning at at 9 a.m. revealed, MT 2 monitors the patient's telemetry and also does "secretarial work." MT 2 stated, she scans physician orders to the pharmacy via the fax machine which is observed approximately 6 feet away from the monitors. She said she answers phone calls, answers the patient call light system, and she enters into the computer which was sitting on the desk to the right of the cardiac monitors. MT 2 said, "We don't constantly look at monitors, if it's not crazy hectic, we try to (watch monitors)."

During an observation on 6/2/16 at 9:44 a.m., MT 2 was working in clinical record charts and not observing the cardiac monitors.

During an observation on 6/2/16, at 9:55 a.m., MT 2 was on the phone and not observing the monitors.

During an interview on 6/2/16 at 10:40 a.m., the monitor technician (MT 1) who was sitting at the DOU 2 north nursing station, reported her duties included watching the cardiac monitor and ward clerk (secretarial) duties. MT 1 does paperwork, answers phones, and does routine unit secretary duties. MT 1 reported, if the nurses are behind in their clerical work, MT 1 enters doctors orders into the computer.

During an observation and consecutive interview with the DOU charge nurse on 2 east (RN 22) on 6/2/16 beginning at 1:45 p.m., RN 22 was sitting in the 2 east nursing station and said the monitoring technician was on a break and she was covering the telemetry monitors. RN 22 was observed answering the phone, making phone calls, paging a physician, and monitoring the patients' call lights. RN 22 was observed turning away from the telemetry monitors during these tasks. RN 22 said, she does not continuously look at the telemetry monitors.

During a interview on 6/8/16 at 9:20 a.m., MT 3 was responsible for monitoring 13-16 patient cardiac rhythm with the monitors located at the nursing station. MT 3 indicated multiple clerical functions required in addition to the monitoring. MT 3 described clerical functions as phone calls, stocking charts, copying papers, responding to doctor's or nurses requests to print forms. MT 3 stated job functions required, "About 40 percent (%) monitoring and 60% clerical functions." Asked if she was able to monitor continuously while doing clerical functions, MT 3 stated, "It's not possible, on some units the copier machine is not within arms length, you can't do both activities. Sometimes the call volume is very high and it's hard to concentrate and you can lose your concentration with lots of distractions."

2a. During an interview on 6/1/16 at 8:05 a.m., administrative staff (ADM 3) reported the facility had no policy regarding transferring patients on telemetry.

During an interview on 5/31/16 at 12:05 p.m., ADM 4 described, when telemetry patients are transferred off the unit, the physician will be called for an order to discontinue the telemetry during the time the patient is out of the department.

During an interview on 6/1/16 at 3:05 p.m., the registered nurse (RN 16) reported the telemetry monitor for a patient had been discontinued while in radiology and no physician had been notified of discontinuing the monitor for the procedure. RN 17 stated, "We never call for an order to discontinue telemetry monitoring" when sending patients for tests off the unit. Administrative staff (ADM 1) stated, "There is a process" for transferring patients without telemetry monitoring. ADM 1 explained, if a telemetry patient is to go for a test out of the department and the physician wants the patient to be monitored, "it is up to the physician to write an order for the patient to be monitored while out of department."

During an interview and concurrent record review on 6/2/16, at 9:30 a.m., RN 17 reported patients should be sent with cardiac monitoring if on intravenous cardiac medications and if having a blood transfusion. RN 17 reported Patient 210 (P 210) had been sent to radiology for CT (computerized tomography - special type of X-ray) of chest without any cardiac monitoring on 6/1/16. RN 17 reported P 210 had been on a diltiazem drip (medication used to treat high blood pressure and certain heart rhythm disorders).

During an interview on 6/2/16, at 9:55 a.m., RN 14 reported, there was no criteria for transporting patients, thee nurses just take off the monitor to send them to X-ray, and document time left the unit and time returns.

During an interview on 6/2/16 at 10 a.m., RN 10 was asked what criteria was used to determine if a patient could go off the unit to radiology without a monitor, RN 10 stated, "If the AFIB ( atrial fibrillation, an irregular often rapid heart rate that can cause poor blood flow) was controlled, ok. It would be my judgement to determine if they needed to be monitored."

During an interview on 6/2/16 at 10:10 a.m. revealed, RN 12 worked on the unit for 6 years and cannot remember ever sending a patient to X-ray with monitor. RN 12 reported, "don't need a doctor's order" to send a patient off the unit without a monitor. There is no criteria for who should be monitored. The nurses document when the patient leaves the floor.

During an interview on 6/2/16 at 10:30 a.m. revealed, RN 13 had worked on the telemetry unit for only 2 weeks and was not sure of any criteria for transporting telemetry patients off the unit.

During an interview on 6/2/16, at 10:35 a.m. revealed, RN 17 was told this morning about the policy regarding transporting telemetry patients.

2b. During a review of the clinical record indicated, Patient 308 was admitted from the emergency department to the DOU. The cardiology consultation dated 5/26/16 indicated the patient was admitted with a history of cardiac disease.

During an interview on 6/2/16, at 9:35 a.m., the monitor technician (MT 2) observing the cardiac telemetry monitors at the second floor east nurse station said that Patient 308 was transported to X-ray the previous day without continuous cardiac monitoring.

Review of the "Interdisciplinary Patient Progress Notes" dated 6/1/16 indicated:
12:04 p.m. - X-Ray ordered
4:10 p.m. - Received X-Ray results.
There was no documentation by the RN to indicate Patient 308 was assessed in order to leave the department without monitoring per facility policy.

During an interview on 6/2/16, at 10:06 a.m. indicated, RN 21 was assigned to Patient 308 on 6/1/16 when he was transported to X-Ray. RN 21 said patients are usually transported to X-Ray without cardiac monitoring. RN 21 confirmed that she did not document an assessment of Patient 308's ability to leave the DOU without monitoring. RN 21 stated, "We send patients to a lot of procedures all of the time, we don't document." RN 21 said, she did not know about the policy and procedure for assessing DOU patients before transporting without monitors.

During an interview with RN 7 working on DOU 2 east on 6/2/16, at 9:45 a.m., RN 7 said there was "No criteria for decision to monitor or not when transporting for a procedure off DOU." RN 7 said they only document when the patient is off the floor and when they return.

During an interview with the RN 22 on DOU 2 east on 6/2/16, at 1:45 p.m., RN 22 stated, "This unit, DOU, (patients) don't need to be monitored off the floor, if they did, they would be in the ICU (intensive care unit). It's in the policy that they (patients) can leave the floor for testing, not in our policy to monitor anyone."

On 6/2/16 at 8:00 a.m., the ADM 3 provided a copy of the facility's policy that addresses patient's on telemetry going for diagnostic testing.

Review of the policy and procedure titled, "DOU Admission/Discharge Criteria," revised 1/13, indicated: "The following will be observed when diagnostic testing and/or procedures are ordered by a physician, thereby allowing the studies to be performed in the appropriate ancillary department.
1. Patients not receiving intravenous or anti-arrhythmic (medications used to suppress abnormal heart beats) agents may have cardiac monitoring interrupted if the following criteria is met...
a. Patients cardiac rhythm has not shown life threatening arrhythmia (improper beating of the heart) within the past 24 hours, i.e. acute bradycardia (slow heart rate) below a rate of 50, PVC's (premature ventricular contractions - extra abnormal heart beats) greater than 5/min. that are not chronic in nature, runs of ventricular tachycardia (pulse rate of more than 100 beats per minute that start in lower part of the heart that can result in death).
b. The patient is ordered to have a procedure done in the ancillary department by the physician.
c. The patient is thermodynamically (temperature) stable with stable blood pressure, pulse and respirations.
d. The patient has not had chest pain within the past 12 hours.
2. In order for the patient to leave the department without monitoring, the patient must be assessed for the above criteria by a RN. The RN will then enter into the patient chart a notation stating that the patient has met the above criteria and is able to leave the department without monitoring.
3. When a patient is to be transported to the main OR, the same criteria is to be adhered to, the SBAR (Situation, Background, Assessment, Recommendation) communication form will be placed in the front of the medical record.
4. Patients receiving a blood transfusion, intravenous vasoactive (medication to control blood pressure) or anti-arrhythmic (group of medications used to suppress abnormal hear beats) medication or who have not met the above criteria will:
a. Be placed on a portable cardiac monitor
b. The intravenous solution infused via a portable infusion pump
c. Have an ACLS (advanced cardiac life support) RN in attendance at all times. "

3. Record review revealed, P 201 was admitted in the ICU on 5/28/16 for respiratory failure.

During an interview and concurrent record review on 5/31/16 at 3:10 p.m., RN 11 indicated P 201 was NPO (nothing by mouth). The nurses flow sheet on 5/29/16 showed, diet type is blank, and no percentage eaten during breakfast, lunch and dinner. The same flow sheet indicated, on 5/30 and 5/31/16, P 201 was NPO. RN 11 was not able produce evidence of a written diet order. Concurrent interview with RN 18 and review physician's diet order revealed, the doctor ordered a cardiac diet since 5/29/16 at 8:05 a.m. and had been missed by the nursing staff.

NURSING CARE PLAN

Tag No.: A0396

Based on observation, interview, and record review, the hospital failed to ensure nursing care plans were put in place for four of 32 sampled patients ( Patients 103, 104, 201 and 206). This created potential for unmet care needs.

Findings:

Review of the facility policy and procedure titled, "Care Planning Process, Interdisciplinary" dated 5/13, indicated in part, "Procedure... 7. A change in patient's condition or patient requirements will be updated on the care plan as soon as is identified...8. The care plan will include patient specific problem(s), the appropriate interventions to be taken by each discipline and the goal...17. The plan of care will be updated or revised as indicated by change in patient's condition or level of care. The appropriate discipline will be responsible for the update/revision..."

1. During a concurrent observation and interview on 6/1/16 at 1130 a.m., on the labor and delivery unit, Patient 103 (P 103) was in her room and sitting on edge of her bed. P 103 was bottle feeding baby laying in her arms. P 103's affect was appropriate to mood, good eye contact, and verbal.

Review of clinical record revealed, P 103 was admitted on 5/29/16 at 11:05 p.m., via the emergency room in labor. P 103 delivered newborn on 5/30/16, at 10:10 a.m. During delivery, P 103 had a 400 cc (cubic centimeter) blood loss and lacerations requiring suturing. P 103's hemoglobin (a protein found in red blood cells that carries oxygen throughout the body) dropped from 11.4 at time of admission, to 7.5 on 5/31/16 at 5:20, a.m.. On 5/31/16, P 103's physician ordered Iron (drug to treat anemia),continue to observe, and to repeat blood work on 6/1/16.

During a concurrent record review and interview with RN 9 on 6/1/16, at 12:15 p.m., record indicated that P 103's care plan was initially completed on 5/29/16 at 11:30 p.m., and updated on 5/30/16, at 1 p.m., and 9 p.m., The problem list did not change from the initial admission problem list and the care plan did not reflect change in hemoglobin or any interventions. RN 9 stated, "Yes, they (nursing staff) should have done that, there are several places that could have been reflected."

2. During a concurrent observation and interview on 6/1/16 at 11:40 a.m., Patient 104 was laying in bed with the head of the bed elevated. Patient 104 was verbal, affect appropriate to mood, and with good eye contact.

During a concurrent record review and interview with RN 9 on 6/1/16 at 11:50 a.m. indicated, P 104 was admitted on 5/31/16 at 6:10 a.m., for a scheduled cesarean delivery. Review of P 104's perioperative (the period of time extending from when the patient goes into the hospital for surgery until the time the patient is discharged) nursing care plan dated 5/31/16, was only completed on one side. RN 9 was asked if the entire care plan was relevant to P 104's hospital procedures and nursing care, RN 9 stated, "This should have been completed because all these areas apply, I think they (nursing staff) just didn't turn the pages of the care plan to complete it."

3. During an interview and concurrent record review on 5/31/16 at 3:45 p.m., RN 11 reported, P 201, admitted for acute respiratory failure (difficulty breathing), had been given nothing by mouth by the nurses since 5/29/16. RN 11 acknowledged, there was no nutritional care plan for P 201.

4. During an interview and concurrent record review on 6/1/16 at 3:55 p.m., RN 15 reported P 206 (P 206), admitted for a cerebral vascular accident (damage to brain from interruption on its blood supply) versus transient ischemic attack (brief stroke-like event that resolves), had been placed on contact isolation (staff and visitors required to gown and glove when entering room to prevent spread of infection) for shingles (a reactivation of the chickenpox virus in the body causing a painful rash). RN 15 acknowledged, there was no care plan intervention related to the psychosocial aspect of isolation due do to lack of actual human contact.

INFECTION CONTROL PROGRAM

Tag No.: A0749

Based on record review, observation, and interview, the hospital's infection control officer failed to develop an effective infection control program for three of 32 sampled patients (Patients 300, 301, and 305) when the I.V. (intravenous - administered through the vein) therapy policy was not followed. This failure placed patients at risk for infection.

1. Patient 300's I.V. tubing was not changed every 96 hours and the I.V. site was not labeled in accordance with facility policy.

2. Patients 301 and 305's IV tubings were not labeled in accordance with facility policy.

Findings:

Review of the facility policy titled, "I.V. Therapy For the Adult Patient" revised on 1/13 indicated, "I.V. sites, dressings and tubings must be changed every 96 hours (4 days) in accordance with accepted procedures for IV therapy." and "The dressing which covers the IV site should be labeled with: Date and time of IV insertion, initials of nurse starting the IV, date of site relocation. An IV tubing should be labeled with: Initials of nurse hanging tubing, Date and time tubing was hung, Date and time tubing is to be discarded."

1. During an observation on 5/31/16 at at 12:20 p.m., Patient 300's (P 300)I.V. insertion site located on the left inner forearm was not labeled. P 300's I.V. solution was infusing at 100 ml (millimeters) per hour. The I.V. tubing was observed with a green label which indicated "start 5/26/16 Discard 5/30/16."

During an observation of P 300 and a concurrent interview on 5/31/16 at 12:30 p.m., registered nurse (RN 19) confirmed, the I.V. site should be labeled and the I.V. tubing should have been changed on 5/30/16.

2. During an observation on 5/31/16 at 12:40 p.m., P 305's I.V. tubing was not labeled.

3. During an observation on 5/31/16 at 12:45 p.m., P 301's I.V. tubing was not labeled.

During an interview on 5/31/16 at 12:46 p.m., RN 20 said all I.V. tubing should be labeled.