HospitalInspections.org

Based on medical record review and interview, the facility failed to ensure contracted medical staff assessed a patient with a change in condition for1 patient (Patient #1) of 4 patients reviewed for a change in condition, resulting in Patient #1's continued decline and subsequent respiratory and cardiac arrest.

The findings include:

Patient #1 was admitted to the facility on 11/9/2019 following a Motor Vehicle Crash (MVC). Patient #1 presented to the facility with Acute Respiratory Failure with Hypoxia (an absence of adequate oxygen in the tissues to sustain bodily functions), Flail Chest (a life-threatening medical condition where a segment of the rib cage breaks and becomes detached from the rest of the chest wall), Traumatic Hemothorax (accumulation of blood between the chest wall and the lungs), Chest Wall and Lung Contusion (bruising), Essential Hypertension, Long Term Use of Opiate Analgesic, and Morbid Obesity.

Medical record review of an Emergency Department Physician's Note dated 11/9/2019 at 8:32 PM showed "...[Patient #1] brought in by EMS [emergency medical service] after motor vehicle crash where he was...ejected driver. At the scene he apparently was little bit confused but was able to answer questions. He complains of severe left sided back and chest pain. He was not hypotensive [low blood pressure] but was tachycardic [increased heart rate]...injury location...L [left] shoulder, L upper arm, L elbow and R [right] elbow...L chest, L flank and back...abdominal pain, back pain, chest pain, extremity pain, nausea and shortness of breath...Review of systems...positive for shortness of breath...positive for chest pain...positive for back pain...positive for confusion...patient has abrasion...chest wall...has a flail segment on the left...I spoke with the trauma surgeon myself. He [trauma surgeon] was already near the hospital and came quickly to take over care of this significantly injured patient..."

Review of a Locum (a contracted Physician who temporarily fills a position) Trauma Surgeon's (Physician #1) History and Physical for Patient #1 dated 11/9/2019 at 9:10 PM showed "...37m [male] s/p [status post] mvc with reported ejection...c/o [complained of] significant chest pain with inspiration, left [side] greater than right...brief loc [loss of consciousness] on scene with confusion reported by ems. [Patient #1] Denies abdominal pain...breathing labored...CT [computed tomography] scans...chest abnormal...multi-level rib fractures, report states 3-8 [rib fractures]...I see 3-12 on independent viewing...small hemothorax...Plan...High risk of worsening pulmonary function given significant thoracic trauma with multilevel rib fractures, pulmonary contusion and hemothorax. Will need aggressive pain control, pulmonary toilet [method used to clear mucus and secretions from the airways] and icu [intensive care unit] monitoring. Explained significance of injuries, complicated by his morbid obesity, which may worsen and progress to requiring intubation [breathing tube], possible pneumonia, and extended hospital course. Will treat with multimodal [multiple] medications. His chronic pain, on methadone [medication used to treat addiction to opioids], also complicates his care and increases his risk..."

Review of a Nurse Practitioner's (NP) Progress Note dated 11/10/2019 at 10:59 AM showed "...Trauma CT scans performed: patient with pulmonary contusion, hemothorax, and multiple left rib fractures/flail chest...patient reports not wanting to move to reposition d/t [due to] pain... BP [blood pressure] 161/80 [at 10:00 AM] he reports difficulty taking a deep breath...states no pain relief since the MVC...Physical exam...diaphoretic [sweating] and moaning...tachycardic [rapid heart rate]...labored breathing, taking shallow breaths, breath sounds clear...supplemental oxygen provided via nasal cannula and breathing treatment...discussed the patient's status and plan of care with the team..."

Review of a Nurse's Assessment Flow Sheet dated 11/11/2019 showed the following BP readings for Patient #1 (normal is 120/80):
12:00 AM 139/78
1:00 AM 116/76
2:00 AM 104/77
2:15 AM 74/47
2:30 AM 76/50
4:00 AM 86/42
4:15 AM 73/29
4:30 AM 54/12
4:45 AM 68/52
5:00 AM 80/40
5:15 AM 81/38
5:30 AM 77/55

Medical record review of a Nurse's Note dated 11/11/2019 at 4:00 AM showed the Nurse called the Physician #1 (1 hour and 45 minutes after the first low blood pressure reading), but there was no documentation of the nature of the call. Further review showed a second Nurse called the Physician #1 at 4:52 AM, but the documentation did not specify the nature of the call.

Review of a telephone order from Physician #1 dated 11/11/2019 at 5:19 AM revealed an order for Ativan (medication used to treat anxiety) 1 milligram to be administered intravenously (IV) to Patient #1. The medication was administered at 5:24 AM.

Review of a Code Blue Event document dated 11/11/2019 showed the facility began cardiopulmonary resuscitation (CPR) on Patient #1 at 5:32 AM. Continued review showed a chest tube (used to remove fluid, air, or pus) was inserted during the code blue.

Review of a Radiology Imaging report dated 11/11/2019 at 6:09 AM showed "...large left pleural effusion [excess fluid between the lungs and the chest]...significantly increased in size from prior exam...mild rightward mediastinal deviation [shift to one side of the chest cavity]...moderate left lung opacification [cloudy], increased from prior exam. This likely represents atelectasis [collapse of the lung] and contusions..."

Review of Telemetry (cardiac monitoring) documentation dated 11/11/2019 at 6:49 AM showed "...PEA [pulseless electrical activity]...physician called [stopped] code..."

Review of a Physician #1's Progress Note dated 11/11/19 at 6:55 AM showed "...called to bedside upon code event around 0530 [5:30 AM], upon arrival resuscitation/cpr in progress. Patient intubated prior to arrival, iv access functioning. Equal bilateral breath sounds present...cxr [chest xray] with left hemothorax, larger than prior, without mediastinal shift. Left ct [chest tube] placed, with return of 1500 cc [cubic centimeters] dark [blood], without improvement. Efforts continued to futility..."

Review of Telemetry documentation dated 11/11/2019 at 7:05 AM showed "...Asystole [no heart beat]..."

Review of a Notification of Death/Disposition of Body dated 11/11/2019 showed time of death 7:05 AM.

During an interview on 3/3/2020 at 3:35 PM the Director of Risk Management stated "...[Patient #1] died on 11/11 [11/11/2019]...coded that morning...did not successfully resuscitate him...internal surgical peer review...they had concerns with the Locum [Physician #1]...some opportunities were there for improvement...when the patient started declining the nurse called the doctor [Physician #1] but the doctor didn't come in to assess the patient...he [Physician #1] gave some orders on the phone...his [Patient #1's] bp [blood pressure] started dropping and he was getting very agitated...gave some Ativan...felt physician should have rounded on patient...I know he had seen the patient earlier that day but did not see him when blood pressure started dropping..."

During a telephone interview on 3/4/2020 at 2:39 PM Registered Nurse (RN) #1 stated he was the night shift nurse who cared for Patient #1. Continued interview revealed RN #1 called the Physician #1 and reported he was "...having a hard time getting his [Patient #1's] blood pressure...he [Physician #1] said 'I am not really concerned with low blood pressure he's [Patient #1] been high all day'...I also told him about [Patient #1] being anxious and having trouble breathing...he [Physician #1] said 'let's give a milligram of Ativan and let me know if it helps'...within minutes after I administered the Ativan his [Patient #1] eyes dilated...started CPR and called a code blue...[Patient #1] was alert and oriented until after I gave the Ativan...[Physician #1] gave me a verbal order...I told someone to get him [Physician #1] here...he had to travel in...paged the operator...asked for whoever the attending is for trauma...[Physician #1] did arrive during the code...put in a chest tube...ton of blood came out...from that point it was such a blur...I told him [Physician #1] about the blood pressures around the time I got the order for Ativan..."

During a telephone interview on 3/4/2020 at 4:54 PM, the Chief Medical Officer stated "...x-ray was done during the resuscitation and he [Patient #1] had a chest full of blood...opportunities were missed along the way...leader of the team [Physician #1] not following essential standards of practice...we pointed that out to this Locum...would have been a chance to mitigate the pulmonary condition...maybe not...quality impact on the patient...he [Physician #1] disagreed...we left it as a validated concern...that Locum is no longer here with us.."

During a telephone interview on 3/6/2020 at 3:15 PM Physician #1 stated "...I put him [Patient #1] in the ICU...aggressive pulmonary toilet...next day [11/10/2019]...saw him...rounded with mid-level [NP #1]...he was doing fine...sleeping resting comfortable...got a call around 5:00 AM [11/11/2019] from the nurse who said he [Patient #1] had intermittent mild hypotension...did not know that [severe hypotension]...don't remember him [nurse] saying he [Patient #1] was hypoxic...by the time I got there...15 minutes later he was coding...hemothorax was associated with rib fractures...the blood associated with his rib fractures did not require any intervention...it is not typical and it is not our practice to do routine chest x-rays...If I had a dollar for every narcotic abusing patient who complained of breathing issues after chest trauma...I would not work anymore...we treated him with multimodal pain medication...first page [phone call] I got was 5:00 AM...when his [BP] was in the 70s...that is not normal...first thing you do is see the patient...this is a young dude with hypotension...yes that was concerning...in retrospect...there was a couple things this guy fell through..."

Based on review medical record review, review of a facility investigation, review of a facility plan of correction, review of staff assignment sheets, and interview, the facility's Quality Assessment and Performance Improvement (QAPI) program failed to establish specific criteria to measure facility improvement and failed to monitor the facility's corrective action plan after an adverse event for 1 patient (Patient #1) of 1 patient reviewed for adverse events.

The findings include:

During the survey it was found one patient (Patient #1) was admitted to the facility's Medical Intensive Care Unit (MICU) on 11/9/2019 following a Motor Vehicle Crash (MVC). Patient #1 presented to the facility with Acute Respiratory Failure with Hypoxia (an absence of adequate oxygen in the tissues to sustain bodily functions), Flail Chest (a life-threatening medical condition where a segment of the rib cage breaks and becomes detached from the rest of the chest wall), Traumatic Hemothorax (accumulation of blood between the chest wall and the lungs), Chest Wall and Lung Contusion (bruising), Essential Hypertension, Long Term Use of Opiate Analgesic, and Morbid Obesity. On 11/11/2019 at 2:15 AM the patient developed significant hypotension (low blood pressure). At 4:00 AM the RN called the Physician (1 hour and 45 minutes later). The patient continued to be hypotensive and at 5:32 AM the patient went into pulmonary and cardiac arrest. The patient was pronounced dead at 7:05 AM.

Review of an undated facility investigation of the adverse event involving Patient #1 on 11/11/2019 showed "...New graduate RN [Registered Nurse], hesitant to ask for assistance with no provider/residents in house [physician]; charge [charge nurse] in staffing [had a patient assignment], Locum [a contracted Physician who temporarily fills a position] not readily available; RN did not ask MD [Medical Doctor] to assess patient in person; RN failed to manually check BP [blood pressure]; duplicate x-ray orders 2 charts open at the same time resulted in rad tech [radiology technician] cancelling one order and other was also cancelled..."

Review of the facility's undated plan of correction implemented after the adverse event on 11/11/2019 showed the correction plan included:
1. Charge Nurse not to be included in staffing
2. Education to radiology technicians to never cancel orders without calling the Physician first
3. Educated new graduate nurses to call the Physician with any changes in patient condition and follow the chain of command
4. Educated staff in MICU to follow chain of command

Review of a staffing assignment sheet dated 2/15/2020 for the 7:00 PM to 7:00 AM shift showed the Charge Nurse was included in nurse staffing for the shift and was assigned to provide one on one care to a patient in the Medical Intensive Care Unit (MICU) during the shift.

During an interview on 3/4/2020 at 4:18 PM the Director of Risk Management stated the facility could not provide a plan for ensuring the Charge Nurse would not be included in staffing and assigned patient care and could not provide documentation to show the radiology technicians were educated after the incident on 11/11/2019 as outlined in the facility's plan of correction. The Director of Risk Management was also unable to provide documentation of the education provided for new graduate nurses and was unable to provide documentation of the staff members who received education regarding physician notification of a change in a patient's condition.

During an interview on 3/10/2020 at 9:45 AM the Chief Nursing Officer (CNO) stated there was concern for the continued assignment of the Charge Nurses to patient care.

During an interview on 3/10/2020 at 1:00 PM the Chief Executive Officer (CEO) stated there was not a written plan for the implementation excluding Intensive Care Unit Charge Nurses from staffing and the facility was not monitoring how often the Charge Nurses were assigned patient care. The CEO was unable to show documentation for monitoring the effectiveness of the facility's plan of correction.

Based on facility policy review, medical record review, review of facility documentation, and interview, the facility failed to promptly notify a Physician of a significant change in a patient's condition for 1 patient (Patient #1) of 4 patients reviewed. The facility's failure resulted an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation, has caused, or is likely to cause injury, harm, impairment, or death) at 42 CFR PART 482.23, Conditions of Participation, Nursing Services.

During a conference with the Chief Executive Officer (CEO), Chief Nursing Office (CNO), Risk Manager, Director of Quality, and the Assistant Vice President of Risk Management on 3/10/2020 at 10:30 AM, the facility presented an Immediate Action Plan for the Immediate Jeopardy. Review of the Immediate Jeopardy Action Plan revealed immediate actions were implemented by the facility and the Immediate Jeopardy was removed on 3/10/2020. The facility remains out of compliance at 42 CFR PART 482.23, Conditions of Participation, Nursing Services (Condition).

The findings include:

During the survey it was found 1 patient (Patient #1) was admitted to the facility's Medical Intensive Care Unit (MICU) on 11/9/2019 following a Motor Vehicle Crash (MVC). The patient presented to the facility with Acute Respiratory Failure with Hypoxia (an absence of adequate oxygen in the tissues to sustain bodily functions), Flail Chest (a life-threatening medical condition where a segment of the rib cage breaks and becomes detached from the rest of the chest wall), Traumatic Hemothorax (accumulation of blood between the chest wall and the lungs), Chest Wall and Lung Contusion (bruising), Essential Hypertension, Long Term Use of Opiate Analgesic, and Morbid Obesity. On 11/11/2019 at 2:15 AM the patient developed significant hypotension (low blood pressure). At 4:00 AM (1 hour and 45 minutes later) the Registered Nurse (RN) called the Physician. The patient continued to be hypotensive and at 5:32 AM the patient went into pulmonary and cardiac arrest. The patient was pronounced dead at 7:05 AM.

During a conference with the Chief Executive Officer (CEO), the Chief Nursing Officer (CNO), the Director of Quality, the Chief Operations Officer (COO), the Risk Manager (RM), and the Assistant Vice President of Risk Management on 3/9/2020 at 6:10 PM, in the conference room, the facility was informed of an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation, has caused, or is likely to cause injury, harm, impairment, or death) at 42 CFR PART 482.23, Conditions of Participation, Nursing Services.

During a conference with the CEO, CNO, RM, Director of Quality, and the Assistant Vice President of Risk Management on 3/10/2020 at 10:30 AM, the facility presented an Immediate Corrective Action Plan for the Immediate Jeopardy. Review of the Immediate Jeopardy Plan of Correction revealed immediate actions were implemented by the facility and the Immediate Jeopardy was removed on 3/10/2020. The facility remains out of compliance at 42 CFR PART 482.23, Conditions of Participation, Nursing Services (Condition).

Review of the Immediate Plan of Correction, which removed the Immediate Jeopardy on 3/10/2020, revealed the following actions were implemented:

Education
A. Education will be provided to all Critical Care nursing staff including, Medical Intensive Care (MICU), Surgical ICU (SICU), Cardiovascular ICU (CVICU) Registered Nurses, and Patient Care Technicians (PCT) on the facility's policy for Chain of Command, Professional Communication Channel. The education included: Key focus on highlighting prompt resolution of issues related to patient care and management and the responsibility of the licensed nurse caring for the patient to contact the physician.
B. Education will be provided by the Nurse Managers (NM) of the Critical Care Intensive Care Units during morning/evening shift huddles.
C. The education will be completed by every critical care staff member providing patient care including licensed nurses, travel nurses, and Patient Care Technicians prior to the beginning of their shift; the staff will sign in they received the education, beginning March 5, 2020.
F. Review of sign-in sheets revealed 54 of 92 members of the Critical Care Intensive Care Units had completed the training.
G. The nursing education program was also reviewed to ensure accurate and through information regarding reporting patients change in condition.
H. New nurse orientation program content will be updated to include additional content regarding reporting patient change in condition. In addition, an updated education packet was developed for all current critical care nursing staff regarding the responsibility of the licensed nurse caring for the patient to contact the treating provider or designee immediately and report the accurate condition of the patient.
I. The facility began deployment of the updated education to all critical care staff for the inpatient critical care units beginning on 3/5/2020.
J. 100% of active staff will receive this education no later than 3/23/2020. Any staff not active during education roll-out will receive education upon return to work and before resuming patient care activities.

Monitoring and Tracking
a. The facility will implement an ongoing audit and monitoring process no later than 3/23/2020.
b. Monitoring will occur through on-going chart audits. A standardized audit tool has been developed and will be deployed no later than 3/23/2020 in MICU/SICU/CVICU.
c. This audit will include a sample size of no less than 10% of current bedded critical care patients at the time of the audit, with no less than 30 records reviewed monthly in each critical care unit.
d. Summary of findings of audits and any needed improvements will be reviewed within the Quality Assessment and Performance Improvement (QAPI) committee.

Responsible Party
The person responsible for the implantation and monitoring of the plan of correction will be the Chief Nursing Officer.

During an interview on 3/10/2020 the Chief Nursing Officer stated the facility had implemented immediate actions related to Chain of Command and Physician Notification for a patient with a change in condition and all staff in all Critical Care ICUs are required to complete the training. Education was provided to RN's and PCTs and their signature was required. The facility implemented ongoing monitoring tools for ensuring adequate nurse to physician communication related to a patient's change in condition which will be reported in the QAPI Meeting, the Joint Quality Council and the Community Board for ongoing review for 1 year.

Refer to A-0392

Based on facility policy review, medical record review, review of facility documentation, and interview, the facility failed to promptly notify a physician of a significant change in a patient's condition for 1 patient (Patient #1) of 4 patients reviewed for a change in condition.

The findings include:

Review of the facility's policy titled "Chain of Command, Professional Communication Channel," dated 5/1/2019 showed "...Licensed nurses work collaboratively with providers to assist the patient in reaching optimal health outcomes during their stay...In situations requiring acute medical care and the presence of a provider, it will be the responsibility of the licensed nurse caring for the patient to contact the treating provider or designee immediately and report the condition of the patient...If unable to elicit timely and appropriate provider response, the licensed nurse shall implement the chain of command..."

Patient #1 was admitted to the facility on 11/9/2019 following a Motor Vehicle Crash (MVC). The patient presented to the facility with Acute Respiratory Failure with Hypoxia (an absence of adequate oxygen in the tissues to sustain bodily functions), Flail Chest (a life-threatening medical condition where a segment of the rib cage breaks and becomes detached from the rest of the chest wall), Traumatic Hemothorax (accumulation of blood between the chest wall and the lungs), Chest Wall and Lung Contusion (bruising), Essential Hypertension, Long Term Use of Opiate Analgesic, and Morbid Obesity.

Review of a Physician #1's order dated 11/9/2019 showed "...Lidocaine [intravenous medication used to treat pain and hypertension] infusion...continuous...1.5 mg [milligrams] [per] min [minute]...Monitor for CV [cardiovascular] effects [hypotension]...If these occur, discontinue lidocaine, notify physician, and obtain a stat [immediate] lidocaine level..."

Medical record review of a Physician's Order dated 11/10/2020 at 5:45 AM showed an order for a "STAT" (immediate) portable chest x-ray (CXR) for a flail chest, but was cancelled on 11/10/2020 at 6:01 AM by Radiology Technologist #1. The cancellation was acknowledged by Registered Nurse on 11/10/2020 at 10:01 AM. There was no documentation the Physician was notified of the cancellation of the CXR.

Review of a Nurse Practitioner's Progress Note dated 11/10/2019 at 10:59 AM showed "...Trauma CT [computed tomography] scans performed: patient with pulmonary contusion, hemothorax, and multiple left rib fractures/flail chest...patient reports not wanting to move to reposition d/t [due to] pain... BP [blood pressure] 161/80 [at 10:00 AM] he reports difficulty taking a deep breath...states no pain relief since the MVC...Physical exam...diaphoretic [sweating] and moaning...tachycardic [rapid heart rate]...labored breathing, taking shallow breaths, breath sounds clear...supplemental oxygen provided via nasal cannula and breathing treatment...discussed the patient's status and plan of care with the team..."

Review of a Nurse's Assessment Flow Sheet dated 11/11/2020 showed the following BP readings for Patient #1 (normal is 120/80):
12:00 AM 139/78
1:00 AM 116/76
2:00 AM 104/77
2:15 AM 74/47
2:30 AM 76/50
4:00 AM 86/42
4:15 AM 73/29
4:30 AM 54/12
4:45 AM 68/52
5:00 AM 80/40
5:15 AM 81/38
5:30 AM 77/55

Medical record review of a Nurse's note dated 11/11/2019 at 1:44 AM showed the Lidocaine infusion was discontinued. Further review showed no documentation the Physician #1 was notified the Lidocaine was discontinued.

Medical record review showed of a Nurse's note dated 11/11/2019 at 4:00 AM showed the Nurse called Physician #1 (1 hour and 45 minutes after the first low blood pressure reading), but there was no documentation of the nature of the call. Further review showed a second Nurse called Physician #1 at 4:52 AM, but the documentation did not specify the nature of the call.

Review of Physician #1's telephone order dated 11/11/2019 at 5:19 AM revealed an order for Ativan (medication used to treat anxiety) 1 milligram to be administered intravenously (IV). The medication was administered at 5:24 AM.

Review of a Code Blue (respiratory/cardiac arrest) event document for Patient #1 dated 11/11/2019 showed the code blue was started at 5:32 AM. A chest tube (used to remove fluid, air, gas) was inserted during the code blue.

Review of Telemetry (cardiac monitoring) documentation dated 11/11/2019 at 6:49 AM showed "...PEA [pulseless electrical activity]...physician called [stopped] code..."

Review of a Physician #1's Progress note dated 11/11/2019 at 6:55 AM showed "...called to bedside upon code event around 0530 [5:30 AM], upon arrival resuscitation/cpr [cardiopulmonary resuscitation] in progress. Patient intubated prior to arrival, iv [intravenous] access functioning. Equal bilateral breath sounds present...cxr [chest xray] with left hemothorax, larger than prior, without mediastinal shift. Left ct [chest tube] placed, with return of 1500 cc [cubic centimeters] dark [blood], without improvement. Efforts continued to futility..."

Review of Telemetry documentation dated 11/11/2019 at 7:05 AM showed "...Asystole [no heart beat]..."

Review of a Notification of Death/Disposition of Body document dated 11/11/2019 showed the time of death for Patient #1 was 7:05 AM.

Review of an undated facility investigation showed "...New grad RN [Registered Nurse]...hesitant to ask for assist with no provider /residents in house...charge [nurse] in staffing...Physician #1] not readily available...RN did not ask MD [Medical Doctor] to assess patient in person...RN failed to manually check BP [blood pressure]...Duplicate x-ray orders...open at the same time resulted in [radiology technician] cancelling one order and other was also cancelled..."

During an interview on 3/3/2020 at 3:35 PM the Director of Risk Management stated "...[Patient #1] died on 11/11 [11/11/2019]...coded that morning...did not successfully resuscitate him...IRC [Incident Review Council]...they decide if it needs further review and it did...on several different levels...some opportunities were there for improvement...when the patient started declining the nurse called the doctor but the doctor didn't come in to assess the patient...he gave some orders on the phone...we felt if it was an experienced nurse...might have gone a little different...his [Patient #1's] BP started dropping and he was getting very agitated...nurse also did not get a manual BP...gave some Ativan...nurse stopped lidocaine when BP was dropping...felt physician should have rounded on patient...I know he had seen the patient earlier that day but did not see him when blood pressure started dropping..."

During a telephone interview on 3/4/2020 at 2:39 PM RN #1 stated "...[Patient #1]...in a lot of pain...on a lidocaine drip...small hemothorax...symptomatic the whole time...thriving [thrashing] all over the bed...he was getting dilaudid [analgesic medication] and oral pain medications...we learned he was on methadone at home...he was tachypneic [shallow breathing], diaphoretic [sweating], pale, tachycardic [rapid heartbeat]...efforts to control his pain was not helping at all...have not had to deal with him [Physician #1] before...went off the orders I had...he [Patient #1] was hypertensive then normal once I gave pain medications...only had trouble later that night...by 3-4 [AM] in the morning he would be screaming...I let the charge nurse know what is going on...lidocaine drip was maxed out...[Patient #1] sweating through sheets...couldn't control pain...had other nurses helping me...I was told his BP was low on the machine...took a BP and it was fine...[automated BP machine] cycling every 30 min...he had a low BP again...I asked my charge if lidocaine was causing low BP...she said yeah that could be part of it...turned it [lidocaine drip] down...then turned it off...gave it another cycle or 2...waited about 30 min...did not want to get an inaccurate representation...I held his next round of pain meds...[Patient #1] was still having trouble breathing...called respiratory...called the physician...told the doctor he [the patient] was anxious and having a hard time breathing...sweating profusely...tachycardic...reported to [Physician #1] on the phone...told him what was going on...that I am having a hard time getting his blood pressure...he [Physician#1] said 'I am not really concerned with low blood pressure, he's been high all day'...also told him about [Patient #1] being anxious and trouble breathing...[Physician #1] said 'let's give a milligram of Ativan and let me know if it helps'...I get Ativan and within minutes after I administered the Ativan his [Patient #1's] eyes dilated...started CPR and called a code blue...I told someone to get him [Physician #1] here...he had to travel in...did arrive during the code...me being as new...I didn't know what else to request...in hindsight could have asked him [Physician #1] to come see him [Patient #1]...did not get a manual BP...I don't believe it would have been accurate with him thriving all over the bed anyway..."

During a telephone interview on 3/4/2020 at 4:54 PM, the Chief Medical Officer stated "...discomfort of a relatively new nurse to escalate uncertainty about how a patient is doing compounded by unfamiliarity with [Physician #1]...order...routine chest x-ray...wasn't done ultimately...because...if two orders are put in and one gets discontinued both get dropped...the care team not looking at the x-ray and wanting to know what it showed is something completely different...standard for trauma...standard for chest trauma...that was a fundamental failure of basic trauma care of a patient with a major chest injury...the whole next day a follow up wasn't attended to...should be top of their mind...then patient got worse...xray was done during the resuscitation and he had a chest full of blood...opportunities were missed along the way..."

During an interview on 3/4/2020 at 5:00 PM the Chief Nursing Officer (CNO) stated the nurse should notify the physician after a change in a patient's vital signs. The CNO stated the nurse did not follow the chain of command and did not provide an adequate response to the patient's low blood pressure.

During a telephone interview on 3/6/2020 at 3:15 PM Physician #1 stated "...got a call around 5:00 AM [11/11/2019] from the nurse who said he [Patient #1] had intermittent mild hypotension when he was agitated...did not know that [severe hypotension]...first page I got was 5:00 AM...when his systolic [BP] was in the 70s...that is not normal...first thing you do is see the patient...this is a young dude with hypotension...yes that was concerning...in retro scope...there was a couple things this guy fell through..."

Based on medical record review, review of a facility investigation, and interview, the facility failed to ensure an immediate (STAT) follow up chest x-ray was completed for 1 patient (#1) of 4 patients reviewed.

The findings include:

Patient #1 was admitted to the facility on 11/9/2019 following a Motor Vehicle Crash (MVC). The patient presented to the facility with Acute Respiratory Failure with Hypoxia (an absence of adequate oxygen in the tissues to sustain bodily functions), Flail Chest (a life-threatening medical condition where a segment of the rib cage breaks and becomes detached from the rest of the chest wall), Traumatic Hemothorax (accumulation of blood between the chest wall and the lungs), Chest Wall and Lung Contusion (bruising), Essential Hypertension, Long Term Use of Opiate Analgesic, and Morbid Obesity.

Medical record review of a Physician's Order dated 11/10/2020 at 5:45 AM showed an order for a "STAT" (immediate) portable chest x-ray (CXR) for a flail chest, but was cancelled on 11/10/2020 at 6:01 AM by Radiology Technologist #1. The cancellation was acknowledged by Registered Nurse on 11/10/2020 at 10:01 AM. There was no documentation the Physician was notified of the cancellation of the CXR.

Review of an undated facility investigation showed the portable chest x-ray was cancelled in error.

During a telephone interview on 3/4/2020 at 2:39 PM Registered Nurse (RN) #1 stated "...that morning he [Patient #1] had a follow up x-ray that got cancelled...I put in a stat chest x-ray on the wrong patient by accident...when the order changed...the x-ray tech cancelled both..."

During a telephone interview on 3/4/2020 at 4:54 PM the Chief Medical Officer stated "...[chest x-ray]...wasn't done ultimately...because of a feature in [computer program]...if 2 orders are put in and one gets discontinued both get dropped...tech [radiology technician] was there and had a plate underneath the patient then stopped...felt must have already been done...but it was actually never done..."