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Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 482.23, NURSING SERVICES, was out of compliance.

A-0395 - Standard: Staffing and Delivery of Care - The facility failed to provide ongoing nursing care based on standards of nursing practice and facility policy. In addition, the facility failed to ensure appropriate staff were notified of abnormal assessment findings in 2 out of 10 medical records reviewed (Patients #4 and #7). This failure prevented timely reassessments and alerting of staff about changes in condition for patients.

Based on interviews and document review, the facility failed to provide ongoing nursing care based on standards of nursing practice and facility policy. In addition, the facility failed to ensure appropriate staff were notified of abnormal assessment findings in 2 out of 10 medical records reviewed (Patients #4 and #7).

The failure prevented timely reassessment and alerting of staff about changes in condition for patients. Patient #7 was readmitted for additional treatment and blood transfusions approximately 7 hours after being discharged from a colonoscopy procedure. Patient #4 was found pulseless, not breathing and cold after reports of abdominal pain and abnormal vital sign results were obtained. The patient expired after unsuccessful attempts of resuscitation were administered.

FINDINGS:

POLICY

According to the policy, Purposeful Rounding, this check includes the 5Ps-Pain, Personal needs (bathroom), Positioning, Pumps, Proximity of personal Items will be checked at a minimum of every 2 hours based on patient needs and/or preference.

According to the policy, Pain Management, assess the patient's response to care, treatment, and service implemented to address pain. Reassess pain, sedation level, respiratory rate and character within one hour after oral, intramuscular, and topical interventions and document.

According to the policy, Time Frames for Initial Assessment and Reassessment, Internal Medicine/Oncology/Orthopedics/Surgical/Telemetry Department/Nursing Unit, the goal is a full assessment every 12 hours or more frequently based on the patient's condition.

1. The nursing staff failed to reassess the patient after abnormal vital signs were obtained and did not provide a timely pain reassessment after pain intervention medications were administered. Furthermore, nursing staff did not report the abnormal assessment and pain findings to the physician assigned to Patient #4's care.

a) Record review showed Patient #4 was admitted to the hospital on 02/20/15 for osteomyelitis. According to the History and Physical, dated 02/20/15, the patient had additional diagnoses of mental retardation, autism disorder and bipolar depression and did not speak english.

The patient remained in the facility, as they were attempting to find placement, until his/her death.

i) Review of a Vital Signs/Pain Flowsheet, dated 06/15/15 at 5:10 p.m., showed Patient #4 had a rapid pulse of 130 beats per minute (BPM). This was an increase from the patient's previous pulse rates of 88 obtained 5 days earlier on 06/10/15 and 76 obtained on 06/08/15. According to the flowsheet the Registered Nurse was notified of the abnormal vital signs.

However, there was no documentation Patient #4's vital signs were reassessed prior to initiation of a Code Blue (an emergency situation in which a patient is in cardiopulmonary arrest), on 06/16/15 at approximately 4:00 a.m., and death.

On 08/05/15 at 2:56 p.m., Registered Nurse #2 (RN) stated s/he was the nurse assigned to care for Patient #4 on 06/15/15 from 7:00 a.m. to 7:00 p.m. RN #2 stated that at approximately 5:00 p.m. (on 06/15/15), Patient #4's mother reported the patient was having stomach pain. RN #2 stated s/he administered acetaminophen to Patient #4 and asked the Certified Nursing Assistant (CNA) to assess Patient #4's vital signs. RN #2 stated the patient was not agitated at the time the vital signs were assessed (which had been noted to increase the patient's pulse in the past). RN #2 stated s/he reassessed Patient #4's pain level but did not reassess his/her vital signs.

Review of a Medication Administration Record entry, dated 06/15/15 by RN #2, documented that Patient #4 received 650 milligrams of acetaminophen at 5:33 p.m. However there was no initial pain assessment documented in the medical record. Additionally, there was no documentation RN #2 reassessed Patient #4's pain level as was reported in the interview, conducted on 08/05/15.

ii) Review of a Care Team note, dated on 06/16/15 at 7:57 a.m., revealed RN #1 documented, that at approximately 7:30 p.m. (06/15/15), the patient's mother reported the patient complained of lower abdominal discomfort after eating. RN #1 documented the patient's mother later reported the patient only consumed a shake and immediately vomited. There was no time documented of when the patient vomited.

Additionally, there was no documentation to show why the note was entered in the electronic medical record over 12 hours after the event and over 3 hours after the patient expired, on 06/16/15 at 4:36 a.m.

On 08/05/15 at 1:06 p.m., RN #1 stated s/he was the nurse assigned to care for Patient #4 on 06/15/15 from 7:00 p.m. until the patient's death the next morning (on 06/16/16). RN#1 stated s/he was notified of Patient #4's increased heart rate of 133 bpm but thought the patient was agitated at the time and did not feel there was any indication to reassess the patient's vital signs or notify the patient's physician. Further, RN #1 stated staff were expected to perform safety checks on each patient every hour. RN #1 stated s/he was busy on the night of 06/15/15 and was last in Patient #4's room at around 1:00 a.m., and not hourly as required.

RN #1 stated s/he was notified by the security guard (who was stationed in the patient's room for safety purposes) at approximately 4:00 a.m., on 06/16/15, that Patient #4 had vomited. RN #1 stated s/he entered Patient #4's room, turned on the lights, and found the patient blue, cold and pulseless in bed. A code blue response was initiated and despite attempts for resuscitation, Patient #4 was pronounced dead at 4:36 a.m.

b) On 08/06/15 at 9:32 a.m., RN #3 stated s/he was the Charge Nurse on the unit Patient #4 was located on from 7:00 p.m. on 06/15/15 until the patient's death the next morning. RN #3 stated a heart rate of 130 bpm was an abnormal rate and the expectation would be to recheck the vital signs in 20 minutes and if the results were still abnormal the expectation would be to notify the patient's physician. In addition, RN #3 stated that after administering acetaminophen, the facility's expectation would be for the nurse to reassess the patient within an hour.

c) On 08/06/15 at 11:39 a.m., the Director of Nursing of Critical Care and Acute Care Services (DON) was interviewed. The DON stated the expectation of nursing staff, after finding abnormal vital signs, would be to recheck the vital signs and if the results were still abnormal the expectation would be for the RN to notify the patient's physician.

d) On 08/06/15 at 11:02 a.m., Medical Doctor #1 (MD) was interviewed and confirmed s/he was assigned to care for Patient #4 on 06/15/15, the day before Patient #4 died. MD #1 stated a heart rate of 130 bpm, a blood pressure at 91/52 mmHg (which was low for Patient #4), and a report of abdominal pain would be concerning and s/he would have expected to be notified of those results. Furthermore, MD #1 stated that if s/he had been notified of the abnormal results, the plan of care for Patient #4 would have changed and would have included ordering a reassessment of the vital signs, having a hospitalist assess the patient, and a possible computerized tomography (CT) scan of the patient's abdomen.

2. The Registered Nurse did not report abnormal findings to the physician in charge of Patient #7's care. Subsequently, the patient was readmitted to the hospital seven hours after his/her discharge.

a) Record review showed Patient #7 originally presented to the emergency department on 08/02/15. According to the Emergency Department (ED) Notes, dated 08/02/15 at 3:01 p.m., the patient presented with diarrhea and bloody stools and was admitted for observation of a lower gastrointestinal (GI) bleed.

Patient #7 underwent a colonoscopy on 08/03/15 at 9:44 a.m. which showed extensive diverticulosis which was the likely cause of recent bleeding.

According to the Discharge Summary, dated 08/03/15 at 2:26 p.m., the patient was doing well and tolerating his/her diet. The patient still had "scarlet" bowel movements but no bright red blood, per rectum.

A Discharge Information entry reported the discharge date and time as 08/03/15 at 3:30 p.m. Pertinent Labs documented on 08/03/15 at 11:52 a.m. reported the patient's Hemoglobin at 8.7 (Reference Range 14.0 - 18.0 grams per deciliter) and Hematocrit at 28.3 (Reference Range 41.0 - 52.0 %).

i) Review of the Intake and Output Flowsheet, dated 08/03/15 at 2:54 p.m. showed RN #4 documented the patient had a bloody, bright red bowel movement with an estimated blood loss of 300 milliliters (approximately 5 hours after the colonoscopy and 30 prior to discharge). This was in contrast to the discharge summary.

However, there was no documentation the physician was notified of the continued bright red stools and estimated blood loss.

ii) On 08/03/15 at 10:45 p.m. the patient returned to the emergency department (via ambulance) with reports of 5 or 6 bloody bowel movements since leaving the hospital earlier and mild chest discomfort and mild dizziness. Laboratory results from the ED visit revealed a Hemoglobin of 5.9 and a Hematocrit of 18.9. The patient was readmitted to the hospital.

b) On 08/06/15 at 1:22 p.m., RN #4 stated s/he cared for Patient #7 on 08/03/15, after the patient returned from the colonoscopy procedure. RN #4 stated s/he did not recall Patient #7 having a bright red bloody bowel movement with an estimated blood loss of 300 milliliters and was unsure why s/he had documented that entry in the medical record. RN #4 stated s/he recalled Patient #7 having brown and maroon colored liquidy stools with some solids. RN #4 also stated the patient was feeling light headed prior to discharge, however, s/he did not inform the physician about this finding because s/he felt it was not a new symptom.

c) On 08/06/15 at 11:39 a.m., the DON stated the expectation would be for the nurse to notify a patient's physician of the presence of bloody stools.

d) On 08/06/15 at 1:52 p.m., MD #2 was interviewed and stated s/he was unaware Patient #7 was having bloody bowel movements after the colonoscopy. MD #2 stated s/he would have changed Patient #7's plan of care and may have not discharged Patient #7 if s/he had been informed the patient was lightheaded and had either scarlet or bloody red stool. MD #2 added that s/he would have expected an assessment and vital signs to be completed by the RN after reports of lightheadedness and bloody stools.