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Patient # 1, an 88 year old Assisted Living (ALU) resident was admitted to the facility on 6/12/11 after a fall from a sitting position at the ALU. She was diagnosed with a fractured left hip and admitted for surgical repair. Patient # 1 had a history of hypertension, irritable bowel syndrome, depression, and advanced dementia. On 6/13/11 she had an open reduction internal fixation of her left hip. Postoperatively she experienced acute renal failure which resolved with hydration. Subsequently her liver function studies were elevated. Antibiotic therapy was changed and the liver studies trended down. An abdominal sonogram revealed a pancreatic cyst. Her blood counts dropped. A GI (gastroenterological) consult was obtained to rule out GI bleeding vs. post-operative blood loss. A CT scan of her abdomen and pelvis with both oral and intravenous contrast "to evaluate further pancreas and liver" was ordered on 6/16/11 at 1:15 PM. An order followed at 1:30 PM for "NGT placement if not able to take one bottle of oral contrast for CT scan of abdomen." (NGT = nasogastric tube - a tube inserted through the nose into the stomach to administer nutrition, medication, etc.) The family was unable/unwilling to consent to IV contrast. A telephone order was received without documented date and time, which read "OK to have CT scan of Abd/pelvix [sic] orally." It should be noted this is a poorly written order, which cannot stand alone as an order and out of context.

Per the Patient progress record dated 6/16/11 there is a nursing entry at 9:40 PM which states, "NGT placed assisted by Dr. ______. Portable Xray not showing tip of the tube. NGT removed and reinserted by RN - 2nd Xray result pending."

The Xray to verify the first NGT placement was performed at 6/16/11 at 10:58 PM. It reads, "IMPRESSION: THERE IS CATHETER THAT LOOPS IN THE LEFT UPPER QUADRANT AND LEFT LUNG BASE. TIP IS OFF THE EDGE OF THE FILM. CHEST X-RAY RECOMMENDED FOR FURTHER EVALUATION. FRANKLIN NURSE CARING FOR THIS PATIENT WAS INFORMED AT 11:05 PM JUNE 16, 2011." A second x-ray to verify the second NG tube positioning was performed on 6/17/11 at 12:17 AM and reads "IMPRESSION: NASOGASTRIC TUBE TIP JUST BELOW THE LEFT HEMIDIAPHRAGM . RECOMMEND ADVANCING IT."

Additional Patient's Progress record notes written during the early morning hours of 6/17/11, one at 2:00 AM, one at 7:00 AM, report "No result of NGT placement. Unable to administer oral contrast until result available......No result of NGT placement Xray report endorsed to incoming shift."

The next nursing progress note that addresses the NGT placement and use is written at 5:00 PM on the 6/17/11 in the Patient's progress record. It reads: " Contrast given through the NGT as ordered. CT informed about contrast given and waiting to be sent down." The next consecutive note appears at 8:30 PM on the same date by nursing who records "Observed patient with increase [sic] distress, adventitious breath sounds noted A/P lung fields - obtain order to do CT scan of abd/pelvis orally only. Unable to obtain consent from the family for IV contrast." The CT scan performed at 9:54 PM on 6/17/11 was reported to the physician and nurse of record: "LARGE AMOUNT OF ORAL CONTRAST IN THE LEFT PLEURAL SPACE WITH A LARGE PNEUMOTHORAX." (A pneumothorax is a collapsed lung.) The nurse reported this finding in the multidisciplinary notes and spoke with a physician who referred the patient to a thoracic surgeon for possible immediate insertion of a Heimlich valve which was performed at 12:15 AM on 6/18/11 per nurse's note. (Heimlich valve is a one way valve that prevents air and fluid from going back in to the chest which is attached to a chest tube.) A second chest tube was inserted later in the day due to worsening respiratory status. Patient # 1's record documents that on 6/18/11 a left chest tube thoracostomy was performed with 1200 cc of creamy colored contrast material removed from the chest cavity. Patient's status continued to deteriorate from this point on. Daily chest xrays showed a worsening of the left lung hydropneumothorax (6/18/11) with increased infiltrates (6/19/11). Contrast media remained in the pleural space on 6/24/11 despite placement of two chest tubes. A 6/30/11 CT scan of the patient's chest found a "complete collapse of the left upper lobe and almost complete collapse of the left upper lobe, sparing only a portion of the anterior segment of the left upper lobe. The right to left shift of the mediastinum is unchanged..."

On 6/20/11 at 3:54 PM a multidisciplinary note reads: "late entry for 6/17/2011 1500 (3:00 PM) "Patient resting in bed, Charge RN awaken patient and informed patient of placing NGT for oral contrast. Salem Sump was 14 F, Primary RN @ bedside, patient was sitted [sic] up in bed.......NGT ws placed with little to no difficulties. Placement was check [sic] by air bolus by Primary RN and Charge RN.....Charge RN aspirate back and get light green drainage. Oral contrast was placed 3/4 of a bottle.......pt. on oxygen...left in seating [sic] up position with NGT in place." This late entry continues "1715 (5:17 PM) Charge RN check placement by air bolus and aspirating back contrast was aspirated back. Charge RN pushed 3/4 of contrast bottle via NGT. NGT was removed once complete."

Then, on 6/21/11 at 1:00 PM in the Multidisciplinary Progress Notes there appears a "Late entry for 6/17/11, 1400 (2:00 PM). Patient was received from prior shift with a Corpak (type of NGT ) in place waiting for results from chest Xray done earlier. Had an order for doppler and was sent to radiology. I was called and informed that patient had pulled out the corpak. When patient came back to the floor , the corpak was found at the side of her head. MD was called and notified but said the test had to be done. Charge nurse notified." This late entry continues: "1720 (5:20 PM) Charge nurse notifies nurse about second contrast that has been given. Patient resting on her back.....high Fowler's......CT tech requested consent to be signed....son called and message left."

Patient #1's condition continued to deteriorate with worsening lung involvement as described above. A 6/21/11 pulmonology consult describes "Iatrogenic hydropneumothorax (collapsed lung) after NGT placement with extravasation of contrast into pleural space." Pulmonology consult also questions a possible esophageal rupture which was later ruled out as the cause of contrast in to the lung. On 7/2/11 she was taken to surgery for left video assisted thoracic surgery (VATS) for decortication of the left lung. (Decortication is a surgical removal of the membrane surrounding the lung secondary to pleurisy or infections. In Patient # 1's case, she was diagnosed with an empyema (infection) from the contrast solution that entered her lung approximately two weeks prior.) The VATS was converted to a left posterolateral thoracotomy with extensive pulmonary decortication and evacuation. Patient # 1 was recovered in the ICU, remaining on the ventilator for respiratory support and vasopressors for circulatory support. The patient's condition continued to deteriorate until her death on 7/14/11. Death was attributed to unspecified septicemia and respiratory failure.

The specimen of the left pleural peel (tissue removed from the lung during surgery) was sent to the pathology lab. The final pathology diagnosis was "Acute necrotizing pleuritis." (the infection was destroying the lining around the lungs).

Nursing Education was reviewed by the surveyor and it provided a 2011 educational tool "GI System station" that is used during orientation and other training opportunities. In demonstrating placement, item 2g. states "Placement checked with air insufflation, residual check, and PCXR required!" (this is highlighted boldly and contains the exclamation mark). Item 2h. continues with "Confirmation of placement per CXR [bold type] needed prior to feeding via tube." On a separate procedure titled "Small-Bore Feeding Tube tips" item 2b. states "After insertion and placement secured by hearing air inserted, secure to nose". Item 2 b i. states Call for x-ray to verify placement."

Additional instructions call for the documentation of the length of the tube that is inserted. This was not found on the three documented insertion attempts. It is also standard nursing practice to document the type and size of the tube inserted and which nares was used. This was not recorded for any of the three insertion attempts. No documentation was found for the required every four hour placement verification. At the very least, in this case, placement should have been assessed prior to insertion of the CT contrast as well a chest Xray performed.

During insertion of either oral or nasal gastric tubes there is a risk of missing the esophagus and entering the trachea. The tube may not enter the stomach at all. It could track its way in to the lungs. The tube can migrate out of the stomach. This would allow administration of feedings, medications, or in this complaint, orally administered liquid contrast to enter the lungs. An improperly inserted gastric tube may lead to aspiration of the contents administered into the lungs. Food and fluids in the lung field cause severe respiratory compromise and complications.

Staff failed to follow hospital policy and procedure for verification of NGT placement prior to use. There is no documentation following the second Xray after the second insertion of 6/16/11-6/17/11 that the Xray recommending further advancement of the tube was acknowledged and acted upon. Staff that inserted the third NGT in the afternoon of 6/17/11 did not confirm placement with an Xray per the hospital policy. An Xray obtained later on that evening after administration of the liquid contrast confirmed it was in Patient # 1's left lung.

Current standards of practice and hospital policy/procedures were not followed by staff. This presented an unsafe environment for Patient # 1 who was recovering without complications from the repair of a left hip fracture. Instead of preparing for discharge to a rehabilitation facility as was ordered on 6/16/11, this patient suffered from complications not related to the surgery. Patient # 1 experienced two chest tube insertions followed by two weeks of restlessness and pain during which she was restrained. Her hospitalization culminated in major lung surgery from which she never recovered.

It is further noted that during the course of Patient # 1's hospitalization she was placed in soft wrist restraints for medical management. It is documented she pulled out intravenous lines, attempted to pull out a chest tube and to get out of bed at different points during her hospitalization. The first documented order for restraint use was received on 6/16/11 at 9:30 PM for " R hand soft restraint." There are additional orders for restraints and documentation in progress notes that restraints were utilized for which orders and Restraint Observation Flow Sheets could not be found.

In a review of Patient # 1's medical record, six documented episodes of restraint were noted. These were found either by order which could appear on the Physician order sheet, the Restraint Order Form, or by a progress note. Sometimes the same order was written on the Physician order sheet and the Restraint Order Form. On 6/21/11 at 9:45 PM a nursing progress note describes receiving an order from a physician for 2-point soft restraint. There is no written order found in the medical record to cover this restraint event.

Patient #2, per a neurology progress noted dated 6/10/11, was placed in restraint during the night. There is no order or other documentation for this restraint episode found in the medical record.

The hospital failed to follow its Restraint Policy 101-01-027 by not obtaining a written order for these two episodes of restraint. Furthermore, the orders that were received were not always based on an examination of the patient by an LIP within 24 hours of initiation of the restraint. Per hospital policy an LIP is defined as a Doctor of Osteopathy, Medical Doctor, Physician Assistant, and Nurse Practitioner.

Hospital policy stipulates that after each 24 hour period of restraint use, before writing a new order, a physician or licensed independent practitioner who is responsible for the care of the patient must see and assess the patient and determine that restraint use continues to be clinically justified. Five of six available renewal orders for Patient # 1 were verbal orders. Three of these five orders were signed late: Telephone order obtained 6/20/11 signed by physician 6/27/11; telephone order of 6/22/11 signed 6/27/11 by a different physician; Telephone order obtained 6/18/11 signed by physician on 6/26/11.

A review of Patient #2's medical record revealed a Restraint Order Form for 6/16/11 without Physician signature.

The hospital failed to follow its policy for assessment of patient by an LIP before continuation of restraint.

Patient # 1 had six documented episodes of restraints. Hospital policy for Obsevation, Assessment, and Monitoring of the patient in restraint states that the patient should be visually observed every hour and assessed every two hours or sooner as iindicated. There is a Restraint/Observation Flow Sheet provided for this purpose. It states that 1. RN only details the description of patient behavior that led to restraint or observation and 2. RN only documents a detailed description of patient behavior indicating need to continue or discontinue restraint or observation. In the documents provided for Patient # 1's medical record review, there was only one Restraint/Observation Flowsheet dated 6/18/11. The RN failed to document every two hours as specified. Times are documented as 12:30 AM, 5, 7 ,and 11 AM, and 3, 8, 10 PM. In each documentation time slot the restraint is continued; there is no documentation to indicate if and when it was discontinued. There are no other records found in the medical record to indicte the every 2 hour assessment by the RN was performed.

Patient # 2 was in restraint for 54 hours by report of the hospital. There is on Restraint/Observation Flow Sheet dated 6/17/11 where the RN is to provide initial behaviors leading to restraint the then doument at least every 2 hours the detailed description of patient behaviors. This flowsheet was initiated at 6 AM on 6/17/11 with accompanying every 2 hour assessment by the RN. Interesting to note is that Patient # 2 suffered a cardiopumonary arrest at approximately 1: 00 PM on 6/17/11. He was intubated and sedated without change in his every two hour assessment. At the 12, 2, 4, and 6 PM the patient is described "confused, pulling at tubes."

The hospital failed to monitor and assess these restrained patients according to hospital policy and prudent standards of care. Failure to provide an ongoing assessment of the restrained patient can lead to patient injury.

During the medical record review of Paitient's # 1 and # 2, multiple medical record deficiencies were found. Progress notes are dated but not timed. This makes it difficult to follow the sequence of care. This is especially difficult when the notes are dated out of sequence as occurred on Patient # 1's record. There is a progress note that begins with a dated and timed note of 6/7/11. The next dated note that appears is 7/4/11. Multiple physician and nurse signatures found on orders are illegible or non existent. For Patient # 1, a telephone order obtained 6/12/11 @ 7:40 AM was not authenticated by the physician. On other orders, one cannot tell who is transcribing physician orders and if that person is also the RN who is taking off the order. Again, handwriting is illegible throughout the record and pre-printed areas are inconsistently completed.

Failure to to write legibly can led to mistakes and misinterpretation of patient care needs. Progress notes and orders that are not timed or dated can also lead to patient care mistakes and errors. Failure to review and sign orders may lead to patient safety concerns.