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Based on review of medical records, staff interview and review of policy and procedures it was determined the nursing department and staff:

1. Failed to ensure a sufficient number of qualified registered nurses, licensed practical nurses and other personnel provided quality nursing care for four (#3, #12, #13, #14) of six patients sampled in the intensive care unit of fourteen patients sampled. Review of facility policy revealed criteria for the level of care a patient required when admitted to the ICU (Intensive Care Unit). Review of medical records for patients located in the ICU during survey revealed the facility failed to staff appropriately to meet the needs of the patients. Review of the medical records for patients located in the ICU during survey revealed nursing staff failed to assess, monitor and titrate IV (Intravenous) medications appropriately and according to physician orders. This practice could lead to deterioration of the patient's health and well-being. (Refer to A0395)

2. Failed to administer and document medications as ordered on four (#3,
#12, #13, #14) of six Intensive Care Unit patients of fourteen patients sampled. This practice could lead to deterioration of the patient's health and well-being. (Refer to A405)

3. Failed to assign a mentor and monitor a novice RN (Registered Nurse) according to the facility's remediation plan of action that was identified on 7/13/2016. This resulted in the RN failing to notify the physician of a patient's change in condition and RN failure to render care to the patient. This practice could lead to the deterioration of patient's health and well-being. (Refer to A395)

The cumulative effect of the above findings determined the facility was not in compliance with the Condition of Participation for Nursing Services.

Based on staff interviews, medical record reviews and review of policies and procedures it was determined the facility failed to show measurable improvement in nursing indicators that were identified and failed to sufficiently analyze adverse patient events and implement preventive actions and mechanisms that included feedback and learning throughout the hospital to ensure patient safety was maintained.

Findings included:

1. Review of the medical record for patient #1 revealed the patient was admitted on 7/10/2016. Review of the nursing admission assessment dated 7/10/2016 at 2:00 p.m. revealed the patient was alert and oriented and vital signs were documented as a blood pressure of 117/79, pulse 118 and temperature of 97.0. Review of the H&P (History & Physical) dated 7/11/2016 revealed the patient was status post abdominal surgery. Review of the physician orders dated 7/11/2016 at 5:59 p.m. revealed a GI (Gastrointestinal) consultation was ordered.

Review of the nursing documentation on 7/12/2016 at 7:30 a.m. revealed the RN documented the patient was noted to have a low axillary temperature of 94.6 F (Fahrenheit) and oral temperature of 95.2. Normal body temperature can range between 97 F and 99 F.

Review of the nursing documentation on 7/12/2016 at 7:57 a.m. revealed the RN completed an assessment of the patient. The RN noted the patient had no abnormal findings. At 8:03 a.m. the RN documented the patient's vital signs as a blood pressure of 91/62, pulse 100, respirations 20 and oral temperature 95.2.

Nursing documentation by the RN on 7/12/2016 at 10:20 a.m. showed the patient had nausea and vomiting. The ARNP (Advanced Registered Nurse Practitioner) was notified. Review of the physician orders dated 7/12/2016 at 10:37 a.m. revealed orders that included a KUB (Kidney, Ureter, Bladder) x-ray and to contact the GI consult regarding the patient's nausea and vomiting.

RN documentation at 11:21 a.m. stated the patient had vomited approximately 100 ml (milliliters) of coffee-ground emesis. Residual check of the feeding tube revealed 20 ml of dark brown, coffee-ground colored residual.

Review of the CNA's (Certified Nursing Assistant) documentation on 7/12/2016 at 2:22 p.m. revealed a blood pressure of 94/64, pulse of 103, 20 respirations and an axillary temperature of 94.4. The CNA documented the RN was notified. The RN documented at 4:13 p.m. three calls were placed to the GI consult and he was awaiting a call back. Review of the RN's documentation at 4:33 p.m. noted the patient had a low axillary temperature of 94.6 and oral temperature of 95.2. The RN documented the patient was reassessed 1 hour later with an axillary temperature of 95.1.

Review of the KUB results dated 7/12/2016 revealed intestinal distention may represent an ileus or blockage. RN documentation at 4:29 p.m. stated the results of the KUB were provided to the GI consultant. Review of the record revealed the GI consultant had not assessed or examined the patient as of 7/12/2016.

Review of facility's Medical Staff Bylaws, Rules & Regulations stated routine consults will be conducted within 7 days. Documentation revealed the GI physician consultant gave a telephone order to the RN that included a follow up KUB in the morning. The RN documented the results of the KUB were provided to the ARNP at 4:41 p.m. at which time a telephone order was entered by the RN for a pulmonary consultation.

Review of the night shift RN assessment on 7/12/2016 at 8:48 p.m. stated the patient was without changes from previous assessment. At 9:40 p.m. the RN documented a change in condition. The RN stated she spoke with the ARNP and was informed orders were given to the day shift RN for a surgical consult for possible bowel obstruction. The RN stated there was no documentation of the order in the medical record by the day shift RN.

Nursing documentation stated the nursing supervisor was informed and the patient's primary should be contacted for further orders. Two calls placed to the answering service with no call back. The nursing supervisor informed the RN to follow up with the surgical consult in the morning at 5:00 a.m.

Review of the medical record revealed the nursing supervisor documented a change in condition regarding the patient at 10:43 p.m. The note indicated a call was received by the patient's significant other with concerns the patient was having increased weakness and shortness of breath. The nursing supervisor informed the significant other the patient's pulse oximetry was 94-96% and the patient was short of breath at rest. She was informed the RT (Respiratory Therapist) would perform an ABG (Arterial Blood Gas) per protocol. The nursing supervisor stated the patient was placed on telemetry for monitoring due to significant others concerns. The telemetry placed by the RN read pulse 102 sinus with history of BBB (Bundle Branch Block) per the monitor tech.

At 11:40 p.m. the night shift nurse documented the patient had an increased respiratory rate, although there was no respiratory rate documented to determine the degree of the tachypnea. Documentation revealed the ABG was completed and revealed the patient was in metabolic acidosis. This is a chemical imbalance of acids and bases in the blood. Documentation revealed the RN notified the pulmonology consultant of the ABG results. Review of the record revealed the pulmonologist had not yet seen or examined the patient.

Nursing documentation revealed the patient's vital signs at 2:00 a.m. were a blood pressure of 110/60, pulse 74, temperature 97.4 and respirations 19. The RN documented at 3:00 a.m. the patient was on telemetry monitoring.

Review of the record revealed a rapid response was called for the patient on 7/13/2016 at 4:50 a.m. Review of the rapid response form revealed the call was made due to tele-monitor call for a drop in the patient's heart rate. The patient was found unresponsive. Documentation stated full measures were taken to revive the patient. Review of the documentation revealed the surgeon that was to be consulted on 7/12/2016, but had not been notified, was in the facility and attended the code for the patient. Documentation revealed at 5:25 a.m. a Code Blue was initiated and resuscitative measures were not successful. The patient expired and was pronounced by the surgeon.

Review of facility documents revealed the facility identified nursing failed to recognize the implications of the abnormal vital signs and communicate the patient's change in condition to the oncoming night shift RN. Nursing failed to document and carry out the MLP (Mid-Level Practitioner) verbal order to notify the surgeon of the x-ray findings. Nursing failed to exercise critical thinking skills in prioritizing work. Lack of nursing supervision of a novice RN was identified. Nursing failed to escalate the patient's change in condition related to a critical lab result (metabolic acidosis) and failed to contact the surgeon with the results of an abnormal x-ray with evidence of a possible bowel obstruction.

Review of facility documents revealed the facility implemented preventive actions and mechanisms for nursing to ensure patient safety was maintained. The action plan included a performance improvement plan for one of the RNs that cared for the patient and one of the nursing supervisors. Additional actions were implemented to ensure nursing supervision of all nurses by nursing supervisors on all shifts to ensure a Change of Condition documented on each patient was reviewed by nursing supervisors to ensure appropriate action/follow-through/escalation. The facility documented this would be completed 7/20/2016.

Review of the RN's personnel file revealed no evidence of a documented performance improvement plan following the events of 7/13/2016. There was evidence the RN was re-educated on change in condition, assessment/reassessment and critical thinking. The education document stated the RN would be assigned a mentor per shift until the RN completed the Graduate Nurse Residency Revised Program.

Review of the nursing assignments revealed the RN returned to work at the facility on 7/24/2016. There was no documentation of the mentor that was assigned to the RN. Review of the medical record for patient #2 revealed the RN was assigned to care for the patient on 7/24/2016.

2. Review of the medical record for patient #2 revealed the patient was admitted on 7/14/2016 to the medical surgical unit.

Review of the patient's vital signs revealed on 7/23/2016 the blood pressure was 105-120s over 58-70s with a heart rate of 80-100s.

Review of the RN nursing assessment on 7/24/2016 at 10:00 a.m. revealed the patient was noted as confused, alert and restless. The RN documented the patient's mental status had deteriorated and had no extremity strength. Breath sounds were noted with bilateral expiratory wheezing. Review of the record revealed no evidence of any interventions or notification to the physician for the noted changes in the condition.

On 7/24/2016 at 10:15 a.m. the RN noted the patient's blood pressure was 68/50, pulse 105 and respirations 17. Review of the record revealed no evidence of any interventions or notification to the physician for the noted changes in the condition.

On 7/24/2016 at 10:41 a.m. the RN documented at 10:25 a.m. a return to the patient's room for reassessment found the patient to be unresponsive with no spontaneous respirations and no palpable pulse. The RN documented the patient was a DNR. Review of the record revealed no evidence the RN provided any interventions or reported the change in the patient's condition at the time it was identified.

Interview with the Director of Quality Management/Risk Manager on 9/7/2016 at 1:50 p.m. stated the facility identified the event as the RN's lack of action and failure to rescue. She confirmed this was the same RN that was involved in the care of sampled patient #1.

Review of the facility's documents revealed there was one change to the previous action plan put into place following the first identified event. Review of the RN's personnel file revealed a performance improvement plan, dated 8/1/2016. It stated the nurse failed to render care to a patient and failed to elevate a change in the patient's condition to the physician and nursing supervisor. The action was termination of the RN. There was no further change to the facility's action plan that was put into place.

Review of the action plan that was in place revealed as part of their corrective actions the nursing supervisors would review the Change of Condition documented on each patient on their assigned unit periodically throughout their shift to ensure appropriate action/follow-through/escalation. The facility documented this would be completed 7/20/2016.

3. Review of patient #10's medical record revealed the RN failed to reassess the patient on 8/20/2016, 8/21/2016 and 8/23/2016 that had significant changes and fluctuations in vital signs. The nurse failed to notify the physician of the significant changes. Review of the physician progress notes revealed documentation by the physician that noted no reported changes by nursing. On 8/23/2016 at 2:55 p.m. the patient went into cardiac arrest and was transferred to the ICU where vital signs continued to decline and the patient expired. There was no evidence the facility identified any concerns of nursing failing to notify the physician of the changes and fluctuations in the patient's vital signs.

4. An interview conducted on 9/9/2016 at 3:07 p.m. with the Director of Quality Management/Risk Manager revealed all mortalities for the past 60 days had been reviewed and no quality of care issues were identified. The Director of Quality Management/Risk Management confirmed patient #10's medical record did not receive an adequate review for quality of care issues.

5. An interview conducted on 09/8/16 at 12:10 p.m. with Patient #10's physician revealed he was unaware of any changes with patient #10's vital signs from 08/19/2016 to 08/23/2016. The physician confirmed his progress notes dated 08/23/16 revealed he personally reviewed the patient's vital signs and no issues were identified. The physician stated "I cannot count on the vital signs always being accurate, however, I believe staff were receiving more training to ensure accuracy of vital signs".

6. Observations, policy review and medical record review revealed the facility failed to provide adequate staffing and supervision for the ICU (Intensive Care Unit) to ensure patient safety and quality of care to the patients.

A review of the facility policy titled "Patient Classification System" #H-PC 01-003, Rev. 06/2016 stated "Intensive /Special Care Unit (ICU/SCU): Complexity/Acuity screen is determined by whether the patient is a 1:1, 1:2 or 1:3 ratio. Patient care activities in the ICU/SCU setting that drive the various ratios are outlined:
**1:3 (Acuity 5)-Assessment (collecting, integrating, analyzing), Planning, Intervention (responding to) and Evaluation of patient information every 2-3 hours with subsequent documentation of such activity.
Drip titration requiring outcomes monitoring and documentation every 2-3 hours.
**1:2 (Acuity 6) - Assessment (collecting, integrating, analyzing), Planning, Intervention (responding to) and Evaluation of patient information every 45-60 minutes with subsequent documentation of such activity.
Drip titration requiring outcomes monitoring and documentation every 45-60 minutes.
**1:1 (Acuity 7) - Assessment (collecting, integrating, analyzing), Planning, Intervention (responding to) and Evaluation of patient information every 15-30 minutes with subsequent documentation of such activity.
Drip titration requiring outcomes monitoring and documentation every 15-30 minutes.

Observation of the ICU on 9/06/2016 at 9:00 a.m. revealed a six bed unit with six beds occupied. It was staffed with two registered nurses and 0.5 certified nursing assistant. There was no charge RN assigned directly to the unit.
Observation of all six ICU patients revealed they were all on mechanical ventilation; five of six of the ICU patients were on contact isolation; six of six ICU patients were on one to four Intravenous (IV) drip medications with each requiring monitoring every 60 minutes or less. Based on facility policy, staffing for ICU would require three RNs.

An interview with the Chief Clinical Officer (CCO) on 9/6/2016 during the tour confirmed the above findings. He stated they had identified the staffing problem in July. Review of nursing assignment for the ICU for the past 2 weeks revealed the ICU continued to be without appropriate staffing for 50% of the shifts reviewed.

Interviews with ICU RNs during survey on 9/7/2016 revealed they were informed by management they were working on the staffing concerns but that it had not happened. Another ICU RN was interviewed. He stated he was transferring to a prn (as needed) position at the facility because he felt like he was not able to make a difference at the facility and did not have enough time to spend with the patients as needed.

An interview on 9/9/2016 at 5:00 p.m. with the CCO revealed he did not feel agency staffing was appropriate for the facility's patient population due to the lack of quality care provided by agency nursing staff. He stated using agency staff was just not an option.

Review of the six patient's medical records in the ICU during survey revealed patient's were not monitored according to facility policy for patient's located in the ICU and receiving IV medication that required frequent assessment and titration.

There was no evidence the facility was monitoring staffing as it related to the quality of care needed by the patients.

Based on observation, policy review and staff interviews it was determined the facility failed to provide a sufficient number of qualified registered nurses, licensed practical nurses and other personnel to provide nursing care for four (#3, #12, #13, #14) of six patients sampled in the intensive care unit of fourteen patients sampled.

Findings included:

A review of the facility policy titled "Patient Classification System", #H-PC 01-003, Rev. 06/2016 stated "Intensive/Special Care Units (ICU/SCU): Complexity/Acuity screen is determined by whether the patient is a 1:1, 1:2, or 1:3 ratio. Patient care activities in the ICU/SCU setting that drive the various ratios are outlined:
**1:3 (Acuity 5) - Assessment (collecting, integrating, analyzing), Planning, Intervention (responding to) and Evaluation of patient information every 2-3 hours with subsequent documentation of such activity.
Drip titration requiring outcomes monitoring and documentation every 2-3 hours.
**1:2 (Acuity 6)-Assessment (collecting, integrating, analyzing), Planning, Intervention (responding to) and Evaluation of patient information every 45-60 minutes with subsequent documentation of such activity.
Drip titration requiring outcomes monitoring and documentation every 45-60 minutes.
**1:1 (Acuity 7)-Assessment (collecting, integrating, analyzing), Planning, Intervention (responding to) and Evaluation of patient information every 15-30 minutes with subsequent documentation of such activity.
Drip titration requiring outcomes monitoring and documentation every 15-30 minutes.

On 09/06/2016 at 9:00 a.m. a tour of the ICU revealed a six bed unit with six beds occupied. It was staffed with two Registered Nurses [RN] and 0.5 certified nursing assistant [CNA]. There was no charge RN assigned directly to the unit.
All six ICU patients were on mechanical ventilation; five of six ICU patients were on contact isolation; six of six ICU patients were on one to four Intravenous [IV] drip medications each. Based on facility policy staffing for ICU would require three RNs.

A review of the four ICU patients' IV drip medication documentation revealed the medication was not monitored or administered per physician orders.

An interview with the Chief Clinical Officer [CCO] on 09/06/2016 during the tour confirmed the above findings and stated they had identified the problem in July. The CCO also stated there was one supervisor assigned to the 3rd floor and was in charge of the Intensive Care Unit [ICU], Progressive Care Unit [PCU] and Medical/ Surgical unit.

An interview with the ICU nurse on 09/07/2016 at 2:30 p.m. revealed the unit was currently staffed at 3:1 and had been for quite awhile. The nurse stated she understood they [management] are working on it but it has not happened yet. The nurse stated she tried to document every 30 minutes as all her patients were on IV drips. Vital signs are taken hourly.

An interview with ICU nurse on 09/07/2016 at 3:00 revealed he currently worked full time but was going to PRN (as needed) soon. He stated the reason for leaving as he needed a change because he did not feel he was able to make a difference and not enough time to spend with patients as needed.

An interview with the 3rd floor supervisor on 09/07/2016 at 3:30 p.m. revealed the facility was trying to address staffing. It was hard to find and retain good qualified staff. He was asked how he would be immediately available to ICU if an emergency happened on 3rd floor medical surgical or PCU units. He stated he was not sure and would need to get someone to cover.

A follow-up interview on 09/09/2016 at 5:00 p.m. with the CCO again stated they were aware of the staffing, were unable to maintain staffing and did not feel agency staffing was appropriate for the patient population.

1. Review of the medical record for patient #3, located in the ICU, revealed a physician order dated 9/06/2016 at 11:25 a.m. for Propofol IV drip to start at 5 mcg [micrograms] per kg [kilogram] per minute, titrate by 5 mcg/kg/min every 5 minutes until desired level of sedation achieved, max rate 50 mcg/kg/min start today (09/06/2016).

The documentation showed:
On 09/06/2016 at 11:55 a.m. the infusion started at 5 mcg/kg/min. On 09/06/2016 at 2:04 p.m. the infusion was titrated at 10 mcg/kg/min

Review of the medical record with the Risk Manager and the Pharmacy Director on 09/07/2016 at approximately 2:00 p.m. confirmed no documentation was noted within the medical record, including the medication administration record [MAR], indicating the patient's sedation level or desired sedation level. There was no documentation found for following the physician's order to "titrate by 5 mcg/kg/min every 5 minutes until desired level of sedation achieved".

A review of the medical record with an ICU RN on 09/09/2016 at 1:30 p.m. confirmed the above findings and lack of documentation.

2. Review of the medical record for patient #12, located in the ICU, revealed a physician order, dated 9/03/2016 at 10:20 a.m. for niCARdipine hydrochloride IV drip, titrate to keep SBP [systolic blood pressure] less than 160.

Nursing documentation revealed:
09/03/2016 at 10:52 a.m. the infusion was started at 5 mg/hr (5 milligrams per hour). There was no systolic blood pressure documented.
09/03/2016 at 11:30 a.m. the infusion was titrated up to 7.5 mg/hr. The SBP was recorded as 189.
09/03/2016 at 11:43 a.m. the infusion was titrated up to 10 mg/hr. The SBP was recorded as 199.
09/03/2016 at 12:35 p.m. the infusion was titrated down to 5 mg/hr. The SBP was recorded as 91
09/03/2016 at 8:11 p.m. Infusion continues at 5 mg/hr. There was no SBP documented.
09/03/2016 at 10:34 p.m. the bag was changed and continued at 5 mg/hr. There was no SBP documented.
09/04/2016 at 3:36 a.m. the bag was changed and continued 5 mg/hr. There was no SBP documented.
09/04/2016 at 9:06 a.m. the infusion was titrated up to 7.5 mg/hr. There was no SBP recorded at 162.
09/04/2016 at 1:31 p.m. the bag changed and the titrate was not specified. The SBP was not documented.
09/04/2016 at 2:26 p.m. the infusion was titrated down to 5 mg/hr. The SBP was recorded as 108.
09/04/2016 at 6:04 p.m. the infusion was titrated up to 7.5 mg/hr. The SBP recorded as 94.
09/04/2016 at 6:05 p.m. the bag was changed. The titration was not specified. The SBP was not documented.
09/04/2016 at 8:51 p.m. the infusion continued at 7.5 mg/hr. The SBP was not documented.
09/04/2016 at 9:01 p.m. The bag and tubing was changed. There was no SBP documented.
09/04/2016 at 9:02 p.m. the infusion was titrated down to 5 mg/hr. The SBP was recorded as 110.
09/07/2016 at 7:00 a.m. the documentation revealed the medication bag was changed and the infusion continued at 5 mg/hr. The SBP was not documented.

Review of the medical record with the Risk Manager and the Pharmacy Director on 09/07/2016 at approximately 2:00 p.m. confirmed there was no documentation within the medical record, including the MAR, indicating why the SBP was not recorded consistently or why the medication was increased with a SBP of 94 when the physician order to keep SBP less than 160 had been achieved and no titration was required.

A review of the medical record with an ICU RN on 09/09/2016 at 1:30 p.m. confirmed the above findings and lack of documentation.

3. Review of the medical record for patient #13, located in the ICU, revealed a physician order dated 9/04/2016 at 3:27 p.m. for Propofol IV drip 10 mg/ml[10 milligrams per milliliter] Increase by 5 mcg/kg/min every 5 minutes until desired level of sedation achieved Start STAT (09/04/2016).

Nursing documentation revealed:
09/05/2016 at 7:44 a.m. the infusion was started at 5 mcg/kg/min.
09/05/2016 at 7:55 a.m. the infusion was titrated at 10 mcg/kg/min.
09/05/2016 at 10:28 p.m. the infusion was titrated at 8 mcg/kg/min.
09/05/2016 at 11:24 p.m. the infusion was continued 8 mcg/kg/min.
09/06/2016 at 2:01 a.m. the bag and tubing was changed. The infusion was at 10 mcg/kg/min.
09/06/2016 at 7:53 a.m. the infusion continued at 10 mcg/kg/min.
09/06/2016 at 9:49 a.m. the infusion was titrated at 12 mcg/kg/min.
09/06/2016 at 4:27 p.m. the bag and tubing was changed. The infusion was at 12 mcg/kg/min.
09/06/2016 at 8:15 p.m. the infusion was titrated at 15 mcg/kg/min.
09/07/2016 at 9:09 a.m. the infusion continued 15 mcg/kg/min.

A review of the medical record with the Risk Manager and the Pharmacy Director on 09/07/2016 at approximately 2:00 p.m. confirmed no documentation within the medical record including the MAR indicating the delay in starting a "STAT" medication or the patient's sedation level or desired sedation level. No documentation was found for following physician's order to "titrate by 5 mcg/kg/min every 5 minutes until desired level of sedation achieved".

A review of the medical record with an ICU RN on 09/09/2016 at 1:30 p.m. confirmed the above findings and lack of documentation.

4. Review of the medical record for patient #14, located in the ICU, revealed a physician order dated 9/04/2016 at 10:20 a.m. for: niCARdipine hydrochloride IV drip, Titrate 2mg/hr every 5 minutes (rapid titration) to 15 minutes (gradual titration). Max dose 15 mg/hr. Decrease to 3 mg/hr IV after reaching SBP less than 160. Start today 09/04/2016.
The documentation showed:
09/04/2016 at 10:58 a.m. the infusion was started at 2.5 mg/hr. There was no SBP documented.
09/04/2016 at 10:59 a.m. the bag and tubing was changed. The infusion was 2.5 mg/hr. There was no SBP documented.
09/04/2016 at 11:00 p.m. had no titration specified. There was no SBP documented.
09/05/2016 3:45 a.m. the infusion was titrated up to 5 mg/hr. The SBP was recorded as 175.
09/05/2016 at 5:10 a.m. the bag was changed. The infusion was 7.5 mg/hr. There was no SBP documented.
09/05/2016 at 8:07 a.m. the infusion continued at 7.5 mg/hr. There was no SBP documented.
09/05/2016 at 8:10 a.m. the infusion was titrated up to 9 mg/hr. The the SBP was recorded as 156.
09/05/2016 at 9:00 a.m. the bag was changed. The SBP was not documented.
09/05/2016 at 12:07 p.m. the bag was changed. The SBP was not documented.
09/05/2016 at 2:20 p.m. the bag was changed. The SBP was not documented.
09/05/2016 at 4:38 p.m. the bag was changed. There was no SBP documented
09/05/2016 at 6:46 p.m. the bag was changed. The SBP was not documented.
09/05/2016 at 9:18 p.m. the bag and tubing was changed. The SBP was not documented.
09/05/2016 at 11:16 p.m. the infusion was titrated down to 10 mg/hr. There SBP recorded as 132.

A review of the medical record with the Risk Manager and the Pharmacy Director on 09/07/2016 at approximately 2:00 p.m. confirmed no documentation within the medical record including the MAR indicating why the medication was not titrated per physician order or why the SBP was not recorded consistently.

A review of the medical record with an ICU RN on 09/09/2016 at 1:30 p.m. confirmed the above findings and lack of documentation.

Based on review of medical records, facility policy and procedures and staff interview it was determined the facility failed to ensure a registered nurse supervised and evaluated nursing care for each patient on an ongoing basis in accordance with hospital policy. The registered nurse failed to assess the patient's needs and change in condition for seven (#1, #2, #3, #10, #12, #13, #14) of 14 patients sampled.

Findings included:

1. Review of the medical record for patient #1 revealed the patient was admitted on 7/10/2016. Review of the nursing admission assessment dated 7/10/2016 at 2:00 p.m. revealed the vital signs were documented with a blood pressure of 117/79, pulse 118 and temperature of 97.0. Review of the H&P (History & Physical) dated 7/11/2016 revealed the patient was status post abdominal surgery.

Review of the physician orders dated 7/11/2016 at 5:59 p.m. revealed a GI (Gastrointestinal) consultation was ordered.

Review of the nursing documentation on 7/12/2016 at 7:30 a.m. revealed the RN documented the patient was noted to have a low axillary temperature of 94.6 F (Fahrenheit) and oral temperature of 95.2. Normal body temperature can range between 97 Fé and 99 Fé.

Review of the nursing documentation on 7/12/2016 at 7:57 a.m. revealed the RN completed an assessment with no abnormal findings. At 8:03 a.m. the RN documented the patient's vital signs as blood pressure of 91/62, pulse 100, respirations 20 and oral temperature 95.2.

RN documentation on 7/12/2016 at 10:20 a.m. stated the patient had nausea and vomiting. The ARNP (Advanced Registered Nurse Practitioner) was notified. Review of the physician orders dated 7/12/2016 at 10:37 a.m. revealed orders that included a KUB (Kidney, Ureter, Bladder) x-ray and to contact the GI consult regarding the patient's nausea and vomiting.

RN documentation at 11:21 a.m. stated the patient had vomited approximately 100 ml (milliliters) of coffee-ground emesis. Residual check of the feeding tube revealed 20 ml of dark brown, coffee-ground colored residual.

Review of the CNA's (Certified Nursing Assistant) documentation on 7/12/2016 at 2:22 p.m. revealed a blood pressure of 94/64, pulse of 103, 20 respirations and axillary temperature of 94.4. The CNA documented the RN was notified. The RN documented at 4:13 p.m. three calls were placed to the GI consult and he was awaiting a call back. Review of the RN's documentation at 4:33 p.m. stated the patient had a low axillary temperature of 94.6 and oral temperature of 95.2. The RN documented the patient was reassessed 1 hour later with an axillary temperature of 95.1.

Review of the KUB results dated 7/12/2016 revealed intestinal distention may represent an ileus or blockage. RN documentation at 4:29 p.m. stated the results of the KUB were provided to the GI consultant. Review of the record revealed the GI consultant had not assessed or examined the patient as of 7/12/2016. Review of facility Medical Staff Bylaws, Rules & Regulations states routine consults will be conducted within 7 days.

Documentation revealed the GI physician consultant gave a telephone order to the RN for a follow up KUB in the morning. The RN documented the results of the KUB were provided to the ARNP at 4:41 p.m. at which time a telephone order was entered by the RN for a pulmonary consultation.

Review of the night shift RN assessment, on 7/12/2016 at 8:48 p.m. showed the patient was alert, appropriate and without changes from previous assessment. At 9:40 p.m. the RN documented a change in condition. The RN stated she spoke with the ARNP and was informed orders were given to the day shift RN for a surgical consult for possible bowel obstruction. The RN stated there was no documentation of this order in the medical record by the day shift RN and no documentation the surgical consultant was notified of the results.

Nursing documentation noted the nursing supervisor was informed and the patient's primary should be contacted for further orders. The nursing supervisor informed the RN to follow up with the surgical consult in the morning at 5:00 a.m.

Review of the medical record revealed the nursing supervisor documented a change in condition regarding the patient at 10:43 p.m. The note indicated a call was received by the patient's significant other with concerns the patient was having increased weakness and shortness of breath. The nursing supervisor informed the significant other the patient's pulse oximetry was 94-96% and the patient was short of breath at rest. She was informed the RT (Respiratory Therapist) would perform an ABG (Arterial Blood Gas) per protocol. The nursing supervisor stated the patient was placed on telemetry for monitoring due to significant others concerns. The telemetry placed by the RN read a pulse of 102 sinus with history of BBB (Bundle Branch Block) per the monitor tech.

At 11:40 p.m. the night shift nurse documented the patient was alert but confused and tachypnic although there was no respiratory rate documented to determine the degree of the tachypnea. Documentation revealed the ABG was completed and revealed the patient was in metabolic acidosis. This is a chemical imbalance of acids and bases in the blood. Documentation revealed the RN notified the pulmonology consultant and informed him of the ABG results. Review of the record revealed the pulmonologist had not yet seen or examined the patient. Orders were received to treat the metabolic acidosis.

Nursing documentation revealed the patient's vital signs noted at 2:00 a.m. were a blood pressure of 110/60, pulse 74, temperature 97.4 and respirations 19. The RN documented at 3:00 a.m. the patient was on telemetry monitoring.

Review of the record revealed a rapid response was called for the patient on 7/13/2016 at 4:50 a.m. Review of the rapid response form revealed the call was made due to tele-monitor call for a drop in the patient's heart rate. The patient was found unresponsive. The patient was resuscitated.

Review of the documentation revealed the surgeon, that was to be consulted on 7/12/2016, but had not been notified, was in the facility and attended the code for the patient. Documentation revealed at 5:25 a.m. a Code Blue was initiated and was not successful. The patient was pronounced by the surgeon.

Review of facility documents revealed the facility identified nursing failed to recognize the implications of the abnormal vital signs and communicate the patient's change in condition to the oncoming night shift RN. Nursing failed to document and carry out the MLP (Mid-Level Practitioner) verbal order to notify the surgeon of the x-ray findings. Nursing failed to exercise critical thinking skills in prioritizing work. Lack of nursing supervision of a novice RN was identified. Nursing failed to escalate the patient's change in condition related to a critical lab result (metabolic acidosis) and failed to contact the surgeon with the results of an abnormal x-ray with evidence of a possible bowel obstruction.

Review of facility documents revealed the facility formulated preventive actions and mechanisms for nursing to ensure patient safety was maintained. The action plan included a performance improvement plan for one of the RNs that cared for the patient and failed to notify the surgeon of the patient's possible bowel obstruction and one of the nursing supervisors for not elevating critical lab results. Additional actions were implemented to ensure nursing supervision of all nurses by nursing supervisors on all shifts to ensure a Change of Condition documented on each patient was reviewed by nursing supervisors to ensure appropriate action/follow-through/escalation. The facility documented this would be completed 7/20/2016.

Review of the RN's personnel file revealed no evidence of a documented performance improvement plan following the events of 7/13/2016. There was evidence the RN was re-educated on change in condition, assessment/reassessment and critical thinking on7/19-7/20/2016. The education document stated the RN would be assigned a mentor per shift until the RN completed the Graduate Nurse Residency Revised Program.

Review of the nursing assignments revealed the RN returned to work at the facility on 7/24/2016. There was no documentation of the mentor that was assigned to the RN. Review of the medical record for patient #2 revealed the RN was assigned to care for the patient on 7/24/2016.

2. Review of the medical record for patient #2 was admitted on 7/14/2016 to the medical surgical unit.

Review of the patient's vital signs revealed on 7/23/2016 the blood pressure was 105-120s systolic over 58-70s diastolic with a heart rate of 80-100s.

Review of the RN nursing assessment on 7/24/2016 at 10:00 a.m. revealed the patient was noted as confused, alert and restless. The RN documented the patient's mental status had deteriorated and had no extremity strength. Breath sounds had bilateral expiratory wheezing noted. Review of the record revealed no evidence of any interventions or notification to the physician for the noted changes in the patient's condition.

On 7/24/2016 at 10:15 a.m. the RN noted the blood pressure was 68/50, pulse 105 and respirations 17. Review of the record revealed no evidence of any interventions or notification to the physician for the noted changes in the patient's condition.

On 7/24/2016 at 10:41 a.m. the RN documented at 10:25 a.m. a return to the patient's room for reassessment found the patient to be unresponsive with no spontaneous respirations and no palpable pulse. Review of the record revealed no evidence the RN provided any interventions or reported the change in the patient's condition at the time it was identified.

Review of the facility documents revealed the facility identified significant concerns with lack of nursing care for the patient. Interview with the Director of Quality Management/Risk Manager on 9/7/2016 at 1:50 p.m. revealed the facility had concerns related to the RN's lack of action and failure to rescue. She confirmed this was the same RN that was involved in the care of sampled patient #1. The facility could not provide documentation the RN was assigned a mentor during the first shift back to work, following re-education related to care and services for patient #1 and documentation a mentor would be assigned to the RN.

Review of the facility's documents revealed there was one change to the previous action plan put into place following the concerns identified on 7/12-7/13/2016. Review of the RN's personnel file revealed a performance improvement plan, dated 8/1/2016, that stated the nurse failed to render care to a patient and failed to elevate a change in the patient's condition to the physician and nursing supervisor. The action was termination of employment. There was no further changes to the facility's action plan that was put into place.

Review of the facility's action plan revealed as part of their corrective actions the nursing supervisors would review the Change of Condition documented on each patient on their assigned unit periodically throughout their shift to ensure appropriate action/follow-through/escalation. The facility documented this would be completed 7/20/2016.

3. Review of the facility a policy and procedure titled "Assessment/Reassessment-Interdisciplinary Patient" released 06/2016, showed the goal of the Assessment/Reassessment process was to provide an interdisciplinary approach for assessment(s) and ongoing reassessment(s) of individual patient care needs and for planning and implementing patient specific care.

Review of Patient #10's vital signs (VSs) record on 09/08/2016 at 8:30 a.m. showed on 08/20/2016 the patient's blood pressure (BP) was 120s to 130s over 60s to 80s with a heart rate (HR) in the 60s to 80s and respirations (RR) 16-20. On 08/20/2016 at 10:34 p.m. the patient's BP was 103/68 with a HR of 105 and RR of 18. Review of the telemetry readings (cardiac monitor) dated 08/20/2016 at 1:54 a.m. revealed a HR of 127 and RR of 24. RN #A failed to reassess the patient with significant difference in HR when compared to the telemetry reading. RN #A also failed to notify the physician of the significant changes in the patient's vital signs.

On 08/21/2016 at 6:14 a.m. patient #10's BP was 103/74 with a HR of 60 and RR of 20. Telemetry readings dated 08/21/2016 at 4:36 a.m. revealed a HR of 120 and RR of 20. At 8:05 a.m. telemetry readings indicated a HR of 112 and RR of 21. At 9:55 a.m. staff obtained vital signs revealed a BP of 94/74 and a HR of 106. At 10:26 a.m. staff obtianed VS were BP 99/62 with a HR of 115 and RR of 22. At 2:50 p.m. the BP was 97/52 with a HR of 111 and RR of 22 obtained by the staff. RN #D failed to assess the patient with a difference in readings from the telemety monitor and staff obtained VS.

On 08/22/2016 at 6:09 a.m. patient #10' s BP was 109/69 with a HR of 109 and RR of 20. At 10:14 a.m. the BP was 118/62 with a HR of 68 and RR of 18. At 8:13 a.m. telemetry readings indicated a HR of 116 and RR of 24. At 9:11 p.m. telemetry readings indicated a HR of 121 and RR of 33. RN #X failed to assess the patient with significant VS changes from telemetry to staff obtained VS.

On 08/23/2016 at 1:48 a.m. patient #10's BP was 93/53 with a HR of 62 and RR of 14. On 08/23/2016 at 2:55 p.m. patient #10 went into cardiac arrest, transferred to ICU and the VS continued to decline. The patient expired on 08/24/2016. LPN #F and RN #E failed to assess the patient with significant VS changes and failed to notify the physician of the changes.

An interview on 09/08/2016 at approximately 11:30 a.m. with the facility Education Coordinator confirmed the discrepancies were not assessed and confirmed the findings.

4. Facility Policy/protocol titled "Propofol Continuous Infusion for Sedation:, #H-MM Fé 60-011 A, stated "Assess patient vital signs, including cardiac rhythm, blood pressure,(to maintain SBP [systolic blood pressure] greater than 90) and oxygen saturation every 15 minutes during dose titration...Assess patient level of sedation every 2 hours using the facility specific sedation scale and document".

Facility Policy/protocol titled "Vasoactive Infusions", #H-MM 03-004, stated "Vasoactive infusions will be administered at the rate prescribed. Infusions may be titrated for the desired effect as stated and ordered by the Prescriber".

Facility Policy/protocol titled "Administration of Medications", #H-MM 05-001, stated "The individual administering the medication(s) must document all medications immediately after administration in the patient's medical record. Clinical assessment necessary before administering a specific type or dose of medication must be documented on the medication administration record [MAR] (example, pulse before digoxin, blood pressure before antihypertensive).

Review of the medical record for patient #3 revealed a physician order on 09/06/2016 at 11:25 a.m. for
a Propofol IV drip start at 5 mcg [micrograms] per kg [kilogram] per minute, titrate by 5 mcg/kg/min every 5 minutes until desired level of sedation achieved, Max rate 50 mcg/kg/min Start today (09/06/2016).
The documentation shows:
The documentation showed:
On 09/06/2016 at 11:55 a.m. the infusion started at 5 mcg/kg/min. On 09/06/2016 at 2:04 p.m. the infusion was titrated at 10 mcg/kg/min

Review of the medical record with the Risk Manager and the Pharmacy Director on 09/07/2016 at approximately 2:00 p.m. confirmed no documentation was noted within the medical record, including the medication administration record [MAR], indicating the patient's sedation level or desired sedation level. There was no documentation found for following the physician's order to "titrate by 5 mcg/kg/min every 5 minutes until desired level of sedation achieved".

A review of the medical record with an ICU RN [intensive care unit registered nurse] on 09/09/2016 at 1:30 p.m. confirmed the above findings and lack of documentation.

5. Review of the medical record for patient #13, located in the ICU, revealed a physician order dated 9/04/2016 at 3:27 p.m. for Propofol IV drip 10 mg/ml[10 milligrams per milliliter] Increase by 5 mcg/kg/min every 5 minutes until desired level of sedation achieved Start STAT (09/04/2016).

Nursing documentation revealed:
09/05/2016 at 7:44 a.m. the infusion was started at 5 mcg/kg/min.
09/05/2016 at 7:55 a.m. the infusion was titrated at 10 mcg/kg/min.
09/05/2016 at 10:28 p.m. the infusion was titrated at 8 mcg/kg/min.
09/05/2016 at 11:24 p.m. the infusion was continued 8 mcg/kg/min.
09/06/2016 at 2:01 a.m. the bag and tubing was changed. The infusion was at 10 mcg/kg/min.
09/06/2016 at 7:53 a.m. the infusion continued at 10 mcg/kg/min.
09/06/2016 at 9:49 a.m. the infusion was titrated at 12 mcg/kg/min.
09/06/2016 at 4:27 p.m. the bag and tubing was changed. The infusion was at 12 mcg/kg/min.
09/06/2016 at 8:15 p.m. the infusion was titrated at 15 mcg/kg/min.
09/07/2016 at 9:09 a.m. the infusion continued 15 mcg/kg/min.

A review of the medical record with the Risk Manager and the Pharmacy Director on 09/07/2016 at approximately 2:00 p.m. confirmed no documentation within the medical record including the MAR indicating the delay in starting a "STAT" medication or the patient's sedation level or desired sedation level. No documentation was found for following physician's order to "titrate by 5 mcg/kg/min every 5 minutes until desired level of sedation achieved".

A review of the medical record with an ICU RN on 09/09/2016 at 1:30 p.m. confirmed the above findings and lack of documentation.

6. Review of the medical record for patient #14, located in the ICU, revealed a physician order dated 9/04/2016 at 10:20 a.m. for: niCARdipine hydrochloride IV drip, Titrate 2mg/hr every 5 minutes (rapid titration) to 15 minutes (gradual titration). Max dose 15 mg/hr. Decrease to 3 mg/hr IV after reaching SBP less than 160. Start today 09/04/2016.
The documentation showed:
09/04/2016 at 10:58 a.m. the infusion was started at 2.5 mg/hr. There was no SBP documented.
09/04/2016 at 10:59 a.m. the bag and tubing was changed. The infusion was 2.5 mg/hr. There was no SBP documented.
09/04/2016 at 11:00 p.m. had no titration specified. There was no SBP documented.
09/05/2016 3:45 a.m. the infusion was titrated up to 5 mg/hr. The SBP was recorded as 175.
09/05/2016 at 5:10 a.m. the bag was changed. The infusion was 7.5 mg/hr. There was no SBP documented.
09/05/2016 at 8:07 a.m. the infusion continued at 7.5 mg/hr. There was no SBP documented.
09/05/2016 at 8:10 a.m. the infusion was titrated up to 9 mg/hr. The the SBP was recorded as 156.
09/05/2016 at 9:00 a.m. the bag was changed. The SBP was not documented.
09/05/2016 at 12:07 p.m. the bag was changed. The SBP was not documented.
09/05/2016 at 2:20 p.m. the bag was changed. The SBP was not documented.
09/05/2016 at 4:38 p.m. the bag was changed. There was no SBP documented
09/05/2016 at 6:46 p.m. the bag was changed. The SBP was not documented.
09/05/2016 at 9:18 p.m. the bag and tubing was changed. The SBP was not documented.
09/05/2016 at 11:16 p.m. the infusion was titrated down to 10 mg/hr. There SBP recorded was 132.

A review of the medical record with the Risk Manager and the Pharmacy Director on 09/07/2016 at approximately 2:00 p.m. confirmed no documentation within the medical record including the MAR indicating why the medication was not titrated per physician order or why the SBP was not recorded consistently.

A review of the medical record with an ICU RN on 09/09/2016 at 1:30 p.m. confirmed the above findings and lack of documentation.

7. Review of the medical record for patient #12, located in the ICU, revealed a physician order, dated 9/03/2016 at 10:20 a.m. for niCARdipine hydrochloride IV drip, titrate to keep SBP [systolic blood pressure] less than 160.

Nursing documentation revealed:
09/03/2016 at 10:52 a.m. the infusion was started at 5 mg/hr (5 milligrams per hour). There was no systolic blood pressure documented.
09/03/2016 at 11:30 a.m. the infusion was titrated up to 7.5 mg/hr. The SBP was recorded as 189.
09/03/2016 at 11:43 a.m. the infusion was titrated up to 10 mg/hr. The SBP was recorded as 199.
09/03/2016 at 12:35 p.m. the infusion was titrated down to 5 mg/hr. The SBP was recorded as 91
09/03/2016 at 8:11 p.m. Infusion continues at 5 mg/hr. There was no SBP documented.
09/03/2016 at 10:34 p.m. the bag was changed and continued at 5 mg/hr. There was no SBP documented.
09/04/2016 at 3:36 a.m. the bag was changed and continued 5 mg/hr. There was no SBP documented.
09/04/2016 at 9:06 a.m. the infusion was titrated up to 7.5 mg/hr. There was no SBP recorded at 162.
09/04/2016 at 1:31 p.m. the bag changed and the titrate was not specified. The SBP was not documented.
09/04/2016 at 2:26 p.m. the infusion was titrated down to 5 mg/hr. The SBP was recorded as 108.
09/04/2016 at 6:04 p.m. the infusion was titrated up to 7.5 mg/hr. The SBP recorded as 94.
09/04/2016 at 6:05 p.m. the bag was changed. The titration was not specified. The SBP was not documented.
09/04/2016 at 8:51 p.m. the infusion continued at 7.5 mg/hr. The SBP was not documented.
09/04/2016 at 9:01 p.m. The bag and tubing was changed. There was no SBP documented.
09/04/2016 at 9:02 p.m. the infusion was titrated down to 5 mg/hr. The SBP was recorded as 110.
09/07/2016 at 7:00 a.m. the documentation revealed the medication bag was changed and the infusion continued at 5 mg/hr. The SBP was not documented.

Review of the medical record with the Risk Manager and the Pharmacy Director on 09/07/2016 at approximately 2:00 p.m. confirmed there was no documentation within the medical record including the MAR indicating why the SBP was not recorded consistently or why the medication was increased with a SBP of 94 when the physician order to keep SBP less than 160 had been achieved and no titration was required.

A review of the medical record with an ICU RN on 09/09/2016 at 1:30 p.m. confirmed the above findings and lack of documentation.

Based on review of facility documents, nursing staff personnel files and staff interviews it was determined the facility failed to ensure nursing personnel were monitored and assigned patients in accordance with their qualifications and competence.

Findings included:

Review of facility documents revealed the facility identified RN (Registered Nurse) (#I) had failed to recognize the implications of abnormal vital signs with signs and symptoms of nausea and vomiting of coffee-ground emesis. The RN failed to communicate the patient's change in condition to the oncoming shift RN. The facility identified the RN failed to document and carry out a physician order to contact the surgeon to inform him of x-ray results indicating the patient had a possible ileus or blockage with evidence of hypotension, hypothermia, nausea and vomiting of coffee-ground emesis.

Review of the medical record for patient #1 revealed the oncoming RN #D informed the nursing supervisor #R of RN #I's failure to document the order to contact the surgeon with the results of the x-ray. Review of the nursing documentation revealed the RN nursing supervisor #R told the RN #D to defer to the patient's attending physician. Documentation revealed two calls were placed to the physician with no evidence of a call back. Review of the nursing documentation by RN #D revealed nursing supervisor #R told the RN #D to follow up with the surgeon in the morning at 5:00 a.m.

Review of the medical record revealed the patient's condition declined and at 4:50 a.m. a rapid response was called for a decline in the patient's heart rate on the telemetry monitor and unresponsiveness as assessed by the RT (Respiratory Therapist). Documentation of the rapid response form revealed the patient went into cardiac arrest and following ACLS (Advanced Cardiovascular Life Support) the patient expired at 5:55 a.m.

Review of facility documents revealed an action plan was put into place by the facility. Review of the action plan revealed RN #I would have a performance improvement plan implemented and that RN #I would be reinstated to the facility's New Grad Program led by the Director of Education.

Review of the personnel file for RN #I revealed no evidence of a documented performance improvement plan as stated by the facility's corrective action plan. Review of the personnel file revealed re-education was provided to the RN on 7/19-7/20/2016. Documentation on the re-education form revealed the RN must attend the next scheduled Graduate Nurse Residency Revised Program and the RN would be assigned a mentor per shift until the Graduate Nurse Residency Revised Program was completed.

Review of the personnel file for RN #I revealed the RN was hired in 2/2016. Review of the personnel file revealed the RN received his RN license on 6/30/2015. Review of the RN's previous history revealed no evidence of any medical/surgical experience.

Interview with the Education Coordinator on 9/8/2016 at 3:30 p.m. revealed the facility implemented a New Grad Program in April 2016 but that RN #I did not participate because the program had started after he was already hired.

Review of the nursing assignments revealed the RN returned to work at the facility on 7/24/2016. There was no documentation of the mentor that was assigned to the RN.

Review of medical record for patient #2 revealed the patient was assigned to RN #I on 7/24/2016. He assumed care of the patient at 7:00 a.m. Review of nursing documentation revealed the RN identified and assessed a change in the patient's condition at 10:00 a.m. and noted the patient's mental status had deteriorated. Review of the record revealed no evidence of any interventions or notification to the physician. Review of facility documents revealed RN #I failed to report the change in the patient's condition to the physician.

Nursing documentation by RN #I revealed at 10:15 a.m. the patient's blood pressure was 68/50, pulse 105 and respirations 17, a significant change in the patient's condition. At 10:25 a.m. documentation by RN #I stated he returned to the patient's room to reassess the patient and found the patient unresponsive with no spontaneous respirations and no palpable pulse. Documentation revealed the nursing supervisor was notified. The RN documented the patient was a DNR (Do Not Resituate). Review of the physician orders confirmed the findings.

Review of facility documents revealed RN #I failed to report a change in condition and failed to rescue the patient. Review of the facility's corrective action plan revealed the same action plan that was implemented for the events of 7/13/2016 with one exception. Review of the personnel file for RN #I revealed a performance improvement plan, dated 8/01/2016. Review of the plan revealed the reason for the performance improvement plan was for failure to render care to a patient and failure to elevate a change in the patient's condition to the physician and nursing supervisor. The facility's action was termination of RN #I.

An interview was conducted with the Education Coordinator on 9/8/2016 at approximately 3:30 p.m. She confirmed review of the personnel file did not reveal evidence of a performance improvement plan following the event of 7/13/2016 for patient #1.

An interview was conducted with the Chief Clinical Officer on 9/9/2016 at approximately 4:15 p.m. He confirmed there was no documentation RN (#I) had a mentor assigned upon his return to patient care on 7/24/2016.

Based on review of medication administration record, facility policy and interviews it was determined the facility failed to administer and document medications as ordered on four (#3, #12, #13, #14) of six Intensive Care Unit patients of fourteen patients sampled.

Findings included:

Facility Policy/protocol titled: Propofol Continuous Infusion for Sedation, #H-MM Fé 60-011 A, states: "Assess patient vital signs, including cardiac rhythm, blood pressure,(to maintain SBP [systolic blood pressure] greater than 90), and oxygen saturation every 15 minutes during dose titration...Assess patient level of sedation every 2 hours using the facility specific sedation scale and document".

Facility Policy/protocol titled: Vasoactive Infusions, #H-MM 03-004, states: "Vasoactive infusions will be administered at the rate prescribed. Infusions may be titrated for the desired effect as stated and ordered by the Prescriber".

Facility Policy/protocol titled: Administration of Medications, #H-MM 05-001, states: "The individual administering the medication(s) must document all medications immediately after administration in the patient's medical record. Clinical assessment necessary before administering a specific type or dose of medication must be documented on the medication administration record [MAR] (example, pulse before digoxin, blood pressure before antihypertensive)".

Facility Policy/protocol titled: Administration of Medications, #H-MM 05/001 PRO, stated "STAT is defined as designation for an actual emergency or life-threatening situation where an immediate response is required".

An interview and record review with the Pharmacy director and the Risk Manager on 09/07/2016 at approximately 2:00 p.m. revealed the facility did not have policy or protocols for all Intravenous [IV] drip medications.


1. Review of the medical record for patient #3 revealed a physician order on 09/06/2016 at 11:25 a.m. for
a Propofol IV drip start at 5 mcg [micrograms] per kg [kilogram] per minute, titrate by 5 mcg/kg/min every 5 minutes until desired level of sedation achieved, Max rate 50 mcg/kg/min Start today (09/06/2016).
The documentation showed:
On 09/06/2016 at 11:55 a.m. the infusion started at 5 mcg/kg/min. On 09/06/2016 at 2:04 p.m. the infusion was titrated at 10 mcg/kg/min

Review of the medical record with the Risk Manager and the Pharmacy Director on 09/07/2016 at approximately 2:00 p.m. confirmed no documentation was noted within the medical record, including the medication administration record [MAR], indicating the patient's sedation level or desired sedation level. There was no documentation found for following the physician's order to "titrate by 5 mcg/kg/min every 5 minutes until desired level of sedation achieved".

A review of the medical record with an ICU RN [intensive care unit registered nurse] on 09/09/2016 at 1:30 p.m. confirmed the above findings and lack of documentation.

2. Review of the medical record for patient #13, located in the ICU, revealed a physician order dated 9/04/2016 at 3:27 p.m. for Propofol IV drip 10 mg/ml[10 milligrams per milliliter] Increase by 5 mcg/kg/min every 5 minutes until desired level of sedation achieved Start STAT (09/04/2016).

Nursing documentation revealed:
09/05/2016 at 7:44 a.m. the infusion was started at 5 mcg/kg/min.
09/05/2016 at 7:55 a.m. the infusion was titrated at 10 mcg/kg/min.
09/05/2016 at 10:28 p.m. the infusion was titrated at 8 mcg/kg/min.
09/05/2016 at 11:24 p.m. the infusion was continued 8 mcg/kg/min.
09/06/2016 at 2:01 a.m. the bag and tubing was changed. The infusion was at 10 mcg/kg/min.
09/06/2016 at 7:53 a.m. the infusion continued at 10 mcg/kg/min.
09/06/2016 at 9:49 a.m. the infusion was titrated at 12 mcg/kg/min.
09/06/2016 at 4:27 p.m. the bag and tubing was changed. The infusion was at 12 mcg/kg/min.
09/06/2016 at 8:15 p.m. the infusion was titrated at 15 mcg/kg/min.
09/07/2016 at 9:09 a.m. the infusion continued 15 mcg/kg/min.

A review of the medical record with the Risk Manager and the Pharmacy Director on 09/07/2016 at approximately 2:00 p.m. confirmed no documentation within the medical record including the MAR indicating the delay in starting a "STAT" medication or the patient's sedation level or desired sedation level. No documentation was found for following physician's order to "titrate by 5 mcg/kg/min every 5 minutes until desired level of sedation achieved".

A review of the medical record with an ICU RN on 09/09/2016 at 1:30 p.m. confirmed the above findings and lack of documentation.

3. Review of the medical record for patient #14, located in the ICU, revealed a physician order dated 9/04/2016 at 10:20 a.m. for: niCARdipine hydrochloride IV drip, Titrate 2mg/hr every 5 minutes (rapid titration) to 15 minutes (gradual titration). Max dose 15 mg/hr. Decrease to 3 mg/hr IV after reaching SBP less than 160. Start today 09/04/2016.
The documentation showed:
09/04/2016 at 10:58 a.m. the infusion was started at 2.5 mg/hr. There was no SBP documented.
09/04/2016 at 10:59 a.m. the bag and tubing was changed. The infusion was 2.5 mg/hr. There was no SBP documented.
09/04/2016 at 11:00 p.m. had no titration specified. There was no SBP documented.
09/05/2016 3:45 a.m. the infusion was titrated up to 5 mg/hr. The SBP was recorded as 175.
09/05/2016 at 5:10 a.m. the bag was changed. The infusion was 7.5 mg/hr. There was no SBP documented.
09/05/2016 at 8:07 a.m. the infusion continued at 7.5 mg/hr. There was no SBP documented.
09/05/2016 at 8:10 a.m. the infusion was titrated up to 9 mg/hr. The the SBP was recorded as 156.
09/05/2016 at 9:00 a.m. the bag was changed. The SBP was not documented.
09/05/2016 at 12:07 p.m. the bag was changed. The SBP was not documented.
09/05/2016 at 2:20 p.m. the bag was changed. The SBP was not documented.
09/05/2016 at 4:38 p.m. the bag was changed. There was no SBP documented
09/05/2016 at 6:46 p.m. the bag was changed. The SBP was not documented.
09/05/2016 at 9:18 p.m. the bag and tubing was changed. The SBP was not documented.
09/05/2016 at 11:16 p.m. the infusion was titrated down to 10 mg/hr. There SBP recorded was 132.

A review of the medical record with the Risk Manager and the Pharmacy Director on 09/07/2016 at approximately 2:00 p.m. confirmed no documentation within the medical record including the MAR indicating why the medication was not titrated per physician order or why the SBP was not recorded consistently.

A review of the medical record with an ICU RN on 09/09/2016 at 1:30 p.m. confirmed the above findings and lack of documentation.

4. Review of the medical record for patient #12, located in the ICU, revealed a physician order, dated 9/03/2016 at 10:20 a.m. for niCARdipine hydrochloride IV drip, titrate to keep SBP [systolic blood pressure] less than 160.


Nursing documentation revealed:
09/03/2016 at 10:52 a.m. the infusion was started at 5 mg/hr (5 milligrams per hour). There was no systolic blood pressure documented.
09/03/2016 at 11:30 a.m. the infusion was titrated up to 7.5 mg/hr. The SBP was recorded as 189.
09/03/2016 at 11:43 a.m. the infusion was titrated up to 10 mg/hr. The SBP was recorded as 199.
09/03/2016 at 12:35 p.m. the infusion was titrated down to 5 mg/hr. The SBP was recorded as 91
09/03/2016 at 8:11 p.m. Infusion continues at 5 mg/hr. There was no SBP documented.
09/03/2016 at 10:34 p.m. the bag was changed and continued at 5 mg/hr. There was no SBP documented.
09/04/2016 at 3:36 a.m. the bag was changed and continued 5 mg/hr. There was no SBP documented.
09/04/2016 at 9:06 a.m. the infusion was titrated up to 7.5 mg/hr. There was no SBP recorded at 162.
09/04/2016 at 1:31 p.m. the bag changed and the titrate was not specified. The SBP was not documented.
09/04/2016 at 2:26 p.m. the infusion was titrated down to 5 mg/hr. The SBP was recorded as 108.
09/04/2016 at 6:04 p.m. the infusion was titrated up to 7.5 mg/hr. The SBP recorded as 94.
09/04/2016 at 6:05 p.m. the bag was changed. The titration was not specified. The SBP was not documented.
09/04/2016 at 8:51 p.m. the infusion continued at 7.5 mg/hr. The SBP was not documented.
09/04/2016 at 9:01 p.m. The bag and tubing was changed. There was no SBP documented.
09/04/2016 at 9:02 p.m. the infusion was titrated down to 5 mg/hr. The SBP was recorded as 110.
09/07/2016 at 7:00 a.m. the documentation revealed the medication bag was changed and the infusion continued at 5 mg/hr. The SBP was not documented.

Review of the medical record with the Risk Manager and the Pharmacy Director on 09/07/2016 at approximately 2:00 p.m. confirmed there was no documentation within the medical record including the MAR indicating why the SBP was not recorded consistently or why the medication was increased with a SBP of 94 when the physician order to keep SBP less than 160 had been achieved and no titration was required.

A review of the medical record with an ICU RN on 09/09/2016 at 1:30 p.m. confirmed the above findings and lack of documentation.