HospitalInspections.org

Based on document review and interview, it was determined for the ICU (intensive care unit), the Hospital failed to ensure there were enough nurses available to care for the patients, and for 3 of 4 patients (Pt's # 1, 2, and 10) clinical records reviewed for monitoring on the Telemetry unit and for 1 of 1 (Pt. #2) patients requiring glucose monitoring, the Hospital failed to ensure assessments and glucose monitoring were performed per policy or as ordered. This potentially placed all patients admitted to the hospital at risk for delay in bed placement and patient monitoring. Refer to deficiencies at A- 392, A-395 A & B. As a result, it was determined that the Condition of Participation for Nursing Services 482.23 was not in compliance.

1. The Hospital failed to ensure there were enough nurses available to care for the patients. See deficiency at A 392.

2. The Hospital failed to ensure assessments were completed upon admission and every 4 hours, as per policy. See deficiency at A-395 A.

3. The Hospital failed to ensure blood sugars were taken as ordered. See deficiency at A-395 B.

Based on document review and interview it was determined that for the ICU (intensive care unit), the Hospital failed to ensure there were enough nurses available to care for the patients. This potentially affected an average daily census of 6 patients in the ICU and patients in the emergency department (ED) waiting for ICU beds.

Findings include:

1. The staffing matrix for the hospital was reviewed on 8/9/17 at 2:00 PM. The matrix included that ICU has a nursing ratio of 1:3 (one nurse to three patients).

2. The ICU daily nursing assignments for June 2017 were reviewed on 8/10/17. The following dates/shifts were under staffed:
6/3/17 - 7:00 PM - 7:00 AM, ICU census 7 - two nurses on duty (1 short). This also caused one patient to wait in the ED for an ICU bed.
6/12/17 - 7:00 AM - 7:00 PM, ICU census 6 - 2 nurses on duty (census at limit for patient ratio). There were 3 patients in the ED waiting for beds in ICU.
6/14/17 - 7:00 PM - 7:00 AM, ICU census 7 - 2 nurses on duty (1 short).
6/16/17 - 7:00 PM -11:00 PM, ICU census 8 - 2 nurses on duty (1 short).
6/17/17 - 7:00 AM - 7:00 PM, ICU census 7 - 2 nurses on duty (1 short).
6/18/17 - 7:00 AM - 7:00 PM, ICU census 4 - 2 nurses on duty. There were 3 patients in the ED waiting for beds in ICU.
6/23/17 - 7:00 PM - 7:00 AM, ICU census 7 - 2 nurses on duty (1 short).

3. During an interview on 8/10/17 at approximately 2:00 PM, the Chief Nursing Officer (E#1) stated, "Our ICU ratio is 1:3. We are having a difficult time recruiting and retaining nurses". E#1 stated that patients are held in the ED because not enough nurses are on the units to care for the patients.

A. Based on document review and interview, it was determined that for 3 of 4 patients (Pt's # 1, 2, and 10) clinical records reviewed for monitoring on the Telemetry unit, the Hospital failed to ensure assessments were completed upon admission and every 4 hours, as per policy.

Findings include:

1. On 8/8/17 at approximately 2:15 PM, the Hospital's policy entitled "Assessment and Reassessment-Multidisciplinary (11/2014)" was reviewed and required, "...critical care initial assessment upon admission and reassessment Q4 hours in the format of flow record..."

2. The clinical record of Pt. #1 was reviewed on 8/10/17. Pt. #1 was a 53 year old admitted on 7/29/16 with the diagnoses of elevated troponin (measures heart damage) and cardiac arrhythmia (abnormal heart rate). Pt. #1 was admitted to the telemetry unit on 7/30/16 at approximately 4:00 AM. A physician's order dated 7/30/16 at 1:51 AM included, "Full admit - telemetry". The clinical record lacked documentation of telemetry strips while on the telemetry unit (upon admission and every four hours).

3. The clinical record of Pt. #2 was reviewed on 8/10/17. Pt. #2 was a 39 year old male admitted to the telemetry unit on 4/8/17 with the diagnosis of left foot ulcer. The clinical record lacked documentation of vital signs as follows:
4/9/17 missing 4:00 AM, 8:00 AM and 8:00 PM; and 4/11/17, missing 12:00 AM.

4. The clinical record of Pt. #10 was reviewed on 8/9/17. Pt #10 was a 81 year old female admitted on 7/22/17 with gastric perforation, gall stones and hematemesis. The clinical record lacked documentation of vital signs from 8/1/17 at 7:50 AM until 8/1/17 at 8:00 PM (missing 12:00 PM and 4:00 PM).

5. During an interview on 8/10/17 at 2:30 PM, the Accreditation and Regulatory Compliance Officer (E#3) stated, "All patients are monitored every four hours on the telemetry unit. This include vital signs and running a strip to place in the chart".


B. Based on document review and interview, it was determined for 1 of 1 (Pt. #2) patients requiring blood sugar monitoring, the Hospital failed to ensure blood sugars were taken as ordered.

Findings include:

1. The Hospital policy titled, "Mission and Scope of Services of the 3 ACU (revised 1/10)" was reviewed on 8/9/17. The policy required, "The patient can expect to receive care that is ... planned for and revised as needed".

2. The clinical record of Pt. #2 was reviewed on 8/10/17. Pt. #2 was a 39 year old male admitted to the telemetry unit on 4/8/17 with the diagnosis of left foot ulcer. A physician's order dated 4/8/17 at 8:08 PM included, "insulin protocol twice a day with sliding scale insulin". The glucose results were documented as follows: 4/9/17 at 10:15 AM - 307, 4/10/17 at 5:46 AM - 409, 4/11/17 at 4:30 AM - 687 and 4/11/17 at 10:45 - 582. (only one blood sugar was monitored each day).

4. During an interview on 8/10/17 at 2:30 PM, the Accreditation and Regulatory Compliance Officer (E#3) stated
that each nurse is to follow the physician's order as written.