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Based on interview and record review, the facility failed to implement a quality assessment and improvement program that was able to identify and analyze trends and patterns of adverse events and near misses, and failed to develop comprehensive corrective measures for an identified systems failure with the potential to cause serious patient harm, resulting in failure to identify and correct gaps in the provision of comprehensive care for all patients served by the facility. Findings include:
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A - 0286 -
1. The facility failed to trend adverse events and near misses to identify patterns or trends indicative of systems problems, resulting in failure to identify and correct gaps in the provision of comprehensive care for all patients served by the facility

2. The facility failed to perform a thorough root cause analysis and implement corrective measures for an allegation of patient neglect, and failed to implement comprehensive corrective measures after an adverse safety event resulting in the failure to identify and correct systems problems with the potential to result in serious patient harm.

Based on interview and record review the facility failed to trend adverse events and near misses to identify patterns or trends indicative of systems problems, failed to perform a thorough root cause analysis and implement corrective measures for an allegation of patient neglect for one (#1) of one patients with allegations of neglect reviewed, and failed to implement comprehensive corrective measures after an adverse safety event for one (#1) of two patients with documented safety events reviewed, resulting in the failure to identify and correct gaps in the provision of comprehensive care for all patients served by the facility, with the potential to result in serious patient harm. Findings include:

On 3/18/19 at approximately 1015 Staff A and Staff B were requested to provide for review a list of adverse events and near misses organized by category from 1/1/19 through 3/1/19 and a list of patient grievances received by the facility organized by category from 1/1/19 through 3/1/19.

On 3/18/19 at approximately 1500, a list of "Safety Solutions First Events" (adverse event/near misses) organized by date and a list of patient grievances organized by date was provided. No type of event, category of event, department involved, or concern was identified on either list. Staff A was requested to provide these lists organized by topic/subject or category.

On 3/18/19 at approximately 1515 Staff A stated that it would take "a little bit of time" to organize the "Safety Solutions First Events" list and the patient grievance list by category/concern/topic, as this was not something the facility usually compiled. Staff A said that Staff Q and Staff N would have to get help from the Informatics Department in order to organize their lists by subject matter/topic/category. Staff A was asked at this time how data from patient grievances and from adverse events and near misses was analyzed by the facility to look for patterns, trends or systems failures to identify potentially needed quality improvement projects. Staff A failed to answer the question.

On 3/18/19 at approximately 1400 the facility Blood Bank was toured and staff (#K, #L, #M) were interviewed regarding Blood Bank procedures for typing and screening for blood transfusions, procedures for pre-operative typing and screening and storage of preoperative blood samples for crossmatching, and dispensing blood products when ordered by the physician.

On 3/18/19 at approximately 1400 the lab manager Staff K was asked what would be done if there was a long delay of two to three hours in dispensing blood to a patient who had a STAT (urgent) order for blood products. Staff K stated, "We would write ourselves up (make a Safety Solutions First report) or the floor (nursing unit) would write us up." When asked if the lab tracked and trended delays or problems in dispensing blood products, Staff K stated, "We don't have a problem. There hasn't been any reason to have any Quality Improvement projects related to delays or problems in dispensing blood products."

When queried at this time, Staff L reported that there had been a recent "situation" involving Patient #1 where there was a delay in administration of urgently needed (STAT) blood products due to a "computer glitch" in the facility's electronic medical record system (EMR). Staff L reported that a "new" medical technologist (med tech) Staff M did not realize that the computer failed to store results when a patient came in for pre-operative (pre-op) testing before surgery for blood typing and screening and to give a blood sample to be stored for a crossmatch test in case a transfusion was needed during or after surgery. Staff L reported that when the patient was admitted for their surgery the computer EMR system deleted/discarded the pre-op test results and marked the stored blood sample expired . Staff L stated that to by pass this problem with the EMR, staff relied on a paper file with the relevant information written on a card which was kept in a paper accordion file folder on a laboratory (lab) counter top. Staff L stated that when the STAT order for blood for Patient #1 came in after his surgery, the Med Tech only checked in the computer to see if Patient #1 had results and a blood sample on file. When she saw they were discontinued (d/c'd) in the computer system, she had to get a new blood sample from the patient and do the blood typing/screening and crossmatching from scratch.

When asked at this time what was put in place to prevent this from happening again, potentially putting other patients in need of urgent blood transfusions at risk for serious harm or death from delayed treatment, Staff L said that she was writing a new Blood Bank policy to by pass the EMR problem, which she said they would not be able to fix. Staff L was asked to explain what changes in procedure she was putting in the new policy. Staff L was asked to provide a draft copy of the new policy and procedure that she was working on, but failed to do so by survey exit. Staff L stated that she hadn't had time to finish the policy yet and declined to show the surveyor what she had written so far.

On 3/18/19 at approximately 1430 Staff L and Staff K were asked what was done to ensure that other "new" med techs would not make the same mistake and rely on information in the EMR instead of a paper file to check for blood type and screen results and the availability of a stored patient blood sample to use for crossmatching. Staff L and Staff K were unable to provide an answer to this at this time. Staff L and Staff K were unable to state that this concern with the EMR was brought to the attention of the lab Medical Director, the facility Information Technology (IT) Department, or the Quality Department to work on a systems correction for this problem with the EMR. Staff L was asked if Blood Bank staff were educated (inserviced) to make sure that all staff were aware that they needed to ignore the results in the EMR and consult the paper file instead when looking for blood type and screen results for surgical patients. Staff K said that he didn't document staff education on this but said that it was discussed during the daily huddle (staff meeting at the start of each shift).

On 3/19/19 at approximately 1600 Staff K provided documentation of a routine daily staff meeting (Daily Muster) dated 2/15 (no year noted) that included as one of the items discussed, "Delay in blood products. (Staff L) will update procedure regarding patient history checks". No outline or details were provided and there was no documentation of staff attendance.

A second document provided by Staff K at this time entitled, "Blood Bank Staff List" contained the following notations, "please review the following procedures. Sign and date this form: "Patient history check - HCLL (rest of policy number, computer retrieval information missing), Receiving Patient Specimen - HCLL (rest of policy number, computer retrieval information missing)". Five of 15 med techs in the facility signed this form on 3/18/19 (the date of the survey). These policies were requested but not provided by survey exit.

On 3/18/19 at approximately 1451 a patient Grievance (a complaint that cannot be immediately resolved) submitted by Patient #1's spouse was reviewed. The grievances included an allegation of a delay in providing an urgent (STAT) blood transfusion and also a failure to assess and monitor Patient #1 after surgery (neglect) . The grievance resolution file for this grievance was requested for review as the list of grievances by category was not yet provided. The Patient Relations Manager, Staff N was interviewed at this time during a review of this grievance investigation and followup. Staff N stated that she was responsible for investigating patient Grievances and coordinating the facility follow up to these grievances. The following information was revealed in the provided Grievance file for Patient #1:

A letter from Patient #1's spouse, dated 2/6/19 and dated as received by the facility on 2/11/19 revealed there were two allegations (of 9 grievances made) of patient neglect that had the potential to result in serious patient harm or death.

One grievance was related to a delay in administering an urgent (STAT) blood transfusion to Patient #1 after post-op bleeding and hypotension required him to be transferred to the Intensive Care Unit (ICU) with diagnoses of Hypotension (low blood pressure) and Hemorrhagic Shock after Post Surgical Bleeding. The allegations of neglect were allegations that the nurse on 6S (medical surgical unit where Patient #1 went after surgery to complete his post-operative recovery) failed to monitor him for post operative complications, resulting in a failure to detect and treat hypotension (low blood pressure) and bleeding from the surgical drain (Jackson-Pratt drain) and the surgical site in a timely manner.

Patient #1 was a 76 year old male who had Davinci laparoscopic robotic prostatectomy at the facility on 1/25/19. Diagnoses included Malignant Neoplasm of Prostate, Prostate Hypertrophy, and Hypertension. Patient #1 was discharged from the facility on 1/29/19.

Email responses from relevant department heads in response to emailed questions from Staff N were included in the grievance investigation file and included the following:

An email response from the Lab Manager Staff K dated 2/13/19 at 1537 noted the following, "This patient was drawn (blood collected) as an outpatient ahead of surgery for a type and screen (blood typing and screening for antibodies to blood). This tube would have been valid for 14 days to allow blood products to be given to the patient. when the system (EMR) discharges the patient account, it sometimes "discards" this tube in our blood bank system. the tube is actually still in blood bank, still valid, and the tech is able to correct this error if caught. the tech working this day went by the fact the system said the specimen was outdated and asked for a new specimen to be collected. The type and screen was ordered at 1805. it was collected at 1830. The type and screen was completed by 1927 and the crossmatch at 1928. Nursing would have been notified immediately."

When queried at this time, Staff N was unaware that Patient #1's blood transfusion was ordered on 1/25/19 at 1711 and the transfusion was not started until 1/25/19 at 2020 (a delay of three hours and nineteen minutes) so the complainant's grievance was substantiated, and Staff K's timeline was inaccurate which minimized the seriousness of the problem. Staff N stated that she relied on the department managers to investigate grievances and did not check to ensure that the investigation was thorough or accurate.

An email response from the 6S unit manager Staff H to Staff N recorded Staff H's investigation of the allegation that Nursing staff failed to monitor Patient #1 post-operatively. This email stated, "The nurse who was taking care of the patient was giving blood. She popped in to help pull the patient over, an then others were checking on the patient. Not just nursing assistants (NA) but other nurses were helping, and monitoring the situation , and post surgical vitals were being completed.

Staff N stated that she did not review Patient #1's medical record herself and was unaware that there was no nursing documentation to indicate that Patient #1 was monitored by nursing staff for post-op complications such as hypotension, nausea and vomiting or excessive bleeding for over four hours after surgery. Staff N was unaware that post-op vital signs were automatically recorded by the automatic blood pressure machine but were not looked at by staff for over four hours. Staff N was unable to explain how Quality Improvement measures would be implemented if quality concerns were not detected due to failure to conduct an accurate and complete investigation of quality of care concerns brought to the facility's attention through the patient complaint and grievance process.

On 3/18/19 at approximately 1520 Staff N what was done to ensure these issues were brought to the attention of the Quality Improvement Department so that a systems correction could be implemented. Staff N was unable to answer this question and said, " the file is still open. I haven't closed it yet (completed it). The File contained the "Grievance Resolution letter (completion and summary to the complainant)" to Patient #1's spouse dated 2/20/19 indicating that Staff N and the facility had completed the investigation and closed the case.

Staff N replied that she relied on the relevant department heads to do the investigation and follow-up related to their departments. There were no recommended corrective measures, and no documentation that this was brought to the attention of facility administration, the relevant Department Medical Directors or the Quality Improvement Department.

On 3/18/19 at approximately 1600 The Director of Patient Care Services Staff B and the Quality Data specialist Staff A were asked if they were aware of the problems identified related to Patient #1's care in the facility. Both stated that these issues had not been brought to their attention. Staff B stated that she would have like to know about the failure to monitor Patient #1's blood pressures and surgical sites post-operatively on 6S before it was brought to her attention on survey.

On 3/19/19 at approximately 1040 a list of "Safety First Solutions" (adverse events and near misses) was provided for review by Staff Q. Two adverse events (Patients #1 and #10) were selected for review with Staff A, Staff B, Staff Q, Staff R and Staff S. Findings were as follows:

Patient #10 was a 58 year old male. The Safety First Solutions event was dated 1/15/19 and was categorized s a "Delay of response to patient condition". Review of the facility investigation and root cause analysis of this event revealed the concern was related to a phsyician failure to enter an order into the electronic medical record (EMR) for a physician consultant to see the patient. The concern was referred for follow-up with the Leadership Council. No concerns were noted with this file, and no nursing concerns related to delay in care or neglect were noted on the list of Safety First Solutions Events.

The adverse events/near misses regarding Blood Bank on the list of Safety First Solutions Events were reviewed and all except for the event related to Patient #1 were related to blood products that were not used when ordered.

A Safety First Solutions Event for Patient #1 was dated 2/13/19 (same date as the Grievance file was opened for Patient #1, and two days after Patient #1's spouse's grievance letter alleging a 4 hour delay in receiving a STAT transfusion was received). The file stated that the incident was reported by Patient #1's surgeon on 2/13/19. Patient #1 was discharged from the facility on 1/29/19.

The Safety First investigation attributed the delay in transfusion to "human factors". The Safety First investigation result was documented as, "Neither the lab nor Pre-op initiated the pre-op labs phase of care, so no pre-op labs were run. Orders were there, they were not initiated. The tech working that day went by the fact that the system said the specimen was outdated and asked for a new specimen to be collected. Once notified, it only took 1.5 hours to have the blood ready." The only corrective measure noted was that Staff L was working on a new policy. There was no documentation to indicate that the concern was brought to the attention of facility administration, the Laboratory Department Medical Director, the Patient Informatics Department (IT) or the Quality Improvement Department.

Staff B, Staff R and Staff S were interviewed at this time and stated that there was no documentation to indicate what time on 1/25/19 the blood arrived on the unit for Patient #1's transfusion, but Blood Bank staff provided documentation that the blood was issued at 1947 on 1/25/19. Review of transfusion records revealed Patient #1's first transfusion was started on 125/19 at 2020 (a delay of three hours and nineteen minutes after it was ordered), not the one and 1/2 hours delay documented in the Safety First Solutions investigation summary. This inaccurate report of the amount of delay in a life saving treatment had the potential to result in minimizing the seriousness of the event and decreasing the severity of the incident, leading to a potential failure to bring it to the attention of the Quality Improvement Department for review.

Based on observation, interview and record review the facility failed to provide organized nursing services which followed the nursing process of identifying and responding to patient needs through assessment, care planning and documentation resulting in unmet care needs for four (#1, #3, #5, and #7) of four patients reviewed for post-operative or invasive device care out of a total sample of 10. Findings include:

See specific Tags:

A 0395 - Failure to assess and monitor a patient for post-operative complications for one (#1) of four reviewed

A 0396 - Failure to perform wound care and dressing changes for surgical incisions and Jackson Pratt insertion sites for three (#3, #5, and #7) of three patients with incisions or drains reviewed for Nursing Care Plans.

A- 405 - Delay in dispensing and administering biologicals (blood products) for one (#1) of one patients reviewed for STAT (urgent) orders for blood product administration.

Based on interview and record review the facility failed to ensure that a registered nurse supervised nursing care and provided timely assessment and monitoring for post-operative complications after transfer to an inpatient nursing unit for one of four (#1) post-operative patients reviewed for post operative care on the 6 South nursing unit, resulting in a possible delay in treatment for postoperative hemorrhage, hypotension, and hemorrhagic shock. Findings include:

On 3/18/19 at approximately 1530 Patient #1's clinical record was reviewed with Staff A, Staff B, Staff R and Staff S and revealed the following information:

Patient #1 was a 76 year old male who had Davinci laparoscopic robotic prostatectomy at the facility on 1/25/19. Diagnoses included Malignant Neoplasm of Prostate, Prostate Hypertrophy, and Hypertension.

A Surgeon's Operative Report dated 1/25/19 at 1228 that Patient #1's surgery was complicated by adhesions (scaring) in the abdomen and, " the size of the prostate as well as the immobility of the prostate within the pelvis." A #10 flat Jackson-Pratt (JP) drain (100 milliliter bulb reservoir) was inserted into the pelvis and brought out through the left side port (an abdominal surgical incision made for the Davinci robotic device). The skin incisions (ports for the robot and camera) were sutured and dry sterile dressings were applied. (A Jackson-Pratt drain is a post operative drain for collecting body fluids from surgical sites)

Patient #1 was transferred from the operating room to the Post-Anesthesia Care Unit (PACU) on 1/25/19 at approximately 1228 and was "handed off" (transferred ) to the 6 South (6S) on 1/25/19 at approximately 1340.

A Critical Care Consultant Physician's Note dated 1/25/19 at 1806 documented that Patient #1 was transferred to ICU sometime after 1723 on 1/25/19 after an Rapid Response Team intervention (a medical emergency team that responds to patients with early signs of deterioration on non-intensive care units to prevent respiratory or cardiac arrest) for "Hypotension after Post-Surgical Bleed" and "Hemorrhagic Shock". The consultant's summary for Patient #1 was documented as, "Upon my evaluation, this patient had a high probability of imminent or life-threatening deterioration due to hemorrhagic shock due to intra-abdominal bleeding and he has anemia due to acute blood loss and abdominal wall subcutaneous emphysema."

On 3/19/19 at approximately 0920 Post Anesthesia Care Unit (PACU) nurse Staff F was interviewed and reported that she assessed Patient #1's JP dressings just before she transferred him to 6S at approximately 1340 on 1/25/19. Staff F stated that she saw a "shadow" (blood visible under the dressing) on his Jackson Pratt (JP) drain site dressing when she assessed him before she transferred him to 6S so she changed the JP site dressing. Staff F documented on 1/25/19 at 1328 that she changed the JP site dressing, emptied 55 milliliters (ml) out of the (100 ml) JP bulb/receptacle and also reinforced (added another layer of padding) the surgical incision dressing because it had a moderate amount of serosanguinous drainage leaking through. Staff F reported that this information was faxed to 6S and entered into Patient #1's electronic Medical Record (EMR) 20 minutes before he was transferred to 6S at 1340. Staff F was able to provide documentation on the EMR that she "handed off" Patient #1 to (staff name was not documented) 6S staff at 1340.

The first Nursing documentation to indicate that Patient #1 was seen by a nurse was dated 1/25/19 at 1630 (2 hours and 50 minutes after transfer from PACU). The nurse (Staff G) did not document that she physically assessed Patient #1, only verbal answers by Patient #1 or his family member to standard admission screening questions were documented.

A Surgery Physician's Progress Note dated 1/15/19 at 2015 documented that he was paged by nursing on 1/25/19 at 1541 (two hours after transfer to 6S) because Patient #1 was hypotensive (had severely low blood pressure) and had bleeding from the JP site. There was no Nursing documentation of this event and no nursing documentation that the Registered Nurse (RN) was the person who assessed the patient and called the physician.

The next Nursing documentation in the EMR was dated 1/25/19 at 1646 (three hours and six minutes after hand off to 6S from PACU.) This was on a "Clinical Information" flowsheet with a drop down menu selection for each field. The assessment was documented as an assessment of "incision/wound/skin (abdomen)" by Staff G. The flowsheet documented six surgical incisions, but did not note size or location. The documentation noted that there was moderate bloody drainage present and the dressing was changed (the number of and location of dressings changed and the amount of bloody drainage was not documented). "Site condition" was documented as bleeding red (bloody) drainage and 100 ml (out of a total bulb/JP reservoir capacity of 100 ml) was emptied from the JP bulb (reservoir). The gauze dressing around the JP was changed. No other nursing documentation was available. The JP reservoir was emptied of it's total maximum capacity, and the dressing around the JP insertion site was changed due to an unspecified (not documented) amount of bloody drainage on it.

It was not clear if the JP overflowed because the reservoir was not changed timely when it was 2/3 full (66 ml) per policy. There was no documentation to indicate that the amount of drainage in the JP was monitored every 15 minutes for the "first few hours on the medical surgical floor (6S) after surgery" per policy. There was no documentation that Patient #1 was assessed by a nurse for the first two hours to three hours on 6S after surgery per policy. There was no documentation that it was a nurse and not an auxilliary staff member who saw Patient #1's low blood pressure and JP site bleeding paged the physician at 1541 (two hours after transfer to 6S).

On 3/18/19 at approximately 1540 Staff S was interviewed regarding the facility automatic vital sign monitoring machine and it's interface with the facility EMR to record vital signs. Staff S said that staff could preselect how often the blood pressure cuff on the patient's arm would automatically pump up to take the patient's blood pressure, and other vital sign readings. Staff S said that these timed vital sign readings would be stored in an archived file on the patient's EMR until a nurse or nursing assistant (NA) "verified them" (looked at them and checked them) and uploaded these "verified" vital sign readings into the EMR. Staff S stated that these archived vital sign readings would be saved in the archive for 24 hours and the nurse could verify them and upload them at any time during this 24 hours. The times documented on the patient's vital sign record on the EMR were the preselected times programmed in by the nursing assistant or nurse at the beginning of the shift (or as needed). Staff S stated that the actual time the nurse "verified" (looked at) these vital signs could be seen if a reviewer right clicked the computer cursor on the entry. Staff S stated that it would take a nurse, "about 30 seconds and three clicks" to verify each automatically saved vital sign reading.

On 3/18/19 at approximately 1545 Patient #1's vital signs from 1/25/19 at 1338 (last vital sign recording from PACU) to 1/25/19 at 2000 (ICU) were reviewed with Staff S in the presence of Staff A, Staff B, and Staff R. This revealed that automatic vital sign recording intervals were selected for Patient #1 by Nursing Assistant (NA) Staff O. Right clicking the cumputer cursor on each entry time revealed the Nurse (Staff G) verified (looked at and assessed) Patient #1's blood pressure/vital signs on 1/25/19 at 1738 (after Patient #1 was transferred to the ICU for Hemorrhagic Shock after bleeding from a surgical incision.") Times of automatic Vital sign monitoring on 1/25/19 were noted as:

Pre-operative Blood Pressure (BP) = 127/98 (normal = 90-140/60-90)
1328: heart rate (HR) = 92 (normal 60-100), BP = 106/73 Monitored by PACU Staff Nurse F
1404: verified by by Staff G at 1738 (three hours and 34 minutes later), Pulse (P)= 82, BP 98/67 (drop in BP > 5 mm Hg)
1406: Verified by Staff O at 1406, P = 89, Respirations (R) = 16, BP not monitored
1419: P = 90, BP = 102/68
1434: verified by by Staff G at 1738, P = 95, BP = 92/63 (drop in BP > 5 mm Hg required to report to RN per policy)
1450: verified by by Staff G at 1738, P = 92, BP = 90/67
1504: verified by by Staff G at 1738, P = 96, BP = 95/57 (low value)
15:35: verified by by Staff G at 1738, P = 101 (high), BP = 78/58 (low)
1539: verified by by Staff G at 1738, P = 99, BP = 70/52 (low)
1540: Physician documented that an unknown staff member notified him that Patient #1 had bleeding and hypotension, fluid bolus given
1604: verified by by Staff G at 1738, (35 minutes of no vital sign recordings after an episode of hypotension and post surgical bleeding, P = 96, BP = 103/69
1635: verified by by Staff G at 1738 (31 minutes of no vital sign recording within first hour after an episode of hypotension and post surgical bleeding), P = 97, BP = 114/67
1704: verified by by Staff G at 1738, (29 minutes of no vital sign recording) P = 105 (high), BP = 115/72 (no vital sign monitoring or assessment documented after this high heart rate unitl 17 minutes later)
1721: Verified at by Staff G at 1721, P = 113 (high), BP = 62/35
1722: (Rapid Response (RRT) Record documentation) Heart Rate (HR) = 89, BP = 76/44
1726 : (RRT documentation) BP = 77/36
1732: (RRT documentation) BP = 122/62
1900: (ICU documentation) HR = 103 (high), BP = 100/53 (low)

A Physician's Surgery Progress Note dated 1/25/19 at 2015 documented that Patient #1 was seen at approximately 1700 on 1/25/19 for a Rapid Response (a medical emergency team that responds to patients with early signs of deterioration on non-intensive care units to prevent respiratory or cardiac arrest) which was called because Patient #1 was unresponsive (unconscious) with his blood pressure dropping to 60/40s (normal Blood pressure >90/60) and bleeding from his surgical sites. Patient #1 was transferred to the Intensive Care Unit (ICU).

On 3/18/19 at approximately 1600 Staff A, Staff B, Staff H, Staff R and Staff S were asked to provide the exact time Patient #1 was transferred to the ICU. This information was not provided by exit despite multiple requests.

On 3/18/19 at approximately 160 the 6S Unit Manager Staff H was interviewed and was unable to provide any additional documentation to indicate that Patient #1 was assessed and monitored for post operative complications by a Registered nurse per facility protocol after transfer to 6S. Staff H stated, "His initial nurse (Staff G) did not see him because she was busy giving a blood transfusion to another post-operative patient, but other nurses did his vitals per policy." Staff H was unable to provide any documentation of this. The nurse that she identified as the one who monitored Patient #1 vitals was unavailable for interview as she was no longer employed by the facility and the telephone number provided by the facility to contact her was disconnected.

On 3/18/19 at approximately 1615 Patient #1's assigned nurse on 6S Staff G was interviewed. Staff G stated., "Normally vital signs are delegated to the Nursing Assistant (NA). When he came up to the floor (6S) it took a nurse and two NA to get him from the gurney (stretcher) to the bed because he was a bigger guy. He had some nausea and was dry heaving. There was a one centimeter spot of blood underneath him when we transferred him off the gurney. He had some shadowing on the JP dressing (blood pooling under the bandage). I did the basics when I got him in but I didn't have time to chart (document).because I had to give a blood transfusion to another post-operative patient. His blood pressure was running a little low. He had an automatic blood pressure cuff. It automatically transfers the readings into (facility's EMR). I didn't save the vital signs that were recorded until five PM. The Nursing Assistant came to get me because his blood pressures were low. The Doctor came to see him and ordered a fluid bolus and the patient's blood pressures went back up. The patient was complaining of nausea and I left to get some (anti nausea medication) when he sat up to throw up, he passed out. and I called for help and we called an Rapid Response because his blood pressure was low and he was bleeding heavily."

During questioning at this time, Staff G reported that the JP should be checked hourly and emptied when it's half full or it will clot off and cause leakage. Staff G was unable to state that this was done or was unable to provide any documentation that it was done. Staff G was unable to explain the gaps in the timeline of her narrative regarding Patient #1 and was also unable to provide documentation that she assessed him every 15 minutes as required, emptied his JP recepticle before it overfilled and monitored him timely and appropriately for hypotension, bleeding, or nausea and vomiting.

On 3/19/19 at approximately 0930 Patient #1's Nursing Assistant on 6S, Staff O was interviewed by telephone. Staff O reported that she had 14-15 patients on average to care for, and cannot monitor all her patient's vital signs. Staff O stated she set up the automatic blood pressure cuff recording intervals for Patient #1 (every 15 minutes for the first hour, then every 30 minutes for two hours). Staff O stated that the only time she went in Patient #1's room after he arrived was when (Staff G) shouted for help from the doorway. Staff O stated she did not know what time that was but stated, "He was off his surgical vitals (checked every 15 minutes for the first hour, then every 30 minutes for two hours) when that happened."

On 3/19/19 at approximately 1100 the facility policy entitled, "Vital Signs, Post-op", number 40.4.252 revised 3/17 was reviewed with Staff B and Staff R. The following staff instructions were noted:

"Immediate Post-operative care continues in the ICU or medical-surgical unit for the first few hours if not discharged home:
Assess vital signs every (Q) 15 minutes x 4, every 30 minutes x 4 and then every 4 hours for the first 24 hours,
Assess cardiopulmonary status and neurovascular status, as described above ( Q 15 x 4 then Q 30 x 4),
Assess gastrointestinal status (e.g. nausea, flatus and bowel sounds),
Assess surgical site and drains (e.g. presence/absence and characteristics of drainage or bleeding,
If drainage or bleeding is present, mark dressing by circling the area of drainage with a marker and indicate the time. Repeat every 10 - 15 minutes,
Monitor for complications (see red flags),
Date and time of transfer to and from the unit,
Red Flags: Life threatening complications can occur in the immediate postoperative period includiing respiratory distress, vomiting and bleeding, hypothermia, oliguria (lack of urine)..."

All abnormal vitals need to be reported to the RN in charge of that patient. The RN will asssess the patient and compre current vitals to baseline vital signs before determining whether further intervention is needed. Changes to report to the RN include:
systolic BP < 90 or > 150 or diastolic BP <50 or >90,
a BP that shows a downward trend of 5 mm HG at each reading should also be reported

On 3/19/19 at approximately 1115 the facility policy entitled, "Drains: emptying and Removal of Wound Suction Drains policy # 40.4.253 revised 02/16 was revealed and revealed the following direction:

"When the drainage receptacle is on half to two-thirds full, it should be emptied and reset to apply suction."

Based on observation, interview and record review, the facility failed to ensure that the nursing care plan goal to promote healing was followed by ensuring that surgical drain insertion sites and surgical incisions were cleansed, assessed and the dressings changed timely for three (#3, #5, and #7) of three patients on the 6S unit with drains and surgical incisions assessed for Nursing Care Plans. Findings include:

On 3/18/19 at approximately 1200 during a tour of the 6S unit, Patients #s 3, 5, and 7 were observed and interviewed. Observation of Patient #3's and #5's surgical sites was not done as they were eating lunch at the time of interview. At the beginning of the tour (approximately 1200) The 6S Unit Manager Staff H and Staff Nurses I and J were asked if there any patients on the unit with wound care or dressing changes due on 3/18/19. All three nurses responded that they were unaware of any wound care or dressing changes due in any of the patients on 6S that day.

On 3/18/19 at approximately 1220, Patient #7 was observed and interviewed. Patient #7's dressings were observed. His surgical wound was covered with a specialized (wound vac) dressing that was changed by physicians only, and his two abdominal Jackson Pratt (JP) drain insertion sites (used to drain fluids after surgery) were covered with undated gauze dressings. Nurse J assisted with observation of Patient #7's surgical incision and drain site dressings. Patient #7 reported that he had abdominal surgery in the facility. Nurse J was asked when the dressings were changed and if they should be dated to indicate this. Nurse J stated that she did not know when they were changed and said that dressings should be dated and timed and initialed so staff could tell when the dressing was last changed. Patient #7 stated that he thought the dressings were put on in the operating room at the end of his surgery and weren't changed since. Patient #7 said, "The doctor came in and lifted the dressings up to check and then patted the dressings back down."

Patients #3 and #5 were unable to state when their drains or surgical dressings were changed and when wound cleansing or treatment was done.

On 3/19/19 at approximately 1100 Patient #7's clinical record was reviewed with Staff S and revealed the following information: Patient #7 was a 46 year old male who was admitted to the facility on 3/15/19 and had an exploratory laparotomy (abdominal surgery) on 3/15/19 at 1345. There were no wound care orders or dressing change orders for any of Patient #7's wounds (surgical incision or JP insertion sites). There was no nursing documentation that nursing staff assessed the JP insertion sites for signs of infection or poor wound healing.

Patient #3 and Patient #5 also had no documentation of surgical site or JP site wound care or dressing changes, or any documentation that nursing assessed the wounds for signs and symptoms of infection.

On 3/19/19 at approximately 1115 patient #3's clinical record was reviewed with Staff S and revealed the following information:

Patient #3 was a 79 year old female who was admitted on 3/4/19 and had surgery on 3/5/19 for an infected post-operative knee joint. She also had a hemovac drain (used to drain fluids after surgery). There were no physician orders for dressing changes or wound care. The first Nursing wound assessment documentation indicated that there was no dressing on the incision, but there was no documentation of when it was removed. There was no documentation to indicate whether the hemovac dressing was the only surgical dressing.

On 3/19/19 at approximately 1130 Patient #5's clinical record was reviewed with Staff S and revealed the following information: Patient #5 was an 80 year old male who had an open abdominal (not laparoscopic) surgery on 3/14/19 for a perforated gallbladder. He had two abdominal drains (JP) and a surgical incision. There were no orders for, or documentation of, incision or JP site wound assessment, wound cleansing and treatment, or dressing changes for gauze dressings placed on these incisions in the operating room more than 72 hours earlier. Patient #5's first documented surgical wound assessment was three days after surgery and did not document why there was no dressing on the incision, when the dressing was removed, who removed the dressing or how the wound was cleansed or cared for. There was no documentation for drain insertion site care, assessment or dressing changes.

There were no physician orders for dressing changes or wound care for all three (#3, #5, #7) post-surgical patients reviewed. There were no orders for Wound Care/Treatment Team consultations and no documentation by the Wound Care/Treatment team for any of the three (#3, #5, #7) surgical patients reviewed. There was no documentation on the type of surgical site dressing Patient #3 and #5 had but nurses documented each shift that the dressing was dry and intact. There was no documentation that these wounds were cleansed, treated or dressings changed regularly.

On 3/19/19 at approximately 1500 the facility policies and procedures on JP drains and for wound care were reviewed and revealed no clear Nursing guidance or instructions for wound care or dressing changes. The policies stated that nurses should refer to facility protocol (the facility had no protocol or standing orders for dressing changes or wound care per Staff A, #B, #D, #E #R and #S) or per physician orders (none noted on the three post-surgical charts reviewed) for wound care and dressing changes.

On 3/19/19 at approximately 1300 Staff B, Staff S and Staff R were asked about this and were unable to provide a policy for JP site care or dressing changes, for wound care or for frequency of gauze dressing changes. All three stated that it was not good nursing practice to leave a gauze dressing in place for more than 24 hours and that surgical incisions and JP insertion sites should be kept clean and assessed for signs of infection. When asked, Staff B and Staff R stated that once the physician does the first dressing change on a surgical incision, the physician should write orders for nursing to cleanse/treat the wounds and change the dressings. Staff B and Staff R noted that this was not done and that there was no facility protocol or standing orders for Nurses to follow if there were no physician orders for wound care of surgical incisions. When asked, Staff B and Staff R stated that there were no facility policies or protocols for how long a gauze dressing can be left in place without being changed or how often a surgical incision should be assessed or cleansed.

Based on interview and record review, the facility failed to ensure that a STAT (urgent) order to transfuse blood products to one (#1) of one patients in hemorrhagic shock (shock from blood loss) was dispensed in a timely manner, resulting in a delay in treatment for a potentially life threatening condition. Findings include:

On 3/18/19 at approximately 1400 the facility Blood Bank was toured and staff (#K, #L, #M) were interviewed at that time regarding Blood Bank procedures for typing and screening for blood transfusions, procedures for pre-operative typing and screening and storage of preoperative blood samples for crossmatching, and dispensing blood products when ordered by the physician.

The Blood Bank Supervisor, Staff L stated that when the laboratory (lab) received an urgent (STAT) order for blood if they had a pre-operative (pre-op) type and screen, they could do an electronic cross match (Crossmatching takes 45 minutes to an hour. It's a trial transfusion done in test tubes to see exactly how the patient's blood will react with potential donor blood before a blood product is dispensed) and dispense the blood in approximately 10 minutes.

Staff K and Staff L were asked at this time if they were aware of any recent situations where there was a significant delay in dispensing a blood product ordered by the physician. Staff L stated that she was aware of a "situation" regarding Patient #1.

On 3/18/19 at approximately 1415 Staff L was interviewed regarding the "situation" that caused a delay in Patient #1 receiving an urgent (STAT) blood transfusion, and reported the following information:

Staff L stated that Patient #1 had labs drawn pre-operatively for blood type and screen, and a sample of his blood was kept in Blood Bank for crossmatching

Staff L stated that a new medical technologist (med tech) did not realize that there was a "glitch" in the electronic record system (EMR) and relied on information on the computer to see if there were type and screen results and a blood sample for crossmatch available. Staff L stated that the computer marked the results and the blood sample as "expired" as soon as the patient was admitted for surgery. Staff L stated that because of this systems problem with the electronic records, there was a paper file kept in Blood Bank where patient blood typing results were recorded. Staff L pointed to a paper accordion file folder and pulled out a paper patient file card for review. The card listed the patient's name, date of sample collection, test date, blood type and screen results, and the location of the collected blood kept for possible cross matching if needed.

Staff L stated when Blood Bank received the STAT order for Blood for Patient #1 the "new" med tech did not look in the paper accordion file but checked the computer and thought that there was no patient blood sample available and that the blood typing results were no longer valid. Staff L stated that there was a delay in dispensing the blood because the med tech (Staff M) had to send a phlebotomist to the patient bedside to collect a blood sample and do a new blood type and screen test, and then crossmatch the patient's blood with the units of blood ordered before they were dispensed.

On 3/18/19 at approximately 1430 an interview was done with Staff M, the med tech involved in dispensing the blood for Patient #1. Staff M was queried about the incident and said, "I should have grabbed his drawcard instead I went straight to the computer and looked up his specimen and it showed me it was expired. His pre-op chart (lab tests drawn before his surgery) was discontinued in "( the facility's EMR system)". The issue was that when I sent the phlebotomist up to draw his blood, the patient was getting a scan done. We asked the floor (unit nursing staff) to call the phlebotomist when he got back. It took a couple of hours for them to call and tell us that the patient was back from the scan. . It took me about 25 minutes to do the type and screen. I called the nursing unit as soon as it was done and someone from nursing came down with the pink slip and took it up."

On 3/19/19 at approximately 1530 Patient #1's clinical record was reviewed with Staff A, Staff B, Staff R and Staff S and revealed the following information:

Patient #1 was a 76 year old male who had Davinci laparoscopic robotic prostatectomy at the facility on 1/25/19 and was discharged on 1/29/19. Diagnoses included Malignant Neoplasm of Prostate, Prostate Hypertrophy, and Hypertension.

A Surgeon's Operative Report dated 1/25/19 at 1223 revealed Patient #1 had an estimated blood loss during surgery of 400 milliliters (ml).

A Physician's Surgery Progress Note dated 1/25/19 at 2015 documented that Patient #1 had an episode of bleeding and hypotension (low blood pressure) at 1541 on 1/25/19 and the physician ordered a "STAT" complete blood count (CBC). The physician documented that Patient #1 was seen again at approximately 1700 on 1/25/19 for a Rapid Response (a medical emergency team that responds to patients with early signs of deterioration on non-intensive care units to prevent respiratory or cardiac arrest) which was called because Patient #1 was unresponsive (unconscious) with his blood pressure dropping to 60/40s (normal Blood pressure >90/60) and bleeding from his surgical sites. The physician noted that the Patient's blood hemoglobin (Hb) level had dropped to 8.6 from a level of 15.4 before surgery (normal for males is 13.8 to 17.2 g/dl). The physician noted that "multiple units of packed red blood cells were ordered and a STAT abdominal/pelvic CT scan (computerized tomography) was ordered. Patient #1 was transferred to the Intensive Care Unit (ICU) and started on levophed (an intravenous vasoconstrictor- constricts blood vessels to raise blood pressure, used to treat shock). The physician's note documented, "Blood Bank was called; transfusion was delayed as type and screen for surgery was now out of date."

A Critical Care Consultant Physician's Note dated 1/25/19 at 1806 documented that Patient #1 was transferred to ICU on 1/25/19 after an RRT for "Hypotension after Post-Surgical Bleed" and "Hemorrhagic Shock, need to give more volume". The consultant's summary for Patient #1 was documented as, "Upon my evaluation, this patient had a high probability of imminent or life-threatening deterioration due to hemorrhagic shock due to intra-abdominal bleeding and he has anemia due to acute blood loss and abdominal wall subcutaneous emphysema."

Review of Physician orders for Patient #1 revealed an order dated 1/25/19 at 1711 for, "Red Blood Cells. Blood, STAT".

A second order dated 1/25/10 at 1711 for, "Transfuse Red Blood Cells Leukoreduced, 1 units. Reason; Acute blood loss postop."

A third Physician order for blood for Patient #1 was dated 1/25/19 at 1727 for, "Red Blood Cells 4 units."

Blood Bank documentation noted that Patient #1's blood sample for type, screen and crossmatch was collected on 1/25/19 at 1830, and the blood was issued to nursing on 1/25/19 at 1947.

A Transfusion Medicine report dated 1/25/19 revealed Patient #1's transfusion of the first unit of blood was started on 1/25/19 at 2020 (three hours and 9 minutes after it was first ordered STAT.)

When asked at this time what was put in place to prevent this from happening again, potentially putting other patients in need of urgent blood transfusions at risk for serious harm or death from delayed treatment, Staff L said that she was writing a new Blood Bank policy to by pass the EMR problem, which she said they would not be able to fix. Staff L was asked to explain what changes in procedure she was putting in the new policy. Staff L was asked to provide a draft copy of the new policy and procedure that she was working on, but failed to do so by survey exit. Staff L stated that she hadn't had time to finish the policy yet and declined to show the surveyor what she had written so far.

On 3/19/19 at approximately 1600 Staff K provided documentation of a routine daily staff meeting (Daily Muster) dated 2/15 (no year noted) that included as one of the items discussed, "Delay in blood products. (Staff L) will update procedure regarding patient history checks". No outline or details were provided and there was no documentation of staff attendance.

A second document provided by Staff K at this time entitled, "Blood Bank Staff List" contained the following notations, "please review the following procedures. Sign and date this form: "Patient history check - HCLL (rest of policy number, computer retrieval information missing), Receiving Patient Specimen - HCLL (rest of policy number, computer retrieval information missing)". Five of 15 med techs in the facility signed this form on 3/18/19 (the date of the survey). These policies were requested but not provided by survey exit.

The facility policies for typing and screening of blood products and on dispensing of blood products was requested but not provided by exit.

Based on interview and record review, the facility failed to ensure that Nursing staff documented information necessary to monitor the patient's condition in the medical record for one (#1) of one patients reviewed for a change in condition and a Rapid Response Team event, resulting in the potential for delays in treatment, lack of coordination and communication between health care team members a potential failure to identify and correct gaps in the provision of comprehensive care for all patients served by the facility. Findings include:

On 3/18/19 at approximately 1530 Patient #1's clinical record was reviewed with Staff A, Staff B, Staff H, Staff R and Staff S and revealed the following information:

Patient #1 was a 76 year old male who had Davinci laparoscopic robotic prostatectomy at the facility on 1/25/19. Diagnoses included Malignant Neoplasm of Prostate, Prostate Hypertrophy, and Hypertension.

Patient #1 was transferred from the operating room to the Post-Anesthesia Care Unit (PACU) on 1/25/19 at approximately 1228 and was "handed off" (transferred ) to the 6 South (6S) on 1/25/19 at approximately 1340. Staff A, #B, #H, #R, and #S were unable to provide documentation of when Patient #1 arrived on 6S or of any Nursing documentation of the Patient #1's status on his arrival to the unit. Staff H was unable to provide any documentation that 6S Nursing staff received report on Patient #1 for transfer to 6S and stated that no permanent documentation of this was kept.

Post Anesthesia Care Unit (PACU) nurse Staff F documented on 1/25/19 at 1328 that she changed Patient #1's Jackson Pratt (JP, surgical drain) site dressing, emptied 55 milliliters (ml) out of the (100 ml) JP bulb/receptacle and reinforced (added another layer of padding) the surgical incision dressing due to moderate amount of serosanguinous drainage leaking through the dressing. Staff F reported that this information was faxed to 6S and entered into Patient #1's electronic Medical Record (EMR) 20 minutes before he was transferred to 6S at 1340. Staff F was able to provide documentation on the EMR that she "handed off" Patient #1 to (staff name was not documented) 6S staff at 1340. Staff B and Staff H reported that they could not find this documentation (report) by Staff F with their EMR log on credentials.

A Surgery Physician's Progress Note dated 1/15/19 at 2015 documented that he was paged by nursing on 1/25/19 at 1541 (two hours after transfer to 6S) because Patient #1 was hypotensive (had severely low blood pressure) and had bleeding from the JP site. There was no Nursing documentation of this event and no nursing documentation that a Registered Nurse (RN) was the person who assessed the patient and called the physician. There was no nursing note documenting interventions implemented in response to this bleeding or hypotension or the patient's response to them. Review of Physician's notes, Physician's orders and Intravenous fluid administration (medication administration) records revealed Patient #1 was given a fluid bolus.

The first Nursing documentation to indicate that Patient #1 was seen by a nurse was dated 1/25/19 at 1630 (2 hours and 50 minutes after transfer from PACU). The nurse (Staff G) did not document that she physically assessed Patient #1. The next Nursing documentation in the EMR was dated 1/25/19 at 1646 (three hours and six minutes after hand off to 6S from PACU.) The assessment was documented as an assessment of "incision/wound/skin (abdomen)" by Staff G. The flowsheet documented six surgical incisions, but did not note size or location. The documentation noted that there was moderate bloody drainage present and the dressing was changed (the number of and location of dressings changed and the amount of bloody drainage was not documented). "Site condition" was documented as bleeding red (bloody) drainage (no quantity documented) and 100 ml (out of a total bulb/JP reservoir capacity of 100 ml) was emptied from the JP bulb (reservoir). The gauze dressing around the JP was changed. No other nursing documentation was available.

Staff B and Staff H were asked at this time how many milliliters Patient #1's JP reservoir could hold. Both stated that there were two sizes of JP reservoirs and they did not have any way of determining which size Patient #1 had. A Surgeon's Operative Report dated 1/25/19 at 1223 documented that Patient #1 had a #10 flat JP inserted (100 ml receptacle).

There were no Nursing Progress Notes available for Patient #1's stay on 6S (from approximately 1340 to 1732 on 1/25/19.

A Physician's Surgery Progress Note dated 1/25/19 at 2015 documented that Patient #1 was seen some time after 1700 on 1/25/19 for a Rapid Response Team event (RRT) (a medical emergency team that responds to patients with early signs of deterioration on non-intensive care units to prevent respiratory or cardiac arrest) which was called because Patient #1 was unresponsive (unconscious) with his blood pressure dropping to 60/40s (normal Blood pressure >90/60) and bleeding from his surgical sites. Patient #1 was transferred to the Intensive Care Unit (ICU). The time of transfer was not documented and Staff B and Staff R were unable to provide the time of transfer or any Nursing documentation of Patient #1's transfer to ICU when requested.

A Critical Care Consultant Physician's Note dated 1/25/19 at 1806 documented that Patient #1 was transferred to ICU after a Rapid Response Team (RRT) intervention for "Hypotension after Post-Surgical Bleed" and "Hemorrhagic Shock". The consultant's summary for Patient #1 was documented as, "Upon my evaluation, this patient had a high probability of imminent or life-threatening deterioration due to hemorrhagic shock due to intra-abdominal bleeding and he has anemia due to acute blood loss and abdominal wall subcutaneous emphysema."

There was no documentation of who noted Patient #1's hypotension and bleeding on 1/25/19 at approximately 1722. There was no Nursing Note documenting this event or Nursing Documentation of an RN assessment of Patient #1 after hypotension was noted.

An undated Rapid Response Record for Patient #1 was incompletely filled out. The "Assessment" section was blank (not completed) and there was no documentation for "Respiratory", Circulation", Neuro" or "other". The section for medications administered during the Rapid Response was blank. The "Recommendations" section was blank (not completed). The section listing the participants only listed two participants, both Registered Nurses. There was no physician listed. The signature section was blank (not completed). The "Name of the RN requesting RRT" was blank (not completed.)

On 3/18/19 at approximately 1545 Patient #1's vital signs from 1/25/19 at 1338 to 1/25/19 at 2000 (ICU) were reviewed with Staff S in the presence of Staff A, Staff B, and Staff R. This revealed that automatic vital sign recording intervals were selected for Patient #1 by Nursing Assistant (NA) Staff O. Right clicking the computer cursor on each entry time revealed the Nurse (Staff G) did not verify (look at and assess) Patient #1's blood pressure/vital sign recordings on 1/25/19 until 1738 (after Patient #1 was transferred to the ICU for Hemorrhagic Shock after bleeding from a surgical incision."). There was no nursing documentation that Patient #1 was assessed by an RN after episodes of hypotension noted on the vital sign monitoring flowsheet.

On 3/18/19 at approximately 1600 Staff A, Staff B, Staff H, Staff R and Staff S were asked to provide the exact time Patient #1 was transferred to the ICU. This information was not provided by exit despite multiple requests.

On 3/18/19 at approximately 160 the 6S Unit Manager Staff H was interviewed and was unable to provide any additional documentation to indicate that Patient #1 was assessed and monitored for post operative complications by a Registered Nurse per facility protocol after transfer to 6S. Staff H stated, "His initial nurse (Staff G) did not see him because she was busy giving a blood transfusion to another post-operative patient, but other nurses did his vitals per policy." Staff H was unable to provide any documentation of this. The nurse that she identified as the one who monitored Patient #1 vitals was unavailable for interview as she was no longer employed by the facility and the telephone number provided by the facility to contact her was disconnected.

On 3/18/19 at approximately 1615 Patient #1's assigned nurse on 6S Staff G was interviewed. Staff G stated., "When he came up to the floor (6S) it took a nurse and two NA to get him from the gurney (stretcher) to the bed because he was a bigger guy. He had some nausea and was dry heaving. There was a one centimeter spot of blood underneath him when we transferred him off the gurney. He had some shadowing on the JP dressing (blood pooling under the bandage). I did the basics when I got him in but I didn't have time to chart (document) because I had to give a blood transfusion to another post-operative patient. His blood pressure was running a little low. He had an automatic blood pressure cuff. It automatically transfers the readings into (facility's EMR). I didn't save the vital signs that were recorded until five PM. The Nursing Assistant came to get me because his blood pressures were low. The Doctor came to see him and ordered a fluid bolus and the patient's blood pressures went back up. The patient was complaining of nausea and I left to get some (anti nausea medication) when he sat up to throw up, he passed out. and I called for help and we called an Rapid Response because his blood pressure was low and he was bleeding heavily." There was no documentation of any of this information reported by Staff G. Staff G reported that the JP receptacle should be monitored hourly during the first three hours after transfer to 6S and emptied when it's half full .

Staff G was unable to provide any documentation that the JP was regularly monitored or emptied when 2/3 full or that Patient #1 was monitored and assessed for post-operative complications such as breathing difficulties, bleeding or nausea and vomiting during his first three hours on 6S. Staff G was unable to explain the gaps in the timeline of her narrative regarding Patient #1 and was also unable to provide documentation that she assessed him every 15 minutes as required, emptied his JP receptacle before it overfilled and monitored him timely and appropriately for breathing difficulties, hypotension, bleeding, or nausea and vomiting.

On 3/19/19 at approximately 1100 the facility policy entitled, "Vital Signs, Post-op", number 40.4.252 revised 3/17 was reviewed with Staff B and Staff R. The following staff instructions were noted:

"Immediate Post-operative care continues in the ICU or medical-surgical unit for the first few hours if not discharged home:
Assess vital signs every (Q) 15 minutes x 4, every 30 minutes x 4 and then every 4 hours for the first 24 hours,
Assess cardiopulmonary status and neurovascular status, as described above ( Q 15 x 4 then Q 30 x 4),
Assess gastrointestinal status (e.g. nausea, flatus and bowel sounds),
Assess surgical site and drains (e.g. presence/absence and characteristics of drainage or bleeding,
If drainage or bleeding is present, mark dressing by circling the area of drainage with a marker and indicate the time. Repeat every 10 - 15 minutes,
Monitor for complications (see red flags),
Date and time of transfer to and from the unit,
Red Flags: Life threatening complications can occur in the immediate postoperative period including respiratory distress, vomiting, bleeding, hypothermia, oliguria (lack of urine)..."

All abnormal vitals need to be reported to the RN in charge of that patient. The RN will assess the patient and compare current vitals to baseline vital signs before determining whether further intervention is needed. Changes to report to the RN include:
systolic BP < 90 or > 150 or diastolic BP <50 or >90,
a BP that shows a downward trend of 5 mm HG at each reading should also be reported