HospitalInspections.org

The Condition of Participation for Quality Assessment and Performance Improvement Program was not met.

Findings include:

Based on records reviewed and interview, for one (Patient #1) patient out of 10 sampled patients, the Hospital failed to measure and analyze aspects of performance that assess processes of care, hospital service and operations for Patient #1's cardiopulmonary arrest event where Nurse #1 did not document vital signs.


Refer to TAG: A-0273

Based on records reviewed and interview for one (Patient #1) patient out of 10 sampled patients, the Hospital failed to measure and analyze aspects of performance that assess processes of care, hospital service and operations for Patient #1's sedation procedure, cardiopulmonary arrest event where Nurse #1 failed to document assessments and vital signs.

Findings include:

The Hospital document titled Management of Moderate and/or Deep Sedation by Non-Anesthesia Personnel, dated November 4, 2016, indicated that during moderate sedation the responsibilities of the Registered Nurse (RN) monitoring the patient include: Documenting blood pressure, heart rate, rhythm and pulse biometry every five minutes, monitoring the patient for adverse reactions, any signs or symptoms are reported to the physician immediately, Level of consciousness is monitored continuously and documented at least every five minutes using the Richmond Agitation Sedation Scale (RASS), administers supplemental oxygen if the oxygen saturation (SPO2) is less than 95% and informs the physician.

On 12/17/19, Patient #1 was scheduled for an emergent cardiac catheterization under nurse sedation. Patient #1's hemodynamic procedure report indicated that Patient #1 arrived at the Cardiac Catheterization Laboratory at 4:54 P.M. and was placed on cardiac, blood pressure and pulse oximetry monitors (SPO2). Patient #1's heart rate was 93, respirations 15, SPO2 99, etCO2 (represents the amount of carbon dioxide (CO2) in exhaled air, which assesses ventilation) was 29.2, blood pressure 153/94, cardiac rhythm normal sinus rhythm (NSR), pain status 0, RASS level 0.

At 5:06 P.M., Nurse #1 administered 25 mcg of Fentanyl (opioid pain medication used for sedation) intravenously to Patient #1. Patient #1 received 1mg of Versed (a benzodiazepine sedative) with no documentation of who administered it.

At 6:30 P.M. Nurse #2 administered 1 mg of Versed to Patient #1 intravenously.

At 6:35 P.M. Nurse #1 administered 1 mg of Versed and 25 mcg of Fentanyl intravenously to Patient #1.

From 6:38 P.M. until 6:47 P.M. Patient #1's documented vital signs were: End-tidal carbon dioxide etCO2 was not documented, at 6:38 P.M. SPO2 (oxygen level) was 90 and from 6:42 P.M. until 6:47 P.M. the SPO2 was 80 (a decreasing oxygen level is possibly life-threatening), at 6:42 P.M. the blood pressure was 90/59 (low).

From 6:53 P.M. until 7:16 P.M. Patient #1's documented vital signs were: etCO2-not documented, at 6:53 P.M. the SPO2 was 80, at 6:57 P.M. the SPO2 was 79, at 7:01 the SPO2 was 77, the SPO2 was not documented from 7:06 P.M. to 7:12 P.M., at 6:53 P.M. the blood pressure was 88/65 and from 7:06 P.M. until 7:16 P.M. the blood pressure was not documented.

At 7:17 P.M. a code blue (resuscitation team) was activated.

From 7:24 P.M. until 7:25 P.M. the Hospital's document titled, Cardiopulmonary Arrest Record, indicated that Patient #1's cardiac rhythm (heartbeat) was documented as pulseless electrical activity (PEA, no heartbeat). The document indicated that Patient #1's cardiac rhythm as PEA at 7:33 P.M. and 7:39 P.M. At 8:04 P.M. the code documentation stopped. There was no documentation from 8:04 P.M. through 8:11 P.M. Patient #1's time of death was recorded at 8:11 P.M.

Patient #1's hemodynamic procedure report indicated from 5:05 P.M. through 9:11 P.M. Patient #1's heart rhythm was unchanged and remained in Normal Sinus Rhythm (normal heartbeat) and from 5:35 P.M. - 9:11 P.M. Patient #1's RASS level was -1 (Drowsy), contradicting the cardiopulmonary arrest record.

During an interview on 3/4/20 at 9:00 A.M., the Director of Quality, Regulatory and Patient Safety acknowledged that the Quality Department's review of Patient #1's cardiac catheter procedure did not review the nursing sedation documentation. The Director of Quality, Regulatory and Patient Safety said that the review did not review the documentation and did not develop any corrective actions to address the lack of documentation.