HospitalInspections.org

The Condition of Participation for Patient Rights has not been met.

Based on clinical record review, review of hospital documentation, interviews, and policy review, for 1 of 3 patients reviewed for the delivery of oxygen (Patient #1), the hospital failed to ensure that a registered nurse supervised the patient to ensure that the patient received oxygen as ordered, and for 1 of 4 patients reviewed for restraints (Patient #5) the hospital failed to ensure that the patient's status and condition were monitored while in restraints and failed to ensure that the patient's behaviors were monitored while in restraints to ensure discontinuation at the earliest possible time.

Please see A144, A174

Based on clinical record review, review of hospital documentation, interviews, and policy review, for 1 of 3 patients reviewed for the delivery of oxygen (Patient #1), the hospital failed to ensure the patient was connected to wall oxygen after being transported to another unit utilizing a portable oxygen tank and as a result, the patient's portable oxygen tank ran dry and the patient did not receive oxygen for approximately 1.5 hours. The findings include:


Patient #1 was admitted to the hospital on 2/12/22 for rapid atrial fibrillation/flutter and was transferred from the telemetry unit to a step-down unit on 2/13/22 for closer monitoring.

Physician orders dated 2/13/22 at 8:11 AM directed to administer oxygen via nasal cannula with a starting rate of 2 liters per minute (LPM) and maximum rate of 6 LPM.

Nurse's notes dated 2/13/22 at 4:45 PM noted patient was alert and confused, heart rate 140-150's, atrial fibrillation/flutter noted on telemetry monitor and MD aware. The note identified the patient would be transferred to another unit for closer cardiac monitoring. Additionally, the note identified the new unit was called and report was provided to the nurse. The note further identified the patient was placed on a portable monitor.

Review of the flowsheets dated 2/13/22 at 5:22 PM noted the patient was on 4 Liters of oxygen and the patient's pulse oxygen saturation level was 95%.

Nurse's notes dated 2/14/22 at 6:10 AM noted the patient was alert and oriented times three, A- flutter on tele-monitor, maintaining oxygen saturation on 4 L of oxygen via NC. The clinical note lacked documentation that the patient's portable oxygen tank ran out.

Interview with RN #1 on 3/11/22 at 10:13 AM stated on 2/13/22 she was transferring Patient #1 to another unit for closer monitoring. RN #1 stated that the patient required oxygen and she placed the patient on portable oxygen for the transfer. RN #1 stated that she called the receiving unit and gave report to the patient's new nurse and reported the patient required oxygen. RN #1 stated that when she and the transport staff brought the patient to the new unit, the nurse who was taking over care for the patient came into the room and they switched the patients leads for the telemetry monitoring and she and the transport staff left. RN #1 stated that it is the responsibility of the receiving nurse to switch the patient from portable oxygen to the wall oxygen.

Interview with RN #2 on 3/11/22 at 12:50 PM stated that she received report on 2/13/22 from the transferring nurse that Patient #1 was on 4 Liters of oxygen and the patient came to the unit around 5:30 PM. RN #2 stated that when the patient arrived, Person #1 had questions and she was talking to them outside of Patient #1's room. RN #2 stated that as she was speaking to Person #1, Person #2 had more questions regarding Patient #1 and during that time she saw the patient's heart rate elevate, so she left Person #2 and called the MD who increased the patients medication. RN #2 stated that she administered the new medication to the patient and then resumed speaking with Person #2. RN #2 stated that during that conversation her next patient arrived on the unit approximately an hour to an hour and 15 minutes after Patient #1 arrived and she went to tend to them. RN #2 stated that she was in her second admission's room until a little after 7:00 PM then gave report to the oncoming nurse. RN #2 stated that when they give report, they do what is called a hand off and go from room to room. RN #2 stated that when she was doing report, she saw the patient's nasal cannula in the patients nose and didn't think anything of it until the next day when she was told the patient was left on the portable oxygen tank that it had run out. RN #2 stated that she did not assess the patient or go back into the patient's room after she administered the medication.

Interview with the Transport Staff on 3/15/22 at 10:00 AM stated that he was notified of the transport and went to the unit, saw the patient required oxygen and grabbed a portable oxygen tank that was at least half full. The Transport Staff stated that he brought the portable oxygen to the room and RN #1 connected the patient to the tank and shortly after that they moved the patient to the new room. The Transport Staff stated that when they arrived, he connected the cables of the bed and left with RN #1.

Interview with RN #3 on 3/15/22 at 10:23 AM stated that she was receiving report at the start of her shift (7PM) when the NA made her aware that Patient #1's oxygen saturation levels were in the high 80% and low 90%. RN #3 stated that she went to the patient's room assessed the patient and found the patient in no respiratory distress, saw the oxygen tubing was still connected to the portable oxygen tank that was empty and connected the patient to the wall oxygen. RN #3 stated that once she placed the patient on the wall oxygen, the patient's oxygen saturation levels came back up into the 90's. RN #3 stated that she notified the provider.

Interview and review of the clinical record with the Nurse Manager on 3/15/22 at 10:45AM stated that RN #3 should have documented her assessment of the patient when the patient's portable oxygen tank was identified as empty and the patient's oxygen saturation levels were noted to be in the 80's.

Review of hospital documentation noted the hospital had two prior incidents related to portable oxygen tanks running out during use in the Emergency Department (ED), one in January 2022 and one in February 2022. The hospital's plan of correction identified in part that ED staff would be educated on the use of portable oxygen tanks.

Interview with RN #2 on 3/11/22 at 12:50 PM identified that she had received education while working in the ED related to transporting patients with portable oxygen, to ensure patients placed on wall oxygen or on a concentrator if they are not in a patient room, and if the patient requires transport, the nurse will go in the patient room when they arrive to ensure the oxygen is switched from a portable tank to the wall unit.

Interview with the Regulatory Manager on 3/10/22 at 9:45 AM identified that following this incident, the hospital immediately began educating all staff on the use of portable oxygen tanks and initiated a hospital system-wide review of portable oxygen use and policies were reviewed/revised.

Review of the hospital policy for Oxygen Management identified that any trained and licensed health care provider and any trained and certified ultrasound or nuclear medical technician may perform oxygen related patient care activities including connecting and disconnecting oxygen supply.

Based on clinical record reviews, interviews, and policy review, for 1 of 4 patients reviewed for restraint use (Patient #5), the hospital failed to ensure that the patient was monitored while in restraints to ensure discontinuation at the earliest possible time. The finding includes:

Patient #5 was admitted on 3/1/22 for evaluation of suicidal ideation.

A nursing note dated 3/1/22 at 7:50 PM identified that Patient #5 was restrained with bilateral wrist restraints at 7:50 PM due to physical aggression towards staff, verbal abuse and agitation. Restraints were discontinued at 11:16 PM.

An MD order dated 3/1/22 at 8:01 PM directed to apply bilateral wrist restraints for a violent/self destructive adult who was a danger to self and others. Restraint discontinuation criteria was identified as absence of behavior that required restraint and ability to adhere to expected behavior and safety.

Review of the clinical record failed to identify that Patient #5 was monitored every 15 minutes during the 3 hours and 26 minutes of restraint, and lacked documentation of Patient #5's behaviors that necessitated the continued use of restraints.

Interview with the Regulatory Manager on 3/16/22 at 8:45 AM identified that patient behaviors during restraint are documented on paper on the patient safety check form. The hospital conducted a search for Patient #5's patient safety check form during this restraint episode but it could not be found.

The hospital policy for restraint use identified the physical and emotional well being of the restrained patient is to be documentaed and the frequency of assessments are documented every 15 minutes. Restraints are discontinued at the earliest possible time. Discontinuation criteria includes improved mental status and that the behavior that led to the restraint is improved.

The Condition of Participation for Nursing Services has not been met.

Based on clinical record review, review of hospital documentation, interviews, and policy review, for 1 of 3 patients reviewed for the delivery of oxygen (Patient #1), the hospital failed to ensure that a registered nurse supervised the patient to ensure that the patient received oxygen as ordered, and for 1 of 4 patients reviewed for restraints (Patient #5) the hospital failed to ensure that the patient's status and condition were monitored while in restraints and failed to ensure that the patient's behaviors were monitored while in restraints to ensure discontinuation at the earliest possible time.

Please see A395

Based on clinical record review, review of hospital documentation and interviews, for 1 of 3 patients reviewed for the delivery of oxygen (Patient #1), the hospital failed to ensure that a registered nurse supervised the patient to ensure that the patient received oxygen as ordered, and for 1 of 4 patients reviewed for restraints (Patient #5) the hospital failed to ensure that the patient's status and condition were monitored while in restraints and failed to ensure that the patient's behaviors were monitored while in restraints to ensure discontinuation at the earliest possible time. The findings include:


a. Patient #1 was admitted to the hospital on 2/12/22 for rapid atrial fibrillation/flutter and was transferred from the telemetry unit to a step-down unit on 2/13/22 for closer monitoring.

Physician orders dated 2/13/22 at 8:11 AM directed to administer oxygen via nasal cannula with a starting rate of 2 LPM with maximum rate of 6 LPM.

Nurse's notes dated 2/13/22 at 4:45 PM noted patient was alert and confused, heart rate 140-150's, atrial fibrillation/flutter noted on telemetry monitor and MD aware. The note identified the patient would be transferred to another unit for closer cardiac monitoring. Additionally, the note identified the new unit was called and report provided to the nurse. The note further identified the patient was placed on a portable monitor.

Review of the flowsheets dated 2/13/22 at 5:22 PM noted the patient was on 4 Liters of oxygen and the patient's pulse oxygen saturation level was 95%.

Nurse's notes dated 2/14/22 at 6:10 AM noted the patient was alert and oriented times three, A- flutter on tele-monitor, maintaining oxygen saturation on 4 L of oxygen via NC. The clinical note lacked documentation that the patient's portable oxygen tank ran out.

Interview with RN #1 on 3/11/22 at 10:13 AM stated she was transferring Patient #1 to another unit on 2/13/22 for closer monitoring. RN #1 stated that the patient required oxygen and she placed the patient on portable oxygen for the transfer. RN #1 stated that she called the receiving unit and gave report to the patient's new nurse and reported the patient required oxygen. RN #1 stated that when she and the transport staff brought the patient to the new unit, the nurse who was taking over care for the patient came into the room and they switched the patients leads for the telemetry monitoring and she and the transport staff left. RN #1 stated that it is the responsibility of the receiving nurse to switch the patient from portable oxygen to the wall oxygen.

Interview with RN #2 on 3/11/22 at 12:50 PM stated that she received report on 2/13/22 from the transferring nurse that Patient #1 was on 4 Liters of oxygen and the patient came to the unit around 5:30 PM. RN #2 stated that when the patient arrived, Person #1 had questions and she was talking to them outside of Patient # 1's room. RN #2 stated that as she was speaking to Person #1, Person #2 had more questions regarding Patient #1 and during that time she saw the patient's heart rate elevate, so she left Person #2 and called the MD who increased the patients medication. RN #2 stated that she administered the new medication to the patient and then resumed speaking with Person #2. RN #2 stated that during that conversation her next patient arrived on the unit approximately an hour to an hour and 15 minutes after Patient #1 arrived and she went to tend to them. RN #2 stated that she was in her second admission's room until a little after 7:00 PM then gave report to the oncoming nurse. RN #2 stated that when they give report, they do what is called a hand off and go from room to room. RN #2 stated that when she was doing report, she saw the patient's nasal cannula in the patients nose and didn't think anything of it until the next day when she was told the patient was left on the portable oxygen tank that it had run out. RN #2 stated that she did not assess the patient or go back into the patient's room after she administered the medication.

Interview with the Transport Staff on 3/15/22 at 10:00 AM stated that he was notified of the transport on 2/13/22 and went to the unit, saw the patient required oxygen and grabbed a portable oxygen tank that was at least half full. The Transport Staff stated that he brought the portable oxygen to the room and RN #1 connected the patient to the tank and shortly after that they moved the patient to the new room. The Transport Staff stated that when they arrived, he connected the cables of the bed and left with RN #1.

Interview with RN #3 on 3/15/22 at 10:23 AM stated that she was receiving report on 2/13/22 at the start of her shift (7PM) when the NA made her aware that Patient #1's oxygen saturation levels were in the high 80% and low 90%. RN #3 stated that she went to the patient's room assessed the patient and found the patient in no respiratory distress, saw the oxygen tubing was still connected to the portable oxygen tank that was empty and connected the patient to the wall oxygen. RN #3 stated that once she placed the patient on the wall oxygen, the patient's oxygen saturation levels came back up into the 90's. RN #3 stated that she notified the provider.

Review of the clinical record on 3/15/22 at 10:23 AM with RN #3 failed to identify that a nursing assessment, including the patient's oxygen saturation levels were documented when the nurse identified the patient's portable oxygen tank ran out.

Interview and review of the clinical record with the Nurse Manager on 3/15/22 at 10:45AM stated that RN #3 should have documented her assessment of the patient when the patient's portable oxygen tank was identified as empty and the patient's oxygen saturation levels were noted to be in the 80's.

Review of hospital documentation noted the hospital had two prior incidents related to portable oxygen tanks running out during use in the Emergency Department (ED), one in January 2022 and one in February 2022. The hospital's plan of correction identified in part that ED staff would be educated on the use of portable oxygen tanks.

Interview with RN #2 on 3/11/22 at 12:50 PM identified that she had received education while working in the ED related to transporting patients with portable oxygen, to ensure patients placed on wall oxygen or on a concentrator if they are not in a patient room, and if the patient requires transport, the nurse will go in the patient room when they arrive to ensure the oxygen is switched from a portable tank to the wall unit.

Interview with the Regulatory Manager on 3/10/22 at 9:45 AM identified that following this incident, the hospital immediately began educating all staff on the use of portable oxygen tanks and initiated a hospital system-wide review of portable oxygen use and policies were reviewed/revised.

Review of the hospital policy for Oxygen Management identified that any trained and licensed health care provider and any trained and certified ultrasound or nuclear medical technician may perform oxygen related patient care activities including connecting and disconnecting oxygen supply.




b. Patient #5 was admitted on 3/1/22 for evaluation of suicidal ideation.

A nursing note dated 3/1/22 at 7:50 PM identified that Patient #5 was restrained with bilateral wrist restraints at 7:50 PM due to physical aggression towards staff, verbal abuse and agitation. Restraints were discontinued at 11:16 PM.

An MD order dated 3/1/22 at 8:01 PM directed to apply bilateral wrist restraints for a violent/self destructive adult who was a danger to self and others. Restraint discontinuation criteria was identified as absence of behavior that required restraint and ability to adhere to expected behavior and safety.

Review of the clinical record failed to identify that Patient #5 was monitored every 15 minutes during the 3 hours and 26 minutes of restraint, to include behaviors and physical condition, and lacked documentation of Patient #5's behaviors that necessitated the continued use of restraints.

Interview with the Regulatory Manager on 3/16/22 at 8:45 AM identified that patient behaviors during restraint are documented on paper on the patient safety check form. The hospital conducted a search for Patient #5's patient safety check form during this restraint episode but it could not be found.

The hospital policy for restraint use identified the physical and emotional well being of the restrained patient is to be documentaed and the frequency of assessments are documented every 15 minutes. Restraints are discontinued at the earliest possible time. Discontinuation criteria includes improved mental status and that the behavior that led to the restraint is improved.



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