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Based on review of 5 of 12 medical records (Patients #1, #2, #3, #4 and #5), interviews and the Hospital policy titled "Caring for a Patient Undergoing Cardiac Catheterization", the Hospital failed to ensure an effective quality assessment and performance improvement program.

Findings include:
1.) The Hospital failed to review and revise the policy titled "Caring for a Patient Undergoing Cardiac Catheterization" to include guidelines for the frequency of pedal (foot) pulse assessment.

2.) The Hospital failed to clarify Doctors' orders for the terms "routine" and "standards of care" for pedal pulse assessment.

3.) The Hospital failed to educate completely and thoroughly educate the cardiac nursing staff about pedal pulse assessment post-cardiac catheterization.

3.) The Hospital failed to monitor that nurses assessed patients' pedal pulses post-cardiac catheterization.
See TAG #'s 0273, 0286

Based on review of 5 of 12 medical records (Patients #1, #2, #3, #4 and #5), interviews, the Hospital policy titled "Care of the Patient Undergoing Cardiac Catheterization" and document review the Hospital failed to:

1.) Analyze the policy titled "Caring for a Patient Undergoing Cardiac Catheterization" and Doctors' orders regarding post-cardiac catheterization pedal pulse assessment.

2.) Analyze and clarify Doctors' orders for the terms "routine" and "standards of care" for pedal pulse assessment.

3.) Monitor that nurses assessed patients pedal pulses post-cardiac catheterization.

Findings include:

1.) Summary review of Patient #1's medical record, 6/20/13 (admission) to 7/30/13 (discharge), indicated that he/she was delivered prematurely and emergently by Cesarean section due to maternal compromise at 32 weeks gestation (2 months early, normal gestation is 40 weeks) at Hospital A on 5/15/13 and treated for prematurity. Patient #1 was transferred to Hospital B for a heart defect. Patient #1's had surgery to repair the heart defect on 5/30/13 at Hospital B. Patient #1 was discharged to hospital C (closer to home) on 6/5/13 and re-admitted to Hospital B on 6/20/13 due to a post-surgery complication. Patient #1 had a cardiac catheterization on 6/24/13. Patient #1 developed tachycardia (fast heartbeat), hypotensive (low blood pressure) and abdominal distention (belly area enlarged) at 8:00 P.M. on 6/24/13. Patient #1 was brought back to the Cardiac Catheterization Laboratory and then to the Operating Room for repair of a left external iliac (abdominal area) artery tear and retroperitoneal hematoma (abdominal bleed) on 6/25/13. Patient #1's post-operative course was complicated by decreased circulation to his/her legs and leg wounds. Patient #1 was discharged to Hospital D, on 7/17/13, for leg wound management, that eventually resulted in bilateral (both) leg amputations.

2.) The Hospital policy titled "Caring for a Patient Undergoing Cardiac Catheterization", dated 2/19/13, indicated that nursing staff would assess the patients' distal pulses every 15 minutes for the first hour following cardiac catheterization and every 30 minutes for the next hour. The policy indicated that if the patient remained in the Catheterization Laboratory Recovery Room (CLRR), the distal pulses would be assessed hourly until discharge from the CLRR.

The Hospital policy titled "Caring for a Patient Undergoing Cardiac Catheterization", dated 2/19/13, did not indicate nursing care interventions of distal pulse assessments for post-cardiac catheterization patients transferred to the Pediatric Cardiac In-Patient Unit (PCIPU) or the Pediatric Cardiac Intensive Care Unit (PCICU) or other possible patient care areas of the Hospital (for example: the Neonatal Intensive Care Unit (NICU).

Doctors' Orders indicated that nurses were to assess pedal pulses every 15 minutes for 2 hours, then every 30 minutes for 2 hours, then every 1 hour per Intensive Care Unit/Inpatient Unit routine but the routine was not indicated in the policy titled "Caring for a Patient Undergoing Cardiac Catheterization".


The Surveyor interviewed the PCICU Nurse Manager at 1:30 P.M. on 10/3/14. The PCICU Nurse Manager said that the review of Patient #1's care did not include a review of the policy titled "Care of the Patient Undergoing Cardiac Catheterization".


2.) Review of 5 of 12 medical records (Patients #1, #2, #3, #4 and #5) did not indicate:

-RN assessments of Patient #1's pedal pulses after 11:10 A.M. to the time of his/her tachycardic, hypotensive event at 8:00 P.M. on 6/24/14;

-that an RN assessed Patient #2's pedal pulses until 8:00 P.M. on 8/18/14 (pedal pulses should have been assessed at approximately 7:15, 7:30, and 7:45 P.M., every 15 minutes according to doctors' orders);

-that an RN assessed Patient #3's pedal pulses;

-that an RN assessed Patient #4's pedal pulses until 8:00 P.M. on 7/25/14 (2 hours after return from the Cardiac Catheterization Laboratory).

-that an RN assessed Patient #5's pedal pulses until 8:00 P.M. on 7/1/14 (5-1/2 hours after return from the Cardiac Catheterization Laboratory).

See TAG #0395

3.) The Surveyor interviewed Registered Nurse (RN) #1 at 12:00 P.M. on 10/3/14, RN #2 at 11:30 A.M. on 10/3/14 and RN #3 at 9:00 A.M. on 10/2/14. The RNs described variations in pedal pulse assessments.

The Surveyor interviewed the PCIPU Nurse Director at 2:15 P.M. on 10/3/14. The PCICU Nurse Manager and the PCIPU Nurse Director said they had expectations for nursing pedal pulse assessment that were not indicated in the policy titled "Caring for a Patient Undergoing Cardiac Catheterization".

See TAG # 0395

Based on review of 5 of 12 medical records (Patients #1, #2, #3, #4 and #5) and interviews, the Hospital failed to completely and thoroughly educate the cardiac nursing staff about pedal pulse assessments post-cardiac catheterization.

Findings include:

The Surveyor interviewed RN #1 at 12:00 P.M. on 10/3/14. RN #1 said that she did not recall a module (learning activity) or policy and procedure regarding re-education on post-cardiac catheterization care.

The Surveyor interviewed RN #2 at 11:30 A.M. on 10/3/14. RN #2 said that she recalled an e-mail (electronic mail) from her Nurse Manager about post-cardiac catheterization care and that the Nurse Manager addressed post-cardiac catheterization care at their 5 minute rounds (report). RN #2 said that she did not believe that the e-mail was a mandatory educational requirement about post-cardiac catheterization care.

The e-mail, dated 8/5/13 at 12:06 P.M., indicated it was sent from the PCICU Nurse Manager to the PCICU staff. The e-mail indicated directions to review the policy titled "Caring for the Patient Undergoing Cardiac Catheterization".

The Surveyor interviewed the Patient Safety (PS) Manager at 11:00 A.M. on 10/6/14. The PS Manager said that nursing education about post-cardiac catheterization nursing care was included in nursing orientation for PCIPCU, but not for PCICU.

Review of 5 of 12 medical records (Patients #1, #2, #3, #4 and #5) did not indicate Patients' #1, #2, #3, #4 and #5 pedal pulses were assessed according to Doctors' Orders or PCICU Nurse Manager and PCICU Nurse Director expectation.

See TAG # 0395.

Based on review of 5 of 12 medical records (Patients #1, #2, #3, #4 and #5), interviews and the Hospital policy titled "Caring for a Patient Undergoing Cardiac Catheterization", the Hospital failed to ensure a well-organized nursing service.

Findings include:

1.) The Nursing Service failed to ensure that Registered Nurses (RNs) assessed patients' distal pedal (foot) pulses post-cardiac catheterization.


2.) The Nursing Service failed to include in the policy titled "Care for a Patient Undergoing Cardiac Catheterization", nursing care interventions of distal pedal pulse assessments for post-cardiac catheterization patients for all areas of the Hospital that a post-cardiac catheterization patient which led to variations in the frequency and duration of nursing assessment of distal pedal pulses.


3.) The Nursing Service failed to ensure patients' pedal pulses were assessed according to Doctors' Orders.


See TAG #0395

Based on review of 5 of 12 medical records (Patients #1, #2, #3, #4 and #5), interviews, the Hospital policy titled "Care of the Patient Undergoing Cardiac Catheterization" and document review, the Nursing Service failed to ensure:

1.) Registered Nurses (RNs) assessed patients' distal pedal (foot) pulses post-cardiac catheterization.

The failure of RNs to assess patients' distal pulses post-cardiac catheterization, according to Doctors Orders and the Cardiac Nurse Manager's and Cardiac Nurse Director's expectation could lead to delayed or no treatment of a threatened limb, in the range of severity from altered blood circulation or altered functional ability of the affected limb to amputation of the affected limb.

2.) That the policy titled "Care of the Patient Undergoing Cardiac Catheterization" include the frequency nurses should assess distal pedal pulses for post-cardiac catheterization patients.

3.) That the policy titled "Care of the Patient Undergoing Cardiac Catheterization" indicated pedal pulse assessments for all patient care units that care for post-cardiac catheterization patients, for example, the Pediatric Cardiac Intensive Care Unit or the Neonatal Intensive Care Unit (NICU).

The failure of the Hospital to clearly indicate nursing care interventions regarding distal pedal pulse assessments for post-cardiac catheterization patients led to nursing practice variations ranging from no distal pedal pulse assessment to varied frequency and duration of assessments.

4.) Patients' pedal pulses were assessed according to Doctors' Orders.

Findings include:

A.) The Hospital policy titled "Caring for a Patient Undergoing Cardiac Catheterization", dated 2/19/13, indicated that nursing staff would assess distal pulses every 15 minutes for the first hour of Catheterization Laboratory Recovery Room (CLRR) stay and every 30 minutes for the next hour, if the patient remained in the CLRR, then hourly until discharge from the CLRR. The Hospital policy did not indicate nursing care interventions regarding distal pulse assessments for post-cardiac catheterization patients transferred to the Pediatric Cardiac In-Patient Unit or the Pediatric Cardiac Intensive Care Unit or other possible patient care areas of the Hospital (for example: the Neonatal Intensive Care Unit (NICU).

B.) The Surveyor interviewed RN #1 at 12:00 P.M. on 10/3/14. RN #1 said that she thought the Hospital's policy related to distal pedal pulse assessments post-cardiac catheterization was to assess the pulses every 15 minutes upon arrival to the Pediatric Cardiac Intensive Care Unit (PCICU) for 1 hour, but she would need to review the policy, and would follow the policy. RN #1 said that she did not know for sure if she documented the assessment of Patient #1's pedal pulses in the electronic medical record.

The Surveyor interviewed the Pediatric Cardiac Intensive Care Unit (PCICU) Nurse Manager at 1:30 P.M. on 10/3/14. The PCICU Nurse Manager said that on review of Patient #1's medical record she knew that RN #1 did not document her assessment of Patient #1's pedal pulses post-cardiac catheterization.

The PCICU Nurse Manager said that the Hospital Internal Investigation regarding Patient #1's care did not include a review the policy titled "Care of the Patient Undergoing Cardiac Catheterization".

The Surveyor interviewed the PCICU Nurse Director and Pediatric Cardiac In-patient Unit (PCIPU) Nurse Director at 2:15 P.M. on 10/3/14. The PCICU Nurse Director said it was his expectation that nurses would assess patients' post-cardiac catheterization pedal pulses every 1 hour along with vital signs and document the assessment. The PCIPU Nurse Director said it was her expectation that nurses would assess patients' post-cardiac catheterization pedal pulses and vital signs every 4 hours and document the assessment.

C.)
1. The electronic medical record, dated 6/24/13, indicated that an RN assessed Patient #1's pedal pulses upon arrival to the PCICU from the Cardiac Catheterization Laboratory at 11:10 A.M. The electronic medical record did not indicate RN assessments of Patient #1's pedal pulses after 11:10 A.M. to the time of his/her tachycardic (fast heartbeat) and hypotensive (low blood pressure) event at 8:00 P.M. on 6/24/13.

Patient #1's Doctors' Orders, dated 6/21/13 at 12:24 P.M. and 6/24/13 at 10:49 A.M., indicated that nurses were to assess pedal pulses with vital signs and nurses were to assess vital signs per the ICU standard of care.

2. The electronic medical record, dated 8/18/14, indicated that Patient #2 returned to Pediatric Cardiac Intensive Care Unit from the Cardiac Catheterization Laboratory at 7:09 P.M. and a RN did not assess his/her pedal pulses until 8:00 P.M. (pedal pulses should have been assessed at approximately 7:15, 7:30, and 7:45 P.M. according to Doctors' Orders). The electronic medical record indicated that pedal pulses were assessed at 12:00, 4:00 and 8:00 A.M. on 8/19/14.

Patient #2's Doctors' Orders, dated 8/18/14 at 7:28 P.M., indicated that nurses were to assess pedal pulses every 15 minutes for 2 hours, then every 30 minutes for 2 hours, then every 1 hour per Intensive Care Unit/Inpatient Unit routine.

3. The electronic medical record, dated 9/26/14, indicated that Patient #3 was admitted to the Pediatric Cardiac Inpatient Unit at 5:30 P.M. The electronic medical record did not indicate an RN assessed Patient #3's pedal pulses.

Doctors' orders, dated 9/26/14 at 11:48 A.M., indicated that nurses were to assess pedal pulses every 15 minutes for 2 hours, then every 30 minutes for 2 hours, then every 1 hour per Intensive Care Unit/Inpatient Unit routine.

4. The electronic medical record, dated 7/25/14, indicated that Patient #4 returned to the Pediatric Intensive Care Unit from the Cardiac Catheterization Laboratory at 6:00 P.M. The electronic medical record did not indicate that an RN assessed Patient #4's pedal pulses until 8:00 P.M. on 7/25/14. The electronic medical record indicated that a nurse assessed pedal pulses at 10:00 P.M. on 7/25/14 and 12:00 A.M. on 7/26/14.

Patient #4's Doctors' Orders, dated 7/25/14 at 6:23 P.M., indicated that nurses were to assess pedal pulses every 15 minutes for 2 hours, then every 30 minutes for 2 hours, then every 1 hour per Intensive Care Unit/Inpatient Unit routine.

5. The electronic medical record, dated 7/1/14, indicated that Patient #5 returned to the PCICU at 2:25 P.M. The medical record did not indicate that an RN assessed pedal pulses until 8:00 P.M. on 7/1/14 (5-1/2 hours later).

Patient #5's Doctors' Orders, dated 7/1/14 at 2:29 P.M., indicated that nurses were to assess pedal pulses every 15 minutes for 2 hours, then every 30 minutes for 2 hours, then every 1 hour per Intensive Care Unit/Inpatient Unit routine.