HospitalInspections.org

Based on policy and procedure review, medical record review, staff and physician interviews, the nursing staff failed to administer tube feedings as ordered for 1 of 2 sampled patients with tube feedings (#1), and failed to reassess 3 of 9 sampled patients that presented to the emergency department (#8, #9 and #7).

The findings include:

1. Review of the hospital's policy "Protocol: Adult Enteral Tube," with revision date of 04/22/2014, revealed "F. An RN is responsible for the initial and ongoing assessment of tube placement, feeding initiation and maintenance,....and the management of feeding intolerance."

Closed medical record review of patient #1 on 03/08/2016-03/10/2016 revealed a 51 year old male admitted on 02/04/2016 through the ED (emergency department) from home for fever, nausea and vomiting with primary diagnosis of pneumonia. Further review revealed past medical history revealed Type 1 Diabetes (inability to regulate insulin and glucose diagnosed as a child), kidney disease, chronic, stage 3 (decreased ability of the kidneys to filter the blood. Level of severity of stage 3 indicating kidneys are damaged moderately, functioning at 30-59 milliliters per minute), hypothyroidism (low functioning thyroid), hypertension (high blood pressure), hyperlipidemia (elevated lipids or fats in the blood), and sepsis (infection in the blood). Patient was discharged to skilled nursing facility on 03/03/2016. Review revealed physician orders on 02/23/2016 at 1650 for tube feedings (liquid nutrition placed in surgically placed tube in stomach) to begin at 2000. "Enteral Nutrition Formula: Standard isotonic. Feeding route: G tube (tube placed surgically in stomach). Enteral Nutrition increasing goal rate: If initial feeding is tolerated of 120 ml (milliliters--unit of measurement), then increase feed as follows: 240 ml." Review of new enteral feeding orders written on 02/24/2016 at 1155 revealed "1 can every 4 hrs (hours)." Further review of new enteral feeding orders written on 02/26/2016 at 1236 revealed "1 can every 4 hrs, 5 x (times-frequency) day." Review of feedings revealed on 02/23/2016 feeding of 120 ml was administered at 2000 and 2400. On 02/24/2016, feedings were administered at 0426, 0800, 1345, 1700, and 2115 (total of 5 cans instead of ordered 6). Review of feedings on 02/28/2016 and 02/29/2016 revealed 4 feedings were administered each day (missing one feeding each day). Review of feedings on 03/01/2016 revealed total of 3 feedings were administered (missing two feedings). Review of feedings on 03/02/2016 revealed 4 feedings between hours of 0800-2215 (missing one feeding). Review of feedings on 03/03/2016, day of discharge, revealed two feedings, one at 0200 and 1245 (10 hrs and 45 minutes apart).

Interview with RN #1 on 03/10/2016 at 0900 revealed tube feedings orders read every 4 hours, usual hours are from 0800 through 2400. "Nurses should write if unable to administer the tube feeding, then call physician."

Interview with MD #1 on 03/10/2016 at 1035 revealed nurses call all the time if unable to give feedings as ordered. "Did not receive phone call from nurses about the tube feedings and inability to give."

Interview with AS #1 on 03/10/2016 at 1045 revealed nurses should write notes and call MD (physician) if unable to give tube feedings. Further interview revealed no documentation on reasons tube feedings were omitted.



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2. Review of the emergency department "Documentation" policy revised 04/07/2015 revealed "... Triage Documentation ... 3. Vital signs will include modality, heart rate, respiratory rate, respiratory rate, blood pressure, temperature and pain level. ... Documentation of Reassessments of patients waiting in the Lobby 1. Observation and patient condition updates are recommended to be performed every two hours or more frequently (from the time of the initial triage) based on patient acuity/ clinical condition. This should include any changes in patient's chief complaint. Changes to ESI (emergency severity index - a measure used for triaging) level should be made based on this reassessment as needed. These reassessments should not preempt the triaging of new patients. Reassessment completion is based on available staffing and patient flow. Every effort should be made for reassessments to be completed in the recommended time frame. ... Pain Documentation All ED (emergency department) patients will have an initial/ongoing assessment and documentation of pain during their ED stay to include: 1. Pain Scale - The intensity of pain is rated by the patient suing the numerical rating scale of '0-10,' where '0' represents no pain and '10' represents the worse pain imaginable. ... 3. Documentation of pain should include all interventions utilized and the responses to those interventions. ..."

Closed ED record review on 03/08/2016 of Patient #8 revealed a 62 year-old female that presented to the emergency department on 01/31/2016 at 1254 via private vehicle. Review revealed vital signs recorded at 1309 were temperature 98.2 Fahrenheit, pulse 83, respirations 16, blood pressure 145/68, oxygen saturation 98%. Review of triage notes at 1311 recorded the patient complained of "colitis attack, states left upper abdominal pain. States pure bright red blood coming from her rectum. Pain 10/10. States nausea/ vomiting. Ao4x. (alert and oriented times four). Ambulatory." Review of the record revealed orders for laboratory studies were initiated at 1313 according to an adult abdominal pain protocol with final results available at 1357. Further review of the record revealed a nursing note at 1653 that recorded the patient left without being seen. Review of the record revealed no nursing reassessment of the patient's pain after triage at 1311 (pain level of 10) through 1653 (3 hours and 42 minutes) when the patient was noted to be gone.

Interview on 03/09/2016 at 1210 with the RN #2 revealed he was the triage nurse for Patient #8. The nurse stated he did not remember the patient. The nurse stated he remembered the day because it was an extremely busy day in the emergency department. The nurse stated "I would have reassessed the patient when I was able. If there was no one to be triaged, I would attempt to re-vital patients in the lobby. The triage nurse and change nurse are responsible to reassess patients waiting in the lobby." The staff member reviewed the patient's record and confirmed the patient complained of abdominal pain at a level of "10" during triage at 1311. The nurse confirmed there was no reassessment of the patient's level of pain prior to the note that the patient left without being seen at 1653.

3. Review of the emergency department "Documentation" policy revised 04/07/2015 revealed "... Triage Documentation ... 3. Vital signs will include modality, heart rate, respiratory rate, respiratory rate, blood pressure, temperature and pain level. ... Documentation of Reassessments of patients waiting in the Lobby 1. Observation and patient condition updates are recommended to be performed every two hours or more frequently (from the time of the initial triage) based on patient acuity/ clinical condition. This should include any changes in patient's chief complaint. Changes to ESI (emergency severity index - a measure used for triaging) level should be made based on this reassessment as needed. These reassessments should not preempt the triaging of new patients. Reassessment completion is based on available staffing and patient flow. Every effort should be made for reassessments to be completed in the recommended time frame. ... Pain Documentation All ED (emergency department) patients will have an initial/ongoing assessment and documentation of pain during their ED stay to include: 1. Pain Scale - The intensity of pain is rated by the patient suing the numerical rating scale of '0-10,' where '0' represents no pain and '10' represents the worse pain imaginable. ... 3. Documentation of pain should include all interventions utilized and the responses to those interventions. ..."

Closed ED record review on 03/08/2016 of Patient #9 revealed a 62 year-old female that presented to the emergency department on 01/31/2016 at 1029 via private vehicle. Review of triage notes at 1033 recorded the patient complained of "Patient with increasing fever since January 11. Cancer patient. Told to come to ER by oncologist. Ao4x. Ambulatory. Afebrile but took 3 Advil." Review revealed vital signs recorded at 1035 were temperature 99 Fahrenheit, pulse 84, respirations 16, blood pressure 162/75, oxygen saturation 95%. Review of the record revealed a point of care glucose level of 147 recorded at 1039. Further review of the record revealed a nursing note at 1556 that recorded the patient left without being seen. Review of the record revealed no nursing reassessment of the patient's pain or reassessment of the patient's vital signs or condition after triage at 1033 through 1556 (5 hours and 23 minutes) when the patient was noted to be gone.

Interview on 03/09/2016 at 1210 with the RN #2 revealed he was the triage nurse for Patient #9. The nurse stated he did not remember the patient. The nurse stated he remembered the day because it was an extremely busy day in the emergency department. The nurse stated "I would have reassessed the patient when I was able. If there was no one to be triaged, I would attempt to re-vital patients in the lobby. The triage nurse and change nurse are responsible to reassess patients waiting in the lobby." The staff member reviewed the patient's record and confirmed there was no assessment of the patient's level of pain and no reassessment of the patient's vital signs or condition prior to the note that the patient left without being seen at 1556.

4. Review of the emergency department "Documentation" policy revised 04/07/2015 revealed "... Triage Documentation ... 3. Vital signs will include modality, heart rate, respiratory rate, respiratory rate, blood pressure, temperature and pain level. ... Documentation of Reassessments of patients waiting in the Lobby 1. Observation and patient condition updates are recommended to be performed every two hours or more frequently (from the time of the initial triage) based on patient acuity/ clinical condition. This should include any changes in patient's chief complaint. Changes to ESI (emergency severity index - a measure used for triaging) level should be made based on this reassessment as needed. These reassessments should not preempt the triaging of new patients. Reassessment completion is based on available staffing and patient flow. Every effort should be made for reassessments to be completed in the recommended time frame. ... Pain Documentation All ED (emergency department) patients will have an initial/ongoing assessment and documentation of pain during their ED stay to include: 1. Pain Scale - The intensity of pain is rated by the patient suing the numerical rating scale of '0-10,' where '0' represents no pain and '10' represents the worse pain imaginable. ... 3. Documentation of pain should include all interventions utilized and the responses to those interventions. ..."

Closed ED record review on 03/09/2016 of Patient #7 revealed a 65 year-old male that presented to the emergency department on 03/07/2016 at 1721. Review of triage notes at 1806 recorded the patient complained of rectal bleeding that started on the day of arrival. Review revealed the patient's hemoglobin was 13 per his primary physician's office visit. Review revealed vital signs recorded during triage were temperature (not recorded), pulse 94, respirations 16 and blood pressure 161/97. Review revealed no documentation of an assessment of pain at triage. Review of physician notes at 2013 revealed the patient had two recent episodes of GI bleeding and was recently admitted to the hospital for a colonoscopy and diagnosed with diverticulitis. Review of the notes revealed the patient had received a blood transfusion during the recent admission. Review of physician notes revealed the patient had no nausea, vomiting abdominal pain or constipation at the time of the examination. Physician notes recorded the patient had chronic pain and takes pain management. Review revealed lab studies were completed. Further review of the record revealed Percocet (oral medication for pain) and Zofran (oral medication for nausea) were administered at 2209. Review revealed the patient discharged home on 03/08/2016 at 0107. Review of the record revealed no nursing assessment of pain or nausea prior to the administration of the medication for pain and nausea. Review revealed no reassessment of the patient's response to the medication.

Interview on 03/09/2016 at 1050 with the RN #3 revealed she was a nursing team leader in the emergency department. The nurse reviewed Patient #7's ED record and stated she was unable to find any nursing documentation of an assessment of the patient's pain at triage, prior to administering pain medication and after administering pain medication. Interview revealed the patient's pain should be assessed at triage, prior to administering pain medication and after administering pain medication. Interview confirmed there was no documented assessment of pain for Patient #7.

Based on policy and procedure review, medical record review, staff and physician interviews, the nursing staff failed to administer medications as ordered for 1 out of 10 sampled patients (#1).

The findings include:

Review of the hospital's policy "Medication Administration," with revision date of 01/26/2016 revealed "Medication Administration: C. Ensure proper time, dose, and route at the time medication is given to patient."

Closed medical record review of patient #1 on 03/08/2016-03/10/2016 revealed a 51 year old male admitted on 02/04/2016 through the ED (emergency department) from home for fever, nausea and vomiting with primary diagnosis of pneumonia. Review of past medical history revealed Type 1 Diabetes (inability to regulate insulin and glucose diagnosed as a child), kidney disease, chronic, stage 3 (decreased ability of the kidneys to filter the blood. Level of severity of stage 3 indicating kidneys are damaged moderately, functioning at 30-59 milliliters per minute), hypothyroidism (low functioning thyroid), hypertension (high blood pressure), hyperlipidemia (elevated lipids or fats in the blood), and sepsis (infection in the blood). Patient was discharged to skilled nursing facility on 03/03/2016. Review of MAR (medication administration record) dated 02/23/2016 to 03/03/2016 revealed medications were documented as given po (oral) throughout hospital stay.

Interview with RN #1 on 03/10/2016 revealed named patient did not swallow morning meds on 02/24/2016. "He spit out the medicines. Then the meds were crushed and I put them in the (feeding) tube. I would not have written a note about patient spitting out the medicines." Further interview revealed no nurses notes were written that medicines were given through the tube.

Interview with MD #1 on 03/10/2016 at 1035 revealed no physician orders on 02/24/2016 for medications to be placed in feeding tube. "Patient was not NPO (nothing by mouth). Patient did not have orders for medicines to be placed in feeding tube." Further interview revealed physician would have expected a phone call from nurses if unable to give medicines by mouth."

Interview with Administrative staff #1 on 03/10/2016 at 1045 revealed nurses are expected to call physician for orders to administer medicines through tube.

NC00115040, NC00114405