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Based on policy review, closed medical record review and staff and physician interviews, nursing staff failed to provide supervision of the delivery of patient care as evidenced by failing to evaluate, monitor and assess a change in the patient's condition, failing to follow physician's orders for cardiac monitoring, failing to ensure "now" orders were completed timely and failing to notify the physician of a change in the patient's condition for 3 of 7 sampled patients (#6, #5 and #3).

The findings include:

Review of the hospital's "Patient Assessment Policy" revised April 1, 2009 revealed nursing reassessments on the medical surgical unit (3W) should be completed every shift and as needed. Review revealed "... II.A. Reassessment times will be patient driven and will vary depending on the patient's clinical condition and symptoms presented. Reassessment also may be for reasons including: To evaluate his or her response to care, treatment and services, to respond to significant change in status and/or diagnosis or condition...D. Reassessments will be documented, as appropriate, in PCS (Patient Care system)... III.C. Focus reassessments may be done anytime the patient's clinical condition changes. The subject of the reassessment depends on the clinical symptoms presented."

Review of the hospital's "Procedure for Central (Remote) Monitoring in the Medical/Surgical Areas" policy revised January 18, 2010 revealed the Central Monitoring Unit (CMU) was to be notified of a physician's order for remote telemetry by floor staff. Further review revealed "...The unit receiving the patient will pick up the cardiac monitoring transmitter from the designated location on their unit. The cardiac monitor should be applied immediately upon arrival to the floor.... Monitored patients should be connected to their transmitters at all times. Transmitters should not be removed for ADL's (activity of daily living) unless ordered by the physician. The transmitter should only be removed during a procedure if deemed necessary by the performing department. The MT (Monitoring Tech) must be notified prior to transmitter removal.... Every 12 hours and prn (as needed) as condition warrants, the MT will run a cardiac rhythm strip report, interpret the cardiac rhythm and document their interpretation...."

1. Closed record review on 02/09/2011 of Patient #6 revealed a 68 year-old female admitted 01/11/2011 for a right femur fracture that occurred after a fall. Review revealed the patient was scheduled for surgical repair of the fracture on 01/13/2011. Review of nursing notes dated 01/13/2011 at 0816 recorded "Alert and oriented times 3, follows commands, extremely anxious, oxygen saturation (O2 sat) 76% (low) on room air, (Physician) notified, patient placed on NC at 4L (nasal cannula at 4 liters oxygen per minute), patient complained of nausea." Record review revealed vital signs recorded at 0817 were temperature 98.8 degrees Fahrenheit, pulse 130, respiratory rate 18 and blood pressure 138/83. Review of physician's orders dated 01/13/2011 at 0750 revealed an order to administer oxygen at 4 liters per nasal cannula. Physician's orders at 0850 revealed an order for cardiac monitor. Physician orders at 1045 were recorded to cancel the planned surgery. Review of nursing notes revealed the cardiac monitor was on at 0954 and showed sinus tachycardia with a heart rate of 108. Review of the record revealed at 1129 "Patient off monitor." Further review revealed a "Resuscitation Record" that recorded the patient had a cardiopulmonary arrest and resuscitation efforts (CPR) were started on 01/13/2011 at 1237. Review revealed the code ended at 1252 and the patient was transferred to the Intensive Care Unit (ICU). Review of physician's notes recorded at 1250 revealed "Code 3 was called ... According to patient's nurse patient was vomiting then had frothy secretions from mouth, then patient got unresponsive, cyanotic face body was blue, Code 3 called. (Physician) was informed. He wanted Code Team to take care until he arrives. When I came, patient was unresponsive, no pulses palpable, CPR was started, patient was hooked to monitors, Epinephrine/Atropine (emergency medications) was given and patient was intubated. Initially O2 (oxygen) saturations were in 40-50%, came up above 90% after successful intubation by RT (Respiratory Therapist) team, then after 5 minutes pulses came back...." Record review revealed the patient was transferred to the Intensive Care Unit (ICU) at 1300 and subsequently transferred to another hospital on 01/13/2011 at 1507. Further review of the record revealed no evidence of a reassessment of the patient's condition after 0817 until cardiopulmonary resuscitation was started at 1237 (four hours and 20 minutes). Record review revealed no evidence the cardiac monitor was on the patient at 1237 when the patient arrested and CPR was initiated.

Interview on 02/10/2011 at 1155 with the registered nurse (RN #3) that provided care to Patient #6 on 01/13/2011 revealed she remembered the patient. Interview revealed the nurse took over care for the patient at 0800. The nurse reviewed Patient #6's record and stated the patient had low oxygen saturation of 76% upon assessment at 0816. The nurse stated the physician was notified and oxygen was started at 4 liters. Interview with the nurse revealed the next assessment of the patient and vital signs were recorded at 1309 in ICU after the Code. Interview revealed the patient had orders for radiology and she was gone from the unit for a period of time. The nurse stated there was no documentation of when the patient left the unit and returned to the unit. Interview further revealed there was a nurse in radiology that could assess the patient while she was off the unit. Interview revealed there was no evidence of an assessment of the patient after vital signs were recorded at 0817 and prior to the code at 1237. Interview revealed the nurse was unable to explain why the patient was off the cardiac monitor at 1129. Interview revealed the patient can go to radiology with a cardiac monitor. Interview revealed there was no evidence of the patient having a cardiac monitor on when she arrested. Interview confirmed there was no cardiac rhythm strip recorded until after the patient arrested.

Interview on 02/09/2011 at 1615 with the Monitor Tech (MT #5) that documented the patient was off the cardiac monitor at 1129 revealed there was no way to tell when the monitor was reapplied unless a strip is run. Interview revealed there was no evidence the patient was on the cardiac monitor between 1130 and 1237 when she arrested.

Interview with administrative nursing staff on 02/10/2011 at 1400 revealed CMU (Central Monitoring Unit) documentation showed Patient #6 was placed on the cardiac monitor at 0900. Interview revealed based on radiology records, the patient was in the CT scanner from 1100 to 1115. Interview revealed it was not known what time the patient returned to the nursing unit from radiology. Interview further revealed the patient had a change in condition and should have had ongoing nursing assessments after the change in condition. Interview revealed there was a nurse in radiology that could monitor the patient while in radiology. Interview further revealed that the patient should have had the cardiac monitor on after the physician's order and there was no evidence it was on when the patient arrested. Interview confirmed nursing staff failed to assess and monitor the patient according to hospital policy.

Consequently the patient had a change in condition and a critical low oxygen saturation reading at 0816 with oxygen applied. The patient was not reassessed after vital signs were taken at 0817 until the Code 3 (resuscitation) was initiated at 1237 (4 hours and 20 minutes since prior assessment). Nursing staff failed to ensure the cardiac monitor was on the patient as ordered by the physician.

2. Closed record review on 02/09/2011 of Patient #5 revealed an 80 year-old male admitted 09/01/2010 with benign prostatic hyperplasia (BPH) for a transurethral resection prostatectomy (TURP) on 09/01/2010. Record review revealed the patient had the TURP done on 09/01/2010 beginning at 1107 under spinal anesthesia that ended at 1149. Review revealed the patient arrived in the post anesthesia care unit (PACU) at 1159. Review of the PACU nursing notes revealed the patient complained of shortness of breath, headache, chest pain rated as a 10 (scale 1 - 10 with 10 worst pain) and nausea at 1210. Nursing notes at 1215 recorded the patient was anxious, demanding and angry with pain unchanged and the anesthesiologist was notified. Notes revealed the patient was anxious, pain unchanged and short of breath at 1220 and an anesthesiologist was in to see the patient. Morphine (pain medication) 5 mg (milligrams) IV (intravenous) was administered for chest pain rated as a 10 at 1225. Nitroglycerine paste (medication for chest pain) was applied at 1228. Nursing notes at 1230 recorded the chest pain was better and rated as a 5. Notes at 1235 revealed an EKG was completed and the patient reported a chest pain level of 4. PACU nursing notes at 1255 revealed the anesthesiologist was in to see the patient and the patient denied pain. Notes revealed the patient began to have weak movement to his lower extremities and reported numbness to L1 (lower spine area) bilaterally. Review of physician's (anesthesiologist) orders at 1305 revealed an order to discharge the patient to the floor for spinal to resolve. Review of physician's (surgeon's) orders at 1140 revealed an order to admit for observation and routine vital signs. Record review revealed the patient was transferred to 3W (medical surgical unit) at 1340. Review of the PACU nursing notes recorded on 09/01/2010 at 1519 revealed "1340 in room, patient assisted to bed using drawsheet per 3 nurses and 1 tech. Patient tolerated well. Return to 2L (2 liters) NC (nasal cannula) to wall port. Siderails up. Family at bedside. Siderails up. Patient begins to c/o (complain of) CP (chest pain). Floor nurse to notify MD (physician) for further orders. Report to (named RN) for continuity of care. VS (vital signs) taken." Review of vital signs at 1340 revealed temperature 98 degrees Fahrenheit, blood pressure 105/64, pulse 88, respirations 18, SAO2 (oxygen saturation) 97%. Review of the 3W floor nursing notes at 1340 revealed the patient was alert and oriented, followed commands and respirations were regular and unlabored. Further review of the record revealed no evidence that the physician was notified of the patient's complaint of chest pain at 1340. Review of nursing notes revealed at 1400 the patient was alert and oriented, followed commands and had an oxygen saturation of 97% on 2 liters of oxygen. Review of the notes revealed the patient asked for coke and immediately vomited it back up. Review of the record revealed the next vital signs were recorded at 1603 (2 hours and 22 minutes after prior vital signs assessed). Review of nursing notes recorded on 09/01/2010 at 1716 revealed "At about 1545 I went in to check on patient. (Respiratory Therapist name) from RT (Respiratory Therapy) entered at same time. We found patient looking waxy and somewhat ashen. His respirations were labored at 22, sat (oxygen saturation) 96%. Patient unresponsive to verbal stimuli, shaking or sternal rub. MRT (Rapid Response Team) called and responded. (Physician) notified. (Hospitalist physician) responded.... Patient finally started to respond. (Patient's physician) arrived and transferred the patient to ICU (Intensive Care Unit)." Record review revealed the patient was transferred to ICU at 1630. Review of physician's notes dated 09/01/2010 at 1630 revealed "Called about patient. Diaphoretic, shallow breathing, decreased mental status. Glucose 70s. No complaint of pain. ... ?Cardiopulmonary event - evaluate medical management ?Sepsis ... Medical Consult." Review of the record revealed physician's orders on 09/01/2010 at 1630 to admit the patient to ICU and consult the hospitalist for medical care. Review of the record revealed the hospitalist wrote an order dated 09/01/2010 at 2000 for an "EKG now." Review of the record revealed the EKG was completed on 09/01/2010 at 2111 (1 hour and 11 minutes after the now order). Record review revealed the patient was subsequently transferred to another hospital for continued care on 09/02/2010 at 2030.

Interview on 02/09/2011 at 1605 with the anesthesiologist (Physician A) that discharged the patient from PACU revealed he was familiar with the case. The physician stated the patient "complained of chest pain in the recovery room, was treated and the problem resolved. He no longer had chest pain. He went upstairs. I was not involved after that. He was not under my care when rapid response was called.... He was going to the floor. His vital signs were stable. He was alert and talking, spinal was resolving. He met criteria and could go.... I was not notified of chest pain after he left PACU. My jurisdiction ends in the recovery room. They should have called (surgeon's name)."

Interview on 02/09/2011 at 1615 with the patient's surgeon (Physician B) revealed the patient was discharged from PACU by the anesthesiologist. The physician stated he was not aware of the patient's complaint of chest pain in the PACU. The physician stated "I can't remember when I was called. I was first notified when the patient had respiratory distress. I came in and (hospitalist name) was doing his initial assessment (during rapid response). I am a urologist. I let the hospitalist handle (medical management). We moved him to ICU.... I met with the family the next day. They requested transfer to (another hospital). It was appropriate." The physician confirmed that he was notified of the patient's respiratory distress and decreased mental status on 09/01/2010 around 1545. The physician confirmed that he was not notified of the patient's chest pain upon arrival to the floor at 1340.

Interview on 02/09/2011 at 1635 with the PACU nurse (RN #1) that provided care to the patient on 09/01/2010 revealed she remembered the patient. The nurse reviewed the patient's record and stated that the patient had chest pain in PACU and the anesthesiologist was notified and saw the patient. Interview revealed an EKG was done and morphine and nitroglycerine paste were administered for chest pain. The nurse stated the chest pain resolved and vitals were stable. Interview revealed the spinal anesthesia was not resolved and an order was written to transfer the patient to the floor for the spinal to resolve. The nurse stated "I took the patient to 3W, gave report to (RN #2) at bedside. After moving him over, he complained of chest pain. The floor nurse (RN #2) was to call (Physician B). I gave her report that the patient had received morphine and nitroglycerine for chest pain and he had no chest pain when we left PACU."

Interview on 02/10/2011 at 1105 with the registered nurse (RN #2) that received the patient on 3W on 09/01/2010 revealed she did not remember the patient. The nurse reviewed the patient's record and confirmed that the patient complained of chest pain upon arrival to 3W at 1340. The nurse confirmed there was no documentation that the physician was notified of the patient's chest pain. The nurse stated "If the patient had chest pain, I should have called the surgeon. I would be responsible to notify the physician of chest pain. I don't see that I notified him." Interview with the nurse revealed vital signs on patients after surgery should be done every hour times four, then every four hours. Interview revealed the patient's vital signs were recorded at 1340 and there was no documentation that vital signs were reassessed until 1611. The nurse stated "Vital signs include blood pressure, temperature, heart rate, respirations and oxygen saturation. I don't know why I missed them." Further interview with the nurse revealed "now orders should be done immediately. No more than 15 minutes after the order is written." Interview confirmed that an order was written at 2000 for an "EKG now" and the EKG was done at 2111. Interview revealed a "now EKG order" should be treated as a stat order and done immediately. Interview revealed the EKG was delayed.

Interview on 02/10/2011 at 1105 with the registered nurse (RN #3) that found the patient unresponsive on 09/01/2010 revealed she remembered the patient "vaguely." The nurse stated she took over care of the patient at 1500. The nurse reviewed the patient's record and stated her first notes regarding the patient were at 1545 when she recorded she found the patient unresponsive and the rapid response team was called. The nurse stated she remembered (RT #4) performing a sternal rub with no response from the patient and stated "He was breathing very labored." The nurse stated Physician B came and the patient was transferred to ICU.

Interview on 02/10/2011 at 1030 with the respiratory therapist (RT #4) that found the patient unresponsive on 09/01/2010 revealed he remembered the patient "vaguely." The staff member stated "I came in the room and he was not doing well. Family was present. I don't think he was real responsive. Vital signs not the best. (RN #3) was there. I don't remember having to summon help. The family was concerned. He didn't respond to shaking. He was lethargic, color not well, breathing was shallow." Interview revealed the rapid response team was called and responded.

Interview on 02/10/2011 at 1250 with nursing administrative staff revealed there was no policy or procedure for post operative vital signs. Interview revealed the expectation for post operative vital signs was vital signs should be assessed every hour times four, then every four hours times 48 hours, then every shift. Interview further revealed vital signs included temperature, pulse, blood pressure, respiratory rate and oxygen saturation. Interview revealed vital signs should be assessed more often as required by the patient's condition. Interview confirmed post operative vital signs were not assessed as expected for Patient #5 after he arrived on 3W following surgery.

Interview on 02/10/2011 at 1250 with nursing administrative staff revealed there was no policy or procedure for now orders as it related to treatments, EKG, lab or radiology studies. Interview revealed a "now" order for an EKG should be completed as soon as possible. Interview revealed an hour was longer than it should take to complete an EKG that was ordered "now." Interview confirmed the EKG ordered "now" for Patient #5 was not completed timely.

Consequently nursing staff failed to notify the physician of a change in condition when the patient complained of chest pain upon arrival to the surgical floor on 09/01/2010 at 1340. The patient was found unresponsive at 1545 (2 hours and 5 minutes after arriving on the surgical floor). Nursing staff failed to reassess the patient's vital signs on the surgical floor after the patient complained of chest pain following surgery. A physician's order for an EKG now at 2000 was not completed until 2111 (1 hour and 11 minutes later). Nursing staff failed to ensure the physician's order was completed timely.

3. Closed record review on 02/08/2011 of Patient #3 revealed an 89 year-old female admitted on 02/03/2011 for fall, weakness, malaise and not able to get out of the bed. Review of physician's admission orders dated 02/03/2011 at 0745 recorded "Admit 4th, Medical Monitor, Condition - Serious." Review of nursing notes revealed the patient arrived on the floor at 0840. Further review of the record revealed the patient had a "sinus rhythm with first degree heart block" noted on the cardiac monitor at 1100. Review of the record revealed no evidence the cardiac monitor was applied upon admission at 0840. Further record review revealed no evidence the cardiac monitor was applied until 1100 (2 hours and 20 minutes after admission).

Interview on 02/09/2011 at 1230 with the nurse (RN #7) that admitted the patient on 02/03/2011 revealed she did not remember the patient. The nurse reviewed the record and stated that she could not find evidence that the cardiac monitor was applied prior to 1100. The nurse stated the cardiac monitor "should be applied as soon as possible after the patient arrived." Interview further revealed the Monitor Tech usually runs a cardiac strip after the monitor is applied. Interview revealed the nurse was not able to explain why the patient did not have the cardiac monitor applied until 2 hours and 20 minutes after the patient arrived to the floor.

Interview on 02/09/2011 at 1615 with the Monitoring Tech (MT #5) that recorded the cardiac rhythm for Patient #3 at 1100 revealed she was unable to remember the patient. The staff member stated that the procedure for a new admission on a cardiac monitor is for the floor nurse to sign out a monitor from the CMU, floor nurse apply the monitor, MT see the rhythm on the monitoring screen and print a strip. The MT stated she would read the strip and give it to the floor nurse before the end of the shift. Interview further revealed the cardiac rhythm strip is printed as soon as possible after the cardiac monitor is applied. The MT stated she "would not wait 2 hours to print a strip after a newly applied monitor."

Consequently nursing staff failed to follow physician's order for cardiac monitoring in a timely manner by failing to apply a cardiac monitor until 2 hours and 20 minutes after Patient #3 was admitted.

Based on review of hospital policy and procedures, medical record review and staff interviews the nursing staff failed to administer blood transfusions according to hospital policy for 1 of 4 sampled patients that received a blood transfusion (#2).

The findings include:

Review of the hospital's Blood Administration policy approved March 8, 2010 revealed vital signs are to be obtained and documented 30 minutes prior to starting the blood transfusion, 15 minutes after the transfusion started and at the completion of the transfusion.

Closed medical record review of Patient #2 revealed a 65 year-old female who was admitted on 01/26/2011 with altered mental status, rule out cerebral vascular accident (stroke). Record review revealed the patient was treated and subsequently discharged on 01/28/2011. Record review revealed on 02/08/2011 the patient received a transfusion of packed red blood cells. Record review revealed the transfusion was started on 01/27/2011 at 1715 and was completed at 2055. Record review revealed documentation of vital signs at 1655 (prior) and 2055 (when the transfusion ended). Record review revealed no documentation of vital signs 15 minutes after the transfusion was started.

Interview with administrative nursing staff on 02/08/2011 at 1445 confirmed there was no available documentation that the nurse assessed the patient's vital signs 15 minutes after the start of the blood transfusion per policy. Interview confirmed nursing staff failed to follow the hospital's blood administration policy.

Based on review of medical staff by-laws, rules and regulations, closed medical records and staff interviews, the hospital failed to ensure the completion of medical records within 30 days following discharge for 2 of 4 closed records reviewed (#1 and #5).

The findings include:

Review of the medical staff by-laws, approved 05/04/2010, revealed ..."12.2 Current requirements post discharge: Once a patient has been discharged, H&P's (History and Physical), OP(operative) notes, and progress notes must be signed within 30 days of discharge. Discharge summaries must be dictated and signed within 30 days of discharge...."

1. Closed record review on 02/08/2011 at 1530 of Patient #1 revealed a 70 year-old male admitted on 12/22/2010 with end stage lung cancer and uncontrolled pain. Record review revealed Patient #1 expired at the hospital on 12/25/2010. Review of the record revealed no discharge summary was present in the medical record at the time of the review.

Interview on 02/08/2011 at 1530 with administrative staff confirmed the discharge summary was not available. On 02/09/2011 at 1020 administrative staff presented a discharge summary for Patient #1.
Review of the discharge summary revealed it was dictated on 01/09/2011 and transcribed on 02/08/2011 at 1442 (45 days after discharge). Further review revealed the discharge summary was recorded as "Report status: draft" and was not signed by the physician.

Interview on 02/09/2011 at 1020 with administrative staff revealed transcription staff had been unavailable due to illness and reports did not get transcribed timely. The staff member confirmed that the discharge summary was not transcribed within 30 days of discharge as required. Interview further confirmed that the discharge summary had not been reviewed and signed by the physician 45 days after the patient's discharge.

2. Closed record review of Patient #5 revealed an 80 year-old male admitted on 09/01/2010 with benign prostatic hyperplasia (BPH) for a transurethral resection prostatectomy (TURP) on 09/01/2010. Record review revealed Patient #5 developed complications following surgery and a consult was requested for "medical management." Record review revealed the patient was transferred to another hospital on 09/02/2010. Review of the consult note revealed the report was dictated on 09/01/2010 at 2129 and transcribed on 09/02/2010 at 0843. Review revealed the consult report was missing a word or words (incomplete) as noted by an underlined area in the middle of the sentence in the context of the report. Further review revealed the consult report was signed by the physician on 11/08/2010 (67 days after discharge).

Interview on 02/10/2011 at 1440 with administrative staff revealed all medical records should be completed within 30 days after a patient's discharge. Interview further confirmed the physician did not follow the medical staff by-laws.

Based on medical staff by-laws, rules and regulations review, anesthesia department policy review, medical record review and staff and physician interview the hospital failed to ensure a post-anesthesia evaluation was completed and documented by an individual qualified to administer anesthesia no later than 48 hours after surgery for 1 of 3 sampled surgical patients (#4).

The findings include:

Review of the hospital's Medical Staff By-Laws, Rules and Regulations, revised April 18, 2010, revealed "...R.2.. Post Anesthesia Care...The The post anesthesia record shall be completed by the anesthetist immediate in the postoperative care area with the following information properly documented, dated and the times: Type of anesthesia and surgery performed, Patient's physical condition including stability of vital signs, principle ailment of patient, quantity of blood loss, status of fluid replacement and level of consciousness on entering and leaving the PACU (post anesthesia care unit)..."

Review of the Anesthesia Department policy A-7 "Anesthesia Responsibilities" effective April 12, 2010 revealed "... Documentation of pre-operative and post-operative anesthesia visits must be done on the anesthesia evaluation sheet by the attending anesthetist before the patient can be discharged..."

Closed medical record review on 02/09/2011 of Patient #4 revealed a 77 year-old male admitted 10/26/2010 for a cystourethroscopy. Record review revealed the patient received spinal anesthesia beginning 10/26/2001 at 1008 and ending at 1106. Record review revealed the patient was discharged on 10/29/2010. Review of the "Post-Operative Assessment" form used by the Anesthesia Department for documentation of the post anesthesia assessment revealed the form was blank with a handwritten note that stated "dischg (discharge)" and no date or time recorded. Further record review revealed no documented evidence of a post-anesthesia evaluation.

Interview on 02/09/2011 at 1605 with an anesthesiologist revealed post anesthesia evaluations are completed within 48 hours after the patient receives anesthesia. Interview further revealed all patients who have received anesthesia should have a post anesthesia assessment prior to discharge.

Interview on 02/09/2011 at 1510 with administrative staff revealed a post-anesthesia evaluation is to be documented by anesthesia staff. Interview confirmed there was no documented evidence of a post-anesthesia evaluation for Patient #4.


NC00069018