HospitalInspections.org

Based on interview and record review, the facility failed to ensure plans of care were followed and updated as needed in 2 of 11 sampled patients reviewed for plans of care (Patient #'s 2 and 3).

Nursing staff failed to notify the physician of a need to update the plan after a decrease in oxygen saturation on Patient #3.

Nursing staff failed to follow the plan of care on Patient #2 and obtain vital signs as ordered by the physician.
This deficient practice had the likelihood to cause harm to all patients.

Findings include:

Review of physician's surgical progress notes revealed Patient #3 was a 61 -year-old female admitted on 01/26/2024 for a laparoscopic cholecystectomy with intraoperative cholangiogram (gallbladder surgery). On 01/26/2024 Patient #3 also had an endoscopic retrograde cholangiopancreatography (ERCP) to remove stones in the bile duct.

According to critical care notes dated 01/28/2024 at 9:57 a.m., a provider documented that post ERCP Patient #3 developed pancreatitis. This AM she developed worsening shortness of breath and she would be transferred to the intensive care unit (ICU). The plan was for chest x-ray, bipap and Lasix. There was documentation in the notes that Patient #3 was on oxygen at 2 liters and had audible wheezing upon entering the room.

According to nursing notes on 01/28/2024 at 10:42 a.m. Patient #3 was in acute respiratory distress with a respiratory rate of 26 and heart rate of 134. Patient #3 is now on a continuous BiPap (non-invasive ventilator).

According to documentation Patient #3 was placed on the Bipap on 01/28/2024 at 12:12 p.m.

Review of a respiratory flow sheet dated 01/30/2024 at 4:52 a.m. revealed the last documentation of Patient #3 having the Bipap on.

According to vital sign flow sheets dated 01/30/2024 the following was documented:

At 07:15 a.m. the oxygen saturation was 97 percent.
At 07:30 a.m.the oxygen saturation was 96 percent.
At 0745 a.m. the oxygen saturation had dropped to 67 percent and no there was no documentation of the Bipap being on or off. There was no documentation of the nurse notifying the physician that the oxygen saturation had dropped to 67 percent.
At 08:00 a.m. the oxygen saturation was documented as being 96 percent.

According to a Code blue sheet Patient #3 coded and was provided cardio-pulmonary resuscitation from 8:09 a.m.- 8:24 a.m. on 1/30/2024. Patient #3 was intubated and placed on a ventilator after being coded.

Documentation on a critical care attending progress note dated 01/30/2024 at 1:45 p.m. revealed" This morning nurse reported she had pulled her BIPAP off. After her BIPAP was replaced, she did not recover her hypoxia and had a bradycardic to PEA arrest (pulseless electrical activity) ..."

During an interview on 10/01/2024 after 1:00 p.m., Staff #13 (Registered nurse/RN preoperative) confirmed the missing documentation in the chart of the physician not being notified of the oxygen saturation and if the Bipap was on or off.

During an interview on 10/01/2024 after 2:00 p.m., Staff #10 (RN quality) stated there was no order to discontinue the Bipap in the record.

During an interview on 10/01/2024 after 2:00 p.m., Staff #3 (RN Quality director) confirmed she could not find documentation of the physician being notified of the drop in oxygen saturation or the Bipap being discontinued.

During an interview on 10/01/2024 after 3:00 p.m., Staff #16 (Pulmonary staff) confirmed there was an order for a continuous Bipap, settings and where the documentation should be in the chart.

During an interview on 10/01/2024 after 4:45 p.m., Staff #12 (RN) confirmed she was the nurse working during the timeframe in question. Staff #12 (RN) stated she kept educating Patient #3 and the family about keeping the bipap on. Staff #12 (RN) stated she could not remember if the Bipap was on or if the physician was called about the oxygen saturation drop.

Review of "Hospital Quality and Safety Committee Minutes" from April- September 2024 revealed no performance improvements addressing physician notification or assessment/reassessment.

Review of an e-mail dated 10/09/2024 at 10:03 a.m., Staff #3 (RN Quality) confirmed there were no general performance improvements addressing these areas.


Review of a facility's policy named "Title: Patient Assessment and Reassessment" revised on 04/2024 revealed the following:

"...IV.PROCESS OR PROCEDURES:
A. Patient Assessment and Reassessment...
2.Consultation of disciplines, other than nursing, is determined by the initial and ongoing assessment data collected by nursing in collaboration with Physician oversight..."




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A review of physician's note, Patient #2 was a 95-year-old male admitted to the Intermediate Care Unit (6th floor Ornelas) of the hospital on 7/25/2024 with a diagnosis of COVID-19 and Pneumonia.

A review of Patient #2's medical record was conducted on 10/01/2024 with Registered Nurse (RN) Staff #10. Further review was conducted on 10/07/2024 at 11:30 AM. A review of the physician admission orders dated 7/26/2024 at 2:49 AM revealed vital signs (blood pressure, temperature, respiration count, and heart rate) were to be taken every 4 hours.

Physician #17 wrote an order on 7/27/2024 at 1723 (5:23 PM) that read, "Vital signs, Q (every) 15 minutes x (times) 4, q 30 minutes x 2, and q 1 hour x 2 then per unit routine". Registered Nurse (RN) Staff #18 acknowledged the order on 7/27/2024 at 5:34 PM. Further review revealed there was no vital signs documented in the medical record after 1:37 PM on 7/27/2024 until 7:33 PM. This was over two hours after Physician #17 wrote the order for specific time parameters for vital signs on 7/27/2024 at 5:23 PM. There should have been 6 sets of vital signs documented from 5:23 PM to 7:33 PM.

An interview was conducted with Quality Director, Staff #3 on 10/07/2024 at 12:59 PM. Staff #3 confirmed no vital signs were documented in the medical record from 1:37 PM until 7:33 PM on 7/27/2024.

An interview was conducted with RN Charge Nurse, Staff #6 on 10/01/2024 after 10:00 AM. RN Saff #6 was asked how often vital signs were taken in the Intermediate Care Unit. RN Staff #6 stated, "Every four hours on this unit unless the physician has written a different order".

A review of the nursing documentation on 7/27/224 at 7:12 PM was as follows:

"Patient found unresponsive in the room. Code initiated". Code (a term used to indicate a patient requires CPR or is?otherwise in need of immediate medical attention, most often as the result of a heart attack or respiratory arrest) was called and Patient #2's heartbeat returned after cardiopulmonary resuscitation (CPR) was performed for 22 minutes.


A telephone interview was conducted with Staff #3 on 10/07/2024 at 12:59 PM. Staff #3 was asked if any vital signs were documented between 1:57 PM and 7:33 PM on 7/27/2024. Staff #3 confirmed there was no vital signs documented in the medical record during that time. Staff #3 confirmed Physician #17 wrote a new order on 7/27/2024 at 5:23 PM for vital sign monitoring. Staff #3 was asked if the facility had a Vital Sign Policy. Staff #3 confirmed the facility did not have a specific policy for routine vital signs. Staff #3 stated, "No, there is not a specific policy for vital signs, but the vital signs were addressed in the Nursing Assessment Policy".


Review of "Hospital Quality and Safety Committee Minutes" from April- September 2024 revealed no performance improvements addressing physician notification or assessment/reassessment.


Review of an e-mail dated 10/09/2024 at 10:03 a.m., Staff #3 (RN Quality) confirmed there were no general performance improvements addressing these areas.


In an interview conducted on 10/07/2024 at 12:59 PM, Staff #3 confirmed the nursing staff failed to assess and document the vital signs per facility policy and physician order.


A review of the hospital policy titled, "Assessment and Reassessment" with a review date of 4/2024 was as follows:
" ...III Policy Statement:

A. It is policy of CHRISTUS Trinity Mother Frances that all patients admitted to the facility receive a complete head to toe assessment by a qualified individual to allow development and implementation of a plan of care that will best meet the individualized health care needs of the patient. The assessment of the care and/or treatment needs of the patient is continuous throughout the patient's hospitalization.

B. All disciplines deemed competent upon initial or ongoing assessment by Physicians, Nursing, Pharmacy, Therapy Services, Respiratory, and Case Management teams, participate in the assessment process to provide a comprehensive, collaborative approach to patient care. Personnel are qualified by level of licensure to perform a complete assessment and reassessment of the patient. A complete assessment includes physical, psychological, emotional, social status, nutritional status, as well as educational needs ...

IV. Process of Procedure


A. Patient Assessment and Reassessment
1 ...
6. Intensive Care and Intermediate Care patients receive an initial assessment upon arrival to the unit. They are reassessed at least every four (4) hours by a RN or sooner based on changes in the patient's condition. Prior to discharge, ICU patients are assessed to determine if they meet discharge criteria..."