HospitalInspections.org

Based on review of medical record (MR) and interview, the facility failed to initiate treatment in response to changes in a patient's condition in a timely manner. This was noted in (1) one of 13 medical records reviewed (Patient #1).

This failure may have caused delay in appropriate care and placed patients at risk for harm.

Findings:

Review of the medical record of Patient #1 revealed: A 22 year old morbidly obese (163.6 kg) 360 lb male with multiple comorbidities which included lymphoma, and supra ventricular tachycardia (SVT). The patient underwent a left knee arthroscopy with anterior cruciate ligament (ACL) repair on 9/22/16 as an ambulatory surgery procedure.
On 9/30/16, at 21:30 hours (9:30 PM), he was admitted to the facility with complaints of pain to the surgical site. Upon admission his vital signs were: heart rate (HR) 76 (normal adult 60-100); oxygen saturation (SpO2) 97% (normal values 95-100%); blood pressure (BP) 127/73 (normal 90-120/60-80).

The nurse documented patient's vital signs as follows:

On 10/1/16 at 8:29 PM - HR 114, SpO2 93%, BP 101/68.
On 10/2/16 at 5:27 AM vital signs - HR 137, SpO2 91%, BP 94/56 revealed further deterioration in the patient's condition.

There was no documentation of an immediate assessment by a physician until more than fourteen hours after, on 10/2/16 at 7:30 PM, when a PGY 1, Staff N, noted vital signs which were recorded on 10/2/16 at 5:27 AM: HR 137, BP 94/56. He noted a treatment plan which included pain control and physical therapy. There was no documented plan to address the patient's rapid heart rate and a drop in his blood pressure.

On 10/2/16 at 9:22 PM, the patient's vital signs were SpO2 93%, BP 94/63. There was no documentation of an ongoing assessment and treatment of the patient's deteriorating condition until 10/3/16 at 2:53 PM when the Rapid Response Team (RRT) was activated for a heart rate of 143, SpO2 86% Attempts to resuscitate him failed and the patient was pronounced dead at 4:11 AM.


At interview on 12/1/16 at 1:32 PM, Staff L reviewed a list of events requiring attending notification. Among these is an "unexpected change in a patient's vitals." He also stated that "all residents have cell phones of the attendings and can reach them at any time."

At interview on 12/5/16 at 11 AM with Staff N who conducted the exam on 10/2/16, he stated he was not the resident who reports inpatient issues to the attending. He revealed that another resident, Staff O held that responsibility. The resident stated he did not report the change in vital signs to the attending.

At interview on 12/5/16 at 11:15 AM, Staff O stated that he was not on duty at that time and referenced another resident as the responsible person.

At interview on 12/6/16 at 10:32 AM, Staff P stated that he was on duty at the time but was not informed of any changes in the patient's status.

The facility's policy Number: E157, Titled: "Early Recognition And Response System Using Rapid Response Teams (RRT) states: the primary provider must be called for any changes in patient condition. The policy also states, "when any staff member is concerned about a patient who is exhibiting signs of symptoms of deterioration, or feels that the patient requires immediate intervention, the staff member will activate the Rapid Response Team...." The guidelines for activating the Rapid Response Team includes the acute change in vital signs in adults, such as a heart rate of 130 or greater.
The patient met this criterion on 10/2/16 at 5:27 am when his heart rate reached 137 and there is no indication that immediate intervention was provided.

Based on review of medical records (MR) and interview, the facility did not ensure that the patient's condition is assessed and changes reported to the physician. This was evident in (1) one of 13 medical records reviewed. (Patient #1).

Findings

Review of MR for Patient # 1 revealed: 10/01/16 at 20:30 hours (8:30 PM) the nurse noted the following; "Patient had episode of panic attack. C/O SOB, not feeling well." The nurse noted she administered oxygen via nasal cannula and that vital signs were stable. The vital signs documented on 10/1/16 at 8:29 PM revealed a rapid heart rate of 114 (normal adult 60-100), and an abnormal value of oxygen saturation of 93% (normal 95-100%).

There was no documentation of a physician assessment for the diagnosis of panic attack and treatment of the patient's condition.


Subsequent vital signs were documented by the nurse as follows:
On 10/02/16 at 5:27 AM, the patient's heart rate was 137, SpO2 was 91%, blood pressure 94/56.
On 10/2/16 at 1:54 PM, the heart rate was 132, blood pressure was 88/62.
There was no documentation of physician notification of the patient's vital signs.


At interview on 12/1/16 at 1:16 PM the Chief Nursing Officer stated, "the nurse must notify the physician or the Patient Care Director when a patient has abnormal vitals."