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Based on interview and record review, the hospital failed to ensure the nursing staff provided the patient teaching in the patient's preferred language for one of two sampled patients (Patient 2). This failure had the potential for unsafe care to the patient.

Findings:

Review of the hospital's P&P titled Interpreter Services dated 8/12/24, showed the purpose of the policy is to ensure compliance with regulatory requirements that protect the patient's rights to access basic health care when limited by language or hearing impairment. The P&P showed the hospital shall provide interpreter services when a patient is Limited English Proficient (LEP), or non-English speaking.

On 9/24/24 at 1033 hours, review Patient 2's medical record was initiated with the Licensing Coordinator. Patient 2's medical record showed the patient was admitted to the hospital on 9/19/24. Patient 2 was non-English speaking and required interpreter services.

Review of the Education dated 9/23/24 at 0855 hours, showed RN 5 discussed multiple topics with Patient 2, including the activity precautions and restrictions, fall prevention, ADL care, mobility and positioning, DVT signs and symptoms, infection signs and symptoms, pain, PE signs and symptoms, and suicide prevention. RN 5 documented the teaching method was through the demonstration and explanation. However, further review of Patient 2's medical record failed to show documented evidence an interpreter was utilized for Patient 2 when the family was not present to assist in translating.

Review of the Education dated 9/24/24 at 0000 hours, showed RN 6 discussed multiple topics with Patient 2, including mobility, bladder management, fall prevention, pain, PE signs and symptoms, safety, self-care, and suicide prevention. RN 6 documented the teaching method was demonstration and explanation. However, further review of Patient 2's medical record failed to show documented evidence an interpreter was utilized for Patient 2 when the family was not present to assist in translating.

The Licensing Coordinator was informed of and acknowledged the above findings.

Based on observation, interview, and record review, the hospital failed to ensure the nursing staff supervised and evaluated the nursing care for two of two sampled patients (Patients 1 and 2) as evidenced by:

1. The nursing staff failed to notify Patient 1's physician when the patient was off the continuous cardiac monitor for approximately two hours despite being newly diagnosed with a heart arrhythmia. In addition, the nursing staff failed to provide Patient 1 with consistent pain management as per the hospital's Nursing Clinical Standards.

2. The nursing staff failed to follow the hospital's Nursing Clinical Standard for Patient 2's extravasation on the left arm including assessment and care management. Additionally, the left AC IV site was incorrectly documented as the right AC IV site.

These failures had the potential for unsafe care to the patients.

Findings:

1. On 9/24/24 at 1102 hours, Patient 1's closed medical record was reviewed with Nurse Manager 1.

Review of Patient 1's medical record showed Patient 1 was admitted to the hospital on 9/12/24, and discharged on 9/13/24.

Review of the Orders dated 9/12/24 at 1460 hours, showed to admit Patient 1 to telemetry unit.

a. Review of the hospital's Nursing Clinical Standard titled Cardiac Telemetry Monitoring - Acute Care Telemetry Unit dated October 2020 showed the following:

* Continuous cardiac monitoring of patients is important for following reasons:

- Prompt identification of cardiac rhythm changes or abnormalities and need for treatment which can prevent adverse events, including hemodynamic compromise and death.

- Assistance in identifying those risks for life-threatening cardiac arrhythmias and/or myocardial ischemia (MI).

* Apply telemetry monitor and pulse oximeter (as ordered) upon admission and ensure patients are monitored throughout telemetry stay.

Review of the Cardiology Inpatient Progress Note dated 9/12/24 at 1534 hours, showed Patient 1 presented to the hospital with type II AV block seen after the outpatient stress test.

Review of the Computed Tomography dated 9/13/24 at 1253 hours, showed the CT angiography coronary artery with evaluation was performed.

Review of the TeleTracking for Patient 1 showed Patient 1 was picked up from the unit on 9/13/24 at 1208 hours and came back to the unit on 9/13/24 at 1355 hours. Patient 1 was off the unit for one hour and 47 minutes.

On 9/24/24 at 1130 hours, Nurse Manager 1 was interviewed. When asked, Nurse Manager 1 stated patients on the telemetry unit would go to the diagnostic testing area without the cardiac monitoring. When asked, Nurse Manager 1 stated no physician's notification or physician's order was needed to remove the cardiac monitoring for the diagnostic procedure. The telemetry nursing staff did not accompany the patients for diagnostic procedures. When asked, Nurse Manager 1 stated it had been a practice on the telemetry unit.

On 9/24/24 at 1320 hours, the CT area was toured with the Chief Radiologic and Supervisor Radiologic in the presence of the Assistant Nursing Director. There were three holding bays in the CT areas. When asked, the Supervisor Radiologic stated the holding bays were for patients who were waiting for transporting back to their units. When asked, the Supervisor Radiologic stated there was no nurse in the holding bays.

On 9/25/24 at 0945 hours, the Internal Medicine- Cardiology was interviewed in the presence of the Officer of Regulatory Office. When asked, the Internal Medicine- Cardiology stated being off the continuous cardiac monitoring for one hours and 47 minutes was relatively long for a patient with new onset AV block cardiac condition.

On 9/25/24 at 1000 hours, the Licensing Coordinator and Officer of Regulatory Office verified the above findings.

b. Review of the hospital's Nursing Clinical Standard titled Pain Management dated October 2023 showed the following:

* Assess/reassess pain intensity/score a minimum of every four hours utilizing the pain assessment tools attached.

* Assess/reassess pain characteristics as follows:

- Baseline assessment (upon first complaint of pain/complaint of new type of pain): location, laterality, quality, time pattern.

* Reassess pain level less than one hour after intervention or as clinically indicated.

On 9/24/24 at 1102 hours, Patient 1's medical record was reviewed with Nurse Manager 1.

Review of Patient 1's medical record showed Patient 1 was admitted to the hospital on 9/12/24 and discharged on 9/13/24.

Review of the Pain Assessment showed the following:

* On 9/12/24 at 1937 hours, Patient 1 complained of a pain level of six out of 10 (0 being no pain and 10 being the worse pain). However, the medical record failed show documentation of the location, laterality, quality, and time pattern.

* On 9/13/24 at 1127 hours, Patient 1 complained of a pain level of 10 out of 10.

Review of the Medication Administration Record dated 9/13/24 at 1133 hours, showed Patient 1 received acetaminophen (a pain medication) 650 mg for pain.

Review of the Medication Administration Record dated 9/13/24 at 1233 hours, showed Patient 1's pain level was unacceptable and the patient refused added analgesics. However, the medical record did not show documentation of the pain level. In addition, there was no added analgesics available for Patient 1 other than acetaminophen.

On 9/24/24 at 1129 hours, Nurse Manager 1 verified the above findings.


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2. Review of the hospital's Nursing Clinical Standard titled Extravasation, Management dated December 2023 showed the following:

* Extravasation is a potential complication of IV therapy and is defined as leakage of intravenous fluid or medications out of the vein. Serious tissue damage may occur, particularly with vesicants.

* Management of a patient with extravasation or suspected extravasation is as follows:

- Assess the IV site and the surrounding area upon identification of extravasation at a minimum of every two hours for 72 hours; assess for swelling, induration, redness, bruising or discoloration, skin translucency, skin cool to touch, pain, itching, circulatory impairment of the distal area, drainage, streak formation, ulceration, and necrosis.

- Upon identification of an extravasated medication which requires an antidote, notify the provider immediately, stop the IV fluid and medication, disconnect the tubing from the IV catheter, attach a 6 ml syringe to the IV catheter hub, apply a tourniquet above the site of the extravasation, then aspirate and check for blood return. If there is no blood return, slowly aspirate as much of the infiltrated fluid as possible, remove the tourniquet and IV catheter.

- Notify the provider with the occurrence of the extravasation, name of the extravasated medication, condition of the extravasation site, and worsening of the extravasation site.

Further review of the hospital's Nursing Clinical Standard showed a table for recommended treatment for extravasation of amiodarone (antiarrhythmic) is to administer hyaluronidase (used to help drugs and other substances move more easily into tissues and be absorbed by the body) 15 units/ml given as a 1 ml subcutaneous injection approximately one-half inch apart of the entire affected area in a clock pattern. It is recommended to put a dry and warm compress. These interventions require physician's orders.

On 9/24/24, Patient 2's medical record was reviewed. Patient 2 was admitted to the hospital on 9/19/24. On 9/21/24, Patient 2 was in the PCU.

a. Review of Patient 2's Vascular Access documentation dated 9/21/24 at 1800 hours, showed RN 7 documented Patient 2 had a right AC peripheral IV.

On 9/25/24 at 0937 hours, an interview was conducted with RN 7 regarding Patient 2. RN 7 confirmed Patient 2's peripheral IV was in the left AC and not the right AC.

b. Review of the physician's order for Patient 2 dated 9/20/24 at 1354 hours, showed to infuse amiodarone 900 mg in Dextrose 5% in water (an IV solution) at 33.33 ml/hr continuously. Further review of the order showed the order was discontinued on 9/21/24 at 1510 hours.

Review of the Vascular Access dated 9/21/24 at 1800 hours, showed RN 7 documented Patient 2's IV site condition had no complications, and the dressing was clean, dry, and intact.

However, review of the Vascular Access documentation on 9/21/24 at 1900 hours, showed RN 8 documented Patient 2's left AC IV was discontinued due to being infiltrated. RN 8 documented there was no blood return, and the IV site was red. RN 8 documented the catheter was removed intact with no complications.

Further review of Patient 2's medical record failed to show the physician was notified of the possible extravasation of the patient's left AC IV as per the hospital's Nursing Clinical Standard. The physician was not notified of the discontinued IV site condition of the left arm until 9/22/24 at 0016 hours, as shown on the Provider Notification flowsheet after Patient 2 was transferred to the Telemetry Unit. The Notification Details showed Patient 2's left AC IV was infiltrated at 1900 hours. The IV was discontinued and a heat pack was applied with arm elevation. The documentation showed the Provider Requested Intervention was to continue to monitor and order US if the patient's condition worsened.

On 9/25/24 at 0937 hours, an interview was conducted with RN 7 regarding Patient 2. When asked, RN 7 stated she discontinued Patient 2's amiodarone IV drip at approximately 1600 hours. RN 7 stated the patient's IV site appeared patent on her assessment with no complications. RN 7 stated the IV was saline locked and no other medications were given through the left AC IV.

c. Review of Patient 2's medical record showed Patient 2 were not assessed or monitored every two hours for 72 hours, nor comprehensive to establish a baseline for subsequent changes within the 72 hours as per the hospital's Nursing Clinical Standard. For example:

- Review of the Incision/Wound assessment documentation showed on 9/22/24 at 2000 hours, Patient 2 had "IV Infiltration/Extravasation" with wound status as "Unchanged". There was no skin dressing, and the site was open to air.

- The Edema Assessment documentation showed on 9/22/24 at 2000 hours, Patient 2 had left arm edema which was localized and dependent.

These assessments for Incision/Wound and Edema remained unchanged and were documented as assessed on 9/23/24 at 0000, 0400, 0855, and 2000 hours; and 9/24/24 at 0000, 0400, and 0800 hours.

Review of the Inpatient Progress Note dated 9/22/24 at 0633 hours, showed RN 8 documented the left AC IV was infiltrated at 2000 hours. RN 8 documented the IV was taken out intact, and a warm pack was applied.

Review of the Inpatient Progress Note dated 9/22/24 at 1929 hours, showed Patient 2 had some redness noted on the left arm and per the report it was due to infiltration.

Review of the Inpatient Progress Note dated 9/23/24 at 1937 hours, showed Patient 2 had redness and induration to the left arm.

On 9/24/24 at 1430 hours, an observation of Patient 2 in Room A was conducted with RN 9. Patient 2 was lying in bed with the HOB elevated in a sitting position. RN 9 stated Patient 2's arm was hardened over the area where the old IV was and very warm to the touch. RN 9 stated Patient 2's arm was swollen, red, and marked with pen. RN 9 stated Patient 2 stated having discomfort on the arm and needed encouragement to keep the left arm elevated.

On 9/25/24 at 1016 hours, an interview was conducted with Patient 2's attending physician, MD 2. When asked, MD 2 stated he assumed care for Patient 2 since 9/23/24. MD 2 stated he noted Patient 2's left arm had pen marking on it, but he was not informed by the prior attending physician of Patient 2's left arm, nor notified from nursing. When asked, MD 2 stated he would expect to be notified of the circumstance leading to the state of Patient 2's arm. MD 2 stated that if he knew of a possible extravasation related to amiodarone on this patient, he would expect comprehensive documentation of what the affected arm looked like, as well as photographs to monitor how the wound was progressing. MD 2 stated if he knew, he would consult with pharmacy on the next steps for an antidote, if needed.

On 9/25/24 at 1121 hours, the above concerns for incorrectly documenting Patient 2's IV site as a right AC IV instead of left AC IV, the lack of timely notification of the IV infiltration and possible extravasation, and the lack of performing comprehensive assessments every two hours for 72 hours to capture how Patient 2's left arm wound was progressing were shared and acknowledged by the Licensing Coordinator.