HospitalInspections.org

Based on record review and interview, the facility failed to conduct a thorough investigation of a grievance and inform the complainant of the findings for 1 of 1 patient (#16) as evidenced by:
-The facility investigation failed to discover that a DNR had been noted in the ED.
-No steps were taken to ensure the incident did not happen again.
-The complainant was not notified by mail of the results of the investigation.

Findings include:

Record review of Patient #16's closed electronic medical record revealed she was admitted to the Emergency Department (ED) on 4/8/14 at 9:16 a.m. She had fallen at home with pain in her left hip and left ankle. She was triaged at 9:18 a.m. and a Detail Assessment was done at 9.24 a.m. by RN #64. In the Detail Assessment there was a notation that read, "Are there cultural, religious, language, developmental or behavioral factors to consider in planning care: Yes. Describe: DNR (Do Not Resusitate)."

On 4/8/14 at 12:04 p.m.ED physician #69 wrote an order to make the patient a "Full Code."

Record review of Patient #16's Physician's Clinical note dated 4/8/14 at 5:55 p.m. by her Attending Physician #70 who wrote this note, "Patient seen in ER (Emergency Room) and evaluated, has DNR status as per daughter and they do not want intubation. Patient's medical record reviewed and I discussed with daughter. Patient stopped all her medications 3 weeks ago and may have given up..." RN #68 was the patient's nurse at this time.

Record review of Patient #16's Physician's Orders revealed no order for DNR from the ED.

Further review of Patient #16's closed medical record revealed she was admitted to ICU on 4/9/14 at approximately 7:00 p.m. with diagnoses of diabetic ketoacidosis and hypotension. She was a "Full Code". On 4/11/14 at 5:15 a.m. there was a Code Blue Record and the patient was resusitated, intubated and put on a ventalator.

Interview on 7/17/14 at 11:00 a.m. with RN #58 in the ED, she was asked what the procedure was if a patient came in the ED with a DNR. She said the facility did not accept an "Out-of-Hospital" DNR if there was time to get a facility DNR. As soon as the nurse knew of a DNR, she was to get the hospital form and have the patient or family member and physician sign it. Then the physician should put an order in the electronic system for a DNR. Once the order was in the computer, then the nurse would place a purple band on the patient's wrist. She said there was no sticker to place on the chart like in ICU (Intensive Care Unit). She said there was no hand off sheet from shift to shift. A verbal report was given at the computer.

Interview on 7/17/14 at 2:00 p.m. with Risk Manager RN #61, she said that when she got the complaint from Patient #16's family member on 4/15/14, the concern was that there was no communication between the ED and ICU about a DNR. RN #61 said that she did not find any DNR in the ED notes and that the patient had an order for a full code. She said the ED Manager RN #59 had tried to contact the complainant several times by phone without a response. She said she had sent three letters asking for the complainant to call her, but did not get a response. She said she quit trying because she thought the complainant may not have wanted to be reminded of her loss. She said she attended a conference on Team STEPPS in June 2014 which was about communications. She said she wanted to initiate the concepts at the hospital to improve communication between units as a response to the complaint. She said she had not initiated anything at this time. She said she did not know if the ED Manager or Director had provided any in-services for their staff on obtaining DNR orders.

Interview on 7/18/14 at 9:00 a.m. with ED Manager RN #59, she said there was no where in the ED computerized system that prompted information about a DNR. When she was asked about the notation made in Patient #16's Detailed Assessment, she said that had to be typed in by the nurse. The ED Director RN #54 was present at this time and said the nurse should have gotten an order from a physician for a DNR and a purple band should have been put on the patient. Risk Manager RN #61 was present at this time and said she had not seen the DNR in Patient #16's ED record when she did her investigation. She was going on the complainants words that a DNR had been discussed.

Record review of Risk Manager RN#61's investigation information revealed a copy of the Code Blue Record, a copy of the Clinical Note by Attending Physician #70, an EKG strip dated 4/8/14, an admisssion order by Physician #70 dated 4/8/14 at 6:17 p.m., and the ED notes. She had a hand written note by the DNR section of the ED notes that the surveyor had found the notation. There were three letters in the investigation file dated 4/16/14, 4/23/14, and 5/6/14. The first two letters stated the facility was in the process of investigating their concerns. The last letter stated, "Our emergency department management team has attempted to contact you by phone to discuss your concerns, and left my name and call back information. As of today, I have not heard back from you." All three letters were written by RN #61 and gave her call back information. None of the letters gave any information about the investigation, i.e. steps taken, the results of the grievance process, and the date of completion.

Record review of the facility's Policy and Procedure for Complaint and Grievance Resolution for Patients and Customers dated 3/99 and revised/reviewed on 5/13 revealed the following:
"To allow all patients and/or their representatives their right to voice complaints and/or grievances about his or her care, and to have those complaints reviewed and, when possible, resolved....
PROCEDURE...
III. The person receiving the complaint will log the complaint into Resolvv (complaint tracking system). Resolvv will electronically notify the Department Director/Manager. The Risk Manager is responsible for reviewing all complaints and for management of Resolvv...
V. The Director/Manager handling the complaint will complete the investigation, follow up with the patient, and enter the findings and actions taken under event response in Resolvv, noting whether or not there was resolution...
VI. The Risk Manager reviews all complaints and grievances and works collaboratively with Department Directors/Managers to ensure that a thorough investigation is conducted and the grievances are resolved timely.
VII. The Hospital will respond to the substance of each grievance while identifying, investigating, and resolving any deeper, systemic problems indicated by the grievance...
XI. some grievances may require more extensive investigation and will be resolved as quickly as possible but within 21 days. The patient will be sent a follow up letter....
X...A. The written response will contain the following elements: name of the hospital, hospital contact person, steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion of the grievance process."

Interview on 7/18/14 at 1:45 p.m. with Director of Quality RN #60, she said the incident with Patient #16 receiving CPR and being intubated and put on a ventilator was not necessarily a sentinal event, but was serious and the facility took it very seriously. The Director of Quality RN #60 was given the concerns that nothing had been done to resolve the grievance. By the time of exit on 7/18/14 at 3:30 p.m., no further information was provided.

Based on record review and interview, the facility failed to comply with advance directives for 1 of 5 patients (#16) with DNR (Do Not Resuscitate) as evidenced by:

-There was a notation in Patient #12's ED Detail Assessment on 4/8/14 at 9:24 a.m. of a DNR
-The Attending Physician #70 made a progress note dated 4/8/14 at 5:55 p.m. that Patient #12 had a DNR and the family did not want her intubated. No order was written.
-Patient #12 was admitted to the ICU on 4/9/14 with a "Full Code" order.
-Patient #12 was given CPR on 4/11/14 in ICU, intubated and put on a ventilator.

Findings include:

Record review of Patient #16's closed electronic medical record revealed she was admitted to the Emergency Department (ED) on 4/8/14 at 9:16 a.m. She had fallen at home with pain in her left hip and left ankle. She was triaged at 9:18 a.m. and a Detail Assessment was done at 9:24 a.m. by RN #64. In the Detail Assessment there was a notation that read, "Are there cultural, religious, language, developmental or behavioral factors to consider in planning care: Yes. Describe: DNR (Do Not Resuscitate)."

On 4/8/14 at 12:04 p.m. ED Physician #69 wrote an order to make the patient a "Full Code."

Record review of Patient #16's Physician's Clinical note dated 4/8/14 at 5:55 p.m. by her Attending Physician #70 who wrote this note, "Patient seen in ER (Emergency Room) and evaluated, has DNR status as per daughter and they do not want intubation. Patient's medical record reviewed and I discussed with daughter. Patient stopped all her medications 3 weeks ago and may have given up..." RN #68 was the patient's nurse at this time.

Record review of Patient #16's Physician's Orders revealed no order for DNR from the ED.

Further review of Patient #16's closed medical record revealed she was admitted to ICU on 4/9/14 at approximately 7:00 p.m. with diagnoses of diabetic ketoacidosis and hypotension. She was a "Full Code". On 4/11/14 at 5:15 a.m. there was a Code Blue Record and the patient was resuscitated, intubated and put on a ventilator.

Interview on 7/17/14 at 11:00 a.m. with RN #58 in the ED, she was asked what the procedure was if a patient came in the ED with a DNR. She said the facility did not accept an "Out-of-Hospital" DNR if there was time to get a facility DNR. As soon as the nurse knew of a DNR, she was to get the hospital form and have the patient or family member and physician sign it. Then the physician should put an order in the electronic system for a DNR. Once the order was in the computer, then the nurse would place a purple band on the patient's wrist. She said there was no sticker to place on the chart like in ICU (Intensive Care Unit). She said there was no hand off sheet from shift to shift. A verbal report was given at the computer.

Interview on 7/17/14 at 2:00 p.m. with Risk Manager RN #61, she said that when she got the complaint from Patient #16's family member, the concern was that there was no communication between the ED and ICU about a DNR. RN #61 said that she did not find any DNR in the ED notes and that the patient had an order for a full code. She said she attended a conference on Team STEPPS in June 2014 which was about communications. She said she wanted to initiate the concepts at the hospital to improve communication between units as a response to the complaint.

Phone interview on 7/17/14 at 2:30 p.m. with Physician #70, he said when he talked to Patient #16's daughter in the ED about a DNR, he believed a nurse was present. He did not know the name of the nurse.

Interview on 7/18/14 at 9:00 a.m. with ED Manager RN #59, she said there was no where in the ED computerized system that prompted information about a DNR. When she was asked about the notation made in Patient #16's Detailed Assessment, she said that had to be typed in by the nurse. The ED Director RN #54 was present at this time and said the nurse should have gotten an order from a physician for a DNR and a purple band should have been put on the patient. Risk Manager RN #61 was present at this time and said she had not seen the DNR in Patient #16's ED record when she did her investigation. She was going on the complainant's words that a DNR had been discussed.

Record review of the facility's Policy and Procedure for DNR Orders and Comfort Care dated 12/01 and revised/reviewed on 4/13 revealed the following:
"IV. The physician has an ethical obligation to honor the resuscitation preferences expressed by the patient or the patient's surrogate...
VI. ORDERS
A. Do Not Resuscitate orders (DNR): In accordance with West Houston Medical Center's commitment to provide appropriate care to its patients, cardiopulmonary resuscitation is attempted whenever a patient suffers a cardiopulmonary arrest unless a DNR Order has been written in the patient's chart by the physician....
PROCEDURE...
II. Nursing responsibility: The patient's primary care RN must review the DNR order, sign off on the order and affix a purple armband to the patient, signifying the DNR status...."

Interview on 7/18/14 at 1:45 p.m. with Director of Quality RN #60, she said that Attending Physician #70 should have written the order when he talked to the patient and family on 4/8/14 at 5:55 p.m. When she was asked if it was also the RN's responsibility to get the order for DNR, when she became aware of one, and put on a purple arm band, RN #60 said it would be.

Based on record review and interview, the facility failed to ensure nursing staff provided DNR (Do Not Resuscitate) orders, DNR arm bands, and monitored 7 of 9 patients (#s 16, 11, 13, 14, 15, 8 and 10) in the Emergency Department and ICU (Intensive Care Unit) as evidenced by:

-Patient #16 was not given an order for DNR when it was noted on 4/8/14 at 9:24 a.m. and again at 5:55 p.m. CPR was initiated on 4/11/14 and the patient was intubated and put on a ventilator.
-Patients #11 and #14 were admitted to the ED with DNRs, but had no documentation that a purple arm band was applied.
-Patient #13 was admitted to ICU on 6/28/14 from ED as a Full Code. A DNR was ordered on 7/3/14 at 1:30 p.m. There was no documentation that a purple arm band had been applied.
-Patient #15 was admitted to ICU where a DNR order was written on 5/20/14 at 11:42. a.m. There was no documentation that a purple arm band had been applied.
-Patients #16, #8, #10, and #11 were not monitored in the ED per protocol.

Findings included:


DNR

Patient #16

Record review of Patient #16's closed electronic medical record revealed she was admitted to the Emergency Department (ED) on 4/8/14 at 9:16 a.m. She had fallen at home with pain in her left hip and left ankle. She was triaged at 9:18 a.m. and a Detail Assessment was done at 9:24 a.m. by RN #64. In the Detail Assessment there was a notation that read, "Are there cultural, religious, language, developmental or behavioral factors to consider in planning care: Yes. Describe: DNR (Do Not Resuscitate)."

On 4/8/14 at 12:04 p.m. ED Physician #69 wrote an order to make the patient a "Full Code."

Record review of Patient #16's Physician's Clinical note dated 4/8/14 at 5:55 p.m. by her Attending Physician #70 who wrote this note, "Patient seen in ER (Emergency Room) and evaluated, has DNR status as per daughter and they do not want intubation. Patient's medical record reviewed and I discussed with daughter. Patient stopped all her medications 3 weeks ago and may have given up..." RN #68 was the patient's nurse at this time.

Record review of Patient #16's Physician's Orders revealed no order for DNR from the ED.

Further review of Patient #16's closed medical record revealed she was admitted to ICU on 4/9/14 at approximately 7:00 p.m. with diagnoses of diabetic ketoacidosis and hypotension. She was a "Full Code". On 4/11/14 at 5:15 a.m. there was a Code Blue Record and the patient was resuscitated, intubated and put on a ventilator.

Interview on 7/17/14 at 11:00 a.m. with RN #58 in the ED, she said she had worked at the facility for 1 1/2 months. She was asked what the procedure was if a patient came in the ED with a DNR. She said the facility did not accept an "Out-of-Hospital" DNR if there was time to get a facility DNR. As soon as the nurse knew of a DNR, she was to get the hospital form and have the patient or family member and physician sign it. Then the physician should put an order in the electronic system for a DNR. Once the order was in the computer, then the nurse would place a purple band on the patient's wrist. She said there was no sticker to place on the chart like in ICU (Intensive Care Unit). She said there was no hand off sheet from shift to shift. A verbal report was given at the computer.

Interview on 7/17/14 at 1:30 p.m. with ED Director RN #54, she said she had a skills check for her staff that included DNR. She said all the staff did training on line during orientation on "Code of Conduct" that included DNR and Patient Rights.

Record review of the facility's Code of Conduct booklet (no date) revealed the following on page 8:
"Patients are provided information regarding their right to make advance directives regarding treatment decisions, financial considerations and the designation of surrogate healthcare decision-makers. Patient advance directives or resuscitative measures are honored within the limits of the law and our organization's mission, philosophy, values, and capabilities."

Phone interview on 7/17/14 at 2:30 p.m. with Physician #70, he said when he talked to Patient #16's daughter in the ED about a DNR, he believed a nurse was present. He did not know the name of the nurse.

Interview on 7/18/14 at 9:00 a.m. with ED Manager RN #59, she said there was no where in the ED computerized system that prompted information about a DNR. When she was asked about the notation made in Patient #16's Detailed Assessment, she said that had to be typed in by the nurse. The ED Director RN #54 was present at this time and said the nurse should have gotten an order from a physician for a DNR and a purple band should have been put on the patient. She said RN #64 had been hired in January 2014 and had been given information on DNR through a skills check the same as RN #58 who knew what to do.

Record review of the facility's Policy and Procedure for DNR Orders and Comfort Care dated 12/01 and revised/reviewed on 4/13 revealed the following:
"IV. The physician has an ethical obligation to honor the resuscitation preferences expressed by the patient or the patient's surrogate...
VI. ORDERS
A. Do Not Resuscitate orders (DNR): In accordance with West Houston Medical Center's commitment to provide appropriate care to its patients, cardiopulmonary resuscitation is attempted whenever a patient suffers a cardiopulmonary arrest unless a DNR Order has been written in the patient's chart by the physician....
PROCEDURE...
II. Nursing responsibility: The patient's primary care RN must review the DNR order, sign off on the order and affix a purple armband to the patient, signifying the DNR status...."

Record review of the following ED RN's records and training revealed the following:
RN #64 - Date of Hire (DOH) 1/6/14
Code of Conduct training 1/6/14. No documented training for DNR
RN #68 - DOH - 6/17/13
Rapid Regulatory Compliance:...Advanced Directives, 6/1/14, 6/25/13
Code of Conduct - 3/11/13

Patient #11

Record review of Patient #11's closed electronic record revealed he was admitted to the ED on 4/9/14 at 5:19 a.m. with a fall at a nursing home with a fractured left hip. He was assessed as a Level 3. He was admitted to the hospital. He had a DNR order in the computer on 4/9/14 at 7:05 p.m. There was no documentation in the ED notes that a purple band had been applied.

Patient #13

Record review of Patient #13's closed electronic record revealed she was admitted to the ED on 6/28/14 at 5:26 p.m. with acute respiratory failure. She was admitted to ICU at 6:58 p.m. with a Full Code. On 7/3/14 at 1:30 p.m. a DNR order was written. There was no documentation that a purple arm band had been applied.

Patient #14

Record review of Patient #14's closed electronic record revealed she was admitted to the ED on 4/1/14 at 5:48 p.m. with pneumonia. She had a notation in her ED notes of a DNR. There was a physician's order for DNR. She was admitted to ICU (Intensive Care Unit). There was no notation in the ED notes or ICU notes that a purple arm band had been applied.

Patient #15

Record review of Patient #15's closed electronic record revealed she was admitted to the ED on 5/19/14 at 6:31 p.m. She was a full code. She was admitted to ICU on 5/19/14 apporximately an hour later. On 5/20/14 at 9:00 a.m. the patient was intubated and put on a ventilator. A DNR was signed by a family member and an order placed in the electronic record at 11:42 a.m. There was no documentation that the purple arm band had been applied.

Interview on 7/18/14 at 11:00 a.m. with ED Manager RN #59, she verified there was no documentation that a purple arm band had been applied to the patients with DNRs admitted to the ED. She said documentation would show the staff followed procedures.

Interview on 7/18/14 at 1:45 p.m. with Director of Quality RN #60, she said that Attending Physician #70 should have written the order when he talked to the patient and family on 4/8/14 at 5:55 p.m. When she was asked if it was also the RN's responsibility to get the order for DNR when she became aware of one, and put on a purple arm band, RN #60 said it would be. When she was informed there was no documentation of arm bands being applied for patients with DNRs, she said the facility did not document when other bands were applied, so would not document when the purple one was applied.

Record review of an ICU record revealed a notation on the electronic record to note if the allergy band was on, "Yes or No". Review of Patient #14 ED record dated 5/19/14 revealed the following under "Patient Safety Parameters": Allergy and Patient Identification Bands in Place and Validated."

Interview on 7/18/14 at 3:30 p.m. with CNO (Chief Nursing Officer) #51, she said she would expect to see that the arm band had been applied in the nurses' notes.


Monitoring Vital Signs

Further review of Patient #16's ED notes on 4/8/14 revealed the following:
- From 12 noon to 5 p.m. (5 hours) there was no documentation of vital signs being taken or assessed.
-At 5 p.m. the patient's blood pressure was 78/62. Up until then the systolic (top number) blood pressure (BP) had been in the 120s and 90s. There was no documentation that the lower BP was assessed or addressed.
-From 5 p.m. to 12 midnight (7 hours) there was no documentation of vital signs being taken or assessed.
Patient #16 was assessed to be at Level 3 for care.

Patient #8

Record review of Patient #8's closed electronic record revealed she was admitted to the ED on 4/7/14 at 5:03 p.m. with diagnosis of unwitnessed fall with shoulder and chest pain. She was assessed as a Level 3. Review of her vital signs revealed they were documented as follows:
5:03 p.m. to 2:11 a.m. (9 hours), to 6:30 a.m. (4 hours), to 10:24 a.m. (4 hours), to 2:07 p.m. (3.5 hours), to 5:09 p.m. (3 hours), to 9:00 p.m. discharge (4 hours).

Patient #10

Record review of Patient #10's closed electronic record revealed she was admitted to the ED on 4/8/14 at 11:50 p.m. with shortness of breath for three days. On oxygen at home and sent to the ED by her physician. She was assessed as a Level 3. Review of her vital signs (VS) revealed they were documented as follows:
11:50 p.m. to 7:37 a.m. on 4/9/14 the vital signs were taken every one to two hours.
From 7:37 to 12:00 p.m. (4.5 hours), to 3:06 p.m. (3 hours).
From 3:06 p.m. to 9:00 p.m. the VS were taken every 1 to 2.5 hours.
From 9:00 p.m. to 1:01 a.m. (4 hours)
From 1:01 a.m. to 9:07 a.m. the VS were taken every 1 to 2.5 hours.
From 9:07 a.m. to 12:04 p.m. (3 hours), to 5:05 p.m. (5 hours), to 8:20 p.m. when left department (3 hours).

Patient #11

Record review of Patient #11's closed electronic record revealed he was admitted to the ED on 4/9/14 at 5:19 a.m. with a fall at a nursing home with a fractured left hip. He was assessed as a Level 3. Review of his VS revealed they were documented as follows:
From 5:19 a.m. to 3:45 p.m. the VS were taken every 1 to 2.5 hours.
From 3:45 p.m. to 9:30 p.m. when he was discharged from the department (4 hours 45 minutes).

During an interview on 7/18/14 at 9:05 p.m. with ED Director RN #54 and ED Manager RN #59, they verified there were no vital signs documented for the times above. RN #54 said the hospital corporation had identified problems with charting and had initiated a report she could monitor on charting. She said she "rolled out" the educational tool for charting reassessments in February 2014 and was now monitoring documentation. She said if she found any problems she would do a one on one retraining for that staff. She said vital signs were taken per the assessment level of the patient from 1 to 5. Level 1 was resuscitation, Level 2 was critical, Level 3 was not as critical, but needed many resources, and Level 4 and 5 required less resources and were not critical. She said vital signs were taken according to their Level. Level 1 would be continuously, Level 2 would be a minimum of hourly, Level 3 would be a minimum of every 2 hours, Level 4 would be every 4 hours and Level 5 would be at a minimum on admission and at disposition