HospitalInspections.org

I. Based on review of documents, policies/procedures, medical record and staff interviews, the governing body failed to ensure physicians followed facility policy for completing patient care admission orders when patients were transferred from one nursing unit of the hospital to another. Problem identified with 1 (of 1) patient that had a feeding tube (Patient #1). Physicians failed to write admission orders for Patient #1 until approximately 6 hours after the Patient had arrived on the Geriatric/Psychiatric (Geri/Psych) unit. Refer to A-0141 for Patient information.

The Geri/Psych Nurse Manager identified 7 patients with feeding tubes in the past 180 days and 1 current patient with a feeding tube.

Patient care requires a physician's order. The physician's failure to provide orders resulted in the nursing staff's inability to provide patient cares including food, hydration, and medications for Patient #1.

Findings include:

1. Review of Patient #1's Geri/Psych medical record showed:

- The patient admitted on 9/5/12 to the geriatric/psychiatric unit for agitation.

- A History and physical dated 9/5/12 revealed the Patient is a resident at an Intermediate Care Facility (ICF) for many years and does have a legal guardian for medical decisions. The Patient has history of Prader-Willi (a rare disorder that results in a number of physical, mental and behavioral problems including a constant sense of hunger), has a G-tube (feeding tube), aspiration risk, depression, and mild mental retardation. Staff from the ICF where the Patient has resided for many years brought the Patient in due to agitation. The ICF staff reported the Patient has been increasingly agitated, attempted to strangle the van driver with a seatbelt, was trying to grab staff by the hair and shake them, the Patient was peeling skin from the patient's fingers and arms. ICF staff said, yesterday, the Patient screamed for over 7 hours straight and required physical restraint by staff due to aggression. In between bouts of agitation, the Patient will alternate from being clingy and needy with staff to sobbing uncontrollably. The Patient is not sleeping much, and last night was agitated until 3 AM before finally going to sleep. And yesterday the Patient managed to pull out the G-tube again, after staff successfully prevented the Patient from doing so at least a dozen times the day before.

The Patient is chronically NPO (nothing by mouth) and is fed through a G-tube, has suffered recurrent bouts of aspiration pneumonia (pneumonia caused by inhaling fluids and /or foreign objects into the lungs) and was recently hospitalized on 8/15/12 for aspiration pneumonia with respiratory failure and shock.

On interview, the Patient repeatedly says he/she is feeling depressed, sad, and admits to wanting to hurt him/herself.

The Patient is apparently below normal range intelligence, has minimal insight with regards to the nature of his/her psychiatric illness, and judgement is poor as demonstrated by aggressive and self-harming behaviors.

2. Review of Patient #1's Medical/Psychiatric unit (Med/Psych) medical record from 9/18/12 to 9/24/12 revealed:

- A document titled "Discontinue/Comprehensive Scheduled Medication List," that physicians review prior to patient transfer, shows which medications a patient is currently taking. This document was completed in the electronic record in the order set section prior to the Patient transferring from the Med/Psych unit to the Geri/Psych unit.

The physician at the receiving unit is responsible for reviewing this document and marking which medications staff should continue to provide and which medications they should discontinue. The Patient arrived on the Geri/Psych unit 9/24/12 at 4:35 PM and the Physician did not review the Patient's current medications or enter orders for medications until 9:48 PM. Review of the orders entered at 9:48 PM showed the Physician only ordered as needed medications and none of the Patient's routine medications that included, in part.

Ferrous Sulfate liquid 60 mg, 3 times daily by GI tube. (a medication used to treat chronic anemia; low iron level in the blood)

Hydrocortisone liquid 20 mg, 2 times daily by GI tube. (a medication used to treat adrenal cortical insufficiency; a condition where the adrenal glands don't secrete enough of the chemicals, produced by the body, that regulate organ function).

Levetiracetam 2 times daily by GI tube. (a medication used to treat seizure tendencies.) According to the manufacturer's directions for use, this medication should not be discontinued abruptly. Doing so could cause a seizure.

Metformin tablet, 500 mg, 2 times daily by GI tube. (a medication used to treat diabetes.)

Omeprazole 20 mg, daily by GI tube. (a medication used to prevent backward flow of acid from the stomach and possible injury of the esophagus and risk of aspiration of the stomach contents.)

Risperidone liquid 4 mg, at bedtime by GI tube. (a medication used to treat depression associated with manic depressive disorder.) According to manufacturer's directions, this medication should not be not be discontinued abruptly. Doing so could result in sleeplessness, nausea, vomiting, lightheadedness, extreme sweating, low blood pressure, increased heart rate, nervousness, dizziness, headache, excessive non-stop crying, and anxiety)

Sertraline 100 mg, daily by GI tube. (a medication used to treat depression) According to manufacturer's directions, this medication should not be not be discontinued abruptly. Doing so could result in worsening depression or suicidal thoughts.)

Trazodone 100 mg, at bedtime by GI tube. (a medication used to treat insomnia)

- Registered Nurse progress notes from the Med/Psych unit dated 9/24/12, showed staff transferred the Patient from the Med/Psych unit to the Geri/Psych unit at 4:35 PM and the nurse gave report to the Geri/Psych nurse at that time.

3. Document review, interviews, and review of Patient #1's Geri/Psych medical record showed staff failed to document when the Patient arrived on the unit, the Patient's condition, physicians orders for admission, medication, and feeding tube orders until 9:48 PM.

- During an interview on 10/3/12, at 1:40 PM, Physician D, Clinical Professor of Psychiatry/Training director for the Geri/Psych unit, reported her duties included supervising and reviewing all care provided to patients on the unit.

Physician D confirmed physicians are responsible when a patient is admitted to their unit to assess the patient, complete a history and physical, review prior routine medications, and prescribe the medications that will be continued on the medication administration record, provide orders directing care of the patient to nursing staff, and diet orders (which would include and order for nutrition through a feeding tube).

Physician D said she recalled Patient #2 transferred from the Medical Psychiatric (Med/Psych) unit to the Geri/Psych unit on 9/24/12 at approximately 4:45 PM. Physician D acknowledged she failed to enter admission orders for the patient because the electronic medical record system wasn't operational and "it didn't occur to anybody that we could pull a set of paper orders and write admit orders on them." Physician D said she had to leave the hospital that day at 4:00 PM, and before leaving she paged the psychiatry on call number and requested they take care of the Patient's admission orders etc. Physician D thought it would go well enough that she could pick up the paperwork the next day for review. Physician D discovered on 9/25/12 AM that this wasn't the case and was stunned when she came in Tuesday (9/26/12) and the orders for the feeding tube and routine medications still weren't written. At the conclusion of the interview Physician D stated, "as a department we do have concerns with delay of care for this patient."

- During an interview on 10/3/12, at 4:10 PM Physician C, confirmed placement of a feeding tube would be included in procedures he would perform as a Internal Medicine/GI Fellow (Fellow-A physician who enters a training program in a medical specialty after completing residency).

Physician C reported he saw Patient #1 on 9/25/12 at 3:00 PM and determined the feeding tube site was closed and a consent for reinsertion with sedation would be necessary. Physician C stated he was unaware of how long it had been since the patient had removed the feeding tube. Physician C acknowledged he failed to document the assessment and findings in the patient's medical record.

Review of Physician C's credential file showed an appointment contract as a resident psychiatrist in the Department of Psychiatry by the University of Iowa Hospitals and Clinics (UIHC) for the period of 7/1/12 through 6/30/13. Physician C signed an agreement on 5/4/12 stating he agreed with the facility's terms and conditions including to abide by all facility policies, procedures and rules.

- During an interview on 10/4/12, at 11:00 AM, Physician A said the geri/psych unit paged him on 9/24/12 at approximately 4:00 PM. Physician A acknowledged he failed to enter admission orders for the patient because the electronic medical record system wasn't operational. Physician A said at 8:00 PM, he paged Physician B, first year resident and assigned the patient's care to Physician B. Physician A was not aware of hospital policy and procedures directing physicians to physically write orders during electronic system down time and admitted if he had been aware a delay in admission orders for the patient would have been avoided.


Review of Physician A's credential file showed an appointment contract with the University of Iowa Hospitals and Clinics (UIHC) for the period of 7/1/12 through 6/30/13. Physician A signed an agreement on 3/12/12 stating he agreed with the facility's terms and conditions including to abide by all facility policies, procedures and rules.

- During an interview on 10/4/12, at 9:40 AM, Physician B, first year resident recalled being paged by Physician A to assume care of Patient #1 on 9/24/12. Physician B went to the geri/psych unit and saw the patient at approximately 5:00 PM. Physician B acknowledged he failed to enter admission orders for the patient because the electronic medical record system wasn't operational. Physician B said, when the electronic medical record system was operational at approximately 9:00 PM, he only entered as needed (PRN) admission orders, which included PRN medications and a nothing by mouth (NPO) diet in the electronic medical record for the patient. Physician B confirmed he failed to review the Patient's routine medication list from the Med/Psych unit and order the routine medication that should continue after the Patient transferred to the Geri/Psych unit. Physician B confirmed that he should have entered the tube feeding orders but was did not know how to place orders for the tube feedings in the electronic medical record.

Review of Physician B's credential file showed an appointment contract with the University of Iowa Hospitals and Clinics (UIHC) for the period of 6/24/12 through 6/30/13. Physician B signed an agreement on 3/31/12 stating he agreed with the facility's terms and conditions including to abide by all facility policies, procedures and rules.

At this point the patient missed 1 scheduled tube feeding, 1 - 150 centimeters (cc) flush of water, and nine routine medications.

4. Review of facility policy titled "Procedure for Medical Record Documentation During Electronic System Downtime," revised 5/11, revealed, in order to ensure that physician orders for patient care are completely and accurately recorded, staff are required to write new orders, placed during computer downtime, on paper.

- Review of facility policy titled "Prescribing Medications for Hospitalized Patients (Inpatients) and Clinic Patients," revised 4/12, revealed staff enters inpatient medication orders electronically, and the order should clearly indicate the route of administration where it applies.

- Review of facility policy titled "Admission Process - Adult Patients," revised 11/09, revealed the following in part, "Purpose: To make the patient's entry to the hospital as comfortable and safe as possible . . ."

5. During an interview on 10/15/12, at approximately 10:00 AM, Physician E said at 2:30 AM, Geri/Psych nursing staff called her to come to the unit because Patient #1 pulled skin off their arm. When Physician E arrived on the unit, the Patient had torn part of the skin off their arm and was bleeding profusely.

Physician E said she knew the Patient had pulled out the feeding tube shortly before midnight on 9/25/12 but did not know all of the Patient's medications were given through the feeding tube. According to Physician E the Patient had pulled the feeding tube out numerous times and she was not overly concerned that this would cause any kind of poor outcome or detrimental effects for the Patient.

Physician E reported, on the evening of 9/25/12, she was contacted by geri/psych nursing staff because the patients blood sugar was low. Physician E ordered an intravenous solution to treat the low blood sugar and provide fluids to improve the Patient's hydration. At this time, Physician E knew the Patient's feeding tube was still out and the Patient had been without nourishment, water, and medications since 9/24/12. Physician E thought the gastrointestinal surgeon was addressing the problem.

- Review of Physician E's credential file showed an appointment contract with the University of Iowa Hospitals and Clinics (UIHC) for the period of 7/1/12 through 6/30/13. Physician E signed an agreement on 3/21/12 stating she agreed with the facility's terms and conditions including abiding by all facility policies, procedures and rules.

6. During an interview on 10/16/12, at 4:00 PM, Physician F, Medical Director of the Med/Psych unit stated patient's with a diagnosis of Prader Willi have a drive to eat. Physician F reported the patient had difficulty swallowing which resulted in aspirating food and fluids into the lungs. According to Physician F, Patient #1 would be unable to understand why the feeding tube is necessary which may contribute to the patient pulling the tube out. Physician F said the patient required assistance with decision making because of mild intellectual difficulties and the Patient would rather drink the formula then put it into a feeding tube.

- During an interview on 10/16/12, from 8:15 AM to 8:45 AM, Pharmacist H confirmed he processed orders for Patient #1 on 9/25/12 at 9:30 AM. Pharmacist H acknowledged he reported problems with missed medications to a physician but failed to document this in the patient's medical record.

- During an interview on 10/16/12, from 10:10 AM to 10:45 AM, Pharmacist Director I confirmed Pharmacist H would have been responsible for coordinating care for Patient #1. He acknowledged Pharmacist H failed to document conversations with Patient #1's medical team regarding medication "issues" in the patient's record.

II. Based on review of documents, policies/procedures, medical record, physician, staff, guardian, and Intermediate Care Provider interviews, the Governing Body failed to ensure a system was in place to assure physicians replaced a feeding tube in a timely manner, for 1 (of 1) inpatient dependent on a feeding tube for all nutrition, hydration, and medication. (Patient #1) Refer to A 144 for Patient information.

The Geriatric/Psychiatric Nurse Manager identified 7 patients with feeding tubes in the past 180 days and 1 current patient with a feeding tube.

Failure to replace the feeding tube in a timely manner resulted in the patient not receiving nutrition, hydration, and medications for a total of 78 hours over an 11 day period of time and admission to the Medical Intensive Care Unit.
Findings include:

1. During an interview on 10/1/12 at 1:00 PM, ICF staff said Patient #1 had been NPO for approximately 5 years. ICF staff reported they had talked with the patients guardian several times from 9/24/12 to 9/25/12 regarding concerns they had with the patient not have a feeding tube. ICF staff said the guardian and 3 staff from their facility went to see Patient #1 on 9/25/12 and expressed their concerns about the patients welfare to nursing staff and physicians but we're told they were waiting for a response from the GI physician's.

- During an interview on 10/2/12 at 8:00 AM, Patient's guardian said they had been the patient's legal representative and designee to make medical decisions since 2004. The guardian reported for the past 8 years the patient experienced problems with aspirating food and fluids because the patient's esophagus (a muscular tube through which food and fluids pass from the mouth into the stomach) did not function normally.

The guardian said ICF staff had contacted her on the morning of 9/26/12 to express concerns they had about Patient #1 not receiving medications or tube feedings for 2 days.

The hospital contacted the guardian on the evening of 9/26/12, to report there had been delays in replacing the feeding tube and the Patient was transferred to the Medical Intensive Care Unit to insert an IV. At that point, the guardian told the hospital that this was unacceptable because the patient had gone without nourishment, water, or medications for at least 48-hours. After the phone call ended, the guardian drove to the hospital, met ICF staff in the lobby and they went to see the patient. According to the guardian, the patient looked frail, had very dry skin, and seemed sadder and more tearful.

This CONDITION is not met as evidenced by:

Based on review of documentation, policies/procedures, guardian and staff interviews, the facility failed to coordinate and implement medical care and services that met the needs of patients with medical and psychiatric diagnoses that were dependent on a feeding tube for nutrition, hydration, and medication, in all patient care areas. Hospital administrative staff reported approximately 2 patients per month in the Geriatric Psychiatric (Geri/Psych) unit required a feeding tube and the unit had an average daily census of approximately 14 patients. The Geri/Psych unit had a current census of 14 patients and 1 patient with a feeding tube.

Although physician and nursing staff were aware of factors that posed a risk to patient's dependent on a feeding tube to meet all of their crucial medical and nutritional needs and intellectually unable to speak for themselves, the facility failed to ensure:

- all patient's admitted to the hospital received optimal treatment and care. (A-0131, A-0144)

- staff informed the patient's legal representative and/or guardian of significant events that resulted in medical complications. (A-0131)

- nursing staff utilized the chain of command to remedy concerns regarding nutrition, hydration, and medication administration for a patient dependent on a feeding tube. (A-0144)

- nursing staff followed policy and procedure for identifying significant delays in provision of nutrition, fluids, and medication; and complete incident reports related to the significant delays for a patient dependent on a feeding tube for all nutrition, hydration, and medication. (A-0144)

- Providing medical care and treatment, in a timely manner, for patients unable to take anything by mouth (NPO) is extremely important to maintain nutrition and hydration. Staff diligence in following facility policies and procedures that direct patient care are critical in order to prevent malnutrition and dehydration.

The cumulative effect of these systemic failures and deficient practices resulted in the facility's inability to prevent a significant change in condition requiring intensive care services.

Based on review of policies, guardian and staff interview, Geriatric Psychiatric (Geri/Psych) nursing staff failed to inform a patient's (Patient #1) guardian that the Patient pulled their feeding tube out on 3 occasions and failed to obtain consent for reinsertion of a feeding tube on 1 occasion. Refer to A 144 for patient information,

The Geriatric/Psychiatric Nurse Manager identified 7 patients with feeding tubes in the past 180 days and 1 current patient with a feeding tube (Patient #1).

Failure to inform the patients guardian when the patient pulled out their feeding tube resulted in the guardians inability to make informed decisions about the patient's course of treatment.

Findings include:

1. Review of "Patient Education" forms dated 9/12/12, showed nursing staff reviewed the "Ongoing Education for the Patient's Plan of Care" that showed facility's interdisciplinary staff formulated the plan on 9/5/12 and updated the document daily thereafter. According to the documentation, facility staff reviewed the following: "You are a member of the healthcare team, Your doctors and nurses want you to help make decisions about the plan of treatment for yourself and/or your loved one, including plans for discharge. Tell the healthcare team about your needs, concerns and/or questions."

-During telephone interviews on 10/2/12 at 8:00 AM and 10/17/12 at 9:30 AM, respectively, Patient #1's guardian said a physician contacted her on 9/25/12 to obtain consent to reinsert the feeding tube. The guardian said she was unaware how long the feeding tube had been out until she went to see the patient on the evening of 9/26/12, at that time she found out the feeding tube had been out for 2 days. The facility did not contact the guardian on 9/6/12 and 9/19/12 when the patient pulled out the feeding tube and physicians reinserted it.

- Review of facility policy titled "Protocol for Documentation of Informed Consent Policy" revised 9/10, showed the facility provided clear instructions, that directed staff to document information provided to patients concerning the medical necessity, possible risks and known alternatives prior to the initiation of care.

- Review of facility policy "Patient Rights and Responsibilities" revised 4/12, showed all patients or patient representatives have the right to receive information about their medical condition and treatment, are given an explanation of all procedures and to be informed about the outcome of their care

- During an interview on 10/3/12, at 10:05 AM, Staff CC, Registered Nurse (RN) acknowledged Patient #1's medical record lacked documentation that showed staff had notified the patient's guardian when Patient #1 pulled out the feeding tube on 9/24/12.

- During an interview on 10/16/12, at 8:05 AM, Staff V, RN, acknowledged Patient #1's medical record lacked documentation that showed staff had notified the patient's guardian when Patient #1 pulled out the feeding tube on 9/6/12 or obtained a consent from the guardian to reinsert it.

Based on review of policies and procedures, medical records, staff interview, and Intermediate Care Facility (ICF) staff interview, Geriatric/ Psychiatric (geri/psych) nursing staff failed to identify significant delays in provision of nutrition, fluids, and medication; and complete incident reports related to the delays in the care of 1 patient (Patient #1).

The Geriatric/Psychiatric Nurse Manager identified 7 patients with feeding tubes in the past 180 days and 1 current patient with a feeding tube.

Failure to replace a feeding tube in a timely manner resulted in Patient #1 not receiving nutrition, hydration and medications for a total of 78 hours in an 11 day period of time.


Findings include:

1. Review of Patient #1's medical record revealed the following:

- A nursing event note dated 9/6/12 at 12:43 PM, showed around noon, the unit secretary was walking by Patient #1's room and saw the feeding tube lying on the floor and told the Nurse Manager who notified Physician D.

- A physician "Surgical Global Care Inpatient" note dated 9/6/12 at 4:40 PM, showed staff replaced the feeding tube.

At that point the feeding tube was out approximately 4 ? hours.

- On 10/16/12, at 8:05 AM, Staff V, Registered Nurse (RN) RN confirmed the record lacked documentation that showed the patient's guardian was notified when the feeding tube was pulled out and replaced on 9/6/12. RN V said the Geri/Psych nurses would be responsible for calling and informing the patient's guardian of the event.

-A nursing event note from the Geri/Psych unit dated 9/12/12 at 9:07 PM, showed a Psychiatric Nursing Assistant found the Patient sitting on the floor at 6:30 PM drinking feeding tube formula from the bottle. RN CC, confirmed the record lacked documentation that showed staff notified the Patient's guardian of the above mentioned event. RN CC said they did not complete an incident report for this incident.

- A physician event note from the Medical Psychiatric (Med/Psych) unit, dated 9/16/12 at 3:14 AM, showed Physician N was called to the Med/Psych unit to examine Patient #1 a little before 1:00 AM, because the Patient had pulled out their feeding tube. Physician N decided that a Foley catheter (a flexible tube that may be inserted into the body) should be placed temporarily to keep the ostomy (opening into a body cavity) open until a more permanent solution could be provided. Physician N called the patient's guardian and obtained a monitored phone consent from the guardian.

- Review of a physician "Med GI/Hepatology" note from the Geri/Psych unit, dated 9/17/12 at 3:33 PM, revealed the patient's feeding tube was replaced after 14 ? hours.

At this point the patient missed 5 scheduled tube feedings.

- A document titled "Doc flow sheet" from the Med/Psych unit, dated 9/19/12 at 12:15 AM, showed the patient pulled out their feeding tube and the physician was notified.

- A physician "Med GI/Hepatology" procedure note dated 9/19/12 at 4:22 PM, revealed, in part, "... gastrostomy tube was inserted easily into the stomach ..."

At this point the feeding tube was out approximately 16 ? hours. The patient missed 2 scheduled tube feedings and 5 medications, including but not limited to, antibiotics, anti-seizure medication, medication to treat adrenal cortical insufficiency, anti-depressants, and a medication to reduce acid reflux.

2. During and interview and medical record review on 10/16/12, beginning at 11:25 AM, Staff V, RN, confirmed the record lacked documentation the patient's guardian was notified of the event.

- A nursing event note from the Geri/Psych unit dated 9/24/12 at 11:36 PM, showed at 11:00 PM, the Patient left their room, went to the day room, grabbed a cup of water from the trash can and drank the water. PNA G saw the Patient in the day room drinking from a cup and took the cup. No one knew how much water the Patient ingested. On 10/3/12 at 10:05 AM, RN CC confirmed the record lacked documentation the patient's guardian was notified of the event.

- A nursing event note dated 9/25/12 at 8:05 AM, showed at midnight a PNA notified RN D that Patient #1 had pulled out their feeding tube. On 10/3/12 at 10:05 AM, RN CC confirmed the record lacked documentation the patient's guardian was notified of the event.

- A physician event note dated 9/25/12 at 5:06 AM showed staff called Physician E around 11:30 PM on 9/24/12. Staff reported that it appeared that the patient swallowed water found outside the Patient's room in a trash can. Staff also informed Physician E that not long after drinking the water, the patient pulled out their feeding tube and staff were unable to administer the Patient's midnight feeding. Physician E documented that Surgery will likely need to be consulted to reinsert the feeding tube.

- Review of an order on 9/25/12 at 9:45 AM showed a consult was ordered with the Department of Surgery to evaluate and reinsert the feeding tube.

- Review of a physician Progress Note dated 9/25/12 at 10:30 AM, revealed, in part, Surgery was consulted to reinsert the Patient's feeding tube and Surgery suggested calling the gastro-intestinal (GI) service since they are the ones who placed it last on 9/19/12. GI came to place a feeding tube in the afternoon, but were unable to because the hole had closed and they needed to perform a new procedure that required consent from the legal guardian. The legal guardian was called and a monitored phone consent was obtained. The after hours GI fellow was notified about what was going on and said he needed to discuss this with his primary team the following morning therefore he could not replace the feeding tube at this time, but would do it in the morning. The medical record lacked documentation of the GI physician's encounter with the patient.

- A nursing event note dated 9/25/12 at 3:05 PM, showed the Patient was received on the morning of 9/25/12 without a feeding tube. Medications which would have been given through the tube had not been given and Physicians D and J were aware. A consult was made that morning for replacing the feeding tube and a Resident from surgical-trauma did come to see the patient but said he would need the team to come to replace the feeding tube. The medical record lacked documentation of the surgical-trauma physician's encounter with the patient.

- A Social Service Progress Note dated 9/25/12 at 4:40 PM, ICF revealed staff from the Patient's residence requested the Patient remain an inpatient for a few more days to ensure the Patient was stable since the Patient recently pulled out the feeding tube, it was currently not being replaced, and the Patient drank water. ICF staff also requested that hospital staff contact them if any complications arose with replacing the feeding tube or if the Patient's status changed.

- A telephone encounter note dated 9/25/12 at 4:54 PM, showed staff obtained phone consent from the patient's guardian for placement of a feeding tube.

- A "PSY - Adult Psychiatry" note dated 9/25/12 at 5:03 PM, revealed staff obtained a monitored phone consent, to replace Patient #1's feeding tube. Staff then notified the after hours gastrointestinal fellow and the on call psychiatric resident about the consent. Staff also informed them the Patient had not had any intake since pulling out the feeding tube on 9/24/12.

- A physician event note dated 9/25/12 at 9:03 PM, revealed, in part, "GI will not put in PEG [feeding tube] tube until tomorrow ..."

- A physician event note dated 9/25/12 at 11:09 PM, showed staff called the physician regarding Patient #1's low blood sugar of 57 and that the Patient was unable to have any intake by mouth because of the Patient's high risk for aspiration. The physician documented to start an intravenous solution of 250 milliliters D5W (dextrose, which is a natural sugar found in the body, and water solution.)

- A nursing event note dated 9/25/12 at 11:34 PM, showed a nurse paged Physician J, a gastrointestinal doctor about replacing the Patient's feeding tube. Physician J returned the call and said he already saw the Patient and could not do anything tonight because he needed consents.

- A nursing event note dated 9/26/12 at 4:42 AM, showed the Patient was cooperative with the IV infusion, which was completed at 12:15 AM. Staff discontinued the Patient's IV access according to the physician's order.

- A physician Progress Note dated 9/26/12 at 8:35 AM, revealed,the GI physician came to place the feeding tube on the afternoon of 9/25/12, but said the hole had already closed therefore, a new procedure was required to put in a new tube and that the procedure would occur on 9/5/12. The Progress Note also showed the Rapid Response Team had to be called because staff were unable to get an IV access to treat hypoglycemia. Therefore, patient was transferred to MICU (Medical Intensive Care Unit) for further treatment of hypoglycemia.

A Monitored Phone Consent note dated 9/26/12 at 8:57 AM, showed consent obtained from the patient's guardian for placement of a feeding tube.

- A Social Service Progress Note dated 9/26/12 at 9:49 AM, revealed staff notified the Social Worker that the Patient's feeding tube was still not replaced. Staff did not contact REM (ICF facility where patient resided), even though it was requested they do so. The Social Worker received a call from ICF staff, wanting a patient update. The ICF staff member was concerned about the slow follow up on the GI consult, after the Patient pulled out their feeding tube. She was concerned about the physician not placing orders when patient was transferred, so patient had not received medications in 48 hours. ICF staff reported that she was also upset about the Patient not obtaining liquids. ICF staff thought all of this was neglectful of the Patient's care. The Social Worker also received a call from the Patient's guardian wanting an update. The Guardian reported she had been in touch with REM staff, and she was also concerned about the current situation. The Guardian was concerned that she was not immediately notified when the Patient pulled the feeding tube out and that GI was not consulted immediately after patient pulled the feeding tube out.

- A nursing event note dated 9/26/12 at 10:00 AM, revealed, in part, Patient received this morning with no IV access, no feeding tube and a blood sugar check of 57 at 8 am. Physician D and Physician J continue to work on having the feeding tube replaced after it was pulled out at approximately 11:55 AM on Monday night 9/24. An order was received by the on-call for D5W bolus at approximately 6:30 AM, but the night shift nurse was unable to reach any hospital nursing staff to put in an IV. This morning several attempts were made to establish an IV access. Each nurse made unsuccessful attempts. At 9:30 AM The Patient's blood sugar dropped further to 48. Physician L, with the rapid response team arranged to admit Patient #1 to the MICU (Medical Intensive Care Unit).

- Review of an order dated 9/26/12 at 10:15 AM showed a consult was ordered with Internal Medicine-Gastro Intestinal Inpatient services and revealed in part "... previous PEG (feeding tube), pt has removed it, tough to keep IV (intravenous) access, in need of PEG stat."

- Nurse KK documented on a Rapid Response Team note dated 9/26/12 at 10:30 AM, that Patient #1's feeding tube had been out for 2 days. The Rapid Response Team was called to the Geri/Psych unit to establish an IV site to treat the patient's blood low sugar of 47 (facility lab range for blood sugar was 65-99). According to the documentation, Geri/Psych nursing staff and Air Core staff were unable to insert an IV so the patient was transferred to the Medical Intensive Care Unit.

- Physician M documented on a "MICU Admit Note" dated 9/26/12 at 1:53 PM, the patient was transferred to the MICU because of the Patient's "profound hypoglycemia." (very low blood sugar) the documentation showed the Patient had pulled out the feeding tube and the frequent interruption of feedings likely resulted in the episodes of hypoglycemia.

- Review of a procedure note on 9/27/12 at 1443 (2:43 PM) showed the patient's feeding tube was replaced after approximately 62 ? hours of being pulled.

At this point, the feeding tube was out for approximately 62 1/2 hours. The patient missed 11 scheduled tube feedings and 1650 cubic centimeters (cc) of water, as ordered by the physician to flush the tube after each feeding, and multiple routine medications, including but not limited to, anti-depressants, anti-itching medication, iron, anti-seizure medication, diabetes medication, anti-psychotic, insomnia medication and medication to prevent reflux.

- A laboratory report showed the Patient's blood urea nitrogen (BUN) was 32 (normal values 10-20) on 9/25/12.

During an interview on 10/18/12, at 9:00 AM, Staff G, Director of Hospital Labs, stated the BUN is measurement of kidney function and an elevated value may indicate dehydration. He said Patient #1's reserves would not be as good as a normal patient and the Patient would be at an increased risk for dehydration. Staff G acknowledged the Patient's diagnosis of diabetes would be an additional risk factor.

3. During an interview on 10/1/12, at 11:05 AM, ICF staff (Intermediate care facility where Patient #1 resides), reported they saw Patient #1 at the hospital on the evening of 9/25/12, on the Geri/Psych unit. ICF staff stated Patient #1 appeared hungry. ICF staff stated "we expressed our concerns to both the nurse and doctor." ICF staff reported, at this point, Patient #1 had not received any medications or feedings for a couple of days.

- During an interview on 10/16/12, at 9:00 AM, Staff K, Geri/Psych Clinical Dietitian, reported patients with a feeding tube are identified to be at increased risk for nutrition-related problems. Additionally, Staff K stated it would be reasonable to expect a feeding tube to be replaced "within 24 hours."


4. Review of incident report's for the past 6 months lacked documentation of the patient pulling out his/her feeding tube and the delays reinserting the feeding tube that ultimately culminated in a rapid response code and transfer to the Medical Intensive Care Unit on 9/26/12.


5. During an interview on 10/3/12, at 3:15 PM, Staff E, Geri/Psych RN, acknowledged physician admission orders are required when patients arrive on the unit, because nurses "cannot do anything for the patient without them." Staff E said she provided care to Patient #1 until 11:30 PM on 9/24/12. Staff E acknowledged the patient did not receive their 8:00 PM feeding and routine medications during her shift. Staff E state she told Staff H, RN, at the change of shift report, Patient #1 still did not have physician orders for medications and nourishment, and the Patient's blood sugar needed to be checked before midnight.

Staff E said she provided care to the patient again on 9/25/12 from 3:00 PM to 11:30 PM. At the change of shift report that day she was informed the patient pulled out their feeding tube at midnight (9/24/12). Staff E confirmed she obtained physician's orders for insertion of an IV catheter into the patient's vein and D5W (IV sugar solution) on 9/25/12, at approximately 9:30 PM, when the patient's blood sugar dropped to 57 (a very low blood sugar). Staff E started the IV solution and it continued infusing until she left work. Staff E reiterated that she did what she was supposed to do by phoning and paging the physicians.

Review of RN E's personnel file showed training for facility policies and procedures upon new hire orientation on 9/10/08, patient rights and responsibilities on 9/8/08 and behavior management on 1/24/12.

- During an interview on 10/3/12, at 1:00 PM, Staff D, Geri/Psych RN, acknowledged she provided care to Patient #1 on 9/25/12 from 7:30 AM to 3:30 PM. Staff D said a physician arrived on the unit at 2:00 PM on 9/25/12 and assessed Patient #1, but took no action towards replacing the feeding tube, left the unit and did not return to the unit before she left for the day.

Review of RN D's personnel file showed training for facility policies and procedures upon new hire orientation on 4/12/00, patient rights and responsibilities on 11/3/11 and behavior management on 11/28/11.

- During an interview on 10/2/12, from 9:05 AM to 11:50 AM, Staff B, Registered Nurse (RN)/Unit Manager on the Geriatric Psychiatric Unit (Geri/Psych) reported nurses on the geri/psych unit have knowledge of medical diseases, and had background experience in procedures including but not limited to performing blood sugars checks, monitoring and providing nourishment and medications through feeding tubes, Intravenous placement (IV) and infusing simple IV solutions, administration of all types of oral medications, and paging and/or contacting physicians of sudden changes in a patient's physical or mental health. She stated nurses have immediate access to all facility policies and procedures and medical reference guidelines.

Staff B confirmed Staff C, RN, told her on 9/25/12 at 8:00 AM, there were approximately 6 hours of delays in admission orders for Patient #1 when the Patient transferred to the unit on 9/24/12. Staff B acknowledged geri/psych nursing staff are educated that when a patient is transferred to their unit, physician's orders are "absolutely" required for "everything" including admission orders. Staff B acknowledged nursing staff failed to follow standard nursing practice to assure orders for patient #1 were obtained in a timely manner and within at least 2 hours after the patient arrived to the unit. She said, after reviewing the patient's medical record, "I determined" at 9:46 PM we obtained orders for the as needed (prn) medications but did not obtain orders for tube feedings and multiple other routine medications. According to Staff B, Patient #1 pulled the feeding tube out on 9/24/12 at midnight and when Staff HH, RN discovered this, she contacted Physician E. Staff B said Physician E failed to provide orders that addressed replacement of the feeding tube and at that point they were at a "stand still." Additionally, Staff B confirmed Physician J provided orders for medications and nourishment through the feeding tube, on 9/25/12 at 9:27 AM; however the patient did not have a feeding tube in place to receive them.

Review of Nurse Manager B's personnel file showed training for facility policies and procedures upon new hire orientation on 9/22/81, patient rights and responsibilities on 10/28/11 and behavior management on 11/29/11.

- During an interview on 10/4/12, at 7:30 AM, Staff C, Geri/Psych RN, reported Patient #1 frequently pulled out the feeding tube and exhibited self-harm behaviors by picking at her skin until it would bleed. Staff C said it would be important that patients with a history of depressive mood disorder received their medication to avoid becoming more depressed, have problems sleeping and potential suicidal or self-harm thoughts. Staff C stated it would be important for patients with a history of diabetes to get their medications to avoid elevation in their blood sugar levels. Staff C confirmed patients should have orders for admission when they arrive to the unit. "I'd like to have them within 30 minutes to an hour." Staff C acknowledged nurses on the geri/psych unit would be educated to page the nursing supervisor "at any time" for assistance, including when the patient pulled out their feeding tube and any delays in physician orders or treatments related to this patient and their tube feedings. Staff C reported if a patient pulled out their feeding tube, nursing should document this on an incident report and would be expected to notify the patient's guardian.

Staff C confirmed she took care of Patient #1 on 9/25/12, during the night shift. Staff C stated she received change of shift report from from Staff E, and that the patient had not had any medications, fluid or formula for at least 24 hours and the Patient's blood sugar check was low. Staff C said the IV, D5W solution was infusing when she came out to the floor. Staff C reported she contacted the on-call psychiatric physician and obtained and order to discontinue the IV access, at 12:15 PM on 9/26/12. Staff C reported when she rechecked the patient's blood sugar at 6:15 AM, and it was 55 (a very low value) she paged the on-call psychiatric physician and obtained obtained orders for another blood sugar check. Staff C stated, "I assumed that the on-call psychiatrist knew at that point it had been approximately 32 hours since Patient received medication or feedings. Staff C said the patient's blood sugar on re-check was 58, so she contacted the on-call psychiatrist again, and obtained orders to insert another IV catheter into the patient's vein and administer D5W solution. Staff C reported, after 45 minutes of attempts, they were unable to start an IV and she turned the patients care over to Staff D, RN, and left for the day. Staff C acknowledged the patient needed their medications and feedings, the patient went a long a period of time without them, and as nurses we should have been more insistent. Additionally, Staff C confirmed that what happened to the patient was an unusual incident, she was aware of the facility policy and procedure for incident reports and acknowledged she failed to complete an incident report.

Review of RN C's personnel file showed training for facility policies and procedures upon new hire orientation on 6/23/93, patient rights and responsibilities on 5/24/93 and behavior management on 11/30/11.

- During an interview on 10/17/12 at 8:00 AM, Staff J, RN, acknowledged when a patient is admitted or transferred to the Geri/Psych unit admission orders are required immediately for a nurse to meet patient care needs.

Staff J said several specialized nursing staff attempted to start an IV, including herself, but were unsuccessful, so a rapid response team was called. According to Staff J, Patient #1 did not have good veins at that point because the Patient was severely dehydrated.

Staff J also said the patient had not received medications or feedings for a couple days and the patient's blood sugar was very low and she was very concerned. Staff J confirmed nursing staff would be responsible for contacting the guardian and completing an incident report when Patient #1 pulled out the feeding tube. Staff do receive education from the hospital when hired and annual competency training.

5. Review of facility policy titled "Assessment, Adult Patient," reviewed 5/10, addressed defining the role and responsibility of the registered nurse in terms of ongoing patient assessment and identification of the patient's nursing care needs. The Registered Nurse is responsible for completing ongoing assessment of patient care needs when warranted by a patient's condition. Ongoing assessment of the patient's nursing care needs include an ongoing consideration of their physical, psychosocial, environmental, self-care factors.

Review of facility policy titled "Hypoglycemia: Preventive Measures (Adult)," reviewed 9/10, outlined measures to reduce the incidence of hypoglycemia which included, events that predispose a patient with diabetes to a hypoglycemic event such as: Decrease in nutritional intake and interruption of enteral feedings (tube feedings).

Review of facility policy titled "Patient Incident Report," reviewed 5/11, revealed the following in part, " Purpose: To reduce morbidity and mortality by documenting and studying unanticipated events, unusual incidents, errors. To facilitate the review and/or correction of potential safety hazards. To identify and rectify accident/error causes by having available first-hand, accurate, written information about events or incidents in which there is a threat to the safety of the patient . . . "

6. During an interview on 10/18/12, at 9:30 AM, Staff II and JJ, Quality and Safety Directors, acknowledged Geri/Psych nursing staff failed to follow policies and procedures for incident reports when Patient #1 pulled their feeding tube out on 9/6/12, 9/16/12, 9/19/12, and 9/24/12. Staff II and JJ emphasized this would be imperative for identification of trends and issues that would require review to avoid similar problems that could affect other patients. Additionally, they described the events that occurred when the patient pulled out their feeding tube as an "unexpected course of events" that warranted Quality Assurance involvement that ultimately would be reviewed by nursing managers, pharmacists, the safety oversight committees, and the governing body. Staff II and JJ said Geri/Psych nursing staff were educated to follow the chain of command (nursing manager and/or assistant nurse manager, and department directors) for any care concerns involving patients that are not addressed in a timely manner.

- During an interview on 10/3/12, at 10:35 AM, Staff R, Geri/Psych RN, stated as a part of expected nursing practice/nursing training, patients with a diagnoses of depression needed to receive their medications daily in order to function. Staff R said this would be a "part of expected nursing practice/nursing training" and "a physician order is necessary when patients arrive to the nursing unit or at least 15 minutes after arrival." Staff R, reported nurses at the facility would be expected to file an incident report and received training when they were oriented that an incident report needed to be completed "immediately" if a tube feeding is missed. The physician and guardian would need to be notified according to facility policy. Additionally, Staff R said physician orders were "particularly important for diabetic patients with a feeding tube" in order to direct nursing staff how to care for the patient and provide medications, and "it could be detrimental" if they did not receive the tube feedings.

- During an interview on 10/3/12, at 10:55 AM, Staff S, Geri/Psych RN, acknowledged physician orders are required when a patient arrives on the unit or "at least within 15 minutes." Staff S stated, You can't really do anything until you get a physician order, and we're advocates for the patients. Staff S acknowledged nursing staff received education regarding facility policy and procedure for admission orders and "the need for physician orders is common nursing knowledge also." Additionally, Staff S, reported nursing staff should complete an incident report if a patient has pulled out a feeding tube and "physicians would have to respond within 15 minutes of the incident."

Based on review of policies, incident reports, and staff interviews, the facility failed to ensure staff completed incident reports when adverse patient events occurred so the Quality Assurance Program could analyze their cause and implement corrective action for 1 (of ) inpatient (Patient #1) who suffered a negative outcome after pulling their feeding tube out on 4 separate occasions. Refer to A 0144 for Patient information.

Failure to identify critical factors through the incident reporting process ultimately resulted in the hospital's inability to review and analyze outcomes of care and take appropriate action as part of the facility's Quality Assurance Process.

Findings include:

1. Review of facility policy titled "Patient Incident Report," reviewed 5/11, revealed the following in part, " Purpose: To reduce morbidity and mortality by documenting and studying unanticipated events, unusual incidents, errors. To facilitate the review and/or correction of potential safety hazards. To identify and rectify accident/error causes by having available first-hand, accurate, written information about events or incidents in which there is a threat to the safety of the patient . . . "

2. Review of incident report's for the past 6 months lacked documentation of the patient pulling out his/her feeding tube, missed enteral feedings, water, medications, and the delays reinserting the feeding tube that culminated in a rapid response code and transfer to the Medical Intensive Care Unit on 9/26/12.

3. During an interview on 10/4/12 at 7:30 AM, Staff C, RN confirmed that what happened to the patient was an unusual incident, she was aware of the facility policy and procedure for incident reports and acknowledged she failed to complete an incident report.

- During an interview on 10/17/12 at 8:00 AM, Staff J, RN confirmed nursing staff would be responsible for completing an incident report when Patient #1 pulled out the feeding tube. Staff do receive education from the hospital when hired and annual competency training.


- During an interview on 10/18/12, at 9:30 AM, Staff II and JJ, Quality and Safety Directors, acknowledged Geri/Psych nursing staff failed to follow policies and procedures for incident reports when Patient #1 pulled their feeding tube out on 9/6/12, 9/16/12, 9/19/12, and 9/24/12. Staff II and JJ emphasized this would be imperative for identification of trends and issues that would require review to avoid similar problems that could affect other patients. Additionally, they described the events that occurred when the patient pulled out their feeding tube as an "unexpected course of events" that warranted Quality Assurance involvement that ultimately would be reviewed by nursing managers, pharmacists, the safety oversight committees, and the governing body. Staff II and JJ said Geri/Psych nursing staff were educated to follow the chain of command (nursing manager and/or assistant nurse manager, and department directors) for any care concerns involving patients that are not addressed in a timely manner.

I. Based on review of documents, policies/procedures, medical record and staff interviews, the governing body failed to ensure physicians followed facility policy for completing patient care admission orders when patients were transferred from one nursing unit of the hospital to another. Problem identified with 1 (of 1) patient that had a feeding tube (Patient #1). Physicians failed to write admission orders for Patient #1 until approximately 6 hours after the Patient had arrived on the Geriatric/Psychiatric (Geri/Psych) unit. Refer to A-0141 for Patient information.

The Geri/Psych Nurse Manager identified 7 patients with feeding tubes in the past 180 days and 1 current patient with a feeding tube.

Patient care requires a physician's order. The physician's failure to provide orders resulted in the nursing staff's inability to provide patient cares including food, hydration, and medications for Patient #1.

Findings include:

1. Review of Patient #1's Geri/Psych medical record showed:

- The patient admitted on 9/5/12 to the geriatric/psychiatric unit for agitation.

- A History and physical dated 9/5/12 revealed the Patient is a resident at an Intermediate Care Facility (ICF) for many years and does have a legal guardian for medical decisions. The Patient has history of Prader-Willi (a rare disorder that results in a number of physical, mental and behavioral problems including a constant sense of hunger), has a G-tube (feeding tube), aspiration risk, depression, and mild mental retardation. Staff from the ICF where the Patient has resided for many years brought the Patient in due to agitation. The ICF staff reported the Patient has been increasingly agitated, attempted to strangle the van driver with a seatbelt, was trying to grab staff by the hair and shake them, the Patient was peeling skin from the patient's fingers and arms. ICF staff said, yesterday, the Patient screamed for over 7 hours straight and required physical restraint by staff due to aggression. In between bouts of agitation, the Patient will alternate from being clingy and needy with staff to sobbing uncontrollably. The Patient is not sleeping much, and last night was agitated until 3 AM before finally going to sleep. And yesterday the Patient managed to pull out the G-tube again, after staff successfully prevented the Patient from doing so at least a dozen times the day before.

The Patient is chronically NPO (nothing by mouth) and is fed through a G-tube, has suffered recurrent bouts of aspiration pneumonia (pneumonia caused by inhaling fluids and /or foreign objects into the lungs) and was recently hospitalized on 8/15/12 for aspiration pneumonia with respiratory failure and shock.

On interview, the Patient repeatedly says he/she is feeling depressed, sad, and admits to wanting to hurt him/herself.

The Patient is apparently below normal range intelligence, has minimal insight with regards to the nature of his/her psychiatric illness, and judgement is poor as demonstrated by aggressive and self-harming behaviors.

2. Review of Patient #1's Medical/Psychiatric unit (Med/Psych) medical record from 9/18/12 to 9/24/12 revealed:

- A document titled "Discontinue/Comprehensive Scheduled Medication List," that physicians review prior to patient transfer, shows which medications a patient is currently taking. This document was completed in the electronic record in the order set section prior to the Patient transferring from the Med/Psych unit to the Geri/Psych unit.

The physician at the receiving unit is responsible for reviewing this document and marking which medications staff should continue to provide and which medications they should discontinue. The Patient arrived on the Geri/Psych unit 9/24/12 at 4:35 PM and the Physician did not review the Patient's current medications or enter orders for medications until 9:48 PM. Review of the orders entered at 9:48 PM showed the Physician only ordered as needed medications and none of the Patient's routine medications that included, in part.

Ferrous Sulfate liquid 60 mg, 3 times daily by GI tube. (a medication used to treat chronic anemia; low iron level in the blood)

Hydrocortisone liquid 20 mg, 2 times daily by GI tube. (a medication used to treat adrenal cortical insufficiency; a condition where the adrenal glands don't secrete enough of the chemicals, produced by the body, that regulate organ function).

Levetiracetam 2 times daily by GI tube. (a medication used to treat seizure tendencies.) According to the manufacturer's directions for use, this medication should not be discontinued abruptly. Doing so could cause a seizure.

Metformin tablet, 500 mg, 2 times daily by GI tube. (a medication used to treat diabetes.)

Omeprazole 20 mg, daily by GI tube. (a medication used to prevent backward flow of acid from the stomach and possible injury of the esophagus and risk of aspiration of the stomach contents.)

Risperidone liquid 4 mg, at bedtime by GI tube. (a medication used to treat depression associated with manic depressive disorder.) According to manufacturer's directions, this medication should not be not be discontinued abruptly. Doing so could result in sleeplessness, nausea, vomiting, lightheadedness, extreme sweating, low blood pressure, increased heart rate, nervousness, dizziness, headache, excessive non-stop crying, and anxiety)

Sertraline 100 mg, daily by GI tube. (a medication used to treat depression) According to manufacturer's directions, this medication should not be not be discontinued abruptly. Doing so could result in worsening depression or suicidal thoughts.)

Trazodone 100 mg, at bedtime by GI tube. (a medication used to treat insomnia)

- Registered Nurse progress notes from the Med/Psych unit dated 9/24/12, showed staff transferred the Patient from the Med/Psych unit to the Geri/Psych unit at 4:35 PM and the nurse gave report to the Geri/Psych nurse at that time.

3. Document review, interviews, and review of Patient #1's Geri/Psych medical record showed staff failed to document when the Patient arrived on the unit, the Patient's condition, physicians orders for admission, medication, and feeding tube orders until 9:48 PM.

- During an interview on 10/3/12, at 1:40 PM, Physician D, Clinical Professor of Psychiatry/Training director for the Geri/Psych unit, reported her duties included supervising and reviewing all care provided to patients on the unit.

Physician D confirmed physicians are responsible when a patient is admitted to their unit to assess the patient, complete a history and physical, review prior routine medications, and prescribe the medications that will be continued on the medication administration record, provide orders directing care of the patient to nursing staff, and diet orders (which would include and order for nutrition through a feeding tube).

Physician D said she recalled Patient #2 transferred from the Medical Psychiatric (Med/Psych) unit to the Geri/Psych unit on 9/24/12 at approximately 4:45 PM. Physician D acknowledged she failed to enter admission orders for the patient because the electronic medical record system wasn't operational and "it didn't occur to anybody that we could pull a set of paper orders and write admit orders on them." Physician D said she had to leave the hospital that day at 4:00 PM, and before leaving she paged the psychiatry on call number and requested they take care of the Patient's admission orders etc. Physician D thought it would go well enough that she could pick up the paperwork the next day for review. Physician D discovered on 9/25/12 AM that this wasn't the case and was stunned when she came in Tuesday (9/26/12) and the orders for the feeding tube and routine medications still weren't written. At the conclusion of the interview Physician D stated, "as a department we do have concerns with delay of care for this patient."

- During an interview on 10/3/12, at 4:10 PM Physician C, confirmed placement of a feeding tube would be included in procedures he would perform as a Internal Medicine/GI Fellow (Fellow-A physician who enters a training program in a medical specialty after completing residency).

Physician C reported he saw Patient #1 on 9/25/12 at 3:00 PM and determined the feeding tube site was closed and a consent for reinsertion with sedation would be necessary. Physician C stated he was unaware of how long it had been since the patient had removed the feeding tube. Physician C acknowledged he failed to document the assessment and findings in the patient's medical record.

Review of Physician C's credential file showed an appointment contract as a resident psychiatrist in the Department of Psychiatry by the University of Iowa Hospitals and Clinics (UIHC) for the period of 7/1/12 through 6/30/13. Physician C signed an agreement on 5/4/12 stating he agreed with the facility's terms and conditions including to abide by all facility policies, procedures and rules.

- During an interview on 10/4/12, at 11:00 AM, Physician A said the geri/psych unit paged him on 9/24/12 at approximately 4:00 PM. Physician A acknowledged he failed to enter admission orders for the patient because the electronic medical record system wasn't operational. Physician A said at 8:00 PM, he paged Physician B, first year resident and assigned the patient's care to Physician B. Physician A was not aware of hospital policy and procedures directing physicians to physically write orders during electronic system down time and admitted if he had been aware a delay in admission orders for the patient would have been avoided.


Review of Physician A's credential file showed an appointment contract with the University of Iowa Hospitals and Clinics (UIHC) for the period of 7/1/12 through 6/30/13. Physician A signed an agreement on 3/12/12 stating he agreed with the facility's terms and conditions including to abide by all facility policies, procedures and rules.

- During an interview on 10/4/12, at 9:40 AM, Physician B, first year resident recalled being paged by Physician A to assume care of Patient #1 on 9/24/12. Physician B went to the geri/psych unit and saw the patient at approximately 5:00 PM. Physician B acknowledged he failed to enter admission orders for the patient because the electronic medical record system wasn't operational. Physician B said, when the electronic medical record system was operational at approximately 9:00 PM, he only entered as needed (PRN) admission orders, which included PRN medications and a nothing by mouth (NPO) diet in the electronic medical record for the patient. Physician B confirmed he failed to review the Patient's routine medication list from the Med/Psych unit and order the routine medication that should continue after the Patient transferred to the Geri/Psych unit. Physician B confirmed that he should have entered the tube feeding orders but was did not know how to place orders for the tube feedings in the electronic medical record.

Review of Physician B's credential file showed an appointment contract with the University of Iowa Hospitals and Clinics (UIHC) for the period of 6/24/12 through 6/30/13. Physician B signed an agreement on 3/31/12 stating he agreed with the facility's terms and conditions including to abide by all facility policies, procedures and rules.

At this point the patient missed 1 scheduled tube feeding, 1 - 150 centimeters (cc) flush of water, and nine routine medications.

4. Review of facility policy titled "Procedure for Medical Record Documentation During Electronic System Downtime," revised 5/11, revealed, in order to ensure that physician orders for patient care are completely and accurately recorded, staff are required to write new orders, placed during computer downtime, on paper.

- Review of facility policy titled "Prescribing Medications for Hospitalized Patients (Inpatients) and Clinic Patients," revised 4/12, revealed staff enters inpatient medication orders electronically, and the order should clearly indicate the route of administration where it applies.

- Review of facility policy titled "Admission Process - Adult Patients," revised 11/09, revealed the following in part, "Purpose: To make the patient's entry to the hospital as comfortable and safe as possible . . ."

5. During an interview on 10/15/12, at approximately 10:00 AM, Physician E said at 2:30 AM, Geri/Psych nursing staff called her to come to the unit because Patient #1 pulled skin off their arm. When Physician E arrived on the unit, the Patient had torn part of the skin off their arm and was bleeding profusely.

Physician E said she knew the Patient had pulled out the feeding tube shortly before midnight on 9/25/12 but did not know all of the Patient's medications were given through the feeding tube. According to Physician E the Patient had pulled the feeding tube out numerous times and she was not overly concerned that this would cause any kind of poor outcome or detrimental effects for the Patient.

Physician E reported, on the evening of 9/25/12, she was contacted by geri/psych nursing staff because the patients blood sugar was low. Physician E ordered an intravenous solution to treat the low blood sugar and provide fluids to improve the Patient's hydration. At this time, Physician E knew the Patient's feeding tube was still out and the Patient had been without nourishment, water, and medications since 9/24/12. Physician E thought the gastrointestinal surgeon was addressing the problem.

- Review of Physician E's credential file showed an appointment contract with the University of Iowa Hospitals and Clinics (UIHC) for the period of 7/1/12 through 6/30/13. Physician E signed an agreement on 3/21/12 stating she agreed with the facility's terms and conditions including abiding by all facility policies, procedures and rules.

6. During an interview on 10/16/12, at 4:00 PM, Physician F, Medical Director of the Med/Psych unit stated patient's with a diagnosis of Prader Willi have a drive to eat. Physician F reported the patient had difficulty swallowing which resulted in aspirating food and fluids into the lungs. According to Physician F, Patient #1 would be unable to understand why the feeding tube is necessary which may contribute to the patient pulling the tube out. Physician F said the patient required assistance with decision making because of mild intellectual difficulties and the Patient would rather drink the formula then put it into a feeding tube.

- During an interview on 10/16/12, from 8:15 AM to 8:45 AM, Pharmacist H confirmed he processed orders for Patient #1 on 9/25/12 at 9:30 AM. Pharmacist H acknowledged he reported problems with missed medications to a physician but failed to document this in the patient's medical record.

- During an interview on 10/16/12, from 10:10 AM to 10:45 AM, Pharmacist Director I confirmed Pharmacist H would have been responsible for coordinating care for Patient #1. He acknowledged Pharmacist H failed to document conversations with Patient #1's medical team regarding medication "issues" in the patient's record.

II. Based on review of documents, policies/procedures, medical record, physician, staff, guardian, and Intermediate Care Provider interviews, the Governing Body failed to ensure a system was in place to assure physicians replaced a feeding tube in a timely manner, for 1 (of 1) inpatient dependent on a feeding tube for all nutrition, hydration, and medication. (Patient #1) Refer to A 144 for Patient information.

The Geriatric/Psychiatric Nurse Manager identified 7 patients with feeding tubes in the past 180 days and 1 current patient with a feeding tube.

Failure to replace the feeding tube in a timely manner resulted in the patient not receiving nutrition, hydration, and medications for a total of 78 hours over an 11 day period of time and admission to the Medical Intensive Care Unit.
Findings include:

1. During an interview on 10/1/12 at 1:00 PM, ICF staff said Patient #1 had been NPO for approximately 5 years. ICF staff reported they had talked with the patients guardian several times from 9/24/12 to 9/25/12 regarding concerns they had with the patient not have a feeding tube. ICF staff said the guardian and 3 staff from their facility went to see Patient #1 on 9/25/12 and expressed their concerns about the patients welfare to nursing staff and physicians but we're told they were waiting for a response from the GI physician's.

- During an interview on 10/2/12 at 8:00 AM, Patient's guardian said they had been the patient's legal representative and designee to make medical decisions since 2004. The guardian reported for the past 8 years the patient experienced problems with aspirating food and fluids because the patient's esophagus (a muscular tube through which food and fluids pass from the mouth into the stomach) did not function normally.

The guardian said ICF staff had contacted her on the morning of 9/26/12 to express concerns they had about Patient #1 not receiving medications or tube feedings for 2 days.

The hospital contacted the guardian on the evening of 9/26/12, to report there had been delays in replacing the feeding tube and the Patient was transferred to the Medical Intensive Care Unit to insert an IV. At that point, the guardian told the hospital that this was unacceptable because the patient had gone without nourishment, water, or medications for at least 48-hours. After the phone call ended, the guardian drove to the hospital, met ICF staff in the lobby and they went to see the patient. According to the guardian, the patient looked frail, had very dry skin, and seemed sadder and more tearful.

This CONDITION is not met as evidenced by:

Based on review of documentation, policies/procedures, guardian and staff interviews, the facility failed to coordinate and implement medical care and services that met the needs of patients with medical and psychiatric diagnoses that were dependent on a feeding tube for nutrition, hydration, and medication, in all patient care areas. Hospital administrative staff reported approximately 2 patients per month in the Geriatric Psychiatric (Geri/Psych) unit required a feeding tube and the unit had an average daily census of approximately 14 patients. The Geri/Psych unit had a current census of 14 patients and 1 patient with a feeding tube.

Although physician and nursing staff were aware of factors that posed a risk to patient's dependent on a feeding tube to meet all of their crucial medical and nutritional needs and intellectually unable to speak for themselves, the facility failed to ensure:

- all patient's admitted to the hospital received optimal treatment and care. (A-0131, A-0144)

- staff informed the patient's legal representative and/or guardian of significant events that resulted in medical complications. (A-0131)

- nursing staff utilized the chain of command to remedy concerns regarding nutrition, hydration, and medication administration for a patient dependent on a feeding tube. (A-0144)

- nursing staff followed policy and procedure for identifying significant delays in provision of nutrition, fluids, and medication; and complete incident reports related to the significant delays for a patient dependent on a feeding tube for all nutrition, hydration, and medication. (A-0144)

- Providing medical care and treatment, in a timely manner, for patients unable to take anything by mouth (NPO) is extremely important to maintain nutrition and hydration. Staff diligence in following facility policies and procedures that direct patient care are critical in order to prevent malnutrition and dehydration.

The cumulative effect of these systemic failures and deficient practices resulted in the facility's inability to prevent a significant change in condition requiring intensive care services.

Based on review of policies, guardian and staff interview, Geriatric Psychiatric (Geri/Psych) nursing staff failed to inform a patient's (Patient #1) guardian that the Patient pulled their feeding tube out on 3 occasions and failed to obtain consent for reinsertion of a feeding tube on 1 occasion. Refer to A 144 for patient information,

The Geriatric/Psychiatric Nurse Manager identified 7 patients with feeding tubes in the past 180 days and 1 current patient with a feeding tube (Patient #1).

Failure to inform the patients guardian when the patient pulled out their feeding tube resulted in the guardians inability to make informed decisions about the patient's course of treatment.

Findings include:

1. Review of "Patient Education" forms dated 9/12/12, showed nursing staff reviewed the "Ongoing Education for the Patient's Plan of Care" that showed facility's interdisciplinary staff formulated the plan on 9/5/12 and updated the document daily thereafter. According to the documentation, facility staff reviewed the following: "You are a member of the healthcare team, Your doctors and nurses want you to help make decisions about the plan of treatment for yourself and/or your loved one, including plans for discharge. Tell the healthcare team about your needs, concerns and/or questions."

-During telephone interviews on 10/2/12 at 8:00 AM and 10/17/12 at 9:30 AM, respectively, Patient #1's guardian said a physician contacted her on 9/25/12 to obtain consent to reinsert the feeding tube. The guardian said she was unaware how long the feeding tube had been out until she went to see the patient on the evening of 9/26/12, at that time she found out the feeding tube had been out for 2 days. The facility did not contact the guardian on 9/6/12 and 9/19/12 when the patient pulled out the feeding tube and physicians reinserted it.

- Review of facility policy titled "Protocol for Documentation of Informed Consent Policy" revised 9/10, showed the facility provided clear instructions, that directed staff to document information provided to patients concerning the medical necessity, possible risks and known alternatives prior to the initiation of care.

- Review of facility policy "Patient Rights and Responsibilities" revised 4/12, showed all patients or patient representatives have the right to receive information about their medical condition and treatment, are given an explanation of all procedures and to be informed about the outcome of their care

- During an interview on 10/3/12, at 10:05 AM, Staff CC, Registered Nurse (RN) acknowledged Patient #1's medical record lacked documentation that showed staff had notified the patient's guardian when Patient #1 pulled out the feeding tube on 9/24/12.

- During an interview on 10/16/12, at 8:05 AM, Staff V, RN, acknowledged Patient #1's medical record lacked documentation that showed staff had notified the patient's guardian when Patient #1 pulled out the feeding tube on 9/6/12 or obtained a consent from the guardian to reinsert it.

Based on review of policies and procedures, medical records, staff interview, and Intermediate Care Facility (ICF) staff interview, Geriatric/ Psychiatric (geri/psych) nursing staff failed to identify significant delays in provision of nutrition, fluids, and medication; and complete incident reports related to the delays in the care of 1 patient (Patient #1).

The Geriatric/Psychiatric Nurse Manager identified 7 patients with feeding tubes in the past 180 days and 1 current patient with a feeding tube.

Failure to replace a feeding tube in a timely manner resulted in Patient #1 not receiving nutrition, hydration and medications for a total of 78 hours in an 11 day period of time.


Findings include:

1. Review of Patient #1's medical record revealed the following:

- A nursing event note dated 9/6/12 at 12:43 PM, showed around noon, the unit secretary was walking by Patient #1's room and saw the feeding tube lying on the floor and told the Nurse Manager who notified Physician D.

- A physician "Surgical Global Care Inpatient" note dated 9/6/12 at 4:40 PM, showed staff replaced the feeding tube.

At that point the feeding tube was out approximately 4 ? hours.

- On 10/16/12, at 8:05 AM, Staff V, Registered Nurse (RN) RN confirmed the record lacked documentation that showed the patient's guardian was notified when the feeding tube was pulled out and replaced on 9/6/12. RN V said the Geri/Psych nurses would be responsible for calling and informing the patient's guardian of the event.

-A nursing event note from the Geri/Psych unit dated 9/12/12 at 9:07 PM, showed a Psychiatric Nursing Assistant found the Patient sitting on the floor at 6:30 PM drinking feeding tube formula from the bottle. RN CC, confirmed the record lacked documentation that showed staff notified the Patient's guardian of the above mentioned event. RN CC said they did not complete an incident report for this incident.

- A physician event note from the Medical Psychiatric (Med/Psych) unit, dated 9/16/12 at 3:14 AM, showed Physician N was called to the Med/Psych unit to examine Patient #1 a little before 1:00 AM, because the Patient had pulled out their feeding tube. Physician N decided that a Foley catheter (a flexible tube that may be inserted into the body) should be placed temporarily to keep the ostomy (opening into a body cavity) open until a more permanent solution could be provided. Physician N called the patient's guardian and obtained a monitored phone consent from the guardian.

- Review of a physician "Med GI/Hepatology" note from the Geri/Psych unit, dated 9/17/12 at 3:33 PM, revealed the patient's feeding tube was replaced after 14 ? hours.

At this point the patient missed 5 scheduled tube feedings.

- A document titled "Doc flow sheet" from the Med/Psych unit, dated 9/19/12 at 12:15 AM, showed the patient pulled out their feeding tube and the physician was notified.

- A physician "Med GI/Hepatology" procedure note dated 9/19/12 at 4:22 PM, revealed, in part, "... gastrostomy tube was inserted easily into the stomach ..."

At this point the feeding tube was out approximately 16 ? hours. The patient missed 2 scheduled tube feedings and 5 medications, including but not limited to, antibiotics, anti-seizure medication, medication to treat adrenal cortical insufficiency, anti-depressants, and a medication to reduce acid reflux.

2. During and interview and medical record review on 10/16/12, beginning at 11:25 AM, Staff V, RN, confirmed the record lacked documentation the patient's guardian was notified of the event.

- A nursing event note from the Geri/Psych unit dated 9/24/12 at 11:36 PM, showed at 11:00 PM, the Patient left their room, went to the day room, grabbed a cup of water from the trash can and drank the water. PNA G saw the Patient in the day room drinking from a cup and took the cup. No one knew how much water the Patient ingested. On 10/3/12 at 10:05 AM, RN CC confirmed the record lacked documentation the patient's guardian was notified of the event.

- A nursing event note dated 9/25/12 at 8:05 AM, showed at midnight a PNA notified RN D that Patient #1 had pulled out their feeding tube. On 10/3/12 at 10:05 AM, RN CC confirmed the record lacked documentation the patient's guardian was notified of the event.

- A physician event note dated 9/25/12 at 5:06 AM showed staff called Physician E around 11:30 PM on 9/24/12. Staff reported that it appeared that the patient swallowed water found outside the Patient's room in a trash can. Staff also informed Physician E that not long after drinking the water, the patient pulled out their feeding tube and staff were unable to administer the Patient's midnight feeding. Physician E documented that Surgery will likely need to be consulted to reinsert the feeding tube.

- Review of an order on 9/25/12 at 9:45 AM showed a consult was ordered with the Department of Surgery to evaluate and reinsert the feeding tube.

- Review of a physician Progress Note dated 9/25/12 at 10:30 AM, revealed, in part, Surgery was consulted to reinsert the Patient's feeding tube and Surgery suggested calling the gastro-intestinal (GI) service since they are the ones who placed it last on 9/19/12. GI came to place a feeding tube in the afternoon, but were unable to because the hole had closed and they needed to perform a new procedure that required consent from the legal guardian. The legal guardian was called and a monitored phone consent was obtained. The after hours GI fellow was notified about what was going on and said he needed to discuss this with his primary team the following morning therefore he could not replace the feeding tube at this time, but would do it in the morning. The medical record lacked documentation of the GI physician's encounter with the patient.

- A nursing event note dated 9/25/12 at 3:05 PM, showed the Patient was received on the morning of 9/25/12 without a feeding tube. Medications which would have been given through the tube had not been given and Physicians D and J were aware. A consult was made that morning for replacing the feeding tube and a Resident from surgical-trauma did come to see the patient but said he would need the team to come to replace the feeding tube. The medical record lacked documentation of the surgical-trauma physician's encounter with the patient.

- A Social Service Progress Note dated 9/25/12 at 4:40 PM, ICF revealed staff from the Patient's residence requested the Patient remain an inpatient for a few more days to ensure the Patient was stable since the Patient recently pulled out the feeding tube, it was currently not being replaced, and the Patient drank water. ICF staff also requested that hospital staff contact them if any complications arose with replacing the feeding tube or if the Patient's status changed.

- A telephone encounter note dated 9/25/12 at 4:54 PM, showed staff obtained phone consent from the patient's guardian for placement of a feeding tube.

- A "PSY - Adult Psychiatry" note dated 9/25/12 at 5:03 PM, revealed staff obtained a monitored phone consent, to replace Patient #1's feeding tube. Staff then notified the after hours gastrointestinal fellow and the on call psychiatric resident about the consent. Staff also informed them the Patient had not had any intake since pulling out the feeding tube on 9/24/12.

- A physician event note dated 9/25/12 at 9:03 PM, revealed, in part, "GI will not put in PEG [feeding tube] tube until tomorrow ..."

- A physician event note dated 9/25/12 at 11:09 PM, showed staff called the physician regarding Patient #1's low blood sugar of 57 and that the Patient was unable to have any intake by mouth because of the Patient's high risk for aspiration. The physician documented to start an intravenous solution of 250 milliliters D5W (dextrose, which is a natural sugar found in the body, and water solution.)

- A nursing event note dated 9/25/12 at 11:34 PM, showed a nurse paged Physician J, a gastrointestinal doctor about replacing the Patient's feeding tube. Physician J returned the call and said he already saw the Patient and could not do anything tonight because he needed consents.

- A nursing event note dated 9/26/12 at 4:42 AM, showed the Patient was cooperative with the IV infusion, which was completed at 12:15 AM. Staff discontinued the Patient's IV access according to the physician's order.

- A physician Progress Note dated 9/26/12 at 8:35 AM, revealed,the GI physician came to place the feeding tube on the afternoon of 9/25/12, but said the hole had already closed therefore, a new procedure was required to put in a new tube and that the procedure would occur on 9/5/12. The Progress Note also showed the Rapid Response Team had to be called because staff were unable to get an IV access to treat hypoglycemia. Therefore, patient was transferred to MICU (Medical Intensive Care Unit) for further treatment of hypoglycemia.

A Monitored Phone Consent note dated 9/26/12 at 8:57 AM, showed consent obtained from the patient's guardian for placement of a feeding tube.

- A Social Service Progress Note dated 9/26/12 at 9:49 AM, revealed staff notified the Social Worker that the Patient's feeding tube was still not replaced. Staff did not contact REM (ICF facility where patient resided), even though it was requested they do so. The Social Worker received a call from ICF staff, wanting a patient update. The ICF staff member was concerned about the slow follow up on the GI consult, after the Patient pulled out their feeding tube. She was concerned about the physician not placing orders when patient was transferred, so patient had not received medications in 48 hours. ICF staff reported that she was also upset about the Patient not obtaining liquids. ICF staff thought all of this was neglectful of the Patient's care. The Social Worker also received a call from the Patient's guardian wanting an update. The Guardian reported she had been in touch with REM staff, and she was also concerned about the current situation. The Guardian was concerned that she was not immediately notified when the Patient pulled the feeding tube out and that GI was not consulted immediately after patient pulled the feeding tube out.

- A nursing event note dated 9/26/12 at 10:00 AM, revealed, in part, Patient received this morning with no IV access, no feeding tube and a blood sugar check of 57 at 8 am. Physician D and Physician J continue to work on having the feeding tube replaced after it was pulled out at approximately 11:55 AM on Monday night 9/24. An order was received by the on-call for D5W bolus at approximately 6:30 AM, but the night shift nurse was unable to reach any hospital nursing staff to put in an IV. This morning several attempts were made to establish an IV access. Each nurse made unsuccessful attempts. At 9:30 AM The Patient's blood sugar dropped further to 48. Physician L, with the rapid response team arranged to admit Patient #1 to the MICU (Medical Intensive Care Unit).

- Review of an order dated 9/26/12 at 10:15 AM showed a consult was ordered with Internal Medicine-Gastro Intestinal Inpatient services and revealed in part "... previous PEG (feeding tube), pt has removed it, tough to keep IV (intravenous) access, in need of PEG stat."

- Nurse KK documented on a Rapid Response Team note dated 9/26/12 at 10:30 AM, that Patient #1's feeding tube had been out for 2 days. The Rapid Response Team was called to the Geri/Psych unit to establish an IV site to treat the patient's blood low sugar of 47 (facility lab range for blood sugar was 65-99). According to the documentation, Geri/Psych nursing staff and Air Core staff were unable to insert an IV so the patient was transferred to the Medical Intensive Care Unit.

- Physician M documented on a "MICU Admit Note" dated 9/26/12 at 1:53 PM, the patient was transferred to the MICU because of the Patient's "profound hypoglycemia." (very low blood sugar) the documentation showed the Patient had pulled out the feeding tube and the frequent interruption of feedings likely resulted in the episodes of hypoglycemia.

- Review of a procedure note on 9/27/12 at 1443 (2:43 PM) showed the patient's feeding tube was replaced after approximately 62 ? hours of being pulled.

At this point, the feeding tube was out for approximately 62 1/2 hours. The patient missed 11 scheduled tube feedings and 1650 cubic centimeters (cc) of water, as ordered by the physician to flush the tube after each feeding, and multiple routine medications, including but not limited to, anti-depressants, anti-itching medication, iron, anti-seizure medication, diabetes medication, anti-psychotic, insomnia medication and medication to prevent reflux.

- A laboratory report showed the Patient's blood urea nitrogen (BUN) was 32 (normal values 10-20) on 9/25/12.

During an interview on 10/18/12, at 9:00 AM, Staff G, Director of Hospital Labs, stated the BUN is measurement of kidney function and an elevated value may indicate dehydration. He said Patient #1's reserves would not be as good as a normal patient and the Patient would be at an increased risk for dehydration. Staff G acknowledged the Patient's diagnosis of diabetes would be an additional risk factor.

3. During an interview on 10/1/12, at 11:05 AM, ICF staff (Intermediate care facility where Patient #1 resides), reported they saw Patient #1 at the hospital on the evening of 9/25/12, on the Geri/Psych unit. ICF staff stated Patient #1 appeared hungry. ICF staff stated "we expressed our concerns to both the nurse and doctor." ICF staff reported, at this point, Patient #1 had not received any medications or feedings for a couple of days.

- During an interview on 10/16/12, at 9:00 AM, Staff K, Geri/Psych Clinical Dietitian, reported patients with a feeding tube are identified to be at increased risk for nutrition-related problems. Additionally, Staff K stated it would be reasonable to expect a feeding tube to be replaced "within 24 hours."


4. Review of incident report's for the past 6 months lacked documentation of the patient pulling out his/her feeding tube and the delays reinserting the feeding tube that ultimately culminated in a rapid response code and transfer to the Medical Intensive Care Unit on 9/26/12.


5. During an interview on 10/3/12, at 3:15 PM, Staff E, Geri/Psych RN, acknowledged physician admission orders are required when patients arrive on the unit, because nurses "cannot do anything for the patient without them." Staff E said she provided care to Patient #1 until 11:30 PM on 9/24/12. Staff E acknowledged the patient did not receive their 8:00 PM feeding and routine medications during her shift. Staff E state she told Staff H, RN, at the change of shift report, Patient #1 still did not have physician orders for medications and nourishment, and the Patient's blood sugar needed to be checked before midnight.

Staff E said she provided care to the patient again on 9/25/12 from 3:00 PM to 11:30 PM. At the change of shift report that day she was informed the patient pulled out their feeding tube at midnight (9/24/12). Staff E confirmed she obtained physician's orders for insertion of an IV catheter into the patient's vein and D5W (IV sugar solution) on 9/25/12, at approximately 9:30 PM, when the patient's blood sugar dropped to 57 (a very low blood sugar). Staff E started the IV solution and it continued infusing until she left work. Staff E reiterated that she did what she was supposed to do by phoning and paging the physicians.

Review of RN E's personnel file showed training for facility policies and procedures upon new hire orientation on 9/10/08, patient rights and responsibilities on 9/8/08 and behavior management on 1/24/12.

- During an interview on 10/3/12, at 1:00 PM, Staff D, Geri/Psych RN, acknowledged she provided care to Patient #1 on 9/25/12 from 7:30 AM to 3:30 PM. Staff D said a physician arrived on the unit at 2:00 PM on 9/25/12 and assessed Patient #1, but took no action towards replacing the feeding tube, left the unit and did not return to the unit before she left for the day.

Review of RN D's personnel file showed training for facility policies and procedures upon new hire orientation on 4/12/00, patient rights and responsibilities on 11/3/11 and behavior management on 11/28/11.

- During an interview on 10/2/12, from 9:05 AM to 11:50 AM, Staff B, Registered Nurse (RN)/Unit Manager on the Geriatric Psychiatric Unit (Geri/Psych) reported nurses on the geri/psych unit have knowledge of medical diseases, and had background experience in procedures including but not limited to performing blood sugars checks, monitoring and providing nourishment and medications through feeding tubes, Intravenous placement (IV) and infusing simple IV solutions, administration of all types of oral medications, and paging and/or contacting physicians of sudden changes in a patient's physical or mental health. She stated nurses have immediate access to all facility policies and procedures and medical reference guidelines.

Staff B confirmed Staff C, RN, told her on 9/25/12 at 8:00 AM, there were approximately 6 hours of delays in admission orders for Patient #1 when the Patient transferred to the unit on 9/24/12. Staff B acknowledged geri/psych nursing staff are educated that when a patient is transferred to their unit, physician's orders are "absolutely" required for "everything" including admission orders. Staff B acknowledged nursing staff failed to follow standard nursing practice to assure orders for patient #1 were obtained in a timely manner and within at least 2 hours after the patient arrived to the unit. She said, after reviewing the patient's medical record, "I determined" at 9:46 PM we obtained orders for the as needed (prn) medications but did not obtain orders for tube feedings and multiple other routine medications. According to Staff B, Patient #1 pulled the feeding tube out on 9/24/12 at midnight and when Staff HH, RN discovered this, she contacted Physician E. Staff B said Physician E failed to provide orders that addressed replacement of the feeding tube and at that point they were at a "stand still." Additionally, Staff B confirmed Physician J provided orders for medications and nourishment through the feeding tube, on 9/25/12 at 9:27 AM; however the patient did not have a feeding tube in place to receive them.

Review of Nurse Manager B's personnel file showed training for facility policies and procedures upon new hire orientation on 9/22/81, patient rights and responsibilities on 10/28/11 and behavior management on 11/29/11.

- During an interview on 10/4/12, at 7:30 AM, Staff C, Geri/Psych RN, reported Patient #1 frequently pulled out the feeding tube and exhibited self-harm behaviors by picking at her skin until it would bleed. Staff C said it would be important that patients with a history of depressive mood disorder received their medication to avoid becoming more depressed, have problems sleeping and potential suicidal or self-harm thoughts. Staff C stated it would be important for patients with a history of diabetes to get their medications to avoid elevation in their blood sugar levels. Staff C confirmed patients should have orders for admission when they arrive to the unit. "I'd like to have them within 30 minutes to an hour." Staff C acknowledged nurses on the geri/psych unit would be educated to page the nursing supervisor "at any time" for assistance, including when the patient pulled out their feeding tube and any delays in physician orders or treatments related to this patient and their tube feedings. Staff C reported if a patient pulled out their feeding tube, nursing should document this on an incident report and would be expected to notify the patient's guardian.

Staff C confirmed she took care of Patient #1 on 9/25/12, during the night shift. Staff C stated she received change of shift report from from Staff E, and that the patient had not had any medications, fluid or formula for at least 24 hours and the Patient's blood sugar check was low. Staff C said the IV, D5W solution was infusing when she came out to the floor. Staff C reported she contacted the on-call psychiatric physician and obtained and order to discontinue the IV access, at 12:15 PM on 9/26/12. Staff C reported when she rechecked the patient's blood sugar at 6:15 AM, and it was 55 (a very low value) she paged the on-call psychiatric physician and obtained obtained orders for another blood sugar check. Staff C stated, "I assumed that the on-call psychiatrist knew at that point it had been approximately 32 hours since Patient received medication or feedings. Staff C said the patient's blood sugar on re-check was 58, so she contacted the on-call psychiatrist again, and obtained orders to insert another IV catheter into the patient's vein and administer D5W solution. Staff C reported, after 45 minutes of attempts, they were unable to start an IV and she turned the patients care over to Staff D, RN, and left for the day. Staff C acknowledged the patient needed their medications and feedings, the patient went a long a period of time without them, and as nurses we should have been more insistent. Additionally, Staff C confirmed that what happened to the patient was an unusual incident, she was aware of the facility policy and procedure for incident reports and acknowledged she failed to complete an incident report.

Review of RN C's personnel file showed training for facility policies and procedures upon new hire orientation on 6/23/93, patient rights and responsibilities on 5/24/93 and behavior management on 11/30/11.

- During an interview on 10/17/12 at 8:00 AM, Staff J, RN, acknowledged when a patient is admitted or transferred to the Geri/Psych unit admission orders are required immediately for a nurse to meet patient care needs.

Staff J said several specialized nursing staff attempted to start an IV, including herself, but were unsuccessful, so a rapid response team was called. According to Staff J, Patient #1 did not have good veins at that point because the Patient was severely dehydrated.

Staff J also said the patient had not received medications or feedings for a couple days and the patient's blood sugar was very low and she was very concerned. Staff J confirmed nursing staff would be responsible for contacting the guardian and completing an incident report when Patient #1 pulled out the feeding tube. Staff do receive education from the hospital when hired and annual competency training.

5. Review of facility policy titled "Assessment, Adult Patient," reviewed 5/10, addressed defining the role and responsibility of the registered nurse in terms of ongoing patient assessment and identification of the patient's nursing care needs. The Registered Nurse is responsible for completing ongoing assessment of patient care needs when warranted by a patient's condition. Ongoing assessment of the patient's nursing care needs include an ongoing consideration of their physical, psychosocial, environmental, self-care factors.

Review of facility policy titled "Hypoglycemia: Preventive Measures (Adult)," reviewed 9/10, outlined measures to reduce the incidence of hypoglycemia which included, events that predispose a patient with diabetes to a hypoglycemic event such as: Decrease in nutritional intake and interruption of enteral feedings (tube feedings).

Review of facility policy titled "Patient Incident Report," reviewed 5/11, revealed the following in part, " Purpose: To reduce morbidity and mortality by documenting and studying unanticipated events, unusual incidents, errors. To facilitate the review and/or correction of potential safety hazards. To identify and rectify accident/error causes by having available first-hand, accurate, written information about events or incidents in which there is a threat to the safety of the patient . . . "

6. During an interview on 10/18/12, at 9:30 AM, Staff II and JJ, Quality and Safety Directors, acknowledged Geri/Psych nursing staff failed to follow policies and procedures for incident reports when Patient #1 pulled their feeding tube out on 9/6/12, 9/16/12, 9/19/12, and 9/24/12. Staff II and JJ emphasized this would be imperative for identification of trends and issues that would require review to avoid similar problems that could affect other patients. Additionally, they described the events that occurred when the patient pulled out their feeding tube as an "unexpected course of events" that warranted Quality Assurance involvement that ultimately would be reviewed by nursing managers, pharmacists, the safety oversight committees, and the governing body. Staff II and JJ said Geri/Psych nursing staff were educated to follow the chain of command (nursing manager and/or assistant nurse manager, and department directors) for any care concerns involving patients that are not addressed in a timely manner.

- During an interview on 10/3/12, at 10:35 AM, Staff R, Geri/Psych RN, stated as a part of expected nursing practice/nursing training, patients with a diagnoses of depression needed to receive their medications daily in order to function. Staff R said this would be a "part of expected nursing practice/nursing training" and "a physician order is necessary when patients arrive to the nursing unit or at least 15 minutes after arrival." Staff R, reported nurses at the facility would be expected to file an incident report and received training when they were oriented that an incident report needed to be completed "immediately" if a tube feeding is missed. The physician and guardian would need to be notified according to facility policy. Additionally, Staff R said physician orders were "particularly important for diabetic patients with a feeding tube" in order to direct nursing staff how to care for the patient and provide medications, and "it could be detrimental" if they did not receive the tube feedings.

- During an interview on 10/3/12, at 10:55 AM, Staff S, Geri/Psych RN, acknowledged physician orders are required when a patient arrives on the unit or "at least within 15 minutes." Staff S stated, You can't really do anything until you get a physician order, and we're advocates for the patients. Staff S acknowledged nursing staff received education regarding facility policy and procedure for admission orders and "the need for physician orders is common nursing knowledge also." Additionally, Staff S, reported nursing staff should complete an incident report if a patient has pulled out a feeding tube and "physicians would have to respond within 15 minutes of the incident."

Based on review of policies, incident reports, and staff interviews, the facility failed to ensure staff completed incident reports when adverse patient events occurred so the Quality Assurance Program could analyze their cause and implement corrective action for 1 (of ) inpatient (Patient #1) who suffered a negative outcome after pulling their feeding tube out on 4 separate occasions. Refer to A 0144 for Patient information.

Failure to identify critical factors through the incident reporting process ultimately resulted in the hospital's inability to review and analyze outcomes of care and take appropriate action as part of the facility's Quality Assurance Process.

Findings include:

1. Review of facility policy titled "Patient Incident Report," reviewed 5/11, revealed the following in part, " Purpose: To reduce morbidity and mortality by documenting and studying unanticipated events, unusual incidents, errors. To facilitate the review and/or correction of potential safety hazards. To identify and rectify accident/error causes by having available first-hand, accurate, written information about events or incidents in which there is a threat to the safety of the patient . . . "

2. Review of incident report's for the past 6 months lacked documentation of the patient pulling out his/her feeding tube, missed enteral feedings, water, medications, and the delays reinserting the feeding tube that culminated in a rapid response code and transfer to the Medical Intensive Care Unit on 9/26/12.

3. During an interview on 10/4/12 at 7:30 AM, Staff C, RN confirmed that what happened to the patient was an unusual incident, she was aware of the facility policy and procedure for incident reports and acknowledged she failed to complete an incident report.

- During an interview on 10/17/12 at 8:00 AM, Staff J, RN confirmed nursing staff would be responsible for completing an incident report when Patient #1 pulled out the feeding tube. Staff do receive education from the hospital when hired and annual competency training.


- During an interview on 10/18/12, at 9:30 AM, Staff II and JJ, Quality and Safety Directors, acknowledged Geri/Psych nursing staff failed to follow policies and procedures for incident reports when Patient #1 pulled their feeding tube out on 9/6/12, 9/16/12, 9/19/12, and 9/24/12. Staff II and JJ emphasized this would be imperative for identification of trends and issues that would require review to avoid similar problems that could affect other patients. Additionally, they described the events that occurred when the patient pulled out their feeding tube as an "unexpected course of events" that warranted Quality Assurance involvement that ultimately would be reviewed by nursing managers, pharmacists, the safety oversight committees, and the governing body. Staff II and JJ said Geri/Psych nursing staff were educated to follow the chain of command (nursing manager and/or assistant nurse manager, and department directors) for any care concerns involving patients that are not addressed in a timely manner.