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Based on medical record review, document review and staff interview, the medical staff was not accountable for the quality of the medical care provided to Patient #2 as evidenced by the lack of documentation regarding patient evaluation and plan of care in response to a change in the patient's neurological status.

Findings include:

Review of the facility's Rules and Regulations of the Medical Staff dated 02/11/19 revealed that pertinent progress notes shall reflect attention to clinical findings and shall be recorded at the time of observation by the attending physician or designee. Clinical problems, interpretations of tests, and treatment plans shall be recorded.

Review of nursing note dated 03/07/19 at 12:37 PM. revealed Patient #2's neurological status was intact upon assessment at 8:00 AM. At approximately 8:45 AM, the Physical Therapist (PT) and Registered Nurse (RN) assisted the patient from a supine (lying down-face up) position to sitting on the side of the bed. Once sitting on the side of the bed, the patient was unable to lift her chin from her chest and was experiencing weakness and tingling in bilateral upper extremities, right greater than left. The patient was placed back in supine position and reassessed. At this point, the patient stated that she did not have sensation in her bilateral lower extremities and was unable to move her lower extremities. The physician and nurse practitioner (NP) were immediately notified and were in to see patient. NPO (nothing by mouth) status maintained and IVF (IV fluids) were continued following the assessment. A Foley catheter was placed and at 12:15 PM the patient was sent to the operating room.

Review of Physical Therapy note dated 03/07/19 at 09:51 AM revealed that upon sitting on the side of the bed the patient presented with increased kyphotic (rounded back) posture with inability to lift chin from chest. The patient was noted to be anxious and reported increased right upper extremity pain. The physician and NP were present at this time. Due to poor posturing and deemingly unsafe per precautions, patient returned to supine. Patient left in supine positioning with RN and NP present.

Review of Physician Progress Notes for 03/07/19 revealed no documentation of the provider assessment and plan of care at the time of the event.

Review of Physician Progress Notes dated 03/07/19 at 2:02 PM in the preoperative holding area, 4.5 hours after the event, revealed the plan of care at this time included cervical (C)-collar application and C-spine precautions.

Interview with Staff (R), PT on 06/11/19 at 9:09 AM and Staff (W), RN on 06/12/19 at 8:55 AM revealed that Staff (X), orthopedic surgeon and Staff ( FF), Nurse Practitioner were present when Patient #2 experienced paralysis.

Interview on 06/12/19 at 10:00 AM with Staff (F), Quality Improvement Project Coordinator, and Staff (H), Director of Nursing verified the above findings.

Based on medical record review, document review, and interview, the hospital failed to ensure nursing staff are providing ongoing patient monitoring consistent with patient's condition. Lack of patient monitoring could negatively impact the patient.

Findings include:

See Tags 0395 and 0396

Based on medical record review, document review and interview, the nursing staff did not supervise and evaluate the nursing care provided to Patient #2. Specifically, the patient was not appropriately monitored during transport, nor were C-spine precautions implemented following a sudden change in neurological status resulting in paralysis.

Findings include:

Review of facility policy and procedure entitled "Interdepartmental Transport of Critical Care Patients" revised 4/2/18 stated that the provider or nurse will assess and document patient's condition immediately prior to transport to determine if clinically stable and capable of tolerating transport. A provider and the Registered Nurse must accompany patients who are physiologically unstable or potentially require acute interventions beyond the scope of nursing. The patient's status during transport and upon return must be documented in the medical record.

Review of nursing note dated 03/07/19 at 12:37 PM. revealed Patient #2's neurological status was intact upon assessment at 8:00 AM. At approximately 8:45 AM, the Physical Therapist (PT) and Registered Nurse (RN) assisted the patient from a supine (lying down-face up) position to sitting on the side of the bed. Once sitting on the side of the bed, the patient was unable to lift her chin from her chest and was experiencing weakness and tingling in bilateral upper extremities, right greater than left. The patient was placed back in supine position and reassessed. At this point, the patient stated that she did not have sensation in her bilateral lower extremities and was unable to move her lower extremities.

Review of Nursing Neurological Assessments on 03/07/19 revealed the following:
-At 08:00AM; Alert and Orientated, Full strength in left upper extremity, mild weakness in right upper extremity, full strength in right and left lower extremities, sensation in right and left upper and lower extremities intact.
-At 09:00AM; Alert and Orientated, Full strength in left upper extremity, mild weakness in right upper extremity, sensation in left upper extremity intact, sensation in right upper extremity intact and tingling, left and right lower extremities flaccid (weak, floppy muscle), sensation in left and right lower extremities intact.
-At 12:00PM; Alert and Orientated, Full strength in left upper extremity, mild weakness in right upper extremity, sensation in left upper extremity intact, sensation in right upper extremity intact and tingling, left and right lower extremities flaccid, sensation in left and right lower extremities intact.
-At 08:00PM; Confused, Severe weakness in left upper and lower extremity with normal tone and sensation intact, left and right lower extremity strength flaccid, tone flaccid, sensation absent.

Review of medical provider order dated 03/07/19 at 09:07 AM revealed STAT (immediate) order for CT (computed tomography) scan cervical spine without IV contrast for new paralysis lower extremity, post-op spine surgery.

Review of Radiology Preliminary Report for CT C-spine dated 03/07/19 revealed start time at 10:36 AM with final report at 11:05 AM noting severe grade 3 anterolisthesis (upper vertebra slips in front of the one below) of C7 on T1, probable cord compression.

Interview with Staff (W), RN on 06/12/19 at 8:55 AM revealed that she was the nurse assigned to Patient #2 on 03/07/19 when the event of sudden paralysis occurred. She stated that this event occurred at approximately 8:45 AM. She recalled assisting the physical therapist to get the patient from supine to sitting on the side of the bed and that when the patient was at the edge of the bed she could no longer feel her legs. She stated that Staff (X), orthopedic surgeon and two nurse practitioners were present. Patient was returned to supine position per direction of Staff (X). She stated that the patient was not wearing brace as this was ordered when out of bed. She stated there was no cervical collar available as that would have to be ordered through physical therapy and occupational therapy. She stated that she did not recall the mode of transportation of Patient #2 to radiology for CT scan but did recall that patient was transported by transportation personnel. She stated she did not accompany Patient #2 to radiology and stated she did not recall the patient returning from radiology and did not know the results of the CT C-spine exam. She stated that she could not recall when Patient #2 went to the operating room.

Interview on 06/12/19 at 10:00 AM with Staff (F), Quality Improvement Project Coordinator, and Staff (H), Director of Nursing verified the above findings.

Based on medical record review, policy review and interview the facility did not ensure nursing staff develop and keep current a nursing plan of care for 5 of 26 patients who had undergone spinal surgery (Patient #2, 21, 22, 25 and 26).

Findings include:

Review on 06/12/19 of facility policy, Initiating an Interdisciplinary Care Plan, last reviewed 04/27/18 revealed all patients shall have an interdisciplinary plan of care initiated within 24 hours of admission. It is the RN's responsibility to initiate the interdisciplinary care plan. The development and re-evaluation of the patient's plan of care is a continuous process and needs to be reviewed and updated daily and with any change in condition.

Medical Record review on 06/12/19 revealed Patient #2, 21, 22, 25 and 26 did not have a nursing plan of care to address the potential for an Alteration in Neurologic Status with associated nursing interventions despite having undergone spinal surgery. Cervical Disectomy and Fusion (operation to remove degenerative or herniated disc from the neck, then fuse the bones together) was performed on Patient #21 and #26. Laminectomy L4-L5 (removal back portion of a vertebra bone in lower back) was performed on Patient #22 and #25.

Interview on 06/12/19 at 10:00 AM with Staff (F), Quality Improvement Project Coordinator, and Staff (H), Director of Nursing verified the above findings.