HospitalInspections.org

A0144

Based on facility policies, medical record, facility documents, and interviews it was determined that the facility failed to provide care in a safe setting in 1 (#2) of 2 cardiac telemetry patients reviewed.

Findings included:
Review of the facility policy and procedures title, "Cardiac Telemetry Monitoring", #WFD.PC.023, review: 07/2022, Purpose 1. To provide guidelines for cardiac telemetry monitoring of patients. 2. To outline process for notification and documentation of cardiac rhythm changes 3. Identify which rhythm or arrhythmia require RN notification/ intervention and identification of proper escalation procedures 4. Identify cardiac rhythm changes requiring provider notification ...
Review of the facility policy and procedure title, "Assessment and Reassessment", #WFD.PC.002, reviewed 01/2023 ...Patient needs will be reassessed throughout the course of care, treatment, and services. The frequency of reassessment is based on his or her plan for care or changes in his or her condition ...Any change in the patient's condition shall require an immediate reassessment with changes in the plan of care reflecting the change in condition ...

Review of the medical record for Patient #2 reveals that on 07/05/2022 arrived to the Emergency Department (ED) with a diagnosis of Syncope (temporary loss of consciousness caused by a fall in blood pressure) and Congestive Heart Failure (can occur it the heart cannot pump or fill adequately). Patient #2's medical record showed on 07/06/2022 at 9:41 AM an order for cardiac telemetry monitoring (a way to monitor a person's heart rhythm remotely). On 07/10/2022 at 12:15 AM Patient #2 telemetry strips (printout of the cardiac rhythm) show a 13 beat run of Ventricular Tachycardia (A condition in which the lower chambers of the heartbeat very quickly). Review of the nursing notes reveals no assessment of patient after the change in rhythm. On 07/09/2022 at 10:06 PM the nursing notes reveals the shift assessment was completed. Review of Patient #2 vital signs shows the last set of vital signs were done 07/09/2022 at 7:29 PM as follows: Blood pressure 103/70, Pulse 118, respiration 15, oxygen saturations 90% on oxygen nasal cannula with no amount of oxygen that patient #2 was on. On 07/10/2022 at 4:03 AM a code blue (Cardiac / respiratory arrest) was initiated with the patient cardiac rhythm as asystole (a cessation of electrical and mechanical activity of the heart). Patient expired at 4:53 AM. No cardiac telemetry strip was noted to be in the medical record for the change in rhythm. Review of the post code note reveals the patient was found unresponsive.

Review of the cardiac monitoring telemetry strips reveals the patient had a 13 beat run of Ventricular Tachycardia (V-Tach) on 07/10/2023 at 12:15 AM and at 07/10/2023 at 4:54 AM V-fib/ V-tach.(V-Fib- Ventricular fibrillation is a type of irregular heart rhythm during which the lower heart chambers contract in a very rapid and uncoordinated manner, resulting in the heart not pumping blood to the rest of the body.) Patient #2 code was called on 07/10/2023 at 4:03 AM no evidence that a cardiac telemetry strip was run at the start of the code.

On 03/01/2023 9:59 AM an interview was held with Staff F who disclosed that there are no nursing notes after the assessment around 10:00 AM for Patient #2.
On 03/01/2023 at 4:22 PM an interview was held with the Chief Nursing Officer in which she disclosed that there were no cardiac telemetry strips for the change in rhythm or rate in Patient #2's medical record.

Based on observation, interview and record review the facility failed to analyze, conduct a thorough investigation and implement preventive actions for of two out of two events (Patient 1 and Patient 10) from the Emergency Department reviewed for the month of February 2023.

Findings:

1. a. On 2/28/2023, the Patient Safety Analysis Report related to Patient 1's grievance was reviewed with the Emergency Department Director. The document indicated:

-Date Grievance/Complaint Filed: 2/3/2023
-Brief Objective Description: "DELAY IN CARE IN THE ED"
-Reporter Additional Comments: "PATIENT WITH CP (chest pain) IN THE ED UNRESOLVED AFTER NITRO TABS...RN DID NOT REEVALUATE PATIENT...PATIENT ENDED UP NEEDING 3 STENTS. DOES NOT FEEL THE STAFF TREATED THE PATIENT WITH URGENCY."
-Investigator Notes: "Patient wife called and discussed concerns...Explained that new and throughout process to ensure Labs and ECG and imaging are done should there be a delay in bed placement..."
-Primary Contributing Factors: "Human Factors/Staff Factors...Lack of Resources"
-Primary Action to Prevent Recurrence: "Standardize Equipment or Process"
-Secondary Action to Prevent Recurrence was blank
-Quality/Patient Safety/Risk Notes: "...Investigation Performed that identified throughout opportunities that resulted in the delayed care to patient. Process improvement underway...Patient and wife contacted by RM (Risk Manager) and Emergency Director...Attempted to discuss process improvement plan but they did not want to discuss further."

b. On 2/28/2023 Patient 1's medical record was reviewed with the Emergency Department Manager (EDM). The medical record indicated Patient 1 was a 72 year old male with history of coronary history disease that required coronary artery bypass grafting and stent placement and myocardial infarction x3. The review further indicated:

-Emergency Patient Record dated 2/2/2023, "...CP (Chest Pain...Chief Complaint: Cardiac Related...Priority: 3...17:28 Reception...1811 Room Placement...2231 Disposition-Admit..."

-"Emergency Provider Report" dated 2/2/2023, 17:53 "...MSE Not Complete The medical screening exam is not complete. Further evaluation and/or treatment is required. The patient will be re-directed to the emergency department..." The document further indicated "...With significant cardiac history present to the ED with complaints of 2 episodes of midsternal chest pain today...recently had a heart attack with stent in October last year..."

-Laboratory result for HS Troponin (high sensitive diagnostic test for detection of heart injury, normal <78 ng/L) dated 2/2/2023, 19:35 - 102 Critical High

-Laboratory result for HS Troponin dated 2/2/2023, 20:51 - 98 Critical High.

-There was no documentary evidence in Patient 1's record of RN reassessments conducted every 60 minutes while waiting in the ED lobby between 17:28 - 20:57 on 2/2/2023

-There was no documentary evidence in Patient 1's record of physician response to the critical high troponin levels resulted at 19:35 and 20:57.

c. On 2/28/2023 at 2:30 p.m. the facility security video recording from the ED lobby on 2/2/2023 observed with the security officer and the Emergency Room Director (EDD). The video recording indicated Patient 1 walked into the facility ED door on 2/2/2023 at 17:22 and registered. Continued observation of the video recording indicated Patient 1 was in the ED lobby until 20:57 (three and a half hours in the ED lobby/waiting room) and was brought back in to the ED floor for bed placement at 20:58 and NOT at 18:11 as indicated in Patient 1's medical record.

d. On 2/28/2023 at 1 p.m., the EDM was interviewed about Patient 1's experience in the ED. The EDM stated she was not aware of Patient 1's concern and only reviewed chart today.

e. On 3/1/2023 at 9 a.m., the Patient Safety Analysis report for Patient 1's grievance was reviewed with the Patient Safety Director (PSD). The PSD stated ED Director conducted the investigation and had details of identified opportunities that resulted in delayed care and the process improvement plan initiated.

f. On 3/1/2023 at 9:10 a.m., the EDD was interviewed. The EDD stated he "Looked through the chart (of Patient 1)."

-The EDD stated the only improvement opportunity he identified was "The troponin lab/blood draw should have been done upon arrival after the EKG, which is best practice."

-The EDD stated the process improvement plan included getting labs done right away with EKG and looking at the staffing grid.

-The EDD was not aware of the discrepancy in Room Placement time on Patient 1's record. The EDD was also not aware of the missing RN reassessments while Patient 1 was waiting in the lobby.

-The EDD stated the investigation details were only in the Patient Safety report. The EDD stated communication of improvement to staff was only "verbal". The EDD stated de did not have any documentary evidence of process improvement plan or audits initiated related to the event concerning Patient 1.

g. On 3/1/2023 at 2:11 p.m., the findings from Patient 1's medical record, ED lobby video recording, Patient Safety Analysis report and interview with the EDD were discussed with the Chief Nursing Officer (CNO) and Chief Operating Officer (COO).

-Both agreed the medical screening exam (MSE) was not completed as documented by the ED provider during the time Patient 1 was waiting in the ED lobby from 17:28 - 20:57 on 2/2/2023. The CNO stated since the MSE was not completed at the time Patient 1 was in the ED lobby reassessments should have been conducted by an RN every 60 minutes and documented as required by "Assessment and Reassessment" facility policy and procedure.

-The CNO and COO stated Patient 1's troponin critical high values necessitated clinical intervention and required documentation of physician response. The COO stated there should, at the least, "Documentation of a reaction from the physician" as stated in the "Critical Values/Test Results" facility policy and procedure. Both agreed there was delay in care. The CNO stated Patient 1 should have at least been on telemetry monitoring.

-The COO stated there is system "data integrity" concern re: Room Placement documented time, and was not accurate representation of Patient 1's experience in the ED. The COO stated it looked like when patients are initially roomed in the lobby, the "Arrival to Bed" time data, which the facility had been tracking and trending showed, ED patients arrival in the ED to bed placement time to be shorter than it really is. The CNO and the COO stated this has "Never been identified" by facility before.

2. a. On 3/2/2023 at 2 p.m. the Patient Safety Analysis report for Patient 10 was reviewed with the PSD. The report indicated:

-Date Reported: 2/3/2023
-Date of Event: 2/3/2023
-Delay Care in Care Issue: "Lack of Timely Response to Order"
-Brief Objective Description: "ORDER FOR PLATELETS WAS PUT IN AT 0842. ORDER WAS ONLY CARRIED OUT WHEN RAPID NURSE AND ICU ATTENDING GOT INVOLVED AT 1445 ...THIS RESULTED IN DELAY OF INTERVENTIONS ..."
-Investigation Notes: " 2/5/2023 Increase in occurrences. Will work with ER leadership Team to educate and monitor...2/6/2023 Platelets ordered for Plavix reversal due to ICH (intracranial hemorrhage) with shift. Patient ended up going to Hospice... please provide: 1.) What caused this to occur (was it lack of knowledge, nurse busy, unable to interpret order, etc) 2.) Was this order communicated to the nurse when it was placed? Was there any delay on the lab's end 2.) (sic) What will be done to prevent this from happening again (specifically)?..."
- On 2/21/2023 the EDD wrote "...High Acuity and census - patient was under care of Admit RN's (registered nurse) and ER RN's during stay. Education was sent to all staff and continuing to monitor."
-Primary Contributing Factor: "Human Factors/Staff Factors...Volume Staffing Ratio"
-Primary Action to Prevent Recurrence Increase in Staffing/Decrease Workload

b. The PSD stated ED Director unable to provide documentary evidence of "Education sent to all staff and monitoring." The PSD stated there was no documentary evidence the "Primary Action to Prevent Recurrence Increase in Staffing/Decrease Workload" indicated in the report or any preventive action was initiated.

c. Review of the facility policy and procedure "Serious Safety Identification, Notification and Management" dated 12/1/20 indicated, "...Perform a thorough and credible patient safety event analysis ...develop actions to eliminate or control the system hazards or vulnerabilities identified as contributing factors ... monitor implementation effectiveness and sustainability of actions ... act when monitoring indicates actions are not effective or sustained ..."

Based on the American Association of Critical Care Nurses guiding principles for staffing, facility staffing grid, staffing schedules and interviews it was determined that the facility failed to provide supervisory oversight in the Intensive Care Units (ICU) to ensure the immediate availability of a Registered Nurse (RN) in two of two Intensive Care Units sampled.

Findings included:

Review of the facility staffing grids (tool to determine nurse to patient ratios) reveals that for the Medical Intensive care unit (MICU) and Neuro/Surgical intensive care unit (NSICU) staffing grid is two patients for one Registered Nurse and a Clinical Care Coordinator/Charge Nurse (CNC) with no patients for both night shift and day shift.

Review of the facility staffing schedules from three shifts on the night shift (7:00 PM to 7:00 AM) and four shifts on day shift (7:00 AM to 7:00 PM) reveals:
In the MICU:
Nightshift
02/25/2023: census 8: 3 RN (2:1 ratio) 1 CN with 2 patients
02/26/2023: census 8: 3 RN (2:1 ratio) 1 CN with 2 patients
02/27/2023: census 8: 3 RN (2:1 ratio) 1 CN with 2 patients
Dayshift
02/25/2023: census 6: 2 RN (2:1 ratio) 1 CN with 2 patients
02/26/2023: census 6: 2 RN (RN 2:1) Charge nurse with 2 patients
02/27/2023: census 6: 3 RN (2 RN 2:1 ratio, 1 RN 1 patient) 1 CN with 1 patient
02/28/2023: census 6: 3 RN (2 RN 2:1 ratio, 1 RN 1 patient) 1 CN with 1 patient

In the NSICU:
Nightshift
02/25/2023: census 8: 3 RN (2:1 ratio) 1 CN with 2 patients
02/26/2023: census 8: 3 RN (2:1 ratio) 1 CN with 2 patients
02/27/2023: census 8: 3 RN (2:1 ratio) 1 CN with 2 patients
Dayshift
02/25/2023: census 8: 3 RN (2:1 ratio) 1 CN with 2 patients
02/26/2023: census 8: 3 RN (2:1 ratio) 1 CN with 2 patients
02/27/2023: census 8: 3 RN (2:1 ratio) 1 CN with 2 patients
02/28/2023: census 8: 3 RN (2:1 ratio) 1 CN with 2 patients

An interview with Staff C On 02/28/2023 at 10:54 AM, Staff C disclosed the ICU charge nurses have patients on both day and night shifts.

According to the American Association of Critical Care Nurses states, dated 09/2018, "Appropriate staffing ensures the effective match between patient and family needs and nurse knowledge, skills, and abilities. Evidence confirms that the likelihood of serious complications or death increases when fewer registered nurses are assigned to care for patients. 8,10 A substantial body of evidence indicates better patient outcomes occur when registered nurses provide a higher proportion of care hours in healthy work environments."

Based on interviews and record reviews the facility failed to:

1. Ensure the facility policy and procedures for "Assessment and Reassessment" and "Critical Values/Test Results" were implemented during the provision of care for one (Patient 1) out of two sampled chest pain walked in patients from the Emergency Department.

2. Ensure the facility policy and procedures for "Assessment and Reassessment" and "Cardiac Telemetry Monitoring" were implemented during a change in condition of a cardiac monitor for one (Patient 2) out of two sampled cardiac monitor patients.

3. Ensure the facility policy and procedures for supervision and evaluation of nursing personnel, "Performance Evaluation" and "Competency Assessment," were implemented by the director of nursing services for five (B, D, M, O, and P) out of six Registered Nurses (RN) personnel files sampled.

Findings:

1. a. Review of the facility policy and procedure titled "Assessment and Reassement" dated 1/2023 indicated, "Emergency Room (ER)...b. All patients entering the Emergency Room are triaged by an RN and assigned a priority based upon their presenting symptoms and the severity of illness. The priorities are categorized as follows:
1) Level 1 - Resuscitation - Patients who require immediate life saving interventions.
2) Level 2 - Emergent - Patients who are in high risk situations, confused, lethargic, and disoriented or in severe pain or distress.
3) Level 3 - Urgent - Patients who are not in a high risk situation but need two or more resources to diagnose and treat their condition.
4) Level 4 - Less Urgent - Patients who require one resource to diagnose and treat their condition.
5) Level 5 - Non-Urgent - Patients who require no resources to diagnose and treat their condition.
...h. Patients are reassessed based on triage priority. Nursing care is evaluated on a continual basis to determine the progress or lack of progress toward patient outcomes and patient goal attainment. Reevaluation is documented and plan of care is revised as appropriate...Reevaluation may include, but is not limited to recheck of vital signs, any change in status, and that there is no change in status from any previous evaluation. Patients are reassessed in the waiting area based on triage guidelines and patients are re-categorized as appropriate.
1) Reassessment prior to a medical screening exam (MSE) are performed by RNs according to acuity level:
a) Level 1/Resuscitative will be performed continuously
b) Level 2/Emergent will be performed every 60 minutes
c) Level 3/Urgent will be performed every 60 minutes
d) Level 4/Less Urgent will be performed every 60 minutes
e) Level 5/Non-Urgent will be performed every 60 minutes
...i. Reassessments should be done anytime there is the following:
1) A change in the patient's condition
2) A significant change in the vital signs
3) To evaluate a treatment intervention..."

b. Review of the facility policy and procedure titled "Critical Values/Test Results" dated 1/23 indicated, "...Critical Values" are results that may necessitate immediate clinical intervention...Reporting "Critical Values" requires documentation. The Date, Time of call placed to physician or nurse, shall be documented in the patient medical record. Documentation of physician response and all interventions must also be done and complete..."

c. On 2/28/2023 Patient 1's medical record was reviewed with the Emergency Department Manager (EDM). The medical record indicated Patient 1 was a 72 year old male with history of coronary history disease that required coronary artery bypass grafting and stent placement and myocardial infarction x3. The facility video recording from the ED lobby indicated Patient 1 walked into the facility ED on 2/2/2023 at 17:22 with complaints of chest pain. Patient 1 was triaged as level 3 Urgent. Patient 1 was in the ED lobby until 20:57 (three and a half hours in the ED lobby/waiting room). The record further indicated:

-"Emergency Provider Report" dated 2/2/2023, 17:53 "...MSE Not Complete The medical screening exam is not complete. Further evaluation and/or treatment is required. The patient will be re-directed to the emergency department..." The document further indicated "...With significant cardiac history present to the ED with complaints of 2 episodes of midsternal chest pain today...recently had a heart attack with stent in October last year..."

-Laboratory result for HS Troponin (high sensitive diagnostic test for detection of heart injury, normal <78 ng/L) dated 2/2/2023, 19:35 - 102 Critical High

-Laboratory result for HS Troponin dated 2/2/2023, 20:51 - 98 Critical High.

-There was no documentary evidence in Patient 1's record of RN reassessments conducted every 60 minutes while waiting in the ED lobby between 17:28 - 20:57 on 2/2/2023

-There was no documentary evidence in Patient 1's record of physician response to the critical high troponin levels resulted at 19:35 and 20:57.

d. On 3/1/2023 at 2:11 p.m., Patient 1's record and the facility policy and procedures were reviewed with the Chief Nursing Officer (CNO) and Chief Operating Officer (COO).

-Both agreed the medical screening exam (MSE) was not completed as documented by the ED provider during the time Patient 1 was waiting in the ED lobby from 17:28 - 20:57 on 2/2/2023. The CNO stated since the MSE was not completed at the time Patient 1 was in the ED lobby reassessments should have been conducted by an RN every 60 minutes and documented as required by "Assessment and Reassessment" facility policy and procedure.

-The CNO and COO stated Patient 1's troponin critical high values necessitated clinical intervention and required documentation of physician response. The COO stated there should, at the least, "Documentation of a reaction from the physician" as stated in the "Critical Values/Test Results" facility policy and procedure.

-Both agreed there was delay in care. The CNO stated Patient 1 should have at least been on telemetry monitoring.


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2. Review of the facility policy and procedure titled, "Assessment and Reassessment", #WFD.PC.002, reviewed 01/2023 ...Patient needs will be reassessed throughout the course of care, treatment, and services. There frequency of reassessment is based on his or her plan for care or changes in his or her condition ...Any change in the patient's condition shall require an immediate reassessment with changes in the plan of care reflecting the change in condition ...

Review of the facility policy and procedure titled, "Cardiac Telemetry Monitoring", #WFD.PC.023, review: 07/2022 ... To outline process for notification and documentation of cardiac rhythm changes ...Policy: Patient being monitored on continuous telemetry will be observed by a telemetry tech or nurse who is competent in cardiac rhythm interpretation & arrhythmia detection. Rhythm changes, life-threatening arrhythmias, and/or loss of signal will be responded to in an immediate manner ...Daily telemetry notification log will be used daily to record telemetry notifications by the monitor tech, calls placed to the care team and alerts or codes initiated from the monitoring station ...Changes in patients rate or rhythm ... The monitor tech should immediately notify the RN of changes in patient rhythm, monitor strips will be run to capture changes in rate or rhythm ...

Review of the medical record for Patient #2 reveals that on 07/05/2022 arrived to the ED with the diagnosis of Syncope (temporary loss of consciousness caused by a fall in blood pressure) and Congestive Heart Failure (can occur it the heart cannot pump or fill adequately). Patient #2 medical record showed on 07/06/2022 at 9:41 AM an order for telemetry monitoring. On 07/10/2022 at 12:15 AM Patient #2 telemetry strips a 13 beat run of Ventricular Tachycardia (A condition in which the lower chambers of the heartbeat very quickly). Review of the nursing notes reveals no assessment of patient after the change in rhythm. On 07/09/2022 at 10:06 PM the nursing notes reveals the shift assessment was completed. Review of Patient #2 vital signs shows the last set of vital signs were 07/09/2022 at 7:29 PM as follows: Blood pressure 103/70, Pulse 118, respiration 15, oxygen saturations 90% on oxygen nasal cannula. On 07/10/2022 at 4:03 AM a code blue (Cardiac / respiratory arrest) was initiated with the patient cardiac rhythm as asystole (a cessation of electrical and mechanical activity of the heart). Patient expired at 4:53 AM. No telemetry strip in the medical record for the change in rhythm. Review of the post code note reveals the patient was found unresponsive.
Review of the facility telemetry logs 07/09/2022- 07/10/2022 for Patient #2 reveals incomplete information (2 episodes with one episode on log and no time noted of the notification). Telemetry logs reviewed from February 1, 2023 through February 27, 2023 shows incomplete logs and not all the telemetry technicians turn the logs in at the end of shift.
On 02/28/2023 at 12:43 PM an interview with Staff E acknowledges that the telemetry logs are not complete, and all the telemetry staff is not turning them in. The expectation is to complete the telemetry logs and to follow the escalation process.

3. Review of the facility policy and procedures titled, "Competency Assessment," effective 6/15/2022, indicated contract staff will be held to the same standards as colleagues and the records must be maintained by the business entity. PURPOSE: To define mechanisms used to assess and maintain competency of colleagues as required for the position and by regulatory agencies...Competency: A competency refers to the knowledge, abilities, and behaviors required to perform assigned duties and responsibilities safely and aptly. Competency Assessment: Competency Assessment shall be conducted initially as a part of orientation and an ongoing basis thereafter...Ongoing Competency Assessment is an essential process for verifying an individual's ability to perform their assigned job role by evaluating the ability to apply knowledge, perform skills and demonstrate critical thinking...An individual with the same education and licensure and who has the knowledge, and/or experience for the skills being reviewed should assess the validation of competency...
Review of the facility policy, "Performance Evaluation," effective 10/01/2020, stated the purpose was to provide guidelines to measure performance through formal performance evaluation at specific intervals, in a timely, fair, and equitable manner. Colleagues should receive a formal performance evaluation, at a minimum, on an annual basis.
Review of the personnel file for Staff B a Register Nurse (RN) in the Progressive care Unit (PCU) reveals no competency assessment was completed.
Review of the personnel file for Staff D a RN in the PCU indicated that Staff M was an agency nurse. The facility was unable to provide documentary evidence that a Competency Assessment was completed.
Review of the personnel file for Staff M a RN in the PCU indicated that Staff M was an agency nurse. The facility was unable to provide documentary evidence that a Competency Assessment was completed.
Review of personnel file for Staff O a RN in the Emergency Department (ED) reveals the last competencies completed was 08/03/2017.
Review of Personnel files for Staff P a RN in the ED reveals no evidence that a Competency Assessment was completed.

On 03/02/2023 between 1:00 PM and 2:30 PM an interview was conducted with the Chief Nursing Officer (CNO) regarding staff competency. The CNO confirmed that the competency assessment are not completed because approximately 2 years ago the company started utilizing HealthStream (computerized continuing education program) and if they don't pass the assigned education then it remains incomplete until they pass it.