HospitalInspections.org

Based on interview and record review, the hospital failed to ensure that each patient was free from neglect by a registered nurse as evidenced by:

The assigned licensed nurse did not take vital signs hourly and did not continuously provide cardiac monitoring with electrocardiogram (EKG) interpretation and assessment of patient's abnormal blood pressure and notification of physician patient was found unresponsive and subsequently died. (Patient 1). (Refer to A-0145.)

The cumulative effect of the systemic problems resulted in the hospital's inability to provide quality health care in a safe and effective manner.

Based on interview and record review, the hospital failed to ensure 1 of 17 patients was free from neglect (Patient 1), when the assigned licensed nurse did not take vital assigns hourly and did not continuously provide cardiac monitoring with electrocardiogram (EKG) interpretation and assessment of patient's abnormal blood pressure and notification of the physician. Patient 1 was found unresponsive and subsequently died.

Findings:

During a review of the clinical record for Patient 1, the Emergency Department Record dated 6/27/14, at 12:24 a.m. indicated Patient 1 was admitted to the Emergency Department (ED) via ambulance on 6/26/14 at 11:53 p.m., with the chief complaint of alcohol intoxication with confusion and agitation. Patient 1 was nauseated, vomiting, and incontinent of stool.

The laboratory test results, dated 6/27/14, at 1:25 a.m., indicated Patient 1's blood alcohol level was 365 milligrams per deciliter (mg/dL) (normal range is less than 10 mg/dL). [Note: Per The Merck Manual for Health Care Professionals elevated alcohol can cause nausea, vomiting, respiratory depression, arrhythmias coma and death].

Physician B's Order Detail dated 6/27/14, and timed at 7:26 a.m., indicated an order to admit Patient 1 to the hospital's Telemetry service (a nursing unit whereby the patient's heart rate and rhythm are continuously monitored externally) with a plan of care to include the following for Patient 1's past medical history of pulmonary embolus and atrial fibrillation, continue on Xarelto (a prescription medicine used to treat patients with atrial fibrillation, deep vein thrombosis and pulmonary embolism, and to help reduce the risk of these conditions occurring again).

During an interview on 7/17/14 at 11:30 a.m., with Administrative Staff E and Administrative Staff F, the hospital did not have a hospital bed available on the nursing telemetry monitoring units. The hospital telemetry bed became available at 6:00 p.m., on 6/27/14. Patient 1 remained in the ED throughout the day.

During an interview on 7/17/14 at 11:30 a.m., Administrative Staff E and Administrative Staff F, stated Patient 1 was triaged at Level 3 should have continuous cardiac monitoring, cardiac rhythm interpretation and vital signs at a minimum of every hour. They stated patient's cardiac monitoring and interpreted rhythm strip is to be posted at the beginning of the shift and then again every 4 hours.

Patient 1's telemetry (cardiac monitoring) strip posted on the Telemetry Log dated 6/27/14 at 6:25 p.m., indicated incomplete documentation for the EKG lead, PR interval, QRS width, QT interval, interpretation and RN signature.
Telemetry strips should have been posted and interpreted per policy titled "Telemetry/EKG Monitoring" every 4 hours or as needed on 6/26/14 at 11:55 p.m., on 6/27/14 at 4:00 a.m., 7:30 a.m., 11:30 a.m., and 3:30 p.m.

Patient 1's ED Summary Report, Trend Review and the Multidisciplinary Discharge Summary indicated no documentation of hourly vital signs on 6/27/14 at 2:00 a.m., 3:00 a.m., 8:00 a.m., 11:00 a.m., 12 noon, 3:00 p.m., and 4:00 p.m. The blood pressure documented on 6/27/14 at 4:57 p.m. was 166/102. The next blood pressure documented at 5:57 p.m. was 175/108 and at 6:15 p.m. was 192/100. There was no re-assessment documented, no contact with the physician regarding the elevated blood pressures. At 6:33 p.m., Patient 1 was found pulseless and breathless by Licensed Staff G and CPR (cardiopulmonary resuscitation) was initiated. CPR was terminated at 6:56 p.m. and Patient 1 was pronounced dead at 6:56 p.m.

Licensed Staff C assumed the care for Patient 1 at approximately 7:00 a.m. on 6/27/14. Licensed Staff C received report from the night shift nurse at 7:25 a.m.

The ED Security Video Timeline of Events on 6/27/14 indicated Licensed Staff C's last encounter with Patient 1 was at 11:21 a.m. and resumed at 1:20 p.m. Licensed Staff C's last encounter with Patient 1 was at 2:07 p.m. and resumed at 6:13 p.m.

The facility policy and procedure titled "Assessment of the Emergency Department Patient" last reviewed 1/14, indicated The Registered Nurse (RN) is responsible for the planning, supervision, implementation, and evaluation of the nursing care provided to each patient in the ED and documented in the electronic medical record or appropriate nursing flow sheet.

The facility policy and procedure titled "Telemetry/EKG Monitoring" last reviewed 3/14, indicated the registered nurse (RN) will assess on admission and at the beginning of each shift and PRN as indicated by the patient's clinical condition: The need for continuous cardiac telemetry monitor observation and monitoring lead. Telemetry strips are posted in the medical record every 4 hours and PRN. The RN is responsible for documenting the rhythm interpretation and verifying by signature. Documentation: For each patient, a baseline EKG strip is posted on the Telemetry Log/unit specific form at the beginning of every shift or upon arrival to the specialty unit. The EKG strip is reviewed by the RN and the following information is documented on the Telemetry Log under the EKG strip: 1. EKG Lead; 2. PR Interval; 3. QRS Width; 4. Interpretation and 5. RN signature. Additional EKG rhythm strips are posted for the following: 1. Changes from baseline rhythm. 2. Acute changes in patient condition, which may be cardiac related, such as chest pain, syncope, or changes in level of consciousness.

Based on interview and record review, the facility failed to provide an organized nursing service for 5 of 17 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4 and Patient 5) as evidenced by:

1. An Emergency Department Registered Nurse (Licensed Staff C) did not provide continuing cardiopulmonary monitoring (continuous monitoring of heart rate/rhythm). This resulted in a delayed recognition of a possible arrhythmia, the patient was found unresponsive and subsequently died. (Patient 1). (Refer to A- 0395.)

1. a. Emergency Department licensed staff failed to reassess Patient 1's chest pain. This failure may have resulted in untreated chest pain. (Patient 1 ). (Refer to A- 0395.)

2. 2 North Telemetry, 2 Northwest Telemetry and 3 North Medical/Surgical Staff Nurses did not provide interpretation of continuing cardiopulmonary monitoring (monitoring of heart rhythm). This may result in a delayed recognition and identification of an arrhythmia and further a delay in treatment. (Patient 3, Patient 4 and Patient 5). (Refer to A- 0395.)

3. An Emergency Department Registered Nurse (Licensed Staff C) did not give four medications ordered by the physician. This has the potential for a delay in treatment and the patient not receiving therapeutic effects of the medication.(Patient 1). (Refer to A-0405.)

4. An Emergency Department Registered Nurse failed to document the specific components of a verbal order, the route, special instructions and the date. This may have resulted in a medication error. (Patient 2). (Refer to A-0407.)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the health and safety of patients who required nursing care and medications.

Based on staff interview, clinical record review and hospital document review, the hospital failed to ensure nursing staff provided assessment and re-assessment for 4 of 17 sampled patients (Patient 1, Patient 3, Patient 4, and Patient 5). These failures may delay recognition of a deteriorating medical status in which Patient 1 died when he was not continuously monitored on a cardiac monitor and vital signs assessed per facility policy and procedure.

Findings:

1. During a review of the clinical record for Patient 1, the Emergency Department Record dated 6/27/14, at 12:24 a.m. indicated Patient 1 was admitted to the Emergency Department (ED) via ambulance on 6/26/14 at 11:53 p.m., with the chief complaint of alcohol intoxication with confusion and agitation. Patient 1 was nauseated, vomiting, and incontinent of stool.

The laboratory test results, dated 6/27/14, at 1:25 a.m., indicated Patient 1's blood alcohol level was 365 milligrams per deciliter (mg/dL) (normal range is less than 10 mg/dL). [Note: Per The Merck Manual for Health Care Professionals elevated alcohol can cause nausea, vomiting, respiratory depression, arrhythmias coma and death].

Physician B's Order Detail dated 6/27/14, and timed at 7:26 a.m., indicated an order to admit Patient 1 to the hospital's Telemetry service (a nursing unit whereby the patient's heart rate and rhythm are continuously monitored externally) with a plan of care to include the following for Patient 1's past medical history of pulmonary embolus and atrial fibrillation, continue on Xarelto (a prescription medicine used to treat patients with atrial fibrillation, deep vein thrombosis and pulmonary embolism, and to help reduce the risk of these conditions occurring again).

During an interview on 7/17/14 at 11:30 a.m., with Administrative Staff E and Administrative Staff F, the hospital did not have a hospital bed available on the nursing telemetry monitoring units. The hospital telemetry bed became available at 6:00 p.m., on 6/27/14. Patient 1 remained in the ED throughout the day.

Patient 1's ED Summary Report, Trend Review and the Multidisciplinary Discharge Summary indicated no documentation of hourly vital signs on 6/27/14 at 2:00 a.m., 3:00 a.m., 8:00 a.m., 11:00 a.m., 12 noon, 3:00 p.m., and 4:00 p.m. The blood pressure documented on 6/27/14 at 4:57 p.m. was 166/102. The next blood pressure documented at 5:57 p.m. was 175/108 and at 6:15 p.m. was 192/100. There was no re-assessment documented, no contact with the physician regarding the elevated blood pressures. At 6:33 p.m., Patient 1 was found pulseless and breathless by Licensed Staff G and CPR (cardiopulmonary resuscitation) was initiated. CPR was terminated at 6:56 p.m. and Patient 1 was pronounced dead at 6:56 p.m.

During an interview on 7/17/14 at 11:30 a.m., Administrative Staff E and Administrative Staff F, stated Patient 1 was triaged at Level 3 should have continuous cardiac monitoring, cardiac rhythm interpretation and vital signs at a minimum of every hour. They stated patient's cardiac monitoring and interpreted rhythm strip is to be posted at the beginning of the shift and then again every 4 hours. They stated there should have been pain assessments and re-assessments at a minimum documented every 4 hours.

The facility policy and procedure titled "Standard of Care/Standard of Practice for Emergency Services" last reviewed 2/14, indicated Level 3 (Urgent) are conditions that could potentially progress to a serious problem requiring emergent intervention. Vital Signs may or may not be outside of normal limits and the presenting condition is anticipated to require the utilization of two or more resources. Typical presentations include, but are not limited to, abdominal pain, vaginal bleeding, seizure, vomiting, and/or diarrhea, fractures. Vital signs every hour and at time of discharge or transfer from ED or more frequently according to patient's condition.

The facility policy and procedure titled "Assessment/Re-Assessment of Patients" last reviewed 8/13, indicated reassessment is ongoing, and frequency is based on patient condition. Patients are reassessed after change of condition.

1. a. Patient 1's History and Physical, dated 6/27/14 indicated right upper quadrant pain probably due to liver congestion.

Patient 1's initial nursing pain assessment was chest pain documented on 6/27/14 at 1:15 a.m. There was no further documentation of Patient 1's pain assessment or re-assessment, which should have been assessed every 4 hours on 6/27/14 at 5:15 a.m., at 7:30 a.m. (the beginning of the next shift), 11:30 a.m., and 3:30 p.m.

The facility policy and procedure titled "Pain Management" last reviewed 7/11, indicated the hospital recognizes pain as "the Fifth Vital Sign" to be assessed at the same time a full set of vital signs are taken. The frequency of pain assessment shall be guided by the intensity of the patient's pain and the effectiveness of pain relief strategies. Assessment of pain is done with a full set of vital signs and should correspond with unit routine or every 4 hours whichever is consistent with patient condition.

2. a. Patient 1's telemetry (cardiac monitoring) strip posted on the Telemetry Log dated 6/27/14 at 6:25 p.m., indicated incomplete documentation for the EKG lead, PR interval, QRS width, QT interval, interpretation and RN signature.
Patient 1's telemetry strips should have been posted and interpreted per policy every 4 hours or as needed on 6/26/14 at 11:55 p.m. (at the time of admission), on 6/27/14 at 4:00 a.m., 7:30 a.m. (the beginning of the next shift), 11:30 a.m., and 3:30 p.m.

During an interview on 7/17/14, at 11:30 a.m., with Administrative Staff E and Administrative Staff F, stated Patient 1 should have had a cardiac monitoring and interpreted rhythm strip posted at the beginning of the shift, posted with rhythm changes and then again every 4 hours.

2. b. Patient 3's face sheet dated 7/11/14 and timed 12:14 a.m., and the Nursing Unit Census dated 7/15/14, indicated she was an 83-year-old patient receiving nursing care on 3 North telemetry nursing unit for symptomatic hyponatremia (low sodium) requiring telemetry monitoring. Patient 3's sodium level on admission was 120 milliequivalents per liter (mEq/L).
[Note: Per The Merck Manual for Health Care Professionals defines hyponatremia as a decrease in the sodium level less than 136 mEq/L.]

Patient 3's telemetry strip posted on the Telemetry Log dated 7/11/14, at 1:34 a.m., indicated incomplete documentation for the EKG lead, PR interval, QRS width and QT interval. The telemetry strips should have been posted and interpreted per policy every 4 hours or as needed on 7/11/14 5:30 a.m., 7:30 a.m., 11:30 a.m., and 3:30 p.m.

Patient 3's telemetry strip posted on 7/11/14 at 6:54 p.m., indicated incomplete documentation for the EKG lead, PR interval, QRS width and QT interval.

Patient 3's telemetry strip posted on 7/12/14 at 3:00 a.m., 3:00 p.m., 7:09 p.m., 10:51 p.m., indicated incomplete documentation for the EKG lead, PR interval, QRS width and QT interval.

Patient 3's telemetry strip posted on 7/13/14 at 7:00 a.m., indicated incomplete documentation for the EKG lead, PR interval, QRS width and QT interval.

Patient 3's telemetry strip posted on 7/14/14 at 3:11 a.m., indicated incomplete documentation for the EKG lead, PR interval, QRS width, QT interval, interpretation and RN signature.

2. c. Patient 4's face sheet dated 7/13/14 and timed at 2:30 p.m., and the Nursing Unit Census dated 7/15/14, indicated he was admitted to 2 North Telemetry Step Down nursing unit for atrial fibrillation (AF) with a rapid ventricular response requiring telemetry monitoring.
[Note: Per The Merck Manual for Health Care Professionals defines AF as a rapid irregular atrial rhythm.]

Patient 4's telemetry strip posted on 7/13/14 at 6:42 p.m., and 7:12 p.m., indicated incomplete documentation for the EKG lead, PR interval, QRS width, QT interval, interpretation and RN signature.

Patient 4's telemetry strip posted on 7/14/14 at 12:20 a.m., and 3:27 a.m., indicated incomplete documentation for the EKG lead, PR interval, QRS width and QT interval.

Patient 4's telemetry strip posted on 7/14/14 at 7:10 p.m., indicated incomplete documentation for the EKG lead, PR interval, QRS width, QT interval, interpretation and RN signature.

Patient 4's telemetry strip posted on 7/14/14 at 11:34 p.m., indicated incomplete documentation for the EKG lead, PR interval, QRS width and QT interval.

Patient 4's telemetry strip posted on 7/15/14 at 3:46 a.m., indicated incomplete documentation for the EKG lead, PR interval, QRS width and QT interval.

2. d. Patient 5 a 96 year old male was admitted to 2 Northwest Telemetry nursing unit for congestive heart failure (CHF) and pneumonia requiring telemetry monitoring. [Note: Per the Merck Manual for Health Care Professionals Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular failure causes shortness of breath and fatigue, and right ventricular failure causes peripheral and abdominal fluid accumulation.]

Patient 5's telemetry strip posted on 7/12/14 at 5:55 p.m., indicated incomplete documentation for the EKG lead, PR interval, QRS width, QT interval, interpretation and RN signature.

Patient 5's telemetry strip posted on 7/12/14 at 7:08 p.m., and 11:39 p.m., indicated incomplete documentation for the EKG lead.

Patient 5's telemetry strip posted on 7/13/14 at 3:30 a.m., indicated incomplete documentation for the EKG lead, PR interval, QRS width and QT interval.

Patient 5's telemetry strip posted on 7/13/14 at 7:18 a.m., and 11:01 a.m., indicated incomplete documentation for the EKG lead, PR interval, QRS width, QT interval, interpretation and RN signature.

Patient 5's telemetry strip posted on 7/14/14 at 7:10 p.m., and 11:35 p.m., indicated incomplete documentation for the EKG lead, PR interval, QRS width and QT interval.

The facility policy and procedure titled "Telemetry/EKG Monitoring" last reviewed 3/14, indicated the registered nurse (RN) will assess on admission and at the beginning of each shift and PRN as indicated by the patient's clinical condition: The need for continuous cardiac telemetry monitor observation and monitoring lead. Telemetry strips are posted in the medical record every 4 hours and PRN. The RN is responsible for documenting the rhythm interpretation and verifying by signature. Documentation: For each patient, a baseline EKG strip is posted on the Telemetry Log/unit specific form at the beginning of every shift or upon arrival to the specialty unit. The EKG strip is reviewed by the RN and the following information is documented on the Telemetry Log under the EKG strip: 1. EKG Lead; 2. PR Interval; 3. QRS Width; 4. Interpretation and 5. RN signature. Additional EKG rhythm strips are posted for the following: 1. Changes from baseline rhythm. 2. Acute changes in patient condition, which may be cardiac related, such as chest pain, syncope, or changes in level of consciousness.

Based on interview and document review, the hospital failed to ensure medications were administered according to physician orders for 1 of 17 patients (Patient 1) when Licensed Staff C failed to administer 4 medications for Patient 1, which caused a delay in treatment.

Findings:

During a review of the clinical record for Patient 1, the Emergency Department Record dated 6/27/14, at 12:24 a.m. indicated Patient 1 was admitted to the Emergency Department (ED) via ambulance on 6/26/14 at 11:53 p.m., with the chief complaint of alcohol intoxication with confusion and agitation. Patient 1 was nauseated, vomiting, and incontinent of stool.

The laboratory test results, dated 6/27/14, at 1:25 a.m., indicated Patient 1's blood alcohol level was 365 milligrams per deciliter (mg/dL) (normal range is less than 10 mg/dL). Note: Elevated alcohol can cause nausea, vomiting, diarrhea, respiratory depression, coma and death.

Physician B's Order Detail dated 6/27/14, and timed at 7:26 a.m., indicated an order to admit Patient 1 to the hospital's Telemetry service (a nursing unit whereby the patient's heart rate and rhythm are continuously monitored externally) with a plan of care to include the following for Patient 1's past medical history of pulmonary embolus and atrial fibrillation, continue on Xarelto (a prescription medicine used to treat patients with atrial fibrillation, deep vein thrombosis and pulmonary embolism, and to help reduce the risk of these conditions occurring again). It was noted Patient 1 had a history of chronic back pain and gastro-intestinal (GI) bleed.

During an interview on 7/17/14 at 11:30 a.m., with Administrative Staff E and Administrative Staff F, the hospital did not have a hospital bed available on the nursing telemetry monitoring units. The hospital telemetry bed became available at 6:00 p.m., on 6/27/14. Patient 1 remained in the ED throughout the day.

The physician's order (Physician B) dated 6/27/14, indicated the following medication orders written at 7:26 a.m.:
1. Neurontin (gabapentin) 600 mg PO QID (a first line agent for the treatment of neuropathic pain).
2. Xarelto (rivaroxaban) 15 mg PO BID with meals (a prescription medicine used to treat patients with atrial fibrillation, deep vein thrombosis and pulmonary embolism, and to help reduce the risk of these conditions occurring again).
3. Carafate (sucralfate) 1GM PO ACHS (an oral gastrointestinal medication primarily indicated for the treatment of an active ulcer).
4. Librium (chlordiazepoxide) 25 mg PO Q 6 HR (a prescription medicine used in the treatment of severe and disabling anxiety) ordered on 6/27/14 at 11:37 a.m.

The Electronic Medications Report (eMAR), dated 6/26/14 and 6/27/14 indicated the Neurontin was scheduled to be administered at 5:00 p.m., the Carafate was scheduled to be administered at 5:30 p.m. and the Xarelto and the Librium were scheduled to be administered at 6:00 p.m. None of the four scheduled doses were administered between 5:00 p.m. and 6:00 p.m.

During an interview with Licensed Staff D, on 7/17/14 at 2:10 p.m., she stated the ED was very busy on 6/27/14 and the hospital was very busy. She stated the ED holding time (patients waiting for a hospital room) was somewhat lengthy on 6/27/14 which was the reason why Patient 1 remained in the ED.

During an interview on 7/17/14 at 2:20 p.m., Administrative Staff E stated patients who were admitted to the hospital and waiting for a hospital room should continue to receive the same level of nursing care in the ED as other inpatients and confirmed Patient 1 missed medications.

The hospital policy and procedure titled "Medication Administration" last reviewed 7/12, indicated prior to administration of a medication, the healthcare provider administering the medication verifies that the medication is being administered at the proper time, in the prescribed dose and by the correct route.
The hospital policy titled "Medication Administration" last revised 7/12, did not define differences between medications administered in the ED and in-patient units.

Based on interview and record review, the hospital failed to document the specific components of a verbal order, the route, special instructions and the date for 1 of 17 sampled patients (Patient 2). This may have resulted in a medication error.

Findings:

Patient 2's, physician's orders (not dated) and timed at 12:00 noon indicated "2 % Lido c Epi 1:100,000 20 ml injectable for chest tube insertion." The medication order was signed by the registered nurse (RN) as a verbal order.
The physician's verbal order did not contain the route such as intravenous (IV), intramuscular (IM), or subcutaneous (SQ), the date the verbal order was received, special instructions such as at bedside for physician use. The verbal order did not contain the read back confirmation (a medication documentation safety process).

During an interview on 7/15/14, at 10:20 a.m., Administrative Staff A and Administrative Staff B confirmed the missing verbal order elements route, date, and the read back confirmation.

The facility policy and procedure titled "Medication Orders - Required Elements" last reviewed 10/13, indicated all medication orders must include as appropriate the following: Patient's name, patient's number, name of medication, strength, volume or concentration as appropriate, dose, route of administration, frequency, rate of administration as appropriate, special instructions if required, signature, date and time. The medical center minimizes the use of verbal and telephone orders. All verbal and telephone orders should contain the elements as written above. All verbal and telephone orders should be immediately written down, read back to the prescriber and content confirmed.