HospitalInspections.org

Based on document review and staff interview, in 1 of 13 medical records reviewed, it was determined staff did not develop a care plan to meet the care needs of the patient and educate the patient on the care requirements.

As a result, a patient who had a physician's order to ambulate with assistance was not assisted with ambulation and was later found unresponsive in the bathroom.

Findings include:

Patient #1 is a 68 year old who was evaluated on arrival in the Emergency Department (ED) on 1/20/16 at 4:32 PM, for shortness of breath and productive cough for 2 weeks. The patient's medical history included anemia, arthritis, diabetes mellitus, hypertension, hypercholesterolemia, chronic obstructive pulmonary disease, Aortic Valve Replacement, gout and morbid obesity. On arrival to the ED, patient oxygen saturation was 72%, however with supplemental oxygen at 4 liters/min via nasal cannula, her saturation levels were over 90%. The patient was admitted on 1/20/16 at 7:54 PM with a primary diagnosis of Pneumonia and was awaiting bed placement in the holding area in the Emergency Department.


An occurrence report dated 1/21/16 at 12:20 AM, nurse noted, "Patient was missing as per patient's neighbor she stated patient went to bathroom few minutes ago - nurse knocked on bathroom door, no answer. Security called - opened bathroom door. Found patient on the floor - pulseless."

An order written by the physician on 1/20/16 at 9:40 PM to ambulate the patient as tolerated with assistance, was not implemented.

The medical record did not contain a care plan that addressed the care needs of the patient and there was no evidence the patient was educated on what her care needs are.

At interview with Staff #1, ED physician, post graduate year 2 (PGY2) on 1/29/16 at 9:00 AM, physician stated that she ordered the patient to ambulate with assistance because the patient's tolerance to ambulation had not yet been determined.When Staff #1 was asked if the patient needed continuous supplemental oxygen, she stated that the patient's need for continuous oxygen therapy had not yet been determined however, the patient was on supplemental oxygen at home as needed and was comfortable in bed and saturating well when she was assessed by the physician on 1/20/16 at 7:54 PM and later when she was reevaluated by a nurse on 1/21/16 at 12:02 AM.

There was no evidence an assessment of the patient was conducted prior to ambulating early in the morning on 1/21/16. As a result, the patient's tolerance to independent ambulation without supplemental oxygen was not assessed.