HospitalInspections.org

Based on review of hospital policy, registered nurse job description, medical records, staff and physician interviews the nursing staff failed to supervise and evaluate care by failing to administer oxygen as ordered for 1 of 3 patients with oxygen ordered (#5).

The findings include:

Review of hospital policy, "Nursing Assessment and Documentation", revised 03/05/2008, revealed "...M. Ongoing Nursing Documentation: ...2. Nursing Progress notes: a. Documentation should include further explanation not defined within the flowsheet, physician notification, changes in the patient's condition, unusual circumstances, and procedures and/or treatments performed...d...Documentation should also occur when the nurse has been notified of abnormal or unusual patient concerns".

Review of the hospital's job description for a registered nurse, effective 02/01/2007, revealed " Responsibilities ...Responsible for directing and coordinating all nursing care for patients based on established clinical nursing standards. Collaborates with other professional disciplines to ensure effective and efficient patient care delivery and the achievement of desired patient outcomes...Performs continuous reassessment of symptoms and changes in patients' conditions and intervenes appropriately...Reviews medical plan of care and assures implementation...Accountable for assuring team members provide safe care, i.e. medication administration...integrity of equipment...".

Closed medical record review of Patient #5 revealed an 88 year-old admitted 10/02/2009 with a left hip fracture requiring an open reduction and internal fixation of the hip. Record review revealed Patient #5 had a history of chronic obstructive pulmonary disease, coronary artery disease, congestive heart failure, type II diabetes, Alzheimers and cerebrovascular accident. Record review revealed a physician's order dated 10/02/2009 at 1525 "O2 (oxygen) 2L (liters) nasal cannula x (times) 12 hr (hours) ; d/c (discontinue) if O2 sat (saturation) > (greater than) 94% on room air". Review of the nursing documentation dated 10/04/2009 at 0730 and 0840 revealed Patient #5 was on 2 liters of oxygen via nasal cannula. Review of the "24 Hour Trends Flowsheet" dated 10/04/2009 revealed Patient #5's oxygen saturation was 96% at 1100 and 91% at 1500. Record review revealed no documentation regarding the use of oxygen at the time the oxygen saturation was measured. Record review revealed no documented evidence that the nurse reassessed the patient's oxygen administration until 2000 (11 hours since previous assessment at 0700). Review of the nurse's documentation of an assessment performed at 2000 revealed the patient was receiving 2L of oxygen via nasal cannula. Further review of the nursing documentation at 2135 revealed "...diaphoretic...SOB (shortness of breath) with labored breathing....". Record review revealed Patient #5 was transferred to the critical care unit and expired 10/05/2009 at 0300.

Interview on 02/17/2010 at 1000 with a staff registered nurse revealed she remembered taking care of Patient #5 on 10/04/2009. Interview revealed "I did a complete assessment at 0730 and he was getting 2 liters of oxygen". Interview further revealed, "At some point during the afternoon, his daughter called me in the room to let me know the oxygen had been turned off at some point during the day. I checked and he had the nasal cannula in but the oxygen was turned off. I turned it back on. I don't know what time it was. I did not call the doctor and did not document anything in the chart". Interview further revealed, "the sat (saturation) was 91 at 1500. I don't know whether it was before or after that when I turned the oxygen back on". Interview confirmed the patient was ordered to have oxygen administered at 2 liters continuously until the oxygen saturation was maintained at 94%. Interview confirmed the patient had not maintained oxygen saturation at 94%.

Interview on 02/17/2010 at 1415 with a respiratory therapist revealed the therapist provided Duoneb (nebulizer) treatments to Patient #5 on 10/04/2009 at 0800, 1200 and 1600. Interview revealed, "I turned the oxygen up to 7-8 liters during the treatment and turned it back to 2 liters when the treatment was completed". Interview further revealed, "he was on continuous oxygen by nasal cannula at 2 liters. That's what was ordered and he had not been weaned to room air".

Interview on 02/17/2010 at 1305 with Patient #5's primary physician revealed, "he had a heart attack and he was in congestive heart failure. He was also having renal failure and was in metabolic acidosis". Interview confirmed the patient was ordered to have oxygen administered at 2 liters continuously via nasal cannula unless his saturation was maintained at 94% at room air. Interview further confirmed "he needed oxygen if his sats were 91%".

Interview on 02/17/2010 at 1300 with administrative nursing staff revealed "nurses should always document if the oxygen is off and why". Interview further revealed "we are rethinking our assessments and are planning to change our policy so they are done more frequently than once per shift".

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