HospitalInspections.org

Based on record review and interview the medical staff failed to follow its policy/bylaws for physician reassessment and returning nursing staff calls for one of 11 sampled patients (SP # 1).


The findings:

1. Review of sampled patient (SP) #1 showed he was first admitted on 7/2/2015 due to a fall and acquired a right hip fracture. SP#1 was readmitted on 8/5/2015 for an elective surgery for the right hip fracture due to increase pain. Pt. underwent a right hip surgery on 8/5/15 under general anesthesia. Review of SP#1 Operative Report dated 08/5/15 revealed the procedure performed was a right hip Hemiarthroplasty under general anesthesia.
Review of the surgeon/MD-D progress notes showed no documentation for 08/6/2015 the first post -operative day.

Interview with MD-D on 06/24/16 at 2:15 PM, the surgeon stated that I did not see the SP #1 on the first day post operatively but patient was seen by other physicians the next day after surgery.

Review of Policy No: BHM BCH-219.00 Interdisciplinary Patient Care Assessment and Reassessment showed that
· Physician Reassessment of patients in the medical surgical units must be reassessed and a progress note written DAILY by the physician or delegated licensed independent practitioner (LIP).
The facility did not adhere to its own policy of Interdisciplinary Patient Care Assessment and Reassessment.



2. The nursing progress notes dated 08/06/15 at 09:30 am showed that a call was placed to the physician regarding agitation and medication per family request, waiting for call back. The next entry on 08/06/2015 at 13:00 PM showed second call out placed to physician regarding medications, waiting for call back at this time. On 08/06/15 at 16:00 PM (over 6 hours later) a note then showed spoke with physician, medications orders revised, family aware, monitoring patient at this time.

Interview with the Chief Medical Officer (CMO) on 06/22/16 at 10:45 AM revealed that psychologist, podiatrist, physicians and dentist compose the medical staff. When physicians do no return calls in a timely manner, there is an escalating protocol and an incident report is complete by the nurse and the physician is counseled by the CMO. The time frame for responding to calls is 30 minutes. Duties of each category of the medical staff are recorded in the by-laws. The requirement of the surgeon is to see pt. on first day post op. On a daily basis, any physicians can see the pt. The allied health is not included in the visitation policy; the physician should see the pt. The allied health is not a substitute for the physician to visit.

Interview with Staff B (Registered Nurse) on 6/22/16 at 2:35 PM, the nurse stated that physicians are called, and after 3 consecutive calls that the physicians does not answer, it is escalated to the house supervisor. Surgeons comes daily, consults come within 24 hours of consultation.

Interview with Unit Supervisor on 6/23/16 at 12:40 PM revealed that recalls SP#1 daughter was involved in the care of the pt., staff provided support on whatever requests is made by the daughter. Daughter was requesting medications to be resumed and the physician was called. Calls are made to physicians and after 2 calls and the physician does not call back, it is escalated to supervisor and then to medical team. For critical issues, calls are made in 15 minute intervals twice, and then if no call back it is escalated. Call is placed again. For non-emergent issues, the physician can call back at a reasonable time, although after 2 calls, staff is to escalate it.

Based on interview and record review, the facility failed to follow the standards of practice as it relate to their policies and procedures for: 1). notification of the physician when medications not administered for one of eleven sampled patients (SP) #1; following the physician's orders for intake and output for one of eleven sampled patients #1; not following their protocol for Code Rescue and Early Intervention for one of eleven sample patients #1;and authorization for transfusion of blood or blood derivatives for one of eleven sampled patients #4.

The Findings:

1. Review of sample patient (SP) #1 Medication Administration Record and Nurse Progress notes revealed that the physician was not notified of the medications not being administered on the following dates and times:

The Metoprolol 25 mg by mouth twice daily was not administered on the following days:
On 08/5/15 at 10:00 PM Reason HR=56
On 08/6/15 at 10:00 PM Reason BP 97/54, Pulse 84
On 08/7/15 at 10:00 AM Reason BP 95/53, Pulse 73

Review of the Policy No BCH-733.10 title Medication Prescribing and Ordering Guidelines revealed that Procedures to Ensure Compliance (04/12) #2.c.ii. Hold Orders may be temporarily held if nursing judgement indicates a problem with dosage, adverse drug reactions, or other reasons, until the attending physician can be contacted. The facility failed to adhere to its policy on Medication Prescribing and Ordering Guidelines.

Interview with the Manager regarding the nursing practice on 06/24/16 at 2:10 PM revealed that for medication administration, the nurse may hold medications and call the doctor to obtain orders for parameters.

2. Review of SP#1 Post-Op Fractured Hip Orders dated 08/5/15 revealed the Intake and output are to be documented every 8 hours for 3 days.

Review of SP#1 Intake and Output documentation revealed on:
08/6/15 at 4:01 PM to 08/7 /15 at 12 midnight no recorded intake
08/7/15 at 12:01 AM to 8:00 AM there is no recorded intake
08/7/15 at 8:01 AM to 4:00 PM there is no recorded intake and output
08/7/15 at 4:01 PM to 12 midnight there is no recorded intake
08/8/15 at 8:01 AM to 4 PM = there is no recorded intake and output

Review of SP #1 "orders discontinued at the time of discharge" showed an Intravenous (IV) order for 1000 ml (milliliters) of Lactated Ringers at a 100 cc /hr (cubic centimeter per hour) was started on 08/06/15 at 23:15 PM and stopped on 08/08/15. The fluid intake was not documented every eight hours as ordered.

3. Review of the nursing progress notes on 08/8/15 at 01:00 AM showed a low blood pressure (BP) of 71/49 systolic/diastolic and rechecked (B/P) was 83/47, and Foley output 50 ml (milliliter ' s). Called spoke with MD-B with order to increase IVF to 120 ml/hr and parameter for the Lopressor. On 08/08/15 at 04:08 AM the B/P was 82/43. At 05:30 AM The physician was called for low Foley output and for the B/P 82/43 and Hespan bolus started. At 07:00 AM, Pt BP was 96/62 and respiratory rate of 28. At 11:30 AM the physician saw the patient, and orders were received, and spoke with the family. On 08/08/2015 at 13:12 PM a (blood) transfusion was in progress, family at bedside, BP 89-77 sys (systolic), HR ( heart rate 70 ' s , will continue to monitor. At 15:30 PM the respiratory rate increased to 32. At 16: 25 the nephrologist seen the patient, orders received, output remained low.

There is no documentation that a " Code Rescue " was called per the Code Rescue and Early Intervention during Patient Crisis protocol.

Review of Policy NO BHM-209-00 Title Code Rescue and Early Intervention during Patient Crisis revealed criteria for initiation of a code rescue that include respiratory rate less than or greater than 28. Symptomatic Blood pressure SBP less than 90 or DBP above 100, and BP not responding to ongoing medical treatment. Unexplained agitation for more than 10 minutes. Note: Symptomatic refers to signs and symptoms of hemodynamic instability. These include, but not limited to: decreased level of consciousness, chest pain, shortness of breath, thread pulse, SBP less than 90.


Further review of the nurse progress notes showed that on 08/08/2015 at 18:27 PM SP #1 daughter approached me, upset, saying no one has done anything for her dad at her request a call was placed to both the nephrologist and the attending physician. At 18:47 PM a " Code Rescue " was called and the (Advanced Registered Nurse Practitioner) ARNP came to evaluate the patient. SP#1 was hypotensive and with altered mental status. IV NS fluid bolus was given, MD-B was informed and aware, antibiotic (Levaquin) and Hespan was ordered. Despite the treatment and monitoring, SP#1 remained hypotensive at 83/46. AT 21:25 PM the intensivist came to see pt and talked to the family about pt ' s. Condition that is not improving and is unstable, for transfer to ICU as ordered. The family decided to place pt. on DNR 3 and was therefore kept on the orthopedic floor instead of ICU. SP#1 on 8/8/15 at 10:04pm expired, MD-B was made aware, the family was at the bedside.

Interview with Staff D on 6/23/16 at 11:00 AM revealed that Code rescues is called on change of pt. status, deteriorating, low blood pressure and patients not getting better after any intervention is given and still not improving. Registered Nurse, Charge nurse, and CP(Clinical Partner) can call for code rescue. Code rescue is called if pt. is deteriorating, change of mental status, also based on multiple criteria or even when RN feels uncomfortable with the pt. condition. There is criteria that is followed.

Interview with Staff B on 6/22/16 at 2:35 PM revealed a nurse practitioner is available on the floor to report and also calls to the (medical doctor) MD for change in condition. Code Rescues are called for changes in BP or vital signs that are symptomatic, a change in level of consciousness, or change in baseline status. On 6/23/16 around 1:00 PM interviewed Staff B again who stated was working as a Resource Registered Nurse on 08/08/15 when she was called by the daughter of SP#1 almost at the change of shift angry and upset; around 6:45 PM to 6:50 PM. The daughter was concerned that the father or SP#1 was not better. Staff B also stated saw the patient and called a code rescue because the patient was pale looking. Code rescue was responded by the ARNP (nurse practitioner) and started the process. Code rescues are generally called for changes in condition or deterioration.

4.Observation of SP #4 blood transfusion on 06/23/16 at 3:07 PM was conducted. Review of SP #4 record showed one unit of packed red blood cells (PRBC) was already administered to SP#4 on 06/21/16. Review of the "Authorization for Blood Transfusion of Blood and Blood Derivatives " showed SP#4 signature dated 06/21/16 at 21:00 PM, but it did not show a mark on either of the 2 options that she:
1. Authorized the transfusion of blood or blood derivatives or
2. Refused the transfusion of blood or blood derivatives.
Staff A, the Unit Manager, the Accreditation Specialist, and Chief Nursing Officer recognized the incomplete consent form.

Interview with the Manager of the Nursing Practice on 6/24/16 at 2:10pm revealed that prior to blood transfusion, 2 nurse performs verification of consent, orders, and go through the policy of correct blood administration.

Review of Policy Title: "Blood/Blood Component Requisition, Specimen Collection, Issuing and Administration-Adult and Pediatric Patient" (revised 08/05/2014) showed that for consent for transfusion, the Authorization for Transfusion of Blood or Blood Derivatives form (BHM) Form 1761 must be signed, and dated by the patient or the health care surrogate prior to administering blood/ blood components.

Based on record review and interview the facility failed to follow its policy for physician notification when not administering medications in one of eleven sample patient (SP)# 1.

The findings included:

Review of sample patient (SP) #1 Medication Administration Record and Nurse Progress notes revealed that the physician was not notified of the medications not being administered on the following dates and times:

The Metoprolol 25 mg by mouth twice daily was not administered on the following days:
On 08/5/15 at 10:00 PM Reason HR=56
On 08/6/15 at 10:00 PM Reason BP 97/54, Pulse 84
On 08/7/15 at 10:00 AM Reason BP 95/53, Pulse 73

Review of the Policy No BCH-733.10 title Medication Prescribing and Ordering Guidelines revealed that Procedures to Ensure Compliance (04/12) #2.c.ii. Hold Orders may be temporarily held if nursing judgement indicates a problem with dosage, adverse drug reactions, or other reasons, until the attending physician can be contacted. The facility failed to adhere to its policy on Medication Prescribing and Ordering Guidelines.

Interview with the Manager regarding the nursing practice on 06/24/16 at 2:10 PM revealed that for medication administration, the nurse may hold medications and call the doctor to obtain orders for parameters.

Based on observation, interview, and record review, the facility failed to follow the standards of practice and its related policy and procedure in obtaining authorization for transfusion of blood or blood derivatives for one of eleven sampled patients (SP #4).
The findings included:
Observation of SP #4 blood transfusion on 06/23/16 at 3:07 PM was conducted. Review of SP #4 record showed one unit of packed red blood cells (PRBC) was already administered to SP#4 on 06/21/16. Review of the "Authorization for Blood Transfusion of Blood and Blood Derivatives " showed SP#4 signature dated 06/21/16 at 21:00 PM, but it did not show a mark on either of the 2 options that she:
1. Authorized the transfusion of blood or blood derivatives or
2. Refused the transfusion of blood or blood derivatives.
Staff A, the Unit Manager, the Accreditation Specialist, and Chief Nursing Officer recognized the incomplete consent form.

Interview with the Manager of Nursing Practice on 6/24/16 at 2:10pm revealed that prior to blood transfusion, 2 nurses perform verification of consent, orders, and go through the policy of correct blood administration.

Review of Policy Title: "Blood/Blood Component Requisition, Specimen Collection, Issuing and Administration-Adult and Pediatric Patient" (revised 08/05/2014) showed that for consent for transfusion, the Authorization for Transfusion of Blood or Blood Derivatives form (BHM) Form 1761 must be signed, and dated by the patient or the health care surrogate prior to administering blood/ blood components.