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Based upon record review and interview, the hospital failed to ensure 1 of 5 patients (#1) received care and services in a manner to prevent physical harm and failed to ensure the effective implementation of an internal investigation with corrective action regarding an incident involving Patient #1 in which the patient had a rubber tourniquet on his arm for a 24 hour period.
Findings:

Interview with S3RN/Patient Safety Officer and S4RN/Quality Assurance Coordinator on 08/15/16 at 2:10 p.m. revealed incidents and/or accidents occurring in the hospital were entered into a computer system called Quantros. S3RN/Patient Safety Officer stated that the occurrence would then be forwarded on to the Patient Care Coordinator of the specific unit for investigation. If the incident caused permanent injury or harm, then a sentinel event along with a root cause analysis would be implemented.

Review of the Quantros Reports revealed on 06/29/16 an incident occurred where a tourniquet was left in place on Patient #1's left upper arm. Further review of the report revealed "Nurse at bedside to pause IV so blood draw could be drawn. B/P (Blood Pressure) cuff was removed and a tourniquet was discovered in place to the left upper arm. Patient had only received routine labs day prior and was done by lab. Patient is not a nurse draw. Nurse questioned lab who states 'looks like it has been there a long time' Tourniquet was removed, skin indented and red. IV going since surgery to left hand. Had Versed and Fentanyl infusion going. Skin later that day, about 12 noon, blistering. Patient was transferred to the step-down unit, started wound care and notified MD."

Review of the medical record for Patient #1 revealed on 06/27/16 the patient underwent a Transoral Robotic Uvulopalatopharyngoplasty with a base of tongue reduction, and an Open Septoplasty. Post-Operatively the patient was admitted to the Intensive Care Unit on a ventilator and sedated with a Versed, Fentanyl, and Diprovan intravenous infusions. On 06/28/16 at 5:00 a.m. S13Phlebotomist drew blood on the patient.

On 06/29/16 at 4:30 a.m. S13Phlebotomist returned to draw another blood sample and when the blood pressure cuff was removed, found that the tourniquet from the 06/28/16 blood draw was still on the patient's left upper arm. Interview with S13Phlebotomist on 08/17/16 at 8:00 a.m. revealed the Registered Nurse was in the room and when she told her the tourniquet had been on the patient's arm since the day prior, the nurse just replied "oh". When questioned about the blood pressure cuff on the 06/28/16 a.m. blood draw, S13Phlebotomist replied after she drew the blood sample she replaced the blood pressure cuff back on the patient's arm not realizing she had left the tourniquet on.

Review of the Intensive Care Unit Nursing Notes dated 06/28/16 timed 7:50 a.m. (7:00 a.m.-7:00 p.m. shift) revealed S14RN documented a shift assessment was conducted and according to the Standards Of Care Checklist Critical Care Record S14RN initialed she turned the patient and performed Range of Motion every two hours. At 6:45 p.m. S14RN documented a patient report was given to the on-coming nurse.

On 06/28/16 from 6:45 p.m. to 7:25 p.m. S15RN documented an initial shift assessment was completed. At 1:00 a.m. S15RN documented the patient was given a bath with linens changed. Review of the form titled Standards of Care Checklist Critical Care Record revealed S15RN documented she repositioned and performed Range of Motion on the patient every two hours. At 4:30 a.m. on 06/29/16, S15RN documented "Phlebotomist at bedside for lab draw, failed to get sample."

Further review of Patient #1's medical record revealed the Registered Nurse failed to document an assessment of the patient's left upper extremity after the tourniquet was removed even though by 12:00 p.m. blisters had appeared.

Interview with S12RN/Patient Care Coordinator of Critical Care on 8/15/16 at 3:00 p.m. revealed when asked if she had reviewed the incident that had occurred involving Patient #1, she replied she reviewed the Quantros report and had an inservice with the Intensive Care Unit nursing staff. When asked if she had investigated the incident to ascertain how two Intensive Care Unit Registered Nurses could conduct shift assessments, turn the patient every two hours and perform Range of Motion, and also give the patient a bath along with changing linens without identifying there was a tourniquet on the patient's arm, S12RN confirmed the incident was not reviewed to identify inadequate patient assessments.

Interview on 08/15/16 at 11:00 a.m. with Intensive Care Unit S9RN revealed when asked about the initial nursing shift assessment, S9RN replied that included a "head to toe" patient assessment.

Interview with S3RN/Patient Safety Officer on 08/16/16 at 2:30 p.m. revealed when asked if the incident involving Patient #1 was considered a sentinel event, she replied "no" because the incident did not cause an extended hospital stay.

Based upon record review and interview, the Registered Nurse failed to supervise and evaluate the nursing care of each patient as evidenced by failing to complete a comprehensive nursing assessment of 1 of 5 patients in the Intensive Care Unit (Patient #1) that included the identification and appropriate nursing interventions relative to a tourniquet that was left on the patient's left upper forearm for a 24 hour period.
Findings:

Interview with S3RN/Patient Safety Officer and S4RN/Quality Assurance Coordinator on 08/15/16 at 2:10 p.m. revealed incidents and/or accidents occurring in the hospital were entered into a computer system called Quantros.

Review of the Quantros Reports revealed on 06/29/16 an incident occurred where a tourniquet was left in place on Patient #1's left upper arm. Further review of the report revealed "Nurse at bedside to pause IV so blood draw could be drawn. B/P (Blood Pressure) cuff was removed and a tourniquet was discovered in place to the left upper arm. Patient had only received routine labs day prior and was done by lab. Patient is not a nurse draw. Nurse questioned lab who states 'looks like it has been there a long time' Tourniquet was removed, skin indented and red. IV going since surgery to left hand. Had Versed and Fentanyl infusion going. Skin later that day, about 12 noon, blistering. Patient was transferred to the step-down unit, started wound care and notified MD."

Review of the medical record for Patient #1 revealed on 06/27/16 the patient underwent a Transoral Robotic Uvulopalatopharyngoplasty with a base of tongue reduction, and an Open Septoplasty. Post-Operatively the patient was admitted to the Intensive Care Unit on a ventilator and sedated with Versed, Fentanyl, and Diprovan intravenous infusions. On 06/28/16 at 5:00 a.m., S13Phlebotomist drew blood on the patient.

On 06/29/16 at 4:30 a.m., S13Phlebotomist returned to draw another blood sample on Patient #1. Interview with S13Phlebotomist on 08/17/16 at 8:00 a.m. revealed when she went to do the morning blood sample draw on 06/29/16 she removed the blood pressure cuff from the patient's left upper arm and noticed the tourniquet from the blood draw on 6/28/16 at 5:00 a.m. was still on the patient's left upper arm. S13Phlebotomist further stated the Registered Nurse was in the room and when she told her the tourniquet had been on the patient's arm since the day prior, the nurse just replied "oh". S13Phlebotomist said that she was unable to obtain a blood sample and returned to the laboratory department and notified her supervisor that the tourniquet had been on Patient #1's arm for 24 hours. When questioned about the blood pressure cuff on the 06/28/16 a.m. blood draw, S13Phlebotomist replied after she drew the blood sample she replaced the blood pressure cuff back on on the patient's arm not realizing she had left the tourniquet on.

Review of the Intensive Care Unit Nursing Notes dated 06/28/16 timed 7:50 a.m. revealed S14RN documented "AM reassessment completed. Pt (Patient) lying in bed sedated on vent (ventilator). Grimaces and withdraws to pain. SR (Sinus Rhythm) on CM (Cardiac Monitor). ETT (EndoTrachael Tube) secured to lip...PIV (Peripheral Intravenous) to R (Right) hand, R (Right) arm, and L (Left) wrist with IV (Intravenous) fluids and meds (medications) infusing without complications..." Review of the form titled Standards Of Care Checklist Critical Care Record revealed S14RN initialed that she turned the patient and performed Range of Motion every two hours. At 6:45 p.m. S14RN documented a patient report was given to the on-coming nurse.

On 06/28/16 from 6:45 p.m. to 7:25 p.m. S15RN documented the shift assessment was completed and identified the left hand IV dressing was clean, dry and intact with no redness or infiltration noted. Review of the form titled Standards of Care Checklist Critical Care Record revealed S15RN initialed she repositioned and performed Range of Motion on the patient every two hours and at 1:00 a.m. gave the patient a bath and changed the bed linens. At 4:30 a.m. on 06/29/16, S15RN documented "Phlebotomist at bedside for lab draw, failed to get sample."

Further review of the Intensive Care Unit RN notes revealed there was no documentation related to an assessment of Patient #1's left arm.

According to interview with S13Phlebotomist the 4:30 a.m. lab draw on 06/29/16 was when the tourniquet was found on the patient's upper arm and the RN was present in the room during this time. There failed to be documented evidence S15RN assessed the patient's left upper arm after the tourniquet was removed or that the physician was notified.

Interview on 08/16/16 at 11:00 a.m. with S9RN revealed when asked about the initial shift assessment, S9RN replied that included a "head to toe" patient assessment.

Interviews on 08/16/16 at 9:30 a.m. 10:45 a.m. and 11:25 a.m. with S5Physician, S6Physician and S7Physician respectively revealed the physicians were not notified of the tourniquet being left on Patient #1 or of the blisters on the patient's arm. S6Physician further stated he found out about the incident from the patient.

Review of the nursing policy titled Nursing Process Implementation, revised 10/2015 revealed: 3) Implementation: a) Patient care is provided and documented in a safe and timely manner; b) Documentation should include all pertinent data in the patient's care, including but not limited to: i) changes in the patient condition, ii) vital signs, iii) intake and output, iv) medications and treatments, v) patient's response, teaching, physical and emotional assessment and care. and 4) Evaluate: a) Evaluation of the patient is done on a continual basis through assessment; b) Plan of Care, discharge needs, and leaning needs are evaluated and address daily; c) Response to care is assessed and documented.

Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed and kept current a comprehensive nursing care plan for each patient as evidenced by failing to individualize patient's nursing care plans to include all the patient's medical diagnoses for which the patients were being treated for 3 (#1, #3, #5) of 5 patient medical records reviewed out of a sample of 5 patient medical records reviewed for nursing care plans.
Findings:

A review of the hospital policy titled "Nursing Process Implementation " presented by S2CNO as being current (10/2015) revealed in part: Planning: The Plan of Care is individualized based on the assessed needs and condition of the patient and family. 1) Evaluation and revisions of the Plan of Care are done as indicated by the patient condition and needs on a daily basis. Implementation: b) Documentation should include all pertinent data in the patient's care, including but not limited to: 1) changes in patient condition. Evaluate: a) Evaluation of the patient is done on a continual basis through assessment.

Patient #1
Review of the medical record for Patient #1 revealed on 06/28/16, the patient sustained blisters to the left upper arm due to a tourniquet. Review of the nursing care plan revealed there failed to be documented evidence the Registered Nurse updated the plan to reflect the skin breakdown and the treatment ordered by the physician. Interview with S9Registered Nurse on 08/16/16/3:30 p.m. confirmed the care plan failed to be updated when the patient's condition changed.


Patient #3
Review of the medical record for Patient #3 revealed she had been admitted to the hospital on 08/15/16 with the diagnoses of Respiratory Distress, COPD acute exacerbation, CHF. A review of the patient's nursing care plan revealed a Supplemental Comprehensive Critical Care Plan for Impairment of skin integrity, Alteration in nutrition, Potential for Infection, Potential for injury related to DVT and Alteration in Comfort. Further review of the patient's nursing care plan revealed no documented evidence that a plan of care was implemented for Respiratory Distress, COPD, and CHF.

Patient #5
Review of the medical record for Patient #5 revealed he had been admitted to the hospital on 08/10/16 with the diagnoses of Respiratory Distress, PAD, ESRD (HD), Neuropathy, Cardiomyopathy. A review of the patient's nursing care plan revealed a Supplemental Comprehensive Critical Care Plan for Impairment of skin integrity, Alteration in nutrition, Potential for Infection, Potential for injury related to DVTs and falls, and Alteration in Comfort, Neuropathic pain related to PAD, Fluid volume excess related to ineffective renal function, Altered elimination related to fluid retention. Further review of the patient's nursing care plan revealed no documented evidence that a plan of care was implemented for Respiratory Distress.

In an interview on 08/17/16 at 8: 15 a.m., S8RN indicated after review of Patient #3's nursing care plan that there was no documented evidence that a plan of care was implemented for Respiratory Distress, COPD and CHF. S8RN further indicated after a review of Patient #5's nursing care plan that there was no documented evidence that a plan of care was implemented for Respiratory Distress.





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