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Based on medical record review, and staff interview, the facility failed to ensure a registered nurse must evaluate the nursing care (A395).

Based on medical record review, and staff interview, the facility failed to ensure a registered nurse must evaluate the nursing care for one of 20 patients reviewed (Patient #5). The hospital census was 4.

Findings include:

Review of the medical record of Patient #5 revealed the patient was transported via ambulance to the emergency department (ED) on 10/21/23 at 3:02 AM. A triage note stated the patient and friends were found unresponsive and drug use was suspected. Review of the emergency medical services (EMS) run sheet revealed the patient was medicated with Narcan five times, at 2:27 AM, 2:29 AM, 2:38 AM, 2:52 AM, and 2:54 AM, enroute to the hospital. An EMS crew member stated in a progress note that the patient had agonal respirations when they arrived. An unsuccessful attempt to intubate the patient was made by EMS crew members as the patient's jaws were noted to be clenched shut. Bag mask ventilation was performed by the EMS crew until arrival at the hospital. The patient remained unresponsive.

Upon arrival to the ED, staff placed a 20 gauge intravenous (IV) line in the patient's left antecubital. At 3:05 AM, the ED timeline revealed the patient remained unresponsive to verbal or painful stimuli. The patient was medicated with Etomidate (a short acting intravenous anesthetic agent used for the induction of general anesthesia) 30 milligrams (mg) intravenously. Rocuronium (anesthetic medication used to relax muscles) 100 mg was administered by an ED staff registered nurse two minutes later, at 3:07 AM. The ED timeline further revealed the ED physician successfully intubated the patient at at 3:10 AM.

At 3:13 AM, the ED physician placed orders for 0.9 % sodium chloride 1000 milliliter (mL) bolus, serum tox screen, urine drug screen, basic metabolic panel, arterial blood gas, complete blood count with differential, indwelling catheter, a computed tomography (CT) scan of the head, and an standard 12 lead electrocardiogram (EKG). At 3:14 AM, a portable stat chest xray confirmed the location of the endotracheal tube was appropriate. The CT scan of the head without contrast was also started at 3:14 AM. The ordered laboratory tests were drawn at 3:21 AM. A respiratory therapist placed the patient on a ventilator at 3:21 AM.

At 3:23 AM, a note to the system wide transfer control center stated the ED physician called from the hospital to arrange a transfer of the patient the intensive care unit (ICU) on main campus.

The indwelling catheter was placed at 3:30 AM. The Medication Administration Record (MAR) revealed the 0.9 % sodium chloride bolus was initiated at 3:37 AM. At 3:51 AM, laboratory results revealed a pH of 6.85 with the reference range being 7.35 - 7.45. At 3:51 AM, the ED physician ordered for nursing staff to monitor vital signs every 15 minutes. Vital signs were assessed at 4:37 AM and 5:10 AM. The patient's pulse was 82 beats per minute, respirations 16 beats per minute, and blood pressure 116/69 at 4:37 AM.

At 4:31 AM a second note to the system wide transfer control center stated the hospital was considering transfer of the patient to an out of network hospital. At 4:38 AM a third note to the system wide transfer control center stated the ED physician stated the family was "adamant" that the patient be transferred out of network to a tertiary facility for further care. By 5:06 AM, arrangements had been made for the patient to be transferred to an out of network tertiary facility as requested by the family. The note revealed report was given to an ICU physician at the tertiary facility.

The ED physician informed the ICU physician at the outside hospital that the patient's pupils were fixed and dilated and decorticate posturing (an abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight) was observed.

At 5:10 AM the patient's pulse was 85 beats per minute, respirations 17 beats per minute, blood pressure 90/61, and oxygen saturation 100%.

At 6:03 AM a cardiac assessment revealed the patient's skin color was dusky and pale and his skin temperature was cool. The patient was discharged from the facility.

The medical record lacked documentation the patient's temperature was assessed while in the Emergency Department.

Staff G was interviewed on 12/14/23 at 5:05 PM. It was confirmed that the medical record lacked documentation vital signs were assessed every 15 minutes as ordered. It was also confirmed that the medical record lacked documentation the patient's temperature was taken.

Review of the outside medical record revealed the patient was admitted to the ICU at 6:17 AM. The patient's temperature at 6:21 AM was 93.6 degrees Fahrenheit. A nurse's note stated a bair hugger (system consisting of a reusable warming unit and single-use disposable warming blankets used to maintain a patient's core body temperature) was applied to maintain the patient's temperature. By 9:00 AM, the patient's temperature was 96.1 degrees Fahrenheit. At 10:43 AM, the flowsheet revealed the patient was arousable, making eye contact, and following commands.

This deficiency represents non-compliance investigated under Substantial Allegation OH00147966.