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NORTHEASTERN VERMONT REGIONAL HOSPITAL 1315 HOSPITAL DRIVE SAINT JOHNSBURY, VT 05819 Aug. 28, 2013
VIOLATION: EMERGENCY SERVICES Tag No: C0200
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on patient and staff interviews and record review the facility failed to conduct assessments to identify the reason for low oxygen saturation (O2 sat) levels, requiring the use of supplemental oxygen, and failed to conduct ongoing assessment of the patient's O2 sats thereby failing to assure appropriate oxygenation status of Patient #1, who presented to the Emergency Department (ED) on two separate occasions within a 12 hour period, prior to discharge from each ED visit. Findings include:
Per record review Patient #1 had a history of a neurologic disorder for which s/he received medications, including; Valium 30 - 50 mg per day (to control muscle spasms), Scopolamine Transdermal patch (to treat nausea), Promethazine (for chronic nausea), and diphenhydramine (used to control abnormal movements), all of which included drowsiness as a side effect; as well as multiple other drugs. The patient underwent a surgical procedure of the right knee on 7/29/31 and was discharged home following the procedure with a prescription for Dilaudid (Narcotic pain medication - can also cause drowsiness) every 4 hours as needed for pain relief.
Patient #1 presented to the ED at 5:09 PM on the evening of 7/31/13 via ambulance with a chief complaint, identified in the ED physician note, as somnolence and fatigue. An EMS report, dated 7/31/13, indicated the ambulance had been dispatched for Patient #1 because of low O2 sats post surgery. The note stated that a visiting nurse and rescue personnel were at the patient's home on the ambulance's arrival; the patient's O2 sat had been reported by rescue members as 89%, and supplemental O2 was initiated at 3L per minute via nasal cannula (NC). Patient #1 was lethargic with slurred speech and complaining of weakness and nausea and his/her temperature was 100.1. The report further indicated the patient reported regular use of Dilaudid, 2 mg by mouth (PO) every 4 hours since his/her surgery 2 days prior, in addition to the use of all other meds. A nursing triage assessment, at 5:09 PM on 7/31/13, noted the patient's recent knee surgery and stated, "groggy today, with a fever, low saO2 per EMS.....pt with slurred words". The record indicated Patient #1's O2 sat was 93% on 3L O2 via NC at the time of triage. A subsequent O2 sat of 95% on 2L of O2 via NC was documented at 7:15 PM and there is no evidence of any further assessment of the patient's O2 saturation level (both with and without the use of oxygen) prior to discharge home. Per Physician #1 ' s (ED Attending physician) note, the diagnosis was identified as UTI (Urinary Tract Infection) and fatigue. Despite the fact that Physician #1 noted, in the Discharge Plan/Instructions, that Patient #1 seemed to be over sedated, and recommended s/he take only as much of the Dilaudid as really needed, and despite the patient's obvious use of supplemental oxygen while in the ED there was no evidence that the patient's low O2 sat had been addressed by Physician #1, and the patient was discharged home, at 7:31 PM, with a prescription for an antibiotic to treat the UTI.
Patient #1 returned to the ED via ambulance 10 hours later, at 5:13 AM on 8/1/13 with a chief complaint of headache and nausea. The EMS report stated that rescue personnel reported an O2 sat of 90% and O2 was initiated at 3L via NC by EMS prior to transport to the hospital. The patient was complaining of nausea and headache and reported to EMS personnel that s/he had not taken the routine Phenergan for the chronic nausea as s/he had been instructed in the ED the previous evening not to take medications because of the over sedation s/he had experienced. The patient's ED nursing admission assessment, at 5:19 AM, indicated an O2 sat of 90% on room air. A subsequent oxygen assessment note, at 5:54 AM, stated "pt arrives on 2L nc via EMS, O2 sat on ra 90%, pt left on 2L nc". There is no further assessment of the patient's O2 saturation prior to discharge home. The patient was seen again by Physician #1 whose note indicates the patient seemed a little more alert than when s/he had been in the ED the evening prior. The note stated Patient #1 received a single dose of Phenergan IM and showed enough improvement to be discharged home. Again, despite the use of supplemental oxygen for what had been identified as low O2 sats, there is no evidence the issue was addressed by the physician during the ED visit, and the patient was discharged home, without supplemental oxygen, at 6:41 AM on 8/1/13.
Per interview, at 7:09 PM on 8/26/13, Patient #1 stated concern regarding the failure of ED staff to address the low oxygen saturation levels during the two ED visits on 7/31/13 and 8/1/13, respectively. The patient stated that during the time of the ED visits, s/he was extremely groggy and cannot recall all the specifics of the visits, however the patient stated that family members present during some portions of the events were concerned that the patient ' s condition had not been fully addressed. Following return home from the second ED visit Patient #1 ' s family members transported him/her to a second health care facility for evaluation, because they felt the patient ' s condition had not improved.
Per review of records the patient was seen in the ED at Hospital #2 at 1:22 PM on 8/1/13. The record indicated the patient was and alert to person, place and time and appeared distressed on presentation to the ED. Further notes identified the patient as extremely dehydrated, with a headache, likely due to dehydration. The plan was to hydrate, discontinue the Dilaudid, and switch to oxycodone. A nursing note at 7:12 PM on 8/1/13 indicated O2 had been initiated at 3 L due to pulse oximetry reading of 78-84% on room air. The note stated the patient was very sleepy, but aroused by voice. A subsequent nurse's note, at 10:16 PM, indicated a decision was made to admit Patient #1 due to O2 sats of 90% on room air. The Discharge Summary stated; "Unable to obtain more history due to somnolence. Complicated pt with [neurologic disorder] treated with large doses of benzos and other meds. S/P arthroscopic surgery started using Dilaudid. Pt admitted for over sedation from diazepam and Dilaudid - during stay oxycodone and Dilaudid d/c (discontinued) and somnolence improved." discharged [DATE].
Per interview, at 3 on 8/27/13, RN #1, who provided direct care for Patient #1 during her ED visit on 7/31/13, confirmed that there was no evidence O2 sats were obtained from the patient on room air prior to the patient's discharge on both visits and that there was no evidence that the patient was discharged home with supplemental oxygen. S/he stated s/he was not aware of any P&P (policies & procedures) regarding specific parameters related to reassessments of oxygen saturation status. RN #1 stated s/he thought reassessment should be done at the nurse's discretion, anytime there is a change in the patient's condition. However, s/he stated that, as a standard of practice, all patients receiving supplemental O2 should always have O2 sat checked while on room air prior to discharge. The CNO (Chief Nursing Officer) and the Director of Quality Programs, both confirmed, during interview at 4:20 PM on 8/27/13, the lack of specific nursing P&P regarding reassessment of oxygen saturations and both agreed O2 sats should have been assessed without use of oxygen prior to the patient's discharge.
During telephone interview, at 6:39 PM on 8/27/13, Physician #1 confirmed there was no evidence in Patient #1's medical record that the low O2 sats had been addressed prior to discharge on either of the patient's two ED visits, for which s/he was the Attending physician.
VIOLATION: NURSING SERVICES - SUPERVISION OF CARE Tag No: C0296
Based on patient and staff interviews and record review nursing staff failed to conduct ongoing reassessment of the oxygen needs of one patient for whom supplemental oxygen was provided during treatment in the Emergency Department. Findings include:

Patient #1 presented to the ED at 5:09 PM on the evening of 7/31/13 via ambulance with a chief complaint, identified in the ED physician note, as somnolence and fatigue. An EMS report, dated 7/31/13, indicated the ambulance had been dispatched for Patient #1 because of low oxygen saturation (O2 sat) post surgery. The note stated that a visiting nurse and rescue personnel were at the patient's home on the ambulance's arrival; the patient's O2 sat had been reported by rescue members as 89%, and O2 was initiated at 3L per minute via nasal cannula (NC). Patient #1 was lethargic with slurred speech and complaining of weakness and nausea and his/her temperature was 100.1. The report further indicated the patient reported regular use of Dilaudid, 2 mg by mouth (PO) every 4 hours since his/her surgery 2 days prior, in addition to the use of all other routine medications, including valium. A nursing triage assessment, at 5:09 PM on 7/31/13, noted the patient's recent knee surgery and stated, "groggy today, with a fever, low saO2 per EMS.....pt with slurred words". The record indicated Patient #1's O2 sat was 93% on 3L O2 via NC at the time of triage. A subsequent O2 sat of 95% on 2L of O2 via NC was documented at 7:15 PM and there is no evidence of any further assessment of the patient's O2 saturation level prior to discharge home.
Patient #1 returned to the ED via ambulance 10 hours later, at 5:13 AM on 8/1/13 with a chief complaint of headache and nausea. The EMS report stated that rescue personnel reported an O2 sat of 90% and O2 was initiated at 3L via NC by EMS prior to transport to the hospital. The patient was complaining of nausea and headache and reported to EMS personnel that s/he had not taken the routine Phenergan for the chronic nausea as s/he had been instructed in the ED the previous evening not to take medications because of the over sedation s/he had experienced. The patient's ED nursing admission assessment, at 5:19 AM, indicated an O2 sat of 90% on room air. A subsequent oxygen assessment note, at 5:54 AM, stated "pt arrives on 2L nc via EMS, O2 sat on ra 90%, pt left on 2L nc". There is no further assessment of the patient's O2 saturation prior to discharge home. The ED physician note stated that Patient #1 received a single dose of Phenergan IM and showed enough improvement to be discharged home. Again, despite the use of supplemental oxygen for what had been identified as low O2 sats, there is no evidence the issue was addressed by the physician during the ED visit, and the patient was discharged home, without supplemental oxygen, at 6:41 AM on 8/1/13.
Per interview, at 7:09 PM on 8/26/13, Patient #1 stated concern regarding the failure of ED staff to address the low oxygen saturation levels during the two ED visits on 7/31/13 and 8/1/13, respectively. The patient stated that during the time of the ED visits, s/he was extremely groggy and cannot recall all the specifics of the visits, however the patient stated that family members present during some portions of the events were concerned that the patient's condition had not been fully addressed.
Per review of records the patient was seen in the ED at Hospital #2 at 1:22 PM on 8/1/13. The record indicated the patient O2 had been initiated at 3 L due to pulse oximetry reading of 78-84% on room air and the patient was subsequently admitted due to O2 sats of 90% on room air.
Per interview, at 3 on 8/27/13, RN #1, who provided direct care for Patient #1 during his/her ED visit on 7/31/13, confirmed that there was no evidence O2 sats were obtained from the patient on room air prior to the patient's discharge on both visits and that there was no evidence that the patient was discharged home with supplemental oxygen. S/he stated s/he was not aware of any P&P (policies & procedures) regarding specific parameters related to reassessments of oxygen saturation status. RN #1 stated s/he thought reassessment should be done at the nurse's discretion, anytime there is a change in the patient's condition. However, she stated that, as a standard of practice, all patients receiving supplemental O2 should always have O2 sat checked while on room air prior to discharge. The CNO (Chief Nursing Officer) and the Director of Quality Programs, both confirmed, during interview at 4:20 PM on 8/27/13, the lack of specific nursing P&P regarding reassessment of oxygen saturations, and both agreed that reassessment of oxygen saturation status should have been conducted, without oxygen, prior to the patient's discharge.
VIOLATION: QUALITY ASSURANCE Tag No: C0337
Based on patient and staff interview and record review the facility failed to evaluate, in a timely manner, the quality of care and services provided to one patient who voiced concerns about their care. Findings include:

Per record review Patient #1 had a history of a neurologic disorder for which s/he received multiple medications whose side effects included drowsiness. The patient presented to the ED (Emergency Department) at 5:09 PM on the evening of 7/31/13 via ambulance with a chief complaint, identified in the ED physician note, as somnolence and fatigue. An EMS report, dated 7/31/13, indicated the ambulance had been dispatched for Patient #1 because of low O2 sats post surgery. The note stated that a visiting nurse and rescue personnel were at the patient's home on the ambulance's arrival; the patient's O2 sat had been reported by rescue members as 89%, and supplemental O2 was initiated at 3L per minute via nasal cannula (NC). Patient #1 was lethargic with slurred speech and complaining of weakness and nausea and his/her temperature was 100.1. A nursing triage assessment, at 5:09 PM on 7/31/13, noted the patient's recent knee surgery and stated, "groggy today, with a fever, low saO2 per EMS.....pt with slurred words". The record indicated Patient #1's O2 sat was 93% on 3L O2 via NC at the time of triage. A subsequent O2 sat of 95% on 2L of O2 via NC was documented at 7:15 PM and there is no evidence of any further assessment of the patient's O2 saturation level (both with and without the use of oxygen) prior to discharge home. Per Physician #1 ' s (ED Attending physician) note, the diagnosis was identified as UTI (Urinary Tract Infection) and fatigue. Despite the fact that Physician #1 noted, in the Discharge Plan/Instructions, that Patient #1 seemed to be over sedated, and recommended s/he take only as much of the Dilaudid as really needed, and despite the patient's obvious use of supplemental oxygen while in the ED there was no evidence that the patient's low O2 sat had been addressed by Physician #1, and the patient was discharged home, at 7:31 PM.
Patient #1 returned to the ED via ambulance 10 hours later, at 5:13 AM on 8/1/13 with a chief complaint of headache and nausea. The EMS report stated that rescue personnel reported an O2 sat of 90% and O2 was initiated at 3L via NC by EMS prior to transport to the hospital. The patient was complaining of nausea and headache and reported to EMS personnel that s/he had not taken the routine Phenergan for the chronic nausea as s/he had been instructed in the ED the previous evening not to take medications because of the over sedation s/he had experienced. The patient's ED nursing admission assessment, at 5:19 AM, indicated an O2 sat of 90% on room air. A subsequent oxygen assessment note, at 5:54 AM, stated "pt arrives on 2L nc via EMS, O2 sat on ra 90%, pt left on 2L nc". There is no further assessment of the patient's O2 saturation prior to discharge home. The patient was seen again by Physician #1 whose note indicated the patient seemed a little more alert than when s/he had been in the ED the evening prior. The note stated Patient #1 received a single dose of Phenergan IM and showed enough improvement to be discharged home. Again, despite the use of supplemental oxygen for what had been identified as low O2 sats, there is no evidence the issue was addressed by the physician during the ED visit, and the patient was discharged home, without supplemental oxygen, at 6:41 AM on 8/1/13.
Per interview, at 7:09 PM on 8/26/13, Patient #1 stated concern regarding the failure of ED staff to address the low oxygen saturation levels during the two ED visits on 7/31/13 and 8/1/13, respectively. The patient stated that during the time of the ED visits, s/he was extremely groggy and cannot recall all the specifics of the visits, however the patient stated that family members present during some portions of the events were concerned that the patient's condition had not been fully addressed. The patient stated s/he subsequently sought care at another hospital where s/he was admitted . S/he further stated s/he had expressed his/her concerns regarding lack of care in the ED at NVRH to the VP of Quality Programs there on 8/7/13 and had further expressed a desire to file a formal complaint regarding the issue.
Per review of records the patient was seen in the ED at Hospital #2 at 1:22 PM on 8/1/13. The record indicated the patient was and alert to person, place and time and appeared distressed on presentation to the ED. Further notes indicated O2 had been initiated at 3 L due to pulse oximetry reading of 78-84% on room air and the patient was admitted at 10:16 PM, due to O2 sats of 90% on room air.
The failure to conduct reassessment of Patient #1's O2 sats, both with and without use of supplemental oxygen, on both visits to the ED, was confirmed by the RN providing direct care during one ED visit, the ED Physician who provided care during both ED visits, the CNO (Chief Nursing Officer) and the VP of Quality Programs during separate interviews on 8/26/13 and 8/27/13.
Per interview, at 7:31 AM on 8/27/13, the VP for Quality Programs confirmed that Patient #1 had verbalized concerns, on or about 8/7/13, about the care provided to him/her during ED visits on 7/31/13 and 8/1/13 and that the patient had later called to request the issue be considered a formal complaint. The VP of Quality further confirmed that although s/he had reviewed the patient's record there had been no further evaluation, to date, by anyone regarding the issue. S/he stated neither the ED physician involved in the case, the ED Medical Director, nor the physician responsible for assessing quality had been made aware of the case as of the date of survey.