The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

GEORGIANA MEDICAL CENTER 515 N MIRANDA AVENUE GEORGIANA, AL 36033 May 16, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
This condition is cited based on review of facility policy and procedure, medical record, incident report, Quality Assurance report, written statement of Medical Record (MR) # 5's roommate (MR # 1), observations and interviews with facility staff, it was determined the facility failed to ensure:

1. Patient grievances were investigated and documented.

2. Implement fall prevention interventions for MR # 5, who was assessed as a moderate risk for falls and sustained a fall.

3. The nursing staff followed the policy for assessment after a fall and reporting findings to the physician after MR # 5 sustained a fall.

4. The nursing staff followed the policy for implementation of post-fall prevention interventions after MR # 5 sustained the fall.

5. The facility staff followed the policy related to the investigation and provide recommendations/actions and follow up concerning MR # 5's fall and ensure this incident was reported to administration within 24 hours.

This had the potential to affect all patients served in this facility, including Medical Record (MR) # 5.

Findings include:


Refer to A119 and A144 for findings.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on review of facility policy and procedure, interview and review of medical record it was determined the facility failed to review, investigate and document a resolution to a patient grievance from a family member. This had the potential to affect all patients served by this facility.

Findings include:

Policy and Procedure: Patient Complaints/Grievances

Policy: "All patient complaints regarding treatment, service... will be forwarded to the Department Manager for investigation and appropriate response."

Procedure:
"A. Any complaint received from a patient while in the facility or after discharge will be forwarded to the Department Manager.

B. Complaints received via telephone will be transferred to the Department Manager.

C. Department Managers are responsible for 'on-the-spot' resolving of patient problems where possible and for notifying the Risk Manager and/or Administrator of complaints expressed to them or their staff.

D. The Risk Manager is responsible for following up on all patient complaints and feedback to the patient, Department Manager and Administration.

E. In the event the Risk Manager is not available, the Administrative Assistant shall assume this function.

F. Hospital Administration retains the responsibility for the final resolution of all patient complaints.

G. A record of the complaint, investigation, follow-up action and response to the patient will be kept using the 'Patient Complaint Documentation' form. This form is to be initiated by the Department Manager receiving the complaint, then forwarded to the Risk Manager."

Medical Record findings:

Medical Record (MR) # 5 was admitted to the facility 3/18/14 by way of the emergency room with complaint of nausea, vomiting, diarrhea and abdominal pain.

MR # 5 was pronounced dead on 3/19/14 at 6:05 AM.


A patient representative called the facility 3/20/14 to speak with a nurse regarding his mother and concerns he had regarding her care.


On 3/20/14 at 2:30 PM, Employee Identifier (EI) # 4, former Director of Nursing, and EI # 2, Assistant Director of Nursing/ Risk Manager, interviewed the roommate of MR # 5.

An interview was documented and a written statement was obtained from the roommate, these were found in the desk drawer of the former Director of Nursing, EI # 4 on 5/14/14 at 2:30 PM.


On 5/15/14 at 2:20 PM an interview was conducted with EI # 1, the Administrator, stated MR # 5's representative called on 3/20/14 and spoke with a Registered Nurse (RN) about MR # 5's care while being hospitalized at the facility. EI # 1 stated the RN would not divulge information regarding MR # 5's care and MR # 5's representative hung up the phone. At this point, EI # 4, the former DON began an investigation. EI # 1 was asked who should have followed up on the investigation EI # 4 failed to complete. EI # 1 stated the information would have gone to EI # 2, (Assistant Director of Nursing) and then to me, the Administrator. EI # 1 verified EI # 2 failed to follow up on the investigation even though she participated in the interview with the roommate on 3/20/14 and did not report any information to the Administrator, EI # 1.

A Patient Complaint Documentation form was not completed, an investigation was not completed and no resolution to concerns expressed was documented.


Summary: The facility failed to follow their own policy related to patient complaints/grievances in that; the facility staff failed to report MR # 5's representative's call related his concerns regarding the care of MR # 5. The facility failed to initiate a complaint/grievance report, nor was there an investigation conducted. The facility staff also failed to report to the Administrator MR # 5's representative's concerns about the care MR # 5 received at the hospital.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, incident report, Quality Assurance form and policy and procedure, Medical Record (MR) # 5's roommate (MR # 1) written statement, observation and interviews, it was determined the facility staff failed to:

1. Implement fall prevention interventions for MR # 5, who was assessed as a moderate risk for falls and sustained a fall.

2. Follow the policy for assessment after a fall and reporting findings to the physician after MR # 5 sustained a fall.

3. Follow the policy for implementation of post-fall prevention interventions after MR # 5 sustained the fall.

4. Follow the policy related to the investigation and provide recommendations/actions and follow up concerning MR # 5's fall and ensure this incident was reported to administration within 24 hours.


This had the potential to affect all patients served in this facility, including Medical Record (MR) # 5.


Findings include:

Policy and Procedure Manual
Fall Prevention Program
Date Written: April 2009

Purpose: The purpose of this program is to provide for safety and quality care for the patients of Georgiana Hospital, to assign responsibility and provide procedures for patients at risk for falls. To systematically assess fall risk factors, provide guidelines for fall preventive interventions, and provide instructions for after fall management.

Procedure: The fall risk assessment will be done and interventions will be taken in regards to the fall risk level. Fall precautions will be initiated on patients that are at moderate risk or high risk for falls...

Staff Responsibilities:

Charge Nurse:

... 2. Enforcing the responsibilities of the staff nurses to comply with interventions.
3. Ensuring that all nursing staff understands the importance of complying with the interventions.
... Admissions Nurses:

... 2. Notify the charge nurse of any patients assessed as moderate or high risk for falls.
3. Follow procedures for interventions related to patients that are moderate or high risk for falls...

All Staff:
1. Ensuring compliance of fall and fall-related injury interventions.
2. Ensuring a safe environment of care by conducting safety environmental assessments...


Post Fall Procedures/Management:

There are two key elements of the post fall procedures/management:

A. Initial Post Fall Assessment:

First priority is to assess the patient for any obvious injuries and find out what happened. The information needed is:

1. Date/time of fall.

2. Patient's description of fall (if possible).
a. What was patient trying to accomplish at the time of the fall ?
b. Where was the patient at the time of the fall (patient room, bathroom, hallway, etc.)?

3. Vital signs (temperature, pulse, respiration, blood pressure).

4. Patient Assessment:
a. Assess for injuries. Notify Physician.
b. Probable cause of the fall.
c. Co-morbid conditions (dementia, heart disease, neuropathy, etc.)
d. Risk factors (gait/balance disorders, weakness)
e. Fall Risk Assessment

5. Current medications (sedatives, narcotics, etc)

6. Other factors:
... b. Wearing correct footwear?...

... 8. Was treatment intervention plan being followed? If not, why not?

B. Documentation and Follow-up:
Following the post-fall assessment and any immediate measure to protect the patient:

1. A quality assurance report should be completed. This report should be forwarded to the Director of Nursing.

2. A detailed note should be entered into the patient's medical record including the results of the post-fall assessment.

3. Any orders received from the physician related to the fall.

4. Re-assess patient using the Fall Risk Assessment Form...

... 6. Initiate further interventions as needed for safety of the patient...


Interventions for Moderate or High Risk for Falls:

... 2. Non-slip or grip footwear...

... 5. Patient oriented to surrounding, including location of bathroom facilities, and/or instructions to call for assistance before getting out of bed...

... 11. Medication review if increased confusion/disorientation...

... 14. Comfort and toileting checks every 2 hours as indicated for patient...



Policy and Procedure Manual
Book II
Incident Reports/ QA (Quality Assurance) Report Form
Date revised: January 2013

Policy: Incident reports/ QA Report Form will be completed on any events that happen that are out of the ordinary of routine patient care or injury to employees, patients or visitors.

"An incident is an event, circumstance or occurrence that is NOT consistent with the care and treatment of a particular patient... Examples of incidents which should be reported are as follows: medications errors, falls, accidents... Employees should discuss the situation with supervisory personnel and complete an incident report when there is any question regarding a situation.

... The proper completion of Quality Assurance reports are a responsibility of every hospital employee. Only actual facts are to be used. All reports should be completed within twenty four (24) hours of the incident and forwarded to administration.

Procedure:

1. Obtain an Incident Report/QA Report form from the nurse's station, Director of Nursing or the QA Coordinator.
2. Return form to Director of Nursing or the QA Coordinator."

***
An observation of Medical Record (MR) # 5's room was conducted on 5/14/14 at 1:30 PM. The surveyors observed no bathroom located in the MR # 5's room. The bathroom was a shared bathroom located across the hallway from the patient's room.


Medical Record Review:

Medical Record # 5 was admitted to the facility 3/18/14 with diagnoses of nausea, vomiting, diarrhea, and Chronic Obstructive Pulmonary Disease (COPD). Review of the MedSurg (Medical/Surgical): Fall assessment dated [DATE] at 10:38 AM revealed the patient was scored as moderate risk for falls. Review of the medical record revealed MR # 5 received the following medications: 5:59 PM - (1) Lortab 7.5 mg (milligrams), 7:34 PM - Toradol 30 mg and Zofran 2 mg. (All of these medications can cause dizziness and/or drowsiness). Review of the Nursing Physical Assessment 3/18/14 at 8:00 PM revealed the Registered Nurse (RN) documented the patient continued to be a moderate risk for falls.

There was no documentation in the medical record the patient was wearing non-slip or grip footwear or if any was provided to the patient. There was no documentation the patient was oriented to surrounding, including location of bathroom facilities, and/or instructions to call for assistance before getting out of bed. There was no documentation the nurse reviewed the patient's medications that were administered for increased confusion, disorientation or sedation. There was no documentation the patient was provided assistance with toileting checks every 2 hours and as needed due to the patient having nausea and vomiting as admitting diagnoses and the toileting facilities located outside the patient's room and across the hallway.


Interviews conducted with a Nursing Assistant, Employee Identifier (EI) # 5 on 5/14/14 at 12:40 PM and EI # 4, the former Director of Nursing, on 5/16/14 at 8:15 AM, revealed MR # 5 sustained a fall while hospitalized .

In an interview 5/14/14 at 12:40 PM with EI # 5, she stated MR # 5 slipped from her bed onto the floor around 2:00 AM on 3/19/14. EI # 5 stated she was not involved with the fall and did not know if the patient or roommate called for help. EI # 5 stated she did not respond to the call related to the fall.

In a telephone interview with EI # 4 on 5/16/14 at 8:15 AM, she stated that she asked EI # 6, Registered Nurse (RN) on duty 3/18/14 from 7:00 PM until 3/19/14 at 7:00 AM, to complete an incident report related to the fall MR # 5 experienced 3/19/14.

A review of the Incident Report revealed the following information:
Date of incident: 3/19/14, there was no time of the occurrence documented.
Location: Nursing unit medical.
Sub-location: Patient room.
Recipient of Occurrence: Inpatient.
Type of occurrence: Found on floor.

To be completed by Medical Practitioners/ Nurse:
Site of injury: N/A (not applicable)
Treatment rendered: None
Condition prior to occurrence: Alert
Condition post occurrence: Alert
Activity orders prior to occurrence: Up ad. lib. (as tolerated)
Activity orders post occurrence: Up ad. lib.

The form was signed by EI # 6, RN.

Quality Assurance Form revealed the following documentation of MR # 5's fall by EI # 6, Registered Nurse (RN):

Quality Assurance Description Investigation: "Pt (patient) called on call light and said upon moving from bed to chair she slipped and lowered herself to the floor. VS (vital signs) taken, no apparent injury, no complaint of pain. (EI # 8), Physician was notified."

The form was incomplete. There was no time of the incident recorded on the incident report or in the medical record. EI # 6 documented vital signs were taken but no vital signs were recorded on the incident report form or in the medical record related to the fall. EI # 6 documented that EI # 8, Physician was notified.

A review of MR # 5's medical record revealed no documentation the patient was assessed for injuries related to the fall, that new interventions were put in place to prevent future falls or that the physician was notified of the patient's fall.


An interview was conducted 5/14/14 at 10:40 AM with Employee Identifier (EI) # 8, Physician. EI # 8 stated he was not aware of the patient's fall on 3/19/14. He did not remember being notified.


On 3/20/14 at 2:30 PM , EI # 4, the former Director of Nursing (DON), and EI # 2, the Assistant Director of Nursing/ Risk Manager, went to interview the roommate of MR # 5.

An interview was documented and a written statement was obtained from the roommate (MR # 1) of MR # 5. These documents were found in the desk drawer of EI # 4, the former Director of Nursing, on 5/14/14 at 2:30 PM. A review of the written statement of MR # 1 dated 3/20/14 at 2:30 PM revealed the following information was obtained: "... (MR # 5) complained all day long with stomach pain... made 2 trips to the bathroom (located across the hallway from the patient's room)... (MR # 5) told the staff (he/she) had an accident in clothes... can't go alone anymore... 10:45 PM (MR # 1) heard something, a thump. Patient tried to get in chair, left leg feels numb... (MR # 5) (was) in floor. (MR # 1) got (EI # 6 and EI # 5) in the room and 2 other nurses. Picked patient up and put (him/her) back in chair. Looked patient over, left elbow hurts, bleeding..."

Review of the written statement from MR # 1 (MR # 5's roommate) with the patient's notes from 3/20/14 revealed the following: "... (MR # 5) tried to get out of bed to get into chair to sit at or around 10:45 PM - 11:00 PM. (MR # 5) fell in floor. I (MR # 1) called for nurses. They came and got (MR # 5) up. Left and came right back in. (Staff) wanted to know where blood was. (MR # 5) had a tear on (his/her) elbow. (MR # 5) sat in chair for a while then back to bed..."

In an interview with EI # 6, RN conducted on 5/15/14 at 7:00 AM, she was asked if EI # 8 was notified of the patient's incident? EI # 6 replied, "yes, after midnight when patient fell and of a skin tear to the patient's right arm."

In an interview with EI # 2, Assistant DON conducted on 5/15/14 at 1:30 PM, EI # 2 was asked when she received the information related to MR # 5's fall. EI # 2 responded, the next day (3/19/14), the report was in my door. The surveyors asked, how incidents reports are completed. EI # 2 responded the bottom of the report (Recommendation/Action, Follow up and the name and title of who completed the investigation) is supposed to be completed. EI # 2 responded that EI # 4, former DON said that she was going to complete an in depth statement and "put the whole thing together".

On 5/15/14 at 2:20 PM, an interview was conducted with EI # 1, Administrator, regarding the incomplete documentation, investigation and resolution of incident involving MR # 5's fall. EI # 1 responded, EI # 4, the former Director of Nursing (DON) had been out with medical issues for 4 of the last six weeks and resigned from the hospital on [DATE]. EI # 1 stated, she knew EI # 4 had spoken to the roommate of MR # 5 and she was concerned over MR # 5. The surveyor's asked who should have completed the investigation. EI # 1 responded, an incident report goes to the DON, then to Risk Management, then forwarded to me after the incident investigation has been completed. EI # 1 verified the incident report and investigation of MR # 5's fall had not been completed according to policy.


Summary: The facility failed to follow their own policy related to implementation of fall prevention interventions for MR # 5, who was assessed as a moderate risk for falls and sustained a fall. The facility failed to ensure the nursing staff followed the policy for assessment and reporting findings to the physician after MR # 5 sustained a fall. The facility failed to follow the policy for implementation of post-fall prevention interventions after MR # 5 sustained the fall.

The facility failed to follow their policy related to the investigation and provide recommendations and/or actions and follow up concerning MR # 5's fall. The facility also failed to ensure this incident was reported to administration within 24 hours.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of medical records, Crash Carts Checks, Crash Cart Medications list, After Hours Pharmacy Log, personnel files, policies and procedures, staffing schedule, nursing standard of practice, written statement of Medical Record (MR) # 5's roommate (MR # 1), observations and interviews it was determined the facility failed to:

1. Ensure the emergency carts were equipped, ready for use in an emergency. Refer to A386 for additional findings.


2. Ensure staff were trained to provide care according to facility policies and procedures related to patient codes. Refer to A392 for additional findings.


3. Ensure nursing staff met the needs of a patient related to:

a. Pain management and documentation

b. Reporting abnormal vital signs

c. Reporting changes in the medical condition of a patient

d. Reporting and documenting a fall

e. Complete assessment of a patient with a complaint of pain. Refer to A 395 for additional findings.


These deficient practices had the potential to affect all patients served by this facility.


Findings include:

Refer to A386, A392 and A395 for findings.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on review of facility policies, Crash Carts Checks, Crash Cart Medications list, After Hours Pharmacy Log, observations and interviews with staff, it was determined the nursing staff failed to ensure the emergency carts were equipped and ready for use in an emergency. This had the potential to negatively affect all patients admitted to this facility.

Findings include:
A. "Policy and Procedure Manual
Code, Resuscitation Bag and Mask
RE: 604.15
Date Written: June 1997
Policy: To provide continued ventilations until normal breathing is restored or other resuscitation measures is employed ...
Documentation:
1. Record:
a. Time resuscitation was started.
b. Time resuscitation discontinued.
c. Any change in patient's condition.
d. Patient toleration and effects.
e. Signature.
f. Dispose of equipment after use. Restock cart.

B. Policy, Procedure, and Formulary Manual
Subject: Emergency drug carts (crash carts)
Date revised: 11/13
Policy: Georgiana Medical Center maintains crash carts and kits equipped with a supply of drugs which are likely to be used in emergency situations and are easily accessible.
Procedure:
1. Carts are located on meg/surg (medical/surgical) floor and in the emergency room .
2. The drug stock in the carts and kits are to be checked monthly by Pharmacist, C.R.N. (Charge Registered Nurse), or D.O.N. (Director of Nurses) for completeness, accuracy, expired medications, and expired fluids. The carts and kits will be checked immediately after each use for restocking by C.R.N. or D.O.N. and any items replaced ...
6. A list of items for each cart and kit is enclosed within each and must match exactly.

C. Policy, Procedure and Formulary Manual
Subject: Stocking specialty areas
Date Revised: 11/13
Policy:
"... 2. emergency room and crash carts will be stocked as needed by a registered nurse or DON ..."

Department of Pharmacy Policies & Procedures
Original Date: 11/13
Department Head or Supervisor
Subject: Drug Distribution when Pharmacist is not on duty
A. Policy: A pharmacist is on call 24 hours a day in order to prepare compounded medication or to provide needed information. Medications that do not require compounding will be obtained by the nursing service.
B. Purpose: To assure the security of the pharmacy and to have a pharmacist always available when needed. To assure that a patient will receive medication ordered within a reasonable amount of time when the pharmacy is closed.
C. Procedures:
1. All medication orders will be reviewed by the nursing staff.
2. The authorized nurse will enter the pharmacy and obtain enough medication to last until the pharmacist is back on duty. One supervising nurse per shift is authorized.
3. The medication taken is then logged in a book along with the following information: patient name, room number, drug and amount, and signature of person obtaining the medication.

On 5/15/14 at 7:00 AM, in an interview with Employee Identifier (EI) # 6, Registered Nurse (RN), Charge nurse revealed there were two cardiopulmonary resuscitation codes on 3/19/14 between 5:00 AM and 6:05 AM. Medical Record (MR) # 4 was a "chemical only code" (no intubation or defibrillation) and MR # 5 was a full code. EI # 6 stated the staff used the same emergency crash cart for MR # 5 that was used for MR # 4. There was no documentation the emergency crash cart was restocked after having been used during cardiopulmonary resuscitation of MR # 4. There was no documentation of the medications given to MR # 4 and MR # 5 during either of the cardiopulmonary resuscitation codes.

Review of the Crash Cart Checks dated 3/17/14 to 3/28/14 revealed no documentation the crash cart was checked by the nursing staff on 3/19/14 and 3/20/14.

Review of the After Hours Pharmacy Log dated 3/19/14 through 3/21/14 revealed no documentation of emergency medications having been removed from the pharmacy to stock the emergency cart.

An observation of the crash cart was conducted on 5/15/14 at 9:15 AM with EI # 7, Registered Nurse (RN). The surveyor reviewed the crash cart medications with EI # 7 and compared to the Crash Cart Medications list, which was in a drawer in the emergency cart located on the Medical/Surgical unit.

The following medications were listed on the Crash Cart Medications list with the following discrepancies in the count:

Atropine 1 milligram (mg) 3 listed on the list with a quantity of 2 available
Sodium Bicarbonate 50 milli-equivalents (mEq) 3 listed on the list with a quantity of 2 available
Adenocard 6 mg/2 milliliters (ml) 3 listed on the list with a quantity of 4 available
Lidocaine 2 grams (gms) 3 listed with 0 (zero) available
Lidocaine 100 mg 2 listed with 4 available
Verapamil 5 mg 4 listed with 3 available
Narcan 0.04 mg 5 listed with 2 available
Narcan 0.02 mg 2 listed with 0 (zero) available
Narcan 1 mg/ml 1 listed with 0 (zero) available
Atropine 0.4 mg/ml 2 listed with 0 (zero) available
Furosemide 40 mg 3 listed with 2 available
Heparin 10,000 units 1 listed with 0 (zero) available
Procainamide 1 gm/ 2 ml 2 listed with 0 (zero) available

An interview was conducted on 5/15/14 at 10:35 AM with EI # 2, Assistant Director of Nursing/Risk Manager confirmed management and staff failed to follow the facility policy for management of the emergency drug carts.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on medical record, policies and procedures, personnel files, staffing schedule, observation and interviews, it was determined the facility failed to ensure all nursing staff were trained to provide emergency care according to facility policies and procedures. This had the potential to affect all patients served by the facility.

Findings include:

Policy and Procedure Manual
RE: 604.10
Date Revised: January 2009
Subject: Code; Calling A Code and Team Duties

"...Procedure:
5. The Charge Nurse or RN (Registered Nurse) will designate the code team duties...
6. The Charge Nurse or RN will remain in charge of the code until the physician arrives to take charge of the situation.
7. ACLS (Advanced Cardiopulmonary Life Support) protocol and algorithms will be followed...
NOTE: ACLS algorithms are attached to the crash cart."

Policy and procedure Manual
RE: 604.20
Date Revised: June 2009
Subject: Defibrillation, Cardioversion and External Pacemaker Application

Policy:
"...Resuscitative measures by the RN will follow ACLS protocol. Protocols are located on the crash carts...
Defibrillation, cardioversion...should be done by the physician or ACLS qualified personnel..."


On 5/14/14 at 1:45 PM, a tour of the medical/surgical unit and interview with Employee Identifier (EI) # 10, Registered Nurse (RN), Charge Nurse was performed. Contents of the emergency crash cart were observed and included a blue notebook with the 2011 American Heart Association Cardiac Arrest Circular Algorithm, Adult Advanced Cardiovascular Life Support two page instruction document. During this interview, EI # 10 reported facility nurses were not ACLS certified.


Review of the 11 staff RN's personnel records on 5/15/14 at 10:15 AM revealed nine of eleven RN's failed to have current ACLS training. Review of staffing schedule revealed the 2 ACLS trained RNs were not scheduled to work from 7 PM on 3/18/14 to 7 AM on 3/19/14.

Review of MR (Medical Record) # 5 revealed EI # 6, RN and EI # 9, RN provided and documented care between 12:25 AM and 6:05 AM on 3/19/14. Review of the personnel records of EI # 6, RN and EI # 9, RN revealed neither had ACLS training documentation.

An interview conducted on 5/15/14 at 11:45 AM with EI # 1, Administrator, confirmed all facility RN's were not ACLS trained. EI # 1 stated she was not aware that any of the nurses were ACLS trained.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on review of Medical Records (MR), review of policy and procedures, standards of nursing practice, written statement of Medical Record (MR) # 5's roommate (MR # 1) and interview with facility Administrative staff, it was determined the facility failed to ensure nursing staff met the needs of a patient related to:

1. Pain management and documentation

2. Reporting abnormal vital signs

3. Reporting changes in the medical condition of a patient

4. Reporting and documenting a fall

5. Complete assessment of a patient with a complaint of pain.

This affected 1 of 9 (Medical Record (MR) # 5) and had the potential to affect all patients served by this facility.

Findings include:
Policy and Procedure Manual
Book II
Total Nursing Care
RE: 612.25
Date Written: September 1996
Dates Revised: January 2001, May 2009

Policy: It is the policy of Georgiana Hospital to provide patients with a primary nurse to provide total nursing care to the patent. The primary nurse will be responsible for organizing and providing the majority of the care required by the patient. The responsibilities of the primary nurse are:
... 3. Accurate and timely documentation on assigned patients ...
... 7. Reporting changes in the patient's condition to the Charge Nurse and/or physician ...
... 12. Reporting any vital information concerning the patient to the physician and/or Charge Nurse.

Policy and Procedure Manual
Book II
Vital signs, Routine and Reporting Abnormal levels
RE: 612.41
Date Written: December 2001
... Reporting Abnormal Levels: The Physician should be notified of any the following abnormal levels, that do not respond to routine or prn (as needed) medications ordered:
Blood Pressure:
Systolic - Greater than 180, Less than 90
Diastolic - Greater than 110
Pulse: Greater than 135, Less than 45
Temperature: Greater than 101.5, Less than 96
Respirations: Greater than 35, Less than 12

The above guidelines are based on adult parameters. Remember these are guidelines only. A patient can be in distress, but their vital signs fall inside these parameters. A full assessment of the patient is necessary to provide adequate information regarding the status of the patient. For example, a patient that presents with a blood pressure (B/P) of 150/90 but the B/P falls to 90/36 in one hour has shown a significant change. This should be reported to the Physician immediately and documented.

Alabama Board of Nursing Chapter 610-x-6
Standards of Practice

610-x-6-.03 Conduct and Accountability. The registered nurse and the licensed practical nurse shall:

"(1) Have knowledge and understanding of the laws and rules regulating nursing...
(4) Be responsible and accountable for the quality of nursing care delivered to patients based on and limited to scope of education, demonstrated competence and nursing experience.
(5) Be responsible for monitoring and evaluating the quality of patient care delivered by personnel under the individual nurse's supervision..."


610-X-6-.09 Assessment Standards

(2) The registered nurse shall conduct and document comprehensive and focused nursing assessments of the health status of patients by:
(a) Collecting objective and subjective data from observations, physical examinations, interviews and written records in an accurate and timely manner as appropriate to the patient's health care needs.
(b) Analysis and reporting of data collected.
(c) Developing a plan of care based upon the patient assessment.
(d) Modifying the plan of care based upon the evaluation patient responses to the plan of care. including:
(i) Anticipating and recognizing changes or potential changes in patient status.
(ii) Identifying signs and symptoms of deviation from current health status
(iii) Implementing changes in interventions
(3) The licensed practical nurse shall conduct and document focused nursing assessment of the health status of patients by:
(a) Collecting objective and subjective data from observations, physical examinations, interviews and written records in an accurate and timely manner as appropriate to the patient's health care needs.
(b) Distinguishing abnormal from normal data.
(c) Recording and reporting the data.
(d) Anticipating and recognizing changes or potential changes in patient status; identifying signs and symptoms of deviation from current health status.
(e) Reporting findings of the focused nursing assessment to the registered nurse, licensed physician, advanced practice nurse, or dentist.

610-X-.06 Documentation Standards

(1) The Standards for documentation of nursing care provided to patients by registered nurses and licensed practical nurses are based on principles of documentation regardless of the documentation format.
(2) Documentation of nursing care shall be:
(c) Complete. Complete documentation includes reporting and documenting on appropriate records a patient's status, including signs and symptoms, responses, treatments, medications, other nursing care rendered, communication of pertinent information to other health team members and unusual occurrences involving the patient...
(d) Timely.
(i) Charted at the time or after the care, including medications, is provided.
Charting prior to care being provided, including medications, violates principals of documentation.

Medical Record findings:

1. Medical Record (MR) # 5 was admitted to the facility 3/18/14 with a chief complaint of nausea, vomiting, diarrhea and abdominal pain. The patient has a history of Chronic Obstructive Pulmonary Disease (COPD).

The physician documented the following plan for care: "Will admit the patient with Ringers Lactate at 125 cc(cubic centimeters)/ hr (hour), Flagyl 500 mg (milligrams) IV (intravenous) q (every) 8 hrs, Zofran 4 mg IV q 4 hrs PRN (as needed) nausea and vomiting, duo neb q 4 hrs PRN shortness of breath and wheezing... resume (his/her) regular home medications... initial blood work in the ER (emergency room ) showed... hypomagnesia which was 1.5... give (him/her) magnesium 2 grams IV times 1... check (his/her) magnesium level tomorrow... keep (him/her) on Oxygen 2 liters per nasal cannula and Protonix 40 mg IV daily.

"... re-evaluate... abdominal pain and due to high risk for gastrointestinal hemorrhage we will not start her on Lovenox for DVT (deep vein thrombosis) prophylaxis at this time , but will continue Plavix due to... history of carotid artery stenosis and follow up with patient as per labs and clinical findings."

MR # 5 arrived to the medical floor 3/18/14 at 10:00 AM with vital signs recorded as:
Blood Pressure (B/P) 122/63
Oxygen saturation (O2 sat) 94 %
Respiration 20
Pulse radial 120
Temperature 98.1 oral.

The physical assessment by the Registered Nurse (RN) documented at 10:30 AM the following:
Level of consciousness: alert and oriented x 3
Sensation: No c/o (complaint of) numbness, no c/o tingling, no c/o pain.
Breath sounds: Clear bilaterally, upper lobe; diminished bilaterally lower lobe.
Weakness: Generalized body weakness/aches.

Nurse's Note: "57 yowf (year old white female) to room... from ER. Pt brought to the room via wheelchair. Alert and oriented x 3. Pt c/o nausea, vomiting, diarrhea, started last night..."
Vital signs at 12:00 PM
Blood Pressure (B/P) 135/57
Oxygen saturation (O2 sat) 98 %
Respiration 20
Pulse radial 128
Temperature 98.1 oral.

MR # 5 received Zofran 2 mg/ml 4 mg IV (intravenous) push at 12:39 PM for nausea and Ativan 1 mg po (by mouth) at 12:53 PM for anxiety.
MR # 5 received Phenergan 50 mg IM (intramuscular) for nausea at 2:00 PM.

Vital signs at 4:00 PM
Blood Pressure (B/P) 112/71
Oxygen saturation (O2 sat) 95 %
Respiration 20
Pulse radial 133
Temperature 101.6 oral.

The change in vital signs, continued increase in the pulse rate and elevated temperature was not reported to the physician.

The patient received Tylenol 650 mg po for temperature at 3:57 PM.

MR # 5 received Lortab 7.5 mg po for pain at 5:59 PM. There was no documentation of a pain assessment, including location, duration or severity.

The nurse reported to the oncoming shift at 6:38 PM, "Pt resting well."

MR # 5 received Toradol 30 mg IV push for pain and Zofran 4 mg IV push at 7:34 PM. There was no documentation of a pain assessment, including location, duration or severity.

Vital signs at 8:00 PM
Blood Pressure (B/P) 98/48
Oxygen saturation (O2 sat) 98 %
Respiration 24
Pulse radial 101
Temperature 98.7 oral.

The physical assessment conducted at 8:00 PM by Employee Identifier # 6, Registered Nurse (RN) documented:
Activity: Resting in bed
Safety: SR (siderail) up as appropriate, bed locked and in low position. Call light within reach.
Level of consciousness: alert and oriented x 3
Sensation: No c/o numbness, no c/o tingling, no c/o pain.
Pulses: all pulses palpable WNL (within normal limits)
Edema: none assessed
Abdomen: soft, non-tender
Bowel elimination: diarrhea.
Nausea/emesis: denies any nausea/vomiting
Nurse's note: "resting in bed, NAD (no acute distress) noted, denies pain, no voiced needs, VSS ( vital signs stable), IV intact...will continue to monitor."

Vital signs at 12:00 AM (midnight)
Blood Pressure (B/P) 89/46
Oxygen saturation (O2 sat) 97 %
Respiration 20
Pulse radial 125
Temperature 99.6 oral.

The change in vital signs, low blood pressure and increase in the pulse rate was not reported to the physician.

MR # 5 received Lortab 7.5 mg at 12:24 AM for pain. There was no documentation of a pain assessment, including location, duration or severity.

MR # 5 received Zofran 4 mg IV for nausea and Toradol 30 mg IV push for pain at 2:20 AM. There was no documentation of a pain assessment, including location, duration or severity.

Vital signs at 4:00 AM
Blood Pressure (B/P) 114/79
Oxygen saturation (O2 sat) 94 %
Respiration 24
Pulse radial 57
Temperature 97.4 oral.

EI # 11, Licensed Practical Nurse documented at 5:39 AM, Levothyroxine 0.088 mg PO was given to the patient.

On 3/19/14 at 5:45 AM the nurses notes documented, "Pt found unresponsive sitting in wheelchair. Pt placed back in bed and CPR (cardiopulmonary resuscitation) started per (EI # 8), physician...Nursing physical assessment at 5:45 AM... crash cart brought into room and ACLS protocol began per (EI # 8)."

At 6:05 AM the nurse documented, "pt pronounced by DR... family not able to be notified at this time."

The nurses failed to document a complete assessment of the patient's pain and/or response to pain medication being administered. The nurse failed to assess the patient with the change in vital signs and failed to report to the physician a change in the patient's status. There was no documentation of a Code being conducted, no cardiac monitoring strips run from the crash cart during a code procedure, no medication documented as administered and no documentation of replacement of drugs taken off the crash cart used during the procedure. The nursing staff provided to the surveyor one cardiac monitoring strip of Asystole with a date of 3/19/14 and a time 6:05 AM.

In an interview 5/14/14 at 12:45 PM with EI # 5, Certified Nurse Assistant (CNA) stated that MR # 5 requested to sit up in the chair after vital signs were taken at 12:00 AM (midnight) and EI # 5 assisted MR # 5 to the wheelchair. EI # 5 stated that she reported MR # 5's vital signs to the nurses each time and the patient being restless and in pain. EI # 5 informed the surveyor that MR # 5 fell at some time during the night shift and they moved MR # 1 (MR # 5's roommate) to another room around 3:00 AM due to MR # 5 being restless.

Review of the medical record revealed no documentation MR # 5 had sustained a fall, an assessment of the patient after having had a fall or that the physician had been notified MR # 5 had fallen.

On 3/20/14 at 2:30 PM , EI # 4, the former Director of Nursing (DON), and EI # 2, the Assistant Director of Nursing/ Risk Manager, went to interview the roommate of MR # 5.

An interview was documented and a written statement was obtained from the roommate (MR # 1) of MR # 5. These documents were found in the desk drawer of EI # 4, the former Director of Nursing, on 5/14/14 at 2:30 PM. A review of the interview with MR # 1 dated 3/20/14 at 2:30 PM revealed the following information was obtained: "... (MR # 5) complained all day long with stomach pain... made 2 trips to the bathroom (located across the hallway from the patient's room)... (MR # 5) told the staff (he/she) had an accident in clothes... can't go alone anymore... Observed niteshift (night shift) Patient complained a lot of pain. Asked to speak with physician before 7 pm shift change. Could not figure out how to use the phone... (MR # 1's spouse) noticed a red place on (MR # 5's) leg... One of the nurse told the patient (MR # 5) (EI # 8, physician) would be in at 7:30 PM. (EI # 8) stepped in the door and spoke with the patient (MR # 5) around 7:30 PM. Feels night shift did not take pain complaints serious. Gave patient Phenergan and Lortab. Did not touch her pain. At 10 PM... rang buzzer and no one answered... Staff came in and would act irritated. 10:45 PM (MR # 1) heard something, a thump. Patient tried to get in chair, left leg feels numb... (MR # 5) (was) in floor. (MR # 1) got (EI # 6 and EI # 5) in the room and 2 other nurses. Picked patient up and put (him/her) back in chair. Looked patient over, left elbow hurts, bleeding... Patient wanted to sit up in a chair complained of being on fire. Wanted ice water and a rag, turned air down. Requested help to get back in bed. Patient still hollering and complaining. About 2 AM , needs to get back up. Can not get relief. Complains of being sick. Wants to be transferred. 2:30 AM Patient telling nurse needs to leave, can't rest, so sick. 3:30 AM back to bed. Needs to get back up. Restless. Patient kept talking to (MR #1). Hollering and screaming..."

Review of the written statement from MR # 1 (MR # 5's roommate) with the patient's notes from 3/20/14 revealed the following: " (MR # 5) wanted to talk to the doctor. Nurses told (MR # 5) the doctor was gone for the day. At or around 7:30 PM (EI # 8, physician) show up. EI # 8 asked MR # 5 what was wrong. (MR # 5) told EI # 8 was in so much pain. Around 8:15 PM, Nurse brings shot in and adds to IV. (MR # 5) eased off 45 minutes and when (MR # 5) awoke, in pain again. MR # 5 started asking again to see the doctor. (MR # 5) said... left leg from hip down was numb. (MR# 5) wanted family to come rub leg. (MR # 5) wanted to be transferred... (MR # 5) tried to get out of bed to get into chair to sit at or around 10:45 PM - 11:00 PM. (MR # 5) fell in floor. I (MR # 1) called for nurses. They came and got (MR # 5) up. Left and came right back in. (Staff) wanted to know where blood was. (MR # 5) had a tear on (his/her) elbow. (MR # 5) sat in chair for a while then back to bed... Kept saying burning up. AC (air conditioner) was on 69 degrees. Nurse turned it to 66 degrees. MR # 5 told nurse needed a pan of ice water. They brought an ice pack..."


An interview was conducted 5/14/14 at 10:40 AM with Employee Identifier (EI) # 8, Physician. EI # 8 stated he was not aware of the patient's fall on 3/19/14. He did not remember being notified.

In an interview on 5/14/14 at 2:40 PM with EI # 2, the Assistant Director of Nursing stated she went into check on MR # 5 on 3/18/14 before she was leaving for the day because she heard her moaning from the hallway. EI # 2 was asked what time of day that was and she did not know because sometimes she leaves at 6 PM and sometimes earlier. EI # 2 went on to say the roommate told her MR # 5 could not get comfortable moving from chair to bed and back. EI # 2 stated that MR # 5 told her she was hurting but not specific about where the pain was located. EI # 2 stated that she told the floor nurse who responded that it was not time for her medication.

In a telephone interview 5/16/14 at 9:00 AM, EI # 9, the emergency room (ER) nurse confirmed she was present in the room with the patient during the code process. EI # 9 stated that the code was typical, could not remember if they shocked the patient but remembered running strips and medications being administered. EI # 9 stated that she did not remember who was to document the events of the code.

The facility failed to ensure the nursing staff assessed MR # 5's pain, including location, duration, severity and response to the administration of pain medications. The nursing staff failed to monitor vital sign changes and report those changes to the physician. The nursing staff failed to document in MR # 5's medical record, the patient experienced a fall or to a report of this to the physician. The nursing staff failed to document cardiopulmonary resuscitative measures.

In a telephone interview 5/16/14 at 8:30 AM with MR # 5's roommate (MR # 1) and spouse, MR # 1 who was with the patient after admission 3/18/14 until moved out of the room at 3:00 AM on 3/19/14. MR # 1 verified he/she wrote a statement on 3/20/14 for EI # 4, the former Director of Nursing and EI # 2, Assistant Director of Nursing. MR # 1 stated that somewhere around 5:00 PM, MR # 5 told the hospital nursing staff, (MR # 5) was sick and needed a doctor and was told the doctors were gone for the day. MR # 5 told the hospital nursing staff he/she needed something for pain and to call son. MR # 5 complained of pain in the left leg and stomach. MR # 1 stated that the hospital nursing staff told MR # 5 they had given all of the medication he/she could have at the time. MR # 1's spouse stated saw a red place on MR # 5's left leg and it was swollen and there was a knot.

MR # 1 stated the EI # 8, the physician, stuck his head in the room around 6:45 PM and ordered her some Toradol for pain.

MR # 1 was asked if he/she was in the room when MR # 5 fell . MR # 1 stated that he/she was and it happened about 10:30 PM -10:45 PM and MR # 1 called on the call light to tell someone MR # 5 needed help. MR # 1 stated it took 10 minutes for someone to answer the call light.

MR # 1 stated they moved her to another room about 3:00 AM and she continued to hear MR # 5 hollering and moaning for about 45 minutes.

MR # 1 stated about 5:10 AM she got up to go across the hall to the bathroom and saw the crash cart outside of MR # 5's door. MR # 1 asked (EI # 5), the nursing assistant if MR # 5 was all right. EI # 5 told her that MR # 5 passed about an hour after MR # 1 was moved out of the room. This would have been about 4:00 AM on 3/19/14.
VIOLATION: CONTENT OF RECORD Tag No: A0449
Based on record review and interviews, it was determined the facility failed to ensure the medical record contained documentation of Medical Record (MR) # 5's fall, changes in the patient's condition, including pain and the events or medications administered during the resuscitative measures for MR # 4 and # 5. This affected 2 of 9 medical records (Medical Record # 4 and # 5) reviewed and had the potential to affect all patient served by this facility.

Findings include:

1. Medical Record (MR) # 5 was admitted to the facility 3/18/14 with a chief complaint of nausea, vomiting, diarrhea and abdominal pain. The patient has a history of Chronic Obstructive Pulmonary Disease (COPD). Review of the medical record revealed the patient received the following pain medications:
Lortab 7.5 mg (milligrams) po (orally) for pain at 5:59 PM.
Toradol 30 mg IV (Intravenous) push for pain at 7:34 PM.
Lortab 7.5 mg at 12:24 AM for pain.
Toradol 30 mg IV push for pain at 2:20 AM.

There was no documentation of a pain assessment, including location, duration and severity or if the patient's pain was relieved.

On 3/19/14 at 5:45 AM the nurses notes documented, "Pt found unresponsive sitting in wheelchair. Pt placed back in bed and CPR (cardiopulmonary resuscitation) started per (EI # 8), physician...Nursing physical assessment at 5:45 AM... crash cart brought into room and ACLS (Advanced Cardiopulmonary Life Support) protocol began per (EI # 8)." There was no documentation in the medical record of the events or medications administered during the resuscitative measures.

At 6:05 AM the nurse documented, "pt pronounced by DR... family not able to be notified at this time."


Interviews conducted with a Nursing Assistant, Employee Identifier (EI) # 5 on 5/14/14 at 12:40 PM and EI # 4, the former Director of Nursing, on 5/16/14 at 8:15 AM, revealed MR # 5 sustained a fall while hospitalized .


In an interview 5/14/14 at 12:45 PM with EI # 5, Certified Nurse Assistant (CNA) stated that MR # 5 requested to sit up in the chair after vital signs were taken at 12:00 AM (midnight) and EI # 5 assisted MR # 5 to the wheelchair. EI # 5 stated that she reported MR # 5's vital signs to the nurses each time and the patient being restless and in pain. EI # 5 informed the surveyor that MR # 5 fell at some time during the night shift and they moved MR # 1 (MR # 5's roommate) to another room around 3:00 AM due to MR # 5 being restless. EI # 5 stated she was in and out of MR # 5's room throughout the night because the patient was restless and in pain.

There was no documentation in the MR # 5's medical record of the patient's restlessness, pain or that the Registered Nurse (RN) was notified of the patient's physical complaints.


In an interview with EI # 6, RN conducted on 5/15/14 at 7:00 AM, she was asked if EI # 8, Physician was notified of the patient's fall. EI # 6 replied, "yes, after midnight when patient fell and of a skin tear to the patient's right arm."

There was no documentation in the medical record the patient sustained a fall or the skin tear as a result of the fall.


Summary: The hospital staff failed to document in MR # 5's medical record of a pain assessment, including location, duration and severity or if the patient's pain was relieved. The hospital staff failed to document the sequence of events during an emergency resuscitation code, including medications administered, defibrillation, chest compressions, Electrocardiogram monitoring of the patient's heart rhythm or if rescue breathing and Oxygen was administered by the staff. The hospital staff failed to document in MR # 5's medical record the patient sustained a fall resulting in a skin tear to the right arm.