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ABRAZO CENTRAL CAMPUS 2000 WEST BETHANY HOME ROAD PHOENIX, AZ 85015 April 9, 2013
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on review of medical record, policies/procedures, hospital documents and staff interviews it was determined a registered nurse failed to:

1. evaluate the care for 1 of 1 patient (#24) as demonstrated by failing to reassess and intervene when the patient's blood pressure was 61/42 and the pulse was 43 at 1800 hours, until two hours later at 2000 hours when the patient was found unresponsive, cool to touch requiring emergent intubation; and

2. supervise the care of 2 of 2 patients with Certified Nursing Assistants (CNA) sitting with the patients in the emergency department (ED) on 04/04/13 at 1530 hours, as evidence by, the CNA's not being able to identify the RN assigned to the patient and identify who to report a patient problem(s).

Findings include:

1. The hospital policy titled Emergency Department Standards of Care: Provision of Patient Care Treatment, and Services, required: "...Patients shall be triaged and ongoing assessment of physical and psychosocial problems of patient within the emergency care system will be performed as evidenced by written or electronic documentation...Reassessment may include, but is not limited to: Patient's current condition/status...Personnel shall assure open and timely communication with emergency patients...team members to ensure the occurrence of effective therapeutic interventions...."

The hospital policy titled Suicide Precautions: Close Observation, required: "...Procedural Documentation...Patient assessment & monitoring...."

Patient #24 arrived in the ED on 02/02/13 at 0922 hours, after overdosing on her boyfriend's Methadone and her Xanax, while expressing suicidal ideation. The patient received Narcan (opiate reversal agent) intramuscularly and intravenously, by Emergency Medical Services prior to arrival in the ED. At 1230 hours the ED physician cleared the patient medically. According to documentation the patient's care was transferred to RN #59, lead charge nurse at 1230 hours.

A sitter (CNA #58) was assigned to observe the patient for safety.

The CNA (#58), sitter's documentation indicated the patient was sleeping from 1415 hours until 1930 hours on 02/02/13.

No RN assessments are documented after the original triage assessment conducted at 0922 hours until 2000 hours when the patient was emergently intubated.

Nursing documentation at 1955 hours included: "...In room to check on both psych patients, sitter in room. Pt pale, cool to touch, vitals taken...BP 61/42, pulse 43, pupils pinpoint, not arousable. Pt rushed to room #2...NRB (non-re-breather oxygen mask) resp. (respiratory) in room set up for intubation. Sitter (Sitter #35) states 'in report c (with) other sitter' (#58) states 'I told RN at 1800 that pt's pulse, blood pressure, O2 sats were low'. No RN went in room to check on a patient...2000...Intubated....vent in room...."

Interviews with the Director of Emergency Services and Risk Management were conducted on 04/04/13. The Director's confirmed documentation did not demonstrate RN oversight of care, with assessments, reassessments, and interventions for abnormal vital signs, with a change in condition at 1800 hours. Interventions began two hours later at 1955 hours. They confirmed the vital signs referenced in the nurse's narrative note above were taken at 1800 hours and not at 1955 hours.

2. The hospital policy titled Sitter Utilization, required: "...Reporting patient activities and events to the nursing staff...."

A tour of the ED was conducted on 04/04/13 at 1530 hours. Two CNA sitters were observed sitting in rooms with patients. The sitters were interviewed. CNA #57 was asked to identify the RN assigned to her patient. She thought the RN was a young male. Interview with CNA #56 revealed she could not identify what RN was assigned to her patient or which RN to report a problem to.

Interviews with the Director of Emergency Services and Chief Nursing Officer were conducted on 04/04/13. They confirmed a RN did not supervise the care of the patients and direct the CNA's sitting with patients.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on review of Pt #24's medical record, hospital documents, and interviews with staff, it was determined the nurse executive failed to ensure nursing staff assigned sitter duties to a competent qualified CNA Sitter, as demonstrated by failing to identify Sitter CNA #58 , did not have an orientation to the ED or CNA Sitter policy prior to sitting with Pt. #24.

Findings include:

The hospital policy titled Sitter Utilization, required: "...Reporting patient activities and events to the nursing staff...."

Patient #24 arrived in the ED on 02/02/13 at 0922 hours, after overdosing on her boyfriend's Methadone and her Xanax, while expressing suicidal ideation. The patient received Narcan intramuscularly and intravenously, by Emergency Medical Services prior to arrival in the ED. At 1230 hours the ED physician cleared the patient medically. According to documentation the patient's care was transferred to RN #59, lead charge nurse at 1230 hours.

A sitter (CNA #58) was assigned to observe the patient for safety.

The CNA (#58) sitter's documentation indicated the patient was sleeping from 1415 hours until 1930 hours on 02/02/13.

Nursing documentation at 1955 hours included: "...In room to check on both psych patients, sitter in room. Pt pale, cool to touch, vitals taken...BP 61/42, pulse 43, pupils pinpoint, not arousable. Pt rushed to room #2...NRB (non-re-breather oxygen mask) resp. (respiratory) in room set up for intubation. Sitter (CNA #Roman) states 'in report c (with) other sitter' (name) states 'I told RN at 1800 that pt's pulse, blood pressure, O2 sats were low'. No RN went in room to check on a patient...2000...Intubated...vent in room...."

Interviews with the Director of Emergency Services and Risk Management were conducted on 04/04/13. They confirmed the vital signs referenced in the nurse's narrative note above were taken at 1800 hours by the sitter and not at 1955 hours.

Review of CNA #58's personnel file indicated she was from an outside nursing registry. Time sheets indicated this was the first time CNA #58 had worked at this acute care hospital. The personnel file did not include orientation to the ED or Sitter policy prior to being assigned sitter duties for Patient #24 on 02/02/13.

The ED Director confirmed during an interview on 04/04/13, that CNA registry sitters are to be oriented to the ED upon arrival and the sitter policy is reviewed with them and documents confirming this are to be added to their personnel file. She confirmed CNA #58 did not have documentation of orientation to the ED or the sitter policy prior to sitting with Patient #24.