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SIBLEY MEMORIAL HOSPITAL 5255 LOUGHBORO RD NW WASHINGTON, DC 20016 March 22, 2013
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record review and staff interview, it was determined that the Emergency Department (ED) clinical nursing staff failed to provide evidence of continual hemodynamic monitoring and clinical reassessment for one (1) patient who presented with documented respiratory distress, abnormal vital signs and rule out Pulmonary Embolism, from the primary physician's medical office. Patient # N1.

The findings included:

In accordance with Title 17 District of Columbia Municipal Regulations (DCMR) for Registered Nurses, Chapter 54, Section 5414, titled 'Scope of Practice, the following directives were included under subsection 5414.1 (a): "The practice of registered nursing means the performance of acts requiring substantial specialized knowledge, judgment, and skill based upon the principles of the biological, physical, behavioral, and social sciences in the following: (a) The observation, comprehensive assessment, evaluation and recording of physiological and behavioral signs and symptoms of health, disease, and injury, including the performance of examinations and testing and their evaluation for the purpose of identifying the needs of the client and family."

The Emergency Department's Policy entitled 'Emergency Nursing Standards of Care and Documentation', with an effective date of January 10, 2012, included and directed the following purpose statement: "Timely, accurate and quality documentation of observations, interventions and teachings provided to patients seeking care in the ED is essential to ensuring that a standardized documentation of the medical record supports the care provided."

Patient # N1 presented to the Emergency Department (ED) on January 23, 2013 at 10:57 AM with chief complaint of weakness, lethargy and worsening shortness of breath. The patient was initially taken by family members to the primary care cardiologist's office, located in the Medical Office Building adjacent to the hospital, for an evaluation of his/her medical condition.

In the cardiologist's office, the patient was found to be lethargic, cyanotic, not following commands, short of breath and having difficulty breathing. He/she was immediately referred to and escorted to the hospital's Emergency Department "to rule out Pulmonary Embolism".

Upon arrival to the ED, the patient was subsequently assessed by the Triage nurse at 11:16 AM and determined to be mildly hypotensive (95/51), tachycardic (139 beats per minute), and in respiratory distress with documented audible wheezing, rapid-labored breathing and a respiratory rate of approximately 30 breaths per minute. The patient's Pulse Oximetry reading was recorded as 99% on two (2) liters of Oxygen.

According to the Triage nurse, Patient N1 appeared clinically ill, was very weak, lethargic, and "was not breathing well". The Triage nurse further acknowledged that the patient's fingers were cold and "cyanotic".

After performing the initial triage assessment, the patient was immediately transported to the ED treatment area because of his/her acute clinical presentation and assisted from his/her wheelchair onto one (1) of the ED stretchers.

Continued review of the ED record revealed that after Patient N1 was placed on an ED stretcher, the primary nurse assigned to his/her emergency care and treatment began a comprehensive assessment and initial ED nursing diagnostic workup at 11:32 AM.

According to the primary nurse, he/she "was able to assess" that the patient was having difficulty breathing on arrival to the treatment bay. The primary nurse described the patient's respiratory efforts as "fast and hard", "tachypneic", and "labored breathing".

The nurse also stated that Patient N1 was not able to "adequately answer questions" secondary to his/her impaired breathing pattern.

At 12:11 PM, the primary care nurse documented his/her "Head-to Toe" assessment findings of Patient N1 into the electronic ED medical record.

According to the primary nurse's evaluation, the following clinical findings were present: Patient had "unsteady gait" requiring "assistance to cart...patient appears generally ill...with SOB, tachypneic...Respiratory assessment findings include respiratory effort, tachypneic...signs of distress, nasal flaring, in mild distress, Breath sounds with rales, to bilateral upper lobes, Breath sounds with wheezing, audibly, scattered. "

A repeat assessment of the patient's vital signs (VS) performed by the clinical nursing staff, at this time, only included measurement of the patient's Blood Pressure (BP) obtained from the left arm: 107/62 at 12:08 PM.

There was no documented evidence that the ED nurse performed and obtained a full assessment of the patient's other pertinent vital signs, to include on-going reassessments of his/her heart rate, respiratory rate, and pulse oximetry measurement.

Consequently, despite documented acuteness of Patient N1's clinical condition and severity of illness, at the time of his/her arrival, there was no supporting evidence found in the ED record to verify if the primary ED nurse continually monitored the patient's hemodynamic status and/or continually reassessed his/her respiratory and cardiovascular system for potentially life-threatening changes.

Specifically, the ED record review concluded that, apart from the initial pulse ox obtained at the time of Patient N1's triage assessment, there were no other pulse ox measurements performed and documented in the medical record to verify that the ED staff was continually monitoring and assessing the oxygen saturation level of the patient's blood.

The ED record also lacked documented evidence that the nurses continually monitored and re-assessed critical components of Patient N1's respiratory system.

This was evidenced by a failure of the ED nurses to include on-going documentation of the patient's auscultated breath sounds and lung reassessments; documented descriptions of the quality and rate of his/her respirations; and on-going reassessments of his/her work of breathing efforts.

The following findings were subsequently documented in the ED record referencing a critical change in the patient's clinical condition:

" Found in respiratory distress at 1245, Code started at 1245...BP: 53/35, Pulse: 40, Respirations: 4, Time: 1245...Pulses absent to the left radial, absent to the right radial...Airway:...Patient intubated orally...Breathing assessment findings: patient's breathing is assisted on 100% Ventilator settings...Circulation assessment findings include no palpable pulse, Blood pressure, hypotensive, Cardiopulmonary resuscitation started...Code terminated. Patient returned to stable rhythm at 1255..."

The patient was subsequently evaluated by the ICU intensivist and admitted to the ICU at 2:39 PM.

A face-to-face interview was conducted with the triage nurse on March 4, 2013 at approximately 12:35 PM, in the presence of the ED Nurse Manager. A subsequent telephone interview was conducted with the ED primary nurse responsible for the care of Patient N1 on March 5, 2013 at approximately 1:05 PM.

The nurses confirmed their respective assessments, physical evaluations, and documentation entries concerning Patient N1, as referenced above.

The record review was completed April 22, 2013.
VIOLATION: CONTENT OF RECORD - CONSULTS Tag No: A0464
Based on record review and staff interview, it was determined that the Emergency Department (ED) medical team failed to provide and include supporting clinical documentation in the medical record, to evidence that all pertinent clinical findings, resulting from the physical evaluation examination of one (1) patient who presented with respiratory compromise and Rule/Out Pulmonary Embolism (PE), had been thoroughly reviewed and assessed; and, accurately and specifically documented. Furthermore, the medical team also failed to include and clearly document, in the medical record, the provisions of emergency care delivered for the specific treatment and management of the patient's presenting clinical symptoms and complaints of respiratory compromise, prior to the patient's medical decline. Patient # N1.

The findings included:

According to information received from a telephone interview conducted with the ED Medical Director on April 3, 2013 at approximately 11:00 AM, the ED was the only patient-care area in the hospital that employs and utilizes "Scribes" to assist the physicians in documentation.

A subsequent review of the job description submitted for 'Scribes', entitled "What Do Scribes Do?", last revised June 26, 2011, included the following directives related to documentation responsibilities of the scribe:

"Overall a scribe's role is clerical; the scribe does not independently author any section of the medical record. The only type of information input afforded to a scribe is discrete material upon which a scribe cannot substantively influence...The central role of a scribe is to record notes at the discretion of the emergency department physician to whom they are assigned. Notes can include the physician's verbalized interaction with patients, physical exam findings, medical decision making, medication orders, laboratory results, radiological reports, clinical re-evaluations, consultations, and dispositions...Scribes ensure the appropriate medical/legal documentation is completed in parallel with the actual clinical care, rather than re-created afterwards."

Interview with the ED Director confirmed that the scribes were "strictly a clerical role" and that there was no physical contact with the patients. The "scribes" reportedly shadow the ED physician the entire shift and are present with the physicians during all patient interviews and assessments.

According to the Director, the scribes take notes "on paper" during the physicians encounter with the patient, and then come out and document the encounter in the computer.

The ED Director clearly affirmed that "we [ED physicians] review all their documentation to make sure that what they're putting down is what we approve". He/she also acknowledged that there are times when the scribes are instructed to change certain words or entries for medical accuracy, physician documentation intent, etc.

Patient # N1 presented to the Emergency Department (ED) on January 23, 2013 at 10:57 AM with chief complaint of weakness, lethargy and worsening shortness of breath. The patient was initially taken by family members to the primary care cardiologist's office, located in the Medical Office Building adjacent to the hospital, for an evaluation of his/her medical condition.

In the cardiologist's office, the patient was found to be lethargic, cyanotic, not following commands, short of breath and having difficulty breathing. He/she was immediately referred to and escorted to the hospital's Emergency Department "to rule out Pulmonary Embolism".

Upon arrival to the ED the patient was subsequently assessed by the Triage nurse at 11:16 AM and determined to be mildly hypotensive (95/51), tachycardic (139 beats per minute), and in respiratory distress with documented audible wheezing, rapid-labored breathing and a respiratory rate of approximately 30 breaths per minute. The patient's Pulse Oximetry reading was recorded as 99% on two (2) liters of Oxygen.

The patient was subsequently transported to the ED treatment area because of his/her acute clinical presentation and assisted from his/her wheelchair onto one (1) of the ED stretchers.

A concurrent review of the ED attending physician's documentation was done at this time, along with an ED course of events time-line review, to identify and determine the actual times of the provision of care administered to Patient N1.

ED record review confirmed the following time-lines relative to the physician encounter and management of Patient N1's emergency care:

**The ED physician was electronically assigned to the patient at 11:14 AM;

**The Past Medical History (PMH) and documented History of Present Illness (HPI) were obtained from the patient's family member at 11:45 AM and 11:48 AM, respectively...Subsequently, according to the documented entries, this initial encounter with an ED physician did not take place until approximately 50 minutes after Patient N1 was first brought to the ED at 10:57 AM;

**And, the initial physical assessment and examination of Patient N1 was documented as being completed by the ED attending physician at 2:54 PM, which was approximately two (2) hours after the patient's ED arrival, clinical decline and subsequent cardiopulmonary arrest.

A subsequent review of the ED attending ' s documented clinical findings written in the patient's HPI, Review of Systems (ROS) history and the Physical Examination (PE) was done.

Record analysis revealed physician documentation vagueness; inconsistencies related to the severity/acuity of the patient's presenting illness and symptomatologies; and inconsistencies related to the accuracy and comprehensiveness of the clinical findings documented.

According to documentation entered by the ED attending physician, the following review of systems history (ROS) and HPI were obtained:

Patient N1 was reportedly weak; had been complaining of cough, and shortness of breath with gradual worsening for six (6) days.

Additionally, the patient had been experiencing lower extremity edema since being diagnosed with DVT eight (8) weeks prior to his/her arrival in the ED.

The following documentation entries were also included in the HPI and ROS, respectively: "Patient has BP of 73/55 in ED ...ROS: limited due to acuity; history given per family, All systems were reviewed and are negative for acute complaints except as described above."

The Physical Exam (PE) findings documented by the ED attending at 2:54 PM were significant for the following: "Patient appears toxic. Patient appears in moderate pain distress...respiratory exam included findings of moderate respiratory distress...Breath sounds diminished...Cardiovascular exam included findings of rate tachycardic...Lower Extremity...no edema..."

However, continued review of the ED record revealed that there were no further documented entries made by the ED physician giving pertinent, detailed clinical descriptions, with documentation specificity, of the comprehensive physical examination findings of Patient N1, determined from a thorough assessment of the patient's individual body systems.

Investigative review of the ED physician documentation specifically noted the following findings:

The ED physician did not include documentation of the actual time Patient N1 was initially evaluated by the medical team for presenting clinical complaints and a determination of the severity of his/her illness;

The ED physician documented Patient N1's appearance as "toxic". However, there was no additional supporting clinical information entered by the ED physician, which specifically named and identified the actual clinical descriptors and/or physical assessment findings observed which resulted in his/her determination that the patient's clinical condition appeared "toxic";

The ED physician did not provide and include medically descriptive evidence of the results of a full assessment and documentation of all pertinent, clinical findings determined from a comprehensive examination of the patient's respiratory and cardiovascular system.

For the Respiratory examination section: The physician only documented that the patient was in "moderate respiratory distress" and his/her "breath sounds were diminished".

There was no further clarification or detailed description of these clinical findings, documented by the ED attending, which accurately reflected and described the severity of Patient N1's respiratory status, referenced in his/her documented entry.

Nor was there a subsequent plan of care and treatment documented by the ED attending that specifically referenced interventions identified to effectively manage these presenting respiratory symptoms.

Under the patient's Cardiovascular section: The ED physician only documented the following: "Cardiovascular exam included findings of, rate tachycardic, rhythm regular".

The ED attending failed to document and include all other pertinent cardiovascular-related clinical assessment findings present, with suspected causes and underlying etiologies, related to the patient's rapid heart rate and falling blood pressure.

Finally, the ED physician failed to document evidence of a complete and accurate 'Lower Extremity' assessment finding.

The patient presented with documented evidence of an on-going and recurrent Lower Extremity Deep Vein Thrombosis (LE DVT) with LE swelling and edema.

Concurrent review of the Intensivist's H&P findings, dictated on January 23, 2013 at 2:58 PM, confirmed the following clinical findings related to Patient N1's lower extremities: "There is 1 to 2 plus edema to the left greater than right distal lower extremities".

However, the ED attending documented the following in his/her physical assessment of the patient ' s lower extremities: "no edema".

A concurrent review of the ED physician treatment orders was also done to determine the ED physician's documented plan of care for the treatment and management of Patient N1's worsening respiratory condition; declining cardiovascular status; and its adverse effects on his/her hemodynamic functions.

Review of the ED medical record and subsequent interview with the ED attending physician revealed that the attending had originally ordered routine diagnostic laboratory studies for Patient N1 before he/she actually evaluated the patient and performed his/her initial physical examination to determine the severity and/or acuteness of the patient's presenting illness.

It was also revealed and determined that from the point of the physician's initial clinical evaluation of Patient N1, at approximately 11:48 AM, until the patient's cardiopulmonary arrest event at 12:45 PM, the ED physician did not give or document any specific treatment orders/instructions to the ED nursing staff for the definitive management and treatment of Patient N1's impaired respiratory symptoms (difficulty and labored breathing).

According to ED documentation and staff interview, the patient began to "brady-down" (heart rate slowed acutely). He/she became unresponsive with shallow respiratory efforts, and progressed into full cardiopulmonary arrest at 12:45 PM.

Patient N1 was subsequently intubated and resuscitated successfully at 12:55 PM. However, the patient remained unresponsive with "very little spontaneous movement"; was placed on a ventilator to support respiratory efforts; and remained hypotensive despite receiving several boluses of intravenous crystalloids in the ED.

Documentation by the ED physician included the following entry under the section titled 'Doctor Notes': "Patient in ER decompensated with Code initiated for bradysystolic respiratory arrest. Patient began to become bradycardic to asystole with respiratory arrest. Patient intubated and admitted to ICU. Discussed with family prior to arrest and afterwards regarding code status and options. Agreed to current plan of treatment."

A telephone interview, conducted on March 7, 2013 at approximately 2:39 PM with the ED attending responsible for the emergency care and treatment of Patient N1, revealed the following findings:

According to the physician, his/her "normal procedure" and usual practice was to review the ED nurse's triage notes and the ED record prior to actually evaluating ED patients assigned to his/her care.

The physician's stated reasoning was because he/she "likes to know what's going on with my patients before I go in to see them, unless they are critical".

In the case of Patient N1, the assigned ED attending acknowledged that he/she reviewed the triage notes documented by the ED nurse and wrote orders for diagnostic laboratory studies prior to his/her actual physical examination and evaluation of the patient, and forming a determination of the severity of the patient's presenting illness.

The ED attending further stated that he/she could not recall whether the triage nurse or the assigned primary care nurse reported their suspected acuity of Patient N1's condition to him/her before he/she reviewed the notes, entered the orders, and saw the patient.

When queried as to when he/she actually evaluated Patient N1 after his/her arrival: the attending stated that according to the "first scribe note written at 11:47", he/she "guesstimated" that he/she "had to have seen the patient within 30 minutes of [his/her] being placed in the cubicle...at least 15-30 minutes".

The ED attending acknowledged that after he/she completed his/her clinical assessment of Patient N1, he/she discussed 'Advance Directives' options with the family. The ED physician further added that he/she recognized the severity of Patient N1's illness, but did not expect the patient to "rapidly decline and crash" while she was in the ED.

The patient was subsequently evaluated by the ICU intensivist and admitted to the ICU at 2:39 PM.

The record review was completed April 22, 2013.