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|LAWNWOOD REGIONAL MEDICAL CENTER & HEART INSTITUTE||1700 S 23RD ST FORT PIERCE, FL 34950||April 9, 2013|
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on clinical record review and staff interviews the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of nursing practice. This fialure affected 1 of 15 sampled patients (# 1) as evidenced by failure to reassess the patient as specified in the facility Nursing Assessment policies and procedures, and failure to follow physician orders.
The findings include:
Facility policy titled Unit Specific Assessment documents, " Emergency Department, initiate Assessment upon arrival, completion time for patients assessed to have an urgent condition, thirty minutes. Re-assessments is an assessment focused on the patient ' s presenting complaint and the initial subjective and objective triage assessment. The reassessment may include some of all of the following: vital signs, a focused physical assessment, general appearance, and or response to treatment. Priority 2, reassessment to be completed every hour if there is a change in condition and upon discharge or admission " .
Facility Policy titled Assessment and Reassessment Plan last revised on 02/2013 documents " The purpose and objective of the assessment and reassessment process is to provide the patient the best care and treatment possible; when seeking entry into the health care setting. Emergency Department: Following stabilization and after a Medical Screening Exam is completed, the patient will be evaluated to determine frequency of reassessment. Priority 1 and 2 patients will be reassessed every hour if there is a change in condition and upon discharge or admission. Assessment and re-assessments are documented in the computer and in the nurse ' s notes of the ED record. Abnormal findings in the assessment and or re-assessment are communicated verbally and or in writing to the Emergency Department physician " .
The facility Policy titled Vital signs in the ED: Normal and Abnormal, last revised on 12/20/12 documents " Abnormal vital signs shall be repeated as defined by this policy. The triage nurse will be notified immediately of any abnormal vital signs and abnormal vital signs are defined as adult systolic blood pressure greater than 160 or less than 90 and diastolic blood pressure greater than 100. Oxygen saturation below 95 % shall be considered abnormal and Respirations above 20. Hourly waiting room reassessments- The reassessments may include some or all of the following: vital signs focused physical assessments, general appearance and response to interventions although a very limited reassessment to ensure that acuity has not changed. Any patient with abnormal vital signs as defined above, pain or change in vital signs will be reassessed for possible change in priority.
The review of the clinical record for patient #1 disclosed the patient arrived at the ED on 03/26/13 at 12:14 AM with complaints of shortness of breath and pedeal edema.
The Rapid Initial Assessment conducted at 12:18 AM, by Nurse #1, documents the patient's vital signs as: blood pressure 181/108 on the right arm, and 191/116 on the left arm; Respirations 24 and Oxygen saturation 92 %. Based on the findings Patient # 1 was prioritize as apriority " 2 " - Emergent.
The documented parameters of the patient's initial vital signs, at 12:18 AM, indicates a blood pressure, Respirations and Oxygen saturation level that are abnormal values as per the facility's policy's stated ranges of "abnormal". The patient's systolic blood pressure is greater than 160 (181-left arm; 191 -right arm)); the diastolic is greater than 100 (108 - right arm; 116 - left arm); Respirations above 20 (24) and Oxygen saturation below 95% (92%). According to the stipulations of the policy these vital signs should be considered abnormal and warrants hourly reassessments in the waiting room. The reassessment for such a priority patient is to include reassment for possible change in priority condition.
The documented reassessments of patient #1 done at 1:17 AM, 2:17 AM and 2:34 AM, yield no evidence substantiating the patient's abnormal vital signs ( blood pressure, Respirations and Oxygen saturation) were reassessed as required and addressed as per facility policy.
Documentation of Nursing Assessment conducted at 4:00 AM documents the patient's respiratory status as "within defined parameters". The assessment does not document actual respiratory rate value, actual oxygen saturation percentage, or documents follow up on the patient's abnormal blood pressure.
Subsequent Nursing Assessment at 7:15 AM, by Nurse #2 documents, the patient has diminished breath sounds, shallow respiration; Oxygen saturation is 89 %; Oxygen applied at 3 liters and Oxygenation improved to 98 %. The Nurse's Note at 7:15 AM also documents the following: First contact with patient; patient in bed. Low oxygenation, pulse oximeter at 89 %. Patient not on any oxygen. Patient placed on 3 liters of oxygen via nasal cannula.
During interview with (the Triage) Nurse #1, who was on duty the night of 03/26/13, conducted on 04/08/13 at 10:46 AM. The Triage Nurse stated, it was a very challenging night; the ED was full. She stated Patient # 1 was stable; she did not recall if she monitored the patient ' s vital signs and Oxygen saturations while in the waiting area, upon inquiry. The Triage Nurse stated, reassessments involve assuring patients have not left the ED and/or have not experienced changes in condition.
This Nurse missed the fact the patient ' s initial blood pressure, respiration, and oxygen saturation were abnormal as defined in the facility policy and warranted continued hourly monitoring to include physician notification of changes in the patient's condition.
During interview with The Director of Emergency Services on 04/08/13 at 12:01 PM, the Director stated, reassessments are based on the triage findings and presenting symptoms. Patient #1 ' s vital signs and oxygenation should have been reassessed by the nurse.
The Director reviewed the clinical record and stated. the patient was taken to the treatment area at 3:48 AM, at that time, the nurse documented the patient was placed on Oxygen and on the cardiac monitor. The Director was not able to locate and provide evidence of Oxygen saturation level results, or the cardiac monitoring strips.
2) Physician Orders dated 3/26/13 at 1:56 AM documents Pulse Oximetry, Oxygen and Cardiac Monitoring.
Review of the clinical record for Patient # 1 failed to yield any evidence the patient was placed on the cardiac monitor while in the ED, per physician's orders.
Facility policy titled " Charting, Nursing Responsibilities " last reviewed on 02/05/13, document " paper documentation generated by the nursing staff will be placed in the appropriate section of the chart, e.g. rhythm strips, eMAR ' s and flow sheets. "
During the interview with The Director of Emergency Services on 04/08/13 at 12:01 PM. The Director reviewed the clinical record and stated, the patient was taken to the treatment area at 3:48 AM, at that time the nurse documented the patient was placed on Oxygen and on the Cardiac Monitor. The Director was not able to locate and provide readings or the cardiac monitoring strips.
During an interview with Registered Nurse #, who cared for Patient # 1, on 04/09/13 at 8:22 AM, the Nurse stated, the night in question was extremely busy, This Nurse was not able to provide evidence of Oxygen saturation levels or vital signs reassessments documented as haven been performed by her during her shift.
3) Facility policy titled " Medication Reconciliation " last revised 10/2011 documents, "The Medication Reconciliation process is initiated by the ED nurse or admission nurse for all inpatient admission or outpatients who convert to inpatient within 24 hours.
Admissions via the emergency room Department:
1. The ED Nurse completing the triage form will obtain a medication history including prescription, over the counter and herbal medications.
2. If the nurse is unable to obtain a complete medication history at the time of triage assessment, the home prior medication list can be updated at any time.
3. Once the decision has been made to admit the patient, the registered nurse or physician will use the ED Home/prior Medications Admission Order to reconcile the medications.
4. Once a patient is admitted to the receiving unit, the admitting RN will complete the verifying that all home/prior medications were addressed as entered into CPCS.
5. Physicians are responsible for continuing or discontinuing medications from the patient ' s prior mediation list.
Clinical record review disclosed Patient # 1 was admitted on [DATE] at 7:55 AM. Physician Order dated 03/26/13 at 4:10 PM documents " Patient to take home medications "
Further review of the Medication Administration Record dated 03/26/13 and 03/27/13 failed to provide evidence that home medications were reconciled as per facility policy within twenty four hours, or obtained and administered prior to the patient discharge on 03/27/13 at 3:28 PM.
Interview with the Registered Nurse who obtained the home medications and discharged the patient on 03/27/13 was not possible as reportedly this nurse is out of the countr.
Medication Reconciliation dated 03/27/13 at 1:27 PM documents Patient # 1 was taking the following medications at home, Soma 350 mg daily, Zocor 40 mg daily, Diovan/ Hctz 160/12.5 mg, Glucophage 1000 mg twice a day and Victoza 1.8 mg daily.
Interview with Registered Nurse # 2, who was assigned to care for Patient # 1, was conducted on 04/08/13 at 12:26 PM. The Nurse did not recall discussing with the patient, or obtaining, or having any concerns regarding the patient ' s home medications.
During an interview with the Chief Nursing Officer (CNO) on 04/08/13 at approximately 4:40 PM, the CNO stated., the facility policy is to reconcile home medications within twenty four hours of admission.