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CAPITAL REGIONAL MEDICAL CENTER 2626 CAPITAL MEDICAL BLVD TALLAHASSEE, FL 32308 April 3, 2014
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interviews, patient record reviews and review of the facility's policies and procedures, the facility failed to ensure that patient care provided by certified nursing assistants (CNAs) was supervised and evaluated to ensure that the CNAs were operating within their scope of practice as regulated by the State of Florida Administrative Code Law 64B9-15.002; failed to ensure a complete admission assessment of the patient's current physical status following surgery and failed to perform an accurate reassessment for a change in patient's condition for three of four open/closed medical records reviewed. (#1, #2 and #3)

The findings include:

1. On 04/02/2014 at 1:37pm an interview was conducted with certified nursing assistant (CNA) "B" who was working on the progressive care unit. The staff member was asked about any special training she had received in regard to her job duties or any special care tasks that she performed for her patients. CNA "B" stated that she had received specialized training to perform finger stick blood sugar testing but stated that the hospital had changed that policy about three months ago and now the nurses were responsible for doing that testing. CNA "B" then stated that sometimes she would suction the patients' tracheostomies. She stated that when she noticed the patients making sounds that indicated they may have "stuff" in their tracheostomy she would suction them to clear the tracheostomy out. She explained that she was a CNA and a medical assistant (MA) and that she was currently in nursing school. CNA "B" was then asked if the hospital had provided her with any training in regards to tracheostomy suctioning and she stated that "No" they had not. She stated that she had a daughter with a tracheostomy and that was where she had learned to perform suctioning and care for the tracheostomy and so if she has a patient that needs suctioning or if the patient needs a new water bottle then she would just go ahead and do it for them. CNA "B" was then asked if she felt as if she had adequate training to perform her job and she stated that she felt as if she was really "over qualified" .

Review of the State of Florida Administrative Code Law 64B9-15.002, which contains the authorized duties allowed for certified nursing assistants, showed that " A certified nursing assistant shall not perform any task which requires specialized nursing knowledge, judgment, or skills, and a certified nursing assistant shall not work independently without the supervision of a registered nurse or a licensed practical nurse." Specific Authority 464.202, 464.203 FS. Law Implemented 464.203, 464.2085 FS. History-New 9-21-06.




On 04/03/2014 at 9:44am an interview was conducted with the Unit Director of the Progressive Care Unit. The unit director was asked to explain what role CNAs play in the care of tracheostomies and she stated that CNAs are there to assist the nurse as needed. The unit director was then asked if CNAs were allowed to perform tracheostomy suctioning and she stated "No, CNAs are not allowed to suction a tracheostomy under any circumstances." She went on to explain that CNAs are not even allowed to change the tracheostomy ties. The unit director was also asked if CNAs are allowed to change the fluid bottles for patients with humidified tracheostomies and she stated that "No" either respiratory or the nurse would be responsible for changing the water bottles for humidified tracheostomies.

2. On 04/02/2014 a closed record review was conducted for patient #1, who underwent a vaginal hysterectomy on 04/01/2014. There was a pre-admission assessment performed on 03/31/2014, prior to the patient's surgical procedure. The patient was admitted on to the facility's Family Care Unit on 04/01/2014 at 16:25 (4:25pm). The admission assessment was incomplete. The Electronic Medical Record (EMR) revealed "Neurologic Assessment" and "Genitourinary Assessment" as "N" which means not within defined parameters. The patient's pain level was rated a "7" and indicated medicated for breakthrough pain, but failed to identify current use of a Patient Controlled Analgesia Unit (PCA pump- pain pump) or an intravenous (I.V.) site. The record did identify the presence of a urinary catheter - indication as "detail peri-op use". There was was no assessment to identify the presence or [DIAGNOSES REDACTED]l bleeding - or identification of the presence of a perineal pad. The nurse currently caring for patient #1 identified that the patient came to the unit with a pain pump system and peri-pad in place.

3. On 04/03/2014 a closed record review was conducted for Patient #2. Patient #2 was admitted through the ED (Emergency Dept.) to the Critical Care Unit (CCU) on 02/05/2014. There was a physician order written at 20:34 (8:34pm) for "nasal cannula 2 liter/minute. Titrate O2(oxygen) up to 4 liters per minutes to maintain O2 saturation > 92%. Notify attending physician if O2 requirement exceed 4 liter/nasal cannula." Nurse note indicates "1900 report received care assumed. Dr. __ in on rounds, new order to decrease IVF (IV fluids) rate to 75ml/hr. Call in am for possible transfer orders to PCU (progressive care unit) pending how patient does tonight per physician". 1915 (7:15pm) vital signs reveal heart rate (HR) 75, respirations (R) 22, blood pressure (BP) 92/45 and an oxygen saturation(O2 sat) of 91% [below physician prescribed parameter]. 1946 (7:46pm) oxygen saturation 100%. The medical record identifies an initial assessment completed by the RN at 20:00 (8:00pm) that reveals .... "Oxygen at 2.0 L via nasal cannula (nc). ....No acute resp distress noted". Heart Rhythm: "paced". 20:00 (8:00pm) P - 76, R 19 , BP 86/40 - No acute respiratory distress noted. - mod[erate] edema. [no oxygen saturation level noted]. 02/06/2014 - 2100 (9:00pm) HR 76 - R 19 - BP 88/52.

Next nursing assessment performed at 02/06/2014 2333 (11:33pm) under Reassessment Comment (page 14), "Assessment findings unchanged since last assessment." There was no other documentation including no vital signs, no oxygen saturation levels noted. There was a BP recorded at 11:00pm 99/56. At 0002 ( 12:02am, now 02/17/2014 - the patient's HR 75 - R 27 - BP 92/52.

There was a "respiratory therapy" note that indicated at 0027 (12:27am) patient's oxygen saturation 98% on 2 liters of oxygen [no other information documented]. 1:00am - HR 75, R 24, 87/48 [no oxygen saturation noted]. 02/07 0115 (1:15am) R 27; 02/07 0130 (1:30am) R 29; 02/07 0145 (1:45am) R 30. [The 0115, 0130, 0145 entries were all acknowledged and entered into the medical record after 0300 - late entries].

The patient respiratory rate was noted to increase, beginning at 1:00am to 1:45am - but there was nothing in the patient's record to identify nursing interventions, or the condition of the patient.

Interview on 04/03/2014 at approximately 2:30pm with the Director of CCU (critical care unit) indicates respiratory alarms are set based on manufacturer's recommendation - the parameters can be narrowed, but cannot be expanded. The Director of CCU indicated the respiratory rate alarm parameters are set at 5 to 30 per minutes and nurse to patient staffing ratios are usually 2 patient to 1 nurse.

It was not identified in the medical record if Patient #2's alarms sounded.

There was Nursing documentation at 03:48am that indicated "0150 (1:50am) change in resp[iration] pattern noted, daughter at bedside states mother breathing is different, noted decreased breath sound, daughter questioned how much O2 (oxygen) pt (patient) was on, informed 2L/min nc, daughter states uses 3-4L/min nc at home, increased O2 to 3L/2L/min nc. Left room to page physician and resp[iratory]. While paging physician, charge nurse called to room by daughter, writer returned to bedside, charge nurse and writer noted patients resp[irations] become agonal (gasps) and code blue was called. (2:00am)

Patient subsequently intubated and placed on mechanical ventilator. New orders were obtained.

Post code nursing assessment - none noted.
Nursing Assessment documented on 02/07/2014 at 0400 (4:00am) - under Reassessment Comment (page 14), "Assessment findings unchanged since last assessment." Nursing assessment fails to accurately assess Patient #2's current physical condition; patient now on ventilator.

Patient #2's medical record failed to indicate the assessment of oxygen saturation rates to ensure, per physician orders - that the patient's oxygen saturation level was maintained at or above 92%. The record fails to identify the condition of the patient or nursing interventions when a change in the patient condition were identified. Post resuscitative procedure -the record fails to identify a nursing assessment and fails to reflect an accurate, complete assessment at 0400, as per the facility's policy and procedure, in a Unit in which the patient requires a higher level of care and monitoring. This writer was unable to ascertain patient's respiratory effectiveness and whether current oxygen administration dose were adequate to sustain the patient's oxygen saturation at or above 92% due to lack of documentation.

4. On 04/03/2014 a closed record review was conducted for Patient #3. Patient #3 was admitted to the facility on [DATE] through the Emergency Department with a diagnosis of [DIAGNOSES REDACTED]%." A review of the record, with the assistance of the Risk Manager, vital signs recorded at 20:30 (8:30pm) heart rate (HR) 123, blood pressure (BP) 107/69 and respirations (R) 13. Unable to locate patient's oxygen saturation level. There was a nursing assessment performed at 20:00 (8:00pm) Additional entries in the record record vital signs at 20:45 (8:45p) - P 119. 21:45 (9:45pm) P 126 - resp 25; 2200 (10:00pm) - P 118, R 9; 2215 (10:15pm) P 123, R19. An additional nursing assessment (per facility policy - every 4 hours), performed at 2356 (11:56pm) indicates "Assessment unchanged".

Last oxygen saturation level located in the record was performed at 17:36 (5:36pm), which was 95% on a 35% Oxygen flow rate. Record entry on 02/23/2014 at 12:00am - the patient's oxygen saturation was record at 77%, BP obtained at 12:36pm was 115/72. There was no documented intervention in the record to address the patient's decrease in oxygen level or was there an indication the physician was notified.

On 04/03/2014 at approximately 3:30pm, an interview was conducted with the Director of CCU, she indicated she would have expected that someone with a low oxygen saturation - to notify the physician, get respiratory therapy involved and would expect an assessment of the patient's condition.

Additional review of the record, revealed an additional nursing assessment performed on 02/23/2014 at 3:34 am, "Assessment findings unchanged since last assessment."

A review of the facility's policy and procedure entitled "Patient Assessment and Reassessment" - Policy number: NUR-035, indicates "A. Initial Screening Assessment. The comprehensiveness and frequency of screening and assessments will be dependent upon a number of factors, including patient needs, program goals, and the care, treatment and services provided as well as patient response. Initial screening and assessments may indicate the need for further data collection or a more intensive or specialized assessment. At a minimum, the need for further assessment is determined by the care, treatment and services and any significant changes in patient condition. In addition to the assessment factors listed above, an initial assessment, will include: 1. Assessment of the patient's current physical condition." "C. Reassessment: ...... 3. Reassessment may be specified/regular intervals related to: a. The patient's response to care, treatment & services b. The patient's response to a significant change in status or diagnosis/condition c. To satisfy legal or regulatory requirements d. To satisfy pre-determined intervals specified by organizational policy or protocol e. To meet time intervals determined by the course of care, treatment and services provided to the patient f. To meet changing discharge planning needs when appropriate in the scope of care of the department involved"