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OTTUMWA REGIONAL HEALTH CENTER 1001 E PENNSYLVANIA OTTUMWA, IA 52501 Dec. 14, 2012
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of documentation, policies/procedures, and medical records and staff interviews, the facility failed to provide medical care and continuous monitoring that met the needs of patients with acute medical diagnosis that were dependent on a naso-gastric tube to treat intestinal obstruction. Hospital administrative staff reported approximately 4 patients per month in the Medical-Surgical (Med-Surg) nursing unit required a naso-gastric tube and the unit had an average daily census of approximately 23 patients. The Med-Surg unit had a current census of 30 patients and no patients with a naso-gastric tube.

Although nursing staff were aware of factors that posed a risk to the patient's dependent on continuous monitoring and management of naso-gastric tubes to treat intestinal obstruction, the facility failed to ensure:

- all patient's admitted to the med-surg unit received care and treatment in accordance with hospital policies and nursing standards of practice. (A-0392)

- med-surg nurses followed physician orders to connect the naso-gastric tube to intermittent suction to aspirate intestinal contents to treat intestinal obstruction. (A-0392)

- med-surg nurses notified the physician of acute changes in patient status. (A-0392)

- med-surg certified nursing assistants notified nursing staff of acute changes in patient status. (A-0392)

- med-surg nurses followed policy and procedure for gastrointestinal assessment of patient's with NG tubes. (A-0392)

The cumulative effect of these systemic failures and deficient practices resulted in the facility's failure to prevent a significant change in Patient #1's condition that resulted in a Code Blue and cardiopulmonary resuscitation. These efforts were not successful and Patient #1 died .
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of documents, policies/procedures, job descriptions, medical record and staff interviews, Medical/Surgical (med-surg) nursing staff failed to follow physician's orders in the care of 1 patient (Patient #1) with a nasogastric (NG) tube (a tube that is passed through the nose and down through the nasopharynx and esophagus into the stomach, used to remove contents small solid materials, gastric secretions and fluid and to decompress the stomach).

The Chief Quality Officer identified an average monthly census of approximately 4 patients with NG tubes. There were no current patient's with a NG tube in the hospital at the time of entrance.

The Med-Surg nurse manager identified an average daily census of approximately 23 patients on that nursing unit.

Failure to follow physician's orders for use of an NG tube prevented removal of gastric fluids or materials from the Patient 1's stomach and placed the patient at increased risk for inhaling these stomach fluids or material into the lung.

Findings include:

1. Review of Patient #1's medical record revealed the following:

- A Emergency Department (ED) nursing clinical report, dated 4/5/12 at 7:55 PM, showed the patient reported abdominal pain, nausea and vomiting that started on 4/4/12. The patient reported no bowel movements for 2 days. The patient vomited several times for a period of 6 hours while in the ED. ED nursing staff administered medications to treat the nausea and vomiting four times and a narcotic analgesic medication to treat pain two times before the patient was transferred to the Intensive Care Unit (ICU) at 2:33 AM on 4/6/12.

- A ED physician clinical report, dated 4/5/12 at 9:00 PM, showed the patient complained of severe vomiting and abdominal cramping with intermittent pain. The patient had a past history of partial colectomy (a removal of a portion of the large intestine for a blockage).

- A abdominal x-ray report, dated 4/5/12 at 9:58 PM, showed a diagnosis of ileus (a blockage of the small and/or large intestine) versus partial small bowel obstruction (a blockage of the bowel that prevents stool from passing and eliminated from the body).

- Physician C reviewed the results of x-rays to the patient's abdomen with Primary Care Physician D at 9:56 PM and the hospital admitted the patient to ICU at 2:33 AM.

- A physician admission order sheet, dated 4/5/12 and un-timed, showed orders to admit the patient to ICU, NPO (nothing by mouth) and a request for surgical consultation from a physician for intestinal obstruction.

- A history and physical, dated 4/6/12, revealed, in part, the [AGE] year old patient presented with a 2-day history of nausea, vomiting, and abdominal pain that was sharp in nature and constant involving the whole abdomen, a fever with shivering and chills on 4/6/12. The patient had a surgical history of colectomy (an operation to remove all or part of the large intestine) for ischemic bowel (inadequate flow of oxygenated blood to the intestines) and a possibility of Pneumonia. The patient's expected duration of stay in the hospital would be 2-3 days. Condition on admission was guarded (a medical term used to describe an uncertain outcome of a patient's condition).

- General Surgeon B documented the following in Patient#1's medical record on, 4/6/12 at 7:20 AM. The Patient's abdominal pain, nausea and vomiting started on 4/5/12. No bowel movement (BM), no flatus (gas generated in or expelled from the digestive tract, especially from the stomach or intestines). Crampy [sic], severe generalized abdominal pain, some fever. Tender and distended. The surgeon diagnosed recurrent small bowel obstruction.

- On 4/6/12 at 7:20 AM, General Surgeon B ordered an NG tube to Low Intermittent Suctioning (LIS) (alternating periods of suctioning by a mechanical device - this would pull contents of the stomach back through the NG tube, past the nose into a closed container positioned next to the patient's bed).

- A nursing progress note from the ICU unit, dated 4/6/12 at 9:25 AM, documented, insertion of an NG tube at LIS with an immediate return of 800 cubic centimeters (cc) brownish/yellow liquid. (800 cc's is approximately 3-1/3 cups.)

- A Computed tomography (CT) scan (a type of computerized x-ray) report dated 4/6/12 at 1:35 PM, showed the patient had a history of abdominal pain and bowel obstruction. The report showed a diagnosis of moderate small bowel obstruction.

- General Surgeon B's problem note, dated 4/7/12 at 7:28 AM, revealed, in part, no flatus or stool, 1300 cc back immediately after an NG was inserted. The Patient was more comfortable with NG and the abdomen was less distended (swelling of the abdomen).

- An abdominal x-ray report, dated 4/7/12 at 9:19 AM, showed a diagnosis of a probable mild to moderate ileus (when the rhythmic contractions that moves material through the bowel stops) and less likely bowel obstruction (blockage or a twist that prevents passage of material through the bowel), unchanged from 4/5/12.

- The nursing plan of care, dated 4/7/12, identified the patient was at risk for aspiration with the goal that the patient would exhibit no signs or symptoms of aspiration. The care plan failed address the fact that the Patient had an NG tube and a diagnosis of possible ileus or bowel obstruction.

- Nursing patient progress notes from the ICU, dated 4/7/12 from 1:00 AM to 11:00 PM, revealed, in part, nursing staff monitored the patient's bowel sounds every 4-6 hours and documented they were hypoactive (delays in the gurgling, rumbling, or growling noises from the abdomen caused by the muscular contractions of peristalsis, the process that moves the contents of the stomach and intestines downward). The patient complained of intermittent episodes of abdominal tenderness and nausea. The total output from the NG tube for 22 hours was 450 cc of light greenish and yellow colored stomach contents (approximately 1-3/4 cups).

- General Surgeon B's order, dated 4/8/12 at 10:00 AM, revealed, in part, clamp NG, if no nausea/vomiting discontinue the NG tube at 4:00 PM and begin a clear liquid diet.

- Nursing patient progress notes from the ICU, dated 4/8/12 at 10:52 AM, showed ICU nursing staff clamped the patient's NG. Clamping the NG tube prevents stomach contents exiting the stomach either by gravity or suction.

- Nursing patient progress notes from the ICU, dated 4/8/12 at 12:42 PM, revealed, in part, 20 minutes after eating the patient complained of nausea, LIS started. At 1:14 PM, nursing staff documented the patient complained of nausea and 500 cc of thick contents from the NG (approximately 2 cups). The patient's bowel sounds were hypoactive.

- An abdominal x-ray report, dated 4/8/12 at 1:55 PM, showed a diagnosis of a probable mild to moderate generalized adynamic ileus and less likely any small bowel obstruction, unchanged compared to 4/7/12 and 4/5/12.

- Nursing patient progress notes from the ICU, dated 4/8/12 at 5:08 PM, revealed, in part, unable to clamp NG to LIS, patient nauseated this afternoon.

- Nursing patient progress notes from the ICU, dated 4/9/12 at 5:08 AM, revealed, in part, patient has emesis of 1000 milliliter (ml) (approximately 1 quart) of light tan foul smelling liquid. Patient states it tastes like stool. Reconnected to LIS, immediate return of 800 ml (approximately 3-1/3 cups) of tan liquid.

- General Surgeon B's problem note, dated 4/9/12 at 7:30 AM, revealed, in part, some low grade fever, vomited through the night, was clamped awhile yesterday. 3200 cc (about 3 quarts and 1 cup) NG drainage. Ileus versus possible small bowel obstruction.

- An abdominal x-ray report, dated 4/9/12 at 10:10 AM, showed a diagnosis of a probable mild generalized adynamic ileus and less likely partial bowel obstruction with some mild improvement since 4/8/12.

- A nursing patient progress note from the ICU, dated 4/9/12 from 7:23 to 7:50 AM, showed the patient's abdomen was distended, tender, nauseated and bowel sounds very hypoactive. The patient reported being anxious, scared, and wants to go home. 300 ml of yellow/brown NG drainage and the NG to LIS. Nursing staff continued to monitor and document the patient's status every 4-6 hours. At 7:45 PM the drainage from the NG was foul, with BM odor present, and light brown in color.

- General Surgeon B telephone staff and ordered them to transfer the Patient to the med-surg unit on 4/10/12 at 9:00 AM. The physician signed the order at 11:00 AM.

- A patient progress note from the ICU dated 4/10/12 from 5:00 AM to the time the patient transferred to the med-surg unit at 10:15 AM, revealed, nursing staff monitored and documented the patient's status every 4-6 hours. 1000 ml (approximately 1 quart) of NG tube drainage was emptied at 5:00 AM and the patient's abdomen firm to touch. ICU Registered Nurse (RN) A documented a nurse to nurse report given prior to discharge.

- Review of nursing patient progress notes from med-surg unit found no gastrointestinal assessment (a standard nursing evaluation of the patient's abdomen to check for swelling, bowel sounds, touching the stomach to determine if it is soft and non-tender and asking the patient is they have nausea, vomiting, and are passing flatus or stool) from the time the patient arrived to the med-surg unit to 3:26 PM, a period of approximately 5 hours.

At this point the NG tube was clamped for a total of 5 hours.

- Patient progress notes from the med-surg unit dated 4/10/12 at 3:26 PM, completed by RN B, revealed, the patient's bowel sounds were hypoactive and the abdomen was firm. The patient complained of abdominal pain of 10 on a scale of 0-10. The NG tube remained clamped during that time.

During an interview on 12/19/12 at 12:15 PM, regarding the care RN B provided to Patient #1 on 4/10/12, RN B reported she cared for the Patient from 10:15 AM to 6:30 PM. RN B said she was aware of the physician's order to connect the NG tube to LIS and failed to follow this order. RN B further stated the Patient did vomit while in her care and she failed to notify the physician, connect the NG tube to LIS as ordered by the physician, or document the characteristics, color, and amount of emesis. RN B verified the NG tube remained clamped while in her care, (8 hours and 15 minutes).

- Patient progress notes from the med-surg unit dated 4/10/12 at 6:17 PM, revealed, the patient complained of nausea, vomiting and a PRN (as needed) medication given for stomach upset and tenderness. The patient continued to complain of abdominal pain of 8 and refused vitals because the Patient was too nauseous and the patient vomited.

At this point the NG tube was clamped for a total of 8 hours.

- Patient progress notes from the med-surg unit, dated 4/10/12 at 8:01 PM, completed by RN C, revealed the patient's lung sounds were diminished (decreased air movement in the lungs), the NG tube remained clamped, the patient complained of nausea and vomiting, and abdominal pain of 7. The patient's progress notes lacked a gastrointestinal assessment.

At this point the NG tube was clamped for a total of 9.5 hours.

- Patient progress notes from the med-surg unit, dated 4/10/12 from 8:01 PM to 11:56 PM, lacked follow up nursing assessments of the patient's status.

At this point the NG tube was clamped for a total of 13.5 hours and 2 med-surg nurses had been assigned to provide care to the patient.

- During an interview on 12/13/12 at 3:45 PM, RN C confirmed med-surg nurses are responsible for assessing patient's for changes in condition frequently throughout the shift, notifying physicians of any changes, and performing a complete gastrointestinal assessment. RN C acknowledged Patient #1 complained of nausea and vomiting and confirmed the physician order for the NG to LIS. RN C stated if the patient had a history of bowel obstruction the nurse should assess for bowel sounds at least once every shift. RN C stated she did not know why she failed to assess Patient #1's bowel sounds and attach the NG to LIS.

- Review of RN C's personnel file showed counseling report forms dated 3/20/12 and 4/13/12. Areas identified on the forms identified RN C received written disciplinary action of job performance including but not limited to the following areas:
a. Physician notification with follow up with any status change is patients reported by the CNA who is assigned to work with you.
b. Proper documentation that portrays actual events and critical thinking on real time events.
c. Incomplete intake and output along with vitals when primary cares are being completed.
d. Incomplete reports at the end of shift.

The Supervisor who signed the written disciplinary action on 4/13/12 documented any further issues will cause further disciplinary actions up to and including termination. Staff C was not in agreement with the areas identified on the report and did not sign the report.

- Patient progress notes from the med-surg unit dated 4/11/12 at 1:15 AM showed Certified Nursing Assistant (CNA) D reported the patient was lying very still, warm to touch, and had shallow respirations. However, review of patient progress notes lacked notification to the nurse that the patient had shallow respirations.

At this point the NG tube was clamped for a total of 14.5 hours and there had been no further nursing assessments and/or reassessment of the patient for about 5 hours.

- Patient progress notes from the med-surg unit dated 4/11/12 at 1:50 AM showed Respiratory Therapist E reported responding to Code O (code blue) on the patient, Cardiopulmonary respiration (CPR) started and CPR stopped at 1:58 AM and Patient #1 died .

- An abdominal x-ray report dated 4/11/12 at 7:38 AM and interpreted on 4/17/12, showed a diagnosis of significant small bowel obstruction at the level of mid to distal jejunum (a section of the small intestine that is close to the stomach).

- Review of discharge summary completed by Physician A on 4/15/12 revealed, the patient was admitted on ,d+[DATE] and expired on ,d+[DATE]. The patient presented with nausea, vomiting and abdominal pain. Abdominal films revealed ileus versus small bowel obstruction patterns. On 4/11 the Patient continued to show obstructive patterns. On the night of 4/11, the Patient was found unresponsive. It appeared the Patient had regurgitated or vomited a significant amount of material around the NG tube and probably aspirated.

Final diagnosis on the discharge summary revealed, probable aspiration pneumonia (a respiratory infection that is caused when food or fluids are aspirated - or inhaled - into the lungs causing and infection in the lungs and can prove deadly if not treated) in a patient with persistent and refractory small bowel obstruction.

2. Interviews included the following:

- During a telephone interview on 12/18/12 at 5:55 PM CNA D confirmed the record lacked documentation that the nurse was notified of the above mentioned event. CNA D said she thought the patient was sleeping very deeply and was not alarmed. CNA D stated she had never taken care of Patient #1 before that night and had no further contact with the patient after 1:15 AM. CNA D said standard CNA practice would be a verbal report at the beginning of the shift from the CNA leaving and then CNA staff would go into the patient's room to check on the patient.

- During a telephone interview on 12/19/12 at 8:15 AM, Physician A confirmed med-surg nurses are responsible for for following physicians' orders. Physician A said he was not aware that nursing staff failed to attach Patient #1's NG tube to LIS for 14.5 hours prior to the Code being called and stated the nurses inappropriately cared for the patient.

- On 12/14/12, the Executive Director of Clinical Operations, presented a document of his review of Patient #1's chart. Review of the document revealed, in part:
-- Nursing care appropriate for patient when in the ICU setting, as the patient continued to have NG to LIS, and lots of return of stomach contents during the ICU stay.
-- Upon transfer from ICU to med-surg the NG was clamped. Again at 3:17 PM it is documented NG was clamped despite order of NG to LIS.
-- At 3:26 PM, [Staff B] does assessment and documents NG tube clamped.
-- At 4:32 PM emesis occurs.
-- At 5:58 PM emesis occurs again.
-- At 6:17 emesis occurs again and a GI assessment is done and patient was made NPO and PRN (as needed) medication given for nausea.
-- At 8:01 PM, [Staff C] documented NG clamped.
-- At 1:50 AM Code Blue occurred. Code continued and eventually called.
-- Conclusion: Appropriate care occurred when this patient was in ICU. However, upon transfer to the med-surg unit, the NG remained clamped, however it was ordered to LIS. This caused the patient to have emesis, and potentially could have lead to complications.

3. Review of facility job description for RN's on the med-surg unit, reviewed 10/07, addressed defining the role and responsibility of the registered nurse in terms of assessment and implementation and evaluation of appropriate nurse care per hospital policies and procedures and consistent and expanding critical thinking skills. (Critical thinking involves trying to figure out something; a problem or an issue and actively and skillfully applying, analyzing and/or evaluating information.)

- Review of facility job description for CNA's on the med-surg unit, reviewed 10/07, addressed defining the role and responsibility of the CNA in terms of reporting to the licensed nurse any change in patient condition.

4. Review of facility policy titled "Intake and Output Assessment," last reviewed 3/31/12, outlined measures to monitor calculating total intake and output including vomitus, and drainage from NG tubes and measuring and recording the type and amount of drainage from the NG tube in the patient's medical record. Additionally, the policy instructed nurses to assess and record the patient's status and notify the physician of any abnormal findings.

During an interview on 12/14/12, the Executive Director of Clinical Operations acknowledged nurses are provided ongoing education regarding hospital policies and procedures and confirmed the nurse should notify the physician of abnormal findings and stated, "This is standard."

5. Review of facility policy titled "Nasoenteric-Decompression Tube Management", last reviewed 10/6/12, addressed defining the role and responsibility of the registered nurse in providing care and continuous monitoring of the NG tube to ensure potency, maintain suction and bowel decompression and to maintain precise intake and output records as an integral part of the patient's care. Additionally, the policy directed the registered nurse to record output and monitor for peristalsis to resume by assessing bowel sounds, passage of flatus and abdominal distention and documenting this information in the patient's medical record.

- During an interview on 12/14/12 at 12:00 PM, the Executive Director of Clinical Operations said the hospital did not have a policy for gastrointestinal assessment. However, it would be nursing standard taught in nursing school, that a head-to-toe assessment of the patient included assessment of the patient's bowel sounds, abdominal tenderness and distention, monitoring for nausea and vomiting and monitoring the color and consistency of NG output, at the very least every shift. Additionally, he confirmed this would be a part of the orientation process and the check list of basic nursing skills for registered nurses on the med-surg unit and the nurse would be responsible for notifying the physician of any changes in the gastrointestinal assessment.