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SAINT JOSEPH LONDON 1001 SAINT JOSEPH LANE LONDON, KY 40741 Aug. 17, 2012
VIOLATION: NURSING SERVICES Tag No: A0385
This condition was not met as evidenced by:

Based on interview, medical record review, and review of facility policies, it was determined the facility failed to ensure a Registered Nurse supervised and evaluated the nursing care of patients in the facility. Based on medical record review Patient #1 experienced hypotension (low blood pressure) on 08/12/12 beginning at 2:35 PM, when facility staff obtained a blood pressure (BP) reading of 70/45, and continuing at 3:05 PM, when Patient #1's BP was 82/38, at 3:25 PM, when the patient's BP was 60/48, and at 3:27 PM, when the patient's BP was noted to be 62/38. According to documentation and interview, after facility staff obtained Patient #1's BP on 08/12/12, at 3:25 PM, a Charge Nurse at the facility called Patient #1's physician to inform him of a change in the patient's condition. However, on 08/12/12, at 3:30 PM, Patient #1 was found by staff to be without a heart rate and without respirations, and cardiac/pulmonary resuscitative measures were implemented. Patient #1 responded to staff's resuscitative efforts and was transported to the Intensive Care Unit for continued evaluation and treatment. Interview and review of the medical record revealed Registered Nurses at the facility failed to adequately assess Patient #1, failed to inform the patient's physician of a change in his/her medical condition for approximately 50 minutes after the patient's blood pressure was initially assessed to be low, and failed to implement interventions to address the patient's low BP from 2:35 PM on 08/12/12 until 3:25 PM on 08/12/12. At 3:30 PM on 08/12/12, Patient #1 was observed by staff to be without a heart rate and respirations, and cardiac/pulmonary resuscitative measures were implemented. Based on the findings, Immediate Jeopardy was identified on 08/17/12, and the facility was out of compliance with the Conditions of Participation at 42 CFR 482.23 Nursing Services (A0385) and the associated Standard at Nursing Services, Registered Nurse Supervision (A0395).

Refer to 42 CFR 482.23, A0395.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on interview, record review, and review of facility policy it was determined the facility failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care of one of ten sampled patients (Patient #1). Patient #1 was admitted by the facility on 08/08/12, with diagnoses to include Chest Pain and Alzheimer's Dementia. According to documentation, on 08/12/12, at 2:35 PM, Patient #1's blood pressure (BP) was 70/45 (normal range 120/80), at 3:05 PM, the patient's BP was 82/38, at 3:25 PM, 60/48, and at 3:27 PM, the BP was 62/38. Documentation revealed RN #2 (Patient #1's primary nurse) was notified by facility staff at 2:35 PM and 3:05 PM, of Patient #1's low blood pressure readings, however, nurse's notes revealed no evidence that an assessment of the patient was conducted or that interventions were implemented. At 3:25 PM, Patient #1's physician was notified of the low BP by the floor Charge Nurse. At 3:30 PM, Patient #1's family member stepped into the hallway requesting assistance and when staff entered the room the patient was found without a heartbeat and without respirations. According to the Code 700 (Respiratory/Cardiac Arrest) report, Cardio/Pulmonary Resuscitation (CPR) was initiated by facility staff. Patient #1 responded to staff's resuscitative efforts and was transported to the Intensive Care Unit for continued evaluation and treatment. Based on the findings, Immediate Jeopardy was identified on 08/17/12, and the facility was out of compliance with the Conditions of Participation at 42 CFR 482.23 Nursing Services (A0385) and the associated Standard of Nursing Services: Registered Nurse Supervision (A0395).

The findings include:

A review of the facility policy, "Chain of Command/Significant Change in Patient Condition/Contacting Physician," dated 05/22/12, revealed the purpose of the chain of command policy was to provide a process to communicate significant changes in patient condition to the physician as well as to obtain a necessary intervention in patient care. Significant changes in the patient's condition were to be reported to the primary physician, unless otherwise ordered, such as the cardiologist or surgeon. If the caregiver was unable to contact a physician in a timely manner for changes in patient condition or needed additional assistance in discussing patient condition with the physician, the following chain of command was to be implemented: RN, Charge Nurse, Clinical Manager or House Supervisor, Departmental Medical Leadership, Chief of Staff, Senior Leadership, or Administrator on call.

A review of the facility policy, "Vital Signs Protocol," dated 08/16/10, revealed on a routine basis staff was to obtain vital signs (temperature, pulse, respirations, and blood pressure) on each patient every four hours.

A review of Patient #1's medical record revealed the facility admitted the patient on 08/08/12, with diagnoses to include Chest Pain and Alzheimer's Dementia. A physician's order dated 08/08/12, revealed Patient #1's vital signs were to be obtained on a "routine" basis. Further review of the physician's order revealed staff was to notify the physician if Patient #1's systolic BP was greater than 160 or less than 90, and/or if the patient's diastolic BP was greater than 110 or less than 50. On the day Patient #1 was admitted to the facility, 08/08/12, facility staff assessed the patient's BP at 7:42 AM, as 154/60.

A review of Patient #1's vital signs obtained by facility staff on Sunday, 08/12/12 (four days after admission), at 10:45 AM, revealed Patient #1's BP was 136/62. The patient's vital signs were obtained again by Nurse Aide (NA) #2 on 08/12/12, at 2:35 PM (approximately four hours after the previous blood pressure), and BP was noted to be 70/45; documentation revealed the primary nurse was notified. Based on documentation in the nurse's notes, a "late entry" by the primary nurse, dated 08/12/12, revealed at 3:00 PM (25 minutes after the previous BP), NA #2 informed her that Patient #1's BP was 78/32, however, there was no documentation the patient's physician was notified at that time, and the NA had not documented the 78/32 BP anywhere in the medical record. Continued review of the medical record revealed the patient's blood pressure was obtained again at 3:05 PM, by RN #1 (the covering nurse while the primary nurse was at lunch) and was noted to be 82/38, and although the patient's primary nurse was notified there was no documentation the physician had been notified of the patient's continued low BP.

According to the medical record, the Charge Nurse obtained Patient #1's BP at 3:25 PM, 20 minutes after the previous BP, and noted the patient's BP was 60/48 in the left arm and 62/38 in the right arm at 3:27 PM. Documentation revealed the Charge Nurse notified the physician of Patient #1's BP after the BP at 3:25 PM, had been obtained.

Although Patient #1's physician was informed of the patient's low BP at 3:25 PM, based on documentation, the facility failed to notify Patient #1's physician of the patient's low BP for 50 minutes after facility staff obtained the first low BP reading at 2:35 PM.

Further review of the medical record revealed the primary nurse assessed Patient #1 at 3:30 PM, and observed the patient had a "blank stare" and was "drooling" from the mouth. Documentation revealed at that time Resident #1's pupils were "pin-point," the patient did not respond to commands, was moved from the chair to bed, and was assessed to be without respirations and no palpable pulse. Further review of the nurse's note revealed a "Code 700" was "initiated" and chest compressions were started. Patient #1 responded to staff's resuscitative efforts and was transported to the Intensive Care Unit for continued evaluation and treatment.

A review of the Code 700 record revealed on 08/12/12, at 3:30 PM, CPR was initiated when Patient #1 was without a heartbeat and no respirations.

Interview with NA #2 on 08/16/12, at 11:00 AM, revealed she had obtained Patient #1's BP at 2:35 PM, noted the BP was 70/45, and immediately called the patient's primary nurse, who was at lunch, to inform her of the low BP. According to NA #2, at that time the primary nurse told the NA she would "be right back."

Interview with NA #1 on 08/16/12, at 10:00 AM, revealed she had been Patient #1's primary nurse aide on 08/12/12. However, NA #1 stated at approximately "2:00 PM," NA #2 obtained the patient's BP and informed her Patients #1's diastolic BP was "38." NA #1 stated at that time she obtained Patient #1's BP, noted the BP was "82/38," and informed the covering nurse. Further interview with NA #1 revealed after she informed the covering nurse of Patient #1's low BP she went to assist another staff member with another patient. NA #1 stated when she returned to Patient #1's room approximately, five minutes later, she asked Patient #1's family member, who was in the room, if the primary nurse had been into Patient #1's room. According to NA #1, the family member informed her the patient's primary nurse had not assessed the patient and had informed the family member she was in the process of a patient transfer. Interview further revealed at that time Patient #1 was very lethargic and when NA #1 went out into the hall after speaking with the family member, she informed the Charge Nurse of the "situation" with Patient #1. NA #1 stated the Charge Nurse obtained Patient #1's BP and that she overheard her say, "I am going to check [his/her] MAR" (medication administration record). However, according to the NA, "after approximately 10 minutes" she heard the family member say Patient #1 was not responding.

Interview with the covering nurse on 08/16/12, at 8:49 AM, revealed on 08/12/12, she had provided care for Patient #1 during the primary nurse's lunch break. The covering nurse stated "around 3:00 [PM] maybe a little after" NA #1 informed her that she had obtained a BP reading of "82/36" from Patient #1. The covering nurse further stated she "went right in," obtained Patient #1's BP of 82/38, and informed the patient's primary nurse who had returned from lunch of the patient's BP. The covering nurse stated she was not aware of what Patient #1's BP normally ran and she did not notify the physician since the primary nurse was back from lunch. Continued interview with the covering nurse on 08/16/12, at 5:28 PM, revealed she had not been in-serviced by the facility on what to do when a resident experienced a change of condition. However, the covering nurse stated she had 22 years of experience as a nurse and acknowledged she knew what she was supposed to do when a patient had a change of condition.

Interview with Patient #1's primary nurse on 08/16/12, at 11:10 AM, revealed she been assigned to provide care for Patient #1 on 08/12/12. The primary nurse stated she had gone to lunch from 2:30 PM to 3:00 PM on 08/12/12, and that "around 3:00" PM, NA #2 called her during her lunch break, informed her Patient #1's BP was "78/32," and that the covering nurse had rechecked the BP and obtained a reading of "82/38." The primary nurse further stated when she returned from lunch she had another patient with chest pain and an elevated BP, who she had received orders prior to lunch to transfer to the Cardiac Special Care Unit, and was unable to transfer prior to lunch due to no bed available. The primary nurse stated at around 3:15 PM, she was in the process of transferring the other patient when Patient #1's family member approached her in the hall to inform her that Patient #1's BP was low. She explained to the family member she was transferring another patient and she "would check it when she came back." The primary nurse further stated that she returned to the floor at 3:25 PM, and the Charge Nurse was in the room checking Patient #1's BP. The Charge Nurse had obtained a BP reading of "60/40" and had informed her she was going to call the physician. The primary nurse stated she immediately went into Patient #1's room where the patient was sitting in a chair and observed the patient's color to be "very pale." According to the primary nurse, Patient #1 was "drooling," and his/her pupils were "pinpoint." The primary nurse further stated Patient #1 did not respond to commands so she and two other staff members moved the patient from the chair to bed where the patient was found to have no pulse and no respirations. Further interview revealed at 3:30 PM, staff initiated CPR on Patient #1. Patient #1 responded to staff's resuscitative efforts and was transported to the Intensive Care Unit for continued evaluation and treatment. Continued interview with the primary nurse on 08/16/12, at 5:13 PM, revealed she had not been in-serviced by the facility on what to do when a patient experienced a change of condition. The primary nurse further stated she had never been in a situation like the one on 08/12/12, where she had two critical patients at the same time and she could not recall the facility in-servicing staff on what to do when something like that occurred. The primary nurse stated her supervisor had always said if there were ever problems staff could call the supervisor, however, the primary nurse stated the supervisors "aren't there on Sundays."

Interview on 08/17/12, at 11:30 AM, with Patient #1's family member, who stated he/she is a Respiratory Therapist with 22 years of medical training, revealed facility staff had obtained the first low BP reading at approximately 2:20 PM to 2:30 PM. The family member stated a second staff person came into Patient #1's room and obtained the patient's BP and the BP was still low. The family member stated 15 to 20 minutes later NA #1 came into the patient's room and informed the family member she had notified the primary nurse of the patient's low BP. Further interview revealed at approximately 3:15 PM, the family member found Patient #1's primary nurse in the hallway and asked the nurse if she had informed Patient #1's physician of the patient's low BP. According to the patient's family member, he/she was informed by the nurse she had not called the physician, she was transferring another patient, and would check Patient #1's BP when she returned. Interview with the family member revealed between 3:15 PM and 3:30 PM, Patient #1's color was getting a "dusky" look and the patient's lips were becoming cyanotic (blue colored) so the family member asked another nurse to assess Patient #1. Further interview revealed the Charge Nurse came into Patient #1's room, rechecked the patient's BP, and noted the BP was still low. The family member stated at approximately 3:25 PM to 3:30 PM, Patient #1 became nonresponsive and the family member went into the hall and requested assistance. Interview further revealed the Charge Nurse came back into the room at approximately 3:30 PM; staff called a "Code" (Code 700) and initiated CPR on Patient #1.

Interview with Patient #1's primary physician on 08/16/12, at 3:00 PM, revealed a systolic BP below 75 could cause problems. The physician stated Patient #1's BP was "perfectly fine" prior to this and one hour was too long to wait to contact him of Patient #1's low BP. The physician further stated he can "handle hypotension when brief on any floor" if he was informed of the patient's BP status prior to the patient coding. The physician further stated staff had contacted him regarding Patient #1's low BP between 3:30 PM and 3:40 PM, and while he was on the phone with facility, staff informed him that Patient #1 "coded." Patient #1's primary physician stated when a patient experienced a change of condition they need to contact the physician.