The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|OCHSNER CLINIC FOUNDATION||1516 JEFFERSON HWY NEW ORLEANS, LA 70121||Jan. 15, 2014|
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by:
1) failing to ensure 7 (#6, #R9, #R10, #R11, #R12, #R13, #R14) of 7 telemetry patients on the 9th floor were continuously monitored by staff.
2) failing to ensure a registered nurse performed an initial nursing assessment on admission to the unit for 1 (#3) of 12 (#1 - #12) patients reviewed.
3) failing to notify a physician of blood pressures beneath ordered acceptable ranges for 1 (#1) of 12 (#1 - #12) patients reviewed.
1) Failing to ensure telemetry patients on the 9th floor were continuously monitored by staff.
Review of a list provided by S6RNInterimDirector revealed there were 7 current patients (#6, #R9, #R10, #R11, #R12, #R13, #R14) on the 9th floor with orders for continuous telemetry monitoring.
Review of the medical record for Patient #6 revealed he was a [AGE] year old current patient admitted to the hospital with osteoarthritis and knee replacement.
Review of a Cardiac monitoring order for Patient #6 revealed an order dated 1/14/14 at 1:38 p.m. for continuous cardiac monitoring on the Post-Operative Surgical Services Unit (9th floor medical /telemetry).
Review of the medical record with S4RNDirector revealed Patient #6 was admitted on [DATE] at 4:40 p.m. Further review revealed telemetry monitoring did not begin registering until 6:59 p.m.
In an interview on 1/15/14 at 3:30 p.m. with S4RNDirector, she said Patient #6 had been admitted on [DATE] at 4:40 p.m. S4RNDirector said after reviewing the telemetry strip for Patient #6, she realized he had not received telemetry monitoring until 6:59 p.m., which was 2 hours and 19 minutes after admission. S4RNDirector also verified there were 7 current patients on the 9th floor unit with constant telemetry monitoring ordered, but there was not a person assigned to constantly visually monitor the telemetry screens. She said there was a telemetry monitor in the nurses' station and one monitor on each hall, but nobody was assigned to continually visually monitor telemetry screens for abnormal rhythms or changes in status. S4RNDirector verified if a nurse was in a patient's room, they would not be able to see any of the telemetry monitors or hear the alarms. S4RNDirector stated none of the patients in the hospital had continuous telemetry monitoring whereby staff is continuously visually monitoring telemetry screens.
In an interview on 1/15/14 at 3:54 p.m. with S32RN, she said she had admitted Patient #6 to the 9th floor on 1/14/14 at 4:40 p.m. S32RN said he had orders for continuous telemetry monitoring when he arrived from PACU (Post-Anesthesia Care Unit). She said she placed Patient #6 on a telemetry monitor when he arrived on the unit and a waveform appeared on the screen in the hallway. S32RN said an hour or so later, she realized his waveform was not on the screen anymore. S32RN said she did not know how long the patient was off of the telemetry monitor. S32RN said when she was in a patient's room she was unable to see or hear the telemetry monitor in the hall. S32RN also said when she is in a patient's room, she does not assign another nurse to watch her telemetry patient's monitor. S32RN verified if there was an employee assigned to continuously visually monitor telemetry patients they would have noticed immediately when Patient #6's waveform disappeared from the telemetry screen.
In an interview on 1/15/14 at 3:07 p.m. S3VPNursing, she said the 5th floor, 7th floor, 9th floor, 11th floor, CICU (Cardiac Intensive Care Unit), Oncology, and the transplant unit has telemetry monitoring but no monitor technician solely responsible for continuous visual monitoring of the telemetry screens. S3VPNursing said the telemetry monitors have not been continuously monitored by staff for at least 8 years at the hospital. S3VPNursing said the hospital had not performed any drills for response time to alarms or performed quality assurance since the telemetry monitor technicians were first eliminated.
2) Failing to ensure a registered nurse performed an initial nursing assessment on admission to the unit.
Review of the Policy entitled "Assessment and Reassessment (hospitalized Patients), Policy Number OHS.NURS.017, with a revision date of December, 2013, and presented as the current policy in place for Ochsner Health System revealed, in part, upon admission to a unit, a registered nurse will assess each patient to collect data, determine any immediate needs and make appropriate care assignments. It further revealed that patients will be re-assessed at the beginning of each shift at a minimum; upon transfer, admit or discharge from another unit; when a significant change in the patient's condition occurs; as per department standards; as per physician orders; and response to intervention.
Review of the document entitled "Post Operative Surgical Services Unit, Operational Standards" (Policy #: 6177-2) revised in October, 2013, and presented by S4RNDirector as the current policy in place for the 9th Floor revealed, in part, that the staff nurse assigned to an admission will complete the initial assessment within one hour, and the admission assessment/data collection must be obtained by an RN (Registered Nurse).
Patient #3 was a [AGE] year old female admitted on [DATE] at 7:20 a.m. with an admitting diagnosis of [DIAGNOSES REDACTED][DIAGNOSES REDACTED], and Left Bundle Branch Block.
Review of Patient #3's medical record revealed a Left Total Complete Mastectomy was performed on 06/03/13 with no complications during the surgical procedure.
Review of Patient #3's physician admission orders to the 9th Floor dated 06/03/13 and timed by S28RN at 4:29 p.m. revealed the physician had ordered vital signs "per unit routine." Further review of Patient #3's medical record revealed S28RN was the nurse who admitted Patient #3 to the 9th Floor on 06/03/13 when Patient #3 arrived to the 9th Floor at 2:34 p.m.
Review of the Nurse's Notes revealed the nursing documentation entered by S28RN on 06/03/13 at 3:00 p.m. did not include an initial nursing assessment and a vital signs assessment on Patient #3. Further review of the Nurse's Notes dated 06/03/13 at 3:00 p.m. revealed documentation under the section labeled "Coping" and "Coping Interventions." The Initial Admit Patient History which included medication reconciliation, immunization history, and medical history was documented on 06/03/13 at 7:18 p.m. by S28RN. Further review of the Nurse's Notes dated 06/03/13 revealed that an initial nursing assessment and a vital signs assessment for Patient #3 was not documented until 8:00 p.m. on 06/03/13.
In an interview on 01/15/14 at 1:35 p.m., S20IS (Information Services) verified there was no documentation in the medical record that Patient #3 had an initial nursing assessment and a vital signs assessment when Patient #3 was admitted on [DATE] at 2:34 p.m. S20IS also verified Patient #3 did not have an initial nursing assessment and vital signs assessment documented on 06/03/13 until 8:00 p.m.
In an interview on 01/15/14 at 1:45 p.m., S4RNDirector verified "per unit routine" (for vital signs) meant that vital signs were to be assessed every 4 hours. S4RNDirector confirmed Patient #3 did not have an initial nursing assessment and vital signs assessment when admitted on [DATE] at 2:34 p.m., and did not have an initial nursing assessment and vital signs assessment until 8:00 p.m. on 06/03/13. S4RNDirector also confirmed that Patient #3 should have had an initial nursing assessment and vital signs assessment on admission to the 9th Floor on 06/03/133 at 2:34 p.m.
3) Failing to notify a physician of blood pressures beneath ordered acceptable ranges.
Review of the medical record for Patient #1 revealed she had been admitted on [DATE] and transferred to the 9th floor (medical/telemetry) on 4/9/13 at 3:34 p.m. with diagnoses which included small bowel obstruction, Hypertension, Type II diabetes and End Stage Renal Disease.
Review of the Physician's Orders dated 3/31/13 revealed an order to notify the physician if the Systolic Blood Pressure was less than 90 or if the Diastolic Blood Pressure was less than 60.
Review of the vital sign flow sheet for Patient #1 revealed the following Blood Pressure entries after admission to the 9th floor:
4/9/13 at 7:50 p.m. - Blood Pressure 106/49 (diastolic below 60).
4/10/13 at 12:15 a.m. - Blood Pressure 95/54 (diastolic below 60).
4/10/13 at 9:00 a.m.- Blood Pressure 95/33 (diastolic below 60).
Review revealed none of the Blood Pressures that were below physician notification parameters had been rechecked for accuracy. Further review revealed no documentation of physician notification of decreased blood pressures on 4/9/13 or 4/10/13 until 9:15 a.m. on 4/10/13.
Review of nursing documentation for Patient #1 dated 4/10/13 at 2:29 a.m. by S17RN revealed the following entry: Agree with assessment done by S14RN on 4/9 at 7:50 p.m.
In an interview on 1/15/14 at 2:30 p.m. with S4RNDirector, she said the nurse taking care of Patient #1 on the night of 4/9/13 and morning of 4/10/13 was S14RN. S4RNDirector said S14RN was a new nurse at the time with about 8 weeks of orientation. S4RNDirector said S14RN's preceptor was S17RN. S4RNDirector said she could not locate any physician notification for Patient #1's decreased blood pressures on 4/9/13 and 4/10/13 until 9:15 a.m. on 4/10/14. S4RNDirector verified the diastolic ranges were below what had been ordered for notification by the physician. S4RNDirector said the physician should have been notified about the decreased blood pressures on 4/9/13 and certainly before 9:15 a.m. on 4/10/13.
|VIOLATION: UNUSABLE DRUGS NOT USED||Tag No: A0505|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interviews and record reviews, the hospital failed to ensure outdated or otherwise unusable drugs were not available for patient use as evidenced by observation of the 9th floor medication refrigerator revealing 1 (#R8) of 4 (#R5, #R6, #R7, #R8) patient specific medications were expired and 3 ((#R5, #R6, #R7) of 4 (#R5, #R6, #R7, #R8) patient specific medications were for patients that had been discharged from 4 to 213 days.
Review of the hospital policy titled Expiration (Beyond Use) Date monitoring, Policy #: 1-2-1, Reviewed 7/8, revealed in part:
All expired medications should be separated into individual bags and placed into expired medication bins located behind the refrigerated carousel in the central pharmacy.
Pharmacy technicians are assigned a specific area and are responsible for assuring that no expired drugs are present in their assigned section.
Review of the hospital policy titled Inspection of Medication Storage Areas, Policy #: 8610-PC-35, Review Dates: 9/06, revealed in part:
Medications must be properly and safely stored throughout the hospital and clinic areas. Each department is responsible for inspecting the medication storage areas within their control.
2. The manager/director for each area is responsible for meeting the safety/storage standards for medications.
5. All expired, damaged, and/or contaminated medications are segregated until they are returned to the hospital pharmacy.
The hospital could not provide a policy on the required removal of patient specific multidose medications from the Pyxis refrigerator after patients were discharged .
Observation of the Pyxis medication refrigerator on the 9th floor on 1/13/14 at 9:30 a.m. revealed the following:
Patient #R5- Opened Regular Insulin multi dose vial with the patient identifier information covering the medication name and expiration date. Review of the census sheets for the 9th floor revealed Patient #R5 had been discharged from the hospital since 1/9/14 (4 days).
Patient #R6- Insulin pen Humalog mix 75/25. Review of the census sheets for 9th floor revealed she had been discharged since 11/15/13 (59days).
Patient #R7- A bottle of Xtandi 40 mg (milligram) capsules. Review of the census sheets for 9th floor revealed Patient #R7 had been discharged on [DATE] (213 days).
Patient #R8- 2 bags of Cefazolin 1 g (gram)/50ml (milliliters). 1 bag had expired on [DATE] at 10:00 p.m. and 1 had expired on [DATE] at 8:30 a.m. Review of the Medication Administration Record for Patient #R8 revealed the medications had been discontinued on 1/11/14 at 3:13 p.m.
In an interview on 1/13/14 at 9:40 a.m. with S6RNInterimDirector, she said all of the patients' medications were kept in the Pyxis (automatic medication dispensing machine). S6RNInterimDirector said if patients were discharged or medications were discontinued, the medications were supposed to be placed in a bin inside the Pyxis for the pharmacist to retrieve. S6RNInterimDirector verified the above mentioned medications should have not been in the Pyxis Refrigerator available for use.
In an interview on 1/13/14 at 10:00 with S7Pharmacist, he said the pharmacy was supposed to check the refrigerators for expired medications or unusable medications monthly. S7Pharmacist said once a patient was discharged or a medication was discontinued, the nurses were responsible for moving the medications to a bin in the Pyxis to be picked up by the pharmacy. S7Pharmacist verified the above mentioned medications in the Pyxis refrigerator on the 9th floor should have been removed when the medications expired or the patients were discharged .
In an interview on 1/14/14 at 1:07 p.m. with S16VPPharmacy, she said pharmacy technicians should be checking the Pyxis refrigerators monthly for expired medications. S16VPPharmacy said the technicians should have also discovered the medications remaining for the discharged patients.