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| CHRISTUS MOTHER FRANCES HOSPITAL | 800 EAST DAWSON TYLER, TX 75701 | June 5, 2012 |
| VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING | Tag No: A0144 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview the facility failed to provide for the physical and emotional care of 1 of 1 patients reviewed. On 6/5/2012 at 8:30 am in the conference room the patient's medical record was reviewed and revealed the following: - Pt #1 was admitted through the Emergency Department (ED) on 1/2/2012 at 1920 hrs. The chief complaint retractable nausea, vomiting and dehydration. Abdomen soft, patient alert and oriented, calm and cooperative. - Orders for pt #1 include routine Intra-venous (IV) Reglan and as needed (PRN) Maalox plus 30 milliliter (ML) every 6 hours, Zofran 4mg orally disintegrating tablet (ODT) every 4 hours and Phenergan 25 mg IV every 4 hours PRN nausea and vomiting (N/V) and Morphine 4 mg IV every 4 hours for pain. 1/2/2012 the following medications were documented as given. - Pt #1 was given PRN Phenergan 25 mg at 2215 hrs - Pt #1 was given PRN Maalox plus 30 ml by mouth at 0415 hrs and was immediately vomited back out. - Pt #1 was given PRN Zofran 4 mg at 0020 hrs - Pt #1 was given PRN morphine 4 mg at 0329 hrs 1/3/2012 the 0705 RN patient assessment documents the pt as alert, oriented and abdomen distended. - Pt #1 was given his first full nursing assessment for the beginning of the shift 1/3/2012 - Pt #1 was given PRN Phenergan 4 mg at 0910 hrs - Pt #1 was give PRN Morphine 4 mg at 0910 hrs - Pt #1 complained of (C/O) nausea, and indicates he feels like when he swallows it gets stuck mid chest. (There was no documentation this information was relayed to the physician) - Pt #1 medical record does not reflect physician notification of reassessment of lack of effectiveness or pt relief of symptoms. - Pt #1 C/O Nausea and pain but declines the nurses offer of another dose of Phenergan and Morphine. - Pt's medical record dated 1/3/2012 documents the physician examined the patient, the medical record is not timed. The RN initiated the contrast for CT at 1630 hrs. - Pt #1 C/O nausea PRN Phenergan given and oral contrast started - Pt #1 unresponsive without pulse or respiration full code initiated. An interview with Pt #1 wife revealed the following: - Pt #1's wife requested a physician to examine her husband during the morning of 1/3/2012. _ - Pt #1's wife indicated she was told by the RN that the physician's were making rounds and would get to him but there were many patient's to be seen. - Pt #1's wife indicated that her husband through up "nearly constantly" but no one was there to help - 1/3/2012 at 1630 hrs Pt #1's wife stated that when the RN requested her husband drink the contrast fluid, she told the RN he had been throwing everything that went down, right back up, and that he could not drink the contrast fluid. - Pt #1's wife stated the RN told her he needed to try to drink as much as possible - Pt #1's wife was asked if the RN stayed in the room to insure her husband could safely swallow, Pt's #1's wife said "no" - 1/3/2012 at 1700 Pt #1's wife ran into the hall way screaming for help. Pt had slumped over in chair with out pulse or respiration. -1/3/2012 1720 hrs pt transferred to Intensive Care Unit status post Cardiac Pulmonary Resuscitation with large volume aspiration and anoxic brain injury. On 6/5/2012 at 1:30 PM the facility policy E-1 PATIENT ASSESSMENT AND REASSESSMENT. Policy 1.1...The assessment of the care and /or treatment needs of the patient is continuous throughout the patient's hospitalization . Procedure 2.4 a. Any significant change in the patient's diagnosis and/or condition necessitates an immediate re-assessment with changes in the plan if care reflecting the change in diagnosis or condition. 2.4 b. Patients are reassessed after treatment, therapy or education sessions to determine the effectiveness (extent of improvement) of the interventions undertaken by the health care team. 2.4 d. Routine reassessment should occur minimally every shift, and an in-depth reassessment should occur if patient changes level of care. 2.12 Reassessment of patient's needs is contingent on the urgency of the patient's condition and/or changes in the patient's condition. 2.13 The following factors are included in the assessment and reassessment of the patient: b. vital signs ...cardiac rhythm. c....fear, anxiety, support system, mental status coping mechanism... The facility failed to insure that RN staff evaluated the emotional as well as physical condition of the patient. The facility failed to insure the RN met the needs of a [AGE] year old man who entered the hospital with dehydration secondary to a 24-48 hours complaint of nausea and vomiting. The patient continued to exhibit nausea and vomiting with the addition of abdominal distention and pain that went unrecognized as significant by the lack of documentation of the changes and assessment of the patient's condition. The facility failed to insure the RN re-assessed the patient after the 0705 shift assessment and reported the changes in the patient's condition to a physician prior to the 4:30 PM rounding by the physician. The facility failed to insure that RN re-evaluate the effectiveness of PRN medication that were given this patient who exhibited recurrent N/V/Pain. |
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| VIOLATION: RN SUPERVISION OF NURSING CARE | Tag No: A0395 | |
| Based on record review and interview the facility failed to insure the registered nurse evaluated the care of 1 of 1 patients. On 6/5/1012 at 9:00 AM in the conference room the medical record of patient (Pt) #1 was reviewed and revealed the following: - 1/2/2012 at 1936 (7:36 pm) hours (Hrs) Pt #1 was first seen in the emergency department (ED)of the hospital. - Pt #1's chief complaint was documented as nausea and vomiting (n/v) which began 24-48 before. - 1/2/2012 at 2130 hrs pt #1 was admitted to the emergency admission (EAU) unit. The nurses narrative assessment documents the patient complained of (c/o) nausea during the assessment and the nurse paged the physician and requested medication for acid reflux. The assessment documents the patients abdomen is soft non-tender bowel sounds present in all 4 quadrants. Patient denies needs. -1/2/2012 2145 hrs physician's order from Dr#1 received- Maalox 30 milliliters(ML) Q6 (every 6 hours) prn (as needed) indigestion. -1/12/2012 at 2215 hrs the nurses narrative documentation records-nausea-phenergan 25mg given for nausea-Maalox given for indigestion-attempted to give medication-pt vomiting again-will continue to monitor. -1/2/2012 at 2250 hrs the nurses narrative assessment documents the patient is received to room 489-2 bowel sounds in all 4 quadrants abdomen soft. Pt c/o n/v med's (medications) given in EAU prior to receiving. will monitor every 1-2 hours. -1/3/2012 0015 hrs Pt c/o nausea see mar (Medication Administration Record) -1/3/2012 0250 hrs Pt c/o/ discomfort and pain to abdomen, Dr. #1 paged see pain flow sheet. -1/3/2012 0245 hrs physician's order from Dr. #1 - Morphine 2-4 MG (milligrams) Q6 hrs PRN pain -Shift change- -1/3/2012 0700 hrs report IPOC (Interdisciplinary Plan of Care) discussed with nurse, no needs voiced -1/3/2012 0705 hrs shift assessment complete...Abdomen distended... -1/3/2012 0910 hrs - pt c/o pain and nausea prn morphine/phenergan given. -1/3/2012 1100 hrs - Pt stated when he swallows it feels like it gets stuck in mid chest. Pt c/o nausea as well. -1/3/2012 1310 hrs - Pt c/o pain and morphine/phenergan offered, pt declines. - 1/3/2012 1416 hrs- Physician #6 left orders for CT scan of abdomen/pelvis with PO and IV contrast as well as lab. -1/3/2012 1630 hrs - PO (by mouth) contrast started,phenergan given for nausea. -1/3/2012 1700 hrs- Wife came out of room screaming for help Pt slumped over in chair code called. Pt had no pulse or respiration see code 44 sheet On 6/5/2012 at 11:00 am an interview with pt #1 wife revealed vomiting accompanied the patient's nausea. She stated she requested the RN contact the physician for pain medication because her husband was in pain. She stated the pain medication did not relieve the pain. She said the nausea medication did very little to relieve the nausea but seamed to make her husband agitated and as the day progressed he became very confused as well. She said that she told the Dr #6 as well as the nursing staff her husband could not hold old anything on his stomach. Both the Dr #6 and the RN told her that her husband needed to try to drink the contrast in order to complete the test. On 6/5/2012 at 2:00 pm an interview with staff #9 revealed that the liquid contrast for a radiographic testing is two (2) 16 ounce bottles of liquid. After instruction has been given the patient and family the contrast is left at the bed side to be sipped on until consumed by the patient. On 6/5/2012 at 1:30 PM the facility policy E-1 PATIENT ASSESSMENT AND REASSESSMENT. Policy 1.1...The assessment of the care and /or treatment needs of the patient is continuous throughout the patient's hospitalization . Procedure 2.4 a. Any significant change in the patient's diagnosis and/or condition necessitates an immediate re-assessment with changes in the plan if care reflecting the change in diagnosis or condition. 2.4 b. Patients are reassessed after treatment, therapy or education sessions to determine the effectiveness (extent of improvement) of the interventions undertaken by the health care team. 2.4 d. Routine reassessment should occur minimally every shift, and an in-depth reassessment should occur if patient changes level of care. 2.12 Reassessment of patient's needs is contingent on the urgency of the patient's condition and/or changes in the patient's condition. 2.13 The following factors are included in the assessment and reassessment of the patient: b. vital signs ...cardiac rhythm. c....fear, anxiety, support system, mental status coping mechanism... The nurse failed to document with in a reasonable time, the evaluation of effectiveness of the PRN nausea medication that was given. The nurse failed to document the evaluation of the pain medication that was given. The nurse failed to document communication with the physician regarding the change in the patient's condition from "abdomen soft to abdomen distended". The nurse failed to evaluate the patient and act as an advocate on the behalf of the patient. There was no documentation the physician had been notified or any new order received between the start of the nurses shift at 0705 and when the physician made his after noon round as 1416 hrs. |
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| VIOLATION: VERBAL ORDERS AUTHENTICATED BASED ON LAW | Tag No: A0457 | |
| Based on document review and interview the facility failed to insure physician's verbal orders were authenticated in a timely manner in 1 of 1 patient records reviewed. On 6/5/2012 at 1:00 pm in the conference room the medical record for patient #1 was reviewed and revealed two (2) verbal telephone orders were documented as received by nursing staff on 1/ and 1/3/2012 respectively. Both telephone orders were electronically signed and dated by physician #1 on 2/21/2012. On 6/5/2012 at 1:30 PM in the conference room the Chief Nursing Officer confirmed the orders were electronically signed greater than 30 days after they were verbally given to the nursing staff. |
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