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.


Based on interviews and record review the facility failed to ensure non-employee/travel licensed nurses who are working in the hospital are adequately supervised and evaluated of the clinical activities, which occur within the responsibility of the nursing services in 1 of 10 sample patients (Patient #5).

The findings included:

Patient #5 (MDS) dated [DATE], with complaints of Chest Pain, Weakness, and Hypertension for the last 3 days. The patient's history included underlining dementia and a fall one week prior. She was triaged for a possible Stroke Alert but she did not have the deficits to qualify for a Stroke Alert. The emergency department physician examined her and had her admitted to telemetry. The admitting physician had accepted the patient and given orders for telemetry. There was no bed available in telemetry, so a nurse from the telemetry unit was sent to care for the patient in the emergency department until the patient could be transported to telemetry. The nurse who was assigned to care for this patient, on 01/31/18 at 7:00 AM, is a non-employee/travel nurse.

The travel nurse stated that she was assigned to 5 patients. These patients were all in the emergency department hallway. She stated the nurse, whom she was relieving, told her that Patient #5 had a rough night, confused throughout the night and trying to climb out of the bed. The nurse had spent a lot of time with the patient because she was so confused. When she received report, the patient had fallen asleep. Within the hour, she was able to wake the patient and let her know that breakfast was there. The patient looked at her and said no to breakfast, "I am tired." She stated that given the fact the patient had been up most of the night, she did not see this as something to be concerned about at the time as the patient had a reason to be tired and worn-out.

The patient's daughter arrived at the hospital about 9:30 AM. The daughter was trying to wake her mother up and said the patient does not seem to be herself. She told the daughter the patient had a rough night and did not sleep much. She stated they attempted to arouse the patient and her blood sugar and vitals were checked. The travel nurse stated another nurse passed by when this was occurring, stopped, and helped her check the patient's blood sugar. She stated that she does not know who the nurse is. She stated the patient was not connected to telemetry when she was with the patient. She did not know the admitting physician's orders are in effect when given and the orders included the patient was to be on telemetry.

The travel nurse stated she and this other nurse agreed to call a Rapid Response. The code tracker log revealed the Rapid Response was called on 01/31/18 at 11:10 AM and the Stroke Code was called on 01/31/18 at 11:15 AM. This log does not indicate who called these codes. The travel nurse stated that she does not know who called the Rapid Response. She stated that she has never called a Rapid Response. She stated that once the patient was taken to CT scan and from there to the Intensive Care Unit, she was not involved with the patient.

The travel nurse stated that she remembers documenting vital signs on this patient and agreed that she did not document the Rapid Response or anything that occurred from that time on. She stated that she now realizes she should have documented and signed off on the patient, and will do so in the future. She could not account for why she did not follow through with documenting the nursing notes into the record.

Review of the travel nurse's documentation failed to include the Rapid Response call, patient's status, interventions, and signing off in the medical record. Review of the record revealed the only documentation in the medical record is from the physician who responded to the Rapid Response and Stroke Code.

The Director of Progressive Care & Telemetry, who had interviewed and agreed to have the travel nurse work on the telemetry unit, could not confirm the travel nurse had training or experience calling a Rapid Response or Stroke Alert Code and subsequently assisting with these.

The Patient Safety Officer confirmed that she and the Vice President Regulatory Compliance had reviewed Patient #5's medical record and interviewed the travel nurse who cared for the patient when the patient required a Rapid Response and Stroke Alert Code. They concluded the travel nurse failed to document any nursing notes including the change in the patient's condition, interventions that were taken, and sign off on the medical record when the patient was transferred to the Intensive Care Unit.

The Corporate Program Manager stated this travel nurse will be placed on the "Do Not Utilize" list.