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CHRISTUS SOUTHEAST TEXAS- ST ELIZABETH 2830 CALDER AVENUE BEAUMONT, TX 77702 March 15, 2018
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on review of records and interview, Registered Nursing (RN) staff failed to take appropriate action upon evaluation of significant change in patient health status in 1 (patient #12) of 2 patients reviewed. The patient condition required Advanced Cardiac Life Support (ACLS) and intubation (a breathing tube placed in the airway and connected to a ventilator). The patient was determined to have neurological deficits in his arms and legs. While the patient was stabilized by the Emergency Department (ED) physician, none of the RNs involved in the patient care notified the attending physician of the decline in patient condition, resulting in an approximate 5-hour delay in the physician's evaluation of the patient.

Findings were as follows:

Review of patient #12's chart revealed on 12-18-2017 at 3:08 A.M. nursing staff, in response to an alarm from the patient's heart monitor, found the patient on the floor and without a pulse. Records indicated that prior to nursing staff entering the room, the patient had an unwitnessed fall, hitting his head. ACLS was started and a Code Blue was called. The ED physician responded and stabilized the patient. The patient was intubated and taken to the Intensive Care Unit (ICU) with orders for further x-rays, labs, and medications.

On 12-18-2017 at 3:40 A.M., the nursing examination noted that both arms and both legs were "flaccid" (soft and limp, without muscle tone). Records show the nurse notified the ICU Charge RN and the House Supervisor RN. No call was made to the attending physician to notify of this significant decline in patient condition. The attending physician did not see the patient until he rounded on the patient at 9:00 A.M.

On 3-14-2018, interview was conducted with Staff #53. Staff #53 confirmed that the investigation into the incident had not identified the delay in physician notification.

On 3-14-2018, interview was conducted with Staff #2. Staff #2 confirmed that the expectation would be that nursing would notify the attending physician immediately or as soon as possible after the event when there was such a decline in patient status.

Review of policies titled, "Admission Assessment/Reassessment", "Fall Prevention Protocol", and "Unanticipated Outcomes" addressed nursing notification of the physician. However, none addressed the expected time-frame for notification of a significant change in patient condition. This was confirmed by Staff #2.