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NYACK HOSPITAL 160 NORTH MIDLAND AVENUE NYACK, NY 10960 May 13, 2016
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on medical record review, document review and interview, it was determined the nursing staff did not perform timely reassessments and monitoring of a patient when his condition deteriorated. This was found in one (1) of 12 medical records reviewed. (Patient #1).

Findings include:

Review of medical record for Patient #1 revealed the following: Patient #1 presented to the emergency department (ED) on March 12, 2016 at 4:41 PM, with a chief complaint of abdominal cramping, pain and fever for 2 days. The patient was alert and oriented to person, place and time, he was in no acute distress and his vital signs were temperature 103 F, pulse 115, respiration 20, blood pressure 154/82 and the oxygen saturation was 98% on room air.

On March 13, 2016 at 3:30 PM, the patient's heart rate increased to 140 (normal range 60 - 100) and the temperature increased to 104.6 F (normal is 98.6 F) at 4:30 PM that day.
At approximately 6:00 PM, the patient's oxygen saturation decreased to 89% (normal range 96-100% on room air) and the respiratory rate increased to between 22 - 26 (normal range 12 - 20 breaths per minute). The patient was given oxygen, nebulizer treatments, Tylenol and the antibiotic was changed. There is documentation in the medical record that the family also reported the patient had mild confusion at 5:00 PM and 50 cc of urinary output that day.

The documentation in the medical record noted that the patient's oxygen saturation was reevaluated at 7:48 PM, approximately 2 hours after it decreased to 89% at approximately 6:00 PM. The oxygen saturation was noted to be 94% at 7:48 PM while the patient was on oxygen. The vital signs and oxygen saturation were not reassessed until another 10 hours later at 5:30 AM, when the patient's heart rate was 120 beats per minute, respiratory rate had increased to 40 breaths per minute, and the oxygen saturation was 88% on 4 liters of oxygen.

There was no documented evidence of reassessment and continuous monitoring of the patient's changed condition. The patient was subsequently diagnosed with hypoxic respiratory failure secondary to Bilateral Pneumonia with Effusions, gram negative blood cultures (Sepsis), a liver abscess and low serum phosphorous.

The facility policy titled "Assessment and Reassessment of Patients," last revised 1/16, states patients are reassessed "following a change in the patient's condition or level of care." The policy also states "all patients are reevaluated to determine response to specific treatment, and when a significant change occurs in the patient's condition or diagnosis."

The findings were shared with the Director of Risk Management on May 13, 2016 at 3:15 PM.