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KENT COUNTY MEMORIAL HOSPITAL 455 TOLL GATE RD WARWICK, RI 02886 Oct. 4, 2018
VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**







Based on record review and staff interview, it was determined that the hospital failed to provide safe and effective nursing care for 4 of 8 sampled patients (patient ID #'s 1, 4, 7 and 8). The severity of this failure was determined to constitute Immediate Jeopardy.

Findings are as follows:

Hospital policy titled "Rapid Response Team", revised April 28, 2017 states, in part:

"...The purpose of this Rapid Response Team policy is to develop a means to intervene before a patient develops a serious medication condition, decrease code blue (cardiac or respiratory arrest) and transfers to ICU, and as a means to improve mortality rate ...

V. Procedure.

1. There is an acute change in the patient's condition.
The triggers for calling the Rapid Response Team will include but will not be limited to: ...
SpO2 (oxygen saturation level) less than 90%...
Acute Mental Status Changes ...
2. The RN calls the primary physician and also pages the Rapid Response Team to patient room ..."

A document labeled "Kent Hospital ...Physician's Orders," titled "Protocol for Prevention/Treatment of Acute Alcohol Withdrawal" revised 11/2012, states, in part:

" ...Complete Kent Acute Alcohol Withdrawal Assessment Scale (KAWAS) by Nurse: ...

If KAWAS > or equal to 5: PATIENT IS WITHDRAWING
i. Check Vital signs
ii. Administer appropriate Benzodiazepine per KAWAS Score
iii. Recheck KAWAS Score & Vital Signs 1 hour after administration of Benzodiazepine

If KAWAS < 5: PATIENT IS NOT WITHDRAWING, BUT MAY BE AT RISK
i. Check KAWAS score every 4 hours x 72 hours
ii. If at any time the KAWAS score > or equal to 5, then must resume the initial frequency of Q 1 hour ...."

1. Record review revealed patient ID #1 (MDS) dated [DATE] with progressive abdominal pain. The patient was admitted to a medical unit in the evening for the treatment of acute pancreatitis, pain medication management, and further workups.

The record revealed a physician's order dated 9/18/2018 at 12:48 PM for Telemetry (an observation tool/monitoring device that allows continuous cardiac and oxygen saturation monitoring). The record lacked evidence that the patient was placed on Telemetry monitoring, that the patient refused Telemetry or that the provider was notified that the Telemetry was not in place.

Review of patient ID #1's physician orders dated 9/18/2018 at 5:08 PM revealed the following:
" ...KAWAS Protocol ...q (every) shift, Use KAWAS Form under PRN (as needed) Task ...
...Vital Signs, Per KAWAS protocol ...
...Lorazepam 2 mg (milligrams)/ml (milliliter), IV push q1hr (hour), PRN KAWAS score 5-7 ...
...Lorazepam 4 mg/ml, IV push q1hr, PRN KAWAS score 8-13 ..."

Review of the subsequent KAWAS assessments and corresponding interventions revealed the following:

On 9/18/2018 at 7:00 PM the patient's KAWAS score was 8. The nurse administered Lorazepam 2 mg at 7:48 PM, instead of the ordered dose of 4 mg.

On 9/18/2018 at 10:00 PM, approximately 2 hours after the above noted administration of Lorazepam, the patient's KAWAS score had increased to 10. The assessment indicated he/she had suffered increased confusion and agitation. The nurse again administered Lorazepam 2 mg (at 10:14 PM) instead of the ordered 4 mg.

A nurse progress summary dated 9/19/2018 documented at 12:00 AM indicates "Patient is agitated, disoriented, restless, and thrashing in bed ..."

A nurse progress summary dated 9/19/2018 documented at 1:17 AM indicates the provider was notified for "Pt O2 status have been at 80% bumped up to 4 liters on nasal cannula and now 84%." The record lacked evidence of response by the Provider or that the nurse called the Rapid Response Team per protocol in response to the patient's change in condition and decreased oxygen saturation level.

A nurse progress summary dated 9/19/2018 indicates that at 2:13 AM " ...This RN went into the patient's room to recheck patients O2 sats and vital signs along with a KAWAS assessment. This RN immediately noticed patient was not breathing and pulseless. This RN called out to call a code and had another nurse call a code blue".

There lacked evidence that the patient was assessed by any provider or that the Rapid Response Team was called until code blue was called at 2:13 AM on 9/19/2018.

During an interview on 10/1/2018 at approximately 2:30 PM, the Risk Manager was unable to provide evidence that the nurse called the Rapid Response Team or that the patient was assessed by a provider following an acute change in condition. The Risk Manager was also unable to provide evidence that the Telemetry was done per physician's order or the hospital policy pertaining to KAWAS was followed.

2. Review of patient ID #4's physician orders dated 9/29/2018 at 5:08 PM revealed the following:
" ...Lorazepam 2 mg/1ml, IV push q1hr, PRN KAWAS score 5-7 ...
...Lorazepam 4 mg/ml (IV push q1hr (hour), PRN KAWAS score 8-13 ..."

Review of the subsequent KAWAS assessments and corresponding interventions revealed that on 9/30/2018 at 1:04 AM the patient's KAWAS score was 6. There lacked evidence that the nurse administered Ativan 2mg as ordered.

3. Review of patientID #7's physician orders dated 10/1/2018 at 1:37 PM revealed the following:
" ...KAWAS Protocol ...q (every) shift, Use KAWAS Form under PRN (as needed) Task ...
...Vital Signs, Per KAWAS protocol ...
...Diazepam 10 mg 1 tab ...q1hr, PRN KAWAS score 5-7 ...
...Diazepam 10 mg 2 tab ...q1hr, PRN KAWAS score 8-13 ..."

Review of the subsequent KAWAS assessments and corresponding interventions revealed the following:

A KAWAS assessment was documented on 10/2/2018 at 8:24 AM and due again at 12:30 PM but was not done until 9:50 PM (approximately 10 hours late).

A KAWAS assessment was documented on 10/3/2018 at 12:53 AM and due again at 10/3/2018 at 4:53 AM but was not done when the surveyor reviewed the record on 10/3/2018 at approximately 10:30 AM (more than 5 hours late).

4. Review of patient ID #8's physician orders dated 9/29/2018 at 2:21 PM revealed the following:
" ...KAWAS Protocol ...q (every) shift, Use KAWAS Form under PRN (as needed) Task ...
...Vital Signs, Per KAWAS protocol ...
...Lorazepam 2 mg/1ml, IV push q1hr, PRN KAWAS score 5-7 ...
...Lorazepam 4 mg/ml (IV push q1hr (hour), PRN KAWAS score 8-13 ..."

Review of the subsequent KAWAS assessments and corresponding interventions revealed the following:

A KAWAS assessment was documented on 9/29/2018 at 10:11 AM and was due again at 2:11 PM but was not done until 10/30/2018 at 4:22 AM (approximately 14 hours late).

A KAWAS assessment was documented on 10/1/2018 at 11:36 PM, and due again on 10/2/2018 at 3:36 AM but was not done until 8:09 AM (more than 4 hours late).

During an interview on 10/3/2018 at approximately 10:30 PM, the Risk Manager was unable to produce evidence that the above physician orders and /or protocol were followed for patient ID #s 4, 7 and 8.

The hospital failed to ensure safe and effective nursing care was provided for these patients.