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 policy review, document review, medical record review, and staff interview, it was determined the facility failed to ensure a registered nurse documented the care provided for one (#3) of five medical records sampled.

Findings included:

On 12/27/18 at approximately 10:45 AM, a review of Patient #3's physician history and physical (H&P) dated 11/23/18 at 1:37 PM showed the patient was admitted with a diagnosis of [DIAGNOSES REDACTED]&P showed the patient reported feeling well overall and well informed regarding the transplant process. The patient's medical record confirmed the patient received a stem cell transplant on 11/29/18.

A review of an abdominal x-ray report dated 12/04/18 at 12:32 PM showed air filled large and small bowel without evidence of bowel distention. The report finding indicated this gas could reflect an ileus (lack of intestinal movement). The abdominal x-ray was otherwise unremarkable.

On 12/04/18 at 6:47 PM, the patient's Advance Practice Register Nurse (APRN) ordered a Nasogastric Tube (NGT) on 12/04/18 at 6:47 PM for a suspected ileus.

A review of the APRN progress note dated 12/04/18 at 7:20 PM revealed documentation that the abdominal x-ray was consistent with an ileus and an NGT was to be placed for abdominal decompression.

A review of RN #A's documentation dated 12/04/18 at 9:35 PM showed that a 14 Fr (French gauge system is used to measure the size of a catheter) NGT was placed and confirmed by auscultation and chest x-ray. The note showed the patient tolerated the procedure well with minimal cough during insertion and stated he was well by nodding in the affirmative. No active bleeding was noted in the mouth or nares.

A review of the Rapid Response Team (RRT) document dated 12/04/18 at 10:00 PM showed the team responded to Patient #3's bedside for profuse bleeding from the mouth and nose, which was his occluding airway. The assessment indicated the patient was aspirating blood.

A review of the Code Blue Record dated 12/04/18 at 10:24 PM showed the patient was coding with no blood pressure, pule, respirations, or heart rhythm.

A review of RN #A's documentation dated 12/05/18 at 00:59 AM showed that approximately 10 minutes after the NGT was placed, the patient's family alerted the staff that patient began to bleed. RN #A went into the room and noted there was blood on the patient's face and chin. The patient began to desaturate his oxygen into the 80's and RRT was called. The NGT was removed and the patient's oxygen continued to desaturate, and a code blue was called at 10:00 PM.

On 12/26/18 at 1:00 PM, a review of the facility incident reports revealed the presence of an incident related to Patient #3 and placement of an NGT. The incident report showed that on 12/04/18, five days post-transplant, the patient developed abdominal distention, cramping, nausea and vomiting. The patient's bowel sounds were absent and an abdominal film was obtained for a suspected ileus (lack of intestinal movement). The APRN ordered a Nasogastric Tube (NGT). The nurse taking care of the Patient #3, (RN #A), who was a new nurse, had requested that a more experienced nurse place the NGT for her patient. The experienced nurse, Nurse #B, made one attempt to insert a 16 Fr NGT and was unable to, so he retrieved a smaller 14 Fr NGT. The placement of the 14 Fr NGT was again attempt without difficulties. Approximately 15 minutes after the placement of the NGT, bleeding was noted on the patient's face and the Patient #3 started to desaturate his oxygen and subsequently coded. The rapid response team (RRT) was called and the patient began to have seizures and loss of a pulse. At that time, a code blue was initiated and chest compressions administered.

A review of RN #A's personnel files showed she was still considered a new nurse and hired on 01/28/18. RN #A was under preceptorship until 01/28/19. RN #A's personnel file revealed a competency for placement of an NGT.

A review of the RN #B's personnel file revealed he had been an RN for several years and had a competency for placement of an NGT.

A review of the facility policy entitled, "Nursing Process, Assessment/Reassessment; Inpatient, #N-09, effective 05/2016, showed the following:
- Defines documentation standards in order to provide an accurate record of patient care, which meets institutional, as well as regulatory requirements.
- Provides a means to record the monitoring of the patient's status.
- Provides a means of communication about the patient's history and current stats via the Electronic Health Record (HER).
- Appoints responsibility and accountability with the RN for fulfilling documentation requirements, including related standards and policies.
- Reassessments will be performed by the RN, as appropriate, with documentation occurring in real time and minimally every shift (12 hours). Reassessments will note the patient's response to interventions and be performed in a time frame suitable for the intervention. Analysis of reassessments data may trigger additional interventions, and subsequent reassessments.

On 12/27/18 at approximately 1:30 PM an interview with the BMT Manager, CRO, and Patient Safety Consultant was performed. The BMT Manager stated she was not sure who put the tube in and "thought" that RN #B had put the tube in. The Manager confirmed that RN #A had stated she did not feel comfortable placing the NGT and asked RN #B to place the NGT. The BMT Manager, CRO, and Patient Safety Consultant all confirmed that Patient 3#'s medical record had no documentation of the two attempts to place the NGT by RN #B. All interviewees confirmed the only documentation in Patient #3's medical record of who placed the NGT was that of RN #A.

A review of Patient #3's physician discharge summary dated 12/08/18 showed a final diagnosis of [DIAGNOSES REDACTED]#3 to comfort measures only. The patient passed away at 4:17 PM on 12/08/18.

On 12/27/18 at approximately 4:25 PM, an interview with the CRO confirmed the above findings in Patient #3's medical record.