HospitalInspections.org

During record review and interview, the facility failed to ensure nursing documentation and follow-up as required for 1 of 1 patient's (Patient #1) physician orders and specific disease processes to prevent adverse effects. The nurse failed to:

~ document an assessment for Patient #1 on the day shift of 4/14/2020;

~ notify the physician of Patient #1's refusal to utilize the ordered Bipap during the 4/14/2020 night shift;

~ administer Patient #1's sliding scale insulin for the 4/15/2020 Blood Sugar of 323;

~ notify the physician of Patient #1's 4/15/2020 85% oxygen saturation (02 Sat) given the order was to notify if 02 Sat < 88% on Oxygen; and

~ document the Epinephrine given during the code on the 4/15/2020 Patient #1's CPR record.

Findings included

There was no 4/14/2020 day shift assessment of the respiratory, cardiac, or abdominal/intestinal systems for Patient #1.

Patient#1's record reflected, "4/14/2020...History and Physical...acute on chronic respiratory failure with pulmonary embolus...Chronic obstructive pulmonary disease...Pneumonia...status post cardiac arrest...morbid obesity...coronary artery disease...diabetes...ankle ulcer...prior history of stroke...profoundly weak...critical illness myopathy...Nurse note: refused CPAP/bipap (supplemental oxygen delivery) last night. O2 (oxygen) via nasal cannula...4/15/2020...Nurse note: assessed at 7:08 (AM)...blood sugar 323 at 7:19...sliding scale order...301 to 350 give 8 units...(No insulin given)...Respiratory note: 7:08...(oxygen saturation Rate) Sp02 85%...heart rate 100...nurse asked for RT (respiratory) to check 02 sat 85% on 3 (liters) lpm. No distress noted. Neb tx (treatment) given. Post neb tx pt stated he wanted to use the bipap...Order notify (Physician) MD if 02 sat < 88% with supplemental oxygen...CPR Record...no meds document Discharge Summary...given 2 doses of epinephrine..."

During record review on 4/30/2020 ending at 5:43 PM, Personnel #4 was asked questions about Patient #1's documentation. Personnel #4 navigated the electronic record for answers and affirmation. Personnel #4 confirmed there was no 4/14/2020 day shift assessment of the respiratory, cardiac or intestinal systems. Personnel #4 confirmed there was no insulin given for the 4/15/2020 blood sugar of 323. Personnel #4 confirmed there was no documentation of physician notification of Patient #1's 4/14/2020 refusal to use bipap or low oxygen saturation rates.

During record review on 4/30/2020 ending at 19:05 PM, Personnel #1 was asked to review the Discharge Summary and confirm the CPR record did not reflect the Epinephrine given for Patient #1. Personnel #1 confirmed the documentation finding.

During a telephone interview on 5/1/2020 from 11:35 AM to 12:22 PM, Personnel #5 was the Patient #1's nurse 4/15/2020. Personnel #5 was asked what she was told in report from the off going nurse. Personnel #5 stated, "That he did not sleep with his bipap. I checked him, and did his assessment, he was fine."

Personnel #5 was asked about notification to the physician for Patient#1's low saturations. Personnel #5 stated, "When Respiratory came in and checked, it was 77%. They started the bipap/treatment. After treatment, his sats were better." Personnel #5 was asked if she notified the physician of Patient #1's 77% or 85% O2 sat per the orders - notify if 02 sats < 88%. Personnel #5 stated, "No, I did not notify him. I would have." Personnel #5 was asked if Patient #1 was coughing. Personnel #5 stated, "No."

Personnel #5 was asked if the Patient #1 received insulin for the blood sugar of 323 prior to the code. Personnel #5 stated, "No. It would have been the tech to perform (blood sugar) and I was not notified of that (blood sugar). There is a notification on the computer that eventually it will pop up - I did not see one. We did take a glucose at the code and it was okay."