HospitalInspections.org

Based on review of medical record, nursing notes, respiratory therapy notes,
physician progress notes, interviews, nursing schedule and review of policy and procedures, hospital staff failed to maintain a patent airway for Patient Identifier (PI # 1) by failing to assure PI # 1's left wrist was restrained to prevent the patient from removing (self extubating) the Endotracheal Tube (ETT, airway catheter inserted in the trachea during endotracheal intubation to assure patency of the upper airway by allowing for maintenance of an adequate air passage, medical-dictionary.thefreedictionary.com) connected to the ventilator, (mechanical air or oxygen pump used to maintain breathing in a person unable to breathe spontaneously. Ventilators provide an intermittent flow of air or oxygen under pressure and are connected to the patient by a tube inserted into the windpipe (trachea) either through the mouth or nose).

As a result of this deficient practice, PI # 1, a patient with a known history of respiratory and cardiac disease, was placed in a potentially life threatening situation on 1/2/17 due to staff's failure to reapply the wrist restraint. Additionally, PI # 1 required extensive monitoring because she was receiving intravenous medications for sedation in order to tolerate the ETT and maintain blood pressure.

This affected PI # 1, one of ten sampled patients and had the potential to affect all patients admitted to the hospital.

Findings Include:

Refer to A-144.

Based on medical record review, interviews and review of policy and procedure, staff failed to investigate a serious incident involving Patient Identifier (PI # 1), a patient with a known history of respiratory and cardiac disease, who self removed her ETT (Endotracheal Tube) connected to a ventilator while in wrist restraints. (ETT: Performed as an emergency procedure when a patient can't breathe on their own. A flexible plastic tube is placed into the trachea (windpipe), usually through the mouth to help breathing, healthline.com). The failure of staff to secure the wrist restraint placed PI # 1 in a potentially life threatening situation. Furthermore, staff failed to report and investigate the incident. This affected one of ten sampled patients, but has the potential to affect all patients who are admitted to the Long Term Acute Care Hospital (LTAC) and experience an adverse event.

Findings include:

Refer to A-286

Based on reviews of medical records, Initial Nursing Assessments, "WoundRounds" (comprehensive wound documentation system), interviews and review of policies and procedures, the hospital failed to thoroughly assess patients' wounds (also known as pressure ulcers, decubitus) on admission, weekly and at discharge. As a result of this deficient practice some wounds were not identified on admission, some wounds were not photographed and/or measured. Two wounds were acquired in the Long Term Acute Care Hospital (LTAC). Some wounds deteriorated potentially causing pain and discomfort to six of ten sampled patients. Because of these deficient practices, the ability to determine the progression of patients' wounds was compromised. This deficient practice affected Patient Identifier (PI) # 1, PI # 2, PI # 3, PI # 4, PI # 5 and PI # 8, six of ten sampled patients and had the potential to affect all patients served.

Findings include:

Refer to A-392.

Based on review of medical record, nursing notes, respiratory therapy notes, physician progress notes, interviews, nursing schedule and review of policy and procedures, hospital staff failed to maintain a patent airway for Patient Identifier (PI # 1) by failing to assure PI # 1's left wrist was restrained to prevent the patient from removing (self extubating) the Endotracheal Tube (ETT, airway catheter inserted in the trachea during endotracheal intubation to assure patency of the upper airway by allowing for maintenance of an adequate air passage, medical-dictionary.thefreedictionary.com) connected to the ventilator, (mechanical air or oxygen pump used to maintain breathing in a person unable to breathe spontaneously. Ventilators provide an intermittent flow of air or oxygen under pressure and are connected to the patient by a tube inserted into the windpipe (trachea) either through the mouth or nose).

As a result of this deficient practice, PI # 1, a patient with a known history of respiratory and cardiac disease, was placed in a potentially life threatening situation on 1/2/17 due to staff's failure to reapply the restraint. Additionally, PI # 1 required extensive monitoring because she was receiving intravenous medications for sedation in order to tolerate the ETT and maintain blood pressure. This affected PI # 1, one of ten sampled patients and had the potential to affect all patients served by the Long Term Acute Care (LTAC) Hospital.

Findings Include:

I. Medical Record Review:

History and Physical dated 12/30/16:

Patient Identifier (PI) # 1 was admitted to Long Term Acute Care (LTAC) on 12/29/16 with a past medical history of Hypertension, Coronary Artery Disease, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure.

Prior to admission, PI # 1 was treated for Bilateral Pneumonia and Pulmonary Edema from heart failure. PI # 1 is admitted for "weaning of" high flow oxygen.

Physical Examination Includes:

General: Alert, awake and oriented x three (person, place and time).
In no acute distress.

Respiratory: Lungs with diminished breath sounds and a few inspiratory crackles at bilateral bases.

Assessment: ...On 50% Ventimask (mask mixes oxygen with room air, creating high-flow enriched oxygen of a desired concentration at a flow equaling or exceeding the patient's inspiratory flow demand, rtmagazine.com). There is a history of acute respiratory failure secondary to bilateral pneumonia...

II. Nurses Notes:

"1/2/17 at 08:00: ...Resting in bed. Respirations even and unlabored....Oxygen at 2 L (Liters) per minute via nasal cannula...

1/2/17 at 19:15: "Pt. (patient) heart rate 43. Entered room to find pt. unresponsive, O2 (Oxygen)
out of nose. Attempts to arouse pt. unsuccessful. Respirations absent. Pulse weak. Respiratory (therapist) notified. Rescue breathing initiated. Vital signs attempted. Oxygen saturation noted 74." (range 95 to 100 percent. Values under 90 percent are considered low,Wikipedia.org).

"Rapid Response (staff to help with medically deteriorating patient) called. Heart rate increasing to 82. Pt. agonal breathing ( abnormal pattern of breathing and brainstem reflex characterized by gasping, labored breathing, accompanied by strange vocalizations and myoclonus ( sudden, involuntary jerking of a muscle or muscle group). An extremely serious medical sign requiring immediate medical attention, as the condition generally progresses to complete apnea (temporary cessation of breathing." (Wikipedia.org).

"1/2/17 at 19:27: Dr...(last name of ER MD, Emergency Room Medical Doctor) at bedside...requesting intubation supplies. Size 8 ETT. Pt. given 20 Etomidate (induction agent /medication used to achieve emergent tracheal intubation, emedicine.medscape.com); 100 milligrams Succincycholine. (paralytic agent; renders patient unconscious and paralyzed within one minute, emedicine.medscape.com). Successfully entubated with Size 8 ETT."

"Pt. placed on vent (Ventilator):
TV: 500 (Tidal Volume, normal volume of air displaced between normal inhalation and exhalation, wikipedia.org);

Peep: 8 (positive end-expiratory pressure): increases volume of gas remaining in the lungs at the end of expiration in order to decrease the shunting of blood through the lungs and improve gas exchange.

RR (Respiratory Rate): 16

FIO2 (fraction of inspired oxygen): 90% (comparison between oxygen level in the blood and oxygen concentration that is breathed, wikipedia.org).

1/2/17 at 2020: Dr. (last name of Medical Director) notified of pt. fidgeting vent (ventilator) and attempts to remove ETT. Restraint ordered (wrist) and Diprivan per protocol (medication with sedative/anesthetic effects used in critically ill patients who require a breathing tube (ETT) connected to a ventilator, Drugs.com and rxlist.com).

1/2/17 at 20:33: Diprivan drip initiated at 5 mcg/kg/hr (microgram/kilogram/hour)...

1/2/17 at 21:15: Diprivan increased to 10 mcg/kg/hr due to pt. biting ETT...

1/2/17 at 22:20:... (Blood Pressure) 76/43. Diprivan decreased to 5 mcg/kg/hr. Pt. alert and attempting to talk...

1/2/17 at 22:30: Dr. (last name of Medical Director) paged.

1/2/17 at 23:49: Dr. (last name of Medical Director) on phone. New orders received

1/2/17 at 22:57: Levophed drip started..." (Medication - vasoconstrictor used to treat life-threatening low blood pressure, rxlist.com). (Medical Director's response time was one hour and 19 minutes even though physician aware PI # 1 was receiving Diprivan.)

"1/3/17 at 01:15: ...Diprivan @ 20 mcg/kg/hr. Levophed at 8 mcg...

1/3/17 at 02:30: Levophed decreased to 4 mcg...

1/3/17 at 03:00: Levophed decreased to 2 mcg...

1/3/17: Pt. peacefully sedated..."

1/3/17 at 05:45: Respiratory at bedside for ABG (Arterial Blood Gas: test to check how well lungs are able to move oxygen into the blood and remove carbon dioxide from the blood, webmd.com).

1/3/17 at 05:50: Pt. found self extubated. SaO2 (Saturated Oxygen; Normal blood oxygen levels are considered 95-100 percent, en.wikipedia.org) noted to be 61%. Respiratory (therapist) at bedside.
Pt. placed on 100% non rebreather mask. SaO2 slowly rising. Dr. (last name of pulmonologist) notified. New orders received.

1/3/17 at 0630: Dr. (last name of pulmonologist) notified of ABG results. New orders for BiPAP
received. BiPAP (machine programmed to deliver air at an inhalation pressure, or IPAP, when the person inhales through the mask and tubing. When patient exhales, the BiPAP unit senses the change and switches to a lower exhalation pressure." (livestrong.com).


III. Respiratory Therapy Notes:

1/3/17 at 05:50: "Pt. self extubated. ABG collected."


IV. Pulmonary Physician Progress Notes:

1/3/17 at 18:01: ..."Overnight she was extremely hypoxic and bradycardic ( slow heart rate, usually less than 60 beats per minute (dictionary.com). She (PI # 1) self extubated herself and was on BiPAP until this evening, on HF (High Flow) Oxygen 10 L/min." (Liters per minute).
Chest to Auscultation (listen with stethoscope): Large Bilateral Effusions (unusual amount of fluid around the lung, webmd.com).

Assessment:
1. Acute Respiratory Failure.
2. Bilateral Pleural Effusion.
3. Pulmonary Edema (fluid accumulation in lungs, which collects in air sacs, making it difficult to breathe; leads to impaired gas exchange and respiratory failure, webmd.com).
4. Pneumonia."


V. Interviews:

Interview on 2/2/17 at 07:50 with the Charge RN (Registered Nurse), Employee Identifier (EI # 2):

The Charge RN (Registered Nurse), Employee Identifier (EI # 2) confirmed she was assigned to care for PI # 1 on 1/2/17 beginning at 19:00. According to EI # 2, she was at the nurses' desk getting report from day shift when she saw PI # 1's cardiac monitor had a low heart rate of 47. EI # 2 said she immediately went to PI # 1's room and found the patient unresponsive. PI # 1's oxygen tubing was out of her nose. EI # 2 (RN) replaced the oxygen in PI # 1's nose and tried to arouse the patient, but was unsuccessful. Respiratory staff came to PI # 1's room and rescue breathing (use of ambu bag) was initiated. Rapid Response called (staff called to assist in emergency situations). The ER (Emergency Room) physician intubated PI # 1.

EI # 2 (RN) confirmed PI # 1 required wrist restraints at 20:20 because she was "fidgety"and tried to remove the ETT. As a result, Diprivan ( medication that provides sedation and analgesia
prior to intubation (emedicine.medscape.com) was initiated to help prevent PI # 1 from removing her breathing tube (ETT).

EI # 2 said she placed a bedside monitor in PI # 1's room to monitor heart rate, blood pressure and respirations every 5 to 15 minutes per protocol when Diprivan and Levophed (maintains blood pressure) were initiated. EI # 2 described Diprivan as providing "moderate sedation."

According to EI # 2, (first name of Respiratory Therapist / RT ) performed an ABG on 1/3/17 at 05:45 AM. (see documentation in nursing note). EI # 2 said she was at the desk and heard PI # 1's oxygen saturation alarm sound. EI # 2 went to PI # 1's room and discovered the patient had removed her ETT at 05:50. PI # 1's wrist restraint was off her left hand. "'I speculate the therapist (Respiratory) failed to put the restrain on after the ABG was drawn." E # 2 was asked if she reported this concern about the restraint to the Respiratory Therapist Manager and or CCO/ Chief Clinical Officer. EI # 2 said, "No. (First name of RT) is the lead therapist."


The RN (EI # 2) stated she stopped the drips (Intravenous Levophed and Diprivan) because PI # 1 was extubated. "You can't have drips without intubation." EI # 2 said she immediately got the respiratory therapist and they assessed PI # 1. EI # 2 notified the pulmonologist and received an order for another ABG. PI # 1 was placed on BiPAP.

Interview on 2/2/17 at 08:30 with EI # 1/ Chief Clinical Officer (CCO):

During the interview, the CCO stated she did not know about the restraint issue until last PM when she discussed the case with EI # 2. The CCO was asked about the review process / root case analysis for this type of serious event. EI # 1 stated, "not officially. We don't. We should though, post event."


Interview on 2/6/17 at 13:20 with EI # 1/ CCO:

During the interview, the CCO confirmed there was no incident report for PI # 1 regarding her self extubation on 1/3/17. EI # 1 confirmed a report was expected from staff about the incident.

Interview on 2/6/17 at 13:20 with EI # 1/ CCO:

During the interview, the CCO verified EI # 2 (RN) was assigned more than two patients on 1/2/17 (shift when PI # 1 extubated herself). According to the CCO, EI # 2 should not have been assigned more than two patients because PI # 1 was on the ventilator. The event (intubation and ventilator support) "occurred at shift change and there was no time to get more staff."


VI. Nursing Schedule 1/2/17:

Shift: 19:00 - 07:00

According to the schedule, five patients were assigned to EI # 2 (RN), including PI # 1.


VII. Policies and Procedures:

Ventilator Sedation via Continuous Infusion in the LTAC (Long Term Acute Care) Setting,
K,11.39 Revision Date: 12/2016

I. Policy...Recommended nurse to patient ratios of 1:2 when RN is caring for a patient on Sedation Infusion. (PI # 1 received Diprivan Intravenously (sedative type medication that slows the activity of the brain and nervous system (drugs.com).

...Facilities (LTAC) may use the Riker Sedation Scale, the Ramsay Sedation Scale or the Richmond
Agitation Sedation Scale for determining sedation level. Scale was not documented in Respiratory Therapy Notes and/or Nurses' Notes.

11. Procedure:
...Sedation Medication Orders must include the following elements:
- Level of desired sedation
- Standard scale being used to measure sedation...

During an interview on 2/6/17 at 1:20 PM, EI # 1/CCO verified there was no documentation on a drip sheet for Diprivan in PI # 1's medical record.


Policy: Restraints K.11.07 Revision Date: 3/2015

Policy: " This policy applies to all staff members...involved in ordering, applying and monitoring, assessing and providing care for any patient in a restraint.

It is the responsibility of the hospital CEO or designee to disseminate this policy and its contents to all appropriate hospital employees and licensed independent practitioners and to ensure compliance...

Definitions:
A restraint is:
A. Any manual method, physical or mechanical device, material or equipment that mobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely, or...

Procedure:
A. Restraint use in acute medical...care as a measure to prevent patient injury (i.e. non-violent/non-self destructive behaviors)...
Indications: attempting to remove medical treatment such as IV's, tubes, catheters, trach's...

Patient monitoring: Patients in restraint will be monitored by trained staff as follows:
a. Every two hours to assure safety and dignity and to attend to comfort needs. Patients will be observed at least every two hours to assure that restraint remains indicated... and that restraining devices remain safely applied and that the patient remains as comfortable as possible..."

Based on medical record review, interviews and review of policy and procedure, staff failed to investigate a serious incident involving Patient Identifier (PI # 1), a patient with a known history of respiratory and cardiac disease, who self removed her ETT (Endotracheal Tube) connected to a ventilator while in wrist restraints. (ETT: Performed as an emergency procedure when a patient can't breathe on their own. A flexible plastic tube is placed into the trachea (windpipe), usually through the mouth to help breathing, healthline.com). The failure of staff to secure the wrist restraint placed PI # 1 in a potentially life threatening situation. Furthermore, staff failed to report and investigate the incident. This affected one of ten sampled patients, but has the potential to affect all patients who are admitted to the Long Term Acute Care Hospital (LTAC) and experience an adverse event.

Ventilator: A machine that gets oxygen into the lungs for patients who have lost all ability to breathe on their own (nhlbi.nih.gov/health/health-topics/topics/vent ).

Findings Include:

I. Medical Record review:

Patient Identifier (PI) # 1 was admitted to Long Term Acute Care (LTAC) on 12/29/16 with a past medical history of Hypertension, Coronary Artery Disease, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure.

Prior to admission, PI # 1 was treated for Bilateral Pneumonia and Pulmonary Edema from heart failure. PI # 1 is admitted for "weaning of" high flow oxygen.

Physical Examination Includes:

General: Alert, awake and oriented x three (person, place and time).
In no acute distress.

Respiratory: Lungs with diminished breath sounds and a few inspiratory crackles at bilateral bases.

Assessment: ...On 50% Ventimask (mask mixes oxygen with room air, creating high-flow enriched oxygen of a desired concentration at a flow equaling or exceeding the patient's inspiratory flow demand, rtmagazine.com). There is a history of acute respiratory failure secondary to bilateral pneumonia...

II. Nurses Notes:

"1/2/17 at 08:00: ...Resting in bed. Respirations even and unlabored....Oxygen at 2 L (Liters) per minute via nasal cannula...

1/2/17 at 19:15: "Pt. (patient) heart rate 43. Entered room to find pt. unresponsive, O2 (Oxygen)
out of nose. Attempts to arouse pt. unsuccessful. Respirations absent. Pulse weak. Respiratory (therapist) notified. Rescue breathing initiated. Vital signs attempted. Oxygen saturation noted 74." (range 95 to 100 percent. Values under 90 percent are considered low. (wikipedia.org).

"Rapid Response (staff to help with medically deteriorating patient) called. Heart rate increasing to 82. Pt. agonal breathing ( abnormal pattern of breathing and brainstem reflex characterized by gasping, labored breathing, accompanied by strange vocalizations and myoclonus ( sudden, involuntary jerking of a muscle or muscle group). An extremely serious medical sign requiring immediate medical attention, as the condition generally progresses to complete apnea (temporary cessation of breathing." (wikipedia.org).

"1/2/17 at 19:27: Dr...(last name of ER MD, Emergency Room Medical Doctor) at bedside...requesting intubation supplies. Size 8 ETT. Pt. given 20 Etomidate (medication / induction agent used to achieve emergent tracheal intubation, emedicine.medscape.com); 100 milligrams Succincycholine. (paralytic agent; renders patient unconscious and paralyzed within one minute, emedicine.medscape.com). Successfully intubated with Size 8 ETT."

"Pt. placed on vent (Ventilator)..."

1/2/17 at 2020: Dr. (last name of Medical Director) notified of pt. fidgeting vent (ventilator) and attempts to remove ETT. Restraint ordered (wrist) and Diprivan per protocol (medication with sedative/anesthetic effects used in critically ill patients who require a breathing tube (ETT) connected to a ventilator, Drugs.com and rxlist.com).

1/2/17 at 20:33: Diprivan drip initiated at 5 mcg/kg/hr (microgram/kilogram/hour)...

1/2/17 at 21:15: Diprivan increased to 10 mcg/kg/hr due to pt. biting ETT...

1/2/17 at 22:20:... (Blood Pressure) 76/43. Diprivan decreased to 5 mcg/kg/hr. Pt. alert and attempting to talk...

1/2/17 at 22:30: Dr. (last name of Medical Director) paged.

1/2/17 at 23:49: Dr. (last name of Medical Director) on phone. New orders received

1/2/17 at 22:57: Levophed drip started..." (Medication - vasoconstrictor used to treat life-threatening low blood pressure, rxlist.com). (Medical Director's response time was one hour and 19 minutes even though physician aware PI # 1 was receiving Diprivan.)

"1/3/17 at 01:15: ...Diprivan @ 20 mcg/kg/hr. Levophed at 8 mcg...

1/3/17 at 02:30: Levophed decreased to 4 mcg...

1/3/17 at 03:00: Levophed decreased to 2 mcg...

1/3/17: Pt. peacefully sedated..."

"1/3/17 at 05:45: Respiratory at bedside for ABG." (Arterial Blood Gas: test to check how well lungs are able to move oxygen into the blood and remove carbon dioxide from the blood (webmd.com).

1/3/17 at 05:50: Pt. found self extubated. SaO2 (Saturated Oxygen; Normal blood oxygen levels are considered 95-100 percent, en.wikipedia.org) noted to be 61%. Respiratory (therapist) at bedside.
Pt. placed on 100% non rebreather mask. SaO2 slowly rising. Dr. (last name of pulmonologist) notified. New orders received.

1/3/17 at 0630: Dr. (last name of pulmonologist) notified of ABG results. New orders for BiPAP
received." (BiPAP: machine programmed to deliver air at an inhalation pressure, or IPAP, inspiratory positive airway pressure during inhalation through the mask and tubing. When the patient exhales, the BiPAP unit senses the change and switches to a lower exhalation pressure (livestrong.com).


III. Respiratory Therapy Notes:

1/3/17 at 05:50: "Pt. self extubated. ABG collected."


IV. Pulmonary Physician Progress Notes:

1/3/17 at 18:01: ..."Overnight she was extremely hypoxic and bradycardic ( slow heart rate, usually less than 60 beats per minute (dictionary.com). She (PI # 1) self extubated herself and was on BiPAP until this evening, on HF (High Flow) Oxygen 10 L/min." (Liters per minute). Chest to Auscultation (listen with stethoscope): Large Bilateral Effusions (unusual amount of fluid around the lung, webmd.com).

Assessment:
1. Acute Respiratory Failure.
2. Bilateral Pleural Effusion.
3. Pulmonary Edema (fluid accumulation in lungs, which collects in air sacs, making it difficult to breathe; leads to impaired gas exchange and respiratory failure, webmd.com).
4. Pneumonia."


II. Interviews:

Interview on 2/2/17 at 07:50 with the Charge RN (Registered Nurse), Employee Identifier (EI # 2):

The Charge RN (Registered Nurse), Employee Identifier (EI # 2) confirmed she was assigned to care for PI # 1 on 1/2/17 beginning at 19:00. According to EI # 2, she was at the nurses' desk getting report from day shift when she saw PI # 1's cardiac monitor had a low heart rate of 47. EI # 2 said she immediately went to PI # 1's room and found the patient unresponsive. PI # 1's oxygen tubing was out of her nose. EI # 2 (RN) replaced the oxygen in PI # 1's nose and tried to arouse the patient, but was unsuccessful. Respiratory staff came to PI # 1's room and rescue breathing (use of ambu bag (hand-held device used to provide ventilation to patients who are not breathing or not breathing adequately, enwikipedia.org) was initiated. Rapid Response called (team from general hospital (LTAC located in general hospital) to assist in emergency situations). The ER (Emergency Room) physician intubated PI # 1.

EI # 2 (RN) confirmed PI # 1 required wrist restraints at 20:20 because she was "fidgety"and tried to remove the ETT. As a result, Diprivan ( medication that provides sedation and analgesia
prior to intubation (emedicine.medscape.com) was initiated to help prevent PI # 1 from removing her breathing tube (ETT).

According to EI # 2, (first name of Respiratory Therapist / RT ) performed an ABG on 1/3/17 at 05:45 AM. (see documentation in nursing note). EI # 2 said she was at the desk and heard PI # 1's oxygen saturation alarm sound. EI # 2 went to PI # 1's room and discovered the patient had removed her ETT at 05:50. PI # 1's wrist restraint was off her left hand. "'I speculate the therapist (Respiratory) failed to put the restrain on after the ABG was drawn." E # 2 was asked if she reported this concern about the restraint to the Respiratory Therapist Manager and or CCO/ Chief Clinical Officer. EI # 2 said, "No. (First name of RT) is the lead therapist."


Interview on 2/2/17 at 08:30 with EI # 1/ Chief Clinical Officer (CCO):

During the interview, the CCO stated she did not know about the restraint issue until last PM when she discussed the case with EI # 2. The CCO was asked about the review process / root case analysis for this type of serious event. EI # 1 stated, "not officially. We don't. We should though, post event."


Interview on 2/6/17 at 13:20 with EI # 1/ CCO:

During the interview, the CCO confirmed there was no incident report for PI # 1 regarding her self extubation on 1/3/17. EI # 1 confirmed a report was expected from staff about the incident.


Interview on 2/6/17 at 13:20 with EI # 1/ CCO:

During the interview, the CCO verified EI # 2 (RN) was assigned more than two patients on 1/2/17 (shift when PI # 1 extubated herself). According to the CCO, EI # 2 should not have been assigned more than two patients because PI # 1 was on the ventilator. The event (intubation and ventilator support) "occurred at shift change and there was no time to get more staff."


III. Policies and Procedures:

1. Occurrence / Event Reporting, E.5.00 Revision Date 09/2016:

Policy: To document, track and trend those happenings which are not consistent with the routine operation of the Hospital or the routine care of a patient. Event reports are important tools on process improvement and are intended for use in improving the quality of patient care...

Procedure:

1. An occurrence or event that is reportable is any event which is not consistent with the routine care of a patient or any circumstances that threaten the physical well being of patients...regardless of whether event an actual injury is involved.

2. Any hospital employee or medical staff member who discovers the occurrence / event or is first to the scene has an obligation to begin the event report process and to complete it an a timely manner...

3. All events will be documented in the Prista/Action Cue system...

4. An event report will be completed by the person discovering the event before leaving their assigned shift...

e. The event report will be immediately sent to the Risk Manager and CCO or supervisor via Action Cue...

f. The manager receiving the report...will also perform a ...manager's review or investigation. Information may include...

- Corrective Actions Taken
- Contributing Causes
- Education Training...

g. If there is an injury, notify the...Risk Manager and CCO by telephone as soon as possible. The Risk Manager will initiate intensive analysis for occurrences which may be more serous in nature.

h. If the circumstances of an event report are found to be of a serious nature...then sentinel event process will be initiated. A Root Cause Analysis may also be conducted.

...6. All reports will be analyzed and monitored for trending patterns...

7. All reports are logged in the Action Cue system and reported through the appropriate committee structure and to the MEC (Medical Executive Committee) and Governing Board.


2. Sentinel Event, E.5.02 Revision Date: 1/2016:

I. Policy: The hospital will have a mechanism in place to address Sentinel Events (a Patient Safety Event that reaches a patient and results in any of the following: Death, Permanent harm and / or
severe temporary harm and intervention required to sustain life, www.jointcommission.org.) and near misses (a Patient Safety Event that reaches a patient and results in any of the following: Death, Permanent harm and / or severe temporary harm and intervention required to sustain life, www.jointcommission.org. A safe environment for patients...is the commitment of the facility. This is achieved by encouraging reporting of errors, adverse occurrences, sentinel events and near miss events. Leadership provides the oversight for implementation of an integrated patient safety program...The review of sentinel events and near miss events...are some methods by which the organization seeks to maintain a safe environment and minimize risk.

Definitions:

1. A sentinel event is an unexpected occurrence involving death, or serious physical or psychological injury, or the risk thereof...

2. Adverse event is an undesirable, usually unanticipated event, such as death or serious injury of a patient...

Procedure:
Sentinel Event:
...C. Take appropriate action to contain the risk and prevent the event from re-occurring....

G. "A ROOT CAUSE ANALYSIS will be conducted utilizing a focus team..."

4. "ROOT CAUSE ANALYSIS must include:

A. The participation by the leadership of the organization and by the individuals most closely involved in the processes and systems under review.

B. Focus will be on systems and processes...not individual performance...

F. The analysis is thorough...and...must include:

i. A determination of the human and other factors most directly associated with the sentinel event, and the processes and systems related to its occurrence...

ii. Identification of risk points and their potential contributions to this type of event.

iii. A determination of potential improvement in processes or systems that would decrease the likelihood of such events in the future...

G. To be credible, the Root Cause analysis must:

i. Include participation by leadership of the organization and by the individuals most closely involved in the process and system under review...

5. Steps to conduct a ROOT CAUSE ANALYSIS:

A. Assign a team to assess the Sentinel Event...

B. Defining the event and identifying the proximate and underlying causes:

i. Describe what happened as accurately as possible.

ii. Create a more detailed definition of the event (when, where, how, why).

iii. Ask what processes and issues were involved and how these were a part of the cause and if there was a common factor...

7. Determination of a sentinel event will be made by the Risk Manager, the CCO, and/or CEO...which will review and prioritize reported occurrences.

8. Response to Sentinel Events:

i. The Risk Manager will initiate immediate investigation of the incident.

9. Response to Near Miss Event;

...B. Adverse events, accidents and errors which are not sentinel events will be investigated and prioritized by the Risk Manager in conjunction with CCO, and reported to the QAPI (Quality Assessment Performance Improvement) Committee, Medical Executive Committee and the Governing Board.

10. Reporting:

...B. Internal Reporting: Sentinel Events, near miss events and adverse events are entered in the Event Reporting System...


3. Ventilator Sedation via Continuous Infusion in the LTAC (Long Term Acute Care) Setting,
K,11.39 Revision Date: 12/2016

I. Policy...Recommended nurse to patient ratios of 1:2 when RN is caring for a patient on Sedation Infusion. (PI # 1 received Diprivan Intravenously (sedative type medication that slows the activity of the brain and nervous system (drugs.com).

To summarize, staff failed to secure PI # 1's wrist restraint adter an ABG was drawn. As a result, PI # 1 was able to remove her ETT connected to the ventilator providing life sustaining respiratory support even though restraints were ordered and applied for self protection of her airway. Furthermore, PI # 1 was at additional risk because she was receiving Diprivan, a medication that causes sedation. Staffing was inadequate based on the hospital's policy and procedure: Ventilator Sedation via Continuous Infusion. PI # 1 needed to be closely monitored by professional nursing staff. Lastly, staff failed to complete an incident report and notify Administration of the concern that staff failed to reappy PI # 1's wrist restraint after an ABG was drawn.

Based on reviews of medical records, Initial Nursing Assessments, "WoundRounds" (comprehensive wound documentation system), interviews and review of policies and procedures, the hospital failed to thoroughly assess patients' wounds (also known as pressure ulcers, decubitus) on admission, weekly and at discharge. As a result of this deficient practice some wounds were not identified on admission, some wounds were not photographed and/or measured. Two wounds were acquired in the Long Term Acute Care Hospital (LTAC). Some wounds deteriorated potentially causing pain and discomfort to six of ten sampled patients. Because of these deficient practices, the ability to determine the progression of patients' wounds was compromised. This deficient practice affected Patient Identifier (PI) # 1, PI # 2, PI # 3, PI # 4, PI # 5 and PI # 8, six of ten sampled patients and had the potential to affect all patients served.

Findings Include:

I. Medical Record Review:

1. Patient Identifier (PI) # 1:

According to the Pre-Admission Assessment dated 12/29/16, PI # 1 had a "Stage I pressure ulcer" documented as "redness to the left buttock."

The Initial Nursing Assessment Dated 12/29/16 at 20:00 revealed:

Wounds Assessment:

"Definitions:
Type: P = Pressure V= Venous A= Arterial D = Diabetic .O = Other (Specify Type)

Mark Areas on Figure (body diagram) With Circled Initial to Indicate Type of Wound AND document in Wound Descriptions below, what is observed.

PU (Pressure Ulcer) Stages:
Stage 1 is indicated by non blanchable redness usually over bony prominence. This stage is seen after prolonged application of pressure. Stage I pressure ulcers can be distinguished when pressure is applied and color does not return. The skin may be hotter or cooler than normal, have an odd texture, or perhaps painful to the patient..."
(According to npuap.org, Stage I may indicate "at risk" persons).

"Stage II is damage to the epidermis, extending into, but not deeper than, the dermis. May present as shallow ulcer with a pink wound bed and no slough...May appear as a blister or abrasion.

Stage 3 involves full thickness of the skin and my extend into the subcutaneous layer (fat). This layer has a relatively poor blood supply and can be difficult to heal...There may be undermining damage or yellow slough that makes the wound much larger than it may seem on the surface.

Stage 4 is the deepest, extending into the muscle, tendon, or bone.

Unstageable pressure ulcers are covered with slough or eschar (dead skin) so the depth cannot be determined.

Wound Description Key:
All pressure ulcers (PU) dressings must be removed and measured at the time of admit, unless otherwise ordered.
Drainage: None, Small Moderate, Large, Odor Drainage Color: Serous, Purulent, Yellow, Green, Serosanguinous, Bloody, N/A
Surrounding Tissue: Macerated, Intact, Callus, Necrotic, Erythema."

PI # 1's Wound Description:

Type: PU
Stage: No documentation
Location: Left buttock
Color: No documentation
Odor: 0
Drainage: 0
Measurements: No documentation
Surrounding Tissue: No documentation

The RN (Registered Nurse) failed to document stage, color, measurements, surrounding tissue and photograph PI # 1's wounds on admission. (A photo will be obtained upon admission, at onset of any new wound, weekly, upon discharge and as needed until wound resolved according to the hospital's WoundRounds Policy and Procedure - refer to entire policy documented below).

1/5/17: Nurses Notes: There was no documentation regarding PI # 1's pressure ulcer in the Daily Nursing Assessment in the Wound Description section or the narrative notes.

1/13/17: Nurses Notes: Wound Description Documentation: "07:00 - 19:00 (Day Shift): See assessment in wound rounds."

There was no documentation by the 19:00 - 07:00 shift (Night Shift) in the nurses' notes. There was no documentation in WoundRounds for PI # 1 on 1/13/17.

1/13/17 at 02:15: Nurses Notes: "C/O (complained of) pain @ lower back. Excoriation to bil. (bilateral) buttock developing...Zinc Oxide not available, out of stock-order in progress. Turned and repositioned..."

1/20/17: Nurses Notes: No documentation regarding pressure ulcer identified on admission (12/29/16)
and/or "excoriation" (noted on 1/3/17). PI # 1 discharged on 1/20/17 at 14:50. No description of PI # 1's pressure ulcer and/or excoriation to buttocks was documented at discharge as required by policy.

No information about PI # 1's pressure ulcer was documented in the WoundRounds system from 12/29/16 though 1/20/17. During an interview on 2/2/17 at 11:45, the Director of Quality Management (DQM) / Employee Identifier (EI # 3), confirmed there was no documentation in the WoundRounds system for PI # 1.

During an interview on 2/2/17 at 11:57, the DQM / EI # 3 confirmed there are no pictures, measurements or WoundRounds for PI # 1. According to the DQM, the RN (Registered Nurse) should have documented the required wound details on admission, including pictures of the wound, on admission and weekly until resolved for PI # 1.

History and Physical dated 12/30/16:

PI # 1 was admitted on 12/29/16 with a past medical history of Hypertension, Coronary Artery Disease, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure.

Physical Examination Includes:

Skin: "Denies any rashes."


2. Patient Identifier # 2:

PI # 2 was admitted on 1/4/17 with a diagnosis of Respiratory Failure.

PI # 2's Wound Description as documented on the Initial Nursing Assessment dated 1/4/17 revealed:
Wounds Assessment: "Blanchable red area to coccyx." No photographs and/or measurements were documented.

On 1/5/17 at 01:40, PI # 2 was identified as high risk on the Braden Scale (Special scoring system to evaluate a patient's risk of developing a pressure ulcer, woundrounds.com).

There were no pictures, no measurements and no WoundRounds documented for PI # 2 as verified by EI # 1 / CCO (Chief Clinical Officer) and EI # 3 (DQM) on 2/2/17 at 11:57. According to EI # 2, (RN-Charge Nurse assigned to PI # 1 on 2/2/17) the registered nurses should have documented the details listed above and photographed the wounds on admission and weekly until resolved.


3. Patient Identifier # 3:

PI # 3 was admitted on 1/30/17 with diagnoses to include Lumbar Abscess (a collection of pus that has built up within the tissue, enwikipedia.com), Iliopsoas (major hip muscles (innerbody.com), Abscess with Osteomyelitis (infection of the bone) and involvement of Epidermal Space and "Overgrowth of Sacral Decubitus." (also known as a pressure ulcer, healthline.com).

According to PI # 3's Wound Assessment (part of the Initial Nursing Assessment) dated 1/30/17, the RN documented:
Type Wound: Pressure.
Stage, if PU: Stage I.
Location: Coccyx.

No measurements were documented and no photographs were taken of PI # 3's pressure ulcer. These deficiencies were verified by the CCO / EI # 1 during an interview on 2/2/17 at 11:54.

4. Patient Identifier # 4:

PI # 4 was admitted on 1/7/17 with diagnoses to include History of Quadriplegia and Status Post Tracheostomy.

According to PI # 4's Wound Assessment dated 1/7/17, the RN documented:
Type Wound: Shearing.
Stage, if PU: Stage I.
Location: Sacrum.
Color: Red.

Although PI # 4 was identified by staff as a moderate risk on the Braden Scale and had a pressure ulcer on admission, no measurements or wound photographs of the sacrum were documented on admission and or weekly on the following dates: 1/7/17, 1/14/17 and 1/21/17.

These deficiencies were verified by EI # 1 / CCO and EI # 3 / DQM during an interview on 2/2/17 at 11:40.

On 1/29/17 at 11:22 AM, a facility acquired Stage II pressure ulcer to the coccyx was documented and photographed for PI # 4.


5. Patient Identifier # 5:

PI # 5 was admitted on 1/19/17 with diagnoses to include Sepsis and Acute Respiratory Failure,
The patient was also admitted with a tracheostomy and was on a ventilator.

History and Physical dated 1/20/17:
According to the Physical Examination PI # 5 had a Stage I decubitus ulcer on the right heel and a Stage II decubitus to her "back."

According to PI # 5's Wound Assessment dated 1/19/17, the RN documented, "See Wound Rounds."

The WoundRounds documentation on 1/19/17 at 22:47 revealed:

Wound: Vertebra (upper-mid).
Type: Pressure
Source: Present on admission.
Clinical Stage: Unstageable
Size in centimeters: 4.50 (Length) x 2.40 (Width) x 0.0 (Depth)


PI # 5's WoundRounds Documentation on 2/2/17 at 13:26 included:

Wound: Sacrum
Type: Pressure
Source: Present on admission
Clinical Stage: Stage 3.
Size in centimeters: 15.00 (Length) x 4.00 (Width) x 3.00 (Depth)

The only pressure wound identified by the RN on admission (1/19/17) was an unstageable wound to PI # 5's Upper-mid vertebra measuring 4.50 (Length) x 2.40 (Width) x 0.0 (Depth).


PI # 5's WoundRounds Documentation on 2/2/17 at 01:50:

Wound: Coccyx
Type: Pressure
Source: Facility Acquired
Clinical Stage: Stage 2
Size in centimeters: 18.00 (Length) x 18.00 (Width) x 0.00 (Depth)

During an interview on 2/2/17 at 12:25, the CCO / EI # 1 verified there was no post debridement photograph on 1/23/17 for PI # 5.

6. Patient Identifier # 8:

PI # 8 was admitted on 1/26/17 with diagnoses to include Pneumonia and Urinary Tract Infection.

According to PI # 8's Wound Assessment dated 1/26/17, the RN documented:
"See Wound Rounds."

During an interview on 2/2/17 at 12:30 the CCO /EI # 1 verified there is no WoundRounds documentation for PI # 8 from 1/26/17 through 2/2/2017.


II. Policy and Procedures:

Assessment and Reassessment, 1.9.00 - Reviewed Date: 1/20/17:

Policy: " Nursing care is provided to patients based on an ongoing assessment of their nursing care needs, formulation of a plan of care, evaluation of the patient's response to, or outcomes resulting from the nursing care provided, and the capability of the patient or caregiver for continuing care...
A RN (Registered Nurse) will perform and document the initial assessment and thereafter a head to toe assessment in every 24 hour period."

Procedure:
"The comprehensive admission of a patient begins at the time that he/she enters the hospital after the pre-admission screening has been completed...

A. Nursing Documentation:
1. A RN is responsible for initiating and completing the comprehensive admission patient assessment within 8 hours of admission. This includes the initial wound care assessment (including wound measurements and photos)...

6. A RN and/or LPN (Licensed Practical Nurse) must document assessments in an ongoing fashion, minimally every twelve hours shift. The LPN must notify the RN of abnormal findings and deterioration in the patient's condition for assessment, physician notification (if applicable) and evaluation of interventions..."


Policy: Method of Wound Documentation Via WoundRounds L.12.16 Reviewed Date: 3/2015

Policy: " To provide guidelines for the documentation of wounds utilizing WoundRounds. Documentation of wounds including a photo will be obtained upon admission, at onset of any new wound, weekly, upon discharge and as needed until wound resolved or patient discharged...

Procedure:
Accessing WoundRounds-Computer

Assessments:
2. If skin issue is noted, area is entered into WoundRounds via PDA (personal data assistance-handheld device) which minimally includes:
a. Measurements
b. Drainage
c. Wound Descriptors
d. Pictures..."