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On the days of the Complaint Investigation based on record review and interview, the hospital failed to ensure its nursing staff reassessed a patient with new onset symptoms with a decrease in the patient's oxygen status, notified the physician of a change in the patient's condition, and the related implementation of the physician's standing medication order for 1 of 1 patient closed record reviewed for care and services. (Patient #1).


The findings include:


Review of Patient's #1's chart on 4/3/13 at 1400 revealed the patient was admitted to the hospital on 12/21/12 with a fracture of the right hip and transferred to the emergency department of another hospital on 12/30/12.

Review of the nurse's assessment on 12/28/12 at 0115 showed the nurse documented the patient's lung sounds were clear. Review of the nurse narrative note dated 12/28/12 at 0200 revealed, "...Robitussin administered for coughing, relief noted...". On 12/28/12 at 0800, staff documented the patient's temperature (T) was 95.8, respirations (R) were 20, and oxygen saturation (O2 sat) 100% (percent) on room air (RA). On 12/28/12 at 0900, nurse notes revealed the nurse documented lung sounds were clear. On 12/28/12 at 1500, review of the patient's chart revealed hospital staff documented the patient's temperature was 96.5, respirations were 18, and the O2 sat was 94% on room air. Review of the patient's medication administration record showed the patient received Robitussin/Guaifenesin on 12/28/12 at 2131 for cough. The patient's chart revealed there were no vital signs obtained and documented until 12/29/12 at 0745. The patient's chart had no documentation of a reassessment of the patient's oxygen status recorded as 94% at 1500 after 1500 and/or notification of the decrease in the patient's oxygen saturation level and that the patient had developed a non productive cough to the patient's physician. There was no documentation that the physician had been notified that staff had implemented the physician's standing order for Guaifenesin.

Review of the nursing assessment dated 12/29/12 at 0115 revealed the nurse documented the patient's breath sounds were clear. The nurse, also documented, "...Robitussin administered for coughing, relief noted, 0 distress...". Review of the patient's medication administration record dated 12/29/12 at 0638 showed the nurse administered Guaifenesin to the patient for a cough. Review of the patient's chart showed staff documented the patient's vital signs on 12/29/12 at 0745 as temperature 95.7, respirations 17, and oxygen saturation 93% on room air. Review of the nurse notes dated 12/29/12 at 1000 revealed the nurse documented, "...Non productive intermittent cough, lungs clear...". Review of the nurse notes dated 12/29/12 at 1215 showed the nurse documented,"Robitussin given for cough", and review of the patient's medication administration record verified the patient received Guaifenesin for cough on 12/29/12 at 1215. Review of the patient's chart showed staff documented the patient's vital sign on 12/29/12 at 1600 as: temperature - 96.5, respirations - 18, and oxygen saturation as 93% on room air. There was no further documentation that the patient's vital signs were obtained until 12/30/12 at 0650. Review of the patient's medication administration records dated 12/29/12 at 2234 showed the patient received Guaifenesin for cough. The patient's chart had no documentation of a reassessment of the patient's oxygen status that was recorded as 94% at 1500 and/or notification of the physician of the decrease in the patient's oxygen saturation level or that the patient had developed a non productive cough. There was no documentation that the physician had been notified that staff had implemented the physician's standing order for Guaifenesin.

Review of the patient's chart revealed the nursing assessment dated 12/30/12 at 0115, showed the nurse documented the patient's breath sounds were clear, and a nurse narrative note dated 12/30/12 at 0115 revealed, "... 0 distress noted...". Review of the patient's medication administration record dated 12/30/12 at 0620 revealed the patient received Guaifenesin for cough. On 12/3012 at 0650, review of the patient's chart showed the nurse documented, "Patient sent to ER (emergency room) for increased heart rated and low O2(oxygen) sat (saturation). Patient was very agitated. Family at bedside. Vitals HR (Heart Rate) 228, O2(oxygen) 77 on room air 90% on non-rebreather. T 99.2, R 29. Left message for daughter to notify of transfer to ER".

On 4/5/13 at 1507, the patient's physician revealed that once the physician authenticates the patient's standing orders, the nurse will initiate the medication or treatment but should inform the physician. The physician stated the medication is recorded on the patient's medication administration record and/or updated during patient rounds. The physician reported staff can write the information in the communication notebook. The physician reported that he/she didn't recall staff communicating that the patient had developed a non productive cough and was administered Robitussin. The physician reported that he/she will review the communication book. The physician reported that he/she remembered the patient and how the patient's condition declined unexpectedly. The physician stated, "Initially, I thought he aspirated something overnight." After the physician reviewed the patient's chart, the physician stated, "I reviewed the physician progress notes and the outcome was surprising. I don't recall being informed of the patient receiving Guaifenesin, and I don't have any notes that the medication was implemented in the communication book. I don't recall being informed of any respiratory symptoms."

On 04/04/2013, during an interview with RN #1, RN #1 stated that he/she remembered the patient being confused and obscessed with bowels. RN #1 stated the patient's heart rate increased and the patient was sent to the emergency room.

On the days of the Complaint Investigation based on record review and interview, the hospital failed to ensure its nursing staff notified the physician of a change in the patient's condition and the related implementation of the physician's standing order for 1 of 1 patient closed record reviewed for care and services. (Patient #1).


The findings include:


Cross Reference to A 0392: The hospital failed to ensure its nursing staff reassessed a patient with new onset symptoms with a decrease in the patient's oxygen status, notified the physician of a change in the patient's condition, and the related implementation of the physician's standing medication order for 1 of 1 patient closed record reviewed for care and services. (Patient #1).