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The Condition of Nursing Services has not been met.

Based on clinical record review and interview for 1 (P#1) of 10 patients reviewed for airway monitoring the hospital failed to ensure that the patient was adequately supervised when the patient was not in the line of site of staff and was not on the pulse oximetry monitor according to hospital policy and the patients plan of care.



Please see A395 and A396

Based on clinical record review and interview for 1 (P#1) of 10 patients reviewed for airway monitoring the hospital failed to ensure that the patient was adequately supervised when the patient was not in the line of site of staff and was not on the pulse oximetry monitor according to hospital policy and the patients plan of care. The findings include:

Patient #1 was admitted to Hospital #1 with diagnoses that included Treacher Collins syndrome, cleft palate, chronic respiratory failure due to upper airway obstruction, developmental delay, tracheostomy and gastrostomy feeding tube.

An Interdisciplinary Care Plan (ICP) dated 7/24/17 indicated P#1 used specialized equipment including pulse oximetry monitoring. The ICP further indicated that P#1 had interventions in place should he/she exhibit behaviors such as pulling or grabbing at his/her tracheostomy or feeding tube. Interdisciplinary team meeting notes dated 9/27/17 through 10/23/17 indicated P#1 walked and crawled independently.

According to a progress note dated 10/24/17, at approximately 8:55 PM, P#1 was found by Respiratory Therapist (RT) #1 cyanotic and apneic (no respirations) with his/her tracheostomy tube out (decannulated). A code was called and documentation identified P#1 was identified to be in cardiac arrest-asystole. Resuscitation was performed in addition to administration of emergency medications for approximately 20 minutes with subsequent return of spontaneous circulation (ROSC).

According to written staff statements and subsequent interviews obtained on 11/27/17 the following sequence of events were identified:

At approximately 8:45 PM NA#1 provided incontinent care and placed P#1 in his/her crib. P#1 was jumping, standing and playing in his/her crib as per usual. NA#1 left P#1 without notifying the nurse that he/she was leaving, which would require the nurse to provide line of sight supervision or placement of the pulse oximetry monitor. NA#1 left P#1 to check on his/her other assigned patients on another hallway.

Interview with NA#1 identified when he/she left P#1 the pulse oximeter was not connected to P#1 and NA#1 did not inform LPN#1 that he/she was leaving P#1, which is the expectation on the Pediatric Unit.

At approximately 8:50 PM RT#1 arrived at P#1's bedside and found P#1 apneic and unresponsive. RT#1 called for immediate assistance.

During an interview with LPN#1 he/she indicated that he/she had not been informed NA#1 was leaving P#1's bedside and Team 2. LPN#1 indicated staff is expected to notify the nurse or the RT when leaving a Team and/or a child requiring connection to pulse oximetry monitoring.

During an interview with the Pediatric Unit Team Leader on 11/15/17 at 11:30 AM he/she indicated the pediatric patients with tracheostomy or respiratory/airway issues are monitored with pulse oximetry unless in direct view of the staff, with the exception of the patients on ventilators.

During a review of the incident on 11/15/17 at 12:15 PM with the Chief Nursing Officer (CNO) he/she indicated, based on statements of the staff assigned to P#1 on the evening of 10/24/17, P#1 was not connected to pulse oximetry monitoring and was not in direct line of sight for a brief period of time prior to being found decannulated.

Hospital Pulse Oximetry policy indicated continuous oximetry is utilized in respiratory/medically complex adult and pediatric patients, who require close monitoring of their oxygenation status. Continuous pulse oximetry monitoring may be suspended if the patient is under direct supervision (line of site) of staff. In addition the staff assignment sheet instructed staff to remember to hand off communication before leaving the team.

Following the decanulation and resuscitation, P#1 was transferred to another acute care hospital (Hospital #2) for further care. According to Hospital #2's records, P#1 was placed on a ventilator, had a Glasgow Coma Score of 1 (less than 3 = vegetative state), had no spontaneous movement, had jerking of the arms and fists, and pupils were sluggish to respond. P#1 was subsequently diagnosed as having suffered a hypoxic brain injury with spasticity.

Based on clinical record review and interview for 1 (P#1) of 10 patients reviewed for airway monitoring the hospital failed to ensure pulse oximetry monitoring was maintained or that the patient was adequately supervised when not on the pulse oximetry monitoring according to hospital policy and the patients plan of care. The findings include:

Patient #1 was admitted to Hospital #1 with diagnoses that included Treacher Collins syndrome, cleft palate, chronic respiratory failure due to upper airway obstruction, developmental delay, tracheostomy and gastrostomy feeding tube.

An Interdisciplinary Care Plan (ICP) dated 7/24/17 indicated P#1 used specialized equipment including pulse oximetry monitoring. The ICP further indicated that P#1 had interventions in place should he/she exhibit behaviors such as pulling or grabbing at his/her tracheostomy or feeding tube. Interdisciplinary team meeting notes dated 9/27/17 through 10/23/17 indicated P#1 walked and crawled independently.

According to a progress note dated 10/24/17, at approximately 8:55 PM, P#1 was found by Respiratory Therapist (RT) #1 cyanotic and apneic (no respirations) with his/her tracheostomy tube out (decannulated). A code was called and documentation identified P#1 was identified to be in cardiac arrest-asystole. Resuscitation was performed in addition to administration of emergency medications for approximately 20 minutes with subsequent return of spontaneous circulation (ROSC).

According to written staff statements and subsequent interviews obtained on 11/27/17 the following sequence of events were identified:

At approximately 8:45 PM NA#1 provided incontinent care and placed P#1 in his/her crib. P#1 was jumping, standing and playing in his/her crib as per usual. NA#1 left P#1 without notifying the nurse that he/she was leaving, which would require the nurse to provide line of sight supervision or placement of the pulse oximetry monitor. NA#1 left P#1 to check on his/her other assigned patients on another hallway.

Interview with NA#1 identified when he/she left P#1 the pulse oximeter was not connected to P#1 and NA#1 did not inform LPN#1 that he/she was leaving P#1, which is the expectation on the Pediatric Unit.

At approximately 8:50 PM RT#1 arrived at P#1's bedside and found P#1 apneic and unresponsive. RT#1 called for immediate assistance.

During an interview with LPN#1 he/she indicated that he/she had not been informed NA#1 was leaving P#1's bedside and Team 2. LPN#1 indicated staff is expected to notify the nurse or the RT when leaving a Team and/or a child requiring connection to pulse oximetry monitoring.

During an interview with the Pediatric Unit Team Leader on 11/15/17 at 11:30 AM he/she indicated the pediatric patients with tracheostomy or respiratory/airway issues are monitored with pulse oximetry unless in direct view of the staff, with the exception of the patients on ventilators.

During a review of the incident on 11/15/17 at 12:15 PM with the Chief Nursing Officer (CNO) he/she indicated, based on statements of the staff assigned to P#1 on the evening of 10/24/17, P#1 was not connected to pulse oximetry monitoring and was not in direct line of sight for a brief period of time prior to being found decannulated.

Hospital Pulse Oximetry policy indicated continuous oximetry is utilized in respiratory/medically complex adult and pediatric patients, who require close monitoring of their oxygenation status. Continuous pulse oximetry monitoring may be suspended if the patient is under direct supervision (line of site) of staff. In addition the staff assignment sheet instructed staff to remember to hand off communication before leaving the team.

Following the decanulation and resuscitation, P#1 was transferred to another acute care hospital (Hospital #2) for further care. According to Hospital #2's records, P#1 was placed on a ventilator, had a Glasgow Coma Score of 1 (less than 3 = vegetative state), had no spontaneous movement, had jerking of the arms and fists, and pupils were sluggish to respond. P#1 was subsequently diagnosed as having suffered a hypoxic brain injury with spasticity.