HospitalInspections.org

Based on observation, interview and record review, the hospital failed to ensure the governing body carried out its functions to effectively manage the hospital and to ensure compliance with regulatory requirements, policies and procedures, patient safety protocols and emergency management of patients.

Findings:

1. The governing body failed to ensure the regulatory requirement for a registered nurse supervision of nursing care was implemented, to include the ongoing assessment of the patient's condition and nursing care needs. The nursing staff working in the ICU failed to immediately recognize and appropriately manage the significant change and continued deterioration of a sampled patient (Patient 1), when he became disconnected from a mechanical ventilator for 23 minutes and had a cardiac arrest for 10 minutes. Cross-Reference - A 395



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2. An interview was conducted with the Chief Executive Officer (CEO) on 8/9/12 at 3:00 P.M. She stated that the facility investigated the incident regarding Patient 1 and the night duty physician's refusal to respond to the questions by Patient 1's family, when the family noticed a change in Patient 1's condition. She stated that the case was referred to peer review and the medical staff had recommendations for the night duty physician.

An interview with the Critical Care Medical Director was conducted on 8/10/12 at 9:00 A.M. He acknowledged that there was no documentation of communication, education or training to the other 10 night physicians, to ensure the night physicians were knowledgeable regarding their duties and responsibilities in responding to a patient or family's request for information regarding medical care.

A review of the hospital's policy titled, "Communication of Unanticipated Outcomes, including Apology and Disclosure," indicated that it is the hospital's policy to "disclose any event that has resulted in harm or death to the patient. Disclosure of serious events should be made to the affected patient, and when appropriate, the patient's family or authorized legal representative."

3. A review of the Governing Board Meeting minutes dated March 19, 2012 was conducted on 8/9/12 at 2:00 P.M. The minutes indicated that, "There were 2 Level 3's reported for 4th quarter: (1) Alarm on patient found turned down in the ICU; (2) Telemetry monitor system had loss of power to server. In the next column under recommendations & actions, "no recommendations" was documented. The next columns titled "evaluations and follow-up" and "responsible person," were blank.

An interview with the Director of Quality Management was conducted on 8/9/12 at 11:00 A.M. The Director of Quality Management stated that during the 4th quarter of 2011, the facility investigated an issue regarding a staff complaint that the volume for the mechanical ventilator alarms in the ICU was turned down. She stated that this was presented to the Governing Board, however there were no recommendations or actions taken. The hospital could not provide any documentation of any actions or recommendations for ICU mechanical ventilator alarms in response to this investigation.

4. The governing body failed to ensure the nursing services provided to patients included the following: compliance with policies and procedures, ongoing assessments and management of patient's care needs to prevent adverse outcomes, compliance with physician drug orders and pain management policy, development and implementation of nursing care plans and compliance with patient safety protocols. Cross Reference A 397; A 405; A 408

The cumulative effect of these systemic problems resulted in the facility's failure to deliver the care in compliance with the Condition of Participation for Governing Body and failure to provide care to their patients in a safe environment.

Based on observation, interview and record review, the hospital failed to ensure its quality assurance and performance improvement program was implemented to ensure the hospital staff's continuing compliance and adherence to hospital policies and procedures, job requirements, staff training, patient assessment, patient safety requirements, emergency procedures and drug administration.

1. The hospital failed to ensure its quality assessment and performance improvement program, relative to the use and continuous monitoring of a patient's mechanical ventilator and cardiac monitor, including the safety alarms, was implemented. The hospital's policy requirement relative to performance of mock alarm codes was not followed. Cross-Reference A 297.

2. The governing board meeting minutes dated 3/19/12, had previously identified the problems related to ventilator alarms being turned down in the Intensive Care Unit (ICU), and a problem with the telemetry monitor system loss of power into the server. There were no documented evidence to indicate the response and actions implemented, including the integration of these concerns into the hospital's quality assurance and performance improvement projects. Cross-Reference A 043

Based on observation, interview and record review, the hospital failed to ensure the delivery of patient care reflected the nursing services staff compliance and adherence to their job requirements, facility policies and procedures, ongoing assessment of patient care needs, prompt recognition and timely response to emergency situations, development of nursing care plans based on the assessed needs of patients, and following physician's orders relative to drug administration.

Findings:

1. The hospital failed to ensure nursing administration provided the ongoing surveillance of the telemetry central station monitor technicians to ensure their compliance with their job requirements, duties and patient care responsibilities. Cross-Reference A 386; A 395

2. The hospital failed to ensure the nursing services provided to patients included the ongoing assessment of significant change and continued deterioration in the patient's condition resulting from a disconnection from a mechanical ventilator and ultimately a cardiac arrest. Cross-Reference A 395; A 386

3. The hospital failed to ensure nursing care plans were developed and implemented to include care and treatment of a pressure ulcer, behavioral management, use of antipsychotic drug, swallowing problem and swallowing precautions. Cross-Reference A 396

4. The hospital failed to ensure the necessary training and supervision was provided to a nurse aide relative to care of a patient with swallowing difficulty and need for liquid thickener to promote safe swallowing and prevent aspiration. Cross-Reference A 397

5. The hospital failed to ensure the nursing staff compliance with physician orders and pain management policy relative to drug administration. Cross- Reference A 405; A 408.

Based on observation, interview and record review, the hospital failed to ensure the right of the designated person who had the legal responsibility to make decisions regarding the medical care of 1 of 1 sampled patients (Patient 1), was observed by the hospital staff. The night physician on duty declined to promptly respond to Patient 1's designated person's repeated requests for explanation and answers to questions, after Patient 1 was found disconnected from his mechanical ventilator and had a cardiac arrest, that was not immediately recognized and effectively managed by the ICU staff.

Findings:

Patient 1 was admitted to the hospital on 5/29/12 for medical care and treatment. The patient's history and physical examination dated 5/29/12, indicated Patient 1's diagnoses included pneumonia and acute respiratory failure requiring a tracheostomy (a surgical opening in the trachea to permit airway) and continuous mechanical ventilation (use of a mechanical device such as a ventilator for artifical ventilation of the lungs). Patient 1 had a history of myocardial infarction (heart attack) and coronary artery disease, requiring the use of a cardiac (heart) monitor and continuous monitoring of his heart function for abnormal rhythm and signs of impending heart attack. Other treatment modalities per the physician's admission orders dated 5/29/12, included the administration of tube feedings via a gastric (stomach) tube, intravenous administration of antibiotics, use of oxygen, urinary catheter and several medications to manage the patient's illnesses.

The physician's history and physical examination dated 5/29/12, indicated the patient was awake and alert, but did not communicate. The nursing admission assessment of the patient described the Patient 1 as alert, awake, but unable to communicate verbally. Patient 1 was bedridden and required total nursing care. The use of a mechanical ventilator and a cardiac monitor were also addressed by the nursing staff in the patient's admission assessment.

On 6/27/12 at 1:05 P.M., an initial onsite visit to the hospital was conducted by the Department in response to the hospital's report of a significant incident involving Patient 1. An interview was conducted with the chief clinical officer (CCO) for nursing services on 6/27/12 at 1:15 P.M. regarding the incident. The CCO stated that on 6/20/12, she received a report from the director of quality management (DQM) regarding an incident involving Patient 1. The report indicated that the tubing that connected Patient 1 to a mechanical ventilator was found disconnected by a respiratory therapist (RT), when the RT came to the ICU on 6/19/12, in the late afternoon. The CCO was not sure about the exact time of the incident at the time of the interview. Patient 1 was found to be in "asystole" (absence of cardiac contractions or heartbeat), per the patient's cardiac monitor. A Code Blue (an emergency procedure activated in response to a cardiac and/or respiratory arrest) was initiated.

A review of the Code Blue cardiopulmonary record for Patient 1 indicated that cardiopulmonary resuscitation (CPR) was initiated on 6/19/12 at 6:52 P.M., and was discontinued at 6:56 P.M., four minutes after Patient 1's heart and lung functions were restored.

On 6/27/12 beginning at 1:20 P.M., an interview was conducted with the nurse manager (NM) regarding Patient 1's incident of 6/19/12. The NM indicated that she had received the same report as specified above. When questioned as to how Patient 1 became disconnected from his mechanical ventilator, and why the two ICU nurses on duty at the time of the incident (RN 1 and RN 2) failed to immediately recognize and respond to the emergent situation, the NM stated that the ICU nurses had told her that they did not know Patient 1 had been disconnected from the mechanical ventilator. Neither one of the nurses heard alarms coming from the ventilator and the nurses station. Hence, no ICU nurses responded to Patient 1's immediate needs, and no emergency interventions were done until the situation was recognized by the respiratory therapist who came to the ICU on 6/19/12 at approximately 6:48 P.M.

The NM added during the interview, that the ventilator is equipped with visible and audible alarms to alert the staff of emergency situations including ventilator disconnections. The hospital's policy dated Oct. 2010 was reviewed, and clearly indicated that all ventilator alarms are interconnected with the nursing call light system. When a ventilator alarm sounded, it would initiate audible and visual alarms at the nurses station. The alarm could also be visually seen on the outside of the patient's room above the door indicated by an amber flashing light. The alarm would repeat continuously until the alarm situation had been responded to and corrected. In spite of the ventilator's safety features, neither of the two ICU nurses on duty that day recognized the adverse event. Both nurses failed to respond quickly to Patient 1's disconnection from the mechanical ventilator, respiratory arrest and cardiac arrest.

In addition, the hospital's policy entitled continuous cardiac monitoring dated May 2010, was reviewed and indicated all patient's cardiac monitors were interconnected to a central telemetry station. The central telemetry station is located in the North Unit which is adjacent to the ICU (about 15 feet distance). Telemetry is the transmission of data electronically to a distant location. Per the NM's interview on 6/27/12 at 4:20 P.M., the central telemetry station is always staffed by a monitor technician 24 hours a day. The NM stated that the monitor technician's responsibilities included the continuous surveillance of all cardiac monitors, the reading, interpreting and reporting of abnormalities, including the cardiac monitor alarms, to the assigned nurse. When the NM was questioned as to how the ICU staff could have missed Patient 1's cardiac monitor and alarms, signaling the lack of heart contractions (asystole), that lasted for 10 minutes on 6/19/12, (6:42 P.M. to 6:52 P.M. as shown in the cardiac/EKG monitor strips), she stated that, the two ICU nurses had told her that neither one heard the cardiac monitor alarms in the ICU, and no report or phone call was made by the monitor technician to alert the ICU nurses of the patient's absence of heart contractions and emergent situation.

On 6/27/12 at 4:20 P.M., Patient 1 was visited in the ICU, by the surveyor. Patient 1 was unresponsive with both eyes closed. Tube feedings and intravenous (via a vein) medications were observed infusing. A mechanical ventilator was in use and a bedside cardiac monitor was also observed attached to the patient.

On 8/08/12 beginning at 3:35 P.M., an interview was conducted with a respiratory therapist (RT), the staff who discovered Patient 1's disconnection from the mechanical ventilator on 6/19/12. The RT indicated she came to the ICU on 6/19/12 at approximately 6:48 P.M. Upon entering the ICU, she heard an alarm sound coming from Patient 1's room. She stated that although the room door was closed, the ventilator alarm sound was still audible from outside the room. She then approached Patient 1 and found the tubing that connected the patient to the mechanical ventilator had been disconnected, with the tubing wrapped around the patient's elbow and laying on the patient's chest. She also noticed that Patient 1's bedside cardiac monitor alarm was on, and the monitor screen showed the absence of cardiac activity/cardiac rhythm. She then immediately reconnected the patient to the ventilator, called out for help and alerted the ICU nurses to call a Code Blue (emergency procedure activated in response to a cardiopulmonary arrest). The RT had also indicated that after the incident, she checked the ventilator history record and was able to determine the length of time that Patient 1 was without mechanical ventilatory support, which was 23 minutes.

A review of Patient 1's cardiac monitor strips (electrocardiogram reading) dated 6/19/12, showed the absence of cardiac contractions (asystole) from 6:42 P.M. to 6:52 P.M. (10 minutes), before Patient 1's incident was recognized and CPR was initiated by the Code Blue team.

On 8/09/12 at 7:20 A.M., an interview was conducted with the ICU nurse (RN 2) who was present during Patient 1's incident of 6/19/12. RN2 confirmed there were two ICU nurses present in the ICU, but neither one of them heard, saw or responded to Patient 1's ventilator and cardiac monitor alarms. RN2 stated that the ICU had 4 patients at that time, and she was quite busy attending to another patient. She then reiterated her awareness of the hospital's policy relative to continuous cardiac and ventilator monitoring of ICU patients, including immediate response to ventilator and cardiac monitor alarms.

The ICU nurse assigned to Patient 1 (RN1) did not respond to the surveyor's repeated requests (3 times) for interview. According to the CCO, subsequent to the incident, RN1 was placed immediately on suspension and eventual termination. Hence, the surveyor was not able conduct an interview with RN1. The other ICU nurse (RN2) was present during the incident and was able to provide the necessary information detailing the incident.

On 8/10/12 at 10:40 A.M., a phone interview was conducted with the monitor technician ( MT1) on duty during the incident. She stated that in addition to her duty as a monitor technician, she was busy attending to other clerical tasks such as answering the telephone and filling out the patient census reports. When questioned if she noticed, heard and reported Patient 1's cardiac monitor alarm to the ICU staff, during the event of 6/19/12, her reply was, "I did not, because I was busy answering the phone."

On 8/10/12 at 8:30 A.M., an interview was conducted with Patient 1's pulmonologist physician (physician specialized in medical care of patients with respiratory illnesses). He expressed his awareness of the 6/19/12 incident involving Patient 1. He indicated that he was involved with Patient 1's care and had spoken to the his family regarding the incident. He stated that based on his medical assessment of Patient 1, there would be no meaningful recovery after the incident. The patient continued to display involuntary jerky movements of his face and extremities.

The pulmonologist physician's progress notes dated 6/21/12, included the physician's documentation indicating that, Patient 1 had a disconnection from his mechanical ventilator for a prolonged period of time, followed by bradycardia (slowing of heart rate) and eventually cardiac arrest. Per the pulmonologist physician's notes, this progressed for a prolonged period of time until it was recognized by the staff. A Code Blue was called and cardiopulmonary resuscitation (CPR) was performed. Although Patient 1 was resuscitated after 4 minutes, he remained unresponsive and continued to exhibit myoclonic jerks (involuntary twitching and spasms of group of muscles). Patient 1 remained critically ill, multi-organ systems were affected, and patient's survival was jeopardized. The patient remained at the facility for continued care and observation.

The neurologist physician's (physician specialized in medical care of patients with diseases of the brain and nervous system) consultation report dated 6/20/12, indicated Patient 1 had remained comatose since the event, and had suffered from hypoxic encephalopathy (dysfunction of the brain secondary to deficiency of oxygen).

On 7/8/12 at 12:01 P.M., eighteen days following the event, Patient 1 expired. An autopsy was requested by the facility, but the family declined.

On 7/31/12 at 10:20 A.M., the patient's designated person was interviewed.
The patient's designated person stated that she was very upset about the hospital, particularly the lack of response to her repeated requests to speak to any physician for explanation and answers to many questions regarding the event of 6/19/12. She stated that she came immediately to the hospital on 6/19/12 at approximately 7:00 P.M.,after being informed that Patient 1 had a cardiac arrest and a Code Blue had been initiated. A respiratory therapist had initially told her that she found Patient 1 disconnected from the mechanical ventilator and the patient's cardiac arrest that followed. No other explanations were provided to the patient's designated person regarding the event. The ICU nurse (RN 1) on duty also declined to give her information detailing the event as it occurred and refused to answer the many questions she had about the event.

Patient 1's designated person then asked RN1 if there was any physician she could speak to regarding the event and her many unanswered questions. It was reported to her by RN1 that the hospital had an onsite physician on duty at that time. The patient's designated person then requested to speak to the physician on duty. However, the physician on duty declined to come to speak to her personally. The patient's designated person added that because of her frustration and the lack of response from the physician on duty, she demanded that Patient 1 be transferred to another facility. It was not until past midnight on 6/20/12, that the physician on duty came and spoke to her briefly, yet many of her questions remained unanswered. The patient's designated person added that it was not until the next day (6/20/12) when hospital administration staff: the chief clinical officer (CCO), chief executive officer (CEO), the director of quality management (DQM)), and the patient's pulmonologist, came and had a discussion with her regarding the 6/19/12 event.

On 8/10/12 at 7:50 A.M., an interview was conducted with the CCO and DQM regarding the event and the hospital's physician coverage particularly in emergencies. The DQM stated that, subsequent to the incident, the physician on duty when the incident occurred had already been terminated by the facility. It was also determined that the supervisor on duty who responded to the Code Blue and had knowledge of the incident, failed to inform any administratie staff that evening of the incident involving Patient 1. Hence, no staff from administration responded or came to the hospital that evening to investigate or speak to the patient's designated person and family.

A review of the hospital's policy entitled, "Communication of Unanticipated Outcomes including Disclosure," dated 1/01/10, revealed a policy statement indicating the hospital's responsibility in respecting the rights of every patient and their legal representatives. This included the right to be informed of unexpected outcomes of care, including adverse outcomes. RN 1 and the physician on duty's failure to provide immediate and appropriate responses to Patient 1's designated person's repeated requests for explanation and responses to questions following the incident of 6/19/12, was in violation of the hospital policy on patient's rights and disclosure of adverse event with unanticipated outcome.

Based on interview and record review, the hospital failed to ensure its quality assurance and performance improvement program was implemented, relative to the use and continuous monitoring of one patient's (Patient 1) mechanical ventilator and cardiac monitor, the implementation of mock codes for ventilator and cardiac monitor alarms per hospital policy, and the ongoing evaluation of the nursing staff compliance with their job description, policies, procedures, and emergency protocols. One of 1 sampled patients (Patient 1) did not receive emergent and appropriate medical and nursing interventions when Patient 1's ventilatory support was disconnected and the patient suffered a cardiac arrest.

Findings:

1. On 6/27/12 at 1:05 P.M., an initial onsite visit of the hospital was conducted in response to the hospital's report of an incident involving Patient 1. An interview was conducted with the chief clinical officer (CCO) for nursing services on 6/27/12 at 1:15 P.M. regarding the incident. The CCO stated that on 6/20/12, she received a report from the director of quality management (DQM) regarding an incident involving Patient 1. The report indicated that the tubing that connected the patient to the mechanical ventilator was found disconnected by a respiratory therapist (RT) when the RT came to the ICU on 6/19/12, in late afternoon. The patient was also found to be in asystole (absence of cardiac contractions or heartbeat), per the patient's cardiac monitor. A Code Blue (an emergency procedure activated in response to a cardiac and/or respiratory arrest) was initiated. A review of the Code Blue (CPR) began on 6/19/12 at 6:52 P.M. and stopped at 6:56 P.M., four minutes after the patient's heart function was restored.

On 6/27/12 beginning at 1:20 P.M., an interview was conducted with the nurse manager (NM) regarding the incident of 6/19/12. The NM indicated that she had received the same report as specified above. When questioned as to how Patient 1 became disconnected from the ventilator and why the two ICU nurses ( RN 1 and RN 2) on duty at the time of the incident failed to immediately recognize and respond to the emergent situation, the NM stated that the ICU nurses had told her that they did not know Patient 1 had been disconnected from the ventilator. Neither one heard the alarms coming from the ventilator. Hence, no one responded to Patient 1's immediate needs and no emergency interventions were done until the situation was recognized by the respiratory therapist who came to the ICU on 6/19/12 at approximately 6:48 P.M.

On 6/27/12 beginning at 4:30 P.M., in light of the above concern, a mock code for the emergency alarm for the cardiac monitor was conducted by the surveyor in the ICU. This was done to evaluate the facility's quality assurance process, including the staff's compliance with the cardiac monitoring policy, including response to cardiac monitor emergency alarm by the nurses and the monitor technician based in the central telemetry station. (Telemetry- transmission of cardiac monitor information electronically to a distant location).

During the cardiac monitor mock alarm code observation, problems were identified relative to the lack of response by the central telemetry station monitor technician (MT2), when the mock alarm code was activated. She failed to recognize both the visual and audible alarms on display on one of the telemetry monitor screen. The monitor technician was observed by the surveyor, CCO and NM not visually monitoring the telemetry screen. She was standing about 2.5 feet away from the screen with her back turned away from the screen and was chatting with another employee. When questioned if she recognized and heard the alarms, she stated, "No." When asked if she had reported the alarm to the ICU staff, she responded, "No."

On 8/10/12 at 8:05 A.M., an interview was conducted with the director of quality management (DQM). The hospital's policy and procedure relative to cardiac monitoring of patients and implementation of mock codes and surveillance monitoring for ventilator and cardiac monitor alarms were also reviewed. The hospital's policy clearly stated that the Chief Clinical Officer (CCO) or the designee, would periodically observe the consistency of 24 hour a day monitoring surveillance and response times, when alarms had been triggered or a monitoring issue was observed. The audits would include a mock alarm code to test staff's response at least annually, each shift for a minimum of two each year.

A request was made for document review to validate the hospital's compliance with Mock Codes for the previous 3 years. The DQM confirmed the mock alarm codes as required by the hospital's policy had not been done. In addition, there were no QA (quality assurance) records to indicate the ongoing evaluation of the nursing staff and monitor technician continuing compliance relative to the hospital's policy on emergency response to ventilator and cardiac monitor alarms.


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2. An interview was conducted with the Chief Executive Officer (CEO) on 8/9/12 at 3:00 P.M. She stated that the facility investigated the incident regarding Patient 1 and the night duty physician's refusal to respond to the questions by Patient 1's family when they noticed a change in Patient 1's condition. She stated that the case was referred to peer review and the medical staff had recommendations for the night duty physician.

An interview with the Critical Care Medical Director was conducted on 8/10/12 at 9:00 A.M. He acknowledged that there was no documentation of communication, education or training to the other 10 night physicians to ensure the night physicians were knowledgeable regarding their duties and responsibilities in responding to a patient or family's request for information regarding medical care. A review of the hospital's policy titled, "Communication of Unanticipated Outcomes, including Apology and Disclosure," indicated that it is the hospital's policy "to disclose any event that has resulted in harm or death to the patient. Disclosure of serious events should be made to the affected patient, and when appropriate, the patient's family or authorized legal representative."

3. A review of the Governing Board Meeting minutes dated March 19, 2012, was conducted on 8/9/12 at 2:00 P.M. The minutes indicated that, "There were 2 Level 3's reported for 4th quarter: (1) Alarm on patient found turned down in the ICU; (2) Telemetry monitor system had loss of power to server. In the next column under recommendations & actions "no recommendations," was documented. The next columns titled, "evaluations and follow-up" and "responsible person," were blank.

An interview with the Director of Quality Management was conducted on 8/9/12. She stated that during the 4th quarter of 2011, the facility investigated an issue regarding a staff complaint that the volume for the mechanical ventilator alarms in the ICU was turned down. She stated that this was presented to the Governing Board, however there were no recommendations or actions taken. The hospital could not provide any documentation of any actions or recommendations for ICU mechanical ventilator alarms in response to this investigation.

Based on observation, interview and record review, the hospital failed to ensure that nursing administration provided the ongoing surveillance of the telemetry central station, to ensure the monitor technicians compliance with their job requirements, duties and patient care responsibilities. The monitor technician failed to recognize, respond and report immediately to the Intensive Care Unit (ICU) nurses, the cardiac monitor alarm that was triggered when 1 of 1 of sampled patients (Patient 1) had a cardiopulmonary arrest. This resulted in a significant delay in recognizing the patient's emergent condition and delay in providing the necessary emergency nursing and medical interventions to help prevent negative outcomes. Subsequent to this incident, the physician indicated that the patient suffered from anoxic encephalopathy (dysfunction of the brain secondary to deficiency of oxygen) and continued deterioration in the patient's condition with no meaningful chance for recovery.

Telemetry - the transmission of cardiac monitor data electronically to a distant location.

Monitor Technician - person assigned to the telemetry central station to continuously observe the cardiac monitor readings, interpret the readings and report abnormalities to the nurse.

Findings:

Patient 1 was admitted to the hospital on 5/29/12, for medical care and treatment. The patient's history and physical examination dated 5/29/12, indicated the patient's diagnoses included pneumonia and acute respiratory failure requiring a tracheostomy (a surgical opening in the trachea to permit airway) and continuous mechanical ventilation (use of a mechanical device such as a ventilator for artifical ventilation of the lungs). The patient had a history of myocardial infarction (heart attack) and coronary artery disease requiring the use of a cardiac (heart) monitor and continuous monitoring of the patient's heart function for abnormal rhythm and signs of impending heart attack (cardiac arrest). Other treatment modalities per the physician's admission orders dated 5/29/12, included the administration of tube feedings via a gastric (stomach) tube, intravenous administration of antibiotics, use of oxygen, urinary catheter and several medications to manage the patient's illnesses.

The physician's history and physical examination dated 5/29/12, indicated Patient 1 was awake and alert, but did not communicate. The nursing admission assessment of Patient 1 described the patient as alert, awake, but unable to communicate verbally. The patient was bedridden and required total nursing care. The use of a mechanical ventilator and a cardiac monitor were also addressed by the nursing staff in Patient 1's admission assessment.

On 6/27/12 at 1:05 P.M., an initial onsite visit of the hospital was conducted in response to the hospital's report of an incident involving Patient 1. An interview was conducted with the chief clinical officer (CCO) for nursing services on 6/27/12 at 1:15 P.M., regarding the reported incident. The CCO stated that on 6/20/12, she received a report from the director of quality (DQM) regarding a significant incident involving Patient 1. The report indicated that the tubing that connected the patient to the mechanical ventilator was found disconnected by a respiratory therapist (RT) when the RT came to the ICU on 6/19/12 in the late afternoon. Patient 1 was also found to be in asystole (absence of cardiac contractions or heartbeat) per the patient's cardiac monitor. A Code Blue (emergency procedure activated in response to a cardiac and/or respiratory arrest) was initiated. A review of the Code Blue cardiopulmonary resuscitation (CPR) record for Patient 1 showed that the CPR was initiated on 6/19/12 at 6:52 P.M. and stopped at 6:56 P.M., four minutes after the patient's heart and lung functions were restored.

On 6/27/12 beginning at 1:20 P.M., an interview was conducted with the nurse manager (NM) regarding the event of 6/19/12. The NM indicated that she had received the same report as specified above. When questioned as to how the two ICU nurses on duty at the time of the event (6/19/12) failed to immediately recognize and respond to the cardiac monitor alarms, the NM stated that the ICU nurses had told her that they did not hear and saw the alarms and no report was received from the telemetry monitor technician regarding the alarm.

The hospital's policy entitled continuous cardiac monitoring dated May 2010, indicated all patients cardiac monitors were interconnected to a central telemetry station. This is located in the North Unit which is adjacent to the ICU (about 15 feet distance). Per NM interview on 6/27/12 at 4:20 P.M., the central telemetry station is always staffed by a monitor technician 24 hours a day. The NM stated that the monitor technician responsibilities included the continuous surveillance of all cardiac monitors, reading, interpreting and reporting abnormalities to the assigned nurse. The NM confirmed the monitor technician's failure to recognize and report to the ICU nurses, Patient 1's abnormal heart rhythm, cessation of heartbeat and the cardiac monitor alarms that were triggered.

On 6/27/12 at 4:20 P.M., Patient 1 was visited in the ICU by the CDPH evaluator. The patient was unresponsive with both eyes closed. Tube feedings and intravenous (via a vein) medications were observed infusing. A mechanical ventilator was in use and a bedside cardiac monitor was also observed attached to the patient.

On 6/27/12, beginning at 4:30 P.M., in light of the above concerns, a mock alarm code for the cardiac monitor was conducted by the CDPH evaluator in the ICU. This was done to evaluate the ICU nursing staff and the cardiac monitor telemetry technician response to emergency alarms and compliance with emergency protocols. A cardiac monitor alarm was activated in Room X. It was observed that the audible and visual monitor alarms were appropriately activated in the ICU. However, 2 minutes had passed and no phone call or report was received from the monitor technician based at the central telemetry station. The evaluator, CCO, NM and an ICU nurse then went to the central telemetry station to determine why no alert call was made to the ICU per hospital policy. The following observations were noted: The monitor technician on duty (MT2) was not visually monitoring the telemetry screens at the central telemetry station (19 patients on telemetry cardiac monitors). The monitor technician was observed standing approximately 2.5 feet away from the telemetry monitor screens, chatting with someone with her back turned away from the telemetry screens. When questioned by the surveyor if she heard the monitor alarm, and if she had noticed the blinking alarm signal on display in the telemetry cardiac monitor screen, she responded "No." When questioned if she called to alert the ICU staff of the cardiac monitor alarm and abnormal heart tracing, she stated, "No." The monitor technician then proceeded to check the telemetry screens upon the instruction of the evaluator. MT2 then acknowledged her failure to recognize, respond and report to the ICU staff a cardiac monitor alarm that had been triggered.

On 8/10/12 at 10:40 A.M., a phone interview was conducted with the monitor technician on duty (MT1) during the hospital reported incident. She stated that in addition to her duty as a monitor technician, she was very busy attending to other clerical tasks such as, answering the telephone, filling out the patient census reports, making copies of medical records for patients transfers/discharge, calling and paging physicians per nurses requests, answering visitors inquiries regarding direction etc, and handing out employee paychecks. She stated that these extra job duties impacted her ability to fully concentrate in the continuous surveillance of all the cardiac monitor telemetry screens, which usually average 18 to 22 patients at a time. When questioned about the 6/19/12 event involving Patient 1, whereby the patient's cardiac monitor strips showed a 10 minute absence of heart activity/rhythm, she indicated that she did not recognize the problem until a Code Blue was called by the ICU staff at 6:52 P.M. on 6/19/12.

On 8/10/12 at 11:00 A.M., a review of the telemetry monitor technician's job description was conducted with the nurse manager. The employee's essential function clearly indicated her role in the continuous observation and surveillance of cardiac monitor readings, interpreting the readings and reporting variances in cardiac rhythms timely, to the nurse assigned to the patient. The added responsibilities as stated by MT1 during the interview, were not delineated in the monitor technician's job description.

The failure of the telemetry monitor technician to comply with her job responsibilities and fulfill her functions relative to the continuous and close surveillance of the cardiac monitor telemetry screens, resulted in a significant incident involving Patient 1. There was no document available for review to indicate the nursing administration's continuing evaluation of the monitor technician's day-to day activities, including how other tasks impacted his or her ability to perform and fulfill their job requirements to ensure that patient care and safety were not compromised.

Based on observation, interview and record review, the hospital failed to ensure that the nursing services provided to patients included the ongoing assessments of the patients conditions and nursing care needs, providing the patients with the right care at the time it was needed, recognizing a significant change and continued deterioration in a patient's condition, and the implementation of appropriate nursing interventions in response to an emergency situation. One of 7 sampled patients (Patient 1) with a mechanical ventilator was found disconnected from his mechanical ventilator for an extended period of time (23 minutes) on 6/19/12, leading to a respiratory arrest followed by cardiac arrest that lasted for 10 minutes. Patient 1's emergent condition was not immediately recognized and managed effectively by the two Intensive Care Unit (ICU) nurses on duty in the ICU at the time of the incident. Consequently, Patient 1 was determined to have suffered from anoxic encephalopathy (dysfunction of the brain related to lack of oxygen) and expired on 7/08/12, eighteen days following the emergent incident. In addition, the nursing staff failed to perform a complete and accurate fall risk assessment, for 1 of 30 sampled patients (Patient 13).

Findings:

1. Patient 1 was admitted to the hospital on 5/29/12, for medical care and treatment. The patient's history and physical examination dated 5/29/12, indicated that Patient 1's diagnoses included pneumonia and acute respiratory failure requiring a tracheostomy (a surgical opening in the trachea to permit airway), and continuous mechanical ventilation (use of a mechanical device such as a ventilator for artifical ventilation of the lungs). The patient had a history of myocardial infarction (heart attack) and continuing heart ailment requiring the use of a cardiac (heart) monitor and continuous monitoring of the patient's heart function. Other treatment modalities per the physician's admission orders dated 5/29/12, included the administration of tube feedings via a gastric (stomach) tube, intravenous administration of antibiotics, use of oxygen, urinary catheter and several medications to manage the patient's illnesses.

The physician's history and physical examination dated 5/29/12, indicated the patient was awake and alert, but did not communicate. The nursing admission assessment of the patient described Patient 1 as alert, awake, but unable to communicate verbally. The patient was bedridden and required total nursing care. The use of a mechanical ventilator and a cardiac monitor were also addressed by the nursing staff in the patient's admission assessment.

On 6/27/12 at 1:05 P.M., an initial onsite visit to the hospital was conducted in response to the hospital's report of a significant incident involving Patient 1. An interview was conducted with the chief clinical officer (CCO) for nursing services on 6/27/12 at 1:15 P.M., regarding the reported incident. The CCO stated that on 6/20/12, she received a report from the director of quality regarding a significant incident involving Patient 1. The report indicated that the tubing that connected the patient to the mechanical ventilator was found disconnected by a respiratory therapist (RT), when the RT came to the ICU on 6/19/12 in the late afternoon. The patient was also found to be in asystole (absence of cardiac contractions or heartbeat), per the patient's cardiac monitor. A Code Blue (emergency procedure activated in response to a cardiac and/or respiratory arrest) was initiated. A review of the Code Blue cardiopulmonary resuscitation (CPR) record for Patient 1 showed that, the CPR was initiated on 6/19/12 at 6:52 P.M. and stopped at 6:56 P.M., four minutes after the patient's heart and lung functions were restored.

On 6/27/12 beginning at 1:20 P.M., an interview was conducted with the nurse manager (NM) regarding the incident of 6/19/12. The NM indicated that she had received the same report as specified above. When questioned as to how Patient 1 became disconnected from the ventilator and why the two ICU nurses on duty at the time of the incident failed to immediately recognize and respond to the emergent situation, the NM stated that the ICU nurses had told her that they did not know Patient 1 had been disconnected from the ventilator, and neither one heard the alarms coming from the ventilator. Hence, neither one responded to Patient 1's immediate needs and no emergency interventions were done until the situation was recognized by the respiratory therapist who came to the ICU on 6/19/12 at 6:48 P.M.

The NM added that the mechanical ventilator is equipped with both visible and audible alarms to alert the staff of emergency situations, including ventilator disconnections. The hospital's policy dated Oct., 2010 clearly indicated that all ventilator alarms are interconnected with the nursing call light system. When the ventilator alarm sounded, it would initiate audible and visual alarms at the nurses station. The alarm could also be visually seen on the outside of the patient's room, above the door indicated by an amber flashing light. The alarms would repeat continuously until the alarm situation had been responded to and corrected. Despite these safety features, neither of the ICU nurses on duty recognized the emergency situation, and failed to respond quickly to Patient 1's disconnection from the ventilator and ultimately his cardiac arrest.

In addition, the hospital's policy entitled, "continuous cardiac monitoring," dated May 2010, indicated all telemetry patients cardiac monitors were interconnected to a central telemetry station. The central telemetry station is located in the North Unit which is adjacent to the ICU (about 15 feet distance). Telemetry is the transmission of data electronically to a distant location. Per NM interview on 6/27/12 at 4:20 P.M., the central telemetry station is always staffed by a monitor technician 24 hours a day. The NM stated that the telemetry monitor technician's responsibilities included the continuous surveillance of all cardiac monitors, reading, interpreting and reporting abnormalities to the assigned nurse. When the NM was questioned as to how the ICU staff could have missed Patient 1's lack of heart contractions (asystole), that lasted for 10 minutes on 6/19/12 (6:42 P.M. to 6:52 P.M. as shown in the cardiac (EKG) monitor strips), she stated that, the two ICU nurses (RN1, RN2) had told her that neither one heard the cardiac monitor alarms in the ICU, and no report or phone call was made by the monitor technician to alert the ICU nurses of Patient 1's cardiac monitor alarms, the absence of heart contractions and the emergent situation.

On 6/27/12 at 4:20 P.M., Patient 1 was visited in the ICU by the Department evaluator. The patient was unresponsive with both eyes closed. Tube feedings and intravenous (via a vein) medications were observed infusing. A mechanical ventilator was in use and a bedside cardiac monitor was also observed attached to the patient.

On 6/27/12 beginning at 4:30 P.M., in light of the above concerns, a mock alarm code for the cardiac monitors was conducted by the Department evaluator in the ICU. This was done to evaluate the ICU staff and telemetry monitor technician's response to emergency alarms and compliance with emergency protocols related to the cardiac monitors. A cardiac monitor alarm was activated in Room X. It was observed that both audible and visual monitor alarms were appropriately activated in the ICU. However, 2 minutes had passed and no phone call or report was received from the telemetry monitor technician. The evaluator, CCO, NM and an ICU nurse then went to the central telemetry station to determine the reason why the monitor technician (MT2) had not called and alerted the ICU staff about the telemetry monitor alarm, as required by the hospital policy. The following observations were noted: The monitor technician on duty was not visually monitoring the telemetry screens at the central telemetry station, which had 19 telemetry patients. The monitor technician was observed standing approximately 2.5 feet away from the telemetry monitor screens, with her back turned away from the screens, and chatting with another employee. When questioned by the evaluator if she heard the alarm and noticed the blinking signal alarm on display on the telemetry screen, she responded "No." When questioned if she called to alert the ICU nurses about the alarm, she stated, " No." The monitor technician only proceeded to check the telemetry screens upon the instruction of the evaluator. She then acknowledged her failure to recognize, respond and report to the ICU nurses that the cardiac monitor alarm that had been triggered.

On 8/08/12, beginning at 3:35 P.M., an interview was conducted with a respiratory therapist (RT), the staff who discovered that Patient 1 was disconnected from the mechanical ventilator on 6/19/12. The RT stated she came to the ICU on 6/19/12, at approximately 6:48 P.M. Upon entering the ICU, she heard an alarm sound coming from Patient 1's room. She stated that although the room door was closed, the ventilator alarm sound was still audible from outside the room. She then approached Patient 1 and found the tubing that connected the patient to the ventilator had been disconnected, with the tubing wrapped around the patient's elbow and laying on the patient's chest. She also noticed that Patient 1's bedside cardiac monitor alarm was on, and the screen showed asystole, the absence of cardiac activity/cardiac rhythm. She then immediately reconnected the patient to the mechanical ventilator, called out for help and alerted the ICU nurses to call a Code Blue (emergency procedure activated in response to a cardiopulmonary arrest). Cardiopulmonary resuscitation (CPR) was immediately initiated by the Code Blue team. The RT had also indicated that after the incident, she checked the ventilator history and was able to determine that the length of time the patient was without ventilatory support was 23 minutes. In addition, a review of the cardiac monitor strips (electrocardiogram tracings/readings) dated 6/19/12, showed the absence of cardiac contractions (asystole) from 6:42 P.M. to 6:52 P.M., indicating Patient 1 had a cardiac arrest for 10 minutes.

On 8/09/12 at 7:20 A.M., an interview was conducted with the ICU nurse (RN 2) who was on duty during the incident of 6/19/12. She confirmed there were 2 ICU nurses on duty in the ICU, but neither one of them heard, saw or responded to Patient 1's ventilator and cardiac monitor alarms. She stated that the ICU had 4 patients at that time, and she was quite busy attending to another patient. She then reiterated her awareness of the hospital's policy relative to continuous cardiac and ventilator monitoring, including management of alarms and emergency situations. She acknowledged the failure of the ICU staff to immediately recognize Patient 1's cardiac and respiratory arrest, including the failure to initiate the appropriate emergency procedures according to hospital policy and ACLS (Advanced Cardiac Life Support) protocols.

The ICU nurse assigned to Patient 1 (RN 1) did not respond to three requests for interview by the evaluator. According to the chief clinical officer (CCO), subsequent to the incident, RN 1 was immediately placed on suspension and was eventually terminated from her job. Hence, the evaluator was not able conduct the interview with the employee. However, RN 2 who was on duty in the ICU during the incident was able to provide the details of the incident as it occurred on 6/19/12.

On 8/10/12 at 10:40 A.M., a phone interview was conducted with the monitor technician (MT1) on duty during the incident. She stated that in addition to her duties as a monitor technician, she was very busy attending to clerical tasks such as answering the telephone and filling out the patient census reports. When questioned if she noticed, heard and reported Patient 1's cardiac monitor alarm to the ICU nurses during the incident, her reply was, "I did not, because I was busy answering the phone."

On 8/10/12 at 8:30 A.M., an interview was conducted with Patient 1's pulmonologist physician (physician specialized in medical care of patients with respiratory illnesses). He expressed his awareness of the 6/19/12 incident involving Patient 1. He indicated that he was quite involved with Patient 1's care and had spoken to his family regarding the incident. He stated that based on his medical assessment of Patient 1, there would be no meaningful recovery after the incident. The patient continued to display involuntary jerky movements of his face and extremities.

The pulmonologist physician's progress notes dated 6/21/12, included the physician's documentation stating that Patient 1 had a disconnection from his mechanical ventilator for a prolonged period of time, followed by bradycardia (slowing of heart rate) and eventually cardiac arrest. Per the physician notes, this progressed for a prolonged period of time, until this was recognized by the staff. A Code Blue was called and CPR (cardiopulmonary resuscitation) was performed. Although Patient 1 was resuscitated, he remained unresponsive and continued to exhibit myoclonic jerks (involuntary twitching and spasms of group of muscles). The patient remained critically ill, and multi-organ systems were affected and the patient's survival was jeopardized.

The neurologist physician's (physician specialized in the care of patients with diseases of the brain and nervous system) consultation report dated 6/20/12, indicated Patient 1 had remained comatose since the incident, and had suffered from hypoxic encephalopathy (dysfunction of the brain secondary to deficiency of oxygen).

On 7/8/12 at 12:01 P.M., eighteen days following the incident, Patient 1 expired. An autopsy was requested by the facility, but the family declined.

The hospital's failure to ensure Patient 1 was provided the necessary nursing care and services to include the close observation and ongoing evaluation of the patient's care needs, immediate recognition and timely response to an emergent situation, and implementation of appropriate emergency procedures according to hospital policy and procedure and advanced cardiac life support protocols (ACLS), resulted in the following:
(a). Patient 1's disconnection from a mechanical ventilator for 23 minutes that was not immediately recognized and emergently managed by the ICU nurses.
(b). Patient 1's cardiac arrest (asystole) that lasted for 10 minutes that was not immediately recognized and emergently managed by the ICU nurses.
(c). The ICU nurses failure to recognize and immediately respond to the safety alarm features built into the mechanical ventilator and cardiac monitor to alert the staff of the emergency situation and the need to respond immediately.



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2. A tour of the south unit was conducted with registered nurse (RN) 5 on 8/7/12 at 8:47 A.M. During an observation of Patient 13's room on 8/7/12 at 8:50 A.M., a card with a "star" was noted posted outside the patient's room. RN 5 stated that the "star" meant that the patient was a fall risk.

Patient 13's medical record was reviewed on 8/8/12 at 8:45 A.M. Patient 13 was admitted to the hospital on 7/3/12, with diagnoses that included metastatic adenocarcinoma of the lung, per the History and Physical, dated 7/4/12.

A review of Patient 13's fall risk assessments indicated that there were no documented fall risk assessments conducted on 8/4/12 on all shifts.

A joint record review and interview with RN 7 (one of the RN assigned to Patient 13 on 8/4/12), was conducted on 8/8/12 at 9:25 A.M. RN 7 acknowledged that Patient 13's fall risk assessment was missed on 8/4/12.

3. A tour of the south unit was conducted with registered nurse 5 (RN5) on 8/7/12 at 8:47 A.M. During an observation of Patient 13's room on 8/7/12 at 8:50 A.M., a card with a "star" was noted posted outside the patient's room. RN 5 stated that the "star" meant that the patient was a fall risk.

Patient 13's medical record was reviewed on 8/8/12 at 8:45 A.M. Patient 13 was admitted to the hospital on 7/3/12 with diagnoses that included metastatic adenocarcinoma of the lung per the History and Physical, dated 7/4/12.

A review of Patient 13's fall risk assessment, dated 8/1/12 at 8:56 P.M., indicated that the patient scored "7" on the fall risk assessment and was not a fall risk. Per the same record, the patient scored "3" for mental status due to confusion and scored "4" for physical status due to frequent toilet use, which totaled to a score of "7" (not a fall risk). However, a review of the fall risk screening tool used to complete the fall risk assessment indicated that the fall risk assessment completed on 8/1/12 at 8:56 P.M. was inaccurate. The registered nurse who completed the fall risk assessment did not score some of the elements that would have placed the patient at a higher score. Based on the fall risk screening tool, the registered nurse did not score the following elements that were applicable to Patient 13: High risk drugs in the last 72 hours (patient was on intravenous narcotic medication) - score of "2"; Age 65 or > (patient was 71 years old) - score of "1"; unstable gait/balance or requires assistance to ambulate or transfer (patient had weakness on her lower extremeties) - score of "4"; Forgets instructions or over estimates own limits (patient was confuse) - score of "2". The registered nurse who completed Patient 13's fall risk assessment missed a total of "9" points, if added to the patient's score, would have made the patient at risk for fall.

A joint record review and interview with registered nurse (RN6) (the RN who completed the fall risk assessment on 8/1/12 at 8:56 P.M.), was conducted on 8/9/12 at 7:45 A.M. RN 6 acknowledged that, the fall risk assessment she completed for Patient 13 on 8/1/12 at 8:56 P.M., was inaccurate. RN 6 acknowledged that she failed to score some of the elements in the patient's fall risk assessment that would have identified the patient as a fall risk.

Based on observation, interview and record review, the hospital failed to ensure nursing care plans were developed and implemented, for 3 of 30 sampled patients (Patients 4, 11, 25).

Findings:

1. Patient 4 was admitted to the hospital on 7/30/12, with diagnoses that included chronic respiratory failure and a Stage IV sacral pressure ulcer, per the patient's admission history and physical. A Stage IV pressure ulcer, per hospital policy involved a full thickness tissue loss with exposed bone, tendon or muscle. The sacral area is the triangular bone located in the lower back.

A review of Patient 4's nursing admission assessment dated 7/30/12, showed the nursing description of the patient's Stage IV sacral pressure ulcer as an 8.0 by 4.0 cm (centimeters) with bloody drainage. Patient 4's initial nursing care plan included the patient's Stage IV pressure ulcer, limited mobility and high risk for developing more pressure ulcers.

The initial treatment protocol ordered by the physician dated 7/30/12, included the wound cleaning, use of collagenase (an enzyme that induces changes in collagen to promote the removal of death tissue) and dressing changes daily.

The nurse's notes dated 8/01/12, indicated that Patient 4 was transferred to another facility for medical evaluation. The patient then returned to the hospital the next day, on 8/02/12. The nursing assessment of the patient upon return to the hospital continued to reflect the presence of a Stage IV sacral pressure ulcer with "dressing intact."

On 8/08/12 beginning at 8:10 A.M., a joint review of Patient 4's medical record, including the patient's nursing care plan and physician's orders was conducted with the nurse manager. The nurse manager concurred with the lack of physician treatment orders until 4 days after the patient's return to the hospital. The patient's nursing care plan to include the active treatment provided to the Stage IV sacral pressure ulcer, was not initiated upon the patient's return to the hospital on 8/02/12.


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2. A review of Patient 25's medical record was conducted on 8/7/12 at 10:30 A.M. Patient 25 was admitted to the hospital on 4/9/12, with a history of dementia and significant chronic mental disorder. A review of the History and Physical (H&P) under assessment and plan, indicated the patient was on lithium and valproic acid. A review of the Medication Administration Record (MAR) also indicated that Patient 25 was prescribed lithium and valproic acid upon admission. A review of the nursing care plan indicated that there was no written care plan for the mental disorder or other thought/ mood disorder or behavioral management related to the patient's diagnosis.
An interview with the Director of Quality was conducted on 8/7/12 at 11 A.M. The Director of Quality stated that, the nurse should have developed and implemented a care plan for the mental disorder based on the documentation by the physician in the H&P, and the prescribed medications listed on the MAR.
During an interview with RN 8, conducted on 8/8/12, RN8 stated that patients with psychiatric diagnosis should be care planned by the RN in the computerized record. She was able to demonstrate in the computer how an RN can develop and implement a nursing care plan for a patient with a psychiatric diagnosis.
A review of the hospital policy titled, "Standards of Patient Care" indicated that, "Each patient can expect that there will be a nursing plan of care with prescribed nursing actions to achieve the stated goals. The plan of care includes relevant physiological and psychological measures specific to the patient's current problems/needs and goals."



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3. Patient 11's medical record was reviewed on 8/8/12 at 10:30 A.M. Patient 11 was admitted to the hospital on 7/18/12, per the facesheet. According to the History and Physical, dated 7/19/12, the patient had a history of previous stroke and pneumonia. A review of the physician's order, dated 7/19/12, indicated that the patient was on pureed diet and honey thick liquids.

A review of the speech pathologist's notes, dated 8/3/12, indicated that Patient 11 was seen by speech therapy for moderately severe oropharyngeal (oral part of pharynx) dysphagia (difficulty swallowing), and the speech pathologist recommended a puree diet and honey thick liquids. However, a review of the patient's electronic medical record showed no active care plan addressing the patient's dysphagia.

A joint record review and interview with speech therapist 5 (ST5) was conducted on 8/8/12 at 1:40 P.M. ST5 stated that Patient 11's dysphagia care plan was initiated by speech therapy. However, ST5 also stated that, when the patient's treatment with speech therapy was discontinued, the patient's dysphagia care plan was also discontinued.

A joint record review and interview with the nursing supervisor was conducted on 8/8/12 at 2:50 P.M. The nursing supervisor stated that when speech therapy discontinued Patient 11's treatment, it did not mean that the patient's dysphagia was resolved. The nursing supervisor stated that the patient should have an active care plan addressing the patient's dysphagia needs in the patient's medical record.

A review of the hospital's policy and procedure titled, "Altered Fluid Consistency," was conducted on 8/10/12 at 8:00 A.M. The policy indicated that, "All care plans will reflect fluid alterations and will also contain any specific swallowing precautions. All treating staff should be thoroughly familiar with these instructions."

Based on interview and record review, the hospital failed to ensure that certified nurse assistants, who were allowed to thickened liquids for patients with swallowing difficulty, were educated and knowledgeable on how to perform the task properly, for 1 of 1 sampled patients (Patient 11).

Findings:

Patient 11's medical record was reviewed on 8/8/12 at 10:30 A.M. Patient 11 was admitted to the hospital on 7/18/12 per the facesheet. According to the History and Physical, dated 7/19/12, the patient had history of stroke and pneumonia. A review of the physician's order, dated 7/19/12, indicated that the patient was on pureed diet and honey thick liquids.

A review of the speech pathologist notes, dated 8/3/12, indicated that Patient 11 was seen by speech therapy for moderately severe oropharyngeal (oral part of pharynx) dysphagia (difficulty swallowing) and recommended puree diet and honey thick liquids.

An interview with certified nurse assistant 5 (CNA5) was conducted on 8/8/12 at 11:00 A.M. CNA 5 stated that he was not aware that Patient 11 had restrictions related to eating or drinking. CNA 5 stated this was not the first time he was assigned to Patient 11. During the interview, CNA 5 was informed that Patient 11 required thickened liquids with honey consistency. CNA 5 was asked how he would thickened the liquids if the patient asked for a glass of water. CNA 5 stated that he would thicken the water with a packet of thickener found in the unit. CNA 5 was shown the packet of thickener that was available in the unit. CNA 5 was provided the packet of thickener and was asked to verbalize how he would thicken the patient's water. CNA 5 read the instruction that was listed on the back of the thickener packet. However, the instruction that CNA 5 read on the back of the thickener packet was the instruction on how to thicken liquids to nectar thick consistency and not honey thick consistency. There was no instruction listed on the back of the thickener packet that would guide the staff on how to properly thicken liquids to a honey thick consistency. The Dietary Manager, who was present during the interview, stated that the staff would add more of the thickener to make the liquid a honey thick consistency. However, the Dietary Manager was not able to verbalize how much more of the thickener was needed to create a honey thick consistency.

A review of CNA 5's employee file was conducted on 8/9/12 at 3:00 P.M. There was no evidence that CNA 5 was educated to ensure that the staff was knowledgeable on how to properly thickened liquids.

An interview with the nursing manager (NM) was conducted on 8/9/12, at 4:05 P.M. The NM acknowledged that the CNAs should have been educated on how to properly thicken liquids.

A review of the hospital's policy and procedure titled "Altered Fluid Consistency" was reviewed on 8/10/12 at 8:00 A.M. The policy indicated that, "Nursing staff or others that deliver any tray or nourishment with altered fluid consistency are held accountable for knowing the individual's plan of care in regards to swallowing interventions. The staff will also ensure that all liquids offered meet the definition of the specific consistency ordered by the physician."

Based on interview and record review, the hospital failed to ensure that, 3 of 7 sampled patients (Patients 2, 3, 14) receiving pain management were given pain medications in accordance with the physician order, assessed pain status and the hospital's policy and procedure on pain management.

Findings:

1. Patient 2 was admitted to the hospital on 8/02/12, because of respiratory failure, urinary tract infection and a deep tissue injury in her sacrum per the patient's history and physical dated 8/03/12.

The physician's orders for treatment dated 8/02/12, included the following: Acetaminophen 650 mg (milligrams) 1 tablet every 4 hours, as needed for mild pain; Morphine Sulfate injection 2 mg, to be given intravenously (via a vein) every 1 hour as needed, for moderate pain, and 4 mg every 1 hour as needed for severe pain.

On 8/08/12 at 9:20 A.M., Patient 2's medication administration record (MAR) was reviewed with the nurse manager (NM). It was noted that the MAR showed the nursing documentation that indicated the administration of Morphine Sulfate injections, that were not in accordance with the physician's order for pain management as follows:

8/03/12 at 12:39 A.M. - Morphine Sulfate 2 mg injection, was given instead of 4 mg for severe back pain (pain scale was documented by the nurse in the MAR as 10 - severe).

8/03/12 at 4:15 A.M. - Morphine Sulfate 2 mg injection was given for severe thigh pain, instead of 4 mg as ordered for severe pain (pain scale was documented by the nurse in the MAR as 10 -severe).

8/03/12 at 11:17 A.M. - Morphine Sulfate 2 mg injection was given for severe pain (pain scale documented by the nurse in the MAR was 8 - severe)

8/04/12 at 1:36 A.M. - Morphine injection 2 mg injection was given for generalized sharp pain (pain scale documented by the nurse was 10 - severe).

The hospital's policy and procedure for pain management was reviewed with the NM on 8/08/12 at 9:40 A.M. The hospital's policy included the ongoing nursing assessment of the patient's pain status using the pain scale parameters as follows:

1 - 3 - mild pain
4 -5 - moderate pain
6 -7 - severe pain
8 - 9 - very severe pain
10 - worst possible pain

The NM confirmed during the interview and joint record review that, the administration of the Morphine Sulfate as given by the nurse was not consistent with the physician's orders and the hospital's pain management scale policy as specified above. The NM had also concurred with the nursing staff's failure to clarify with Patient 2's physician the hourly intravenous administration of Morphine Sulfate.

2. Patient 3 was admitted to the hospital on 6/04/12, with diagnoses that included urinary bladder obstruction and chronic pain syndrome, per the physician's history and physical dated 6/04/12. The physician's orders dated 6/28/12, included the administration of Morphine Sulfate 2 mg by intravenous injection, every 1 hour as needed for moderate pain, and 4 mg every 1 hour as needed for severe pain.

A review of Patient 3's medication administration record (MAR) was done with the nurse manager (NM) on 8/07/12 at 1:05 P.M. The following nursing documentation was noted:

7/20/12 at 1:53 P.M. - Morphine Sulfate injection 2 mg was given instead of 4 mg for severe pain. The patient's pain scale was documented by the nurse as 8 - severe per pain scale policy.

7/25/12 at 11:30 P.M. - Morphine Sulfate injection 2 mg was given for a pain scale of 9 instead of 4 mg as ordered for severe pain. Per hospital policy, scale of 9 was considered severe pain.

8/06/12 at 6:00 P.M. - Morphine Sulfate injection 2 mg was given for pain scale of 8, severe pain per hospital policy. The order was to give 4 mg for severe pain.

The NM confirmed during the interview and joint record review that, the hospital's policy for pain assessment and pain management was not followed by the nursing staff. The drug administration as documented by the nursing staff in the MAR was not in accordance with the physician's orders for Patient 3.


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3. Patient 14's medical record was reviewed on 8/7/12 at 1:50 P.M. Patient 14 was admitted to the hospital on 7/31/12, with diagnoses that included acute respiratory failure, per the History and Physical, dated 8/1/12. A review of the physician's order sheet indicated the following orders:
On 7/31/12 at 5:09 P.M., Hydrocodone 5 mg (milligrams)/Acetaminophen 325 mg (pain medication), 1 tablet per feeding tube every 4 hours as needed for mild pain;

On 7/31/12 at 5:09 P.M., Hydrocodone 5 mg/Acetaminophen 325 mg, 2 tablets per feeding tube every 4 hours as needed for moderate pain;

On 7/31/12 at 5:09 P.M., Morphine sulfate (pain medication) intravenously, 1 mg every 2 hours as needed for moderate pain;

On 7/31/12 at 5:09 P.M., Morphine sulfate intravenously, 2 mg every 2 hours as needed for moderate pain;

On 7/31/12 at 5:09 P.M., Oxycodone 5 mg/Acetaminophen 325 mg 1 tablet, per feeding tube every 4 hours as needed for severe pain;

On 7/31/12 at 5:09 P.M., Oxycodone 5 mg/Acetaminophen 325 mg 2 tablets, per feeding tube every 4 hours as needed for severe pain

A review of Patient 14's medication administration record indicated that morphine 2 mg, was administered to the patient on 8/6/12 and 8/7/12, for a pain scale ranging from 7 to 10, which was severe pain per the hospital's policy. A review of the hospital's policy and procedure titled, "Pain Management" indicated that a pain score of 4 - 5 was moderate pain and pain score of 6 - 10 was severe pain.

A joint record review and interview with the Director of Pharmacy (DOP) was conducted on 8/7/12 at 2:40 P.M. The DOP stated that the list of pain medications ordered by the physician should have been clarified because, two medications were ordered for the same indications, and medications with two dosages were ordered for the same indications. The DOP stated that the orders were confusing. The DOP also acknowledged that the licensed nurses did not follow the physician's order when morphine 2 mg was administered to Patient 14 for severe pain, when the order indicated to give morphine 2 mg for moderate pain.

4. Patient 14's medical record was reviewed on 8/7/12 at 1:50 P.M. Patient 14 was admitted to the hospital on 7/31/12 with diagnoses that included acute respiratory failure, per the History and Physical, dated 8/1/12. A review of the physician's order sheet indicated the following orders:

On 7/31/12 at 5:09 P.M., Hydrocodone 5 mg (milligrams)/Acetaminophen 325 mg (pain medication) 1 tablet per feeding tube every 4 hours as needed for mild pain.

On 7/31/12 at 5:09 P.M., Hydrocodone 5 mg/Acetaminophen 325 mg, 2 tablets per feeding tube every 4 hours as needed for moderate pain;

On 7/31/12 at 5:09 P.M., Morphine sulfate (pain medication) intravenously, 1 mg every 2 hours as needed for moderate pain;

On 7/31/12 at 5:09 P.M., Morphine sulfate intravenously 2 mg, every 2 hours as needed for moderate pain;

On 7/31/12 at 5:09 P.M., Oxycodone 5 mg/Acetaminophen 325 mg, 1 tablet per feeding tube every 4 hours as needed for severe pain;

On 7/31/12 at 5:09 P.M., Oxycodone 5 mg/Acetaminophen 325 mg, 2 tablets per feeding tube every 4 hours as needed for severe pain

A review of Patient 14's medication administration record indicated that 2 tablets of Oxycodone 5 mg/Acetaminophen 325 mg, was given to the patient on 8/3/12 at 10:45 A.M. However, there was no documentation that the patient complained of pain and at what rate.

A joint record review and interview with licensed vocational nurse 5 (LVN5) was conducted on 8/8/12 at 10:05 A.M. LVN 5 stated that Patient 14 complained of pain that day, but LVN5 forgot to document the patient's pain rate on the patient's medical record. LVN 5 acknowledged that the pain assessment should be completed prior to giving the PRN (as needed) pain medications to the patient.

Based on interview and record review, the hospital failed to ensure that a change in medication order, communicated by the physician to a registered nurse, was documented as an order in the medical record, for 1 of 1 sampled patients (Patient 12).

Findings:

Patient 12's medical record was reviewed on 8/9/12 at 10:45 A.M. Patient 12 was admitted to the hospital on 7/24/12, with diagnoses that included acute respiratory failure (inadequate gas exchange) requiring mechanical ventilation per the History and Physical, dated 7/25/12.

A review of the physician's order, dated 7/25/12 at 9:58 P.M., indicated an order for Neosynephrine intravenous drip, 100 mg (milligrams) base solution D5W 250 milliliters (ml) at 10 to 200 micrograms (mcg)/minute (min).

On 7/28/12 at 12:58 P.M., an order was written for "Norepinephrine intravenous drip at 2 to 20 mcg; Titrate to keep the mean arterial pressure (MAP - the average blood pressure in an individual) greater than 65; Start only when Neosynephrine drip is at maximum dose."

A review of Patient 12's medication administration record for Neosynephrine indicated that on 7/28/12 at 4:00 A.M., the patient was receiving Neosynephrine at 130 mcg/min. Per the same record, the dosage was increased to 160 mcg/min on 7/28/12 at 8:08 P.M., which was not at the maximum dose of 200 mcg/min, as indicated in the physician's order. However, a review of the medication administration record for Norepinephrine, dated 7/28/12 at 7:30 P.M., indicated that the patient was receiving 3 mg/kg/min of the Norepinephrine, which was contrary to the physician's order to start Norepinephrine when the Neosynephrine dose was at the maximum dose.

A review of the nursing notes, dated 7/28/12, indicated that at 2:54 P.M., a registered nurse informed Patient 12's physician regarding the patient's low blood pressure and increased heart rate. Per the nursing note, the physician ordered to give Norepinephrine, which was a change in the medication's original order. However, other than the nursing notes, there was no documentation regarding the change in order for Norepinephrine in the physician's order record. There was no documentation that the conversation between the physician and the registered nurse regarding Norepinephrine was written as an order. In addition, the registered nurse did not document in the medication administration record, the date and time when Norepinephrine was administered to the patient, as well as the dosage of the medication given.

A joint record review and interview with the Director of Pharmacy (DOP) was conducted on 8/9/12 at 4:15 P.M. The DOP stated that the original order for Norepinephrine should have been discontinued and a new order should have been written, when the physician informed the registered nurse to give Patient 12 Norepinephrine on 7/28/12 at 7:30 P.M., even if the Neosynephrine was not at the maximum dose, which was contrary to the original order.

Based on observation, interview and record review, the hospital failed to ensure that thickeners were available in the units for staff to use, for patients with swallowing difficulty who required liquids with honey thick consistency.

Findings:

An interview with registered nurse (RN) 5 was conducted on 8/7/12 at 9:10 A.M. RN 5 stated that thickeners were available on the unit and were stored in the supply room. RN 5 was asked to get a packet of the thickener that was available in the unit. RN 5 brought back a yellow packet called "Thick It." The front of the packet indicated "nectar-like consistency." On the back was the packet directions which indicated, "Slowly sprinkle contents of packet into 4 fl. (fluid) oz (ounce) of liquid while stirring briskly with a spoon, fork or wire whisk. Once thickener is dissolved, allow liquid to stand for a minute to thicken. One packet will thicken most liquids to nectar-like consistency." On the bottom right corner where the directions were indicated, was a short instruction which stated that, "For Spoon-Thick Consistency: Add two packets to 4 fl. 0z. liquid." However, there were no instructions on how to make honey thick liquids. There were no other packets of thickener found in the unit that staff could have used to thicken liquids to a honey thick consistency.

On 8/8/12 at 11:10 A.M., the Dietary Manager brought a pink packet of thickener to an interview. The packet was called "Thicken Up." On the back of the packet were instructions on how to make liquids with nectar thick consistency, as well as, honey thick consistency. The Dietary Manager stated that the packets were available in the kitchen. The Dietary Manager was not aware that the packets of thickener that could have been used to thicken liquids to a honey thick consistency were not available in the units.