HospitalInspections.org

Based on medical record review, document review and interview, in one (1) of 18 medical records reviewed, it was determined the nursing staff failed to (a) reassess a patient's deteriorating condition and (b) follow the facility's policy when an acute change in a patient's condition was identified. This was evident for Patient #1.

Findings include:

Review of medical record #1 identified the following: the patient presented to the emergency department on 3/26/17 at 8:59 PM with complaints of a stomach virus for one (1) week and cough and shortness of breath for two (2) days. The patient had a previous medical history of a pacemaker, Atrial Fibrillation, Coronary Artery Disease, Diabetes Mellitus, Hypertension (high blood pressure) and high cholesterol. Upon admission, the patient's white blood cell (WBC) count was elevated at 15 (normal range 4.5 - 11 K/UL), the blood urea nitrogen level was 33 MG/DL (normal level 7-17) and she had difficulty breathing. The admitting diagnoses were Bronchitis and Asthma.

Nursing documentation on 3/31/17 at 8:00 AM revealed the heart rate was 80 beats per minute (normal range 60-100) but at 9:10 AM it had increased to 120 beats per minute, which represents a change of 40 beats each minute.

The policy titled "Vital Signs Procedure," last revised 12/2017; states "more frequent monitoring of any or all vital signs will be done when indicated by patient care needs."

The nurse documented on 3/31/17 at 9:47 AM that the patient complained of abdominal pain and the patient pointed to the left lower quadrant of her abdomen. The abdomen was noted to be distended and firm with positive bowel sounds x 4.

There was no documentation in the medical record that the patient's vital signs and the patient's condition were reassessed.

Nursing documentation at 11:40 AM on 3/31/17 revealed the heart rate had dropped to 50 beats per minute, the B/P was 85/50 (normal 120/80) and she was verbally unresponsive.

The policy titled "Assessment and Reassessment of Patients," last reviewed 6/17 states; "the patient will be reassessed by the RN each shift or upon transfer or change in patient's condition."

The policy titled "Rapid Response Team" effective 10/15; states "the rapid response team will be activated by the clinical staff member if the patient has an acute change in one or more of the following criteria - uncontrolled pain, any concern that the patient's condition has changed and heart rate change of 20 beats per minute from baseline."

The nursing staff did not follow these policies when the patient's condition changed at 9:10 AM and 9:47 AM on 3/31/17.

A rapid response was called at approximately 11:45 AM on 3/31/17, two hours after there was a change in the patient's condition.

These findings were shared with Staff A, the Director of Quality on 4/26/17 at 4:00 PM.

Based on medical record review, document review and interview, in one (1) of 18 medical records reviewed, it was determined the nursing staff did not formulate a care plan to meet the changing needs of a patient. This was evident for Patient #1.

Findings include:

Review of medical record #1 identified the following: the patient presented to the emergency department on 3/26/17 at 8:59 PM with complaints of a stomach virus for one (1) week and cough and shortness of breath for two (2) days. The patient had a previous medical history that included a pacemaker, Atrial Fibrillation, Diabetes Mellitus, and Hypertension. Upon admission on 3/27/17 at 4:20 AM to an inpatient unit, the patient's WBC count was elevated at 15 (normal range 4.5 - 11 K/UL), the blood urea nitrogen level was 33 MG/DL (normal level 7-17) and she had difficulty breathing. The admitting diagnoses were Bronchitis and Asthma.

Review of the physician's note revealed the WBC had increased to 20.5 on 3/30/17 at 8:05AM, the blood glucose at 5:16 PM that day had increased to a 417 (normal range 70-100) and the nephrologist documented that the patient had an Acute Kidney Injury.

Nursing documentation on 3/31/17 at 8:00 AM revealed the heart rate was 80 beats per minute but at 9:10 AM it had increased to 120 beats per minute, which represents a change of 40 beats each minute.

Nursing documentation at 11:40 AM on 3/31/17 revealed the heart rate had dropped to 50 beats per minute, the B/P was 85/50 (normal 120/80) and she was verbally unresponsive.

Nursing documented on 3/31/17 at 9:47 AM that the patient complained of abdominal pain to the left lower quadrant of her abdomen. The abdomen was noted to be distended and firm with positive bowel sounds x 4.

There was no documentation in the medical record that the patient's vital signs and the patient's condition were reassessed.

There was no documentation in the medical record that a nurse revised the patient's nursing care plan.

The policy titled "Nursing Documentation of Patient Care in the Electronic Medical Record", last revised 9/17 states; "updates to the plan of care (problems, interventions, goals) should be documented in the medical record."

The nursing staff did not follow this policy when the patient's condition changed at 9:10 AM and 9:47 AM on 3/31/17.

These findings were shared with Staff A, the Director of Quality on 4/26/17 at 4:00 PM.