HospitalInspections.org

Based on interview and record review the facility failed to ensure that a Registered Nurse documented, assessed, monitored, supervised care and notified the physician of a patient change in condition per facility policy for one (#1) of three patients reviewed for a change in condition, out of a total sample of 10, resulting in the potential for less than optimal outcomes and incomplete and inaccurate clinical records. Findings include:

On 6/8/19 at 1400 Patient #1's clinical record (EMR) was reviewed with the Director of Nursing Staff B, and the Regional Chief Nursing Officer Staff L and revealed the following information:

Patient #1 was an 89 year old female who was a long term resident in a skilled care facility (SNF). Patient #1 had a tracheostomy (surgical opening in her neck for breathing), PEG (Percutaneous endoscopic gastrostomy - a tube surgically inserted through the skin into the stomach for tube feedings) and dementia while in the SNF.

Patient #1 was admitted to the facility on 5/22/19 after a prolonged hospitalization. Admitting diagnoses included Hypoxemic Respiratory Failure, with Dependence on mechanical ventilation, Severe Sepsis, Pneumonia, Myopathy, Protein Calorie Malnutrition, Dementia, Chronic Stage IV Renal Failure (end stage), Congestive Heart Failure, Morbid Obesity, Diabetes Mellitus Type II, Thrombocytopenia, Pressure Injury of Sacral Area, Cardiomyopathy, Anoxic Brain Damage, Toxic Encephalopathy and Dysphagia. Patient #1 was unresponsive on admission and throughout her stay in the facility.

Patient #1 was a full code (full cardiopulmonary resuscitation and all possible measures to prolong life) on admission until cardio-pulmonary resuscitation (CPR) was stopped on 6/21/19 at 1915 per responsible party/family request and the patient was pronounced dead.

A Respiratory Therapy (RT) daily documentation form for Patient #1 dated 6/21/19 noted that Patient #1 was placed back on mechanical ventilation with full support at 1801 (6:01 PM). There was a question mark next to the heart rate at 1801, which was noted as 86 beats per minute. A RT note dated 6/21/19 at 1801 noted that the patient was placed back on the ventilator with full support. The 6/21/19 at 1801 RT note documented that Patient #1 was disconnected from the mechanical ventilator and given manual respiratory support (rescue breathing) with an ambu bag but did not indicate why this was done or what the patient's vital signs were. This note continued to document that a full code ( cardio-pulmonary resuscitation) was in progress from 1821 until the patient was pronounced dead at 1915. There were no additional RT notes for Patient #1 and no documentation of monitoring or interventions between 1801 and when CPR was started at 1824.

A Nursing Note for Patient #1 dated 6/21/19 at 1800 documented, "Patient observed to have decreased SPO2 (blood oxygenation level as measured by a finger probe - a pulse oximeter- placed on the patient's finger) and fluctuating. Family member at bedside. RT and writer at bedside to assess and implement interventions." There was no further nursing documentation until 2000 (45 minutes after Patient #1 expired) when the nurse (Staff F) documented that the organ donation agency was called and noted that the agency declined organs from Patient #1. The last set of vital signs documented by Nursing for Patient #1 was noted at 1400. The next set of vital signs noted by Nursing was noted on 6/21/19 at 1824 after a code blue (cardio-pulmonary resuscitation team called) was called and CPR was started.

A Code Blue Record for Patient #1 dated 6/21/19 at 1824 noted that the code blue was called in response to the patient's low heart rate (HR) in the 20's (normal HR > 60). The Code Blue Record documented that Patient #1 had no pulse (cardiac arrest) when the code was started at 1824. There was no documentation to indicate that Patient #1 was monitored or assessed between 1801 and 1824.

On 7/8/19 at 1500, review of the facility staff cell phone alarm alert system revealed the following documented alerts/alarms to the staff cell phone alarm system ( which were automatically sent to Patient #1's RT Staff E and Patient #1's assigned Nurse Staff F):

Patient #1's pulse oximeter alarmed at 1750, 1752, 1800 1804, 1804, 1806, 1819, 1823, and the mechanical ventilator alarmed at 1824. There was no documentation to indicate the patient was assessed after these alarms, what the SPO2 and vital signs were after these alarms, whether the patient appeared in declining condition, or what staff interventions were done for these alarms (except for the notation by the RT at 1801 and the nursing note 1800 (documented, "Patient observed to have decreased SPO2 and fluctuating. Family member and writer at bedside to assess and implement interventions.") There was no documentation of any nursing assessment or interventions done for Patient #1 between 1800 and 1824 (cardiac arrest, CPR started). There was no documentation to indicate that the attending physician was notified of the patient's change in condition as required per facility policy.

On 7/8/19 at 1515 Patient #1's RT Staff E was interviewed. Staff E reported that Patient #1's consultant Pulmonologist Staff H assessed Patient #1 and said that she was doing well only 15 minutes before her pulse oximetry (pulse-ox - measures SPO2) alarms started going off on 6/21/19 at 1750. Staff E said, "I heard the alarm on my phone ring and I was on my way down the hall (to patient #1's room) and (Staff Nurse F) was already coming from there. Her SATs (SPO2) were down. I put her on the vent. We probably was in there 20 minutes before we called the code." Staff E was asked why she did not document vital signs and SPO2 and patient response or lack of response to interventions and said, "I was too busy trying to help her (Patient #1) at the time to do any documentation." Staff E stated that Patient #1 developed bradycardia (dangerously low heart rate) "in the 30's (normal >60), but could not state when or provide documentation.

On 7/8/19 at 1530 Patient #1's assigned nurse, Staff F was interviewed regarding Patient #1 and said, "I was in the patient's room talking to the niece when the pulse -ox went off (alarm for low SPO2). I saw (Staff E) in the hallway and flagged her in. (Staff E) got her back on the vent (mechanical ventilator). At one point (Staff E) was bagging her (rescue breaths with an ambu bag). Eventually her pulse was dropping. I didn't trust the pulse readings on the cardiac monitor in the room or on the pulse-ox so I ran up to the desk (nursing station) to see the telestrip. (Staff K) was the telemetry monitor. She told me that (Patient #1) was going brady (bradycardia) with a heart rate in the 30's. We called a code." Staff F was unable to state at what time Patient #1's heart rate became bradycardic and was unable to say at what time the patient started to decline or why Staff E started manually giving artificial respiration to Patient #1 with an ambu bag instead of leaving her on the ventilator. There was no documentation of what time this occurred or what the patient's response to it was. When asked why she did not document any vital signs or assessment of Patient #1 from 1800 to 1824, Staff F stated that she was too busy caring for Patient #1 to have time to document."

On 7/9/19 at 1100, the telemetry technician Staff K was interviewed by phone and reported that she knew that she should have recorded a cardiac monitoring strip (recording of cardiac rhythm) and put it in Patient #1's EMR (medical record) when her heart rate dropped below 45 and again when her heart stopped. Staff K said that she forgot because the Unit Clerk called in sick that day so she was overwhelmed with doing both her job and the Unit Clerk's.

On 7/9/19 at 1200, the Regional Chief Nursing Officer Staff L was interviewed and stated that per policy, the telemetry monitor should alert the nurse and place a cardiac monitoring strip on the patient's EMR whenever a patient had a change in heart rhythm or if the heart rate dropped below 45. Staff L noted that there was no documentation this was done for Patient #1 on 6/21/19 at or after 1750. Staff L stated that per policy, the assigned nurse should document an assessment of the patient if there was a change in heart rhythm or abnormal vital signs and should document any interventions implemented and the patient's response to them. Staff L said that if a patient was noted to have a decline their condition, a change of condition documentation form should be completed and the physician notified. Staff L reported that this was not done for Patient #1 on 6/21/19.

On 7/9/19 at 1230 review of the facility policy entitled "Telemetry, Alarms, Prioritization", dated 6/10, revised 10/1/18 revealed the following statement, "Any new dysrythmia or change in rhythm will be captured on a strip, interpreted and the charge nurse notified. This strip will be placed on the chart. The rhythm changes listed below are considered a significant change and require further assessment, documentation and notification of the physician at a minimum. Based on other assessment data, such as patient symptomatology these rhythm changes may also warrant the need to call a Rapid Response Team: ...new onset bradycardia, any heart rate > 125 or < 45. Prior to notification, the assigned nurse will have CURRENT vital signs including temperature, current laboratory data and current head to toe assessment."

On 7/9/19 at 1245 the facility policy entitled, "Change in Patient condition", dated 03/04, revised 10/1/18 revealed the following statements, "Early Recognition and Intervention Policy, SBAR communication Process and a method of supporting the clinical staff through Rapid Response Team (RRT) will be utilized." "Significant change in condition described, "any heart rate >125 or < 45, change in respiratory rate or work of breathing, pulse oximetry < 90. It is the responsibility of the charge nurse to ensure that the process to assess the patient occurs in a timely fashion and to gather other relevant data. The complete assessment should appear on the nursing flow sheet/EMR. The change in condition and physician communication should be documented in the clinical notes or EMR"