HospitalInspections.org

Surveyor: Rose, Leatha A.
Based on medical record reviews, staff interviews, and policy reviews, the facility failed to ensure that the registered nurses evaluated and supervised the nursing care of 2 of 10 patients (#4, #3,) to ensure that care was provided in accordance with the needs of the patients, physician orders and was responsive to intervention and changes in condition. Both of these patients expired in the facility. It was determined that the above findings had the potential to affect all patients in the facility. The hospital's census for this visit was 21 patients.

Findings include:

Review of the medical record for Patient #4 revealed the patient was admitted to the facility on 01/14/11, from a long term acute care hospital with a diagnosis including, but not limited to, respiratory and kidney failure, congestive heart failure, and hypertension.

Patient #4's medical record revealed on 01/18/11, at 5:35 AM, the patient care technician went into the patient's room during rounds. This employee discovered the patient did not have a pulse, was not breathing, and chest compressions were started. The documentation for the nurses note revealed there was an attempted intravenous access without success, the patient was placed on a heart monitor, and asystole (absence of pulse) was noted. The medical record revealed a cardiopulmonary code was called, but was not successful. The medical record was silent to any monitoring by staff for this patient after 9:00 PM on 01/17/11 until the patient was discovered on 01/18/11 at 5:35 AM.

Review of the discharge summary for Patient #4 revealed that at the time of the death the patient had been doing well, appeared to be making nice gains without any new complaint, and was actually showing much better energy and ability to cooperate. Review of the medical record for Patient #4, revealed the facility did not follow physician's orders to obtain vital signs, failed to notify the physician of the patient's development of edema and decline in status, and failed to notify the physician the patient was refusing attempts to ambulate due to fatigue.

Review of the medical record for Patient #3, revealed the patient was admitted from a short term acute care hospital to this facility for acute rehab on 11/16/10 (time of admission was not documented), and expired in this facility on 11/17/10. On admission, the patient had diagnoses of congestive heart failure and right sided heart failure.
An initial nursing assessment was conducted on 11/16/10 at 9:00 PM for this patient. This assessment stated the patient had an irregular pulse rate, a history of atrial fibrillation, dusky cyanotic nail beds, and stated the patient was receiving oxygen at 2 liters per minute per nasal cannula. Vital signs were ordered by the physician every four hours for the first 24 hours. The only documentation in the medical record the vital signs were taken was at 8:00 PM on 11/16/10. The patient's radial pulse was elevated at that time to 108 beats per minute, blood pressure was 133/84, and respiration rate had increased to 24 per minute. Although there was a physician's order to notify the physician if the patient's pulse was greater than 100 per minute, there was no documented evidence the physician was notified of the patient's elevated pulse rate, or increased respiratory rate. The physician was not notified the patient refused to take the bedtime insulin at 8:00 PM, as well as a blood pressure medication, a stool softener, an antianxiety medication, and pain medication.
According to documentation in the nursing progress notes, the patient was restless and attempted to get out of bed on 11/16/10 at 9:44 PM, and on 11/17/10 at 12:30 AM, and 2:00 AM. On 11/17/10 at 3:00 AM, the medical record documented the patient was discovered without respirations or a palpable pulse by a patient care tech. The nurse was notified, verified the absent respirations and pulse, and initiated CPR. 911 was called, and the supervisor was notified. On 11/17/10 at 3:20 AM, the nursing progress note documented the patient was unresponsive to efforts made by squad, and was pronounced dead at that time. The coroner released the body at 3:45 AM on 11/17/10; however, the coroner's report was not available for review.
Please refer to 42 CFR 482.23(b)(3); RN Supervision of Nursing Care; Tag A395.

Based on medical record reviews, staff interviews, and medical record policy reviews, this Condition of Participation is due to incomplete and inaccurate medical records. This affected at least 4 of ten sampled patients, and any patients who have had standing physicians' orders since 10/08. The facility census was 21.

Findings include:

Physicians's orders were not timed when written and verified by staff.

One patient's medical record lacked documentation of a peripheral intravenous central catheter for five days. Nursing and physical therapy documented different reasons the intravenous catheter came out on 03/22/11.

Vital sign documentation was missing in the medical records for two patients who expired in the facility.

One patient's medical record was missing the time of admission.

Medical records lacked notification of physicians when the patients' status changed, when the patient's vital signs were elevated, and when the patient refused medications.

The physicians' standing order sheet, used since 10/08, for patients was inaccurate related to prescribed oxygen saturation levels.

Refer to A438.

Based on medical record reviews, staff interviews, and policy reviews, the facility failed to ensure that the registered nurses evaluated and supervised the nursing care of 2 of 10 patients (#4, #3, ) to ensure that care was provided in accordance with the needs of the patients, physician orders and was responsive to intervention and changes in condition. Both of these patients expired in the facility.

Findings include:

Review of the medical record for Patient #4 was completed the afternoon of 03/23/11. The patient was admitted from a long term acute care facility on 01/14/11, with orders to evaluate and treat for speech, occupational, and physical therapy. The patient had diagnoses of, but not limited to, respiratory failure, chronic obstructive pulmonary disease, congestive heart failure, chronic kidney disease, high blood pressure (well controlled), diabetes, bilateral pleural effusion, and a tracheostomy (capped and not used). The patient also had a history of abdominal and back edema, which was resolved prior to admission to this facility.

According to the medical record, Patient #4 had a consultation note dictated by Staff I, a medical doctor, on 01/16/11. The consultation note revealed the patient had no apparent cardiopulmonary distress and received oxygen by nasal cannula. The consultation note revealed the patient's lungs showed good air entry and were somewhat decreased in the bases, along with some generalized bilateral weakness in the lower extremities. This consultation note was silent to documentation for any edema. The consultation note further revealed the patient had recent pneumonia, septic shock, respiratory failure, pseudomonas, and was recovering well.

The medical record revealed the events that took place in this facility up until the patient expired were as follows:

The admission orders revealed the Patient's vital signs should be done every four hours for the first 24 hours, then every eight hours for the next 72 hours.
Physician's orders were not followed for vital signs as follows:
On 01/15/11, vital signs were obtained at 6:00 AM, 5:00 PM and 8:00 PM (should have been every 4 hours), on 01/16/11 vital signs were obtained at 6:00 AM and 8:00 PM (should have been every 8 hours), and on 01/17/11 vital signs were obtained at 6:00 AM and 8:00 PM (should have been every 8 hours). Interview with Staff D, on 03/24/11 at 9:10 AM, stated the times for the vital signs every eight hours should be at 6:00 AM, 2:00 PM, and 10:00 PM.

On 01/16/11 the nursing assessment revealed the patient developed (2 plus pedal) bilateral pitting edema in the lower extremities. There was no documentation in the medical record the physician was made aware of the patient's change of condition regarding the edema. The medical record did show the physician was in to see the patient on 01/15/11 and 01/16/11; however, the physician progress note did not reveal that the physician was aware of the presence of edema as documented in the nursing notes on 01/16/11. The nursing assessment for 01/17/11, revealed the patient had generalized edema (all over the body). There was no documentation in the medical record the physician was made aware of the patient's change of condition for the edema.

The medical record revealed, on 01/17/11, the patient was receiving physical therapy at 5:46 PM. The therapy note stated the patient was refusing attempts to ambulate due to fatigue. The therapy note further revealed the therapist would discuss this with nursing and the physician, and find a resolution with the team members. There was no documentation in the patient's medical record this discussion was done.

Patient #4's medical record revealed on 01/18/11, at 5:35 AM , the patient care technician went into the patient's room during rounds. This employee discovered the patient did not have a pulse, was not breathing, and chest compressions were started. The documentation for the nurses note revealed there was an attempted intravenous access without success, the patient was placed on a heart monitor, and asystole (absence of pulse) was noted. The medical record revealed a cardiopulmonary code was called but was not successful. The medical record was silent to any monitoring by staff for this patient after 9:00 PM on 01/17/11 until the patient was discovered on 01/18/11 at 5:35 AM. This was verified during an interview with Staff D on 03/24/11 at 3:30 PM.

The medical record revealed a discharge summary on 01/18/11, which documented a discharge diagnosis of post severe respiratory insufficiency, which had been improving. The summary further revealed that the patient was no longer on oxygen or with respiratory support, but apparently had a cardiovascular arrest the morning of 01/18/11, and did not respond to resuscitative efforts. Interview with Staff D, the morning of 03/24/11 at 9:30 AM, stated the discharge summary had inaccurate information because the patient was still on oxygen therapy up until he/she expired.

The facility policy titled "Communication of Change/Perception of a Change of a Patient's Condition" policy number NSG-128; revised 08/2010 lacked specific information about physician notification

An interview was conducted with Staff L on 03/25/11 at 11:50 AM. This employee stated he/she would have notified the physician on 01/16/11 as soon as the two plus bilateral pedal pitting edema developed, because this was a change of condition for the patient.

Interview with Staff J, a physician, on the morning of 03/25/11 at 11:50 AM, stated the times he/she had assessed the patient he/she did not see any type of edema. Staff J further stated if the nurse did see the patient with bilateral pitting edema and/or generalized edema, he/she, or the internal physician, should have been made aware of this change in condition. Staff J also stated it was a surprise when the patient coded and expired, as the patient had been progressing well during their stay in the facility. This physician stated he/she was notified of the patient's death after it occurred. The physician stated the staff member who notified her stated they had been in the room to check on the patient approximately 45 minutes before the patient was found without respirations and pulse. However, the medical record was lacked evidence of this visit by staff before the patient was discovered.

Interview with Staff D, throughout the complaint investigation of 03/22/11 through 03/25/11, stated the nurses, patient care technicians, and the nursing assistants make rounds on the patients every two hours, and stated the only time there was any documentation on the patients was when there was a change in the patient's condition.

The surveyor asked Staff D for a policy in regards to making rounds on the patients.
On 03/24/11, in the morning, Staff D revealed a policy titled "Daily Nursing Assessment" (policy #NSG 202). The policy revealed if the patient is without complaint, does not have a medical condition that warrants it, and is medically stable, the night shift would not wake the patient to assess lung sounds. The policy further revealed if any reassessments are abnormal, documentation shall be entered into the patient's medical record regarding the problem area, abnormality, the intervention, and any follow-up that was performed.

On 03/25/11 at 1:00 PM, an interview was conducted with an LPN (licensed practical nurse) Staff K regarding notification of changes in patients. This employee stated he/she knew to notify the Registered Nurse (RN) in the event of change of condition of patient (i.e..., Vital signs, gut instinct, any reports from therapy or patient care technicians) and would notify the physician if the patient refused medications, if pulse parameters are out of normal range, or if no edema to pitting edema to generalized edema occurred (would notify the RN). This employee stated rounding on patients is done every 15 minutes by patient care technicians (PCTs) and every 1/2 hour by this nurse. The nurse stated they would document at least daily on the patient and with any status change.

On 03/25/11 at 1:10 PM, an interview with an RN (Staff L) revealed the physician would be notified if there was anything out of the normal on a patient and this would be documented in the patient's medical record. Staff L stated notification of physician included if the patient refused medications, if the patient had edema and then pitting edema. The nurse stated this would be a change in condition and he/she would not wait until the patient had generalized edema to notify the physician.

On 03/23/11, medical record review, conducted for Patient #3, revealed the patient was admitted from the hospital to the facility in the evening of 11/16/10. The medical record was silent to the time of admission. On admission, the patient had diagnoses of congestive heart failure and right sided heart failure. On 03/24/11 at 2:30 PM, during an interview, Staff D stated the estimated time of arrival for this patient to the facility was 7:00 PM; however, verified this was not documented in the medical record.
An initial nursing assessment was conducted on 11/16/10 at 9:00 PM for this patient. This assessment stated the patient had an irregular pulse rate, a history of atrial fibrillation, dusky cyanotic nail beds, and stated the patient was receiving oxygen at 2 liters per minute per nasal cannula. Vital signs were ordered by the physician every four hours for the first 24 hours. The documentation in the medical record revealed the vital signs were taken was at 8:00 PM on 11/16/10. The patient's radial pulse was elevated at that time to 108 beats per minute, blood pressure was 133/84, and respiration rate had increased to 24 per minute. Although there was a physician's order to notify the physician if the patient's pulse was greater than 100 per minute, there was no documentation the physician was notified of the patient's elevated pulse rate or increased respiratory rate.
The medical record revealed physician's orders for blood sugar levels per accucheck before meals and at bedtime, and for insulin to be given at bedtime. At 8:00 PM on 11/16/10, the patient's blood sugar was elevated at 174. The patient refused to take the bedtime insulin at 8:00 PM, as well as a blood pressure medication, a stool softener, an antianxiety medication, and pain medication. A blood pressure medication was ordered; however, was omitted at that time due to not being available from the pharmacy. There was no documented evidence the physician was notified of the patient's irregular elevated pulse or the elevated blood sugar and of the patient's refusal to take the insulin and other medications.
According to documentation in the nursing progress notes, the patient was restless and attempted to get out of bed on 11/16/10 at 9:44 PM, and on 11/17/10 at 12:30 AM, and 2:00 AM. On 11/17/10 at 3:00 AM, the medical record documented the patient was discovered without respirations or a palpable pulse by a patient care tech. The nurse was notified, verified the absent respirations and pulse, and initiated CPR. 911 was called, and the supervisor was notified. On 11/17/10 at 3:20 AM, the nursing progress note documented the patient was unresponsive to efforts made by squad, and was pronounced dead at that time. The coroner released the body at 3:45 AM on 11/17/10.
An interview conducted with Staff D, on 03/24/11 at 2:30 PM, verified there was no documented admission time to the facility, verified the lack of physician notification regarding the patient's elevated pulse, refusal of medications, and unavailability of the blood pressure medication. This staff also verified vitals signs for this patient were not done every 4 hours in accordance with physician's orders, as they were were taken one time after admission.
On 03/25/11 at 11:50 AM-12:25 PM, an interview was conducted with a physician (Staff J) who was partially responsible for Patient #3's care. This physician stated the nursing staff should have notified the physician about the patient's elevated pulse and respiration rate and of the patient's refusal of medications.

The discharge summary revealed Patient 3's discharge diagnosis would be shared with the coroner as it was likely to be a repeat arrhythmic event with a severe tricuspid regurgitation, worsening pulmonary hypertension, worsening left atrial size and right heart failure along with the patient's atrial fibrillation, pacemaker, restrictive lung disease, and probably reoccurrence of the patient's bilateral effusions. The discharge summary revealed the patient was found pulseless and without respirations, a full code was ordered at which time the patient did not respond to the resuscitative efforts.

These findings were shared in an interview the afternoon of 03/24/11, at 3:30 PM, with Staff A, B, C, and D (Administrative and Nursing Staff ), with no additional information received regarding an investigation into the deaths of Patients #4 and #3.

Staff B, chief nursing officer, stated he/she was well aware of the problems at the facility. Staff D stated the death for Patient #4 on 01/18/11 was reported to him/her in January 2011, which in turn was reported to the former Chief Nursing Officer (CNO). However, Patient #4 expired on 01/18/11 and the former CNO was terminated on 01/14/11. Staff D stated the facility lacked documented evidence that Administrative staff were informed of Patient #3's death in November 2010. Staff D stated there is no documentation an investigation into these two patient deaths (Patient #4 and #3) was performed.

Review of the facility's policy titled "Sentinel/Reportable Event" policy number RM 05; revised 08/2010, directed the following procedure for sentinel events: "To have a positive impact on improving patient care, treatment, and services, the hospital ensures a focus on understanding the causes and addressing strategies in preventing sentinel/reportable events... facilities shall perform a Root cause Analysis (RCA) for any sentinel/reportable event." A sentinel event is described by this policy as an "...unexpected occurrence involving death....". A root cause analysis for the two patient deaths were not provided during the survey.


19966

Based on medical record reviews, staff interviews, and medical record policy reviews, the facility failed to maintain accurate and complete medical records for 4 of 10 sampled patients (Patients #1, #2, #3, and #4), and any patients who had standing physicians' orders since 10/08. The total census was 21.

Findings include:

a) Patient #1's medical record was reviewed on 03/23/11. The patient was admitted for therapy services on 03/17/11. A physician's order, dated 03/17/11, stated TPN (total parenteral nutrition) per pharmacy. A 03/18/11 physician's order stated stop D10 (intravenous fluid) when TPN (total parenteral nutrition) starts. A physician's order, dated 03/22/11, lacked a time the order was written by the physician or verified by staff. This order stated the patient's peripheral intravenous central catheter (PICC) line should be replaced, and a psychiatric consult for anxiety. The medical record was silent to the patient having a PICC line, until this order was written on 03/22/11 (five days after admission).

The medical record documentation did not accurately document an episode when the patient's PICC line was accidentally pulled out in physical therapy. A physical therapy note, dated 03/22/11 at 11:26 AM, stated the following: "Prior to ambulation in parallel bars, PICC line became entangled in wheelchair, and was pulled out". A nursing note, dated 03/22/11 at 4:38 PM, stated the "patient pulled out his/her PICC line this AM". On 03/22/11 at 11:20 AM, interviews with the patient, and a family member, revealed the PICC line was pulled out by a staff member in therapy.
This incomplete and inaccurate medical record was verified with Staff D on 03/24/11 at 2:25 PM.

This patient's medical record revealed a signed physician's order for oxygen at 2 liters per minute, and keep oxygen saturation levels less than 90%. On 03/23/11 at 10:28 AM, when the surveyor questioned Staff D as to whether this order should have stated keep oxygen saturation levels greater than 90%, this staff replied "yes", stating this was a "typo error" on the physician's standing order sheet.

A review of this standing physician's standing order sheet, revised 10/08, stated a section for oxygen, keep SATS (oxygen saturation) less than (blank)%. On 03/23/11 at 10:30 AM, when Staff D was questioned as to whether form should have stated "greater than" and not "less than", the employee stated the form had a "typo error" and the less than symbol was incorrect. This employee stated this form has been used on all patients since 10/08. Staff D gave the surveyor an updated version of this form on 03/23/11 at 3:00 PM. Staff D stated was corrected to state "greater than" for the oxygen saturation percents.

b) On 03/23/11, a medical record review was conducted for Patient #2. This patient was admitted to the facility on 03/15/11 for therapy services. The patient had a diagnoses of debility, acute renal failure, status post acute respiratory failure, high blood pressure, chronic obstructive pulmonary disease, diabetes mellitus, and swallowing difficulty. Admission orders included contact isolation for an infectious organism in the colon. The patient was receiving an antibiotic every 6 hours beginning on 03/16/11. This antibiotic was discontinued on 03/22/11 at 8:00 PM.
On 03/21/11, the physician wrote orders for an three medications for this patient. This physician's order lacked a time the order was given. This was verified with the physician (Staff J) on 03/23/11 at 10:30 AM.

c) On 03/23/11, a review of Patient #3's medical record revealed the patient was admitted from the hospital to the facility in the evening of 11/16/10. The medical record was silent to the time of admission. The patient had diagnoses of congestive heart failure and right sided heart failure.
The first nursing documentation in the patient's chart on 11/16/10 was an initial nursing assessment conducted at 9:00 PM. Vital signs were ordered by the physician every four hours for the first 24 hours. The only documentation in the medical record these were taken was at 8:00 PM.
At 3:00 AM, on 11/17/10, the patient was discovered without respirations and palpable pulse by a patient care tech. The nurse was notified, verified the absent respirations and pulse, and initiated CPR. 911 was called, and the supervisor was notified. On 11/17/10 at 3:20 AM, the nursing progress note documented the patient was unresponsive to efforts made by squad, and was pronounced dead at that time. A physician's progress note dated 11/17/10 lacked a time the note was written, and stated the physician suspected increased blood sugar from steroids given for respiratory care.
An interview with Staff J on 03/23/11 at 10:30 AM, stated the physician's orders should be timed and dated when written and verified by staff.




19966

d) On 03/23/11, review of the medical record for Patient #4 revealed a total of nine physician orders since the patient was admitted on 01/14/11 until the patient's death on 01/18/11. The physician orders revealed there was three of nine physician orders that were without out a time on the order as to when the order was received.

Review of the medical record for Patient #4 revealed the patient was admitted to the facility the evening of 01/14/11. The admission orders revealed the patient's vital signs should be done every four hours for the first 24 hours, then every eight hours for the next 72 hours. Physician orders were not followed for vital signs.

On 01/15/11, vital signs were obtained at 6:00 AM, 5:00 PM and 8:00 PM (should have been every 4 hours), on 01/16/11 vital signs were obtained at 6:00 AM and 8:00 PM (should have been every 8 hours), and on 01/17/11 vital signs were obtained at 6:00 AM and 8:00 PM (should have been every 8 hours).
Interview with Staff D, on 03/24/11 at 9:10 AM, stated the times for the vital signs every eight hours should be at 6:00 AM, 2:00 PM, and 10:00 PM.

Review of the agency's policy on 03/24/11, in the afternoon, titled Orders for Medications and Treatment (Policy #NSG 130) revealed all orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner, or another practitioner who is responsible for the care of the patient. This was verified with Staff D on 03/24/11 at 2:25 PM.

Based on medical record review and staff interviews, the facility failed to ensure one of ten sampled patients received an antibacterial medication in a timely manner in accordance with facility policy. This involved Patient #2. The facility census was 21.

Findings include:

On 03/23/11, a medical record review was conducted for Patient #2. This patient was admitted to the facility on 03/15/11 for therapy services. The patient had a diagnoses of debility, acute renal failure, status post acute respiratory failure, high blood pressure, chronic obstructive pulmonary disease, diabetes mellitus, and swallowing difficulty. Admission orders included contact isolation for a contagious bacterial organism in the colon. The patient was receiving an antibiotic every 6 hours beginning on 03/16/11. This antibiotic was discontinued, by the physician, on 03/22/11 at 8:00 PM.
On 03/21/11, the physician wrote orders for an antibacterial medication to be administered one time a day (Levaquin 500 milligrams orally one time a day for 5 days), for Vitamin C 500 milligrams twice a day with meals, and for acidophilus twice a day for 10 days. This physician's order lacked a time the order was written or signed by the physician. This was verified with the physician (Staff J) on 03/23/11 at 10:30 AM, who stated the orders should be timed and dated when written and verified by staff. A notation on the order stated it was faxed to the pharmacy at 12:45 PM. This medication administrative record (MAR) documented a start date of 03/22/11 at 8:26 AM. The first dose of the antibacterial and acidophilus medications were not given until the evening of 03/22/11 at 8:00 PM. The first dose of the Vitamin C was not given until 5:10 PM on 03/22/11.

On 03/24/11, a review of facility policy NSG 130 titled Orders for Medication and Treatment stated Nursing will transfer or transmit all medication related orders to the pharmacy in a timely manner. All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner. Routine medication orders will be administered within 2 hours of the time the order is written or verbalized or at the next appropriate administration time.
On 03/24/11 at 2:30 PM, it was verified with Staff D this policy was not followed to give the aforementioned medications to Patient #2 in a timely manner in accordance with facility policy. This employee verified the physician's order lacked a time of when the medication was ordered. Staff D stated routine medication times were 8-9 AM, 1-2 PM, and at bedtime.
An interview with Staff J on 03/25/11 at 12:00 PM, revealed the facility did not give the medications in a timely manner, that they should have been given on 03/21/11 due to being available in the facility. This employee verified the physician's order lacked a time the order was given; however, stated the medications were available in the facility due to being kept in stock, and due to the pharmacy being notified on 03/21/11 at 12:45 PM of these medication orders.