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Based on medical record review, facility policy review, and staff interview, the facility failed to ensure staff followed a physician order and promptly administered a medication ordered as needed to increase the blood pressure of a patient and failed to ensure staff nurses continued a physician ordered infusion of a medication also used to treat hypotension. This affected two (Patients #1 and #4) patients.

See A405

Based on record review, interview and policy review, the facility failed to ensure staff followed physician orders to administer medications to treat a low blood pressure. This affected two (Patients #1 and #4) of ten patients reviewed.

Findings include:

1. Review of the medical record of Patient #1 revealed the patient was admitted to the facility on 12/06/22 at 6:37 PM with acute kidney injury requiring hemodialysis, monitoring of renal function, and treatment of stage four sacral pressure ulcer. According to the attending physician's history and physical, the patient had a medical history of essential hypertension, recent cerebrovascular accident, multiple myeloma, and type 2 diabetes mellitus. On admission a physician ordered for the patient to be medicated with Midodrine (drug used to treat low blood pressure by stimulating nerve endings in blood vessels causing blood vessels to tighten, thereby, increasing blood pressure) 10 milligrams (mg) by mouth every six hours as needed for low blood pressures. The only instruction for this medication administration was to hold the medication if the patient's systolic blood pressure was greater than 120.

On 12/12/22 at 8:00 AM, on 12/12/22, the patient's blood pressure was 104/61. The medical record lacked documentation the patient was medicated with Midodrine. The same day, at 8:00 PM, the patient's blood pressure was 98/55. Again, the medical record lacked documentation Midodrine was administered. A nurse's note on 12/12/22 acknowledged the patient's systolic blood pressure was less than 110, however, the note didn't indicate a provider was notified. On 12/13/22 at 8:00 PM the patient's blood pressure was 90/57. The medical record lacked documentation the patient was medicated with the as needed Midodrine for low blood pressure. The patient's blood pressure remained low on 12/14/22, 12/15/22, and 12/16/22. The medical record lacked documentation the patient was medicated with Midodrine any of these days. The patient received hemodialysis as ordered until it was discontinued on 12/22/22 as the patient's kidney function was determined to be stable.

On 12/30/22 at 8:15 AM, the patient's blood pressure was 109/49. The medical record lacked documentation the patient was medicated with Midodrine as ordered. At 8:28 AM, his blood pressure was lower, at 84/43. Although the medical record revealed that the provider was notified of the patient's low blood pressure, there was no documentation the Midodrine was administered to treat the patient's blood pressure. An intravenous fluid bolus of sterile 0.9% saline solution to treat the low blood pressure was administered at 9:18 AM. The patient's blood pressure continued to drop. At 10:56 AM the patient's blood pressure was 77/44. Although the physician was notified of the low blood pressure at 11:10 AM, the medical record again, lacked documentation the PRN medication to increase the blood pressure was administered. A note composed by a case manager at 3:00 PM stated, "Was at bedside with patient and family. Patient's BP still in the 60's. Patient has PRN Midodrine ordered." The note further stated the attending physician was called by the case manager and asked if the Midodrine was to be PRN every six hours or administered at a scheduled frequency. The physician ordered for the Midodrine to be administered on a schedule, three times a day. At 3:17 PM the patient's blood pressure remained low at 75/61. Midodrine 10 mg was administered by mouth at 3:25 PM. At 6:00 PM the patient was transferred to a more acute unit and placed on a Levophed (a potent alpha/beta-agonist causing vasoconstriction and increased blood pressure used to treat hypotension, shock, or bradycardia) drip. At 11:30 PM the patient became bradycardic with a heart rate from the 60's to 40's. A code blue was called and despite aggressive resuscitative measures, the patient pronounced deceased at 12:04 AM.

2. Review of the medical record of Patient #4 revealed the patient was admitted to the facility on 12/02/22 with diagnoses including recent bacteremia requiring antibiotics, subarachnoid bleed, and endocarditis. The patient was a full code.

On 12/03/22 at 7:30 PM, Patient #4's blood pressure was 91/46. On 12/04/22 at 12:00 PM, the patient's blood pressure was 70/45. The physician was notified and ordered a 250 milliliter (ml) intravenous fluid bolus. At 1:00 PM when the patient's blood pressure remained low, the attending physician ordered a Levophed drip two micrograms per minute on 12/04/22 at 12:25 PM. The Levophed drip was discontinued on 12/05/22 at 12:30 AM. The medical record lacked documentation a physician ordered for the Levophed to be discontinued.

A nursing note on 12/06/22 at 8:00 PM stated the patient was moaning with "guppy" breathing. A nurse's assessment revealed every needle mark on the patient's body, excoriation on buttock, and in skin folds were oozing blood. By 4:47 AM the patient's respirations were agonal. The patient's spouse was contacted who "made it clear that patient wants breathing tube and all measures." The attending physician was called at 6:00 AM and updated on the patient's condition. The physician ordered for patient to be placed on bilevel positive airway pressure (BiPap). As staff were attempting to place the patient on BiPap, the patient became bradycardic with a heart rate of 32 beats per minute. Cardiopulmonary resuscitation was initiated. Despite aggressive resuscitative efforts, the patient did not survive and was pronounced deceased at 7:13 AM.

During interview on 01/10/22 at 3:35 PM, Staff C confirmed that the medical records in both of these incidents lacked documentation that nurses followed physicians orders related to administration of PRN Midodrine for a low blood pressure and discontinuation of a Levophed drip without an order.

Based on record review and interview, the facility failed to ensure the availability of emergency tracheostomy supplies at the bedside in case of emergency. This affected one (Patient #3) of ten sampled patients.

Findings include:

Review of the medical record of Patient #3 revealed the patient was admitted to the facility on 11/30/22 at 2:15 PM with a diagnosis of acute respiratory failure status post tracheostomy. On admission, the respiratory care flow sheet documented Patient #3 had a size 8 tracheostomy tube with 21% heated aerosol tracheostomy collar. The decannulation/extubation risk assessment completed on admission revealed that a same size inner cannula and one size smaller were at the bedside as precautionary measures.

Review of a progress note dated 12/07/22 at 10:45 AM documented the Respiratory Therapist (RT)was called to patient's room for suction. Upon entering room, the patient's oxygen saturation was in the 70 percent range. Upon RT evaluation the inner cannula of the tracheostomy was out. There was no spare inner cannula at bedside and the RT immediately went to supply room to get a new one. Once the RT returned with the new inner cannula trach, she noted that a secondary RT had reinserted the old inner cannula as the patient's oxygen saturation continued to decrease.