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SAINT JOSEPH MEDICAL CENTER
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
A. Based on clinical record review and staff interview, it was determined that for 13 of 13 nurses (E#'s 8-20) who care for a postoperative heart patient (Pt.#8), the Hospital failed to ensure staff were trained in the use of a heart device (Tandem Heart).
Findings include:
1 The clinical record for Pt. #8 was reviewed on 2/15/12 at approximately 10:00 AM. Pt. #8, a 62 year old male, was transferred from another Hospital with an acute MI on 9/26/11. The clinical record contained an operative report, dated 9/27/11 and signed by the surgeon indicating that Pt. #8 was taken to the OR for open heart surgery. The surgical consent dated 9/27/11 was signed by the patient for a coronary artery bypass graft. The surgeon documented that the pt. was placed on a balloon pump but after an 1.5 hours the patient 's heart began failing and that he discussed with the family that the Pt. needed a ventricular assist device (VAD) for support in order for the Pt. to recover from the MI. The family agreed and a tandem heart (VAD) heart was connected without any untoward event. Pt. #8 arrived to the CVICU on 9/27/11 at approximately 10:24 PM. The clinical record contained documentation that a program representative (E#1) was in the OR when the tandem heart (left ventricular heart device) serial number 00144965 was inserted without complications. Pt. #8 remained with a VAD until 10/3/10 when the device was removed. Pt. #8 was transferred to a specialty hospital on 10/28/11 for ventilator weaning and was listed as alert, oriented and talking around tracheotomy prior to transfer.
2. Program Representative (E#1) was interviewed by telephone on 2/15/12 at approximately 11:45 AM. E#1 stated that he arrived to the OR and explained the operation of the Tandem Heart to all of the OR nurses prior to the surgical procedure. E#1 also stated that he provided in-services to nursing staff on the CVICU on 9/27, 9/28 and 9/29/11 on monitoring and use of the Tandem Heart device. However, E#1 could not provide any staff in service sign in sheet documentation.
3. The Patient Care Manager (E#3) of 4 West was interviewed on 2/15/12 at approximately 2:30 PM. E#1 stated that she in serviced her staff on the Tandem Heart on 9/27/11 however did not have documentation of the in-service.
4. The Nurse Director of the Operating Room (E#7) stated during an interview on 2/15/12 at approximately 2:40 PM stated that her staff were in serviced by a program representative (E#1): however, E#1 took the sign in sheet documentation .
5. The above findings were verified with the `Director of Risk Management on 2/15/12 at approximately 3:45 PM
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
A. Based on clinical record review and staff interview, it was determined that for 13 of 13 nurses (E#'s 8-20) who care for a postoperative heart patient (Pt.#8), the Hospital failed to ensure staff were trained in the use of a heart device (Tandem Heart).
Findings include:
1 The clinical record for Pt. #8 was reviewed on 2/15/12 at approximately 10:00 AM. Pt. #8, a 62 year old male, was transferred from another Hospital with an acute MI on 9/26/11. The clinical record contained an operative report, dated 9/27/11 and signed by the surgeon indicating that Pt. #8 was taken to the OR for open heart surgery. The surgical consent dated 9/27/11 was signed by the patient for a coronary artery bypass graft. The surgeon documented that the pt. was placed on a balloon pump but after an 1.5 hours the patient 's heart began failing and that he discussed with the family that the Pt. needed a ventricular assist device (VAD) for support in order for the Pt. to recover from the MI. The family agreed and a tandem heart (VAD) heart was connected without any untoward event. Pt. #8 arrived to the CVICU on 9/27/11 at approximately 10:24 PM. The clinical record contained documentation that a program representative (E#1) was in the OR when the tandem heart (left ventricular heart device) serial number 00144965 was inserted without complications. Pt. #8 remained with a VAD until 10/3/10 when the device was removed. Pt. #8 was transferred to a specialty hospital on 10/28/11 for ventilator weaning and was listed as alert, oriented and talking around tracheotomy prior to transfer.
2. Program Representative (E#1) was interviewed by telephone on 2/15/12 at approximately 11:45 AM. E#1 stated that he arrived to the OR and explained the operation of the Tandem Heart to all of the OR nurses prior to the surgical procedure. E#1 also stated that he provided in-services to nursing staff on the CVICU on 9/27, 9/28 and 9/29/11 on monitoring and use of the Tandem Heart device. However, E#1 could not provide any staff in service sign in sheet documentation.
3. The Patient Care Manager (E#3) of 4 West was interviewed on 2/15/12 at approximately 2:30 PM. E#1 stated that she in serviced her staff on the Tandem Heart on 9/27/11 however did not have documentation of the in-service.
4. The Nurse Director of the Operating Room (E#7) stated during an interview on 2/15/12 at approximately 2:40 PM stated that her staff were in serviced by a program representative (E#1): however, E#1 took the sign in sheet documentation .
5. The above findings were verified with the `Director of Risk Management on 2/15/12 at approximately 3:45 PM