HospitalInspections.org

Based on review of documents and interviews with facility staff, the registered nurse, staff #3 failed to properly supervise the patient care of patient #1 as facility policy was not followed when repositioning an intubated patient. Patient #1 subsequently became extubated while being repositioned.

The findings were:

The facility policy entitled "Tracheostomy Tube and Airway Management": #T01-R1 with a revised date of 4/1/13 reflected in part "Purpose: 1. To maintain patent airway for patients ...A high risk airway assessment will be completed at the time of admission and each shift thereafter until the airway has been discontinued. If the airway has been identified as high risk the RT will implement the High Risk Airway Plan of Care which includes the following: a. The physician will be notified of the assessment findings; b. The patient's nurse and charge nurse will be notified of the assessment findings; c. The RT will report to all clinical staff during each shift huddle the high risk status of the airway; d. A sticker will be placed on the patient's Kardex identifying the airway as high risk; e. A sign will be placed at the head of the patient's bed; f. RT will be present during all activity; g. RT and RN will accompany patient on all transports; h. The use of a sitter will be considered."

Patient #1's medical record included a nurses' note dated 1/17/14 0335 by RN, staff #3 which reflected "Pt (patient) turned & repositioned due to pt BM (bowel movement). Pt O2 (oxygen) sat (saturation) decreased. Finger probe on & wave form good. RRT (rapid response team) called. RT (respiratory therapist) at bedside. This RN to get intubation x-ray. Family at bedside." At 0340 "see RRT notes for complete history of incident." The RRT Response Record dated 1/17/14 from 0335 - 0450 reflected the reason called "extubation." The findings reflected "pt in respiratory distress due to ET (endotracheal tube) dislodgement. O2 sat decreased, improved with bagging." Interventions reflected "attempted reinsertion of ET, bagging pt. Physician, staff #4 0350, attempt of ET insertion ...0405 decompressing abd (abdomen), 150 cc out of OG (oral gastric tube), 0429 attempt #7 ...0450 attempt x 10, checked per staff #4, 0455 ET tube secured. 0500 on vent."

An incident report regarding patient #1 by the quality manager, staff #1 dated 1/17/14 0630 reflected in part "RN holding vent tubing and oral ET tube in place while 2 CNAs (certified nursing assistant) turned and cleaned up pt following a bowel movement. RT in room next door ...RT entered room when vent (ventilator) alarm went off ...RT, staff #5 immediately recognized pt's ET tube was dislodged, pulled it out and began bagging pt with 100% O2. RRT called. House doctor, staff #4 at bedside for intubation after multiple attempts to intubate patient, she was reintubated."

In an interview with the facility quality manager, staff # 1 stated that patient #1 was being cleaned up by two CNA's following a bowel movement with the RN stabilizing patient #1's endotracheal tube. Staff #1 confirmed the facility policy "Tracheostomy Tube and Airway Management" was in force and the only policy which addressed the high risk airway plan of care. Staff # 1 stated the policy said a RT was to be present during all activity.

The personnel file of RN, staff #3 was reviewed and contained a "Note to file" dated 1/17/14 by the CNO, staff #6 which reflected "On the morning of 1/17/14 staff #3's patient was extubated while being repositioned and cleaned. Staff #3 was watching the airway and two techs were cleaning and repositioning the patient. The RT was in the other room, he heard the vent alarm and immediately returned and assisted the patient. The ETT was dislodged and the patient had to be reintubated. Staff #3 failed to ensure a respiratory therapist was in the room watching the airway. We discussed the policy related to high risk airways. Staff #3 voiced understanding."