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Based on observation, staff interviews, medical record review, and review of facility documents, it was determined that the facility failed to ensure an organized nursing service.

Cross Reference: CRF 482:23(b)(3)

Based on observation, staff interviews, medical record review, and review of facility documents, it was determined that the facility failed to ensure acceptable standards of nursing practice.

Findings include:

Reference #1: Facility policy "Telemetry, Alarms, prioritization" states, " ...4. The Monitor Techs/Telemetry Techs (MT/TT) will notify the Charge Nurse or Assigned Nurse of a telemetry alarm, a change in rhythm or signal. ...6. Telemetry must be monitored at all times. ...Alarms, Analysis, Documentation and Notification ...2. Telemetry alarms will be set appropriately and be "On" at all times. NO ONE MAY SUSPEND AN ALARM FOR ANY REASON, EXCEPT FOR TRANSPORTS OR SHOWERS. ...4. Asystole, Vtach fib and low and high heart rate, as well as leads off alarms may never be disabled. ...6. 24/7 Observation of the telemetry shall be the responsibility of the MT/TT, Charge Nurse, RT or assigned nurse ...7. The person responsible for observing telemetry will wear the Telemetry Monitor Attendant badge. If that person must leave the monitors, he/she will hand the badge to another telemetry competent staff member. ... 12. The rhythm changes listed below are considered a significant change and require further assessment, documentation, and notification of the physician at a minimum. ...a. VTach/VFib will result in resuscitation efforts (based on resuscitation orders) and automatically called to the physician ...g. Change in Heart Rate, defined as either an increase or decrease of baseline rate by 20%. This will also include any heart rate >125 or <45. ..."

Reference #2: Facility policy "Change in Patient Condition" states, " ...Documentation: 1. 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 electronic medical record (EMR). ..."

1. On 11/25/18 at 0335, Patient #2 was found unresponsive. Resuscitation efforts were unsuccessful.

2. Upon review of Medical Record #2 on 2/22/19, the following were noted:

a. The "H&P Notes" of 11/22/18 indicated, "Cardiovascular: Regular rhythm, PPM/ICD (pacemaker with implantable cardioverter-difibulator), history of Ischemic cardiomyopathy and Ischemic heart disease (chronic)."

b. The Attending "Progress Notes" of 11/24/18 at 1554 indicated, "Cardiovascular: negative for irregular heartbeat."

c. The Nephrology "Progress Notes" of 11/24/18 at 1800 indicated, "Cardiovascular: normal heart rate and normal rhythm."

d. The "LTACH Progress Notes" of 11/24/18 at 1841 indicated, "Cardiovascular: "normal rate."

e. The Telemetry rhythm strips signed by Staff #13, Registered Nurse assigned to Patient #2, indicted the following:

i. 2/24/18 at 1900-"sinus rhythm with A paced beats [sic]," heart rate (HR) sixty eight (68) beats per minute (BPM)"

ii. 2/24/18 at 2109-"wide complex tachycardia, HR one hundred and two (102) BPM"

iii. 2/25/18 at 0319-"Brady with a two (2) second pause, HR forty three (43) BPM"

iv. 2/25/18 at 0329:22 (and 22 twenty two seconds)-"V Tach, HR one hundred and nineteen (119) BPM"

v. 2/25/18 at 0329:46 (and forty six seconds)-"V Tach/V Fib"

vi. 2/25/18 at 0420 "Expired"

f. The "Nursing Flowsheets" on 11/25/18 at 0335 indicated, "absent left and right radial pulses, PEA (pulseless electrical activity), skin color dusky/gray, absent breath sounds, level of consciousness-unresponsive, right and left pupil nonreactive, no pulse-respirations or blood pressure. Compressions initiated, defibrillated/cardioverted, Patient intubated at 0351."

g. The Physician "Significant Event Notes" of 11/25/18 at 0508 indicated, "responded stat to Code Blue at 0335. ...Patient in Asystole ...code unsuccessful and stopped at 0420." Date and death recorded as 11/25/18 at 0420."

3. There was no evidence in the medical record, Staff #13 notified the physician of cardiac rhythm changes on 11/24/18 at 2109 for "wide complex tachycardia" for Patient #2.

4. There was no evidence in the medical record, Staff #13 was notified, at the time of the changes, of Patient #2's cardiac rhythm at 0319 and 0329.

a. The facility "Timeline" indicated Staff #13 was notified of the Patient's dysrythmias on 11/25/18 at 0334.

5. Upon interview on 2/22/19 at 1120, Staff #2 confirmed that when the dysrythmias occurred on 11/25/18 at 0319 and 0329 for Patient #2, Staff #8 was covering the telemetry monitoring. He/she reported being distracted and turned to speak to another staff member for about ten (10) minutes, and did not hear the telemetry alarms. Staff #2 confirmed that Staff members do not have the ability to mute or decrease the volume for alarms.

6. The above findings were confirmed with Staff #1 and Staff #2.

Reference #3: Facility policy "Documentation Standards" states, " ... Purpose: ...1. Provide a current, complete and concise description of the patient's status with minimal duplication of information. ...11. Dating and Timing entries: ...D. If information needs to be entered for a previous occurrence, do the following: 1) Enter the actual date and time the entry is being made in the data column 2) Enter the necessary information, starting the entry with "Late Entry", including the date and time of the actual occurrence ...13. The documentation must reflect that the patient has been assessed by a RN every 12 hours and every time there is a significant change in condition. ...16. Documenting a late entry in the clinical record. ...D. Write "late entry" or "addendum note" referencing the date the documentation is referring to. ..."

1. The "Nursing Assessment" on 11/25/18, had multiple entries entered after Patient #2 was pronounced "expired" at 0420. These assessments were not documented as a "late entry" per policy.

a. The "Glasgow Coma Scale" assessment was completed on 11/25/18 at 0430.

b. The "Pain Assessment" was completed on 11/25/18 at 0909.

Reference #4: Facility policy "Resuscitation Orders (Directive For Care)" states, " ... 1. Upon admission, all patients must have resuscitation orders documented in the medical record. ...2. The order must be signed by a competent patient, or designee, and physician. Once signed by the patient, or designee the order will be followed. ...4. A physician must document in the medical record any discussions that establish or change the Resuscitation Order for the patient. ..."

1. Review of physician orders in Medical Record #2 indicated, a "Full Resuscitation" Order was entered for Patient #2 by the physician on 11/22/18.

a. There was no evidence of documentation in the medical record by the physician indicating discussions with the Patient or designee regarding resuscitation per above policy.

2. The facility Resuscitation Orders/Consent for Patient #2, noted "Full Resuscitation (FR) All indicated methods of resuscitation are to be used" was not obtained until 11/25/18 at 0830. The Patient expired on 11/25/18 at 0420.

i. There was a Telephone Order (TO) giving full consent from the "mother" with no date and time noted.

ii. There were two (2) Registered Nurse signatures as witnesses, dated 11/25/18 at 0830, and a physician signature dated 11/26/18.

iii. The facility "Record of Death" for Patient #2, noted the date and time of death as 11/25/18 at 0420.

3. The above findings were confirmed with Staff #1 and Staff #2.

Reference #5: Facility policy "Care of The Patient After Death" states, " ...POLICY: ...8. If the family is not present, the belongings should be given to the mortician and noted in the chart. 11. If there is a significant delay in locating family, the body should be sent to host hospital to be secured in the morgue. If no morgue is available, call the Medical examiner to secure the body until the family can be located. 12. An authorization to release the body must be signed by the nearest relative. The signature of legal next of kin is required unless consent is obtained by telephone and witnessed by two licensed personnel. ...15. Fill out the Certificate of Death ..."

1. Upon review of the "Record of Death" form, it was determined that nine (9) of nine (9) forms were not completed. The following were noted:

a. In Medical Record #1 the "Record of Death", "Patient's Belongings" did not specify who the belongings were given to, the relationship to the Patient or the date given.

i. The "Disposition of Body", did not include Family/POA (power of attorney) or their signature and printed name. There was no witness to the signature of consent that was obtained by telephone.

b. In Medical Record #2 the "Record of Death", "Patient's Belongings" did not specify who the belongings were given to, the relationship to the Patient or the date given.

i. The "Disposition of Body", did not include the name of the Patient/body being released, the Family/POA or their signature and printed name, and the relationship to the deceased. There was no witness signature of consent that was obtained by telephone.

c. In Medical Record #3 the "Record of Death", "Disposition of Body", did not include the name of the Patient/body being released.

d. In Medical Record #6 the "Record of Death", "Disposition of Body", there was no witness signature of consent that was obtained by telephone.

e. In Medical Record #7 the "Record of Death", "Disposition of Body", did not include the name of the Patient/body being released, the Family/POA or their signature and printed name, and relationship to the deceased or the date and time. There was no witness signature of consent that was obtained by telephone.

f. In Medical Record #8 the "Record of Death", "Patient's Belongings", did not specify who the belongings were given to, the relationship to the Patient or the date given.

i. The "Disposition of Body", did not include the name of the Patient/body being released, the Family/POA or their signature and date and time. There was no witness signature of consent that was obtained by telephone.

g. In Medical Record #9 the "Record of Death", "Disposition of Body", did not include a witness signature of consent that was obtained by telephone.

h. In Medical Record #10 the "Record of Death", "Disposition of Body", did not include the name of the Patient/body being released, Family/POA or their signature and printed name, and relationship to deceased or the date and time. There was no witness signature of consent that was obtained by telephone.

i. In Medical Record #11 the "Record of Death", "Disposition of Body", did not include the name of the Patient/body being released.

2. The above findings were confirmed with Staff #1.

Reference #6: Facility policy "Emergency Equipment (Code Cart and Defibrillator) Checking Procedure" states, " ...PERFORMED BY: Staff with documented competency [RN (Registered Nurse) or RT (Respiratory Therapist)]. ...PROCEDURE: RNs and RTs with demonstrated competency will complete the Emergency Equipment/Crash Cart every shift for items such as: ...All drawers locked on the crash cart ...Testing of defibrillator. ...This procedure will be completed at the beginning of every shift and documented on the Emergency Equipment/Code Cart Check List (see example form below). If any items are found to be out of compliance, the charge nurse will be notified and the Code Cart/Intubation Box or Defibrillator will be replaced. ..."

1. During a tour of the patient care unit on 2/21/19, accompanied by Staff #1, review of the "Emergency Equipment/Code Cart Check List" atop Crash Cart #3 indicated the following:

a. On 2/2/19 at 0700 and 1900, and on 2/3/19 at 0700 and 1900, the handwritten entry "open" was entered in the "Tear-away Plastic Lock Intact w (with)/ all Crash Cart drawers locked" column.

2. There was no documentation that the charge nurse was notified or that the cart was replaced, per policy.

3. The above findings were confirmed with Staff #2.

Reference #7: Facility policy "LABELING OF MEDICATIONS" states, " ...Beyond Use Dating on Multi-Dose Sterile Injectable Medications ...6. Single Use/Single Dose Injectable Products will be discarded immediately after use (not to exceed 1 hour) when opened in non-ISO 5 air (such as at bedside, medroom [sic], etc.) ..."

1. During a tour of the High Side Wing of the patient unit on 2/21/19 at 1315, accompanied by Staff #1, A WOW (Workstation On Wheels) (ROCMOB13L0519) in the hallway had an open drawer containing an opened single-use vial of Metoprolol Tartrate 5mg/5ml.

2. Upon interview in the afternoon of 2/21/19 , Staff #4 stated that the vial of Metoprolol should have been discarded after it was used and not be placed in the WOW.

3. The above findings were confirmed with Staff #1.

Based on staff interviews, medical record review and review of facility documents, it was determined the facility failed to ensure complete and concise descriptions of occurrences, in the medical record.

Findings include:

Reference #1: Facility policy "Change in Patient Condition" states, " ...Documentation: 1. 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 electronic medical record (EMR). ..."

Reference #2: Facility policy "Documentation Standards" states, " ... Purpose: ...1. Provide a current, complete and concise description of the patient's status with minimal duplication of information. ...11. Dating and Timing entries: ...D. If information needs to be entered for a previous occurrence, do the following: 1) Enter the actual date and time the entry is being made in the data column 2) Enter the necessary information, starting the entry with "Late Entry", including the date and time of the actual occurrence ..."

1. On 1/14/19 at 1130, Patient #3 coded and resuscitation efforts were unsuccessful.

2. Upon review of Medical Record #3 on 2/22/19, the following was noted:

a. The Patient "Admission History and Physical" of 1/4/19 indicated, the Patient was "intubated treated for aspiration pneumonia was not waking up and off for extubation ...neurology evaluation ...patient had a posterior reversible encephalopathy syndrome."

b. The Respiratory Therapist "Progress Note" of 1/14/19 at 0821 indicated, Patient vent settings "tolerating well ...Patient shows no signs of distress or shortness of breath. ..."

c. The Physician "Progress Note" dated 1/14/19 at 1046 indicated, "tc [trach] on vent ...Lungs: few rhonchi and basal fine rales ...Plan: ...stable ..."

d. The "Nursing Note" dated 1/14/19 indicated the following:

i. Staff #13 at 1130: " ...Noted trach is slightly deviated to left side RT [Staff member #15] called and came at bedside. ..."

ii. Staff #13 at 1140: " ...heard vent alarming ...found pt [Patient] is obtunded and blue, and trach is almost out-called RRT [Rapid Response Team] ...RT [Respiratory Therapist-Staff #15], and RT [Respiratory Therapist-Staff #6] came together and bagged pt [Patient] orally, but with resistance, Code Blue called. ..."

e. Staff #6's-Respiratory Therapist "Progress Notes" on 1/14/19 for Patient #3, noted the following:

i. 1140: "paged stat to room. ...RT [Respiratory Therapist-Staff #15] and I rushed to the room. Patient's Spo2 [oxygenation saturation] was around 87-89%. ..."

ii. 1141: "Upon assessment ...trach has been moved sideways and there was swelling of the Patient's cheeks with crepitation under pressure. ..sub acute emphysema ...attempted unsuccessfully to reposition the trache ...Code Blue was called

iii. 1147: "The Code continued and was ended by house physician ..."

f. Physician "Significant Event" note on 1/14/19 at 1244 indicated, "Code blue called for O2 [oxygen] desaturation after her [Patient] trache [sic] tube had become displaced and subcutaneous emphysema began to develop ...subsequently lost pulse ...intubated and O2 [oxygen] saturation was restored but rhythm and pulse could not be restored. Death was pronounced at 1225. ..."

3. The facility "Timeline" as reported by Staff #15, Respiratory Therapist, for events on 1/14/19 between the hours of 1131 and 1139, indicated the following:

a. " ...[Staff #15] entered room [Patient #3] ...noted drop in Spo2 [oxygen saturation] (low 80s), low volumes noted on vent, ...air added to cuff, volumes remained the same. Attempted to suction patient, not able to pass catheter completely, Spo2 [oxygen saturation] improved slightly (mid 80s), tried to readjust trach, Patient grabbed suction catheter with tight grip and was pulling, hand removed by [Staff #15] ...[Staff #15] left [Patient] room to find [Staff #6] for help ... and asked to come to [Patient's] room. ..."

4. Upon interview on 2/22/19 at 1340, Staff #1 and Staff #2 stated that Staff #15, did leave Patient #3's room for "a minute to minutes" and that it was not an acceptable standard of care.

5. There was no documented evidence in the medical record of an assessment or treatment from Staff #15, for Patient #3, between the hours of 1130 and 1140.

6. The above findings were confirmed with Staff #1, Staff #2 and Staff #9.

Based on staff interviews, medical record review and review of facility documents, it was determined the facility failed to ensure that all respiratory orders are documented in the medical record.

Findings include:

Reference: Facility policy "Trach Care" states, " ...PROCEDURE: ...6. If flanged sutures are present, and the trach is greater than 10 days old, obtain physician's orders for suture removal. ..."

1. On 11/13/19, Patient #3 was admitted with a trach and was vent dependent.

a. The facility document, "Preadmission Intake" on 1/3/19, indicated the patient's trach was inserted on 1/2/19.

b. The Respiratory Therapist "Assessment" on 1/14/19 at 0502 indicated, "cuffed tracheostomy, secured, sutures in place; crusty. Sutures removed, dressing applied."

2. Upon interview on 2/21/19 at 1318, Staff #6 stated that respiratory therapists do remove flange sutures within seven (7) to ten (10) days of insertion, with a physician order.

a. The facility policy states if the trach is greater than ten (10) days old, an order for suture removal must be obtained.

3. There was no documented evidence of a physician order for the removal of flange sutures in Medical Record #3.

4. The above findings were confirmed with Staff #1 and Staff #2.