HospitalInspections.org

Based on record review and interview the facility failed to provide adequate staffing to ensure the immediate availability of a Registered Nurse for bedside care of patients on the patient care units for more than a twenty four hour period.
Failed to follow it's Nursing policy which require "An RN will be immediately available to assist and supervise patient care as well as to respond to emergency situations". Citing wings C and D.

Findings:

Observation on 7/28/11 at 10:45 am at the facility revealed three patient care wings B,C and D. The B wing was vacant. All wings had a nursing station and the wings are separated by walls and long corridors. Staff on either wing can only communicate by phone or walk to the unit. Staff nor patients on the C Wing are not able to visualize or hear what is happening on the D Wing . An assigned House supervisor is not physically able to supervise care on both wings at the same time.

Review of the assignment sheets for the D wing dated 7/27/11 and 7/28/11 revealed patients located in rooms 801 -901 were assigned to the care of a Licensed Vocational Nurse (LVN) on the 7am -7pm shift and the patient's care was handed off to another LVN for the 7pm - 7 am shift . There was no assigned Registered Nurse on the Unit to supervise the nursing care of the patients.
Review of assignment sheets for the C wing dated 7/27/11 and 7/28/11 revealed patients in rooms 509 were assigned to the care of an LVN on the day shift and was handed over to the care of an LVN on the night shift. There was no assigned Registered Nurse (RN) to supervise the care of the patients.
Review of nurses notes and assignment sheets for Patient # 1 cited in a complaint allegation revealed documentation on her nurses notes dated 2/24/11 -3/1/11 that the patient was cared for by an LVN without any documentation of a Registered Nurse's evaluation of the patient's care.

Review of the facility's Nursing Supervision policy dated October 2010 revealed information that "An RN will be immediately available to assist and supervise patient care as well as to espond to emergency situations".

During an interview on 7/28/11 at 12:45 pm at the facility with Staff # 52, Chief Nursing Officer she stated the facility had an RN house supervisor on each shift. She further stated she realize that was not adequate supervision.

Based on record review and interview the facility failed to identify a change in a patient ' s condition when the patient went from being alert to place and person, to being unresponsive to verbal or physical stimulation. The facility failed to ensure a registered nurse assessed the patient and inform the physician of the change in the patient ' s condition. Failed to follow it's Nursing policy which require "An RN will be immediately available to assist and supervise patient care as well as to respond to emergency situations".
Citing one (1) patient (#1) named in a complaint allegation.
Findings:
Review of complaint narrative revealed information that the facility staff found patient #1 on 3/1/11 at 3:30 am with her PICC line pulled out. The patient bled profusely as she was on blood thinners. The facility ' s staff did nothing until 9:30 am when Paramedics picked her up for a scheduled day surgery intervention at an acute care facility.

Review of nurses ' notes dated 2/28/11 at 7am revealed documentation that Patient# 1 was alert and oriented to person and place. There was no sign or symptom of distress, oxygen at 15 liter via face mask. Right PICC Line dressing intact.
Notes dated 2/28/11 at 7:00 pm revealed documentation that Patient # 1 was in stable condition, assessment within normal limits patient unable to communicate needs but shows no signs or symptoms of pain or discomfort, she was able to be awaken by touch. At 11:00 the patient was asleep and resting comfortably.
Review of nurses notes dated 3/1/11 at 3:00 documented "went into patient ' s room to draw labs and the PICC was out of the patient ' s am, called for assistance and placed a binder over the area so that it would not bleed out".
There was no documentation that the patient ' s condition was assessed. No vital sign was documented or there was no information regarding blood loss from the PICC line site.
Review of nurses' notes dated 3/1/11 at 6:40 am revealed information that a physician was called regarding a critical lab value for the patient and was awaiting call back. There was no indication that a physician was informed that the patient ' s PICC line was pulled out or the condition of the patient.
Review of nurses ' notes dated 3/1/11 at 7:17 am revealed documentation that the patient was asleep in bed, blood pressure was 103/53, pulse 89, respiration 20 and temperature 97.7, 'will continue to monitor".
At 8:30 am notes stated "patient in bed still asleep respirations 32 labored breathing. Unable to arouse, does not open eyes to verbal or physical stimulation 02(oxygen) via non- rebreathing mask at 15 liter. Oxygen saturation 95%, heart rate 90. Still does not open eye or respond to voice will continue to monitor.
Further review of nurses ' notes dated 3/1/11 at 9:13 am revealed EMS (Emergency Medical Services) present at patient ' s bedside states that the patient did not respond to voice or sternal rub and questioned whether or not they should transport the patient. There was documentation that Staff # 50 (Licensed Vocational Nurse) instructed EMT to transport the patient to M Hospital where she was scheduled for a central line placement, the staff also stated the patient would already be at a hospital if she required further treatment or evaluation. There was documentation that the Charge nurse also instructed EMS staff to transport the patient to M Hospital.
There was no documentation that the Registered Nurse evaluated the patient ' s condition or that a physician was called.
Review of Emergency Room notes at M Hospital dated 3/1/11 revealed that at 10: 17 am Patient # 1 arrived in the ER via ambulance service. She was triaged at 10:23. The patient was unresponsive to commands she was dyspnec, agonal respirations, shortness of breath, and lethargic. She was hypoxic with oxygen saturation at 85% on room air. There was documentation that the patient was sent to the facility for IVC( Inferior Vena Cava) filter placement. Physician assessment was conducted at 10:19 am and she was intubated (rapid sequence intubation) at 10:40 am. A central line was placed and the patient was admitted to the Intensive Care Unit in critical but stable condition on 3/1/11 at 2:46 pm.
Review of Discharge Summary from M Hospital dated 6/1/11noted that the patient was intubated and carefully monitored her condition declined and she expired on 3/13/11.
Review of the facility's Nursing Supervision policy dated October 2010 revealed information that "An RN will be immediately available to assist and supervise patient care as well as to espond to emergency situations".
During an interview on 7/28/11 at 11:15 am with Staff # 52 Chief Nursing Officer she stated the Registered Nurse in charge should have assessed the patient ' s condition and inform the physician in house of the patient ' s condition. The CNO further stated the facility had the capability of providing respiratory care for patients including intubation.