HospitalInspections.org

Based on policy review, medical record review and staff interviews the hospital's nursing staff failed to supervise and evaluate patient care by failing to monitor patients' vital signs as ordered and reassess patients after changes in vital signs for 2 of 14 open, inpatient records reviewed (#35, #36).

The findings include:

Review of current hospital policy entitled, "Assessment/Reassessment of Patient," revealed "I. PURPOSE: To establish guidelines for assessment and reassessment of patients at the time of admission and throughout hospitalization. II. PHILOSOPHY: It is our belief that clinical treatment of patient should be based on prompt, accurate determination of their needs by clinicians who are best qualified to define their needs. III. DEFINITIONS: A. Patient Assessment: The systematic collection and review of patient-specific data gathered from the patient ...B. Reassessment: The continuous or repeated collection and review of patient-specific data. IV. STANDARDS, A. Hospital Standards...2. Parameters That Must Be Assessed: a) Treatment of patients shall be based on current and potential patient needs as identified in assessments/reassessments. The minimum needs to be assessed include: (1) Biophysical status of the patient ...5. The documented initial assessment shall contain guidelines for reassessment including: a) The future time frame specified by the clinical discipline ...; b) Clinical parameters which reflect changes in the patient's condition or responses to; c) Therapies and interventions ..."

Review of current hospital policy entitled, Assessment/Reassessment of Patients in ICU, revealed "I. PURPOSE: To provide guidelines for assessment and reassessment of patients in the (ICU) Intensive Care Unit ....III. DEFINITIONS: A. Vital Signs: Blood pressure, pulse, respirations and temperature, pulse oximetry ...IV. STANDARDS: E. Vital signs will be taken on all patients every hour or as often as patient's condition warrants, or as ordered by physician ..."

1. Medical record review of patient #35 revealed a 55 year old female admitted on 10/31/2010 at 2000 with a diagnosis of "Febrile Neutropenia (decreased White Blood Cells with fever), Ascites (accumulation of fluid in the abdominal cavity), and NASH (Non Alcoholic Steato Hepatitis or Fatty Liver)." Medical record review of physician's orders dated 10/31/2010 at 2000 revealed "VS q 4 hrs (Vital Signs every 4 hours)...O2 @ 2 LPM (Oxygen at 2 Liters per minute) to keep sats (Oxygen saturation) > (greater than) 92%." Medical record review of nursing "Flowsheet" revealed vital signs documented at 10/31/2010 at 2141 were as follows: Temperature (T) 99.1, Pulse 78 beats/min. (BPM), Respirations 20 breaths/min. (RPM), Blood Pressure (BP) 94/44 and Oxygen saturation 95% on 2 Liters/min Oxygen. Medical record review revealed the next recorded vital signs were documented on 11/1/2010 at 0734, 9 hours and 53 minutes later. Medical record review did not reveal documentation that nursing notified the physician of the patient's low blood pressure. Medical record review revealed the patient's vital signs were documented on 11/01/2010 at 0734 and on 11/01/2010 at 1500, a 7 hour and 26 minute interval between vital signs. Medical record review revealed the patient's vital signs were documented on 11/01/2010 at 1750 and on 11/02/2010 at 0250, a 6 hour and 10 minute interval. Medical record review revealed the patient's vital signs on 11/02/2010 at 1108 were T=98.1, BPM=78, RPM=20, BP=109/35 and Oxygen saturation = 90 % on room air. Medical record review revealed no documentation of nursing intervention for the patient's decreased oxygen saturation of 90%. Medical record review revealed no documentation of physician notification that the patient's oxygen saturation dropped below his prescribed lower limit of 92%. Medical record review revealed the next recorded vital signs were documented on 11/02/2010 at 1755, 6 hours and 47 minutes later.

Interview on 11/3/2010 at 1030 with the Unit Manager during computer review of the patient's medical record confirmed the patient's vital signs were ordered every 4 hours and were not documented as ordered. Interview confirmed there was no documentation that the nurse reassessed the patient for a drop in blood pressure and oxygen saturation. Interview confirmed there was no documentation that the physician was notified of either drop in blood pressure or oxygen saturation. Interview revealed the nurse failed to supervise and evaluate patient care by failing to monitor the patient's vital signs as ordered and failing to notify the physician of changes in the patients vital signs.

2. Medical record review of patient #36 revealed a 40 year-old male admitted on 11/01/2010 to the Intensive Care Unit (ICU) with a diagnosis of Malignant Hypertension (a type of hypertension in which blood pressures suddenly increased to dangerously high levels). Medical record review of physician's orders dated 11/01/2010 at 1335 revealed "vitals q 4 (vital signs every 4 hours)." Medical record review revealed the nurse documented the patient's vital signs (Temperature, Pulse Rate, Respiratory Rate, Blood Pressure and Oxygen Saturation) on 11/01/2010 at 1722. Medical record review revealed the patient's temperature at 11/01/2010 at 1722 was 96.5 degrees Fahrenheit. Medical record review revealed the patient's temperature was not retaken again until 11/02/2010 at 0700, an interval of 13 hours and 38 minutes. Medical record review revealed the nurse documented the patient's vital signs (including temperature) on 11/02/2010 at 0700. Medical record review revealed nursing did not record the patient's temperature until 11/02/2010 at 1830, an interval of 11 hours and 30 minutes.

Interview on 11/3/2010 at 1040 with the Unit Manager during computer review of the patient's medical record confirmed the patient's vital signs were ordered every 4 hours. Interview revealed vital signs includes monitoring the patient's temperature. Interview revealed nursing failed to supervise and evaluate patient care by failing to monitor the patient's temperature as ordered every 4 hours.

Based on hospital policy review, observations during tour and staff interviews the hospital failed to ensure drugs used in the Radiology Department for adverse side effects of procedures were not outdated.

The findings include:

Review of current hospital policy "Medications, Management of Unusable" revised February 2008, revealed "...IV. Standards C. Drugs that are expired, damaged, defective, recalled or in any way not fit for use shall be removed from stock, returned to the pharmacy, and segregated from other drugs while awaiting their disposal ..."

During tour of the Radiology Department on 11/04/2010 at 1000 observation of the radiology crash cart revealed a locked tackle box. When the box was opened it was observed to contain medications that may be used in case of an adverse reaction to chemicals or drugs used during radiology procedures. These medications were Glucagon injectable (1) expired 9-2010, Heparin 5,000 units/mL inj. (units per milliliter injectable) (4) expired 2-2010, Hep-Lock Flush 100 units/mL 30 mL (1) expired 3-2010, Furosemide 100 mg/10mL (100 milligrams per 10 milliliter) inj (1) expired 7-2010, Sodium Bicarbonate 8.4 %PFS 50 ml (1) expired 4-2010, and Solu-Medrol 125mg/2mL inj (2) expired 8-2010. Observation revealed a second drug box was located in the radiology room. When the box was opened it was observed to contain medication that would be used in case of an adverse reaction to chemicals or drugs used during radiology procedures. These medications were Diphenhydramine 50 mg/mL (milligrams per milliliter) inj (1) expired 5-2009, Dextrose 50% PFS 25gm (grams) (2) expired 12-2010, Glucagon inj (1) expired 8-2009, Heparin 5,000 units/mL inj (4) expired 12-2009, Hep-Lock Flush 100units/mL 30mL (1) expired 5-2009, Furosemide 100 mg/10mL inj (1) expired 3-2009, Narcan 1mg/mL 2mL inj (2) expired 1-2009, Sodium Bicarbonate 8.4% PFS 50 mL expired 10-2009 and Solu-Medrol 125mg/2mL inj. (2) expired 12-2009.

Interview on 11/04/2010 at 1030 with the Director of Pharmacy revealed all medications stored outside of the pharmacy are stored in omnicells (automated medication dispensing and storage machines) or in secured crash carts. Interview revealed the only exception is in the dialysis and emergency departments. Interview revealed the dialysis and emergency departments have one (1) medication box located in each area used to store medications for transport/emergency. Interview revealed the pharmacy maintains a log book for each medication box used to store medications in hospital departments which are not stored in the omnicells or crash carts. Interview revealed the medication boxes are checked monthly by pharmacy technicians for outdated/expired medications. Interview revealed the boxes are secured with control tags. Interview revealed the pharmacy had no log book for the two medication boxes located in radiology. Interview revealed the pharmacy staff was unaware the two boxes in the radiology department existed therefore monthly checks were not being performed. Interview revealed the pharmacy staff does not know when the boxes were created. Interview confirmed the two radiology medication boxes contained inventory charge/control sheets initialed by a hospital pharmacist. Interview revealed "they fell through the cracks."

Telephone interview on 11/04/2010 at 1200 with Pharmacy Technician #1 revealed she was the technician assigned to perform rounds in the radiology department. Interview revealed she performs monthly rounds to include checks for outdated/expired medications in the department. Interview revealed she checks the expiration dates for the medications stored inside of the crash cart. Interview revealed she does not check any boxes stored on top of the crash carts. Interview revealed she was unaware of the two medication boxes stored in radiology. Interview confirmed she did not check the two medication boxes for outdated/expired medications on a monthly basis.

Based on observation of kitchen practice and review of the log for food temperatures at the serving line the hospital failed to ensure temperatures of chilled foods leaving the serving line were at or below recommended standards (41 degrees Fahrenheit).

The findings include:

Review of "Patient Food Services, Workstation Tray Assembly Procedures and Daily Meeting" dated as revised 7/08, policy entitled Procedures "Food and Nutrition Supervisor" revealed "No more than 20 minutes prior to serving: Take temperatures, taste food and record on Taste/Temperature Record...If cold food above 41 F (Fahrenheit), contact Director..."

During the tour of the kitchen on 11/03/2010 at 1145 it was observed that the fruit was at 45 degrees Fahrenheit, orange juice was 48 degrees Fahrenheit, and jello was 44 - 45 degrees Fahrenheit. Review of the Cafe Temperature, taste sheet for cook and Cafe Associate, from 10/17/2010 through 11/2/2010 revealed no temperature monitoring being conducted for chilled foods. Interview with the Dietary Department Manager on 11/03/2010 at 1230 confirmed temperatures for chilled foods were not being monitored.

Based on hospital policy review, staff interviews, medical record review and observation the hospital failed to ensure nursing staff had approved medical protocol/guidelines for the administration and monitoring of Propofol (anesthetic agent) for 4 of 4 medical record review of patients placed on Propofol (#39, 43, 44, & 45) and failed to ensure medication was administered as ordered for 1 of 8 surgical records reviewed (#7).

The findings include:

Review of the hospital policy, "Moderate Sedation, Management of", last reviewed 10/09, revealed "... Definitions ...E. "Deep Sedation: A drug-induced depression of consciousness during which patients cannot be easily aroused but responds purposely following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. ... H. Moderate Sedation: A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. (NOTE: Reflex withdrawal from a painful stimulus is not considered a purposeful response.) No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained...". Review of the policy did not indicate the frequency in which a patient should be assessed or provide recommended titration rates for increasing or decreasing the dosage.

Interview with intensive care unit nursing staff on 11/3/2010 at 1300 revealed they do not use a hospital protocol for the administration of Propofol. During interview, the nursing staff presented the Propofol manufacturer's guidelines to this surveyor with the guidelines the hospital follows, highlighted in yellow, for the use of Propofol (anesthetic agent). The guidelines state "Most adult ICU (Intensive Care Unit) patients recovering from the effects of general anesthesia or deep sedation will require maintenance rates of 5 to 50 mcg/kg/min (micrograms per kilogram per minute) (0.3 to 3 mg/kg/h) (milligrams per kilogram per hour) individualized and titrated to clinical response (see Dosage and Administration). With medical ICU (Intensive Care Unit) patients or patients who have recovered from the effects of general anesthesia or deep sedation, the rate of administration of 50 mcg/kg/min or higher may be required to achieve adequate sedation...increased by increments of 5 to 10 mcg/kg/min...Most adult patients require maintenance rates of 5 to 50 mcg/kg/min... . Review of another document (manufacturer's guidelines) presented that the nursing staff revealed the hospital uses as a guideline stated "Intensive Care Unit Sedation"..."patients should be monitored for early signs of significant hypotension and/or cardiovascular depression, which may be profound." Review of the manufacturer's guidelines did not indicate the frequency in which a patient should be assessed or provide recommended titration rates for increasing or decreasing the dosage.

1. Open medical record review of patient #39 revealed a 50 year old male admitted through the ED (emergency department) on 11/02/2010 at 2244 for drug overdose, depression, anxiety and alcoholism. Further review of the patient's medical record showed physician orders on 11/03/2010 at 0935 "Please call anesthesia for intubation". Record review revealed the patient was placed on a ventilator at 0945 on 11/3/2010. Record review revealed a physician's order at 0957 on 11/03/2010 to put patient in "Restraints - B soft wrist" and at 1055 the physician ordered "Propofol for sedation 5mcg/kg/hr (micrograms per kilograms per hour) and titrate so that pt. (patient) stirs to gentle shaking". At 1400 on 11/03/2010 the nurse wrote a clarification order "Propofol for sedation begin @ 5 mcg/kg/min. (micrograms per kilograms per minute) and titrate so that pt. stirs to gentle shaking". Continued review of the patient's medical record revealed no further orders regarding the titration of the medication "Propofol". Review of the medication record showed the patient started receiving 5mcg/kg/min. at 1100 on 11/03/2010, at 1644 the Propofol was increased to 10.3263 mcg/kg/min, with no clinical assessment documented to indicate the need for increasing the Propofol. At 1900 Propofol was increased to 16.5221, at 2000 decreased to 14.4568, at 2100 decreased to 12.3916, at 2200 decreased to 10.3263, on 11/04/2010 at 0000 decreased to 8.261, at 0300 increased to 10.3263, at 0900 decreased to 6.1958, and was still at 6.1958 at 0944. Review of the Neurological Clinical Assessment flow sheets for this time frame revealed no documented reasons given for increasing or decreasing the amount of Propofol given. Review of the vital sign assessments showed the patient's vital signs were being monitored between every half hour to one hour.

Interview with a registered nurse on 11/03/2010 at 1300 revealed the hospital had no written protocol for increasing or decreasing the amount of Propofol to be given to a patient. Interview revealed the nursing staff relied on physician orders and in the absence of orders used the manufacturer's guidelines for the administration of Propofol.

Observation on 11/04/2010 at 0920 revealed the nurse checking patient #39 for response, by shaking the patient and calling out his name. Observation revealed no response at all by the patient, the patient was being ventilated with a ventilator and per this observation would classify this patient as being in Deep Sedation per hospital definitions.

Interviews on 11/03/2010 at 1300 with the ICU nurse providing care to this patient indicated there were no documented/approved protocols for the use of Propofol and that they followed manufacturer's guidelines. She also indicated that she documented the vital sign monitoring every 1 hour and assessment every 4 hrs.

Interview with the ICU nurse supervisor on 11/03/2010 at 1315 revealed the nursing staff followed the manufacturer's guidelines when administering Propofol.

Interviews with administrative nursing staff on 11/03/2010 at 1530 indicated the hospital had no written/approved protocols for the use of Propofol and nursing staff followed the manufacturer's guidelines for the administration of Propofol.

Interview with the hospital's CNO (Chief Nursing Officer) on 11/04/2010 at 1330 revealed the hospital was using manufacturer's guidelines for the administration of Propofol. Interview further revealed this practice was inappropriate and the hospital would be developing approved protocols for administering Propofol.

2. Closed medical record review of patient #43 revealed a 72 year old patient admitted on 05/30/2010 with respiratory abnormality. On 06/01/2010 at 0200 the patient was placed on a ventilator, and placed in soft wrist restraints on 06/02/2010 at 0030. On 06/02/2010 at 1445 the physician orders were to put patient on "Diprivan (anesthetic agent) gtt (drip) per protocol for sedation." Rreview of the medication administration record showed the patient was started on Diprivan on 06/02/2010 at 1732 receiving 5mcg/kg/min (16.94mg) until 2000 when the Diprivan was increased to 9.6331 (70mg). On 06/02/2010 at 2300 the Diprivan was increased to 13.7616 (100mg) until 6/3/2010 at 0500 when the Diprivan was decreased to 9.6331 (70mg). At 0600 the Diprivan was decreased to 5.5046 mcg/kg/min (40mg) until 06/04/2010 at 0100 when the Diprivan was increased to 9.6331 (70mg). At 0500 the Diprivan was again decreased to 5.5046 (40mg), then increased to 9.6331 (70mg) at 0759. At 0959 the Diprivan was decreased to 50mg, at 1059 it was decreased to 40mg, until 1259 when the Diprivan was decreased to 0mg. However on 06/04/2010 at 2159 the record shows the Diprivan was restarted at 40mg. until 06/05/2010 at 0659 when the Diprivan was decreased to 20mg . At 0759 the Diprivan was decreased to 0mg. On 06/05/2010 at 0935 physician orders were to Extubate...D/C (discontinue) Diprivan (Propofol). There were no physician orders to decrease the Diprivan prior to the order to discontinue the Diprivan. Review of the Neurological Clinical Assessment flow sheets for this time frame revealed no documented reasons given for increasing or decreasing the amount of Propofol given. Review of the vital sign assessments showed the patient's vital signs were being monitored between every half hour to one hour.

Interview on 11/04/2010 at 1145 with the nurse who took the orders for Patient #43 on 06/02/2010 for Diprivan indicated when asked what protocol she used, stated "I use the manufacturer's guidelines". She also indicated she documented patient monitoring every 15 to 30 minutes.

Interview with the physician at 11/04/2010 at 1200 revealed the physician wrote the order for Patient #43 to receive Diprivan on 06/02/2010. Further interview revealed he was aware that the nursing staff use the manufacturer's guidelines for the administration of Diprivan.

Interviews on 11/04/2010 at 1145 with the ICU nurse providing care to this patient, while the patient was still in ICU, indicated there were no documented/approved protocols for the use of Propofol and that they followed manufacturer's guidelines. She also indicated that she documented the vital sign monitoring every 15 to 30 minutes.

Interview with the ICU nurse supervisor on 11/03/2010 at 1315 revealed the nursing staff followed the manufacturer's guidelines when administering Propofol.

Interviews with administrative nursing staff on 11/03/2010 at 1530 indicated the hospital had no written/approved protocols for the use of Propofol and nursing staff followed the manufacturer's guidelines for the administration of Propofol.

Interview with the hospital's CNO (Chief Nursing Officer) on 11/04/2010 at 1330 revealed the hospital was using manufacturer's guidelines for the administration of Propofol. Interview further revealed this practice was inappropriate and the hospital would be developing approved protocols for administering Propofol.

3. Closed medical record review of patient #44 revealed a 41 year old patient admitted on 07/29/2010 at 2331 with pneumonia. Record review revealed a physician's order dated 08/01/2010 at 1141 to transfer the patient to ICU. Record review revealed Patient #44 was placed on a ventilator and a physician's order dated 08/02/2010 at 2345 for "Diprivan (anesthetic agent) gtt "(drip). Review of the medication administration record shows the patient was started on the Diprivan on 08/03/2010 at 0000 receiving 73.5294 mcg/kg/r (hr) (300mg). Review revealed on 08/04/2010 at 0100 the Diprivan was increased to 85.7843 mcg/kg/r (hr) (350mg), then at 0821 decreased to 36.7647 mcg/kg/r (hr) (220mg). On 8/4/2010 at 0959 the Diprivan was increased back to 300mg and the patient continued to receive the 300mg until 1359, on 8/5/2010, at the time of transfer to another hospital. Record review revealed a physician's order dated 08/05/2010 at 0945 to "attempt to wean Propofol sedation goal=drowsy patient with sluggish response to gentle shaking using lowest effective doses of sedatives ". Record review revealed a physician's order dated 08/05/2010 at 1145 to transfer the patient to another acute care hospital for acute respiratory failure. Review of the Neurological Clinical Assessment flow sheets for this time frame revealed no documented reasons given for increasing or decreasing the amount of Propofol given. Review of the vital sign assessments showed the patient's vital signs were being monitored between every half hour to one hour.

Interview with the ICU nurse supervisor on 11/03/2010 at 1315 revealed the nursing staff followed the manufacturer's guidelines when administering Propofol.

Interviews with administrative nursing staff on 11/03/2010 at 1530 indicated the hospital had no written/approved protocols for the use of Propofol and nursing staff followed the manufacturer's guidelines for the administration of Propofol.

Interview with the hospital's CNO (Chief Nursing Officer) on 11/04/2010 at 1330 revealed the hospital was using manufacturer's guidelines for the administration of Propofol. Interview further revealed this practice was inappropriate and the hospital would be developing approved protocols for administering Propofol.

4. Closed medical record review of patient #45 revealed a 69 year old patient admitted to out patient day surgery on 06/21/2010 at 0001 for Thyroid Total w/nimms (total thyroidectomy) pre operative. Record review revealed on 06/21/2010 at 1400 the patient was intubated at 1400. Record review revealed a physician's order at 1430 to admit to ICU (Intensive Care Unit) inpatient, trach (tracheostomy) tray by bedside with 8 shiley trach and at 1445 an order was written for "Diprivan drip - STAT (immediately) @ 5ml/hr. (milliliters per hour) may titrate as needed. Review of the medication administration record revealed the patient received 0.7079mcg/kg/hr (70 mg) from 06/21/2010 at 1910 through 06/22/2010 at 0559 when the patient received 35 mg and at 0659, 0mg. Record review revealed the Diprivan was discontinued at 0659. Review of the Neurological Clinical Assessment flow sheets for this time frame revealed no documented reasons given for increasing or decreasing the amount of Propofol given. Review of the vital sign assessments showed the patient's vital signs were being monitored between every half hour to one hour.

Interview with the ICU nurse supervisor on 11/03/2010 at 1315 revealed the nursing staff followed the manufacturer's guidelines when administering Propofol.

Interviews with administrative nursing staff on 11/03/2010 at 1530 indicated the hospital had no written/approved protocols for the use of Propofol and nursing staff followed the manufacturer's guidelines for the administration of Propofol.

Interview with the hospital's CNO (Chief Nursing Officer) on 11/04/2010 at 1330 revealed the hospital was using manufacturer's guidelines for the administration of Propofol. Interview further revealed this practice was inappropriate and the hospital would be developing approved protocols for administering Propofol.



22798

5. Review of the hospital policy, "Medication Administration", revised 11/2008, revealed, "...IV. Standards...L. Administration Times...2. "Stat" and "Now" medications will be administered within 30 minutes of the time ordered. ...".

Closed record review of Patient #7 revealed a 67 year-old admitted 11/03/2010 in the outpatient pain clinic with chronic back pain and for the placement of a spinal cord stimulator. Record review revealed a physician's order dated 11/03/2010 at 1000 for Ancef 2 grams IV (intravenously). Record review revealed no documented evidence that the nurse administered the medication.

Interview on 11/03/2010 at 1415 with administrative nursing staff confirmed a physician's order for Patient #7 to receive Ancef 2 grams IV on 11/03/2010 at 1000. Interview confirmed there was no documented evidence that the nurse administered the medication to Patient #7.

The registered nurse caring for Patient #7 on 11/03/2010 was not available for interview.