HospitalInspections.org

Based on observation and interview, the facility failed to ensure patient and visitor safety via properly preventing and/or containing COVID-19, in that,

Staff did not offer or require the surveyor to wear a N-95 mask into the COVID Unit's two COVID positive patients' rooms; and

The COVID Unit Room #3's Intravenous pump alarm was not heard from the hallway outside the closed door.

Findings included

During a tour of the COVID unit with the infection control nurse and nurse manager on 11/04/2020 ending at 4:04 PM, the nurse and surveyor prepared to enter Room #3 and #2. No N-95 mask was offered for the surveyor protection. Once inside the Room #3, the intravenous pump alarm could be heard. The nurse was not prepared for the alarms and opened the door to ask someone to get her a saline flush for the line.

During an interview on 11/04/2020 ending at 4:04 PM, Personnel #6 was asked about not being able to hear the alarm at the desk or in the hallway. Personnel #6 replied, "I just know when it will be going off. She just has antibiotic drips, not continuous." Personnel #6 was asked and stated they did not allow visitors for the COVID Unit patients. They may visit from outside the window.

During an interview on 11/04/2020 after the tour of the COVID Unit, Personnel #4 was informed the staff did not offer or require the surveyor to wear a N-95 mask into both COVID positive patient rooms. Personnel #4 stated, "I thought about it at the time. CDC (Center for Disease Conrol) does say it is okay to be in the area (nurses station, hallway) with a regular mask, but in patient rooms a N-95 mask."

The facility's 9/24/2020 revised "COVID-19 Policies" required, "limit the risk of exposure of COVID-19...use of proper PPE (Personal Protective Equipment)...N-95 mask if available..."

Based on record review and interview, the facility failed to ensure supervisory and staff personnel to each nursing unit to provide, when needed, an immediately available registered nurse to provide care for any patient, in that,

*for 20 of 24 shifts (11/03/2020 PM, 11/02/2020 PM, 11/01/2020 AM, 10/31/2020 AM, 10/30/2020 AM and PM, 10/29/2020 AM & PM, 10/28/2020 AM & PM, 10/27/2020 AM & PM, 10/26/2020 AM & PM, 10/25/2020 AM & PM, 10/24/2020 AM & PM, and 10/23/2020 AM & PM) there was no immediately available RN due to the house supervisor being assigned primary care patients and some shifts being total care without a patient care technician; AND

*for 3 of 24 shifts (10/29/2020 AM, 10/28/2020 AM, and 10/27/2020 AM) the "Daily Assignment Sheet" reflected the AM House Supervisor was the only RN and was assigned patients.

Findings included

The facility had two (2) nursing units. One upstairs and one downstairs.

The 11/03/2020 "Daily Assignment Sheet" reflected the PM House Supervisor was assigned patients.

The 11/02/2020 "Daily Assignment Sheet" reflected the PM House Supervisor was assigned one patient.

The 11/01/2020, and 10/31/2020 "Daily Assignment Sheet" reflected the AM House Supervisor was assigned two patients - one was Patient #1, a Critical Observation patient, Acuity 5 (highest), on a ventilator, and multiple critical care drips who decompensated on 11/01/2020 and was sent as an acute transfer to a local emergency room.

The 10/30/2020, 10/29/2020, and 10/28/2020 "Daily Assignment Sheet" reflected the AM and PM House Supervisors were assigned patients. As well as, there being no AM Patient Care tech requiring Total Care for the House Supervisor patients.

The 10/29/2020, 10/28/2020, and 10/27/2020 "Daily Assignment Sheet" reflected the AM House Supervisor was the only RN.

The 10/27/2020, 10/26/2020, 10/25/2020, 10/24/2020, and 10/23/2020 "Daily Assignment Sheet" reflected the AM and PM House Supervisors were assigned patients.

The facility's September 2019, approved "Nursing Staffing Plan" required, "minimum of two registered nurses supervising ...RN supervisor/Charge nurse will be immediately available to assist with and supervise patient care and to respond to emergency situations ..."

During an interview on 11/05/2020 ending at 11:28 AM, Personnel #9 was asked if the house supervisor has patients often. Personnel #9 stated, "Sometimes."

During an interview on 11/05/2020 ending at 12:21 PM, Personnel #1 was asked about the House Supervisor having patients assigned to them. Personnel #1 stated, "when census was low they would have 1-2 patients sometimes. We try not to do it."

During an interview on 11/05/2020 ending at 1:25 PM, Personnel #8 was asked if house supervisor has patients assigned. Personnel #8 stated, "Yes. Mostly in the dayshift. I had a critical care patient, too. They had a respiratory issue about the same time. It was a very hard day."

Based on record review and interview, the facility failed to ensure the registered nurse supervised and evaluated the care for each patient, in that,

1 of 1 patient (Patient #1) did not have physician directed titration orders for the Levophed titration being completed;

1 of 1 patient (Patient #1) did not get a STAT Chest X-Ray and STAT ABG (Arterial Blood Gas) ordered via telephone during an episode of respiratory distress; and

1 of 1 patient (Patient #1) did not have the 11/01/2020 6:00 AM PEEP 10 order implemented. (Positive End-Expiratory Pressure)

Findings included

Patient #1's record reflected a 11/01/2020 13:23 PM Rapid Response with the patient subsequently leaving the facility via ambulance at 15:25 PM. Nursing documented O2 Sats (Oxygen Saturation Rate) as low as 80%, Bagged, and Respiratory Rate (Total Rate) as high as 32."

***There was no documented physician directed titration orders for the (decreasing amount of medication) Levophed titration being completed by the nursing staff throughout the patient admission.

Levophed was decreased on 11/01/2020 from 10.3 to 8.3 mcg/min at 12:00, one and one half hours before respiratory distress that sent the patient out acutely.

Levophed was decreased on 11/01/2020 from 8.3 to 6.3 mcg/min at 14:00, a half hour after the patient had respiratory distress that sent the patient out acutely.

During an interview on 11/05/2020 ending at 12:21 PM, Personnel #1 was asked about the respiratory distress incident and the Levophed titration. Personnel #1 confirmed the findings and stated there was a Mandatory nursing meeting set up and skills fair for drip education due to the titration findings.

***There were no documented orders or results completed for the orders (STAT Chest X-Ray and STAT ABG) Personnel #12 stated he ordered via telephone on 11/01/2020 when the staff reported acute respiratory distress. There was no documented reason or clarification for nursing not completing these orders and writing them in the record.

During a telephone interview on 11/05/2020 ending at 3:02 PM, Personnel #12 was asked about Patient #1. Personnel #12 stated, "They called me because the patient was unstable. BP (blood pressure) dropping and desating (oxygen Saturation Rate dropping). I said STAT Chest X-ray and Stat ABG. They called back, no results, but that the patient was not better, looking worse, afraid she was going to code, I told them to send her out."

During an interview on 11/06/2020 at 2:00 PM, Personnel #10 was asked about the Rapid Response and sent out of Patient #1 on 11/01/2020. Personnel #10 stated, "I initiated RRT (Respiratory Response Team). I found her in distress. Nurses called the doctor he said to increase peep, but the (new) order was what she was already on - 15. My recollection ABG in an hour after the change, but she was already on the setting and we did not take an hour before we had to get order to send out - so no ABG was drawn. Personnel #10 was asked about the doctor saying he ordered a STAT Chest X-Ray and Stat ABG. Personnel #10 stated, "I did not talk to the doctor."

***There were no documented orders for the difference between the last Physician ventilator orders (11/01/2020 0600 decrease Peep to 10) and the 11/01/2020 documented ventilator settings (PEEP +5) provided and the verbalized (PEEP 15) provided by the dayshift respiratory therapist.

The Ventilator documentation changed from 11/01/2020 at 04:00 to 07:20 (change of respiratory personnel),
"0400 0720 1125 1320
Mode AC AC AC AC
PS/IPAP -- 10 10 10
PEEP 15 +5 +5 +5
Total Rate 26 25 25 26."

The 11/01/2020 physician order reflected, "06:00 per (name of doctor) decrease PEEP to 10."

During record review and interview on 11/05/2020 ending at 1:40 PM, Personnel #11 reviewed the respiratory documentation. Personnel #11 confirmed the above findings.

During an interview on 11/06/2020 at 2:00 PM, Personnel #10 was asked about the Rapid Response and sent out of Patient #1 on 11/01/2020. Personnel #10 stated, "Nurses called the doctor he said to increase peep, but the order was what she was already on."

Based on record review and interview, the facility failed to ensure legible medical records for each patient, in that,

Patient #1's 11/01/2020 nurse notes, physician notes and respiratory notes had to be read/interpreted during review.

Findings included

The medical record for Patient #1 was primarily written/paper. Some dictated notes were present. Much of the written documentation (11/01/2020 nurse notes, two physician notes, respiratory notes) was illegible to the surveyor and for those who were asked to read the content of the written notes.

During an interview on 11/05/2020 at 11:28 AM, Personnel #9 slowly read her written notes aloud for interpretation.

During record review and interview on 11/05/2020 ending at 1:40 PM, Personnel #11 reviewed/interpreted the respiratory documentation.

During an interview on 11/05/2020 ending at 12:21 PM, Personnel #1 was asked about the readability/legibility of the written nurse and physician notes. Personnel #1 stated, "Yes. It is hard sometimes to read them."

The facility's 11/28/2018 revised "Hospital Chart Completion" policy required, "The legibility of all chart entries is a critical to patient care as the timeliness. Therefore, all entries in the medical record must be legible ..."

Based on record review and interview, the facility failed to ensure compliance with medical staff policies for the provision of respiratory care services including physician orders, in that,

3 of 6 daily (11/01/2020 and 10/31/2020) documentation sheets were not completed to evidence standard of care provided for a ventilator patient (Patient #1) including prevention of pressure injury (location and mark of Endotracheal tube); and

Patient #1's new PEEP order on 11/01/2020 at 6:00 AM was not carried out. There was no order for the PEEP ventilator setting that was documented for Patient #1.

Findings included

Patient #1's 11/01/2020 physician order reflected, "06:00 per (name of doctor) decrease PEEP to 10." There was no indication this order was carried out/followed.

Patient #1's ventilator documentation changed from 11/01/2020 at 04:00 to 07:20 (change of respiratory personnel),
"0400 0720 1125 1320
Mode AC AC AC AC
PS/IPAP -- 10 10 10
PEEP 15 +5 +5 +5
Total Rate 26 25 25 26"

There were no documented orders for the difference between the last Physician ventilator orders (11/01/2020 0600 decrease Peep to 10) and the 11/01/2020 documented ventilator settings (PEEP +5) provided and verbalized (PEEP 15) provided by the dayshift respiratory therapist.

Patient #1's record reflected a 11/01/2020 13:23 PM Rapid Response with the patient subsequently leaving the facility via ambulance at 15:25 PM. Nursing documented O2 Sats (Oxygen Saturation Rate) as low as 80%, Bagged, and Respiratory Rate (Total Rate) as high as 32."

There was no daily documentation by respiratory of the Patient's lip/mouth injury/lip ulcer.

There was no documentation by respiratory on 11/01/2020 on the "Respiratory Therapy" Form; and the "Ventilator/BIPAP Daily Flow Sheet" after 13:20 PM. The O2 Sat documented at 92% and there was no indication the patient had to be bagged.

The top of the "Respiratory Therapy" Form was left completely blank including, "Emergency Trach @ bedside? []Yes []No ETT/Trach Size and Type:______ Secure/Repositioned? []Yes []No" for 11/01/2020, 10/31/2020, 10/30/2020, and 10/29/2020.

There was no documentation/completely blank/no patient label on page two (2) of the "Ventilator/BIPAP Daily Flow Sheet" including size of the tube, mark of the lip line, cuff pressure, placement verified, repositioned, secured, Ambu-bag and safety documentation for 11/01/2020, and 10/31/2020.

During record review and interview on 11/05/2020 ending at 1:40 PM, Personnel #11 reviewed the respiratory documentation. Personnel #11 confirmed the above findings.

During an interview on 11/05/2020 ending at 2:12 PM, Personnel #7 stated, "when she arrived at the room respiratory was bagging the patient. At some point, respiratory had her bag the patient while she went to get supplies and checked tubing. The patient was put back on the vent. They called 911." Personnel #7 stated, "the ET Tube was in the middle of the mouth."

During a telephone interview on 11/05/2020 ending at 3:02 PM, Personnel #12 was asked about Patient #1. Personnel #12 stated, "They called me because the patient was unstable. BP (blood pressure) dropping and (oxygen Saturation Rate falling/not enough oxygen) desating. I said STAT Chest X-ray and Stat ABG (Arterial Blood Gas). They called back, no results, but that the patient was not better, looking worse, afraid she was going to code, I told them to send her out." Personnel #12 was asked about a ulcer on her mouth. Personnel #12 stated, "It was a difficult intubation. It was on the bottom lip."

During an interview on 11/06/2020 at 2:00 PM, Personnel #10 was asked about the Rapid Response and sent out of Patient #1 on 11/01/2020. Personnel #10 stated, "I initiated RRT. I found her in distress. (described care given which was not documented) Nurses called the doctor he said to increase peep, but the order was what she was already on. My recollection a ABG in an hour after the change, but she was already on the setting and we did not take an hour before we had to get a order to send her out - so no ABG was drawn." Personnel #10 was asked about the doctor saying he ordered a STAT Chest X-Ray and Stat ABG. Personnel #10 stated, "I did not talk to the doctor."

The facility's May 2019, revised "Respiratory Therapy Daily Documentation" required, "All appropriate blanks shall be completed for every treatment...Mechanical Ventilations/shall be charted on the treatment flowsheet, with treatments being charted on the back of the form...flow sheets shall be labeled..."

The facility's 11/28/2018, revised "Hospital Chart Completion" policy required, "fully and accurately reflect a patient's care and are completed..."