HospitalInspections.org

Based on document review and interview the facility failed to ensure a Registered Nurse followed physician orders and facility policy related to assessments for 2 of 10 patients
(patients #6 and 10).

Findings include;

1. Facility policy titled "Guidelines for Nursing Care" last reviewed/revised January 2018 indicated the following: " ...PROCEDURE: A specific physician order will supersede the minimum frequencies noted ...Routines/Guidelines ...Vital Signs - HOU [High Ops Unit] ...Vital signs (TPR [temperature, pulse, respirations], BP [blood pressure], SAO2 [oxygen saturation]) ...Every 4 hours and with change in condition ...."

2. Review of patient #6's medical record indicated the following:
(A) The patient had a physician order for vitals every 4 hours with start date of 4/8/18 at 8:00 p.m. and no stop date. Admit diagnosis of acute and chronic respiratory failure.
(B) The medical record lacked documentation for vital signs every 4 hours for the following dates and times:
4/9/18 at 12:00 a.m., 4:00 a.m. and 6:52 p.m.
4/10/18 at 1:15 a.m. and 5:15 a.m.
4/11/18 at 2:34 a.m.
4/12/18 at 3:30 a.m. and 9:44 p.m.
4/13/18 at 3:11 a.m., 7:11 a.m. and 8:26 p.m.
4/14/18 at 2:26 a.m., 12:23 p.m., 4:23 p.m. and 8:57 p.m.,
(C) The medical record lacked documentation of blood pressure and oxygen saturation assessed or documented
on 4/9/18 at 2:52 p.m.
(D) The medical record lacked documentation of temperature assessed or documented on 4/9/18 at 8:08 p.m., 4/9/18 at 9:15 p.m.,4/12/18 at 2:15 p.m., and 5:44 p.m., 4/13/18 at 4:26 p.m., 4/15/18 at 7:45 a.m. and 11:51 p.m., 4/19/18 at 6:43 p.m., 4/21/18 at 7:35 a.m., 4/23/18 at 11:36 p.m. and 4/24/18 at 3:20 a.m.
(E) The medical record lacked documentation of temperature and blood pressure assessed or documented on 4/10/18 at 10:58 a.m. and 10:34 p.m., 4/11/18 at 5:33 a.m., 4/12/18 at 4:59 a.m. and 11:31 p.m. 4/13/18 at 8:06 a.m. and 10:56 p.m., 4/14/18 at 5:34 a.m., 8:23 a.m., 4/17/18 at 8:25 p.m., 4/20/18 at 9:48 a.m. and 11:14 p.m.
(F) The medical record lacked documentation of diastolic blood pressure and oxygen saturation assessed or documented on 4/11/18 at 12:27 p.m. and 4/21/18 at 8:19 a.m.
(G) The medical record lacked documentation of the temperature and oxygen saturation assessed or documented on 4/13/18 at 11:50 a.m. and 4/20/18 at 12:00 p.m.
(H) The medical record lacked documentation of temperature and respirations assessed or documented on 4/20/18 at 3:50 p.m.

3. Review of patient #10's medical record indicated the following:
(A) The patient had a physician order for vital signs every 4 hours with a start date of 4/5/18 at 12:00 a.m. and no stop date. Admit diagnosis of acute on chronic respiratory failure.
(B) The medical record lacked documentation for vital signs every 4 hours for the following dates and times:
4/5/18 at 3:00 a.m. and 8:30 p.m.
4/6/18 at 12:30 a.m. and 4:30 a.m.
4/7/18 at 5:14 p.m.
4/8/18 at 3:30 a.m., 6:19 p.m. and 10:19 p.m.
4/9/18 at 2:19 a.m. and 3:30 p.m.
4/10/18 at 4:15 a.m. and 12:12 p.m.
(C) The medical record lacked documentation of temperature assessed or documented on 4/6/18 at 11:30 p.m.
(D) The medical record lacked documentation of blood pressure and temperature assessed or documented on 4/7/18 at 11:32 p.m., 4/8/18 at 10:41 a.m. and 4/9/18 at 11:37 a.m.

4. During an interview with A1 (Director of Quality Management) on 4/25/18 at 6:15 p.m., he/she verified lack of documentation of complete vitals every 4 hours as ordered by the physician for patient #6.

5. During an interview with A3 (Chief Clinical Officer) on 4/25/18 at 7:50 p.m., he/she verified lack of documentation of complete vitals every 4 hours as ordered by the physician for patient #10.

Based on document review and interview, the facility failed to ensure nursing staff were educated and competent in the care of a patient with an arterial line prior to the patient's admission to the facility for 10 of 10 Registered Nurses whom cared for patient #2. (#N1, N2, N3, N4, N5, N6, N7, N8, N9 and N10)

Findings include;

1. Facility policy titled "Clinical Staff Competency" last reviewed/revised 11/2016 indicated the following: "...POLICY: Vibra Hospital of Fort Wayne has established and implements a mechanism for evaluating the competency of clinical staff to ensure that each employee is capable of performing the duties to which he/she is assigned per organizational, state, and federal requirements. Clinical staff competencies are designed to establish and maintain a patient care environment that promotes the well-being of patients, visitors, and staff. Competency measurements consist of current licensure, experience in specialty area, knowledge base, essential skills, and behavior. Behaviors are the linking of knowledge and skills adjusted to patient needs. Definitions: A. Competence is defined by three elements: a specific knowledge base, skills in using equipment and performing procedures, and behaviors that integrate critical thinking and standards to meet the patient's needs and achieve desired outcome ...
PROCEDURE: 1. Directors and Managers will establish competency standards based on the characteristics of the patients, the services provided, risk assessment, frequency of occurrence and equipment used. 2. All competency skills checklists must be approved through the Education Department prior to use. ...3. Leaders are responsible to that competence of all staff is assessed, maintained, improved, and demonstrated for the duration of employment. 4. Competency will be measured against established standards, and during designated intervals. 5. Learning activities may consist of self-study modules, review of policy/procedures, hands-on experience with preceptor or qualified observer. 6. Competence may be established but is not limited to any of the following: a. Performance, knowledge or skills observed, verified, and evaluated by a qualified observer, preceptor, or educator. b. Observation of ongoing competent performance. c. Certification. d. Testing. ...9. Staff assignments are based on their education, experience, licensure and assessment of current competence. 10. Staff for whom certain competencies have not been established may be assigned patient care responsibilities in that area when appropriate supervision is available ...."

2. Job description titled "Chief Clinical Officer - LTAC [Long Term Acute Care]" last reviewed/revised 5/2017 indicated the following: POSITION SUMMARY: Responsible for directing and facilitating the activities of nursing and clinical services. Assumes an active leadership role in the hospital's decision making structure and process. Ensuring and facilitates competence of the clinical staff, appropriate staffing for patient care, and clinical program development. ...Assures appropriate staff for the acuity of the patients. Works closely with Physicians to address patient care needs and enhance patient care systems. Promotes the facility through active involvement and participation in external and internal activities concerning health care services. POSITION SUPERVISORY RESPONSIBILITIES: Supervises the following positions: Manages and directs designated clinical departments, which may include, but are not limited to, nursing ...and staff development ...."

3. Job description titled "Nurse Supervisor - LTAC" last reviewed/revised 2/2015 indicated the following: POSITION SUMMARY: ...Responsible for personnel, management, and coordination of nursing service activities for the scheduled working shift, in accordance with established philosophy, objectives and policies of the hospital. The supervisor works with employees and other managers to develop systems and procedures necessary for daily operations, and provides training, information and support to solve problems and accomplished assigned objectives. POSITION SUPERVISORY RESPONSIBILITIES: Supervises: Nurses and Nursing Support Staff. ...JOB FUNCTION: ...Facilitates staff development of all levels of nursing employees in conjunction with the Nurse Educator ...."

4. Job description titled "Registered Nurse - LTAC" last reviewed/revised 2/2017 indicated the following: POSITION SUMMARY: ...Specific components of the Registered Nurse role include demonstrating clinical competence; managing patient care; improving quality of care; ...utilizing professional skills; fulfilling responsibilities of the role of the hospital; and developing clinical expertise per specialty ...."

5. Review of patient #2's medical record on 4/24/18 at 5:25 p.m., indicated the following:
The patient was admitted on 3/27/18 at 2055 hours and expired via terminal wean on 3/29/18 1524.
" ...Nursing ICU [Intensive Care Unit] Admission Assessment ...Date: 03/27/2018 Time: 20:56 [hours] ...Comment: ART LINE IN RIGHT GROIN, LINE ZERO AND GOOD WAVE FORM, PRESSURE BAG ON NS [Normal Saline] 500 ML BAG ...."
" ...Patient Care Notes ...3/29/18 11:10 [hours] ...Right Artial [Arterial] line is leveled and zero ...."

6. Review of #N1, N2, N3, N4, N5, N6, N7, N8, N9 and N10's (Registered Nurses) personnel records and training transcripts beginning on 4/25/18 at 12:08 p.m. with A4 (Human Resource Manager) and A8 (Nurse Educator) lacked documentation of any completed competencies related to arterial line education.

7. During an interview with A3 (Chief Clinical Officer) on 4/24/18 at 11:15 a.m., he/she indicated the facility admits patients with PICC (peripherally inserted central catheter) lines, central lines, and peripheral lines. A1 indicated the facility does not admit patients with arterial lines and has not admitted patients with arterial lines during the time period of 3/25/18 to 4/24/18.

8. During an interview with N2 (Unit Supervisor) on 4/24/18 at 1:45 p.m., he/she indicated the unit currently had no patients with arterial lines. N2 indicated has had one arterial line in the last year and it was approximately 2 months ago. N2 indicated the patient with the arterial line was admitted with it.

9. During an interview with A8 on 4/24/18 at 3:00 p.m., she indicated the facility typically does not accept patients with an arterial line. Facility normally always ask that it is discontinued or addressed prior to arrival to the facility. A8 indicated he/she had just found out a couple of weeks ago after the patient had expired that there was a patient admitted with an arterial line. A8 verified it was a problem and he/she had not verified the nursing staff competency related to the arterial line.

10. During an interview with A3 on 4/24/18 at 3:05 p.m., he/she indicated the facility has the capabilities and equipment to care for a patient with an arterial line. A3 verified he/she was unaware there was a patient admitted with an arterial line until A8 had mentioned in their interview on 4/24/18 at 3:00 p.m. A3 verified the facility does not accept patients with an arterial line.

11. During an interview with A5 (Chief Marketing Officer) on 4/24/18 at 3:10 p.m., he/she indicated they were unaware of any patients admitted with an arterial line.

12. During an interview with A8 on 4/24/18 at 3:15 p.m., he/she indicated arterial line training and competency was not part of the annual training or department specific training/competencies even on the HOU (High Ops Unit). He/she indicated on the HOU department specific competencies there was a section on arterial lines, but he/she always marked it N/A (not applicable) because the facility did not accept patients with arterial lines and so it did not apply. A8 indicated he/she was informed of a patient who was admitted with an arterial line a couple of weeks ago in an informal meeting. A8 was unable to state the date, who was in the meeting or what the meeting was about.

13. During an interview with A7 (Clinical Liaison Registered Nurse) on 4/25/18 at 12:40 p.m., he/she indicated they unaware patient #2 had a femoral arterial line. He/she indicated they do not obtain admissions orders prior to admission, but does notify the physician. A7 verified Facility #2 does not accept/admit patients with arterial lines, because they are not trained on them and arterial lines are not part of their competencies. A7 indicated he/she was a staff nurse at Facility #2 prior to taking the position of Clinical Liaison.

14. During an interview with A8 on 4/25/18 at 3:30 p.m., he/she verified nursing staff are not provided arterial line training/education because the facility does not admit patients with arterial lines.

15. During an interview with A3 on 4/25/18 at 7:45 p.m., he/she verified patient #2's medical record that the patient had an arterial line while inpatient at the facility.

Based on document review and interview, the facility failed to ensure a complete and accurate medical records which included ensuring the patients had a physician order to admit inpatient for 4 of 10 (Patients #2, 6, 7, 9) a discharge order for 1 of 10 patients (Patient #10) or a physician order for a femoral arterial line for 1 of 10 patients who were admitted inpatient. (Patient #2)

Findings include;

1. Facility policy titled "Medical Record Documentation Requirements LTCH [Long Term Care Hospital] and IRF [Inpatient Rehabilitation Facility]" last reviewed/revised April 2018 indicated the following: POLICY: All medical records will contain documentation to substantiate care and treatment provided. PROCEDURE: 7.The inpatient admission order contains the statement: a. LTAC - Admit as an inpatient to (name of facility) ...16. Discharge order ...."

2. Review of patient #2's medical record indicated the following:
(A) The patient was admitted on 3/27/18 at 2055 hours.
(B) " ...Nursing ICU [Intensive Care Unit] Admission Assessment ...Date: 03/27/2018 Time: 20:56 [hours] ...Comment: ART LINE IN RIGHT GROIN, LINE ZERO AND GOOD WAVE FORM, PRESSURE BAG ON NS [Normal Saline] 500 ML BAG ...."
" ...Patient Care Notes ...3/29/18 11:10 [hours] ...Right Artial [Arterial] line is leveled and zero ...."
(C) The medical record lacked a physician order to admit inpatient and a physician order related to the patient's right femoral arterial line.

3. Review of patient #6's medical record indicated the following:
(A) The patient was admitted on 4/8/18 at 1706 hours.
(B) The medical record lacked a physician order to admit inpatient or admit to ICU when the patient was transferred from medical/surgical area to the HOU [High Ops Unit] on 4/17/18.

4. Review of patient #8's medical record indicated the following:
(A) The patient was admitted on 4/11/18 at 1418 hours.
(B) The medical record lacked a physician order to admit inpatient.

5. Review of patient #9's medical record indicated the following:
(A) The patient was admitted on 4/12/18 at 2035 hours.
(B) The medical record lacked a physician order to admit inpatient.

6. Review of patient #10's medical record indicated the following:
(A) The patient was admitted on 4/4/18 at 2116 hours and discharged to home on 4/10/18 at 1659 hours.
(B) The medical record lacked a physician order to discharge the patient to home.

7. During an interview with A3 on 4/25/18 at 5:56 p.m., he/she indicated patient #6 had no order to admit to inpatient at the facility or an admit to inpatient once the patient was transferred from the medical/surgical area to the HOU on 4/17/18. He/she indicated the patient was transferred due to being placed on a Cardizem drip and should've had a physician order to admit to inpatient intensive care (HOU) unit.

8. During the medical records review beginning on 4/24/18 at 4:00 p.m. with A3 (Chief Clinical Officer), he/she verified the information in the patients #2, 6, 8, 9 and 10's medical records.

9. During an interview with A3 on 4/25/18 at 7:45 p.m., he/she verified patient #2's medical record that the patient had an arterial line while inpatient at the facility.