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Based on Record review and interview, it was determined that the facility failed to provide nursing services to meet the needs of 6 of 20 patient records reviewed.

Findings were:

Based on review of medical records, hospital policies and procedures, nursing reference manuals, and staff interviews, the hospital failed to ensure that nursing services were furnished according to acceptable standards of care, as abnormal vital signs were not assessed or monitored as ordered, neurological checks were not assessed, monitored or documented as ordered, and patient teaching for patient controlled analgesia (PCA) pumps was not conducted.
Cross refer - A0395


Based on personnel file review and interview, it was determined that the facility failed to ensure that 1 of 4 nursing personnel had the specialized qualifications and competencies required in their job description.
Cross refer - A0397


Based on record review and interview, it was determined that orders for 2 medications were not complete as required by the facility's policy, and the medications were administered to a patient without the orders being complete.
Cross refer - A0405

Based on record review and interview, the facility failed to conduct a comprehensive investigation for an adverse patient event timely and within the timeframe specified in their policy.

Findings were:

An event occurred during the admission of Patient #12 on 10/16/14, and a root cause analysis (RCA) was conducted. However, upon review of the RCA document it was revealed that the RCA was not conducted until 2/2015, which is beyond the timeframe specified in the facility's policy.

Facility policy, Sentinel Event...POLICY #: QUA.002.01, stated in part, "PROCEDURE:...II...A...The RCA team will begin its analysis as soon as possible, but not to exceed 10 working days of the event identification."

In an interview with Marcia Rose, Quality Director the afternoon of 4/2/14, the above findings were confirmed.

Based on a review of medical records, hospital policies and procedures, nursing reference manuals, and staff interviews, the hospital failed to ensure that nursing services were furnished according to acceptable standards of care, as abnormal vital signs were not assessed or monitored as ordered, neurological checks were not assessed, monitored or documented as ordered, and patient teaching for PCA pumps was not conducted. This was evident in 5 out of 20 patient records reviewed (Patients #9, 10, 13, 17, & 18).

Findings included:

Review of the medical record for Patient #13 revealed an order dated 11/23/14, at 0655, with stop date of 12/2/14, which stated, "Notify MD: Pulse less than 60 or greater than 100. BP Systolic less than 90 or greater than 180. Respirations less than 12 or greater than 24."
There were multiple instances of vital signs for Patient #13 which were out of range with no documentation of MD notification or other nurse intervention, such as respirations documented as 0 (zero) and including the following:

· On 11/23/14, systolic BP documented as less than 90 and pulse greater than 100.

· On 11/24/14, there were more than 20 instances of pulse greater than 100 and more than 10 instances of respirations greater than 24 that were flagged in the medical record.

· 2 instances of respirations documented as 0 (zero) and flagged with no documented assessment, intervention, or recheck of vital signs.

· On 11/25/14, there were more than 15 instances of pulse greater than 100 and 3 instances of respirations greater than 24 that were flagged as abnormal. 4 instances of respirations documented as 0 (zero) with no documented assessment, intervention, or recheck of vital signs. Several instances of respirations documented as less than 12 or greater than 24 with no documented assessment, intervention, or recheck of vital signs.

· On 11/26/14, at 0400, BP was 78/44, (previous BP was 103/41, subsequent at 0700
124/78, 3 hours later) with no recheck of BP documented. At 0700, respirations were documented as 0 (zero), at 1000 respirations documented as 10 and vital signs were not documented again until 1637. At 2000, her BP was 120/94, respirations 14; however at 2100 her respirations were 9, and BP 54/21, flagged in the medical record.

· On 11/27/14, vital signs were documented as follows: 0100 respirations 9 (flagged); 0300 respirations 10 (flagged) BP 98/38 (flagged); 2200 respirations 9 (flagged); 2300 respirations 10 (flagged).

· On 11/28/14, vital signs were documented as follows: 0200 respirations 10 (flagged); 0300 respirations 8 (flagged); 0500 respirations 0, BP 138/88; 0600 respirations 0 BP 87/23 (flagged); 0700 respirations 4 BP 134/85; 1900 respirations 6 (flagged); 2200 respirations 7 (flagged).

· On 11/29/14, vital signs were documented as follows: 0200 respirations 8 (flagged); 0400 respirations 5 (flagged); 0600 BP 129/72; 0700 BP 157/103 (flagged); 1200 BP 83/56 (flagged).

· On 11/30/14, vital signs were documented as follows: 1200 pulse 107, BP 89/54 (flagged -BP not taken again until 1600); 2000 BP 108/56 (flagged).


Review of the medical record for Patient #9 revealed an order dated 8/30/13, at 1741, with stop date of 9/3/13, which stated, "Notify MD: Pulse less than 60 or greater than 100. BP Systolic less than 90 or greater than 180. Respirations less than 12 or greater than 24."
Review of the record revealed multiple instances of vital signs which were out of range with no documentation of MD notification or other nurse intervention or were flagged as abnormal including the following:

· On 8/30/13, vital signs were documented as follows: 1900 respirations 0; 2000 pulse 53, BP102/49 (flagged), 2100 pulse 56; 2200 pulse 58.

· On 8/31/13, vital signs were documented as follows: 0600 BP 106/42 (flagged); 1010 pulse 59; 1200 respirations 10 (flagged); 1900 pulse 57.

· On 9/1/13, vital signs were documented as follows: 0415 pulse 58; 1000 BP 96/41 (flagged); 2100 10 (flagged).

· On 9/2/13, vital signs were documented as follows: 0100 respirations 27, 0200 BP 89/34 (flagged), 0500 pulse 55.


In an interview with Staff #11, RN, Clinical Informatics Supervisor, the morning of 4/2/14, in the hospital conference room, the surveyor reviewed and confirmed documentation of abnormal vital signs, including respirations documented as "0" (zero) in the medical record. Staff #11 stated that the vital signs are imported directly from the vital sign equipment into the EMR, but the EMR system requires the nurse to click on the vital signs to have them entered, meaning that the nurse was aware of the abnormal (and at times, incorrect) vital signs values that were being entered. Staff #11 confirmed that the nurse should document an assessment after abnormal vital signs, and should especially document accurate vital signs when the vital signs entered in the EMR are presumably not accurate, such as respirations of zero.


Review of hospital policy, Physician Notification of Changes in Patient Condition and Care, Policy # PC.052.02, last revised/reviewed 12/2014, stated in part, "For any patient, for the duration of the hospital stay, the nurse caring for the patient should notify the attending physician and any consultants for patient care and orders related to the following: ...
5. Change in hemodynamics"


Review of the medical record for Patient #9 revealed had orders for Neuro checks every 2 hours entered on 8/30/13, at 1743, stop date 9/2/2013, at 2020.

Review of the medical record revealed that the neuro check flow sheets were not completed in the electronic medical record (EMR) for Patient #9 every two hours as ordered, including the following:

· 8/30/13, completed at 2000, next completed at 0000 (4 hours later)

· 8/31/13, at 0400, next completed at 0745 (3 hours, 45 minutes later)

· 9/1/13, at 0500, next completed at 0745 (2 hours, 45 minutes later)

In addition, one shift did not have neuro checks completed in the EMR flow sheet on 8/31/13. There was a neuro check flow sheet completed at 0745, but the next neuro check flow sheet was not entered until 1900. The nurse failed to document complete neuro checks in the EMR flow sheet; merely documented the following:

· 1000 "Nero (sic) unchanged from previous"

· 1100 " ...pt is here to r/o stroke"

· 1200 "Ongoing assessment unchsanged (sic). Neuro assessment unchanged"

· 1400 "No changed in neuro assessment"

· 1600 "Ongoing assessment unchanged neuro unchanged"

· 1800 "Neuro assessment unchanged"

There was no means to determine what specifically had been assessed during the day shift on 8/31/13 as the required content included in the EMR neuro flowsheet was not documented.


Review of the medical record for Patient #10 revealed an order for neuro checks every hour from 6/19/14, at 2309, through 6/21/14, at 1342. Review of the nursing neuro checks for Patient #10 revealed neuro checks were conducted as ordered every hour with the exception of 6/21/14, when checks were documented at 0400, and the checks were not documented again until 0700 (3 hours later).


Review of Patient #17's Nurses' note dated 2/22/2014, at 11:30 am, reflected that a doctor advised the nursing staff to do neurological checks every hour times 6 hours per Medical Research Council criteria, then every 2 hours.

Review of Patient #17's nursing flow sheet reflected:
· On 2/22/2014, 9:37 am, complete neurological assessment documented.
· On 2/22/2014, 11:30 am, no neuro changes noted, there was no evidence of a neuro assessment.
· On 2/22/2014, 1:05 pm, no neuro changes noted, there was no evidence of a neuro assessment.
· On 2/22/2014, 6:30 pm, no neuro changes noted. There was no evidence of a neuro assessment.

Review of Patient #18's physician's orders dated 3/1/2014, reflected Neuro Assessment- every 2 hours, Instructions- then with scheduled vital signs. Stop after 8 times.
Review of Patient #18's nurses flow sheet reflected:
· On 3/1/2014, 10:00 pm, complete neurological assessment documented.
· 3/2/2014, 7:30 am, complete neurological assessment documented.
· 3/2/2014, 10:00 pm, complete neurological assessment documented.
· 3/3/2014, 12:00 am, no changes noted. (No assessment documented)
· 3/3/2014, 7:15 am, complete neurological assessment documented.


Hospital policy, Nursing Assessment and Reassessment PC.004.01, last revised/reviewed 2/2015, stated, in part, "III. Unit specific Assessment and Reassessment Criteria
A. Adult Intensive Care Unit 1. A comprehensive assessment will be completed by the RN at the beginning of each shift and with each change in RN, the content of which will be defined by the Assessment and Cares flowsheet and plan of care."


Hospital policy, Critical Care Standards of Care PC.025.02, last revised/reviewed 12/2014, stated, in part, "LRMC in accordance with the standards of acute care nursing to safely and competently care for acute care patients and their families will utilize the following: A. Chulay, M. & Burns, S.M. AACN Essentials of Critical Care Nursing, 2010 (2nd)."


The surveyor requested the manual in use for neurological nursing standards of care in use by the LRMC ICU, which was provided by Staff #11, RN, Clinical Informatics Supervisor the afternoon of 4/2/14 in the hospital conference room.


Review of American Association of Critical-Care Nurses, Essentials of Critical Care Nursing revealed the following: "Although there is no single method of performing a neurological evaluation, a systematic, orderly approach offers the best results ....Serial assessments, couple with accurate documentation, allow for detection of subtle changes in neurologic status ....A baseline examination is established and subsequent assessments are compared. At a minimum, serial neurologic assessment includes level of consciousness, orientation, motor response, pupil size, and reaction to light."


In an interview with Staff #11, RN, Clinical Informatics Supervisor the afternoon of 4/2/14, in the hospital conference room, she confirmed the neuro checks which were not completed as ordered. Staff #11 also confirmed that the neuro checks were not documented completely per nursing standards to "allow for detection of subtle changes in neurologic status" by merely documenting "no change" in a progress note. The nurse failed to document the required content included in the EMR neuro check flowsheet for Patient #9 and there was no means to determine what had actually been assessed in this patient with compromised neurological function.

During an interview on 4/1/2015, at 11:25 am, Staff # 11, RN, Clinical Informatics Supervisor confirmed there were no nursing notes to reflect the completion of the ordered hourly neurological checks for patient #17 and every two hour neurological checks for patient #18. Staff # 11 further stated the neurological assessment needed to be completed as the physician ordered and a full assessment is needed to catch small neurological changes in the patient.

Review of the medical record for Staff #13 revealed she had an order for Hydromorphone PCA 50 mg with a loading dose 0.4 mg, PCA dose 0.2 mg, lockout interval 10 minutes, 1 hour limit 1.2 mg, stop after 48 hours. Staff #29, RN documented at 11/23/14, at 1900, that Patient #13 had "Dilaudid PCA at bedside." There was no documented evidence in the medical record that Patient #13 received any education on the PCA pump, despite receiving doses through the PCA pump. Staff #11, RN, Clinical Informatics Supervisor, confirmed that there was no documentation in the education flowsheet for PCA patient education on 4/2/15 in the hospital conference room.


Review of hospital policy, Patient Controlled Analgesia, Policy # PC.044.01, last revised/reviewed 12/2014, stated, in part, "Licensed nursing professions are responsible for ...ensuring that patients are able to safely meet their own needs for pain management through frequent assessment and patient education ...The licensed nursing professional at LRMC will ...document all actions and patient responses appropriately ...Patient Education:

1. Review an appropriate pain rating scale with the patient.

2. Review the principles of PCA use with the patient and family members ...

4. Instruct the patient and family members to report common side effects ...

Patient Preparation: ...

2. Ensure that the patient understands the teaching ...

Documentation should include the following: ...

6. Patient teaching and any reinforcement needed."


Review of the Texas Nurse Practice Act §217.11. Standards of Nursing Practice, stated in part,

(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: ...

(D) Accurately and completely report and document:

(i) the client ' s status including signs and symptoms;

(ii) nursing care rendered;

(iii) physician, dentist or podiatrist orders;

(iv) administration of medications and treatments;

(v) client response(s); and

(vi) contacts with other health care team members concerning significant events regarding client's status;"


These deficient practices had the likelihood to cause harm in all patients admitted with orders for vital signs, neuro checks, and PCA pumps.

The above findings were confirmed in an interview with Staff #1 and Staff #2 the afternoon of 4/2/15 in the hospital conference room.


28460

Based on personnel file review and interview, it was determined that the facility failed to ensure that 1 of 4 nursing personnel had the specialized qualifications and competencies required in their job description.

Findings were:

Review of the personnel record for Staff #12 indicated that 12/18/14, was his last day of orientation as a Critical Care RN. As of the date of the survey Staff #12 had not completed any training in Health Stream, the computer based training program used by the facility that provides training for HIPAA, Infection Control, Emergency Preparedness, Stroke Management, Pain Management, etc. Staff #12 also did not have a current ACLS certification, his prior certification expired in October of 2014.

Review of the job description for the job title, Critical Care RN, stated the following, in part, "Demonstrates Competency in the Following Areas: ...Demonstrates knowledge of cardiac monitoring, identifies dysrhythmias and treats appropriately based upon ACLS protocol ...
Professional Requirements: ...Completes annual education requirements ...Regulatory Requirements: ...Current ACLS and BLS certification."

The above information was confirmed by Staff #11 in an interview on 4/2/15.

Based on record review and interview, it was determined that orders for 2 medications were not complete as required by the facility's policy, and the medications were administered to a patient without the orders being complete.

Findings were:

A facility policy, Titrating Medications ...Policy #:MM.025.01, stated the following, in part, "PURPOSE: To describe the appropriate use and ordering procedures for medication titration orders ...PROCEDURE: I. Orders for medications that require titration must include the desired state the prescriber desires for the patient (i.e., titrate medication to achieve B/P of __/__)."

Review of the medical record for Patient #12 revealed that the patient had 2 medications ordered that were to be administered as continuous/titrated infusions.
The two medications were:

· "Norepinephrine Infusion 4mg/250ml ...Titration Instructions Conc: 16mcg/ml Start @ 0.5-1mcg/min titrate to 2-4mcg/min," this medication was ordered on 10/16/14 and discontinued on 10/18/14.

· "Dopamine Infusion 400mg/250ml ...start @ 2 - 5 mcg/kg/min to a max dose of 20 - 50 mcg/kg/min - cardiac and BP monitoring," this medication was ordered on 10/16/14 and discontinued on 10/26/14.

Both of these orders were telephone orders taken by a nurse and they did not "include the desired state the prescriber desires for the patient (i.e., titrate medication to achieve B/P of __/__)."

Both of these medications were administered to Patient #12 during the time period in which the incomplete orders were active.

The above findings were confirmed in an interview with Staff #4 on 3/31/15.

Based on record review and interview, the facility failed to follow their policies and procedures regarding care in the Emergency Department.

Findings were:

A facility policy, Care and Treatment of the Suspected Stroke Patient ...Policy #: ER.024.02, said the following in part, "PROCEDURE: Presentation: Patient presents with stroke or suspected stroke may qualify for thrombolytic therapy ...Emergent Evaluation: Patients with stroke or suspected stroke are evaluated emergently ...2. CVA PROTOCOL: ...1. A cranial Computer Tomographic scan (CT scan) should be performed within 25 minutes of presentation to the ED."

The facility's position description for the job title "Emergency Department Registered Nurse" stated the following in part, "Demonstrates Competency in the Following Areas:...Uses triage process to ensure timely and appropriate care to patients. Accurately assigns triage categories."

Review of Patient #6's medical record revealed that the patient was triaged by an Emergency Department (ED) nurse at 2:00 PM and numbness and tingling were listed as the reason for visit, yet under the neurological section "no" was selected for the question "Is this patient exhibiting possible stroke-like symptoms?" Patient #6 had a medical screening exam (MSE) by a physician at 2:39 PM and transient ischemic attack (TIA) documented on the problem list. A CT scan was not completed until 3:26 PM.

Review of Patient #20's medical record revealed that the patient was triaged by an ED nurse at 12:54 AM on 11/18/14, the triage document reflected that the patient was not exhibiting possible stroke-like symptoms. A CT scan was not completed until the following day on 11/19/14. After the CT scan, Patient #20 was newly diagnosed with a cerebrovascular accident (stroke).

Patients #6 and #20 were not identified to have stroke-like symptoms during triage and they did not have a CT scan within the timeframe (25 minutes) specified in the facility policy, Care and Treatment of the Suspected Stroke Patient.

The findings in the medical record were confirmed with staff #11.