HospitalInspections.org

Based on interview and record review, the facility failed to ensure the facility's policies and procedures (P&P) were implemented, for five of 20 sampled patients (Patients 7, 9 13, 14, and 20), when:

1. For Patients 7 and 9, the physician was not notified by the nursing staff of the patient's elevated blood pressure (BP, the force of the blood pushing against the walls of the arteries [big blood vessel], normal blood pressure is 120/80) readings on multiple days, in accordance with the physician's order;

2. For Patient 9, the physician was not notified by the nursing staff of the patient's elevated BP readings on September 8, 2025. In addition, the medication clonidine (medication to lower the BP) was not administered to Patient 9 in accordance with the physician's order;

3. For Patient 13, the nurse did not notify the physician of SpO2 (oxygen saturation, the amount of oxygen in the blood, normal is 92 percent [%] or greater) less than or equal to 90;

4. For Patient 14, the physician was not notified by the nursing staff Patient 14's respiratory rate (RR, the number of breaths a person takes per minute, normal is 12 to 20) was greater than or equal to 30, in accordance with the physician's order; and

5. For Patient 20, RN 2 removed a pulmonary artery (PA, a large blood vessel from the heart leading to the lungs) catheter (a thin flexible tube inserted into a large vein and threaded into the heart and the pulmonary artery used to monitor heart and lung function) two hours and 15 minutes prior to the ordered time by the doctor.

These failures had the potential to delay treatment and worsen Patients 7, 9 13, 14, and 20's health conditions.

Findings:

1. On November 17, 2025, at 10:30 a.m., a review of Patient's 7's record was conducted with the Registered Nurse Quality Analysis (RNQ) 3. A facility document titled, "Inpatient History & [and] Physical" dated September 9, 2025, was reviewed. The document indicated Patient 7 was admitted to the facility on September 9, 2025, and presented to the emergency department (ED) with a chief complaint (symptoms which led a patient to go to the ED) of weakness in both legs for the past two months and had an admitting diagnosis of metabolic acidosis (when acid builds up in the blood). The document indicated Patient 7 stated he was drinking alcohol prior to his arrival to the ED and his last alcohol drink was 12 hours prior to his arrival to the ED. The document indicated Patient 7 stated he usually drinks four to six shots of alcohol a day.

An untitled facility document, dated September 2, 2025, was reviewed. The document indicated, "...Notify MD [physician] parameters [specific and measurable guidelines or limits used to monitor a patient's health and guide clinical decisions] for vital signs [vs, measurements of your body's basic functions, including temperature, pulse (heart rate), respiratory rate (RR, normal is 12 to 20 breaths per minute), oxygen saturation, and BP]...Order Details...Frequency...Until discontinued... SBP [systolic blood pressure, the top number in a blood pressure reading, measures the pressure in the arteries when the heart beats and pumps blood, normal is 120] less than or equal to 85...SBP greater than or equal to 160..."

A facility document titled, "Flowsheet History," dated August 6, 2025, through September 5, 2025, was reviewed. The document indicated, "...09/02/2025 [September 2, 2025] 0645 [6:45 a.m.]...[BP] ...116/103...09/04/25 [September 4, 2025]...171/85...09/05/2025 [September 5, 2025] 0408 [4:08 a.m.]...161/90...09/05/2025 0515 [5:15 a.m.]...161/107..."

There was no documented evidence the physician was notified by the nursing staff notified of Patient 7's elevated blood pressure readings on September 2, 4, and 5, 2025.

On November 17, 2025, at 1:06 p.m., an interview was conducted with RNQ 3. RNQ 3 stated there was no documentation the nurse notified the physician of Patient 7's elevated blood pressures. RNQ 3 stated the nurse did not follow the physicians' order in reporting Patient 7's vital signs that were abnormal.

2. On November 17, 2025, at 11 a.m., a review of Patient's 9's record was conducted with RNQ 3. A facility document titled, "Inpatient History & Physical," dated September 6, 2025, was reviewed. The document indicated Patient 9 was admitted to the facility on September 6, 2025, and presented to the ED with a chief complaint of syncope (the medical term for fainting, which is a brief, temporary loss of consciousness caused by a sudden drop in blood flow to the brain) episodes and a urinary tract infection (UTI, an infection anywhere in the urinary system).

a. An untitled facility document, dated September 5, 2025, was reviewed. The document indicated, "...Notify MD for vitals...Order Details...Frequency...Until discontinued...Order Questions...SBP less than or equal to 85...SBP greater than or equal to 160..."

An untitled facility document, dated August 8, 2025, through September 8, 2025, was reviewed. The document indicated, "...09/08/2025 [September 8, 2025] 1519 [3:19 p.m.]...[blood pressure, normal is 120/80] ...188/77...09/08/2025 1613 [4:13 p.m.]...174/77..."

There was no documented evidence the physician was notified by the nursing staff of Patient 9's elevated blood pressure readings on September 8, 2025.

b. An untitled facility document, dated September 6, 2025, was reviewed. The document indicated, "...cloNIDine (CATAPRES) Tablet 0.1 MG [milligram, unit of measurement]...Ordered Dose 0.1 mg...Frequency: Every 4 [four] hours PRN [as needed] for high blood pressure...Duration 3 [three] days...Scheduled Start Date/Time: 09/06/2025 [September 6, 2025] 1849 [6:49 p.m.]...End Date/Time: 09/08/25 1955 [7:55 p.m.]...Admin [sic, administration] Instructions: The indicated use for this medication is: PRN for SBP > [greater than] 180..."

There was no documented evidence clonidine medication was administered on September 8, 2025, when Patient 9's BP readings were 188/77 at 3:19 p.m., and 174/77 at 4:13 p.m.

On November 17, 2025, at 11:15 a.m., an interview was conducted with RNQ 3. RNQ 3 stated there was no documentation the nurse notified the physician of Patient 9's elevated BP radings on September 8, 2025. RNQ 3 stated the nurse did not follow the physicians' order in reporting blood pressures which were abnormal. RNQ 3 stated the nurse did not administer clonidine medication when Patient 9 should have received a dose on September 8, 2025, in accordance with the physician's order.

3. On November 17, 2025, at 2:17 p.m., a review of Patient 13's record was conducted with the Chief Nursing Informatics Officer (CNI). An untitled and undated facility document was reviewed. The document indicated, "...Admit Date: 11/14/25 [November 14, 2025]...Adm [sic, Admitting] Diagnosis [the identification of the nature of an illness]: chronic osteomyelitis [a long-lasting infection of the bone]..."

A facility document titled, "Inpatient History & Physical," dated November 14, 2025, was reviewed. The document indicated, "...CHIEF COMPLAINT: cellulitis (an infection of deep layers of the skin)...with chronic osteomyelitis..."

A facility document titled, "Order Report," dated November 14, 2025, was reviewed. The document indicated, "...Notify MD for vitals signs...SpO2 less than or equal to 90..."

An untitled and undated facility document was reviewed. The document indicated, "...11/16 [November 16, 2025] 0701 [7:01 a.m.] - [to] 11/17 [November 17, 2025] 0700 [7 a.m.]...1641 [4:41 p.m.]...SpO2...88..."

There was no documented evidence the physician was notified of Patient 13's SpO2 of 88 on November 16, 2025, at 4:41 p.m.

On November 17, 2025, at 2:40 p.m., an interview was conducted with the CNI. The CNI stated there was no documentation from the nursing staff regarding Patient 13's condition. The CNI stated there was no documentation the physician was notified of Patient 13's SpO2 of 88 on November 16, 2025.

On November 17, 2025, at 11:36 a.m., an interview was conducted with RN 1. RN 1 stated if there are "parameters" for vital signs set by the physician and "anything that falls outside of the parameters in the order," the RN should communicate it with the doctor.

4. On November 18, 2025, at 9:42 a.m., a review of Patient 14's record was conducted with the CNI. An untitled and undated facility document was reviewed. The document indicated, "...Adm Diagnosis...Acute respiratory failur* [sic, failure] [a sudden and life-threatening condition where the lungs cannot get enough oxygen]..."

A facility document titled, "Inpatient History & Physical," dated April 21, 2025, was reviewed. The document indicated, "...CHIEF COMPLAINT: shortness of breath..."

A facility document titled, "Order Report," dated April 21, 2025, was reviewed. The document indicated, "...Notify MD for vitals...RR greater than or equal to 30..."

An untitled and undated facility document was reviewed. The document indicated, "...04/27 [April 27, 2025] 0701 [7:01 a.m.] - 04/28 [April 28, 2025] 0700 [7 a.m.]...2300 [11 p.m.]...resp rate [RR]...30...0000 [12 a.m.]...34..."

There was no documented evidence the physician was notified of Patient 14's RR of 30 on April 27, 2025, at 11 p.m., and the RR of 34 on April 28, 2025, at 12 a.m.

On November 18, 2025, at 11:12 a.m., an interview was conducted with the CNI. The CNI stated there was no documentation the physician was notified of Patient 14's RR of 30 on April 27, 2025, at 11 p.m., and RR of 34 on April 28, 2025, at 12 a.m. The CNI stated there were documentation from the nursing staff regarding Patient14's condition. The CNI stated the nurse should have contacted Patient 14's physician to notify him Patient 14's elevated RR in accordance with the physician's order. The CNI stated it is important to notify the physician because "if the patient is declining, the physician should be made aware of the patient's condition."

On November 17, 2025, at 11:36 a.m., an interview was conducted with RN 1. RN 1 stated if there are "parameters" for vital signs set by the physician and "anything that falls outside of the parameters" in the physician's order, the RN should communicate it with the doctor.

5. On November 18, 2025, at 2:02 p.m., a review of Patient 20's record was conducted with the CNI. An untitled and undated facility document was reviewed. The document indicated, "...Admit Date: 11/8/25 [November 8, 2025]...Adm Diagnosis: Syncope and collapse..."

A facility document titled, "CARDIOLOGY INPATIENT ADMISSION HISTORY & PHYSICAL," dated November 8, 2025, was reviewed. The document indicated, "...CHIEF COMPLAINT/REASON FOR ADMISSION: Inferior STEMI [ST (a specific part of the heart's electrical activity) Elevated Myocardial Infarction (heart attack), a specific type of heart attack where the bottom part of the heart muscle is damaged because its blood supply is blocked]..."

A facility document titled, "Discharge Summary," dated November 16, 2025, was reviewed. The document indicated, "...Admission Diagnosis: STEMI...Procedure: On 11/12/2025 [November 12, 2025] the patient [Patient 20] underwent Coronary Artery Bypass Grating times 3 [Triple Bypass, a heart surgery which creates new paths for blood to flow around three blocked coronary arteries (heart blood vessels)]..."

A facility document titled, "Order Report," dated November 12, 2025, was reviewed. The document indicated, "...Discontinue Swan -Ganz [a pulmonary artery catheter]...on 11/12/25...D/C [Discontinue] at 0600 [6 a.m.]..."

A facility document titled, "Plan of care," dated November 13, 2025, authored by RN 2, was reviewed. The document indicated, "...Patient had a desaturation event [an event where the amount of oxygen in a person's blood drops to a level which is too low] following PA catheter removal at approximately 0345 [3:45 a.m.]..."

A facility document titled, "Physician Notification," dated November 13, 2025, was reviewed. The document indicated, "...PA [Physician Assistant] notified in person at 0500 [5 a.m.] of Patient's [Patient 20's] respiratory decline starting after laying flat for PA removal..."

On November 18, 2025, at 2:52 p.m., an interview with RN 3 was conducted. RN 3 stated they should always follow the physician's orders. RN 3 stated she would "never adjust the time" indicated in the doctor's order. RN 3 stated it is important to follow the ordered time when a PA catheter needs to be removed "so that everybody is on the same page and everybody is in aggreance [sic, agreement] that the patient is stable" and the patient does not need additional "hemodynamic monitoring [a way nurses use measurements to see how well a patient's heart is pumping and how well the blood is flowing through the body]."

An article published online by the National Institute of Health (a nationally recognized organization for research) titled, "The contemporary pulmonary artery catheter. Part 1: placement and waveform [study of graphical representations of signals like electrical activity] analysis," dated February 10, 2021, was reviewed. The article indicated, "...the classical pulmonary artery catheter has...its clinical use for hemodynamic monitoring...Adequate catheter placement and detailed understanding...are a prerequisite for the correct interpretation of physiology [the study of how the human body works] and pivotal in clinical decision making [the process health professionals use to gather and interpret patient data, diagnose conditions, and determine the best course of action for a patient's treatment]..."

A facility's P&P titled, "Patient Care Manual," dated December 5, 2023, was reviewed. The policy indicated, "...RN progress notes...Change in patient condition...Communication with the provider...The nurse must document and use the "Provider Notification" smart text [a standardized text template used by clinical staff]...all ...change in patient condition must be communicated to the provider in-person or by phone..."