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Based on record review and interview, the hospital failed to assess, document assessments, and inform the physician of continual changes in the patient's condition in order to allow medical decisions to be made in one (Patient #15) of 20 records reviewed. This failure resulted in Patient #15's continued rectal bleeding for seven hours prior to the patient's transfer to another facility. The patient died within five hours of the transfer.

Refer to Tag A-0395

Based on clinical record review and staff interview,the hospital failed to ensure that a complete and accurate medical record was maintained for five (Patient # 6, 9, 10, 15 and 18) of 20 record reviewed.


This failed practice:


a. Allowed Patient #15 to have continued rectal bleeding for seven hours prior to the patient's transfer to another facility. The [atient died within five hours of the transfer.


b. Provided no evidence of patient care provided to Patient #18.


b. Potentially increased pain and discomfort for patients due to lack of accurately documenting the patient's pain assessment and response to pain medications or interventions for Patients #6, 9, and 10).


See Tag A-0449

Based on record review and interview, the hospital failed to assess, document assessments, and inform the physician of continual changes in the patient's condition in order to allow medical decisions to be made in one (Patient #15) of 20 records reviewed.


This failed practice resulted in Patient #15's continued rectal bleeding for seven hours prior to the patient's transfer to another facility. The patient died within five hours of the transfer.


Finding:


Document titled "Patient Care Record" dated 01/05/19 with hourly timing between 7:00 am 01/05/19 through 6:00 am 01/06/19 shows the following:

a. Hourly rounds and bed rest were documented as performed between 7:00 pm and 6:00 am; however, the patient was transferred to another facility at 12:30 am on 01/06/19.

b. Activity was marked hourly as "sleeping" between midnight and 6:00 am on 01/06/19; the patient was transferred to another facility at 12:30 am on 01/06/19.

c. Head of bed elevated was marked "as tolerated" between 7:00 pm and 6:00 am; the patient was transferred to another facility at 12:30 am on 01/06/19.

d. Safety precautions of bed in low position, call light in reach and side rails up were marked hourly between 7:00 pm and 6:00 am; the patient was transferred to another facility at 12:30 am on 01/06/19.



Documentation from the medical record on 01/05/19 through 01/06/19 included the following:

12:50 pm: Nursing notes document Dr. Levine ordered fleets enema at Patient #15's representative's request and it was given. There was no order signed by the physician; the only documentation of an order was in the nursing notes.

1:40 pm: Nursing notes document Dr. Levine ordered KUB (an x-ray of the kidney, ureter and bladder) for stool. There was no signed order by the physician; the only documentation of an order was in the nursing notes.

5:00 pm: Nurse noted blood, copious amount, and Dr. Levine and the charge nurse notified. BP 99/68. There was no documentation the charge nurse assessed the patient.

5:45 pm: Documentation of telephone order from Dr. Levine to obtain I-stat Chem-8, assess hemoglobin (Hgb). Repeat in one hour.

6:00 pm: I stat Chem-8 was done by charge nurse.

6:09 pm: I stat Chem-8 showed Hgb* (via Hct) of 16.7 and hematocrit (Hct) of 49, the patient was on 11 liters of oxygen via flow by.

6:30 pm: Nursing notes documented, report received by evening nurse (LPN) that the day nurse (RN) had reported rectal bleeding bright red in color. Evening nurse assessed the patient with the day nurse and noted the presence of dark reddish runny substance coming out of patient's rectum. Staff O (RN charge nurse) suggested the evening nurse call Dr. Levine and ask to hold the patient's scheduled Eloquis (a blood thinning medication). "Spoke with Dr. Levine, an order given to hold Eloquis dose tonight". There was no signed order by the physician; the only documentation of an order was in the nursing notes. There was no documentation of the amount of rectal bleeding in the medical record or the amount of rectal bleeding conveyed to the physician.

7:29 pm: I stat Chem-8 showed Hb* (via Hct) of 16 and Hct of 47; there was no indication patient was on oxygen at this time.

8:00 pm: Nursing note stated there was large amount of reddish dark runny liquid from rectum. The patient was given Zofran IV for nausea and stomach discomfort. CBC was ordered by the charge nurse for the next morning. There was no documentation the RN charge nurse assessed the patient; there was no documentation the physician was notified of the large amount of blood.

9:00 pm: Nursing note stated patient pad changed and a large amount of dark liquid noted. There was no documentation that the RN charge nurse was notified of the continued "large amount of dark liquid" or that the RN charge nurse assessed the patient; there was no documentation the physician was notified of the continued "large amount of dark liquid".

9:30 pm: Telephone order was noted for the patient to have CBC the next morning.

11:00 pm: Nursing notes documented "no change. More reddish thick liquid discharge rectally". There was no documentation that RN charge nurse was notified of the continued "reddish thick liquid discharge" or that the RN charge nurse assessed the patient; there was no documentation the physician was notified of the continued "more reddish thick liquid discharge".

11:00 pm: Pads changed. BP 121/50.

12:15 am: A telephone order to discharge patient to St. Francis ER

12:30 am: Nursing notes documented the patient's daughter insisted the patient be sent to a bigger hospital. The evening nurse "consulted with (Staff R) PA". The RN charge nurse called Dr. Levine to inform him of patient's daughter's decision and Dr. Levine ordered the patient discharged via a telephone order. There was no documentation that Staff R assessed the patient or provided care to the patient.

1:21am: Patient arrived at St. Francis Hospital emergency room. Vital signs on arrival: BP 88/76, P: 34, R: 40

1:41 am: Hgb: 15.2; patient tested positive for MDRO (multi-drug resistant organism). Clinical impression by St. Francis emergency room physician was GI (gastrointestinal) hemorrhage

5:36 am: Patient died.


Staff L, PAM Specialty CNO (02/06/19 at 2:30 pm) stated, she would have expected to see documentation of events that transpired between 5:00 pm and the time of the Patient #15's transfer.


Staff P, the day charge nurse (02/07/19 at 8:47 am) stated, she checked on Patient #15 frequently and that Patient #15 "kept saying he was ready to die". There was no documentation of the frequent checks or the Patient #15's suicidal ideation comments in the record; there were no actions taken in response to the comments.


Staff O, the night charge nurse (02/07/19 at 8:41 am) stated, that Patient #15 "had a lot of blood" and that "I didn't document" any of this and would expect the primary nurse to document observations and care provided by all staff.


Staff R, the Physician Assistant (02/07/19 at 10:52 am) stated, he/she was not aware of Patient #15 until he/she was asked to sign the discharge papers; he/she never saw Patient #15. Staff R was available from 7:00 pm through 7:00 am each night for patient care; Staff R was not consulted regarding Patient #15.


Dr. Levine (2/7/19 at 3:15pm) stated, he did not recall nursing specifically saying "massive amount of blood" when discussing Patient #15; he did acknowledge bleeding and ordered the Eloquis to be held that evening. He did not see Patient #15 that evening.


A document titled "Post Acute Out Huddle" for Patient #15 was reviewed. The huddle convenes within 24 hours of an "acute out" and involves the following members to complete a set of questions: DSI, CEO, DON, Respiratory, Therapy, DQM and Case Management. There was no involvement, or interviews, with the staff involved in the care of Patient #15. The DQM (2/8/19 at 8:15 am) stated, she does not usually interview staff involved, only goes by the documentation in the medical record. Documentation from the medical record was reviewed by the "Post Acute Out Huddle" and the recommendation of what could be done to prevent this from occurring again was: None.

Based on record review and interview, the hospital failed to:

A. Document assessment and care of the patient (Patients #15 and 18)

C. Ensure the patients' pain and response to pain medications were documented in the patient's medical record (Patients #6, 9, and 10)


Finding:


Patient #15:

Document titled "Patient Care Record" dated 01/05/19 with hourly timing between 7:00 am 01/05/19 through 6:00 am 01/06/19 shows the following documentation:

a. Hourly rounds and bed rest were documented as performed between 7:00 pm and 6:00 am; the patient was transferred to another facility at 12:30 am on 01/06/19.

b. Activity was marked hourly as "sleeping" between midnight and 6:00 am on 01/06/19; the patient was transferred to another facility at 12:30 am on 01/06/19.

c. Head of bed elevated was marked "as tolerated" between 7:00 pm and 6:00 am; the patient was transferred to another facility at 12:30 am on 01/06/19.

d. Safety precautions of bed in low position, call light in reach and side rails up were marked hourly between 7:00 pm and 6:00 am; the patient was transferred to another facility at 12:30 am on 01/06/19.



Documentation from the medical record on 01/05/19 through 01/06/19 included the following:

12:50 pm: Nursing notes documented Dr. Levine ordered fleets enema at Patient #15's representative's request and it was given. There was no order signed by the physician; the only documentation of an order was in the nursing notes.

1:40 pm: Nursing notes documented Dr. Levine ordered KUB for stool. There was no signed order by the physician; the only documentation of an order was in the nursing notes.

5:00 pm: Nurse noted blood, copious amount, and Dr. Levine and the charge nurse notified. BP 99/68. There was no documentation the charge nurse assessed the patient.

6:30 pm: Nursing notes documented report received by evening nurse (LPN) that the day nurse (RN) had reported rectal bleeding bright red in color. Evening nurse assessed the patient with the day nurse and noted the presence of dark reddish runny substance coming out of patient's rectum. Staff O (RN charge nurse) suggested to the evening nurse to call Dr. Levine and ask to hold the patient's scheduled Eloquis (a blood thinning medication). "Spoke with Dr. Levine, an order given to hold Eloquis dose tonight". There was no signed order by the physician; the only documentation of an order was in the nursing notes. There was no documentation of the amount of rectal bleeding in the medical record or the amount of rectal bleeding conveyed to the physician.

8:00 pm: Nursing note stated there was large amount of reddish dark runny liquid from rectum. The patient was given Zofran IV for nausea and stomach discomfort. CBC was ordered by the charge nurse for the next morning. There was no documentation the RN charge nurse assessed the patient; there was no documentation the physician was notified of the large amount of blood.

9:00 pm: Nursing note stated patient pad changed and a large amount of dark liquid noted. There was no documentation that the RN charge nurse was notified of the continued "large amount of dark liquid" or that the RN charge nurse assessed the patient; there was no documentation the physician was notified of the continued "large amount of dark liquid".

12:30 am: Nursing notes documented the patient's daughter insisted the patient be sent to a bigger hospital. The evening nurse "consulted with (Staff R) PA". The RN charge nurse called Dr. Levine to inform him of patient's daughter's decision and Dr. Levine ordered the patient discharged via a telephone order. There was no documentation that Staff R assessed the patient or provided care to the patient.


Staff L, PAM Specialty CNO (02/06/19 at 2:30 pm) stated, she would have expected to see documentation of events that transpired between 5:00 pm and the time of the Patient #15's transfer.


Staff P, the day charge nurse (02/07/19 at 8:47 am) stated, she checked on Patient #15 frequently and that Patient #15 "kept saying he was ready to die". There was no documentation of the frequent checks or the Patient #15's suicidal ideation comments in the record; there were no actions taken in response to the comments.


Staff O, the night charge nurse (02/07/19 at 8:41 am) stated, that Patient #15 "had a lot of blood" and that "I didn't document" any of this and would expect the primary nurse to document observations and care provided by all staff.


A document titled "Post Acute Out Huddle" for Patient #15 was reviewed. The huddle convenes within 24 hours of an "acute out" and involves the following members to complete a set of questions: DSI, CEO, DON, Respiratory, Therapy, DQM and Case Management. There was no involvement, or interviews, with the staff involved in the care of Patient #15. The DQM (2/8/19 at 8:15 am) stated, she does not usually interview staff involved, only goes by the documentation in the medical record. Documentation from the medical record was reviewed by the "Post Acute Out Huddle" and the recommendation of what could be done to prevent this from occurring again was: None.



Patient #18

A 75 year old female admitted for surgical wound and ostomy management. Patient #18 was admitted on 08/28/18 and discharged 09/05/18. On the day of discharge, there was no day shift assessment documented; there was no repositioning documented; there was no care documented for Patient #18. There was a brief note at 6:30 am that Patient #18's respirations were even and unlabored. At 9:45 am, there was an order written and noted in the chart to transfer Patient #18 to St. Francis Hospital.


40336



Patients #6, 9, and 10


Hospital Policy Nursing #38, "Pain Management" (01/19) stated, post acute medical plans, supports and coordinates activities and resources to assure that each patient report of pain was recognized and addressed appropriately. This included but was not limited to: assessment and regular reassessment of pain, and within one hour of intervention.


Hospital Policy Nursing #36, "Nursing Documentation" (09/18) stated, pain symptoms indicated current status of pain control, intensity and location of pain. If pain was daily, complete the pain comfort assessment guide.


A review of medical records showed:


1. Patient #6, a 75 year old male was admitted for a bone infection. On 02/01/19 at 1:25pm under the medical record heading "Pain Assessment and Intervention" there was no documentation of a pain assessment or pain rating. The medical record stated oral medication was administered at that time. There was no documentation of a pain reassessment under the heading of "Evaluation of Effectiveness".


2. Patient #9, a 58 year old female was admitted for acute respiratory failure and a broken hip. On admission, Patient #9 had an acute pain rating of 6 out of 10 (10 being the worst pain). There was no documentation of an intervention for the pain and no reassessment of the pain.


3. Patient #10, a 65 year old male was admitted for acute respiratory failure with low oxygen levels in the blood. On admission, Patient #10 had a chronic, generalized pain rating of 10. The relief measure showed a medication of fentanyl drip and there was no documentation of a pain reassessment.


The RN Nurse Manager (02/06/19 at 11:45am) stated pain should be assessed regularly and reassessed after an intervention.