**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and record review the facility failed to ensure non-employee/travel licensed nurses who are working in the hospital are adequately supervised and evaluated of the clinical activities, which occur within the responsibility of the nursing services in 1 of 10 sample patients (Patient #5).
The findings included:
Patient #5 (MDS) dated [DATE], with complaints of Chest Pain, Weakness, and Hypertension for the last 3 days. The patient's history included underlining dementia and a fall one week prior. She was triaged for a possible Stroke Alert but she did not have the deficits to qualify for a Stroke Alert. The emergency department physician examined her and had her admitted to telemetry. The admitting physician had accepted the patient and given orders for telemetry. There was no bed available in telemetry, so a nurse from the telemetry unit was sent to care for the patient in the emergency department until the patient could be transported to telemetry. The nurse who was assigned to care for this patient, on 01/31/18 at 7:00 AM, is a non-employee/travel nurse.
The travel nurse stated that she was assigned to 5 patients. These patients were all in the emergency department hallway. She stated the nurse, whom she was relieving, told her that Patient #5 had a rough night, confused throughout the night and trying to climb out of the bed. The nurse had spent a lot of time with the patient because she was so confused. When she received report, the patient had fallen asleep. Within the hour, she was able to wake the patient and let her know that breakfast was there. The patient looked at her and said no to breakfast, I am tired. She stated that given the fact the patient had been up most of the night, she did not see this as something to be concerned about at the time as the patient had a reason to be tired and worn-out.
The patient's daughter arrived at the hospital about 9:30 AM. The daughter was trying to wake her mother up and said the patient does not seem to be herself. She told the daughter the patient had a rough night and did not sleep much. She stated they attempted to arouse the patient and her blood sugar and vitals were checked. The travel nurse stated another nurse passed by when this was occurring, stopped, and helped her check the patient's blood sugar. She stated that she does not know who the nurse is. She stated the patient was not connected to telemetry when she was with the patient. She did not know the admitting physician's orders are in effect when given and the orders included the patient was to be on telemetry.
The travel nurse stated she and this other nurse agreed to call a Rapid Response. The code tracker log revealed the Rapid Response was called on 01/31/18 at 11:10 AM and the Stroke Code was called on 01/31/18 at 11:15 AM. This log does not indicate who called these codes. The travel nurse stated that she does not know who called the Rapid Response. She stated that she has never called a Rapid Response. She stated that once the patient was taken to CT scan and from there to the Intensive Care Unit, she was not involved with the patient.
The travel nurse stated that she remembers documenting vital signs on this patient and agreed that she did not document the Rapid Response or anything that occurred from that time on. She stated that she now realizes she should have documented and signed off on the patient, and will do so in the future. She could not account for why she did not follow through with documenting the nursing notes into the record.
Review of the travel nurse's documentation failed to include the Rapid Response call, patient's status, interventions, and signing off in the medical record. Review of the record revealed the only documentation in the medical record is from the physician who responded to the Rapid Response and Stroke Code.
The Director of Progressive Care & Telemetry, who had interviewed and agreed to have the travel nurse work on the telemetry unit, could not confirm the travel nurse had training or experience calling a Rapid Response or Stroke Alert Code and subsequently assisting with these.
The Patient Safety Officer confirmed that she and the Vice President Regulatory Compliance had reviewed Patient #5's medical record and interviewed the travel nurse who cared for the patient when the patient required a Rapid Response and Stroke Alert Code. They concluded the travel nurse failed to document any nursing notes including the change in the patient's condition, interventions that were taken, and sign off on the medical record when the patient was transferred to the Intensive Care Unit.
The Corporate Program Manager stated this travel nurse will be placed on the Do Not Utilize list.
Violation Name: PATIENT RIGHTS: NOTICE OF RIGHTS(A-0117)
Based on facility document review, staff interviews and review of the facility's policy and procedure for transferring patients, it was determined the facility failed to ensure each patient's next of kin or designated representative was notified when initiating a transfer of a patient on 1 of 10 sampled patient (Patient #4).
The findings included:
Medical record reviews conducted on 05/02/17, the patient was transferred from the 4th floor to the 5th floor, to be monitored on the telemetry unit, a higher level of care. The receiving nurse noted the patient was alert and oriented and her call light was within reach. The record failed to reveal the patient's family or responsible party was notified.
Interview with the Chief Nursing Officer, on 08/22/17 at approximately 3:32 PM, revealed when they transfer patients to another room on the same floor, they do not notify the patient's family or responsible party. When they transfer a patient to a different floor or when the patient has experienced a change of condition, they notify the patient's family or responsible party.
Review of the Policy & Procedure for Transferring a Patient reveals the patient's family will be notified when the patient is transferred to a higher level of care.
Interview with the Director of Progressive Care and Telemetry Units, on 08/24/17 at approximately 2:00 PM, he stated they transferred the patient to the telemetry unit to be monitored more closely and regularly. He confirmed the record did not indicate the patient's family or responsible party was notified of the patient's transfer to the 5th floor telemetry unit.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, clinical record, and facility policy review, it was determined the facility failed to ensure an appropriate plan of care, assessment and treatment free of medication errors, in 1 of 10 Patients (Patient #1), as evidenced by a medication, Keppra, being administered to Patient #1 when there is evidence in the clinical record that Patient #1 has an allergy to Keppra.
The findings include:
Review of the electronic clinical record of Patient # 1 indicates he was admitted to this acute care Medical Center on 7/25/12 through the 10/25/12, at which date he was discharged to a skilled nursing facility (SNF). Patient #1 is a [AGE] year old male with an admission diagnosis of Cardiac Arrest.
Patient #1 was living in an assistant living facility (ALF) were he was found un-responsive in cardiac arrest. He was transported to this Medical Center by emergency medical services (EMS) to the emergency room .
The emergency department (ED) Physician examination dated 7/25/12 at 10:16 AM revealed that a previous record acquired from another Medical Center indicates allergies in the past to: Keppra, Erythromycin, Macrolide, Zithromycin, Lovenox, and Aspirin.
During the interview on 12/3/12 at1:18 PM with the quality assurance manager, she was given a copy of the patient ' s record. This record review reveals Patient #1 was admitted to the Intensive care unit (ICU) on 7/25/12. Patient #1 has a previous medical history of; cardiac arrest prior to arrival, cardiac arrhythmia, hypertension, seizures, mild renal insufficiency, urinary tract infections (UTI), and dyslipidemia.
Review of the Physician's admission orders dated 7/25/12 at 1:02 PM revealed a medication to prevent seizures; Keppra 500 mg intravenous (IV) every 12 hours, was ordered. The medication administration record (MAR) indicates Keppra was given on 7/25/12 at 4:26 PM once, and discontinued on 7/25/12 at 6:49 PM.
The further electronic clinical record indicates no adverse effect was incurred from this one dose of Keppra, and a Physician order to discontinue Keppra was acquired in a timely manner.
The Vice President of Regulatory compliance (VPRC) was interviewed on 12/4/12 at 11:45 AM, she was given and electronic record of the emergency department (ED) Physician ' s history and physical (H&P) of Patient #1. This document indicates Patient #1 has past history of allergies to the medication Keppra. The VPRC acknowledged that the Pharmacy tracking system did not automatically communicate this allergy noted in the ED H&P to the Pharmacy admission scanning document system. She stated she did not know why the allergy for Keppra was not listed when the Keppra was administered to Patient #1 on 7/25/12 at 4:26 PM, even though this medication Keppra was scanned by the administration nurse before given the Keppra and no allergies to Keppra were identified by the pharmacy scanning computer records.
The VPRC further stated she believed the Pharmacy electronic system should have forwarded the allergy from the ED H&P to the current allergy listing and does not know why it did not. The VPRC upon inquiry states the facility is currently investigating why the documented allergy noted in the ED H&P did not flow to the admission records pharmacy medication allergies section, and that information technology is presently investigating this lack of communication of Patient #1 ' s allergies.
Review of the facility policy and procedures (P&P) entitled Medication administration and documentation indicates on page 2, section 4, line a: To administer medication appropriately, the administrating person must know the patient ' s diagnosis and the disease involved, and any allergies the patient has should be clearly marked on the chart, on the MAR and on an allergy band applied to patient ' s wrist. The VPRC and the Quality assurance Manager stated after review of the clinical record that this communication of allergies must have not been present due to the nurse administration of the medication, after scanning the medication Keppra and the Patient ' s wrist ID band.