Gundersen Lutheran Medical Center

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50644 Based on record review and interview, facility nursing staff failed to react and respond to an acute change in medical condition for 1 of 1 (Patient #2) patients with acute changes in a total universe of 10 patient records reviewed. Findings include: A review of facility policy #17947211 titled, “Code Blue and Medical Response Plan, GL-6129” last revised 5/20/2025 revealed, “To provide effective recognition, notification and response in the event of an acute change in patient condition or emergency situation as outlined in this policy...1. Adult Patient: Change in patient status or a concern about care... A review of Patient #2’s medical record revealed: -On 6/1/2025 at 7:50 AM: “Restraint loosened. Patient took left mitt off.” Patient #2 remained in right mitt restraint. -On 6/1/2025 at 10:00 AM: “MRT (Medical Response Team) called. Patient #2 expired at 10:05 AM.” -On 6/1/2025 at 10:29 AM, “Progress Notes” written by Physician N revealed, “MRT called this AM. [Patient #2] was seen prior to this, about an hour before, and at this time he was much more alert that the day prior but somewhat agitated and delirious ...While doing wound cares, [Patient #2] was complaining of being thirsty. He was aggressive with staff and was able to grab some Vaseline at bedside for wound cares and try to eat it. Staff did their best to take this away from the patient. He did get some of this in his mouth. They were attempting to then suction this out when he began feeling more SOB (short of breath). Soon, he became cyanotic and unresponsive. MRT was called. Rhythm strips c/w (consistent with) asystole and despite bag mask attempts, saturations did not improve as well. Given he was DNR/DNI, attempts at CPR/intubation were not made. On exam he was pulseless and had no respirations.” -On 6/2/2025 at 9:40 AM, “Progress Notes” written by RN F revealed, “Patient was confused, agitated, and combative, took off his left mitt restraint and refused to put it back on with multiple attempts by this writer. He got a hold of Vaseline bottle sitting on bedside table and ate it. Took this writer multiple attempts to retrieve Vaseline bottle from patient. Patient went into respiratory distress later, this writer tried to suction out the Vaseline without success, patient then became cyanotic and unresponsive, MRT called.” A review of facility adverse event #189622 written by RN F on 6/2/2025 related to Patient #2 revealed, “...at 0852 (8:52 AM)...This writer did notice that there was a tub of Vaseline sitting on patient’s tray table next to him on his left side...this writer witnessed the patient grab the tub of Vaseline with his left hand. This writer stopped flushing the NG, resumed the tube feed, and told patient to give the Vaseline back...This writer went and attempted to pull the tub out of the patient’s left hand by pulling on the tub, but the patient had a strong grip on it and would not let it go...It is noted that this writer noticed patient’s mouth was shiny and there was some shiny substance on the patient’s chest. This writer suspect that patient may have ingested some Vaseline, but this writer was not 100% sure as it was not witnessed by this writer...around 0908 (9:08 AM)...writer witnessing the patient grabbing onto the Vaseline...this writer noticed the patient removing the Vaseline cover and then witnessed the patient, with the four fingers on his left hand, scooped up a large amount of Vaseline (approximately two tablespoon full), lowered his whole body down towards his left hand and ate the Vaseline off his fingers...This writer told [CNA G] that she did not need help because this writer did not want patient to be more agitated by having more people involved...At this point, this writer believes the shiny substance that was seen on patient’s mouth and chest was probably Vaseline and that this was probably the second time the patient ingested Vaseline..., the patient stated he could not breath and wanted to get suctioned...around 0953 (9:53 AM) writer went to suction the patient...This writer noticed that patients mouth was coated with Vaseline and when writer went to suction patient’s mouth, this writer was able to suction a small amount of Vaseline which ended up coating the inside of the yanker making is difficult to suction further The patient became more anxious as it looked like he could not clear out his throat. This writer got some water and cleared out the yanker and then resume to suction the patient’s mouth as possible. Nothing was being suctioned out, the patient started struggling to breath, this writer hit the Staff Assist button on the wall and soon help arrived and MRT called.” During an interview on 6/19/2025 at 10:15 AM with Manager E, he stated that RN F was in Patient #2’s room “almost continuously” from 9:05 AM until Patient #2 expired at 10:05 AM. Manager E stated that CNA G was in and out of Patient #2’s room during this time as well. Manager E stated that a Rapid Response was called at 10:00 AM, and they found that there was a “large gap of time that she had no answers for, and that there was a lack of response from RN F.” Manager E stated that “it is the scope of the RN to determine if action needed to happen quicker, and in this situation it was felt strongly that action could have been taken sooner.” Manager E stated that there is a Hospitalist on site 24/7 and RN F should have got the physician at the bedside sooner to assess the patient. Manager E stated that there was communication with the physician earlier that morning regarding switching restraints from mitt to wrist, but no conversation or communication about Patient #2 ingesting Vaseline. During an interview on 6/19/2025 at 11:24 AM, CNA G that around 9:45 AM she walked by Patient #2’s room and heard commotion, so she stepped into Patient #2’s room. CNA G stated that she saw the blue cap of the Vaseline container in Patient #2’s left hand, and both wrist restraints in place. CNA G stated she stayed in the room to help get the cap from Patient #2, but never saw the tub of the Vaseline. She stated she cleaned up Patient #2’s left arm because it was covered in Vaseline. CNA G stated that Patient #2 was talking to them the whole time she was cleaning him up and never thought he was at risk for aspiration. CNA G stated she then looked at Patient #2’s face and noticed residue on his lips, and then Patient #2 stuck out his tongue to show her the Vaseline on it. CNA G stated that she told RN F that Patient #2 had Vaseline in his mouth, and RN F told her that she would clean it up. CNA G stated that she never saw the actual tub of Vaseline, so didn’t know how much was gone. CNA G stated that RN F told her she was good to leave the room and that she would clean up the Vaseline on Patient #2, so she left the room and only a few minutes later heard the call for rapid response to Patient #2’s room. CNA G stated she was told to grab Yankauer suctions and bring them to Patient #2’s room, and when she arrived Patient #2 was not breathing and multiple Yankauer suctions were used, and each one was clogged with Vaseline after use. CNA G stated that she wished she would have got help sooner or notify a Physician or Team lead on the floor when she realized Patient #2 ingested the Vaseline. She stated she did get coached and debriefed on the situation and now knows that she should have reported the situation sooner to someone and knows to escalate the situation if something similar happens in the future.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 43264 Based on record review and interview the facility failed to ensure that a restraint assessment was completed every 2 hours for patients in restraints per facility policy in 3 of 10 patient medical records reviewed (Patients (Pt.) #2, 4, 5) out of a total universe of 10 medical records reviewed. Findings include: A review of facility policy, titled “Restraints and Seclusion, GL-6014”, last approved 09/18/2023, revealed: “...Protective (Nonviolent) restraints prevent interference with medical treatment, promote medical healing, or prevent the patient from exiting the bed...Special considerations...Four side rails...RN is to document “not in use” every 2 hours when the patient is out of bed...PROTECTIVE RESTRAINT...B. Nursing...2. Ongoing Monitoring a. The following assessment areas are documented in the Restraint Flowsheet: i. Psychological status ii. Skin and circulation iii. Range of motion iv. Food and fluids v. Elimination vi. Physical comfort a. At these time frames: i. On initiation ii. Every 2 hours until discontinued i. a 30 minute extension window is acceptable if needed...Discontinuation...ii. When the RN determines restraints are no longer required, the restraints should be removed, and the order discontinued. iii. Document “discontinued” in the Protective Restraint Status row...” Review of Pt. #2’s medical record revealed an admission on 05/27/2024 for Pneumoperitneum (air or gas in abdmoninal cavity). Pt. #2 was a current inpatient. The record revealed bilateral wrist restraints were ordered and in use on 05/27/2024. Review of the restraint flowsheet revealed no assessments documented on 05/27/2024 from 3:30 PM until 8:00 PM - a period of 4 hours 30 minutes between restraint assessments. Review of Pt. #4’s medical record revealed an admission from 05/26/2024 - 05/30/2024 for C1 cervical fracture. The record revealed an order for the use of all 4 side rails up (as requested by patient/family) on 05/26/2024 & 05/27/2024 with no assessments documented from 6:00 PM on 05/26/2024 until 9:26 AM on 05/27/2024 - a period of 14 hours 26 minutes between restraint assessments. Review of Pt. #5’s medical record revealed an admission on 05/24/2024 for C6 cervical fracture. Pt. #5 was a current inpatient. The record revealed bilateral wrist restraints were ordered and in use on 05/27/2024. Review of the restraint flowsheet revealed no assessments documented on 05/27/2024 from 4:00 AM until 7:45 AM - a period of 3 hours 45 minutes between restraint assessments. The above findings were confirmed on 05/30/2024 at 3:30 PM during medical record review with Quality & Patient Safety Nurse E who stated that there should have been documentation of either “not in use or discontinued” on the restraint flowsheet if the patients were out of bed or restraints were removed.”