You are cross-covering 80 floor patients overnight and a nurse calls you for one of them because her monitor keeps having the finding shown above. You look at the sign-out given and it's a 40 year old woman admitted for abdominal pain. The last set of labs were:
WBC 11, Hgb 11, Hct 31, Plts 210
Na 134, K 4.1, Cl 101, HCO3 22, BUN 12, Cr 0.9, Glucose 220, Ca 10, Mg 1.7, Phos 4
UA with 1+ leukocyte esterase and 5-10 WBC.
You stop by her floor and jot a quick order in the chart on your way to the call room. An hour later, you hear a rapid response being called for this patient. When you run to the bedside, you hear the nurse saying, "She isn't responsive. Her vitals are HR 62, BP 102/68, RR 6, O2 sat 94% on room air."
Challenge: This illustrates a JCAHO (Joint Commission on Accreditation of Healthcare Organizations) violation...what happened?
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