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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23, Nursing Services, was out of compliance.

A-0395 A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and document review, the facility failed to provide nursing services in accordance with facility protocol and policies. Specifically, the facility failed to ensure registered nurses (RNs) assessed cardiac patients according to facility policy in one of three medical records reviewed (Patients #1). Additionally, staff failed to assess patients according to both facility policy and physician orders after the administration of scheduled medications in two of three medical records reviewed (Patients #1 and #3).

Based on interviews and document review, the facility failed to provide nursing services in accordance with facility protocol and policies. Specifically, the facility failed to ensure registered nurses (RNs) assessed cardiac patients according to facility policy in one of three medical records reviewed (Patient #1). Additionally, staff failed to assess patients according to both facility policy and physician orders after the administration of scheduled medications in two of three medical records reviewed (Patients #1, and #3).

Findings include:

Facility policy:

According to the Assessment Timeframes by Department policy, patients in the intermediate care unit (MCU), will receive an assessment twice in a twelve-hour period, and PRN (as needed) if their condition changes. Patients on the telemetry unit and Med/Surg (medical surgical) unit will receive a full assessment once in a twelve-hour period and focused assessments as needed based on the patient's condition.

1. The facility failed to ensure patients were assessed according to facility protocol and policies.

A. Record review

i. A review of Patient #1's medical record revealed on 12/21/23 the patient was admitted from the emergency department to the MCU (intermediate care unit) for a diagnosis of AFib RVR (an irregular heartbeat where the electrical signaling in the heart is disorganized and causes parts of the heart to beat out of sync).

According to the History and Physical, the provider examined Patient #1 during morning rounds on 12/22/23. The provider documented that Patient #1 would be taking oral diltiazem (a medication that relaxes the blood vessels in the body and lowers heart rate and blood pressure) four times daily starting on 12/22/23, with a plan to monitor Patient #1' s heart rate to ensure the rate stayed controlled without hypotension (abnormally low blood pressure).

A provider's order was written for diltiazem 90 milligrams (mg) four times a day. The order also included instructions to monitor Patient #1's heart rate and blood pressure and to hold the medication if the heart rate dropped below 60 beats per minute, or if the systolic (the top number in a blood pressure that measures the pressure in the arteries) blood pressure dropped below 100. The provider's order instructed the RN to reassess Patient #1's heart rate and blood pressure within two hours after a held dose of medication. If the heart rate and blood pressure were above 60 beats per minute or 100 systolic, the medication was to be administered. If the heart rate was below 60 beats per minute or 100 systolic, the RN was to contact the provider.

Further review of Patient #1's nursing flowsheet revealed a nurse administered an initial dose of oral diltiazem 90 mg at 10:27 a.m., with Patient #1's heart at 91 beats per minute and blood pressure at 114/78. There was no evidence that nursing staff held or administered the remaining three doses of diltiazem ordered for Patient #1 on 12/22/23. From 10:27 a.m. to 7:00 p.m., there was no evidence that staff obtained Patient #1's heart rate or blood pressure to determine if the medication was effective or if the provider should be contacted for vital signs out of the range specified in the provider order.

This was in contrast to provider's order which instructed to administer diltiazem four times daily and to assess the patient's heart rate and blood pressure before and after the medication was administered.

At 7:00 p.m. staff found Patient #1 unresponsive, in asystole (a type of cardiac arrest where the heart stops beating completely). Staff called a code blue (a code used to indicate a patient required resuscitation) and CPR (cardiopulmonary resuscitation) was initiated. After approximately twelve minutes of CPR, a return of spontaneous circulation was achieved. Patient #1 was transferred to the intensive care unit (ICU) and subsequently died on 12/23/23 at 2:59 a.m., after a second cardiac arrest.

An additional review of Patient #1's flowsheets revealed on 12/22/23, the day shift (7:00 a.m. to 7:00 p.m.) nurse completed a full assessment on Patient #1 at 9:08 a.m. From 9:08 a.m. until 7:00 p.m., when the code blue was called, there was no evidence a second full nursing assessment was performed on Patient #1.

This review was in contrast to the Assessment Timeframes by Department policy which read patients in the intermediate care unit (MCU), were to receive an assessment twice in a twelve-hour period, and PRN (as needed) if their condition changed.

ii. A review of Patient #3's medical record revealed on 3/9/24 the patient was admitted from the emergency department to the cardiac unit with the following diagnoses: atrial flutter with rapid ventricular response (an irregular heart rhythm causing the upper chambers of the heart to beat rapidly), cardiomyopathy (a disease that makes it harder for the heart to pump blood), and AICD (a device that can detect a life-threatening, abnormal heartbeat and deliver a shock) discharge.

A further review of Patient #3's medical record revealed on 3/10/24 the provider ordered an intravenous (IV) infusion of amiodarone 360 mg in D5W 200 milliliters (mL) (a medication used to treat life-threatening heart rhythm problems called ventricular arrhythmias). The provider's order for amiodarone included an order to monitor Patient #3's blood pressure at baseline, then every 15 minutes for one hour, then every hour for four hours, then per unit standard of care.

A review of nursing flowsheets revealed a nurse started the amiodarone IV infusion 3/10/24 at 12:42 p.m. Staff documented that Patient #3's blood pressure was 98/57 at 12:45 p.m., 85/50 at 1:00 p.m., 97/54 at 1:15 p.m., 102/60 at 1:00 p.m. At 2 p.m., Patient #3's blood pressure was 102/69. At 4:46 p.m., Patient #3's blood pressure was 99/61. There was no evidence that staff measured Patient #3's blood pressure from 2:00 p.m. until 4:46 p.m. (a period of two hours and 46 minutes) while the Amiodarone was infusing.

This was in contrast to the provider order which stated to obtain Patient #3's blood pressure every hour for four hours (after the initial blood pressure was obtained at 15-minute increments for an hour).

B. Interviews

i. An interview was conducted on 3/11/24 at 1:01 p.m. with certified nursing assistant (CNA) #2. CNA #2 stated CNAs answered call lights, took the patient's blood pressure and other vital signs (heart rate, respiratory rate, and temperature), and conducted patient checks. CNA #2 stated the RNs and CNAs would alternate checking on patients every hour. CNA #2 stated it was important to make sure patients were taken care of and to check on patients constantly.

An additional interview was conducted on 3/12/24 at 3:45 p.m. with CNA #2. CNA #2 stated they would only check a temperature as part of vital signs on patients admitted in MCU rooms, because those patients would have been monitored automatically from monitoring equipment in the room for blood pressure, heart rate, and oxygen saturation. CNA #2 stated it was important to check vital signs, including blood pressure because a patient's condition could change. CNA #2 stated a patient's blood pressure could become too high or too low. CNA #2 stated all vital signs should have been documented in the patient's chart. CNA #2 stated it was important to check telemetry leads because an issue with telemetry monitoring might mean the patient did not have a heart rate. CNA #2 further stated the risk of not monitoring a patient could be death.

ii. An interview was conducted on 3/11/24 at 5:00 p.m. with RN #6. RN #6 stated nurses should have completed a full assessment once per shift for patients admitted to a regular telemetry bed, with reassessments throughout the shift. RN #6 stated patients admitted under MCU status should have received two or more full assessments. RN #6 stated patient assessments were important to relay information to the physician and to identify changes in patient condition. RN #6 stated physicians would order increased frequency of vital sign monitoring with certain cardiac medications including amiodarone and diltiazem. RN #6 stated it was important to monitor vital signs when giving cardiac medications because these medications could have impacted the patient's heart rhythm and rate. RN #6 stated the risk of not monitoring a patient's vital signs would be missing a cardiac event, or changes in a patient's heart rhythm.

iii. An interview was conducted on 3/14/24 at 8:42 a.m. with the cardiac unit clinical nurse manager (RN) #3. RN #3 stated nurses should have completed one head-to-toe assessment per twelve-hour shift if the patient was admitted to the telemetry unit. RN #3 stated nurses should have completed two head-to-toe assessments in a twelve-hour shift if the patient was admitted to the MCU. RN #3 stated the protocol on the cardiac unit was for nurses to obtain vital signs at the beginning of the 12-hour shift, and then the CNA would obtain vital signs at 12:00 p.m. and 4:00 p.m. RN #3 stated the protocol for patients admitted in the MCU was for nurses to obtain vital signs at least every two hours, if not more per physician orders. RN #3 stated it was important to assess patients, and obtain vital signs, to provide early intervention for any subtle changes in patient condition. RN #3 stated it was important to follow physician orders for vital signs because some cardiac medications could have caused immediate changes in blood pressure and heart rate. RN #3 stated not monitoring vital signs could have led to a significant drop, or elevation, in a patient's heart rate or blood pressure. RN #3 stated it was important to monitor vital signs to know if a medication was effective. RN #3 stated not monitoring a patient according to department guidelines or physician orders was a risk to patient safety.

iv. An interview was conducted on 3/14/24 at 10:22 a.m. with physician (Physician) #4. Physician #4 stated they would not have been aware of changes in a patient's condition unless the nurses were assessing the patient frequently. Physician #4 stated nurses should have followed physician orders for monitoring a patient when administering cardiac medications. Physician #4 stated it was important to monitor and assess patients in the cardiac unit to identify clinical changes earlier and because patients' clinical status could have changed rapidly. Physician #4 stated the risk of not monitoring patients would be a change in heart rhythm, weakness, or loss of consciousness.

v. An interview was conducted on 3/12/2024 at 11:25 a.m. with director of quality (Director) #1. Director #1 stated nurses should have assessed patients in the cardiac units following the MCU assessment guidelines if the patient was admitted to the MCU. Director #1 stated nurses should have assessed under medical surgical assessment guidelines if the patient was admitted to a regular room in the cardiac unit.