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The Condition of Quality Assessment Process Improvement was not met based on record review of 2 of 12 sampled patients (Patients #1 and #2), interviews and review of the Hospital policies titled:

1.) Peri-operative Management of Patients with Obstructive Sleep Apnea (OSA),

2.) Emergency Department (ED) Protocols Medical Executive Approval,

3.) Medication Use, Ordering, Transcription and Administration of Medications,

4.) Patient Assessment, Re-Assessment, Care Planning and Documentation and

5.) Pain Assessment and Management Protocol and the Hospital document titled Director of the Emergency Department, Job Description, the Hospital failed to ensure an effective quality assessment and performance improvement program aimed to improve health outcomes and prevent medial errors.

Findings include:

1.) The Hospital failed to recognize that Nursing Staff were using the World Wide Web (internet) for medication information and that Policy titled Medication Use, Ordering, Transcription and Administration of Medications did not indicate Hospital approved resources for medication information.

Refer to TAG #A-283

2.) The Hospital failed to in a timely manner to revise and implement, the policy titled Peri-Operative Management of Patients with Obstructive Sleep Apnea and implement mechanisms that include feedback and learning throughout the Hospital.

Refer to TAG #A-286 and TAG #A-309

3.) The Hospital Governing Body failed to assume full responsibility for the operations of the Hospital, to set as a priority, a timely implementation of the Corrective Action Plan developed after Patient #2's cardio-respiratory arrest.

Refer to TAG #A-309

Based on record review of 2 of 12 sampled patients (Patients #1 and #2), interviews and review of the Hospital policy titled Medication Use, Ordering, Transcription and Administration of Medications the Hospital failed to 1.) recognize that Nursing Staff were using the World Wide Web (internet) for medication information. 2.) The Hospital failed to identify approved sources for medication information.

2.) That the policy titled Medication Use, Ordering, Transcription and Administration of Medications did not indicate Hospital approved resources for medication information.

Findings include:

1.) Review of Patient #1's medical record indicated that he/she had a history of obesity, high blood pressure (heart disease risk factor) asthma, allergies and sensitivities to narcotic medicines and was on sedative medication for anxiety. Patient #1 presented to the Hospital Emergency Department with complaint of abdominal pain from an un-repaired hernia and nausea. Registered Nurse (RN) #1 medicated Patient #1 for pain with Dilaudid (a narcotic), Thorazine (anti-psychotic used to treat nausea), and Zofran (used to treat nausea)for nausea. RN #1 found Patient #1 approximately 53 minutes later in cardio-respiratory arrest (without pulse or respirations) on 10/6/14. Patient #1 suffered anoxic brain injury (brain damage due to a lack of oxygen) and died. Patient #1 was not monitored on a cardio-respiratory or oxygen saturation monitor.

Patient #2 had hip-replacement surgery on 4/08/14, had a history of sleep apnea, received many doses of narcotics after his/her operation for pain that was not controlled and suffered a cardio-respiratory arrest on 4/9/14. Patient #2 was not on a cardio-respiratory or oxygen saturation monitor.

Patient #2's cardio-respiratory arrest occurred 6 months before Patient #1's cardio-respiratory arrest.

2.) The Hospital policy titled Medication Use, Ordering, Transcription and Administration of Medications, dated 5/2012, did not indicate Hospital approved resources for medication information.

Although, the document, titled Medication Safety (from the nursing orientation program, date not documented) indicated that it was the nurse's responsibility to know the medications administered to the patient and that if the nurse was not familiar with the medication the following were resources were available:

· Pharmacy staff,
· The Medication Administration Record (MAR) label,
· The Adult Intravenous (IV) Policy on the Hospital intranet (computer),
· Micromedex (medication information program) on the Hospital Internet (computer),
· Monograph (information page) on every drug on the MAR.


3.) The Surveyor interviewed RN #1 at 10:00 A.M. on 11/10/14. RN #1 said that other Nurses who worked in the Emergency Department (ED) use the internet to obtain information about medicines.

The Surveyor interviewed RN #2 at 1:00 P.M. on 11/10/14 during a tour of the Emergency Department. RN #2 said that she used her personal mobile phone to access the internet web site called Epocretes to access information about patient medicines.

The Surveyor interviewed the Chief Nursing Officer (CNO) at 1:00 P.M. on 11/10/14 during a tour of the Emergency Department and the CNO said that the Hospital did not approve the internet web site, Epocretes, as a resource for medication information for nurses.

Based on record review of 2 of 12 sampled patients (Patients #1 and #2), interviews, review of Hospital Internal Investigations and the Hospital policy titled Patient Assessment, Re-Assessment, Care Planning and Documentation, the Hospital failed to implement actions and mechanisms that include feedback and learning throughout the Hospital.

Findings include:

1.) The Hospital policy titled Patient Assessment, Re-Assessment, Care Planning and Documentation, dated 7/2009, indicated that a nursing assessment included reviewing previous medical record documentation.

2.) The Surveyor interviewed the Risk Manager, at 10:00 A.M. on 11/7/14, regarding the Hospital Internal Investigations regarding Patient #1 and Patient #2. The Risk Manager said that there were communication errors regarding Patient #2's history of sleep apnea. The Risk Manager said that the Hospital subsequently made pain medication dosage changes to doctors order sheets and developed an information sheet on the medication Thorazine.

Although the Hospital Internal Investigation regarding Patient #2 indicated that Physicians and Nurses failed to communicate Patient #2's history of sleep apnea and the Hospital made medication dosage changes, the Hospital failed to educate Physicians, Physician Assistants and Nursing Staff, throughout the Hospital, regarding handoff communication, responsibilities to review previous medical record documentation and the medication improvements the Hospital made.

The Hospital failed to educate the Nursing Staff regarding the new monograph on Thorazine and to use only Hospital approved resources for information on medications.

Based on record review of 2 of 12 sampled patients (Patients #1 and #2), interviews and review of the Hospital policy titled Peri-Operative Management of Patients with Obstructive Sleep Apnea (OSA), the Hospital Governing Body failed to assume full responsibility for the operations of the Hospital. The Governing Body failed to ensure implementation of the Corrective Action Plan developed following Patient #2's cardio-pulmonary arrest.

Findings include:

1.) The Hospital policy titled Peri-Operative Management of Patients with Obstructive Sleep Apnea (OSA) that the Hospital developed in response to the Corrective Action Plan following Patient #2's cardio-pulmonary arrest, on 4/9/14, remained in draft form, awaiting 2 committees' approval, and the policy was not implemented at the time of the survey, on 11/07/14.

2.) The Surveyor interviewed the Risk Manager, at 10:00 A.M. on 11/7/14. The Risk Manager said the Corrective Action Plan (CAP), regarding Patient #2's cardiac-respiratory arrest in 4/2014, was to develop new guidelines for patients with Obstructive Sleep Apnea. The Risk Manager said that after Patient #1's cardiac-respiratory arrest, on 10/6/14, the Corrective Action Plan (CAP) was to revise the policy titled Peri-Operative Management of Patients with Obstructive Sleep Apnea to include all patients, not just patients having surgery. The Risk Manager said that the OSA policy was not yet approved, was on the agenda for 2 committee and one committee meeting scheduled for 11/2014 and the other committee meeting scheduled in 12/2014.

Based on record review of 2 of 12 sampled patients (Patients #1 and #2), interviews and review of the Hospital policies titled: (1.) Emergency Department Protocols Medical Executive Approval and (2.) Peri-Operative Management of Patients with Obstructive Sleep Apnea (OSA), the medical staff failed to ensure accountability to the governing body for the quality of the medical care provided to the patients.

Findings include:

1.) The Hospital policy titled Peri-Operative Management of Patients with Obstructive Sleep Apnea (OSA), which the Hospital developed in response to the Corrective Action Plan regarding Patient #2's cardio-pulmonary arrest, in April 2014, remained in draft form, awaiting 2 committees' approval and the policy was not implemented at the time of the survey, on 11/07/14.

The Hospital draft policy titled Peri-Operative management of Patients with Obstructive Sleep Apnea (OSA), dated July 2014, did not indicate which patients would require increased surveillance or continuous cardiac or oxygen saturation monitoring.

2.) Review of Patient #1's medical record indicated that he/she was obese, was snoring, had Chronic Obstructive Pulmonary Disease (COPD) and was taking Lorazepam (sedative medication) at home.

Review of Patient #2's medical record indicated that: (a.) his/her diagnosis of sleep apnea was documented at his/her pre (before) surgery appointment, (b.) he/she had ineffective pain management after surgery and received multiple doses of narcotics (pain medication that causes sedation and respiratory depression) and (c.) his/her routine night-time medication for depression was administered on the evening prior to his/her cardio-respiratory arrest.

3.) On 11/7/14, the Surveyor reviewed the Hospital's internal investigations regarding Patients #1 and #2. The Policy titled Peri-Operative Obstructive Sleep Apnea remained in draft form, was not approved by the Medical Staff, staff education was not completed and the policy was not implemented.

4.) The Surveyor interviewed Emergency Department (ED) Physician #1 at 11:14 A.M. on 11/10/14. ED Physician #1 said Patient #1 had presumed sleep apnea because he/she was snoring.

The Surveyor interviewed the Risk Manager at 10:30 on 11/7/14 and she said that Patients #1 and #2 were not monitored with a heart or oxygen saturation monitor prior to their cardio-respiratory arrest.

Based on record review of 2 of 12 sampled patients (Patients #1 and #2), interviews and review of the Hospital policies titled:

(1.) Emergency Department (ED) Protocols Medical Executive Approval,

(2.) Patient Assessment, Re-Assessment, Care Planning and Documentation,

(3.) Pain Assessment and Management Protocol and the Hospital documents titled:

Director, Emergency Department Job Description, and

Emergency Department Registered Nurse (RN) Job Description, the Nursing Services failed to ensure that RNs monitored Patient #1 and #2 (patients with a higher risk for over sedation and respiratory depression and received narcotic medications) when receiving these medications.

Findings include:

1.) The Hospital policy titled Emergency Department Protocols Medical Executive Approval, dated 12/2012, indicated that adult patients with abdominal pain should be monitored on a cardiac monitor if the patient was elderly and or the patient had a history of heart disease.

The Hospital policy titled Patient Assessment, Re-Assessment, Care Planning and Documentation, dated 7/2009, indicated that a nursing assessment included analysis and summary of collected information and was used by the Registered Nurse (RN) for appropriate plan of care.

The Hospital policy titled Pain Assessment and Management Protocol, Dated 10/2010, indicated that: (a.) When opioids (Narcotic medications, Dilaudid and Morphine) were administered, the potential for opioid-induced respiratory depression should always be considered and (b.) Characteristics of patients who are at higher risk for over sedation and respiratory depression were patients with sleep apnea or sleep disorder, morbid obesity with high risk of sleep apnea, snoring, pre-existing pulmonary or cardiac disease and patients receiving other sedation drugs.

2.) The Hospital document titled Director, Emergency Department (ED) (date not documented) indicated that it was within the responsibility of the ED Nurse Director to participate in the development and implementation of policies and procedures that guide and support patient care.

The Hospital document titled ED RN (date not documented) indicated that it was within the job description for the ED RN to assess physical, mental and psychological status of the patient and synthesize patient care information to formulate appropriate nursing diagnosis.

3.) Patient #2:

Nursing Note, dated 4/08/14 at 11:54 A.M. indicated that Patient #2 had a history significant for asthma, cardiac disorders, gastric bypass, hypertension, depression, stroke and was overweight.

The Medication Administration Record, dated 4/8/14 at 1:42 P.M. to 8:57 P.M., indicated that Patient #2 received Morphine twice, Dilaudid twice and his/her routine medication for depression.

4.) The Surveyor interviewed Registered Nurse (RN) #1 at 10:00 A.M. on 11/10/14. RN #1 said that Patient #1 could not walk well and used a wheelchair, he/she had took medication for anxiety, had allergies to some narcotics and he/she had chronic obstructive pulmonary disease (COPD). RN #1 said that Patient #1 did not need to be on a cardiac monitor or oxygen saturation monitor because Patient #1 was not having chest pain, did not receive a high dose of Dilaudid (pain medication) and Thorazine and Zofran (medications to treat nausea) did not require monitoring.

Patient #1:

The ED Physician Report, dated 10/6/14 at 1:36 P.M. indicated that Patient #1 presented to the ED with abdominal pain and had a history significant for asthma, anxiety, hypertension and chronic abdominal pain.

The ED Visit Summary, dated 10/6/14 at 2:30 P.M., indicated Patient #1 was talking Lorazepam (medication) for anxiety when needed and was allergic to Fentanyl and Morphine (pain medications).

The Nursing Note, dated 10/6/14 at 19:11 P.M., indicated Patient #1's family told RN #1 that Patient #1 does not do well with pain medication.

The Medication Administration Record, dated 10/6/14, indicated that RN #1 administered Dilaudid (pain medication) at 2:11 P.M., Zofran and Thorazine at 2:14 P.M. (nausea medication) to Patient #1.

Based on record review of 1 of 12 patients sampled (Patient #1), review of the Hospital Internal Investigation about Patient #1, interviews and Hospital policies titled:

(1.) Emergency Department (ED) Protocols Medical Executive Approval,

(2.) Pain Assessment and Management Protocol and

(3.) the Hospital document titled Director, Emergency Department Job Description, the Emergency Services Medical Staff failed to ensure policies and procedures were in place to monitor Patient #1 (a patient with a higher risk for over sedation and respiratory depression and received narcotic medications) when receiving these medication.

Findings include:

1.) The Hospital policy and procedure titled Emergency Department Protocols Medical Executive Approval, dated 12/2012, indicated that Hospital staff should put adult patients with abdominal pain should on a cardiac monitor if the patient was elderly and or the patient had a history of heart disease.

The policy did not indicate continuous cardiac (heart) or oxygen saturation monitoring for patients with chronic disease, a history of narcotic or medication allergy and sensitivities, diagnosed or suspected sleep apnea, respiratory illness or a combination of illnesses. The policy did not indicate at what age was considered elderly or define heart disease.

The Hospital did not have a policy regarding which patients would receive continuous cardiac (heart) or oxygen saturation monitoring.

The Hospital policy titled Pain Assessment and Management Protocol, Dated 10/2010, indicated that: (a.) When opioids (Narcotic medications, for example: Dilaudid and Morphine) were administered, the potential for opioid-induced respiratory depression should always be considered and (b.) Characteristics of patients who are at higher risk for over sedation and respiratory depression were patients with sleep apnea or sleep disorder, morbid obesity with high risk of sleep apnea, snoring, pre-existing pulmonary or cardiac disease and patients receiving other sedation drugs.

The Hospital document titled Director, Emergency Department (ED) (date not documented) indicated that it was within the responsibilities of the Nurse Director of the ED to participate in the development and implementation of policies and procedures that guide and support patient care.

2.) Review of medical records for Patient #1 and Patient #2 did not indicate that they were monitored with a cardiac or oxygen saturation monitor prior to their cardio-respiratory arrest.

3.) The Surveyor interviewed the Risk Manager at 10:30 on 11/7/14 and she said that Patient #1 and #2 were not monitored with a heart or oxygen saturation monitor prior to their cardio-respiratory arrest.