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Based on review of medical records, policies/procedures, hospital documents, and staff interviews, it was determined the hospital failed to comply with the provision of nursing services by failing to:

A 0395: evaluate the nursing care provided to patients as demonstrated by:

1. a Registered Nurse failed to assessed Pt # 1; after a transfer from the intensive care unit (ICU) to the medical/surgical/telemetry floor; after a fall; prior to finding the patient with agonal respirations and bradycardia resulting in the patient's death;

2. RN #6, a non-employed agency nurse, failed to document physical assessments for 4 of 4 patients in the MS/T unit on 04/24/13, during her first shift at this hospital (Pt #'s 3, 8, 12 and 21);

3. nursing failed to document physical assessments/reassessments for 1 of 1 patients transferred emergently to another acute care facilities (Pt #13);

4. nursing failed to document physical assessments/reassessments for 2 of 3 patients transferred from the ICU to the medical/surgical/telemetry unit within 4 hours (Pt #'s 10 and 12); and

5. nursing failed to implement fall precautions for 4 of 4 patients (Pts #'s 1, 10, 12 and 20).

A 0396: develop and keep current, a nursing care plan for 4 of 4 patients identified at risk for falls (Pt #'s 1, 10, 12 and 20).

A 0398: require the adequate supervision and evaluation of non-employee nursing personnel as demonstrated by:

1. RN #'s 6 and 7 were working on 04/26/13 at the Northwest Campus' South Unit, without verification of competencies by the hospital prior to patient care activities;

2. RN #6's first work day was 04/24/13 at the Northwest Campus, no physical assessments were documented for 4 of 4 patients assigned to her care (Pt #'s 3, 8, 12 and 21); and

3. the Director of Nursing Services did not identify RN #6, was not adequately supervised or evaluated during the first work day at this hospital per policy.

The cumulative effect of these systemic problems resulted in the hospital's failure to meet the condition of participation for Nursing Services.

Based on review of medical records, policies/procedures, hospital documents, and staff interviews, it was determined the hospital failed to:

1. require Patient #1's root cause analysis thoroughly evaluated the incident and identified opportunities for improvement regarding nursing assessments/reassessments and fall policy implementation; and

2. identify nursing for failure to implement fall precautions for 4 of 4 patients (Pts #'s 1, 10, 12 and 20).

Findings include:

The hospital policy titled Investigating Serious and Sentinel Events, revised 06/2011, required: "...Purpose...Facilitate the determination of the causes of medical errors, rapid performance improvement...each event is analyzed for improvement opportunities...."

The hospital policy titled Fall Prevention, revised 01/2011, with the Local Addendum effective 01/2013, required: "...All newly admitted patients will be screened on admission by a nurse for risk of fall, and appropriate fall precaution interventions will be initiated at that time...A score of (greater than or equal to 10) = At Risk...Patients identified at risk for falls via the Falls Risk Screening Tool...will have an interdisciplinary care plan initiated by the registered nurse under the heading 'potential for self-injury related to risk for falls'...Addendum D: Kindred Hospitals of Arizona through the Fall PIT (performance improvement team) team have agreed that once a patient is identified as a fall risk during any time of their stay, they will remain a fall risk and precautions will remain in place even if the fall risk assessment falls below the high risk on certain shifts/days...."

1. On 02/22/13, Pt #1 was transferred from the ICU to a Med/Surg/Tele (MS/T) unit. Telemetry was ordered for the patient, but was not initiated. The patient arrived in the MS/Tele unit at 1600 hrs. According to a hospital report for 02/22/13 at 1725 hours, Patient #1 fell and was found sitting on the floor. The patient explained he "tried to get to the bathroom and fell." At 1931 hrs the patient had a small volume nebulizer (SVN) treatment and the HR was noted to be 124 (higher than the previous readings). At 2150 the patient was found with agonal respirations, a blood pressure of 67/48 and a heart rate (HR) of 52. The patient expired.

The Hospital conducted a root cause analysis (RCA).

The hospital did not identify the following opportunities for improvement:

A. a registered nurse did not document any physical assessments/reassessments on the patient from 1600 hours through 2150 hours;

B. nursing did not assess the patient after a fall and follow the hospital policy; and

C. a respiratory therapist noted the patient's HR was 124 pre-treatment and did not notify nursing.

On 04/24/13, the Chief Clinical Officer (CCO) and the Director of Quality Management (DQM) confirmed a registered nurse did not assess/reassess Pt #1 from 1600 through 2150 hours, or after a fall and the Respiratory Therapist did not communicate Pt #1's increased HR. They confirmed that they did not identify these opportunities for improvement during their RCA and take actions.

On 04/26/13 at 1300, during an interview with the DQM at the Northwest Campus, she confirmed the hospital was not auditing nursing records for compliance with documentation of physical assessments. She was unaware of the findings with the lack of documentation of physical assessments.

2. Reference A 0395 #5 regarding patients identified as "At Risk" for falls according to the hospital's screening tool, and no interventions were documented on the care plans.

On 04/26/13 at 1300, during an interview with the DQM at the Northwest Campus, she confirmed the hospital's Performance Improvement Team for Falls was no longer meeting. She confirmed recently the fall rate had increased. She was unaware of the findings that nursing staff were not documenting implementing fall precaution interventions.

Based on review of medical records, policies/procedures, hospital documents, and staff interviews, it was determined a registered nurse failed to evaluate the nursing care provided to patients as demonstrated by:

1. a Registered Nurse failed to assessed Pt # 1: after a transfer from the intensive care unit (ICU) to the MS/T unit; after a fall; and prior to finding the patient with agonal respirations and bradycardia resulting in the patient's death;

2. RN #6, a non-employed agency nurse, failed to document physical assessments for 4 of 4 patients in the MS/T unit on 04/24/13, during her first shift at this hospital (Pt #'s 3, 8, 12 and 21);

3. nursing failed to document physical assessments/reassessments for 1 of 1 patients transferred emergently to another acute care facilities (Pt #13);

4. nursing failed to document physical assessments/reassessments for 2 of 3 patients transferred from the ICU to the medical/surgical/telemetry unit within 4 hours (Pt #'s 10 and 12); and

5. nursing failed to implement fall precautions for 4 of 4 patients (Pts #'s 1, 10, 12 and 20).

Findings include:

The hospital policy titled Assessment/Reassessment-Interdisciplinary Patient, revised 08/2012, required: "...All patients...will have...appropriate follow up assessments based upon their individual needs...The goal of the Assessment/Reassessment process is to provide the patient the best care and treatment possible...Patients admitted to the medsurg/tele unit will be physically assessed within the first 4 hours...."

1. Patient #1 was admitted on 02/19/13, with the following diagnoses: acute respiratory failure; status post cardiac arrest; right pneumothorax with chest tube; and altered mental status and severe metabolic encephalopathy.

Medical record review revealed the following on 02/22/13:

1545 hours: transferred to the MS/T unit;

1725 hours: the patient was found sitting on the floor;

2150 hours: a rapid response was initiated and was unsuccessful and Pt #1 expired.

Nursing documentation on 02/22/13, after transfer to the MS/T unit did not contain a physical assessment/reassessment of the patient.

The CCO and Employee #8 confirmed on 04/24/13, that nursing did not document a physical assessment/reassessment of the patient for the five hours prior to the rapid response and death of Pt #1.

According to a hospital report for 02/22/13 at 1725 hours, Patient #1 fell and was found sitting on the floor. The patient explained he "tried to get to the bathroom and fell."

Nursing documentation did not include a physical assessment of the patient after the fall.

The CCO and Employee #8 confirmed on 04/24/13, that nursing did not assess the patient after the fall on 02/22/13 at 1725 hours. They confirmed Pt #1 fell on 02/22/13 at 1725 hours.

2. Review of medical records for Pt #'s 3, 8, 12 and 21 revealed RN #6 did not document physical assessments on any of her assigned patients, on her first day working at this hospital.

On 04/26/13 at 1000 hours, Employee #8 confirmed no physical assessments were documented for Pt #'s 3, 8, 12 and 21.

3. The hospital policy titled Assessment/Reassessment-Interdisciplinary Patient, revised 08/2012, required: "...Patients are reassessed based on...a significant change in status...."

Patient #13 was admitted on 03/18/13 and discharged on 04/24/13, with multiple chronic and acute diagnoses including: Right distal femur fracture; severe debility; end stage renal disease; chronic respiratory failure; sleep apnea, morbid obesity neuro-behcet syndrome; bladder cancer; pulmonary hypertension; chronic adrenal insufficiency; iatrogenic Cushing disease; MRSA pneumonia; pseudotumor cerebri; mastitis; and Clostridium difficile colitis.

On 04/24/13 at 1005 hours, nursing documented: "seizures while sitting up in the wheelchair, had emesis. Family notified. Treatment initiated...Pt was transported at 1027 to (name of other acute care hospital)...."

The medical record documentation for 04/24/13, did not contain a physical assessment of Pt #13, prior to the seizure, after the seizure or prior to transfer to the acute care hospital.

Employee #8 confirmed the finding that no physical assessment was documented for Pt. #13 for the day shift (0630-1830).

4. Patient #10 was admitted on 01/28/13, with the following diagnoses: severe chronic obstructive pulmonary disease (COPD); streptococcal pneumonia with empyema; and hospital acquired pneumonia.

On 02/24/13 at 1703 hours, the patient was transferred from the ICU to the MS/T unit.

The first physical assessment documented by the MS/T nurse was 4.75 hours later at 2145 hours.

On 04/26/13, Employee #8 confirmed the physical assessment was conducted 4.75 hours after the patient arrived in the MS/T unit.

Patient #12 was admitted on 04/09/13, with the following diagnoses: complex abdominal wound due to multiple intracutaneous fistulae; intra-abdominal abscess; fecal peritonitis; malnutrition; anemia; acute renal failure; Crohn's disease; leukocytosis; atrial fibrillation; and left sided atelectasis.

On 04/19/13 at 1519 hours, the patient was transferred from the ICU to the MS/T unit.

The first physical assessment was documented by the second shift nurse assigned to the patient 5 hours later. No physical assessment was documented by the day shift RN accepting the patient from the ICU.

On 04/26/13, Employee #8 confirmed the physical assessment was conducted 5 hours after the patient arrived in the MS/T unit.

5. The hospital policy titled Fall Prevention, revised 01/2011, with the Local Addendum effective 01/2013, required: "...All newly admitted patients will be screened on admission by a nurse for risk of fall, and appropriate fall precaution interventions will be initiated at that time...A score of (greater than or equal to 10) = At Risk...Patients identified at risk for falls via the Falls Risk Screening Tool...will have an interdisciplinary care plan initiated by the registered nurse under the heading 'potential for self-injury related to risk for falls'...Addendum D: Kindred Hospitals of Arizona through the Fall PIT (performance improvement team) team have agreed that once a patient is identified as a fall risk during any time of their stay, they will remain a fall risk and precautions will remain in place even if the fall risk assessment falls below the high risk on certain shifts/days...."

The following patients were identified as "At Risk" for falls according to the hospital's screening tool:

Patient #'s 1, 10, 12 and 20.

Patient #1 had a fall on 02/22/13 at 1725, and nursing documented interventions on 02/22/13 at 1745, 10 minutes after the patient's fall. No interventions were documented prior to the fall.

Medical records were reviewed to see what fall interventions were implemented for the patients. No interventions were documented on the care plans for patient #'s 10, 12 and 20.

The above findings regarding fall precaution interventions and fall scores were confirmed by Employee #8, RN #21 and RN #22, during the survey from 04/24/13 through 04/26/13.

Based on review of medical records, policies/procedures, and staff interviews, it was determined the nursing staff failed to develop and keep current, a nursing care plan for 4 of 4 patients identified at risk for falls (Pt #'s 1, 10, 12 and 20).

Findings include:

Reference tag 0395 #5 under findings regarding patients identified as "At Risk" for falls according to the hospital's screening tool, and no interventions were documented on the care plans.

During the Complaint Validation conducted 04/24/13 through 04/26/13, Employee #8, RN #21 and RN #22, confirmed the nursing staff failed to develop and implement a fall risk prevention care plan.

Based on review of medical records, policy and procedures, personnel files, and staff interviews, it was determined the Director of Nursing failed to require the adequate supervision and evaluation of non-employee nursing personnel as demonstrated by:

1. RN #'s 6 and 7 were working on 04/26/13 at the Northwest Campus' South Unit, without verification of competencies by the hospital prior to patient care activities;

2. RN #6's first work day was 04/24/13 at the Northwest Campus. No physical assessments were documented for 4 of 4 patients assigned to her care (Pt #'s 3, 8, 12 and 21); and

3. the Director of Nursing Services did not identify RN #6 was not adequately supervised or evaluated during the first work day at this hospital per policy.

Findings include:

1. The hospital policy titled Competency Verification of Caregivers, revised 11/2010, required: "...Staffing Agency Personnel...clinical department manager/designee will review and approve the scope of practice/job description and competencies for agency personnel prior to patient care activities...."

A tour of the Northwest Campus South Unit was conducted on 04/26/13 at 0830 hours. The unit had 10 patients and was staffed with 2 RN's (RN #'s 6 and 7) and 1 CNA. Both RN's were non-employed staff from a contract agency and no core registered nurse staff were present on the unit.

Interview on 4/26/13 at the Northwest Campus South Unit with RN #6 revealed this was
RN #6's second hospital shift at this hospital. RN #6 had a 5-patient assignment, with telemetry patients. RN #6 explained orientation was provided the first day worked, 4/24/13, approximately one hour before the shift started.

Interview on 4/26/13 in the med/surg/telemetry south unit with RN #7 revealed a 5-patient assignment, including telemetry patients. RN #7 stated orientation was provided the first day worked, 4/26/13, approximately 15 minutes before the shift started.

RN #'s 6 and 7's personnel files contained self assessments for competencies. The agency did not verify the competencies and accepted the self assessments from the nurses.

On 04/26/13 at 1150, the CCO explained the hospital accepts the self assessments completed by each nurse. The hospital does not assess or verify the competencies of the agency staff prior to patient care activities.

2. The hospital policy titled Assessment/Reassessment-Interdisciplinary Patient, revised 4/2013, required: "...Nursing Department: Patients are reassessed at a minimum every shift-based on level of care and needs by a licensed nurse...The assessment(s) are recorded in the patient medical record...."

Review of medical records on 4/26/13 for patient #'s 3, 8, 12 and 21, revealed RN #6 failed to document physical assessments/reassessments for patient #'s 3, 8, 12 and 21 on 4/24/13.

Interview on 4/26/13 with RN #8 confirmed physical assessments were not documented for patient #'s 3, 8, 12 and 21 on 04/24/13.

3. Review of the hospital document titled Agency Personnel Performance Evaluation included: "...to be completed after the first shift worked...addresses...facility policies and procedures, completion of assignments...performing appropriate skills necessary to meet or exceed standards...accurate and timely documentation...."

Interview with CCO on 4/26/13, confirmed a performance evaluation was not completed for RN #6, and it is the hospital's expectation that the evaluation is completed.