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Based on clinical record reviews, review of hospital policies and procedures, review of hospital logs, reports, meeting minutes, staffing records and staff interviews, it was determined:

(A-385) Nursing Services: The Governing Body failed to be accountable and ensure there were organized nursing services 24-hours per day with an adequate number of qualified nursing staff to assess the individual needs of each patient and then deliver and/or supervise the care required in accordance with physician orders, policies and procedures, and nursing standards of care. This deficiency poses a high potential risk that the individual needs of each patient will not be met.

Findings include:

A review of the Hospital's Board Meeting Minutes included the following:

10/28/2015: The Chief Nursing Officer (CNO) reported as needed Registered Nurses (RN's) would be hired to replace agency nurses.

11/18/2015: The CNO reported that there 25 Registered Nurses hired with a, "...goal to have no agency usage by 01/01/2016."

02/16/2016: The CNO reported nursing turnover was lower at the end of 2015 than the turnover rate at the end of 2014.

There was no documentation that the Governing Board was informed of the hospital's inability to provide sufficient numbers of nursing staff to meet the needs of the patients.

The effect of this systemic problem resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on review of the hospital's Quality Improvement Plan, hospital documents and staff interviews, it was determined the hospital failed to develop and implement and maintain a program that ensured steps were taken to identify, analyze and correct problems which directly impact the safe delivery of nursing care and services to patients.

Findings include:

(A-286) The hospital failed to develop a quality improvement plan related to the hospital's inability to provide sufficient numbers of nursing staff to meet the needs of patients.

The effect of this systemic problem resulted in the hospital's ability to ensure effective and ongoing monitoring of the safe delivery of nursing care and services.

Based on review of hospital policies and procedures and staff interviews, it was determined the hospital failed to develop a quality improvement plan related to the hospital's inability to provide sufficient numbers of nursing staff to meet the needs of patients.

Findings include:

The hospital's Quality Improvement Plan Policy included: "The Department Leaders are accountable to Administration, the Quality Council and the Board for the quality and safety of care/services and performance of their staff and departments. Department Directors and Managers are responsible for the systematic monitoring and analysis of the quality and safety of care provided in their departments. Directors will: 1. Submit opportunities for improvement to the Quality Council for prioritization 2. Promote the development of standars of care and criteria to objectively measure the quality and safety of care/services rendered in their departments. 3. Monitor and analyze the processes in their areas that affect patient care, safety, outcomes and satisfaction.

A review of the hospitals policies and procedures for staffing revealed no system to identify how to identify the types, numbers and qualifications required to meet the individual needs of each patient. Although the hospital had an "Acuity Form," it was not utilized on each unit. A random review of daily staffing records for February and March 2016 revealed numerous days where staffing levels did not meet the staffing guidelines grid.

During individual interviews conducted with over 9 nursing staff representative of the nursing units, the staff reported concerns with "unsafe" staffing levels and their inability to provide the level of care required by each patient. The examples of the care not provided included the late administration of medications, toileting, turning and repositioning of patients, not being able to document in a timely manner, and extended periods of time of not being able to get to a patient's room. The staff reported communicating their concerns through the hospital's chain-of-command up to and including the Chief Nursing Officer.

The Chief Nursing Officer (CNO), the Director of Nursing, the Chief Quality Officer, and the Director of Risk reported during interviews that the hospital had experienced staffing challenges the earlier part of the year which they attributed to a combination of "high patient volumes" and the flu season with staff calling in sick. The CNO acknowledged many occasions of over saturation and surge activity in the Emergency Department of which patient demand exceeding nurse availability. In order to accommodate this, the limited number of available staff were expected to float to other units and/or take on a higher patient load/assignment including in their Intensive Care Units. The CNO reported the hospital decided not to limit or halt elective surgeries when there was a high volume of patients in the ED needing inpatient beds.

The Chief Quality Officer reported in an interview that the CNO had elected to develop a "Shared Governance Team" for nursing rather than a structured Quality Improvement Project detailed in the hospital's policies and procedures.

Refer to Tags A-386 and A-392 for clinical record review findings.

Based on review of clinical records, review of hospital policies and procedures, review of daily nurse staffing records and staff interviews, it was determined the hospital failed to provide organized nursing services 24-hours per day with an adequate number of qualified nursing staff to assess the individual needs of each patient and then deliver and/or supervise the care required in accordance with physician orders, policies and procedures, and nursing standards of care.

Findings include:

(A-386): The Chief Nursing Officer failed to implement and monitor a system to determine the types and numbers of nursing personnel necessary to meet the needs of each patient based on their acuity which poses a risk to patient health and safety.

(A-392): The hospital failed to establish and implement a staffing plan to ensure there were sufficient numbers of qualified nursing staff to:

1. Meet the individual needs of patients in the Emergency Department (ED) which resulted in nursing care and services not provided following physician orders and hospital policies. (Patients #1, #29, #34, and #35)

2. Meet the individual needs of patients which resulted in nursing care and services not provided following physician orders and hospital policies and procedures for:

a. Patients requiring monitoring for alcohol withdrawal. (Patients #2 and #4)

b. Patients requiring monitoring after cardiac catheter procedures. (Patients #10, #26, and #28)

c. Patients requiring monitoring after invasive procedures. (Patient #6)

d. Medication Administration. (Patients #8 and #40)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on clinical record review, review of hospital policies and procedures, review of daily nurse staffing records, and staff interviews, it was determined the Chief Nursing Officer failed to implement and monitor a system to determine the types and numbers of nursing personnel necessary to meet the needs of each patient based on their acuity which poses a risk to patient health and safety.

Findings include:

The hospital's policy titled Plan for the Provision of Patient Care Policy included: "Patient care requirements are determined on the basis of demonstrated patient needs, appropriate interventions and priority for care. Staffing plans are developed based on the level and scope of care, frequency of the care to be provided and determination of the number, mix and competencies of the staff to most appropriately provide care to the population served, based on a budgeted average daily census...While staffing patterns are in place for each department, they are designed with average acuity and typical patient types in mind. As such, they provided guidelines, from which staffing decisions can be made on a day-to-day, shift-to-shift, on an even hourly basis (sic). Each patient is assessed by the professional staff caring for the patient. In making staff decisions, the acuity is considered along with skill mix in making daily patient care assignments."

The hospital's Acuity Monitoring Policy included: "Northwest Medical Center (NMC) has a process for assessing the acuity of patients and adjusting staffing based upon the nursing care required for the patient population...Definition: Acuity: A determination of the level and type of nursing services, based upon the patient's illness or injury, required to meet the needs of the patient...Ongoing assessments of the patient's needs are performed by nursing staff to ensure there are sufficient numbers , types, and qualifications of nursing personnel to meet the patients' needs...If a determination is made there will be insufficient nursing personnel available, the department manager/supervisor or administrative nursing supervisor is contacted. Additional staff and resources are reallocated or additional staff is brought in to meet the needs of the patient population."

The hospital had a unit specific "Staffing Guideline" which was based on census and nurse to patient ratio. There was also an Acuity Form which was divided into 3 types of patients: Stable Patient Typical Workload; Complex Patient Increased Workload; and High Risk Highest Workload.

A review of the daily staffing records for February 2016 and March 1 through March 20, 2016 revealed the form was not used consistently throughout the hospital. For example, the Patient Care Services section of the hospital's policy for Plan for the Provision of Patient Care Policy specific to patients admitted to the Acute Care Telemetry Unit included: "Services provided to patients and customers are varied, individualized and may include, but are not limited to: Cardiac disease; Cardiovascular Surgery; Thoracic Surgery; Pulmonary disease: Invasive cath lab and special procedures...The staffing plan for ACT is based upon the number of patient care hours necessary to meet the patient's needs. These hours are based upon the frequency of the vital signs, medications required, and the quantity and complexity of nursing care and interventions. The staffing mix is composed of RN's Nurse Tech's and MT (Monitor Technicians)/UC's (Unit Clerks). Staff assignments are based upon census, acuity, staff mix, competency and skill level. A staffing grid serves as a guideline for making staffing decisions, but is varied dependent on patient needs."

The Director of the ACT Unit stated during an interview that the Acuity Form was not used on that unit because all of the patients scored at the highest level of 4, "High Risk Highest Workload."

The hospital's Plan for the Provision of Patient Care Policy included: "Intensive Care (CVICU/MSICU) Scope of Services...Services provided to patients and customers are varied, individualized and may include, but are not limited to: Invasive cardiovascular monitoring...Ventilator and other advanced respiratory support...Titration of vasoactive medications...Other specialized assessments and monitoring requiring close monitoring by nursing...Staffing Requirements...Staffing in the ICU is based on the AZDHS (Arizona Department of Health Services) standards at a 1:2 RN to patient ratio. Based on patient acuity, the ratio may flex to a 1:1. The patient ratio is based on the frequency of vital signs, the quantity and complexity of nursing care and interventions as well as the amount of observation time the patient requires...The ICU bases its patient care on the standards of care defined by the American Association of Critical Care Nurses."

A sample of daily nurse staffing records for the 20-bed Medical/Surgical Intensive Care Unit (MSICU) was reviewed and included the following:

02/12/2016: According to documentation on the Daily Assignment Sheet for the 7 a.m. to 7 p.m. shift one of the RN's on the schedule was assigned 4 ICU patients and another RN was assigned three patients. Two of the RN's on the 7 p.m. to 7 a.m. shift were assigned three patients.

02/13/2016: On the 7 a.m. to 7 p.m. shift, 3 RN's were assigned 3 patients and 1 RN had 1 ICU patient in addition to 4 "downgraded" patients. On the 7 p.m. to 7 a.m. shift, 2 RN's were assigned 3 ICU patients. "Downgraded" was explained to mean the patient's acuity level had been downgraded from an Intensive Care status.

02/14/2016: On the 7 p.m. to 7 a.m. shift, 1 RN was floated to another unit. Three RN's on the 7 p.m. to 7 a.m. shift had 3 patients assigned to each of them. There was 1 Nurse Technician for the unit.

02/15/2016 - Documentation revealed there were 10 RN's scheduled for the 7 a.m. to 7 p.m. shift and 1 of the RN's was floated to another unit. Eight nurses had 2 patients assigned to them and 1 nurse had 4 patients, 3 of which were downgrades. The Charge Nurse was included in the staffing and had 2 patients. There was 1 Nurse Technician for the entire unit.

Information obtained during staff interviews and other sources revealed the staffing record for 02/15/2016 was not reflective of the activity during the shift which significantly impacted the staffing. The Charge Nurse had to accompany one of her assigned patients off of the unit for an MRI procedure which meant her other patient had to be assigned to another RN. One of the other RN's was the "BAT Responder" for the hospital which is the "Brain Attack Team" who responds to a possible stroke occurring. A BAT was called around the same time that the Charge Nurse left the unit with her patient which meant the 2 patients assigned to the BAT RN had to be assigned to another RN(s). This resulted in one of the RN's having 4 ICU patients for a period of four to five hours with no PCT (Patient Care Technician) available to assist her.

Separate interviews were conducted with four nursing staff members who confirmed the above nurse staffing. The nursing staff described the staffing as "dangerous" and "unsafe" and expressed their concerns that medications were not administered on time and turning and repositioning needs were not being performed to prevent skin breakdown. In addition, the required chlorhexidine baths at least every 24 hours to reduce central line associated blood-stream infections were not being performed, and the frequent oral care needed by many patients was not being performed. The staff reported ICU patients are often confused and combative requiring multiple staff members to control them with the potential of patients and staff being injured when there are not sufficient numbers of staff available. The staff reported that they were not provided with any structured orientation to the other nursing units when they were required to float such as the location of the pyxis, location of supplies and equipment, and other unit specific details.

During random individual interviews, of approximately nine total staff, conducted with nursing staff representative of the nursing units, the staff reported concerns with "unsafe" staffing levels and their inability to provide the level of care required by each patient. The examples of the care not provided included the late administration of medications, toileting, turning and repositioning of patients, not being able to document in a timely manner, and extended periods of time of not being able to get to a patient's room. Nursing staff cited examples of family members assisting with ambulating and toileting patients because nursing staff were too busy.

One example provided to the surveyor was during one shift when there was one male Nurse Technician assigned. Family member(s) of a female patient requested the patient be assisted for incontinence care by a female staff member only. The RN assigned to the patient was not able to get to the patient's room for several hours because of the acuity needs of other patients.

Another example provided was of a "hospice" patient who required assistance for turning and repositioning. There were no Nursing Technicians assigned and the RN assigned to the patient during one shift was not able to get to the patient's room to do this. The RN reported the patient's urinary catheter bag had not been emptied and it was: "...so full it looked like it was going to explode."

All of the staff reported going through the "chain-of-command" in voicing their concerns to the hospital's nurse leadership.

Members of the hospital's leadership team including Nursing, Quality Improvement and Risk Management reported during interviews that there were staffing concerns earlier in the year. They had no data that showed patient care was negatively impacted by insufficient numbers of nursing staff. The "data" they referred to were reports generated through their occurrence reporting system. They denied receiving complaints or concerns from nursing staff. They acknowledged there was no policy or protocols to orient float nurses to a unit to which they have not worked.

Based on review of medical records, review of hospital policies and procedures, review of nurse staffing schedules, and staff interviews, it was determined the hospital failed to establish and implement a staffing plan to ensure there were sufficient numbers of qualified nursing staff to:

1. meet the individual needs of patients in the Emergency Department (ED) which resulted in nursing care and services not provided following physician orders and hospital policies. (Patients #1, #29, #34, and #35)

2. meet the individual needs of patients which resulted in nursing care and services not provided following physician orders and hospital policies and procedures for:

a. Patients requiring monitoring for alcohol withdrawal. (Patients #2 and #4)

b. Patients requiring monitoring after cardiac catheter procedures. (Patients #10, #26, and #28)

c. Patients requiring monitoring after invasive procedures. (Patient #6)

d. Medication Administration. (Patients #8 and #40)

Failure to provide the cumulative needs identifed above poses a high potential risk to the health and safety of each patient.

Findings include:

1. The hospital's policy titled Interdisciplinary Assessment-Reassessment Policy revealed patient's in the ED who had not been evaluated by an ED physician should be reassessed at least every 2 hours or more frequently as clinically indicated if they were triaged at an acuity level of 3, 4 or 5.

Patient # 1

Patient #1 presented to the Emergency Department (ED) on 11/27/2015 at 11 a.m. with a chief complaint of "collapsed lung." The patient was triaged by a Registered Nurse (RN) at 11:40 a.m. The RN documented the patient reported she was running approximately one hour prior to arrival and had shortness of breath and left sided chest pain. The patient rated her pain at "9" on a pain scale level of 0 to 10 with 0 meaning no pain and 10 meaning excruciating pain. The patient's vitals signs were recorded as follows: Blood Pressure (BP): 139/76; Pulse: 100 beats per minute; Respiratory Rate: 22 breaths per minute; and oxygen saturation level: 100%. There was no documentation that the RN listened to the patient's lungs. The patient was assigned an acuity level of "3" (Urgent) and was sent back to the ED lobby to wait. The following is the sequence of events after the patient was triaged.

2:42 p.m., three hours later, the patient was called back to the triage area from the lobby, and a Nurse Practitioner (NP) ordered a chest x-ray and labwork. There was no documentation that the NP performed a physical assessment of the patient. The NP reported during a later telephone interview that she assessed the patient but did not document the assessment.

2:50 p.m. The chest x-ray was performed and revealed: "...increasing size of a left upper lung cavitary lesion. Recommend CT scan of the chest for further evaluation as this likely represents progression of disease. based on comparison with a previous x-ray...."

3:57 p.m. An ED physician was assigned to the patient. The specific time of his evaluation was not documented. The physician's documentation included: "...The patient presents with chest pain . Patient went on a run this morning and felt sudden left-sided chest tightness and short of breath. The onset was 4 hours ago and abrupt. The course/duration of symptoms is constant. Location: left chest. Radiating pain: left arm, left side of the neck. The character of symptoms is tightness and pressure. The degree at onset was severe. The degree at maximum was severe. The degree at present is severe, 9/10. There are exacerbating factors including exertion and breathing...Associated symptoms: shortness of breath and neck pain, cough...Respirations are non-labored, diminished breath sounds along the left posterior lung field...." The physician ordered a CT scan of the chest and intravenous Dilaudid for the patient's pain which was administered at 6:52 p.m.

4:30 p.m. The patient was taken to a room in the ED, five and one-half hours after her arrival. She had been held in one of the Triage bays from 2:42 p.m. until 4:30 p.m. and required to wear a mask because the NP thought she might be contagious.

5:42 p.m. The first nursing assessment of the patient was completed. Although the physician documented the patient had diminished breath sounds in her left lung, the RN documented in the Respiratory Assessment section was that the patient had no respiratory symptoms and that her breath sounds in all lobes were "clear." The patient's reported pain level was "8."

6:49 p.m. The physician ordered intravenous Dilaudid for the patient's pain which was administered at 6:52 p.m.

8:14 p.m. The CT scan was performed and revealed the patient had developed "left pneumothorax, comprising approximately 30% of the left lung volume." A pneumothorax (collapsed lung) occurs when air leaks from the lung into the space between the lung and chest wall.

The ED physician performed a pericardiocentesis (tube thoracostomy) at approximately 11 p.m. (the exact time of the procedure was not documented) which was attached to suction to remove the air in the pleural space. The patient received intravenous fentanyl during the procedure. The chest x-ray performed after the procedure at 10:38 p.m. showed that the left lung had re-expanded and the patient's lungs appeared clear.

11:15 p.m. The ED physician documented the patient would be admitted to the Critical Care Unit and wrote admission orders which did not include medication(s) for pain management. The patient remained in the ED throughout the night. There was no physician documentation of the patient after the insertion of the chest tube at 11 p.m. until the on-coming physician's documentation at 8:32 a.m. on 11/28/2015.

The patient's pain level assessed by the ED RN at 12:35 a.m. on 11/28/2015 was "9," however, there was no documentation that the RN notified a physician of the patient's level and requested orders for pain management.

6:23 a.m. The RN documented there were no changes in the assessments of the patient from 5:42 p.m. on 11/27/2015. There was no documentation that the RN assessed the chest tube and suction during the night to ensure proper placement and functioning.

7:30 a.m. The ED RN documented an assessment of the chest tube as: "Absence of expected fluctuation." There was no documentation that this was communicated to a physician.

7:44 a.m. Another chest x-ray was performed following the ED physician's order at 5 a.m. The x-ray revealed the pneumothorax had reoccurred and measured 5.5 cm (centimeters).

8:32 a.m. The oncoming ED physician documented: "Approximate 7:45 a.m. the radiology tech came into the doctor's area and notified me that the patient who had been admitted last night had a pneumothorax reaccumulated. I quickly reviewed the chest x-ray and concurred and subsequently put on a mask and entered the patient's room. I evaluated the urisil. I found the indicator not to oscillating suggesting that the urisil had stopped functioning. By asking the patient to take slow deep breaths I saw that indeed the thoracostomy tube was functioning properly. She had difficulty taking deep breaths because no pain medications have been given to the patient. I asked the nurse to provide a single dose of 4 mg of morphine. I contacted the hospitalist...no evidence that there had been orders other than the initial orders written. I am unaware if the patient had been evaluated by the hospitalist since that time. I also found that the thoracostomy tubes seem to be positional and that when I placed a slight amount of traction on the tube the indicator seems to oscillating (sic) more reliably...I upgraded the patient to ICU. I asked the hospitalist to come and evaluate the patient and apparently he is in route to do so...."

8:15 a.m. the ED RN documented the patient was anxious, had pain with inspiration and had not received any medications since 10 p.m. the previous evening. The RN's documentation included: "...3 way valve less than effective...."

9:01 a.m. The admission History and Physical was performed by the hospitalist.

12 noon. The patient was transferred to the Cardiovascular Intensive Care Unit from the Emergency Department.

Patient # 29

Patient #29 presented to the ED on 04/05/2016 at 9:49 p.m. with complaints of left upper quadrant pain. The patient was triaged at 10:27 p.m. and sent back to the lobby. The patient left at 4:18 a.m. on 04/06/2016 without a nursing reassessment or receiving a medical screening examination. The RN documented the patient was "encouraged" to stay. The patient returned to the ED at 10:36 a.m. with the same complaint of severe abdominal pain in addition to nausea, vomiting and fever. The patient was evaluated by a Physician's Assistant. An abdominal CT scan revealed a bowel obstruction from an incarcerated hernia. The patient was admitted and had surgery later that evening.

Patient # 34

Patient #34 presented to the ED on 11/27/2015 at 12:25 p.m. with flank and abdominal pain. The patient was triaged at 1:36 p.m., over one hour later and sent back to the lobby. The patient was not called to go back to a room until 6:42 p.m., over 5 hours later and the patient had left. There was no documentation the patient was reassessed during the 5 hours.

Patient #35

Patient #35 was over the age of 68 and presented to the ED on 11/27/2015 at 4:40 p.m. with a chief complaint of lacerations and neck injury after a fall. The patient was not called for triage until 5:30 p.m., 50 minutes later at which time the patient had left.

There are 29 beds in the hospital's ED. A review of the ED Activity Log for 11/27/2015 revealed there were 157 patients who presented for care and services, 32 of which arrived by emergency medical services (EMS). There were 4 patients who left Against Medical Advice (AMA); 4 patients who left prior to being triaged, 2 of which were not called for triage for over 1 hour after they presented; 5 patients left after they were triaged, 1 of whom left after 6 hours in the lobby and no nursing reassessment.

Forty-four of the 157 patients who presented to the ED on 11/27/2016 were admitted as in-patients. Those patients remained in the ED under the care of the ED staff until an appropriate inpatient bed became available. The longest length of stay in the ED on that day was over 25 hours (Patient #1) before an inpatient bed became available.

A review of the ED staffing record for 11/27/2015 revealed there were four RN vacancies from their normal staffing pattern which was acknowledged by the Director of Emergency Services during an interview on 03/10/2016.

2a. The hospital did not have a specific policy and procedure for alcohol withdrawal protocol, however, one of the Nurse Educators provided the surveyor with a copy of their "NWMC Nursing Self-Learning Packet: Alcohol Withdrawal-Delirium Tremens Protocol." Documentation in the packet included: "For many individuals with a significant physical dependency, a cluster of withdrawal symptoms known as alcohol withdrawal syndrome (AWS) may appear upon the cessation of or reduction of alcohol consumption, or when individuals reach a level of such significant tolerance that they cannot consume enough alcohol to delay withdrawal...Depending on the degree of physical dependence, withdrawal signs and symptoms are frequently minor but can develop into a severe or even fatal condition. AWS can range from discomfort and mild tremor to alcohol withdrawal related delirium, hallucinations, seizures, and death...Withdrawal related seizures and delirium are more severe manifestations of alcohol withdrawal. Alcohol delirium is a medical emergency and has an estimated 5% mortality rate in patients with alcohol withdrawal...Use of antipsychotics, such as haloperidol, is somewhat controversial. It is sometimes used with benzodiazepines in patients with severe agitation or hallucinations. However Haloperidol can lower seizure thresholds and has been associated with QT prolongations and torsade de pointes. It should be used with cardiac monitoring and NEVER alone for alcohol withdrawal."

The self-learning packet included examples of physician orders, the assessment and scoring tool and the Alcohol Withdrawal/Delirium Tremens Flow Record. The assessment guidelines on the Flow Record indicated the patient should be assessed every hour when the CIWA(Clinical Institute Withdrawal Assessment of Alcohol Scale) score was greater than 25 AND before and 15 minutes after IV medication administration or before and 60 minutes after oral medication administration. The guidelines directed assessments to be completed at a minimum of every four hours.

Patient # 2

Patient #2 was admitted on 02/07/2016 for alcohol abuse and withdrawal seizure. The physician's admission History and Physical dated 02/07/2016 included: "...he was brought in because he did pass out due to an alcohol withdrawal seizure...The patient has been started on benzodiazepines. We'll continue seizure precautions and medically assisted this gentleman as he withdraws from alcohol...The patient has been started on the CIWA protocol. We'll admit to ACT for careful monitoring."

The physician ordered CIWA protocol was initiated while the patient was in the ED. The nursing documentation in the Flow Record did not follow the guidelines for assessment and documentation. For example, the patient was given intravenous Ativan 1 mg at 9 a.m., however was not assessed again until 10:45 a.m., almost two hours later at which time he received another 2 mg IV Ativan. He was reassessed at 12:30 p.m. when he received 2 mg IV Ativan, and not reassessed again until 2:10 p.m., at which time he received Ativan 2 mg IV again. The next documented assessment was at 8 p.m., a delayed period of almost six hours. The patient remained in the ED through 02/08/16, up until the morning of 02/09/2016. The last documented assessment of the patient in the ED was at 5:40 a.m. and he received 2 mg of IV Ativan . He was not assessed again until 10:45 a.m. after he was transferred to the ACT Unit, a period of five hours later. Eighteen of 64 entries in the Flow record were incomplete and/or inaccurate. For example, on 02/13/2016 at 9 p.m., the numbers in the individual columns totaled 6, however, the number documented in the total column was "4." There was no Sedation or Agitation score documented. At 10 p.m., all of the scores were "0", however, "4" was documented in the total column. The next assessment at 4 a.m. on 02/14/2016 was scored all 0's but was totaled at "4." Sedation, Agitation and vital signs were not documented for the prior two entries.

Nursing documentation on 02/09/2016 for Patient #2 included the following:

2:14 p.m.: Dr. (name) informed of pt agitation and impulseness (sic)...Reviewed recent meds given and consideration for haldol. Dr. (name) in agreement."
3 p.m.: Dr. (name) on unit, informed of q 1 h (every 1 hour) CIWA assessments not feasible d/t (due to assignment and other patients' needs and acuity. Physician voiced understanding and confirmed pt is stable. Continue to monitor and provide medications PRN (as needed, notify if CIWA score increases markedly."

According to the ACT Unit daily nurse staffing schedule dated 02/09/2016, there were 18 patients. Both the 7 a.m. to 7 p.m. and 7 pm to 7 am shifts had three RN's assigned and each RN had five patients a piece, and the Charge Nurse had 3 patients. There was one Nursing Tech (NT) for the unit on the day shift and two on the night shift. According to the hospital's ACT Staffing Guidelines, there should have been five RN's and two NT's assigned for both shifts.

Patient # 4

Patient #4 was admitted on 02/22/2016, and started on a physician-ordered CIWA protocol. The first entry was dated 02/22/2016 at 10 a.m., and revealed a Total CIWA-Ar Score of "26." The patients blood pressure was 177/116; respiratory rate (RR) 22; and heart rate (HR) 94 beats per minute. The patient was given 2 mg of Lorazepam IV. The patient was not reassessed until 12:52 p.m., almost three hours later. The CIWA-Ar Score was "24" and his vital signs were: BP: 183/117; RR: 22; and HR:108. The patient was administered 2 mg of Lorazepam IV. The patient was not assessed again until 2:15 p.m., over one hour later.

At 3:40 p.m. the patient's CIWA -Ar score was "21" and he was given 2 mg of IV Lorazepam. The patient was not assessed again until 7:15 p.m. and the CIWA-Ar score was "22." The patient was not medicated because the IV access was "lost." The patient was not assessed again until 9:57 p.m. and was scored at 23 and was medicated. The patient was not medicated for withdrawal for over 6.5 hours. The assessments on documentation on the form did not follow the hospital's assessment guidelines. There were nine entries that the patient was "sleeping" and no assessment completed.

2b. The hospital's policy titled Femoral Arterial and Venous Sheaths - Bedside Removal with Hemostasis Policy included: "Care of the Patient Post Hemostasis: 1. Provide Patient education on length of bed rest, and activity restrictions. 2. Check groin site, dressing, VS and pulses every 15 minutes x4, every 30 minutes x2 and every hour x 4 or as condition warrants, or as ordered. 3. Monitor pulse ox continuously for at least one hour. 4. When the patient resumes previous activity level, assess the groin site for any signs or symptoms of complications. When patient transitions from sitting and/or standing, reassess groin site."

The hospital's policy titled Radial Arterial Sheath - Management and Hemostasis using Radial Artery Compression Device Policy included: "The compression device is to be left on for ~ hours post procedure for interventional cases or per physician order...When it is time to remove the band, the operator withdraws 3 milliliters of air every 15 minutes while observing for any bleeding at the insertion site...If there is no bleeding...1. The operation continues to remove the air until the balloon is completely deflated and observe for bleeding. 2. If there is no bleeding, remove the band and place an occlusive transparent dressing over the radial percutaneous site. 3. Apply flexible arm board to affected wrist and sling to affected arm, if ordered. 4. Instruct patient/family not to manipulate affected wrist for 24 hours and immediately report any signs of bleeding. Care of the Patient Post Hemostasis: a. Provide patient education on length of bed rest, and activity restrictions. b. Assess wrist site (including CMs check), dressing, VS and pulses every 15 minutes x 4, every 30 minutes x 2 and every hour x 4 or as condition warrants, or as ordered. c. Monitor pulse ox continuously or as condition warrants or as ordered. d. When the patient resumes previous activity level, assess the wrist site for any signs or symptoms of complications. When patient transitions from sitting and/or standing, reassess wrist site."

Arteries are high pressure systems and the risk for significant bleeding after an invasive procedure is high. Early assessment and monitoring of patients post cardiac catheterization is essential to prevent a life-threatening complication.

Patient # 10

Patient #10 had a cardiac catheterization procedure on 02/13/2016. The procedure start time was 9:44 a.m. Documentation in the Cardiac Cath Lab report revealed the sheath was removed from the patient's right groin at 10:10 a.m. and manual pressure was held until hemostasis obtained at 10:30 a.m. The Cath Lab RN called report to the RN on the ACT Unit at 10:40 a.m., and the patient was transferred to the unit at 10:50 a.m. The physician's orders post procedures at 10:08 a.m. included: "Per Hemostasis Policy...." There were vital signs documented at 11 a.m. and not again until 4 p.m. The RN's narrative documentation at 7:07 p.m. included: "~1115 pt returned to room from cath lab...rt groin access site soft, no bruising or discoloration, right DP pulse 2+, vss (vital signs stable)...1554 Dr. (name) returned page, writer reported pt HR decreasing to 30s and slowing (sic) increasing back to 50-60s rhythm a-flutter...~pt OOB (out of bed), no change in right groin site, palpalable (sic) right DP...." There was no documentation that the patient's groin site, dressing, vital signs and pulses were assessed following the frequency directed in the policy and procedure.

Documentation on the daily nurse staffing schedule dated 02/13/2016 for the 7 a.m. to 7 p.m. shift on the ACT Unit revealed a patient census of 21. There were three RN's assigned to seven patients each and one NT for all 21 patients. According to the "ACT Staffing Guidelines," there should have been six RN's and two NT's assigned to the unit.

Patient # 26

Patient #26 had a left heart catheterization on 02/13/2016. The procedure started at 12:17 p.m. The arterial sheath from the right femoral artery was removed at 12:30 p.m. and angioseal applied. Hemostasis was obtained at 12:33 p.m. and the case ended at 12:34 p.m. The physician's post-procedure orders at 2:39 p.m. were for the patient to be on "absolute" bedrest for four hours and the head of the bed could be elevated 30 degrees after three hours. The patient was transferred to the Telemetry Unit at 1:50 p.m. The vital signs were obtained and recorded at 2:15 p.m. There was no documentation of a nursing assessment of the patient on the Telemetry Unit until 3 p.m. which included an assessment of the patient's "left" groin. There was no documentation of the patient's activity restriction or patient education regarding activity restriction. There was another set of vital signs recorded at 3:32 p.m. and no other assessments were recorded until 7 p.m. by the next shift.

A review of the daily staffing record for the Telemetry Unit on 02/13/2016, revealed the RN who assumed care of Patient #26 after the heart catheterization was assigned six patients, and the RN was also orienting a new employee. The hospital had no documentation of the acuity levels of the patients.

Patient # 28

Patient #28 had a cardiac catheterization procedure on 02/26/2016, through the right radial artery. The procedure start time was 12:13 p.m. The sheath was removed at 12:30 p.m. and a "TR Band" applied and 12cc of air inserted. A TR Band is a compression device to assist hemostasis of the radial artery after a transradial procedure. The patient was transferred to the unit at 12:34 p.m. The physician's post-procedures orders were written at 12:51 p.m. and included vital signs every 15 minutes for one hour, every 30 minutes for one hour, then one time in one hour. The patient was to be on bed rest for one hour then ambulate "per early ambulation protocol." Vital signs were recorded at 3 p.m. There was no documentation of an assessment of the site or pulses until 8 p.m. by the next shift.

2c. Patient # 6

Patient #6 was admitted with diagnoses of chronic heart failure, persisting left pleural effusions. The patient developed atrial fibrillation and was started on a continuous IV heparin (anticoagulant) drip in anticipation of cardioversion. The patient was scheduled for a thoracentesis (removal of fluid from the space between the lungs and the chest wall) and placement of a drainage catheter in her lung on 03/03/2016, and the IV heparin was discontinued four hours prior to the procedure following physician's orders. The patient returned to the ACT Unit at 5:30 p.m. on 03/03/2016, and a physician gave verbal orders to restart the heparin drip four hours after the procedure. The heparin drip was restarted at 11:32 p.m. on 03/03/2016. A nursing assessment was completed at 8 p.m. on 03/03/2016. There was no documentation specific to the status of the drainage catheter. Vital signs were recorded at 11:57 p.m., 1 a.m. on 03/04/2016 and 4:13 a.m. A nursing narrative note on 03/04/2016 revealed the RN was notified by a physician at 6:20 a.m. that the patient was bleeding from the chest drain site. The RN documented direct pressure was applied and physician orders received to discontinue the heparin, and the aspirin the patient also took. "STAT" lab draws were performed and the unit's Charge Nurse was notified. The physician who found the patient bleeding documented at 6:37 a.m.: "Copious bleeding demonstrated at chest tube insertion site...Discontinue heparin and aspirin. It is recommended that anticoagulants not be restarted. Type and Screen...Nursing staff instructed to apply direct pressure. Repeat CBC and type and screen." There was no other documentation by the night RN nor was there any assessment or other documentation by the on-coming RN for the 7 a.m. to 7 p.m. shift. A physician's progress note dated 03/04/2016 at 10:42 p.m. included: "I was called to bedside for hypotension, according to nurse patient's BP had been steadily dropping this evening...she is awake alert but lethargic, amiodarone drip on hold for now...I will transfer her to CVICU for close monitoring and start her on pressor...." The patient continued to decline and was discharged home on 03/08/2016 with recommendation for hospice comfort care.

The RN on the night shift of 03/03/2016 to 03/04/2016 stated during an interview on 03/22/2016 that she was orienting a new employee on that night, and that Patient #6 was assigned to him. She stated she was at the nurses' station when the physician came out of the patient's room and told her the patient was bleeding. The RN responded to the room and was shocked to see how much blood there was. She stated the pad underneath the patient was soaked. She stopped the heparin drip, called the Charge Nurse and applied pressure to the site.

The RN on the day shift of 03/04/2016 stated during a subsequent interview on 03/22/2016 that he recalled the patient situation and that he assisted the night nurse in caring for the patient. He was not able to recall why he did not do an assessment or documentation on the patient during his shift.

A review of the staffing record for the 7 a.m. to 7 p.m. shift on 03/04/2016 revealed there were 20 patients on the ACT Unit. There were a total of five RN's on the Unit which included the Charge Nurse. The RN assigned to the patient had five patients assigned to him. According to the hospital's ACT Staffing Guidelines, the unit should have had six RN's on the unit.

2d. The hospital's Skin and Wound Care Policy included: "Guidelines: 1. Skin assessments are completed and documented by nursing staff with every full body assessment. 2. When skin breakdown is present, routine care, monitoring and prevention strategies are the responsibility of the staff nurse...7. The Wound Care Team will follow up for pressure ulcer present on admission (POA) weekly, hospital acquired pressure ulcer two times a week. 8. Patient's primary nurse will document the location, drainage, color and presence of dressings. 9. The Wound Care nurse will stage and provide measurement documentation."

Patient # 5

Patient #5 was admitted on 03/16/2016, and had pressure ulcers identified at that time. A wound care nurse evaluated the patient's skin on 03/17/2016 and documented two areas. Wound #1 was on the sacrum measuring 5 x 3cm and 5 x 15 cm with the entire area measuring 7.6 cm x 22 cm. The wound bed center was described as having "yellow adherent slough...." and the surrounding area: "Distal edge has firm purple area with some exfoliation. Within the bright pink area are several purple irregularly shaped poorly defined discolored areas and some exfoliation resembling effects of shear or moisture." The wound care nurse documented the wound was not stageable with the surrounding are resembling deep tissue injury. The recommended treatment was Santyl covered with Mepilex daily. Santyl is an enzymatic ointment used to breakdown and remove dead tissue from a wound. Mepilex is an absorbent foam dressing. The physician's order was for the dressing change using Santyl to be performed daily.

Wound #2 was located on the patient's right coccyx and measure 1 x 1.4 cm x 0.1 cm. The wound was documented to be a Stage 2 with a recommended treatment of a moisture barrier and Mepilex dressing every 12 hours.

A review of the nursing documentation revealed the dressing to the sacrum was performed twice on 03/18 and 03/19/2016 rather than the physician order of once a day. On 03/23/2016 at 8 p.m. the documentation reflected the wound(s) were "open to air." The documentation revealed the dressing change to the right coccyx area was performed twice on 03/18/2016, and then there was no documentation on that area after that.

The documentation of turning and repositioning was sporadic including but not limited to the following: 03/16/2016 at 10 p.m.; 03/17/2016 at 9:35 a.m. over 11 hours later; 03/18/2016 at 7 p.m., 9 1/2 hours later: 03/18/2016 at 7:27 a.m., 12 1/2 hours later; 03/18/2016 at 7 p.m., 11 1/2 hours later; 03/20/2016 at 8 p.m., 23 hours later; 03/20/2016 at 9 p.m., 25 hours later.

Observation was made of a dressing change on 03/24/2016 at 10 a.m. The appearance of the wound was significantly different from the photograph taken at the time of admission. The wound bed appeared to have the yellow slough referred to in the initial assessment, however a significant area surrounding the wound was open. It was evident that the top layer of skin had been removed during the treatments as there was a section of tan skin that was loosely adhering. After cleansing the area, the RN applied Santyl not only to the actual wound bed, but also to the surrounding open skin and to the section of skin loosely stuck on. The surveyor asked how often the treatment with Santyl is performed and she responded two times during the shift.

A wound care nurse, who was not the same nurse who made the original assessment and documentation on 03/17/2016, documented the following on 03/24/2016 at 1:34 p.m.: "Pt is seen briefly for follow up weekly assessment of needs...Staff are repositioning frequently...Staff completed the dressing change today prior to this assessment...The pts sacral wound per nursing only with a small area of yellow slough. POC (plan of care) for daily dressing changes with Santyl and Mepilex foam. Per nursing wound is improving and necrotic tissue/slough is diminishing which is the goal for wound resolution."

A third wound care nurse evaluated the patient's skin on 03/25/2016 and documented that she "cross-hatched" the slough in the wound bed of sacral wound and applied Santyl ointment. She removed "deroofed skin with sharps" on the wound to the right of the coccyx and applied thin Duoderm.

A follow-up review of the documentation of dressing changes was made by the surveyor on 04/04/2016 which revealed a dressing change on 03/26/2016 at 9 p.m. to the coccyx using Mepilex rather than the physician order Duoderm. On 03/27/2016 at 8 a.m., dressing changes were performed to both the sacrum and coccyx using Santyl and Mepilex. The physician's order for the coccyx wound was Duoderm, not Santyl.

An interview was conducted on 04/04/2016 with the wound care nurse who made the original assessments as well as the Director of the Wound Care Program. They reported there was no monitoring to ensure the nursing staff were following physician orders for wound care, to ensure patients were being turned, repositioned, and to ensure that skin assessments were being performed and documented accurately.

Patient # 6

Patient #6 was admitted on 02/18/2016. Documentation revealed the patient was admitted with a Stage 1 pressure ulcer and was evaluated by one of the hospital's wound care nurses on that date. The location of the area was the coccyx/sacrum and it measured 4 cm x 4 cm and the wound bed described as "maroon, non blanchable, intact." The wound care nurse made recommendations including turning every 2 hours avoiding the back. Documentation of turning and repositioning of the patient was inconsistent. The following are examples of the documentation:

02/19/2016- The patient was turned/repositioned between 6-7 p.m., however, there was no documentation again until 02/20/2016 between 7-8 a.m., a period of approximately 12 hours.

02/21/2016- The patient was turned and repositioned at 1 a.m. but not again until 9-10 a.m., a period of 8 hours.

02/22/2016- The patient was turned/repositioned at 9-10 a.m.; 10-11 a.m. and not again until 8 p.m., a period of 9 hours.

02/23/2016- The patient was turned/repositioned at 2-3 a.m.; 9-10 a.m., a period of 6 hours; and 8-9 p.m.,