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Based on interview and record review the hospital failed to comply with the Condition of Participation for Nursing Services as evidenced by:

1. The facility failed to implement an effective system that provided oversight of staffing and maintenance of a safe environment for patients on continuous telemetry monitoring (A-0395).

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 interview and record review, the facility failed to provide a safe environment for one of 30 sampled patients (Patient 1) when Patient 1's primary care nurse, Registered Nurse A (RN A), failed to follow facility policy and perform required assessments on Patient 1 and RN A failed to implement basic life support (BLS) in an emergency situation for Patient 1.

These failures resulted in lost opportunities to intervene and provide appropriate timely treatment to Patient 1. Patient 1 expired on 12/18/2022.

Findings:

During a record review of Patient 1's history and physical (H&P), dated 9/16/2022, the H&P indicated Patient 1 was a 56 year old male with a history of hypertension (high blood pressure), type two diabetes (a condition which affects the way the body processes blood sugar), and chronic kidney disease (progressive damage and loss of function in the kidneys). The facility H&P indicated Patient 1 presented to the emergency department and complained of difficulty breathing with shortness of breath and high blood pressure. The note further indicated Patient 1 had "...severe left ventricle hypertrophy" (LVH; thickening of the wall of the heart's main pumping chamber). The H&P indicated the "...worsening shortness of breath was concerning for heart failure (CHF; a chronic condition in which the heart doesn't pump as well as it should) exacerbation." Patient 1 was admitted to the hospital.

During a record review of Patient 1's physician orders, dated 9/16/2022, Patient 1 had an order for continuous telemetry monitoring (device used to monitor continuously the heart, respiratory rate, and oxygen saturation while transmitting information to a central monitor) with the indication of CHF.

During a record review of Patient 1's physician orders, dated 9/16/2022, Patient 1 had an order for 10 liters (L) oxygen.

During a record review of Patient 1's physician orders, dated 9/16/2022, for vital signs (measurement of body's most basic function: blood pressure, heart rate, temperature, respiration, oxygen saturation, pulse) to be taken every four hours.

During a record review of Patient 1's "Care Summary," dated 9/17/2022, it indicated Patient 1 was on bedrest and should get up with assistance of two people. It further indicated to keep a urinal within reach for Patient 1.

During a review of the day shift staffing assignment, dated 9/17/2022, indicated registered nurse A (RN A) was assigned to provide nursing care to Patient 1.

During a record review of the care timeline in Patient 1's electronic medical record, the night shift nurse for Patient 1 gave "RN Handoff, " on 9/17/2022 at 7:35 a.m., to RN A prior to RN A assuming care for Patient 1.

During a record review of Patient 1's "Care Summary," dated 9/17/2022 at 2:13 a.m., it indicated the night shift contacted the provider regarding a change in condition of Patient 1 when he had changes in blood pressure and heart rate.

During interview with the Director of Critical Care (DCC), on 8/2/2023 at 10:10 a.m., she indicated she conducted the investigation of the care provided by RN A to Patient 1, on 9/17/2022. She indicated she interviewed all relevant staff, including RN A, and reviewed all records related to the incident. She indicated there were several failures by RN A:
1. bedside handoff report from the the night shift nurse to the day shift nurse, RN A, did not occur at Patient 1's bedside.
2. RN A did not assess and document vital signs, a full body assessment and a cardiac strip for Patient 1.
3. When RN A was notified Patient 1 was off telemetry monitoring, RN A did not go to Patient 1 to assess or to place telemetry monitoring and oxygen back on Patient 1.
4. RN A did not initiate BLS procedure and instead attempted paging for help and then yelling for assistance in the hall. RN A did not check the patient and did not activate the CODE BLUE process in the room on the wall.

During interview with the Director of Critical Care (DCC), on 8/2/2023 at 10:10 a.m., she confirmed the handoff reporting should have occurred at bedside and stated this is the facility's expectation. She indicated both nurses reported the bedside report took place at the nursing station. The DCC indicated bedside report is the nurse's ability to first put eyes on their patient and make observations, answer any questions, and address any new care concerns. The DCC indicated the night shift nurse contacted the provider during the night shift because of a significant change in heart rate fluctuations and hypotension as documented in Patient 1's medical record. She indicated RN A should have followed up on this by assessing Patient 1. The DCC indicated she reviewed all of RN A's patients on 9/17/2022 and Patient 1 should have been RN A's most critical. She indicated RN A should have triaged Patient 1 as the most urgent and most pressing in terms of assessment and care of the patients assigned to him.

During an interview with the DCC, on 8/2/2023 at 10:10 a.m., the DCC indicated RN A stated he only looked Patient 1 through the window in the hallway and that he never entered Patient 1's room. She stated "...this is not our expectation." The DCC indicated RN A did not assess and document vital signs, a full body assessment
and a cardiac strip for Patient 1. She stated RN A did not enter Patient 1's room to complete any of these tasks. She indicated this was unacceptable and indicated RN A should have checked Patient 1's vital signs, reviewed a cardiac strip for Patient 1, and should have conducted a full assessment on Patient 1. The DCC stated the facility expectation is that the primary nurse of Patient 1, RN A, should have taken vital signs before 8:00 a.m., conducted a full assessment on Patient 1 between 7:30 a.m. and 9:00 a.m., checked all lines, reviewed a telemetry strip, and documented all assessments in Patient 1's EMR. She added the cardiac telemetry monitoring strip that was printed for review indicated Patient 1's strip indicated "ischemia" (inadequate blood supply and poor circulation in the heart).

During an interview with the DCC, on 8/2/2023 at 10:10 a.m., the DCC indicated when RN A was notified Patient 1 was off telemetry monitoring and no longer being monitored by central monitoring, on 9/17/2022 at 8:26 a.m., RN A informed the staff in central monitoring Patient 1 was in the bathroom. The DCC indicated the oxygen tubing was not able to be kept on while going to the restroom because the tubing length was not long enough and further indicated Patient 1 was on 10 L of oxygen. The DCC indicated RN A should have immediately gone to Patient 1 and telemetry monitoring and oxygen should have been placed back on Patient 1. She indicated the facility expectation is that Patient 1 should have been placed back on monitoring within three minutes.

During an interview with the DCC, on 8/2/2023 at 10:10 a.m., she stated when RN A found Patient 1 lying on the floor, on 9/17/2022 around 8:50 a.m., he did not initiate BLS procedure and instead attempted paging for help and then yelling for assistance in the hall. She stated RN A did not check the patient and did not activate the CODE BLUE process in the room on the wall. She indicated all Registered Nurses are BLS trained, and the facility's expectation would have been for RN A to follow the BLS training and respond with securing the scene for safety, assessing Patient 1, and calling for help by pressing "Code Blue" in the room and not leaving the patient to get help. The DCC indicated another nurse on the unit started CPR on Patient 1. The DCC indicated this was a delay in care and a failure by RN A.

During record review of Patient 1's physician "ED to Hosp-Admission" note, dated 9/17/2022, indicated Patient 1 "suffered a collapse and a PEA cardiac arrest on 9/17/2022. The note indicated Patient 1 received three rounds of cardiac pulmonary resuscitation (CPR: emergency procedure consisting of chest compressions and often artificial ventilation). The note indicated Patient 1 was intubated (a tube inserted into the airway to keep it open and provide oxygen) for airway protection due to cardiac arrest (sudden unexpected loss of heart function). Patient 1 was put on a ventilator (machine that moves air in and out of the lungs and controls how much the patient gets). The note further indicated the patient had "acute hypoxic/metabolic encephalopathy (occurs when brain doesn't get enough oxygen and results in brain damage)."

During record review of Patient 1's "Progress Notes," dated 10/12/2022, indicated a brain MRI (magnetic resonance imaging; test that provides detailed images of almost every internal structure) showed "...restricted diffusion ...concerning for hypoxic anoxic encephalopathy."

During record review of Patient 1's "Neurology follow-up consult note,"dated 10/17/2022, indicated Patient 1 was in an intensive care unit (ICU) since 9/17/2022 and was intubated on no sedation, does not respond to voice, light, or touch, and does not open eyes. The physician further documented it was "...unlikely the patient will walk, talk or communicated with his family in a meaningful way." The note indicated Patient 1 had "...significant, irreversible anoxic brain injury" and with treatment has "...shown no improvement and has minimal brainstem reflexes."

During record review of Patient 1's "Inpatient Nephrology consult follow up note," dated 10/26/2022, indicated Patient 1 was dialysis dependent and anuric (no longer urinating) since 9/17/2022. The physician note indicated "...we do not recommend long term HD (hemodialysis) given the patient's anoxic brain injury and absence of improvement....It is clear dialysis is not benefiting this patient." The note indicated the physician was seeking to establish "...an explicit time limit to life sustaining interventions, after which we will plan to withdraw dialysis."

During a record review of Patient 1's "ICU Discharge Summary, dated 12/18/2022, it indicated after Patient 1 had a PEA cardiac arrest on 9/17/2022, he was transferred to an ICU for care until his death on 12/18/2022. The note indicated while in the ICU he was treated for status epilepticus (seizures lasting longer than 5 minutes), he developed a pseudomonas bacteremia infection in his lungs, one eye, and had several sacral (between lower back and tailbone) decubitus ulcers (skin and soft tissue injuries that form as a result of constant or prolonged pressure on the skin). On 10/21/2022 he went into cardiac arrest, and CPR was performed. During this time, Patient 1 "...developed dialysis dependent renal failure...." The note indicated there was no improvement and Patient 1 had a "...grim prognosis for devastating anoxic injury and low likelihood of a meaningful recovery." The note indicated on 12/2/2022 Patient 1's code status was changed to do not resuscitate. The note indicated on 12/18/2022 Patient 1 went into asystole (when the heart stops beating) and was pronounced expired at 2:55 am.

During a record review of Patient 1's "death certificate worksheet" completed by the physician, dated 12/18/2022, it indicated the immediate cause of death was "diffuse anoxic brain injury due to a PEA arrest due to CHF exacerbation due to uncontrolled hypertension."

Record review of facility policy, "Standards of Care: Implementation in the Progressive Care Unit," revised 10/2021, indicated patients are to be assessed by a Registered Nurse at least twice per shift. Policy further indicated cardiac rhythm will be continuously monitored via telemetry

Record review of facility policy "Nursing Standards Manual: Telemetry," revised 7/2022, indicated the patient's primary care registered nurse should print and review the cardiac strip " ...at least once at the beginning of each shift ...and document the interpretation in the electronic health record."

Record review of facility policy "Nursing Standards Manual: Telemetry," revised 7/2022, indicated vital signs should be taken by the primary care nurse every four hours and documented in the electronic health record.

Record review of facility policy "Nursing Standards Manual: Telemetry," revised 7/2022, indicated the maximum time from when a telemetry alarm is first initiated for any reason to the time someone responds should not exceed three minutes. The policy further indicated if, for any reason, prior to removal of telemetry monitoring the patient needs to be assessed for stability.

Record review of facility policy "Code Blue Protocol," revised 7/2021, indicated any staff trained in BLS should respond to cardiopulmonary arrest with BLS protocols and initiate cardiac resuscitation unless otherwise specified by a written order.

Record review of the facility's job description "Clinical Nurse I," revised 10/18/2022, indicated Registered Nurses must document nursing care and patient response to care, must provide nursing care based on the patient care plan and respond in a timely manner to changes in condition, and must possess BLS certification.