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Based on document reviews and staff interviews, it was determined the Governing Body failed to ensure the hospital functioned in a manner for the provision of quality care in a safe environment as evidenced by non-compliance with the Conditions of Participation for Medical Staff and Nursing Services.

Findings include:

The Board of Trustee Bylaws of Northwest Medical Center dated December 2016 included the following: "...The purposes, goals and objectives of the Board of Trustees of Northwest Medical Center shall be to: 1.1.(a) Support, manage and furnish facilities, personnel and services; provide for diagnoses, medical surgical and hospital care, outpatient care and other hospital and medically-related services to sick, injured, or disabled persons...3.10 RESPONSIBILITIES...The responsibilities and obligations oft he Board shall include: 3.10(a) Assuming responsibility for Medical Staff oversight and quality care evaluation...3.10(b) Requiring a process designed to assure that all individuals who provide patient care services, but who are not subject to the Medical Staff privilege delineation process, are competent to provide such services and receiving reports of quality assurance information regarding competency of care providers not subject to the privilege delineation process....7.2 MEDICAL STAFF GOVERNANCE...7.4 Allied Health Personnel (AHP) The Board may approve specific clinical privileges for individuals who are not part of the Medical Staff, but who may render patient care services within the Hospital setting. Each member of the AHP shall be assigned and made accountable to the appropriate clinical section of the Medical Staff...The terms and conditions of AHP status, and the exercise of clinical privileges, shall be as specified in the appropriate section of Medical Staff Bylaws or as more specifically defined in the notice of individual appointment...."

Cross reference: A-0338: Medical Staff Condition of Participation:
- Cross reference: A-0347: Patient #1 presented to the Emergency Department with sudden onset of severe chest pain. Medical Staff #1, a Physician's Assistant, was notified multiple times by RN Staff #7 of his concern for the patient's ongoing presentation of severe unrelieved chest pain with agitation and anxiety. Further imaging was not ordered after the initial chest x-ray. Medical Staff #1 did not consult with a supervising physician on duty. The patient coded and died in the ED approximately four hours after arrival.

- Cross reference: A-0353: Medical Staff #3 failed to complete an Operative Report for a surgical procedure performed on Patient #13 per Medical Staff Bylaws, Rules and Regulations; and Medical Staff #4 failed to document a telephone call to an on-call specialty physician to discuss options to treat Patient #2's critical low blood pressures.

Cross reference: A-0385: Nursing Services Condition of Participation.

- Cross Reference: A-0392: The hospital failed to ensure there was documented plan to determine the types and numbers of nursing care personnel necessary in all areas of the hospital to provide nursing care to each patient based on their acuity. Patient #1 presented to the Emergency Department with signs and symptoms concerning for aortic dissection. The Registered Nursing (RN) assigned to the patient had three other patients assigned to him. Patient #1 died within four hours of arrival. Patient #3 presented to the ED after a suicide attempt and was placed in a hallway bed without one to one observation per hospital policies. The patient eloped.

The hospital failed to ensure there was documented evidence that all nursing staff were assessed to be competent in the skills required for their job description prior to assigning them to patient care.

- Cross Reference: A-0395: Patient #1 presented to the ED with severe chest pain. The RN assigned to the patient's care did not perform physical reassessments pertinent to the patient's complaints. The patient died within four hours of an undiagnosed aortic aneurysm. Patient #3 presented to the Emergency Department (ED) and was a high risk for suicide. Suicide precautions were not implemented, and the patient eloped.

The cumulative effects of these systemic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Governing Body to be accountable for the functioning of the hospital and the provision of quality care in a safe environment.

Based on document review and and staff interviews, it was determined the governing authority failed to be accountable for the quality of provided by Medical Staff as evidenced by:

- Cross reference: A-0347: Patient #1 who presented to the Emergency Department with sudden onset of severe chest pain. Medical Staff #1 was notified multiple times by RN Staff #7 of his concern for the patient's ongoing presentation. Further imaging was not ordered after the initial chest x-ray. Medical Staff #1 did not consult with a supervising physician on duty. The patient coded and died in the ED approximately four hours after arrival.

- Cross reference: A-0353: Medical Staff #3 failed to complete an Operative Report for a surgical procedure performed on Patient #13 per Medical Staff Bylaws, Rules and Regulations; and Medical Staff #4 failed to document a telephone call to an on-call specialty physician to discuss options to treat Patient #2's critical low blood pressures.

The cumulative effect of these systemic deficient practices resulted in the hospital's failure to meet the requirements for the Condition of Participation for Medical Staff to ensure the provision of quality care.

Based on review of clinical records, hospital policies and procedures, Medical Staff Bylaws / Rules and Regulations, Medical Staff Credential files, and staff interviews, it was determined the governing authority failed to be accountable for the quality of care provided by a medical staff member to Patient #1 who presented to the Emergency Department and died approximately four hours after arrival.

Cross reference: A0043, A0338, and A0353

Findings include:

The hospital's Medical Staff Bylaws April 2021 included: "...An Allied Health Professional ('AHP') shall be identified as an individual, other than a Practitioner, who is qualified to render direct or indirect medical or surgical care under the supervision of a Practitioner who has been afforded privileges within their scope of practice to provide such care in the Hospital...Only AHPs holding a license, certificate or other official credential as provided under state law, shall be eligible to provide specified services in the Hospital as delineated by the MED and approved by the Board. AHP's must...Unless permitted by law and by the Hospital to practice independently, provide written documentation that a Medical Staff appointee has assumed responsibility for the acts and omissions of the AHP and responsibility for directing and supervising the AHP....5.5 Responsibilities...Each AHP shall: a. Provide his/her patients with continuous care at the generally recognized professional level of quality...MEDICAL STAFF RULES AND REGULATIONS...CONSULTATIONS...The attending Practitioner or AHP acting within his/her scope of practice and delineated clinical privileges i primarily responsible for requesting consultation when indicated by patient care needs or when the patient care needs exceed the privileges of the attending practitioner or AHP, and for calling in a qualified consultant...."

Patient #1 presented to the hospital's Emergency Department (ED) on 01/16/2023 at 2:15 p.m., and the medical screening examination was initiated at that time by Medical Staff #1, a Physician's Assistant (PA). The PA's Emergency Documentation included: "...(Patient #1) is an otherwise health 65-year old male who presents emergency [sic] with chest pain. He states that he has had this pain now for about 1 hour. He was at his primary care doctor's office. States that this pain started in the back and has moved to the front and has been there ever since. He currently rates the pain a 12 out of 10...He presents afebrile, he does clutch his chest. He did have relief of pain with meds given in the ED. He has 2 negative troponins. He has most notably a creatinine of 3.7, he has not seen a doctor in several years and does not manage his high blood pressure. He has a heart score of 4. He did not have any relief with nitro given in the field...He was admitted to hospital for new onset of kidney disease and chest pain. He is in stable condition...." The Emergency Documentation included an Addendum dated 01/16/2023 at 8:17 p.m. by the PA which included the following: "At 1800 (6 p.m.) I walked by this patient's room and saw that he was on the floor of the doorway unconscious and unresponsive. He was found to have agonal respirations. No carotid or femoral pulse was palpable. CPR was immediately initiated and the patient was transferred to a bed in the room using a slide board. Dr. (name) and Dr (name) came to assist given his acute change in patient condition. ACLS was initiated. Dr. (name) performed a bedside ultrasound which showed free fluid in the abdomen and left side of the chest cavity. Patient was intubated by Dr. (name). Attempted to resuscitate the patient until TOD (time of death) 1819 (6:19 p.m.). He was PEA (pulseless electrical activity) on the monitor on every pulse check. Top differential diagnosis at this point is a aortic dissection. At the time of his event patient's blood pressures documented were 122/74 mm hg and then 178/76 mm hg. Prior to this I had checked on patient a couple of times and he was in no acute distress. comfortable [sc] on the bed sleeping at times. His pain did not appear intractable based on my reexaminations of this patient. His EKG done twice did not show significant ST segment changes to suggest acute ischemia. Chest x-ray without acute findings and his second troponins had resulted within normal limits. He did not have a history of chronic illness and was very healthy...."

The Emergency Documentation also included an Addendum by a physician (Medical Staff #2) who responded and assisted in the care of the patient at the time the patient was found unresponsive The physician's documentation included: "This physician was called into the room at the time of patient's code. The patient was not evaluated by this physician prior to him becoming apneic and pulseless. CPR was in progress, patient was given epinephrine and chest compressions and was intubated by Dr. (name). Prior to his collapse he was complaining of worsening chest pain radiating into his back...At the time of initial evaluation, the recorded last blood pressure showed 178/76 with his sudden collapse there was immediate concern for aortic dissection, PE (pulmonary embolism) or pneumothorax... POC (point of care) ultrasound showed lung sliding bilaterally as well. His LV (left ventricle) was not significantly dilated, and he had no large pericardial effusion. The patient was noted to have free fluid in his left thoracic chest as well as LUQ (left upper quadrant) on exam, concerning for aortic dissection, however the exact cause of his collapse is unknown. Throughout the resuscitation, on multiple pulse checks he remained pulseless and had no coordinately cardiac contractions noted on POC ultrasound. Time of death was called at 1819 (6:19 p.m.). Family was informed with (Medical Staff #1)...." The following is a synopsis of the course of events in the ED.

-2:15 p.m.: Arrival by ambulance. Nurse triage and medical screening examination initiated. Vital signs: Blood Pressure (BP) 122/74; Pulse 64; Respirations 18.
-2:20 p.m. EKG performed
-2:44 p.m.: Vital signs - BP 178/76; Pulse 60; Respirations 12
-2:51 p.m.: Morphine 4 mg intravenous IV) push administered
-3 p.m.: Nursing Note - "Pt received 4 mg of (Morphine) with no apparent relief. Pt still complaining of '12 out of -10' pain. Pt is restless and clutching his chest. Physician aware." Vital signs: BP 171/88; Pulse 56; Respirations 17.
-3:07 p.m. Chest x-ray performed
-3:15 p.m. Nursing Notes - "During rounding, pt found in severe pain writhing around on stretcher. Upon entering room pt stood up and grasped chest. Pt had pulled monitor cables off. RN offered pt to sit on stretcher and be reconnected to acquire vitals. Pt placed back on monitor. RN requested pain meds from provider.
-3:55 p.m. Fentanyl 50 mcg IV push administered
-4 p.m. Blood Pressure: 219/120
-4:04 p.m. Blood pressure: 212/109
-4:45 p.m. Nursing Notes - "Pt complaining of pain. States 'the other meds aren't working'. Physician aware."
-4:52 p.m. Orders written by Medical Staff #1 for inpatient admission
-5:06 p.m. EKG performed
-5:25 p.m. Nursing note - "Patient unable to find position for adequate comfort. Pt has laid face down, on his side, at the foot of stretcher, at the heat of the stretcher, etc. He has tried standing, sitting, laying and walking yet seems unable to get relief. Physician aware of pt's presentation."
-6:25 p.m. Nursing note - "...Pt's RN witnessed charge RN (name) answering a call light to patients room. Patient asking for pain medication. Patient's RN told patient that he would ask the physician. At 1755 (5:55 p.m.), a loud noise came from the direction of pt's room. RN immediately responded to find pt face down in the doorway to room...Pt's RN called for assistance and began providing care for patient. Upon checking for pulse, pt was agonally breathing with no palpable pulse. By this time help had arrived...Pt lifted to stretcher and resuscitation efforts ensued."

There was no documentation in the clinical record that Medical Staff #1 acknowledged being advised of the patient's unrelieved pain as documented above. There was also no documentation consulted with a supervising physician during the patient's time in the ED until the patient coded.

The patient's death was a reportable case to the Office of Medical Examiner (OME). Documentation in the Medical Examiner Report dated 01/18/2023 revealed the cause of death was: "... ruptured aortic dissection due to hypertensive cardiovascular disease."

A focused review was conducted of the clinical records two other patients who presented to the ED and were diagnosed with aortic dissection, Patient #2 and Patient #13. Patient #2 presented to the ED on 01/23/2023 and Patient #13 presented to the ED on 02/28/2023. The medical providers who provided and directed the care to those patients identified the potential signs and symptoms of aortic dissection and obtained emergent CT scans to confirm the diagnosis.

An interview was conducted on 03/07/2023 with Staff #7 who was assigned to the care of Patient #1 on 01/16/2023. Staff #7 reported that neither the morphine and fentanyl administered were effective on the patient's pain. Staff #7 stated that although continuous telemetry monitoring was ordered, the patient repeatedly ripped off the leads trying to get relief from the pain. The nurse stated he was concerned that the source of the pain was not being addressed, and shared his concern with Medical Staff #1. The nurse asked Medical Staff #1 about the possibility of additional labs and/or imaging, and Medical Staff #1 only ordered a urine drug screen. There was an order in the clinical record dated 1/16/2023 at 4:55 p.m. for a urine drug screen.

A review of Medical Provider #1's credential file revealed privileges for critical care services were granted on 2/23/2022. Medical Provider #1 then requested privileges for emergency services which were granted on 08/22/2022. The credential file included a "Physician - Physician Assistant Delegation Agreement" for Northwest Medical Center dated 11/11/2022. The Instructions to Applicants included: "This Delegation Agreement will be kept on file at Northwest Medical Center...and reviewed annually during the month of December...." Delegation of Medical Services / Scope of Practice included: "The physician assistant is the agent of their supervising physician in the performance of all practice related activities, including the ordering of diagnostic, therapeutic and other medical services. The physician assistant may perform the following services delegated by the supervising physician...11. Seek consult from supervising physician, other on-duty physicians or on-call physicians regarding any task, procedure or diagnostic problem which the physician assistant determines necessary...." The form also included a section titled "Supervision and Evaluation of Performance" which detailed how and when the supervision would be performed. For example, the supervising physician is directed to review selected patients seen by the physician assistant on a weekly basis, document the reviews on a log, and submit the logs to the "medical director" every two weeks. The surveyor requested documented evidence that the reviews were made and documented on a log, however, the hospital was not able to provide that documentation. Staff #6 and Staff #10 reported during an interview on 03/28/2023 that the Physician-Physician Assistant Delegation Agreement was between the Physician Assistant and the supervising physician and not dictated or monitored by the hospital's Medical Staff Bylaws and Rules and Regulations. Staff #6 stated they (Medical Staff) only required the PA's submit evidence of a supervising physician which would be reviewed every three years during the re-credentialing process. Staff #6 and Staff #10 stated that although the form in Medical Staff #1's credential form specifically included the name of Northwest Medical Center, they determined the form was developed by the contracted emergency services group and did not represent the practice of Medical Staff Services.

The surveyor was informed that Patient #1's clinical record had been submitted to Medical Staff Services for possible peer review.

Based on clinical record review, review of hospital Medical Staff Bylaws, Rules and Regulations, and staff interview, it was determined:

1. Medical Staff #3 failed to complete an Operative Report for a surgical procedure performed on Patient #13.

2. Medical Staff #4 failed to document a telephone call to an on-call specialty physician to discuss options to treat Patient #2's critical low blood pressures.

Cross reference: A0043, A00338, and A0347

Findings include:

1. The Medical Staff Rules and Regulations included the following: 3.3.-3 Operative/Procedure Reports: Operative/procedure reports shall include a preoperative diagnosis, detailed account of the findings at surgery or invasive procedure as well as the details of the surgical/invasive procedural technique, the surgery or invasive procedures performed including a description of the surgery or invasive procedure, the specimens removed, the post-op diagnosis, name of practitioner and any assistants, and any estimated blood loss. Operative or invasive procedural reports shall be written (or dictated) within 48 (forty-eight) hours following surgery/invasive procedure. A post-procedure note must be entered before the patient is transferred to the next level of care if the operative report is not placed in the record immediately after surgery. The report should be authenticated by the practitioner as soon as possible and made a part of the patient's current medical record...Any practitioner failing to dictate operative/procedural notes as required herein will be brought to the attention of the Chief of Staff for appropriate action...."

Patient #13's clinical record was reviewed on 03/16/2023. The record included an "AZN IntraOp OR Summary" which revealed the patient was taken to the Operating Room on 03/02/2023 at 4 p.m. for a thoracotomy performed by Medical Staff #3. The Operative Report was not able to be located, and Staff #4 requested assistance from Medical Records staff in locating the document. The Operative Report was still not able to be located in the medical record on 3/22/2023, and medical records staff reported the patient was discharged on 03/20/2022 and any records not yet in the electronic record would be scanned in. The Operative Report was located in the clinical record on 03/28/2023. The report was completed by Medical Staff #3 on 03/23/2023, twenty-one days after the procedure.

2. The Medical Staff Rules and Regulations also included: 2. Emergency Department...2.7 An appropriate Emergency Department medical record shall be kept for every patient receiving emergency services...The Emergency Department medical record shall include...g. Treatment given and plans for management...."

Patient #2 presented to the ED on 01/16/2023 and was diagnosed with an aortic dissection and subsequently transferred to another acute care hospital for care and treatment. An interview was conducted with Medical Staff #4 on 02/23/2023 and reported that started making transfer arrangements as soon as he identified the ascending aortic aneurysm. He explained the patient needed the services of both a Cardiothoracic (CT) and Vascular surgeons and that they only had a CT surgeon on-call. He added that he called the CT surgeon on-call to ask advice medications that might be us to keep the patient's pressures up. He said he did not call the CT Surgeon for a formal consult and therefore did not document the conversation in the medical record...."

Based on document reviews and staff interviews, it was determined that the hospital failed to meet the requirement for Condition of Participation for Nursing Services and to ensure the provision of quality care in a safe environment as evidenced by:

Cross reference: A-0392: Failure to have a documented plan to determine the types and numbers of nursing care personnel necessary in all areas of the hospital to provide nursing care to each patient based on their acuity. Patient #1 presented to the Emergency Department with signs and symptoms concerning for aortic dissection. The Registered Nursing (RN) assigned to the patient had three other patients assigned to him. Patient #1 died within four hours of arrival. Patient #3 presented to the ED after a suicide attempt and was placed in a hallway bed without one to one observation per hospital policies. The patient eloped.

2. Failure to ensure there was documented evidence that all nursing staff were assessed to be competent in the skills required for their job description prior to assigning them to patient care.

Cross reference: A-0395: Failure to ensure a Registered Nurse (RN) assessed and evaluated the care on an ongoing basis for:

1. Patient #1 who presented to the ED with severe chest pain. The RN assigned to the patient's care did not perform physical reassessments pertinent to the patient's complaints. The patient died within four hours of an undiagnosed aortic aneurysm.

2. Patient #3 who presented to the Emergency Department (ED) and was a high risk for suicide. Suicide precautions were not implemented, and the patient eloped.

The cumulative effects of these systematic deficient practices resulted in the facility's failure to meet the requirement for Condition of Participation for Nursing Services and to ensure the provision of quality care in a safe environment.

Based on document reviews and staff interviews, it was determined the hospital:

1. Failed to have a documented plan to determine the types and numbers of nursing care personnel necessary in all areas of the hospital to provide nursing care to each patient based on their acuity. Patient #1 presented to the Emergency Department (ED) with symptoms concerning for aortic dissection. The hospital failed to ensure there were sufficient numbers of qualified nursing available to adequately monitor the patient. Patient #1 died within four hours of presenting to the ED. Patient #3 presented to the ED and assessed to be at high risk for suicide. The hospital failed to ensure there were sufficient numbers of qualified nursing available to provide the patient with 1:1 observation. The patient eloped.

2. Failed to ensure there was documented evidence that all nursing staff were assessed to be competent in the skills required for their job description prior to assigning them to patient care.

Cross reference: A0043, A0385, and A0395

Findings include:

1. The hospital's "Acuity Staffing Assignment and Monitoring Policy" most recent revision date was "1/23/19". Documentation in the policy included: "Northwest Medical Center (NMC) has a process for assessing the acuity of patients and adjusting staffing and assignments based upon the nursing care required for the patient population...Patient acuity is measured at least twice in a 24 hour period. This acuity is then utilized when assignments are made by the Clinical Nurse Leader or designee...." The policy did not identify the types of nursing personnel required for each unit, for example: Staff Nurses, Charge Nurses, Patient Care Technicians (PCT), etc. The policy did not include a mechanism to assess the nursing needs of each patient.

Patient #1 presented to the hospital's Emergency Department (ED) by Emergency Medical Services (EMS) on 01/16/2023 at 2:15 p.m. and was triaged by an RN at that time who documented the patient's chief complaint was sharp mistral chest pain radiating to his back which started one hour prior to arrival. The patient's pain level was documented to be "10/10." The RN assigned the patient's ESI acuity level of 2. RN Staff #7 assigned to the patient's care documented multiple entries of the patient's unrelieved pain and the patient tearing off the telemetry leads. The patient died in the ED within four hours of arrival. An autopsy perform revealed the cause of death was aortic dissection. Refer to Tag A-0395 for more specific details related to Patient #1.

RN Staff #7 reported during an interview that he was concerned about the patient's presentation for aortic dissection and acknowledged physical assessments related to that presentation were not documented. RN Staff #7 also reported he had three other patients assigned to him at that time.

Patient #3 was taken by Emergency Medical Services (EMS) on 02/17/2023 at 3:50 p.m. to the hospital's Emergency Department (ED). The patient was triaged by Staff #12 at that time who documented the patient called EMS after a suicide attempt by taking antianxiety pills. Staff #12 assigned an ESI acuity score of 3 even though the patient was assessed to be at "High Risk Level" for suicide. The only intervention documented was, "Other: in ambulance bay, waiting for RM (room)." The patient was evaluated by a physician at 6:12 p.m. whose documentation included: "...Patient does attest to having suicidal ideations with attempt today...Patient is currently voluntary for behavioral health evaluation...I was informed at 1913 that the patient had eloped. Patient was in one of the hallway beds...I was not made aware of her elopement prior to being able to reevaluate her....."

An interview and record review was conducted the ED Nursing Director, Staff #3, who agreed the patient was not provided with 1:1 observation.

Interviews were conducted with Nursing Supervisors on each inpatient unit during observations of the units. Each Nursing Supervisor referred to a staffing grid document that determined the ratio of nurses to patients. Nursing leadership on the two intensive care units reported the standard ratio of nurses to patients was one RN to two patients or one RN to one patient (high acuity). The surveyor asked about the types of nursing staff used on the ICU's unit in addition to Registered Nurses. The response was if PCT's were assigned to the unit, they would be floated elsewhere in the hospital a majority of the time. An interview with an RN on one of the intensive care units present during the tour reported that PCT's could assist a patient with ambulating or other activities of daily living which may or may not be done if the RN is tied up with high acuity patients.

Nursing Leadership on the Acute Care Telemetry 25-bed unit reported the nurse:patient ratio was 1:4 (one RN to four patients). The nurse:patient ratio on the Medical and Neuro Units was reported to be 1:6. The hospital's policy did not include or reference the use of a staffing grid.

The Chief Nursing Officer reported during interviews that the current hospital's nurse staffing policy did not include a method to determine the acuity of each patient or a clear process for ensuring the types and numbers of nursing personnel would be assigned to meet the needs of each patient.

2. The hospital's policy titled, "Position Descriptions and Competencies" had an effective date of 05/15/2019. There was no documentation on the policy that it had been reviewed and/or revised after that date. Documentation in the policy included: ....All staff, contractors, volunteers, and students, must demonstrate competency as required by The Joint Commission standards, state and federal regulations, and Facility policy. All departments must have a process for determining staff competency at the time of hire and for assessing and documenting continued competency...."

The policy titled, "Orientation / Reorientation" had an effective date of 11/01/2016, however, no documentation of a review and/or revision after that date. Documentation in that policy included: "...Nursing Skill Proficiency. All new nursing staff...will be required to demonstrate proficiency in nursing skills required for their unit. Nursing orientation to the unit must be individualized for each staff member by having the unit manager assign the new employee to a preceptor. It will be the responsibility of the preceptor or manager to identify deficiencies noted on the appropriate competency assessment and provide the resources to enable the new employee to become proficient...The completed competency assessment must be returned to the Facility's Human Resources Department as soon as orientation is complete...."

A random sample of education records of RN's from different units of the hospital were selected for review. A review of RN Staff #14's education file revealed a hire date of 07/18/2022 as a "new graduate" from nursing school. The New Employee Department Competency Verification - Emergency Department had 41 pages of skills for the employee to be determined competent in by the Evaluator. Several of the required skills on the form had no documentation that Staff #14 was verified to be competent in. For example, there was no documentation that the employee was verified to be competent for: External Pacing and EKG's; differentiating between chemical, behavioral, and medical/surgical restraints; assessing fetal heart tones; and the employee's role in an emergency delivery. The last page of the competency verification form was signed by the Staff #14 on 02/08/2023. The Clinical Educator's Signature line was blank.

A review of RN Staff #13's education file revealed a form titled "Competency Checklist for Care of Patient at Risk for Harm to Self/Others." There were seventeen items on the checklist as well as columns for the Evaluator to initial and date that the employee was found competent/ knowledgeable for each item. The form was signed by the employee on 01/30/2023, however, the Evaluator's Signature line was blank.

RN Staff #16 revealed had a hire date of 05/16/2022 and was assigned to the Neuro Unit. The employee's education file included a "Central Line Competency Assessment Tool. The instructions included: Preceptors/managers assess competencies using the Methods and age Categories below. Multiple methods and age categories are recorded." The form included multiple activities under the categories of Central Line Site Care; Intermittent Medication Administration; and, Blood Draw from Central Venous Catheter. The column for the method of assessment was not completed, however, the form was signed by the employee and the Evaluator on 06/08/2022.

The above employee records were reviewed with an RN Clinical Educator who acknowledged there was no consistency in how the methods of assessing competencies in a specific activity/skill are documented.

The above employee records were reviewed with the Chief Nursing Officer (CNO) during an interview on 03/28/2023. She verified the inconsistencies in assessing competencies of nursing staff on different units.

Based on record reviews and staff interviews, it was determined the hospital failed to ensure a Registered Nurse (RN) assessed and evaluated the care on an ongoing basis for:

1. Patient #1 who presented to the ED with severe chest pain. The RN assigned to the patient's care did not perform physical reassessments pertinent to the patient's complaints. The patient died within four hours of an undiagnosed aortic aneurysm.

2. Patient #3 who presented to the Emergency Department (ED) and was a high risk for suicide. Suicide precautions were not implemented, and the patient eloped.

Cross reference: A0043, A0385, and A0392

Findings include:

The hospital's "Interdisciplinary Assessment - Reassessment Policy" included the following: "POLICY: Northwest Medical Center assesses and reassesses patient based upon their individual needs including physical, psychological and social cultural status...Initial Emergency Department Nursing Assessment begins with a primary assessment that includes, but is not restricted to, evaluation of the airway, breathing, circulatory status, level of consciousness, pain level, and the nature of the complaint. During the triage process, Acuity of the patient is assigned using the five level triage algorithm, Emergency Severity Index (ESI)...Nursing reassessment: completed throughout the course of care and is focused on both intervention efficacy and changes in patient condition. Patients in the emergency department will be reassessed accordingly. It is understood that patient condition in the emergency department commonly changes and reassessment will be completed as clinically indicated...."

The hospital's "Suicide Risk Assessment and Interventions Columbia Protocol in Non-Behavioral Health Setting" included: "...All adolescent and adult patients...who present for care and services will be screened for suicide ideation and behavior using the Columbia Protocol...Based on the severity and immediacy of suicide risk assessed using the Columbia Protocol, patient safety measures and interventions will be implemented as a means to keep patients from inflecting harm to self. This policy is applicable to patients admitted to non-behavioral health setting whether inpatient or outpatient...during the nursing admission assessment, triage, or initial intake...One to One (1:1) Observation: Intervention for high risk for suicide. Continuous observation and staff are able to see the patient in clear view and staff can respond immediately to intervene and assure safety at all times, including while the patient sleeps, uses the toilet, bathes, etc....Assess the environment of care in a patients room and complete the Safe Room Check List

The hospital's "Triage - Emergency Department Policy" included: The Emergency Severity Index (ESI) is a tool for use in emergency department triage...." ESI Level 2 was defined as: "the patient is critically ill but does not need immediate medical interventions, however can move to resuscitation level if care is not started timely....Examples (but not limited to) Active chest pain...suicidal or homicidal ideation

Patient #1 presented to the hospital's Emergency Department (ED) by Emergency Medical Services (EMS) on 01/16/2023 at 2:15 p.m. and was triaged by an RN at that time who documented the patient's chief complaint was sharp mistral chest pain radiating to his back which started one hour prior to arrival. The patient's pain level was documented to be "10/10." The RN assigned the patient's ESI acuity level of 2.

The patient was evaluated by Medical Staff #1 whose documentation included: "...(Patient #1) is an otherwise healthy 65-year old male who presents emergency [sic] with chest pain. He states that he has had this pain now for about 1 hour. He was at his primary care doctor's office. States that this pain started in the back and has moved to the front and has been there ever since. He currently rates the pain a 12 out of 10...He presents febrile, he does clutch his chest.

The following is a synopsis of the course of events in the ED.

-2:15 p.m.: Arrival by ambulance. Nurse triage and medical screening examination initiated. Vital signs: Blood Pressure (BP) 122/74; Pulse 64; Respirations 18.
-2:44 p.m.: Cardiovascular and Neurological assessment documented by RN Staff #7 Vital signs - BP 178/76; Pulse 60; Respirations 12
-2:51 p.m.: Morphine 4 mg intravenous IV) push administered
-3 p.m.: Nursing Note - "Pt received 4 mg of (Morphine) with no apparent relief. Pt still complaining of '12 out of -10' pain. Pt is restless and clutching his chest. Physician aware." Vital signs: BP 171/88; Pulse 56; Respirations 17.
-3:07 p.m. Chest x-ray performed
-3:15 p.m. Nursing Notes - "During rounding, pt found in severe pain writhing around on stretcher. Upon entering room pt stood up and grasped chest. Pt had pulled monitor cables off. RN offered pt to sit on stretcher and be reconnected to acquire vitals. Pt placed back on monitor. RN requested pain meds from provider.
-3:55 p.m. Fentanyl 50 mcg IV push administered
-4 p.m. Blood Pressure: 219/120. There was no documentation Medical Staff #1 was notified.
-4:04 p.m. Blood pressure: 212/109. There was no documentation Medical Staff #1 was notified.
-4:45 p.m. Nursing Notes - "Pt complaining of pain. States 'the other meds aren't working'. Physician aware."
-5:25 p.m. Nursing note - "Patient unable to find position for adequate comfort. Pt has laid face down, on his side, at the foot of stretcher, at the heat of the stretcher, etc. He has tried standing, sitting, laying and walking yet seems unable to get relief. Physician aware of pt's presentation."
-6:25 p.m. Nursing note - "...Pt's RN witnessed charge RN (name) answering a call light to patients room. Patient asking for pain medication. Patient's RN told patient that he would ask the physician. At 1755 (5:55 p.m.), a loud noise came from the direction of pt's room. RN immediately responded to find pt face down in the doorway to room...Pt's RN called for assistance and began providing care for patient. Upon checking for pulse, pt was agonally breathing with no palpable pulse. By this time help had arrived...Pt lifted to stretcher and resuscitation efforts ensued."
-6:19 p.m. Time of death called.

The patient's death was a reportable case to the Office of Medical Examiner (OME). Documentation in the Medical Examiner Report dated 01/18/2023 revealed the cause of death was: "... ruptured aortic dissection due to hypertensive cardiovascular disease."

There was no documentation that nursing physical reassessments were performed following nursing standards of care for the care of a patient with symptoms of aortic dissection. The following documentation was located on the website for RNpedia. "Aortic Dissection Nursing Management." https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-notes/aortic-dissection/, accessed 04/12/2023.

"Suspect dissection if a patient presents with signs and symptoms of acute MI (AMI) but lacks classic electrocardiographic (ECG) changes of MI. Unlike AMI, pain from an aortic dissection comes on suddenly. Anterior chest pain that mimics AMI pain usually is associated with aortic arch or aortic root dissection. Dissection interrupts blood flow to the coronary arteries (most often the right coronary artery), leading to inferior-wall MI. Signs and symptoms of cardiac tamponade-including muffled or distant heart sounds, hypotension, jugular venous distention, and pulsus paradoxus-must be recognized early for the patient to have a chance of surviving.

Patient Monitoring:
Continuously monitor arterial BP during acute phase to evaluate the patient's response to therapy.
Continuously monitor ECG for dysrythmia formation, ST segment or T-wave changes, suggesting coronary sequelae or a decrease in arterial blood flow.

Patient Assessment:
Assess neurologic status to evaluate the course of dissection. Confusion or changes in sensation and motor strength may indicate compromised cerebral blood flow (CBF).
Auscultate for changes in heart sound and signs and symptoms of heart failure, which may indicate that the dissection involves the aortic valve.
Compare BP and pulses in both arms and legs to determine differences...."

Staff #7 reported during an interview on 03/07/2023 that the patient's symptoms were concerning for aortic dissection, and acknowledged there were no nursing physical assessments of the patient after the initial assessment.

Patient #3 was taken by Emergency Medical Services (EMS) on 02/17/2023 at 3:50 p.m. to the hospital's Emergency Department (ED). The patient was triaged by Staff #12 at that time who documented the patient called EMS after a suicide attempt by taking antianxiety pills. Staff #12 assigned an ESI acuity score of 3 even though the patient was assessed to be at "High Risk Level" for suicide. The only intervention documented was, "Other: in ambulance bay, waiting for RM (room)." The patient was evaluated by a physician at 6:12 p.m. whose documentation included: "...Patient does attest to having suicidal ideations with attempt today...Patient is currently voluntary for behavioral health evaluation...I was informed at 1913 that the patient had eloped. Patient was in one of the hallway beds...I was not made aware of her elopement prior to being able to reevaluate her....."

Nursing documentation by Staff #12 dated 02/17/2023 at 7:13 p.m. included: "pt pulled out IV and eloped through ambulance door, PCSO (Pima County Sheriff) contacted by charge nurse...." There was no documentation in the record that suicide precautions were initiated.

Patient #3 returned to the ED on 02/18/2023 at 1:13 a.m. The patient was triaged by RN Staff #13 during which time the suicide risk assessment was performed revealing the patient was at high risk for suicide. The only high suicide risk intervention documented by RN Staff #13 was "Physician Notification."