HospitalInspections.org

48212

Based on observation, interview and record review, the facility failed to ensure its emergency services followed regulatory requirement to post signage in the emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) to notify patients of their rights to receive medical examination and treatment for emergency medical condition.

This deficient practice had the potential for patients not knowing their rights to been seen by ED physician and to receive medical examination and treatment for emergency medical condition.

Findings:

During a concurrent observation and interview on 3/19/2024 at 12:03 p.m. with the Director of Nursing (DON), in the emergency department (ED), there was no signage to indicate the rights of individuals to examination and treatment for emergency medical condition posted in ED waiting room or ED treatment area. DON confirmed that there was no signage in the ED waiting room and in ED treatment area.

During a concurrent interview and record review on 3/21/2024 at 12:08 p.m. with the DON, the facility's policy and procedure (P&P) titled, "EMTALA Compliance [Emergency Medical Treatment and Active Labor Act] (law requires hospital emergency departments that accept payments from Medicare to provide an appropriate medical screening examination to anyone seeking treatment for a medical condition)," dated 1/2024 was reviewed. The P&P indicated, "It is the policy of [the facility] to comply with the EMTALA obligations. The policies are mandated by Section 1867 of the Social Security Act, as amended, and regulations adopted in 1994 ... Signage: [the facility] shall post signs conspicuously in lobbies, waiting rooms, admitting areas and treatment rooms where examination and treatment occurs in the form required by [the federal agency] that specifies the rights of individuals to examination and treatment for emergency medical conditions. Signs shall be posted in the Emergency Department, Labor and Delivery, ambulatory clinics and other locations where patients may present for emergency services." The DON stated there should be EMTALA signage in the ED waiting room and treatment area for patients to see because it is patients' rights to know that they have the rights to be seen by the ED physician.

Based on interview and record review, the facility failed to report death associated with restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) within 24 hours after one of 30 sampled patients (Patient 1) had been removed from restraints, in accordance with the regulations and the facility's policy and procedures. Patient 1 had hard/leather four-point (on both wrists and both ankles) restraints within 24 hours prior to his (Patient 1) death.

This deficient practice had resulted in the facility not complying with the regulatory reporting requirement and had the potential to delay an investigation which may result in patient harm (skin tear, strangulation, etc.) for other patients who may be on restraints.

Findings:

During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/8/2023, the H&P indicated, Patient 1 was admitted to the facility with diagnoses of hypoxia (a condition in which the body lacks adequate oxygen supply), psychosis (a mental disorder characterized by a disconnection from reality), hypertension (high blood pressure), and diabetes mellitus (high blood sugar).

During a review of Patient 1's "Code Blue Note (physician documentation regarding patient medical emergency event)," dated 9/9/2023, the Code Blue Note indicated Patient 1 died on 9/9/2023 at 5:28 a.m.

During a concurrent interview and record review on 3/19/2024 at 2 p.m. with the Director of Performance Improvement (DPI), Patient 1's "Restraints Flowsheet (Nursing documentation recording when restraints is being used)," was reviewed. The Restraints Flowsheet indicated Patient 1 was placed on hard/leather four-point restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) on 9/8/2023 at 2:30 a.m. and was removed from restraints on 9/8/2023 at 7:48 a.m. DIP confirmed that Patient 1 was on four-point restraints from 9/8/2023 at 2:30 a.m. to 9/8/2023 at 7:48 a.m.

During an interview on 3/22/2024 at 10:12 a.m. with the DPI, DPI stated the facility did not look through Patient 1's medical record to identify Patient 1 was on four-point restraints during this hospitalization. DPI stated Patient 1 had restraints on within 24 hours prior to his (Patient 1) death and it should have been reported to the federal agency per regulation.
871022

During a review of the facility's policy and procedure (P&P) titled, "Restraints: Violent Behavior or Seclusion (involuntary confinement)," dated 8/15/2023, the P&P indicated, "The hospital must report the following information to [federal agency]: Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion."

Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by:

1. The facility failed to follow State and Federal regulatory standards regarding safe patient care assignments. Over 50% of the patient care assignment in one of 3 sampled units (Unit 1) consisted of licensed vocational nurses (LVNs). Two LVNs (LVN 1 and 2) were assigned to perform direct patient care in the Gero-Psychiatric Unit (Unit 1, a unit that serves the general population hospitalized for mental and/or behavioral health illnesses) on 3/19/2024, from 7 a.m. to 7 p.m. There was only one Registered Nurse (RN) who had oversight for both LVNs (LVN 1 and LVN 2). This deficient practice had the potential to result in patient needs not being met when a Registered Nurse is not readily available in cases of emergency. (Refer to A-0392)

2. The facility failed to ensure one of two sampled charge nurses- Charge Nurse 2 (CN 2), a Registered Nurse, remained free of job duties that prevented her (CN 2) from fulfilling the functions of a Charge Nurse for one of three sampled units (Unit 2). In the Critical Care Unit (Unit 2, a floor within a hospital where critically ill patients receive specialized medical and nursing care), CN 2 was assigned the following duties: Charge Nurse, provision of direct patient care (CN 2 was assigned 2 patients), and training of two Registered Nurses (RNs) (RN 2 and 6). This deficient practice had the potential to affect the daily operations of Unit 2 and compromise the delivery of patient care when the charge nurse is not readily available to assist in case of an emergency such as a code blue (patient with unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]), etc. (Refer to A-0392)

3. The facility failed to ensure one of 30 sampled patients (Patient 1) received an initial nursing physical assessment upon admission to the Telemetry (a unit in the hospital where patients undergo continuous heart monitoring). This deficient practice resulted in an initial nursing physical assessment not being performed for Patient 1 and had the potential for changes in Patient 1's condition to go unidentified. (Refer to A-0395)

4. The facility failed to perform vital signs (VS, temperature, blood pressure, pulse, respiratory rate) and oxygen saturation (blood oxygen level) check every four (4) hours for one of 30 sampled patients (Patient 1), in accordance with the facility's policy and procedure. This deficient practice had the potential for changes in Patient 1's vital signs to go unidentified by staff and Patient 1's needs not being addressed in the event of a change of a condition, which may result in patient harm and/or death. Patient 1 subsequently suffered a cardiopulmonary arrest (loss of heart function, breathing, and consciousness) and expired (died). (Refer to A-0395)

5. The facility failed to ensure the registered nurse (RN 5) had oversight over Patient 1's overall care, ensuring that a nocturnal (nighttime) CPAP (Continuous Positive Airway Pressure machine, machine that uses mild air pressure to keep breathing airways open while you sleep) order was carried out by the respiratory therapist (RT 2) for one of 30 sampled patients (Patient 1). This deficient practice had the potential for Patient 1's breathing to stop during sleep. (Refer to A-0395)

6. The facility failed to monitor the side effects of Zyprexa (olanzapine, an antipsychotic that treats mood disorders) and Ativan (lorazepam, a sedative that treats anxiety) after administration to one of 30 sampled patients (Patient 1). This deficient practice had the potential for potential side effects (low blood pressure, muscle weakness, slurred speech, dizziness etc.) and changes in condition to go undetected. Patient 1 subsequently suffered a cardiopulmonary arrest (loss of heart function, breathing, and consciousness) and expired (died). (Refer to A-0395)

7. The facility failed to ensure a Registered Nurse (RN) provided oversight over Licensed Vocational Nurses' (LVN 1, 2, and 3) assessments (in depth evaluation conducted by a RN that evaluates a patient's current physical, mental and emotional state) for two of 30 sampled patients (Patient 27 and Patient 28), in accordance with the facility's policy and procedure regarding assessment and reassessment and professional standards of practice. This deficient practice resulted in assessments documented by LVNs without any RN's oversight and had the potential for an inaccurate assessment of Patient 27 and Patient 28's condition that may delay the provision of necessary medical treatment. (Refer to A-0395)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on observation, interview and record review, the facility failed to:

1. Follow State and Federal regulatory standards regarding safe patient care assignments. Over 50% of the patient care assignment in one of three sampled units (Unit 1) consisted of licensed vocational nurses (LVNs). Two LVNs (LVN 1 and 2) were assigned to perform direct patient care in the Gero-Psychiatric Unit (Unit 1, a unit that serves the general population hospitalized for mental and/or behavioral health illnesses) on 3/19/2024, from 7 a.m. to 7 p.m. There was only one Registered Nurse (RN) who had oversight for both LVNs (LVN 1 and LVN 2).

This deficient practice had the potential to result in patient needs not being met when a Registered Nurse is not readily available in cases of emergency.

2. Ensure one of two sampled charge nurses- Charge Nurse 2 (CN 2), a Registered Nurse, remained free of job duties that prevented her (CN 2) from fulfilling the functions of a Charge Nurse for one of three sampled units (Unit 2). In the Critical Care Unit (Unit 2, a floor within a hospital where critically ill patients receive specialized medical and nursing care), CN 2 was assigned the following duties: Charge Nurse, provision of direct patient care (CN 2 was assigned 2 patients), and training of two Registered Nurses (RNs) (RN 2 and 6).

This deficient practice had the potential to affect the daily operations of Unit 2 and compromise the delivery of patient care when the charge nurse is not readily available to assist in case of an emergency such as a code blue (patient with unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]), etc.

Findings:

1. During an observation on 3/19/2024 at 11:22 a.m., in the Gero-Psychiatric Unit (Unit 1, a unit that serves the general population hospitalized for mental and/or behavioral health illnesses), Charge Nurse 3 (CN 3 -a Registered Nurse), Licensed Vocational Nurse (LVN) 1 and LVN 2 were observed in the unit (Unit 1). There were 12 patients in the unit.

During a concurrent interview and record review on 3/19/2024 at 11:22 a.m. with CN 3, the "Daily Assignment Sheet: Day, 7 a.m. - 7 p.m.," dated 3/19/2024, was reviewed. CN 3verified LVN 1 was assigned 6 patients, and LVN 2 was assigned 6 patients. CN 3 was assigned as the Charge Nurse. CN 3 stated the patient ratio is one licensed nurse to six patients (1:6). CN 3 did not have a direct patient care assignment and was training a Registered Nurse, who was not independently taking a patient care assignment.

During the same interview, CN 3 stated Charge Nurse duties included oversight of patient care provided by LVN staff, unit rounding and orientation of new staff. CN 3 said that in addition to Charge Nurse duties, responsibilities included completing the psychiatric and physical assessments for all 12 patients in Unit 1. CN 3 stated that all assessments documented by LVNs required co-signature by a Registered Nurse. CN 3 further stated that shift psychiatric assessments and physical assessments required verification and signature of a Registered Nurse, since this was not within the scope of practice for LVN staff. CN 3 verified that he (CN 3) had oversight for 2 LVNs (LVN 1 and LVN 2) on 3/19/24 and had to verify assessments for a total of 12 patients.

During an interview on 3/22/2024 at 2:25 p.m., with the Director of Nursing (DON), the DON stated the following: Unit 1 has a ratio of 1:6 for licensed nursing staff (which included LVNs). If there are assigned LVN staff, there must be a Registered Nurse assigned to oversee the delivery of patient care for each LVN because LVNs have a limited scope of practice. The Charge Nurse does not take patients. Registered Nurses in training are not included in ratios.

During the same interview with the DON, the DON stated that the facility follows Federal and State staffing regulations. The DON stated she (DON) was unaware that patient care assignments should be up to 50% of LVNs to RNs (If there are 2 LVNs, there has to be 2 RNs to provide oversight. In this case, there were 2 LVNs and 1 RN on duty on 3/19/24). The DON confirmed that the total number of patients assigned in Unit 1 to LVNs for direct patient care on 3/19/2024, 7 a.m. - 7 p.m., was 100%.

During a review of the facility's policy and procedure (P&P) titled, "Staffing Plan," dated 2/2024, the P&P indicated the following: "Scope: ...9. Mental Health Unit... Purpose: To maintain adequate number of nursing staff and appropriate skill mix to meet patient care needs ... Policy: 8. All units will be staffed by RNs with appropriate training for patient acuity. If LVN's are utilized, the RN will complete the initial assessment and will perform a reassessment at least every shift, and whenever there is a change in condition (Title XXII [a set of rules and regulations established by the California Department of Social Services that governs community care facilities, including Health Care Services]) 9. Staffing assignments are made each shift by the Charge Nurse and are based on patient care needs, skill of the caregiver (competency) and degree of supervision required by the Registered Nurse ... 11. Delegation of nursing care activities to a Licensed Vocational Nurse (LVN), Certified Nursing Assistant (CNA) or other assistive personnel are based on the Registered Nurse assessment of the individual's competency and ability to carry out the task in a safe and effective manner ..."

During a review of the Title 22 regulations (a set of regulations in which the objective is to protect the health, safety, and well-being of patients in healthcare facilities) under Nursing Services Staff, the regulations indicated, "Licensed Vocational Nurses may constitute up to 50 percent of the licensed nurses assigned to patient care on any unit ..."

2. During an observation on 3/19/2024 at 10:10 a.m., in the Critical Care Unit (Unit 2, a floor within a hospital where critically ill patients receive specialized medical and nursing care), Charge Nurse (CN) 2, RN 2 and RN 6 were observed in the unit. There were 4 patients in the unit (Unit 2).

During a concurrent interview and record review on 3/19/2024 at 10:10 a.m. with CN 2, the "Critical Care Assignment Sheet: 7 a.m. - 7 p.m.," dated 3/19/2024, was reviewed. CN 2 verified the following information on the assignment sheet: Charge Nurse, provision of direct patient care assignment (beds 2 and 4), and training of two Registered Nurses (RN 2 and RN 6). CN 2 stated that her (CN 2) Charge Nurse duties are making the daily assignment and oversight of ICU staff. CN 2 further stated she (CN 2) was the primary nurse for the patients in beds 2 and 4 and at the same time she (CN 2) was providing training for two nurses (RN 2 and RN 6).

During a concurrent interview and record review on 3/22/2024 at 2:25 p.m., with the Director of Nursing (DON), the DON verified CN 2 was listed as the Charge Nurse on the "Critical Care Assignment Sheet." The DON verified that CN 2 should not perform Charge Nurse duties and patient care concurrently. The DON said that while in a Charge Nurse role, the Charge Nurse should not have an assigned patient care assignment. DON stated that the nurses on Unit 2 make their own assignments and should not assign a charge nurse using one of the Registered Nurses in the unit. The DON further stated that Unit 2 does have a Charge Nurse and any Charge Nurse duties should be assigned to the House Supervisor.

During the same concurrent record review with the DON, the following records were reviewed: Patient care assignment titled "Critical Care Unit: 7 a.m. - 7 p.m.," dated 3/17/2024, the assignment indicated an assigned charge nurse with an assignment of one patient. Patient care assignment titled "Critical Care Unit: 7 a.m. - 7 p.m.," dated 3/18/2024, the assignment indicated an assigned charge nurse with an assignment of two patients.

During a review of the facility document titled "Job Description: Charge Nurse- ICU," dated 2/2018, the document indicated the following information: "The Charge Nurse may perform direct patient care within scope of practice and clinical competency to ensure patient safety and patient/nurse ratios; he/she shall be temporarily relieved of Charge Nurse duties during such times by Director/designee and shall document details of same on patient care assignment record."

During a review of the facility's policy and procedure (P&P) titled, "Staffing Plan," dated 2/2024, the P&P indicated the following: "Scope: ...2. Critical Care Units ... Purpose: To maintain adequate number of nursing staff and appropriate skill mix to meet patient care needs ... Policy: 8. All units will be staffed by RN's with appropriate training for patient acuity. If LVN's are utilized, the RN will complete the initial assessment and will perform a reassessment at least every shift, and whenever there is a change in condition (Title XXII [a set of rules and regulations established by the California Department of Social Services that governs community care facilities, including Health Care Services] 9. Staffing will be maintained at a level that will allow appropriate response in a crisis. Minimum staffing will be two personnel (one being RN) as long as patients are present on the unit ... Procedure: ... 9. Staffing assignments are made each shift by the Charge Nurse and are based on patient care needs, skill of the caregiver (competency) and degree of supervision required by the Registered Nurse ..."

Based on interview and record review, the facility failed to:

1.a. Ensure one of 30 sampled patients (Patient 1) received an initial nursing physical assessment upon admission to the Telemetry (a unit in the hospital where patients undergo continuous heart monitoring). This deficient practice resulted in an initial nursing physical assessment not being performed for Patient 1 which had the potential for changes in Patient 1's condition to go unidentified.

1.b. Perform vital signs (VS, temperature, blood pressure, pulse, respiratory rate) and oxygen saturation (blood oxygen level) check every four (4) hours for one of 30 sampled patients (Patient 1), in accordance with the facility's policy and procedure. This deficient practice had the potential for changes in Patient 1's vital signs to go unidentified by staff and Patient 1's needs not being addressed in the event of a change of a condition, which may result in patient harm and/or death. Patient 1 subsequently suffered a cardiopulmonary arrest (loss of heart function, breathing, and consciousness) and expired (died).

1.c. Ensure the registered nurse (RN 5) had oversight over Patient 1's overall care, ensuring that a nocturnal (nighttime) CPAP (machine that uses mild air pressure to keep breathing airways open while you sleep) order was carried out by the respiratory therapist (RT 2) for one of 30 sampled patient (Patient 1). This deficient practice had the potential for Patient 1's breathing to stop during sleep.

1.d. Monitor side effects of Zyprexa (olanzapine, an antipsychotic that treats mood disorders) and Ativan (lorazepam, a sedative that treats anxiety) after administration to one of 30 sampled patients (Patient 1). This deficient practice had the potential for potential side effects (low blood pressure, muscle weakness, slurred speech, dizziness etc.) and changes in condition to go undetected. Patient 1 subsequently suffered a cardiopulmonary arrest (loss of heart function, breathing, and consciousness) and expired (died).

2. Ensure a Registered Nurse (RN) provided oversight over Licensed Vocational Nurses' (LVN 1, 2, and 3) assessments (in depth evaluation conducted by a RN that evaluates a patient's current physical, mental and emotional state) for two of 30 sampled patients (Patient 27 and Patient 28), in accordance with the facility's policy and procedure regarding assessment and reassessment and professional standards of practice.

This deficient practice resulted in assessments documented by LVNs without any RN's oversight and had the potential for an inaccurate assessment of Patient 27 and Patient 28's condition that may delay the provision of necessary medical treatment.

On 3/21/2024, at 3:19 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's non-compliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Chief Nursing Officer (CNO), Director of Nursing (DON), Director of Performance Improvement (DPI), and the Director of Pharmacy (DOP). Patient 1's medical history included obstructive sleep apnea (intermittent airflow blockage during sleep) maintained on nocturnal (nighttime) CPAP machine (Continuous Positive Airway Pressure machine-a machine that provides mild air pressure to keep breathing airways open while you sleep), asthma (a condition in which a person's airways become inflamed, narrow, and swollen, making it difficult to breathe), morbid obesity (weighing 100 pounds over the recommended weight), presented to the Emergency Department (ED, responsible for providing treatment to patients arriving in the facility who are in need of immediate care) on 9/7/2023 via paramedics because of assaultive behavior towards parents. Patient 1's initial oxygen saturation was 93 % (normal is between 95 - 100%) on room air. While in the ED, on 9/8/2023, Patient 1's required supplemental oxygen ranged from 2 Liters (L) to 8 L after receiving a ketamine (a strong sedative). Due to Patient 1's oxygen needs in the ED, Patient 1 was admitted to the Telemetry unit (a unit in the hospital where patients undergo continuous heart monitoring) on 9/8/2023 at 12:30 a.m. for hemodynamic monitoring (assessment of the patient's circulatory system). A physical assessment was not performed upon admission to the unit, until 10 p.m. on 9/8/2023. Patient 1's vital signs (blood pressure, temperature, pulse, respiratory rate, and oxygen saturations) were not monitored every four (4) per facility policy. Patient 1's last vital sign (VS) was documented on 9/8/2023 at 8 p.m., no VS were documented at 12 midnight or 4 a.m., on 9/9/2023. Nursing staff did not ensure Patient 1's physician's order of a nocturnal CPAP was implemented by the respiratory therapist. On 9/9/2023, Patient 1 received Zyprexa (olanzapine, an antipsychotic that treats mood disorders) at 2:23 a.m., and Ativan (lorazepam, treats anxiety) at 3:16 a.m. for agitation and aggressive behavior. Nursing staff did not monitor side effects (low blood pressure, muscle weakness, slurred speech, dizziness, etc.) of these medications. On 9/9/2023 at 4:54 a.m., Patient 1's heart rate dropped and a Code Blue (patient with unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]) was called. At 4:55 a.m., Patient 1 suffered a cardiopulmonary arrest (sudden, unexpected loss of heart function and breathing). Patient 1 was pronounced dead on 9/9/2023 at 5:28 a.m.

On 3/22/2024 at 4:45 p.m., the IJ was removed in the presence of the CNO, DON, DPI, and DOP after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interview, and record reviews. The IJ Removal Plan included the following: Immediate and ongoing staff education and training relating to patient assessment upon admission and thereafter for changes in condition, guidelines of assessment/reassessment of side effects of medications, standards of care, and nursing oversight and responsibility for total care of patient, including carrying out all orders, hand off communication (the transfer of essential information and the responsibility for care from one healthcare provider to another), and vital signs review and documentation. Staff will be trained prior to starting their shift. The charge nurse or supervisor will perform daily audits focusing on assessments, vital signs, nursing oversight to ensure all orders are carried out, and monitoring for side effects of medications, etc., to ensure the above guidelines are being followed at all times. The audits will begin immediately, using a newly created audit tool titled, "Performance Improvement Indicators."

Findings:

1.a. During a review of Patient 1's "ED (Emergency Department, provides treatment to patients arriving in the facility who are in need of immediate care) Physician Note," dated 9/7/2024 at 7:41 p.m., the Note indicated the following: Patient 1 was brought by paramedics and police because of assaultive behavior towards parents ... Patient 1 said he (Patient 1) had to use a CPAP (Continuous Positive Airway Pressure machine, machine that uses mild air pressure to keep breathing airways open while you sleep) machine because of sleep apnea (a potentially serious disorder in which breathing repeatedly stops and starts). Patient 1's diagnoses included diabetes (high blood sugar), asthma (a condition in which a person's airway becomes inflamed, narrow, and swollen, making it difficult to breathe), psychosis (a mental disorder characterized by a disconnection from reality), Pulse oximetry (oxygen saturation, normal is between 95 % to 100%) was 93 % on room air ...Because of his (Patient 1) assaultive behavior Patient 1 was treated with IM (Intramuscular, administered in the muscle) Zyprexa and Ativan ...

During a review of Patient 1's ED note titled "Continuation/Procedure Notes," dated 9/8/2023 at 9:52 a.m., the note indicated the following: Briefly, Patient 1 with history of intellectual disability (when there are limits to a person's ability to learn at an expected level and function in daily life), diabetes, and hypertension (high blood pressure) brought to the ED for acute agitation (a state of intense anxiety, heightened arousal [an abnormal state of increased responsiveness to stimuli], and increased motor activity [movement quality]). Patient 1 struck his father, was placed on a 5150 hold (72-hour involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavior disorders] hospitalization when evaluated to be a danger to self or others) by police and brought to the ED for further care ...Patient 1 was acutely (severe and sudden in onset) agitated from time to time and required sedation with a variety of medications, including antipsychotics (medications to treat symptoms of psychosis [disconnection from reality]) and anxiolytics (treat anxiety), and antihistamines (an allergy medication that can cause drowsiness). Patient had a history of sleep apnea (intermittent airflow blockage during sleep) and was noted that his (Patient 1) oxygen saturations were 93 % on arrival and supplemental oxygen was initiated. Patient 1's agitation persisted despite the above medications. Patient was treated with small dose IV of Ketamine (a strong sedative) ...He (Patient 1) had short- lived episode of hypoxia (lack of oxygen in the tissues) that was overcome by placing patient (Patient 1) on supplemental oxygen ...and sitting patient (Patient 1) upright (patient was morbidly obese). Patient 1 had subsequent short-lived episodes of hypoxia, treated by increasing oxygen. Currently on 2 Liters (L) with saturation of 96 %.

Because of the need for continued oxygenation support, Patient 1 was not medically cleared for psychiatric purposes and admitted to the hospitalist service. On re-revaluation at 9:15 a.m., agitation had improved. However, Patient 1 had episodes of hypoxia requiring oxygen support. Oxygen support was continued ...Medical admission warranted ...Patient 1 required inpatient admission and ongoing acute care as they (Patient 1) are at risk for decompensation (failure of an organ to compensate for the functional overload resulting from disease) and/or an adverse event (an undesirable clinical outcome ...The decision to admit was made after careful consideration of Patient 1's past medical history, clinical risk factors, co-morbidities (the existence of more than one disease or condition within the body at the same time), and diagnostic studies ...Patient 1 will be admitted for further therapy, hemodynamic monitoring (evaluates how well the heart is working) ...

During a review of Patient 1's "ED nurses notes," dated 9/8/2023 at 8:23 a.m., the ED nurses notes indicated "ER MD wants O2 (oxygen) on Patient (Patient 1) continuously. Patient (Patient 1) currently on 8 Liters via NRB mask (non-rebreather mask (used to deliver 70 to 100 percent of oxygen if a patient needs high-concentration oxygen but does not need help breathing) ..." At 9:08 a.m., Patient 1 was on 6 L of O2 via nasal cannula. At 9:10 a.m., Patient 1 was on 2 L of O2 via nasal cannula. At 12:10 p.m., "Changed Patient 1's O2 to 4 L. Patient 9Patient 1) saturating at 97 %.

During a review of Patient 1's "Nursing Assessments," dated 9/8/2023 at 10 p.m. the assessment indicated the following: Patient 1 was oriented to person and name. Sleep pattern: intermittently (with periods of being awake in between sleep), mood was uncooperative, mental status: forgets limitations. Respiratory effort was non-labored, on room air. Patient 1 was on a monitor, electrocardiogram (records electrical signals from the heart) rhythm was sinus rhythm (when heart beats in a regular organized way) ... No other nursing physical assessments were documented while Patient 1 was in the Telemetry unit.

During a review of Patient 1's "Code Blue Note," dated 9/9/2023 at 6:27 a.m., the Code Blue Note indicated the following: Patient (Patient 1) was given multiple doses of antipsychotics (treats mood disorders), anxiolytics (treats anxiety) in the ED yesterday for agitation psychosis. Patient 1 was also noted to become borderline hypoxic around 93 % (oxygen saturation) in the ED. Patient 1 was admitted to the medical service and a Code Blue (patient with unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]) was called ...around 4:53 a.m. Upon arrival at the bedside, CPR (cardiopulmonary resuscitation, an emergency procedure consisting of chest compressions and artificial ventilation [a means of assisting breathing]) was in progress ...We continued the code for 35 minutes ... Unfortunately, the code was terminated, and Patient 1 was pronounced (dead) at 5:28 a.m.

During a review of Patient 1's "Discharge Summary (a narrative document for communicating clinical information about what happened to the patient in the hospital)," dated 9/9/2023 at 10:59 p.m., the Discharge Summary indicated the following: Discharge diagnosis included the following: cardiopulmonary arrest (unexpected loss of heart function, breathing, and consciousness) ...acute hypoxic respiratory failure (when the respiratory system [consist of lungs, etc.] cannot adequately provide oxygen to the body) possible due to pulmonary embolism (blood clot to the arteries of the lungs), could also have underlying cardiac (heart) issue ...Patient 1 in the early morning of 9/9/2023 was found to have heart rate dropping at 4:53 a.m., and Code Blue was called in which Patient 1 was found in PEA (pulseless electrical activity, a condition characterized by unresponsiveness and no pulse) arrest. ACLS (advanced cardiac life support, a group of procedures and techniques that treat immediate life-threatening conditions) procedure was followed ...Patient 1 was pronounced (dead) at 5:28 a.m.

During a concurrent interview and record review, on 3/19/2023 at 2:43 p.m., with the Director of Infection Control (DIC) and the Director of Performance Improvement (DPI), the DIC and DPI stated the following: Patient 1 was admitted to the Telemetry Unit on 9/8/2023 at 12:30 p.m. The DIC and DPI verified there was no evidence that an initial head to toe assessment had been performed by the nursing staff upon Patient 1's arrival to the Telemetry Unit. The Head-to-Toe assessment was performed last on 9/8/2023 at 10 p.m. The DIP and DPI stated that on 9/8/2023 at 4:54 a.m., Patient 1's heart rate dropped, a Code Blue was called, and Patient 1 expired on 9/8/2024 at 5:28 a.m.

During a concurrent interview and record review, on 3/20/2024 at 11:24 a.m., with the Director of Nursing (DON), the DON stated the following: Patient 1 was admitted to the Telemetry unit on 9/8/2024 at 12:30 p.m. Nursing staff did not perform an initial nursing head to toe assessment upon admission to the unit. A nursing head to toe assessment was performed on 9/8/2024 at 8 p.m. Nursing staff should perform an initial head to toe assessment as soon as possible, upon admission to the unit and every shift thereafter to identify any changes in condition.

During a review of the facility's policy and procedure (P&P) titled, "Patient Assessment and Care Planning Interdisciplinary," dated 7/2023, the P&P indicated the following: It is the policy of the Hospital that each patient admitted shall receive a complete head to toe assessment by a qualified individual so that a plan of care can be developed to best meet the needs of the patient ...Purpose ...To determine care required to meet the patient's initial needs, disability and illness, as well when they change in response to care ...At the time of admission each patient shall have a complete initial physical/psychological assessment completed by a registered nurse (RN) ...Reassessment of patient condition is performed according to specific unit guidelines, when there is a significant change in condition or response to a procedure or intervention.

1.b. During a review of Patient 1's "Vital Signs (blood pressure, temperature, pulse, respiratory rate, and oxygen saturations)," on 9/8/2023 in the Telemetry Unit (a unit in the hospital where patients undergo continuous heart monitoring), the vital signs were as follows:

On 9/8/2023 at 12:43 p.m., Temperature (Temp) was 97.4 degrees Fahrenheit (F, normal is between 97.7 to 99.5 F), Pulse was 81 (normal is 60 to 100), Respiratory Rate 18 (RR, normal is 12 to 20), Blood Pressure (BP) was 105/62 (normal is between 90-140/60-90), Pulse oximetry (pulse ox, oxygen saturation in the blood) was 97 % (normal is 95% to 100 %), oxygen flow rate at 4 Liters (L) via nasal cannula (NC, a device to deliver supplemental oxygen).

On 9/8/2023 at 3:28 p.m., Temp was 98.2 F, Pulse was 81, RR was 19, BP was 117/89, pulse ox was 92 %, oxygen flow rate at 4 L via NC.

On 9/8/2023 at 8 p.m., Temp was 98.2 F, Pulse was 68, RR was 20, BP was 136/65, pulse ox was 99 % on room air.

During a concurrent interview and record review on 3/20/2024 at 11:24 a.m. with the Director of Nursing (DON), the DON stated the following: Vital signs (VS) included temperature, blood pressure, pulse/heart (pulse) rate, respiratory rate, and oxygen saturation (measures the amount of oxygen in the blood). The DON verified that Patient 1's last VS were checked on 9/8/2023 at 8 p.m., there was no evidence that vital signs were checked on 9/9/2024 at 12 a.m., and at 4 a.m. The DON stated Patient 1's vital signs should be checked every four (4) hours in the Telemetry Unit to identify changes in the patient's condition. The DON verified that VS had no not been checked at 4 a.m., to identify any changes in Patient 1's condition, and around that time, Patient 1's heart rate dropped, a code blue was called, and Patient 1 expired on 9/9/2023 at 5:28 a.m.

During a review of Patient 1's "Physician's Order," dated 9/8/2023 at 10:36 a.m., the order indicated to perform routine vital signs (every 4 hours) per unit policy.

During a review of Patient 1's "Physician's Order," dated 9/8/2023 at 10:36 a.m., the order indicated "2 L (liters) nasal cannula to keep o2 (oxygen) saturation at greater than 92%. Additional comments: Nocturnal (nighttime) CPAP (continuous positive airway pressure, a machine that uses mild air pressure to keep breathing airways open while you sleep).

During a review of the facility's policy and procedure (P&P) titled, "Vital Signs," dated 2/2024, the P&P indicated the following: Vital signs include blood pressure, heart rate, respiratory rate, temperature, and pain. Routine vital signs for telemetry/DOU (Definitive Observation Unit, provides the second-highest level of care) patients are every four (4) hours ...Routine vital signs will be taken at 4 a.m., 8 a.m., 4 p.m., 8 p.m., and 12 a.m.

During a review of the facility's policy and procedure (P&P) titled, "Standard of Care Telemetry, Medical Surgical, Rehab," dated 10/2023, the P&P indicated the following: Oxygen saturation with pulse oximeter (device used to measure the oxygen level of the blood) per physician's order.

1.c. During a review of Patient 1's "Physician's Order," dated 9/8/2023 at 10:36 a.m., the order indicated "2 L (liters) nasal cannula to keep o2 (oxygen) saturation at greater than 92%. Additional comments: Nocturnal CPAP (continuous positive airway pressure, a machine that uses mild air pressure to keep breathing airways open while you sleep).

During a review of Patient 1's "Respiratory Progress Notes," dated 9/8/2023, the Respiratory Progress Notes indicated the following:

At 5:30 p.m., Type of intervention: Initial. Oxygen check, previously on 12 hours of oxygen. Pulse ox was 94%, oxygen delivery at 4 Liters (L) via nasal cannula (NC).

At 9:13 p.m., Type of intervention: Subsequent. Oxygen check, previously on 12 hours of oxygen. Pulse ox was 94 %, oxygen delivery at 4 L via NC. Adverse reaction: Patient 1 refusing ABG (arterial blood gas, a test that measures the amount of oxygen and carbon dioxide in the blood), agitated, oxygen in use.

During a review of Patient 1's "Nursing Assessments," dated 9/8/2023 at 10 p.m., the Nursing Assessments record indicated the following: Patient 1's was oriented to person and name. Sleep pattern: intermittently (with periods of being awake in between sleep), mood was uncooperative, mental status: forgets limitations. Respiratory effort was non-labored (when breathing is not difficult or impaired), on room air. Patient 1 was on a monitor, electrocardiogram (records electrical signals from the heart) rhythm was sinus rhythm (when heart beats in a regular organized way) ... No other nursing physical assessments were documented while Patient 1 was in the Telemetry unit.

During a concurrent interview and record review on 3/20/2024 at 11:24 a.m. with the Director of Nursing (DON), the DON stated the following: A nursing head to toe assessment was performed on 9/8/2024 at 8 p.m. There were no other assessments or interventions documented by the nursing staff. The DON stated primary nurse should have oversight over the patient's total care, to ensure all orders are carried out. The DON verified there was no evidence in the medical record that the respiratory therapist provided a nocturnal CPAP for Patient 1 and no evidence that the nurse ensured the CPAP order was carried out.

During a review of the facility's policy and procedure (P&P) titled, "Staffing Plan," dated 2/2024, the P&P indicated the following: A Registered Nurse completes patient assessment, planning, and evaluation of care for each patient.

During a review of the facility's policy and procedure (P&P) titled, "Standard of Care Telemetry, Medical, Surgical, Rehab (Rehabilitation)," dated 10/2023, the P&P indicated the following: Each nurse will assess and evaluate age-appropriate patient status, initially and ongoing.

1.d. During a review of Patient 1's Emergency Department (ED, provides treatment to patients arriving in the facility who are in need of immediate care) "Medication Administration Record (MAR)," the MAR dated 9/8/2023 indicated the following:
At 6:27 a.m., Patient 1 received Zyprexa (olanzapine, an antipsychotic that treats mood disorders) 5 MG (milligrams, a unit of measurement) IM (intramuscular- administered in the muscle).

At 7:23 a.m., and 11:03 a.m., Patient 1 received 40 MG of ketamine (a short-acting anesthetic [a medication at causes loss of feeling] that causes people to feel separated or detached from their body or physical environment) IM for aggressive behavior.

During a review of Patient 1's "ED Summary Report," dated 9/8/2023 at 8:23 a.m., the ED Summary Report indicated "Patient 1's oxygen saturation (O2 sat) was 80% (normal is 95 to 100%). Oxygen therapy 8 Liters (L). Oxygen delivery method Non-Rebreather Mask (an oxygen mask that delivers high concentrations of oxygen) and oxygen saturation with oxygenation 100%."

During a review of Patient 1's ED "Nursing Notes," dated 9/8/2023, the ED Nursing Notes indicated the following:

At 8:23 a.m., "ER MD wants oxygen on Patient 1 continuously. Patient 1 currently on 8 Liters (L) oxygen via Non-Rebreather Mask.

At 9:08 a.m., Patient 1 currently on 6 L oxygen via nasal cannula (NC, a device that delivers extra oxygen through a tube into the nose)

At 9:10 a.m., Patient 1 now on 2 L oxygen via NC ...

At 12:10 p.m., Changed Patient 1's oxygen to 4 L. Patient is saturating 97 %."

During a review of Patient 1's "MAR (Medication Administration Record)," dated 9/8/2023 and 9/9/2023, in the Telemetry Unit (a unit in the hospital where patients undergo continuous heart monitoring), the MAR indicated the following:

On 9/8/2023 at 2:58 p.m. Patient 1 received Zyprexa (olanzapine, an antipsychotic that treats mood disorders, side effects may include drowsiness, dizziness, lightheadedness, slow heartbeat, and interrupted breathing during sleep) 10 MG IM.

On 9/9/2023 at 2:23 a.m., Patient 1 received Zyprexa 10 MG IM.

On 9/9/2023 at 3:16 a.m. Patient 1 received Ativan (lorazepam, a sedative that treats anxiety by producing a calming effect, side effects may include drowsiness, dizziness, headache etc.) 1 MG IV (intravenous, administered in the vein).

During a review of Patient 1's "Nurses Notes," dated 9/8/2023 to 9/9/2023, the Nurses Notes indicated the following:

On 9/8/2023 at 12:30 p.m., Patient 1 admitted to hospital ...

On 9/8/2023 at 12:30 p.m., Patient 1 received sleepy after a dose of ketamine (an anesthetic which causes people to feel separated or detached for their body or physical environment) ...easily arousable (awaken from sleep) ...

On 9/8/2023 at 6:15 p.m., Code grey (combative or violent patient) called because Patient 1 was agitated and trying to pull out his foley (urinary) catheter and leave the hospital.

On 9/8/2023 at 7:30 p.m., Patient 1 "agitated and medicated." Patient 1 is calming down with sitter at bedside ...

On 9/9/2023 at 4:54 a.m., Heart rate dropping, Code Blue (patient with unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]) called.

On 9/9/2023 from 4:58 a.m. to 7:37 a.m., Code team arrived. Heroic efforts unsuccessful ...Physician (MD 1) pronounced Patient 1.

During a concurrent interview and record review on 3/19/2024 at 2:29 p.m. with the Director of Pharmacy (DOP), the DOP stated the following: When medications are administered, patients should be monitored for side effects or patient's response to the medication. Patient 1 received Ativan, which could cause respiratory depression (when a patient breathes too slowly or shallowly thus preventing proper gas exchange in the lungs) and the respiratory status, including respiratory rate, and oxygen saturation had to be monitored. The DOP added that the heart rate should be monitored as well for changes in response to the medications.

During a concurrent interview and record review on 3/20/2024 at 11:24 a.m. with the Director of Nursing (DON), the DON stated the following: The DON said there was no evidence that Patient 1 was monitored for side effects of Ativan or Zyprexa to identify any changes in the patient's (Patient 1) condition.

During a review of the facility's policy and procedure (P&P) titled, "Administration of Medications," dated 1/2023, the P&P indicated the following: Documentation- When a routine or PRN (as needed) medication is administered to a patient, documentation of any response to that medication must appear in the Nursing Notes and/or MAR, as well as any actions required to monitor and correct the response.

2.a. During a review of Patient 27's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/8/2024, the H&P indicated Patient 27 was admitted to the facility with diagnoses of mood disorder (mental disorder in which the underlying problem primarily affects a person's persistent emotional state) and neurocognitive disorder (a significant decline in at least one of the domains of cognition which include executive function, complex attention, language, learning, memory, perceptual-motor, or social cognition).

During an interview on 3/19/2024 at 11:25 a.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated the charge registered nurse (RN) should oversee her (LVN 2) patients and should sign off her (LVN 2) shift head to toe assessment (in depth evaluation conducted by a RN that evaluates a patient's current physical, mental and emotional state). LVN 2 confirmed that the charge registered nurse did not sign off on LVN 2's assessment notes.

During a concurrent interview and record review on 3/22/2024 at 11:02 a.m. with the Director of Nursing (DON), Patient 27's "Nursing Flowsheet (nursing documentation for patient head to toe assessment)," from 3/10/2024 to 3/19/2024, was reviewed. The nursing flowsheet indicated the assessment was performed by LVN 1, 2 and 3 on the following dates without a RN co-signature:

3/11/2024 at 10:44 a.m. by LVN 1
3/11/2024 at 10:07 p.m. by LVN 3
3/19/2024 at 10 a.m. by LVN 2
DON stated there was no RN co-signature to validate the assessments completed by LVN 1, 2, and 3 and there was no documentation to show there was RN oversight for Patient 27. DON stated RN assessment was needed for patients to identify any issues and to address problems.

During a review of the facility's policy and procedure (P&P) titled, "Scope of Vocational Nursing Practice/Registered Nurse (RN) Supervision," dated 2/2024, the P&P indicated, "The RN will provide supervision of the LVN as required by state and federal regulations. The RN will ensure that delegation of care is appropriate and within the scope of the LVN ...Nursing process/ documentation: the RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN."

During a review of the facility's policy and procedure (P&P) titled, "Staffing Plan," dated 11/2023, the P&P indicated, "All units will be staffed by Registered Nurses (RN) with appropriate training for patient acuity. If Licensed Vocational Nurses (LVN) are utilized, the RN will complete the initial assessment and will perform a reassessment at least every shift, and whenever there is a change in condition."

2.b. During a review of Patient 28's "History and Physical (H&P)," dated 3/15/2024, the H&P indicated Patient 28 was admitted to the facility with diagnoses of acute (new onset) psychosis (a mental disorder characterized by a disconnection from reality), dementia (condition characterized by impairment of brain function interfering daily functioning) and hypertension (high blood pressure).

During a concurrent interview and record review on 3/22/2024 at 12 p.m. with the Director of Nursing (DON), Patient 28's "Nursing Flowsheet," from 3/15/2024 to 3/19/2024, was reviewed. The nursing flowsheet indicated the assessment was performed by Licensed Vocational Nurses (LVN 1, 2, 3 and 4) on the following dates without a Registered Nurse (RN) co-signature:

3/15/2024 at 10:30 a.m. by LVN 4
3/15/2024 at 10:51 p.m. by LVN 3
3/16/2024 at 10:43 a.m. by LVN 1
3/16/2024 at 10:37 p.m. by LVN 3
3/17/2024 at 10:10 a.m. by LVN 1
3/17/2024 at 10:35 p.m. by LVN 2
3/18/2024 at 10:02 a.m. by LVN 1
3/18/2024 at 10:11 p.m. by LVN 3
DON stated there was no RN co-signature to validate the assessments completed by the LVN 1, 2, 3, and 4 and there was no documentation to show there was RN oversight for Patient 28 from 3/15/2024 to 3/18/2024 for total of four days. DON stated RN should document and validate assessments completed by LVN because it was not the LVN's scope of practice to perform assessment.

During a review of the facility's policy and procedure (P&P) titled, "Scope of Vocational Nursing Practice/Registered Nurse (RN) Supervision," dated 2/2024, the P&P indicated, "The RN will provide supervision of the LVN as required by state and federal regulations. The RN will ensure that delegation of care is appropriate and within the scope of the LVN ...Nursing process/ documentation: the RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN."

During a review of the facility's policy and procedure (P&P) titled, "Staffing Plan," dated 11/2023, the P&P indicated, "All units will be staffed by Registered Nurses (RN) with appropriate training for patient acuity. If Licensed Vocational Nurses (LVN) are utilized, the RN will complete the initial assessment and will perform a reassessment at least every shift, and whenever there is a change in condition."

Based on interview and record review, the facility failed to ensure respiratory services carried out an order for a nocturnal (nighttime) CPAP (continuous positive airway pressure machine, a machine that uses mild air pressure to keep breathing airways open while you sleep) for one of 30 sampled patients (Patient 1).

This deficient practice had the potential for Patient 1 to have pauses during sleep, potentially causing low oxygen saturation levels (oxygen in the blood), which can affect the heart.

Findings:

During a review of Patient 1's "ED (Emergency Department, provides treatment to patients arriving in the facility who are in need of immediate care) Physician Note," dated 9/7/2024 at 7:41 p.m., the ED Physician Note indicated the following: Patient 1 was brought by paramedics and police because of assaultive behavior towards parents ... Patient 1 said he (Patient 1) had to use a CPAP (continuous positive airway pressure machine, a machine that uses mild air pressure to keep breathing airways open while you sleep) machine because of sleep apnea (a potentially serious disorder in which breathing repeatedly stops and starts). Patient 1's diagnoses included diabetes (high blood sugar), asthma (a condition in which a person's airway becomes inflamed, narrow, and swollen, making it difficult to breathe), psychosis (a mental disorder characterized by a disconnection from reality), Pulse oximetry (oxygen saturation, normal is between 95% to 100%) was 93% on room air ...Because of his (Patient 1) assaultive behavior Patient 1 was treated with IM (intramuscular, administered in the muscle) Zyprexa (olanzapine, an antipsychotic that treats mood disorders) and Ativan (lorazepam, treats anxiety) ...

During a review of Patient 1's ED note titled, "Continuation/Procedure Notes," dated 9/8/2023 at 9:52 a.m., the note indicated the following: Briefly, Patient 1 with history of intellectual disability (when there are limits to a person's ability to learn at an expected level and function in daily life), diabetes (high blood sugar), and hypertension (high blood pressure), brought to the ED for acute (Severe and sudden onset) agitation. Patient 1 struck his (Patient 1) father, was placed on a 5150 hold (72-hour involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavior disorders] hospitalization when evaluated to be a danger to self or others) by police and brought to the ED for further care ... Patient 1 was acutely agitated from time to time and required sedation with a variety of medications, including antipsychotics (medications to treat symptoms of psychosis [disconnection from reality]) and anxiolytics (treat anxiety), and antihistamines (an allergy medication that can cause drowsiness). Patient had a history of sleep apnea (intermittent airflow blockage during sleep) and was noted that his (Patient 1) oxygen saturations were 93% on arrival and supplemental oxygen was initiated. Patient 1's agitation persisted despite the above medications. Patient 1 was treated with small dose IV (intravenous, administered in the vein) of Ketamine (a strong sedative) ...He (Patient 1) had short- lived episode of hypoxia (lack of oxygen in the tissues) that was overcome by placing patient(Patient 1) on supplemental oxygen ...and sitting patient (Patient 1) upright (patient was morbidly obese). Patient 1 had subsequent short-lived episodes of hypoxia, treated by increasing oxygen. Currently on 2 Liters (L) with saturation of 96 %.

Further review of Patient 1's ED note titled, "Continuation/Procedure Notes," dated 9/8/2023 at 9:52 a.m., indicated that because of the need for continued oxygenation support, Patient 1 was not medically cleared for psychiatric purposes and admitted to the hospitalist service. On re-revaluation at 9:15 a.m., agitation had improved. However, Patient 1 had episodes of hypoxia requiring oxygen support. Oxygen support was continued ...Medical admission warranted ...Patient 1 required inpatient admission and ongoing acute care as they (Patient 1) are at risk for decompensation (failure of an organ to compensate for the functional overload resulting from disease) and/or an adverse event (an undesirable clinical outcome ... The decision to admit was made after careful consideration of Patient 1's past medical history, clinical risk factors, co-morbidities (the existence of more than one disease or condition within the body at the same time), and diagnostic studies ...Patient 1 will be admitted for further therapy, hemodynamic monitoring (evaluates how well the heart is working) ...

During a review of Patient 1's "ED Nurses notes," dated 9/8/2023 at 8:23 a.m., the ED Nurses notes indicated, "ER MD wants O2 (oxygen) on Patient (Patient 1) continuously. Patient (Patient 1) currently on 8 Liters via NRB mask (non-rebreather mask (used to deliver 70 to 100 percent of oxygen if a patient needs high-concentration oxygen but does not need help breathing) ..." At 9:08 a.m., Patient 1 was on 6 L of O2 via nasal cannula. At 9:10 a.m., Patient 1 was on 2 L of O2 via nasal cannula. At 12:10 p.m., "Changed Patient 1's O2 to 4 L. Patient saturating at 97%."

During a review of Patient 1's "Physician's Order," dated 9/8/2023 at 10:36 a.m., the order indicated "2 L (liters) nasal cannula to keep o2 (oxygen) saturation at greater than 92%. Additional comments: Nocturnal CPAP (continuous positive airway pressure, a machine that uses mild air pressure to keep breathing airways open while you sleep).

During a review of Patient 1's "Respiratory Progress Notes," dated 9/8/2023, the Respiratory Progress Notes indicated the following:
At 5:30 p.m., Type of intervention: Initial. Oxygen check, previously on 12 hours of oxygen. Pulse ox was 94%, oxygen delivery at 4 Liters (L) via nasal cannula (NC).
At 9:13 p.m., Type of intervention: Subsequent. Oxygen check, previously on 12 hours of oxygen. Pulse ox was 94 %, oxygen delivery at 4 L via NC. Adverse reaction: Patient 1 refusing ABG (arterial blood gas, a test that measures the amount of oxygen and carbon dioxide in the blood), agitated, oxygen in use.

During a concurrent interview and record review on 3/19/2024 at 3:30 p.m. with respiratory therapist (RT) 1, RT 1 stated the following: Respiratory therapists were responsible for carrying out orders related to the respiratory system. Patient 1 had an order for a nocturnal CPAP dated 9/8/2024 at 10:36 a.m. to be carried out at night. There was no evidence that a nocturnal CPAP had been provided by a respiratory therapist for Patient 1. There was no documentation of any attempts to place a nocturnal CPAP for Patient 1. In addition, RT 1 stated when a patient uses a CPAP, respiratory therapists are required to check the patient every 2 hours for correct machine settings, machine function, patient's heart rate and oxygen saturation. RT 1 stated Patient had a history of sleep apnea, and not using a CPAP at night, may cause pauses or respirations, that can lead to low oxygen saturations, which can affect the heart.

During a concurrent interview and record review on 3/20/2024 at 11:24 a.m. with the Director of Nursing (DON), the DON stated there was no evidence in Patient 1's medical record that the respiratory therapist provided a nocturnal CPAP for Patient 1.

During a review of a document titled, "Plan for Provision of Patient Care," dated 2024, the document indicated the following: A variety of support services are available 24 hours a day. These include pharmacy, respiratory ...These services are accessed through a physician order ...Services can include assessment of the patient's needs, actual administration of patient care, and/or educational services to the patient and family ...Respiratory Care ...Provide safe and appropriate respiratory care ...