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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES was out of compliance.

A0392 - The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. Based on observations, interviews, and document review, the facility Based on observations, interviews, and document review, the facility failed to ensure minimum staffing requirements were maintained to allow adequate numbers of licensed registered nurses to provide nursing care to all patients as needed, in accordance with the facility's nurse staffing plan and in accordance with Code of Colorado Regulations (CCR) 1011-1 Chapter Four regulations.

A0395 - A registered nurse must supervise and evaluate the nursing care for each patient. Based on observations, interviews, and document review the facility Based on observations, interviews, and document review, the facility failed to ensure patients were continuously monitored in accordance with facility policy in order to meet physician ordered pulse oximetry (pulse ox, a medical device used to measure the saturation of oxygen carried in red blood cells) ranges ordered to identify a change in a patient's condition in one of two patient care units observed.

Based on observations, interviews, and document review, the facility failed to ensure minimum staffing requirements were maintained to allow adequate numbers of licensed registered nurses to provide nursing care to all patients as needed, in accordance with the facility's nurse staffing plan and in accordance with Code of Colorado Regulations (CCR) 1011-1 Chapter Four regulations. Additionally, the facility failed to have an established process to reduce nurse-to-patient assignments to align with patient acuity demands in accordance with Code of Colorado Regulations (CCR) 1011-1 Chapter Four regulations.

Findings include:

Facility policies:

The Staffing Guideline policy read, variations to the staffing plan may be needed for emergent circumstances or may be appropriate based on the actual acuity on the unit at any given time. The charge nurse should use the staffing plan for guidance and adjust based on clinical judgment of acuity. The nurse in charge should consider patient acuity, staff experience, staff competency, and individualized patient needs when making patient assignments. Whenever the nursing clinical staff are made aware of emergent staffing concerns and complaints, they have the ability to escalate these complaints and concerns up through leadership.

The Surge and Capacity Management policy read, the emergency department (ED) will evaluate and stabilize all patients presenting to the ED. Subsequent transfer will be arranged if unable to provide appropriate services. If the required hospital resources are not readily available, the patient will be transferred to an appropriate trauma center, specialty care center, or other appropriate facility.

References:

According to the Standards for Hospitals and Health Facilities Chapter 4 - General Hospitals 6 CCR 1011-1 Chapter 4, Part 14.7 Nurse Staffing Plans, (A) Master Nurse Staffing Plan, (1) The nurse staffing committee shall annually develop and oversee a master nurse staffing plan for the hospital that: (c) Includes minimum staffing requirements for each inpatient unit and emergency department that are aligned with nationally recognized standards and guidelines; (e) Includes guidance and a process for reducing nurse-to-patient assignments to align with the demand based on patient acuity; (f) Is voted on and recommended by at least sixty (60) percent of the nurse staffing committee (B)(5) The nurse staffing committee shall: (6) Make the hospital's complaint and feedback process available to all providers, including clinical staff nurses, nurse aides, and EMS providers, and include information on the Department's complaint reporting process.

The Master Staffing Plan read, the staffing plans are built for specific patient types and average unit acuity with unit type with consideration of patient flow, patient turnover, and acuity. The facility has detailed unit staffing plans that guide appropriate staffing for each census level. The unit staffing plan provides clear guidance to the number of caregivers needed at each patient census level.

The staffing plans, which were identified by staff as the facility's staffing grids, were provided by Facility A (separately licensed facility certified under Facility B) and Facility B. The staffing plans listed the name of each unit at the facility, specified the variable patient census range for each unit, and the specified number of registered nurses (RN) and certified nursing assistants (CNA) expected to be staffed and present on each unit according to the current patient census. The staffing plans specified the nurse-to-patient ratios according to the patient census and amount of nurses required. The staffing plans read, the unit charge nurse would make adjustments as needed based on clinical judgment of acuity.

1. The facility failed to ensure minimum staffing requirements were maintained in accordance with the facility's staffing plan to allow adequate numbers of licensed registered nurses (RNs) to provide nursing care to all patients as needed.

A. Observations

i. Observations were conducted in the intensive care unit (ICU) of Facility A on 3/3/25. Observations revealed the ICU unit had a census of 13 patients. Staffing for the unit included the unit manager with no patient assignment and five staff nurses. Observations revealed one RN's assignment included four patients who had a downgraded status (not ICU level patients), three RNs had two ICU level patients, and one RN had three ICU level patients (a triple assignment).

ii. Observations were conducted in the ICU of Facility B (a separately licensed facility certified under Facility A) on 3/4/25. Observations revealed the ICU had a census of 32 patients. Staffing for the unit included one charge nurse without a patient assignment, one resource nurse (a nurse without a patient assignment and used as extra help on the unit), one CNA, and 13 RNs. Observations revealed seven RNs had triple assignments. Additionally, the ICU had three additional patient admissions expected for the day shift (a post-operative open heart surgery patient, a stroke patient transfer from an internal system hospital, and an intubated [a tube inserted into the windpipe to keep the airway open and assist with breathing] ED patient).

iii. Observations were conducted in the ICU of Facility A on 3/5/25. Observations revealed the ICU had a census of 10 patients. Staffing for the unit included one charge nurse without a patient assignment, two RNs with two ICU level patients, and two RNs with triple assignments.

These observations were in contrast to the unit staffing grids for the ICU which indicated the nurse-to-patient ratio for the ICU was 1:2 (one RN to two patients).

Additionally, these observations were in contrast to the staffing plans which specified the nurse-to-patient ratios according to the patient census and amount of nurses required. The staffing plans read, the unit charge nurse would make adjustments as needed based on clinical judgement of acuity.

B. Document review

i. A document review of Facility A's daily staffing assignments for the ICU unit from 1/1/25 through 3/4/25 was conducted. The staffing assignments revealed the day shift RNs had triple assignments on 1/4/25, 1/5/25, 1/9/25, 2/10/25, 2/14/25, 2/15/25, 2/16/25, 2/17/25, 2/18/25, 2/22/25, 2/24/25, 2/25/25, and 3/3/25. Additionally, document review revealed the nightshift RNs had triple assignments on 1/4/25, 1/5/25, 1/7/25, 1/12/25,1/19/25, 1/23/25, 1/25/25, 1/29/25, 2/5/25, 2/6/25, 2/8/25, 2/9/25, 2/14/25, 2/15/25, 2/17/25, 2/18/25, 2/23/25, 2/24/25, 3/1/25, and 3/3/25. All shifts listed above had at least one triple assignment and as many as four triple assignments for the shift.

ii. A document review of Facility B's daily staffing assignments for the ICU unit from 1/1/25 through 3/4/25 was conducted. The staffing assignments revealed the day shift RNs had triple assignments on 1/8/25, 1/9/25, 1/10/25, 1/27/25, 2/6/25, 2/7/25, 2/9/25, 2/15/25, 2/20/25, 2/21/25, 2/22/25. 2/26/25, and 3/4/25. Additionally, document review revealed the nightshift RNs had triple assignments on 1/5/25, 1/6/25, 1/9/25, 1/11/25, 1/13/25, 1/14/25, 1/17/25, 1/18/25, 1/19/25, 1/25/25, 1/26/25, 1/27/25, 2/2/25, 2/3/25, 2/5/25, 2/6/25, 2/11/25, 2/12/25, 2/15/25, 2/19/25, 2/20/25,2/23/25, 2/24/25, 2/25/25, 2/28/25, 3/1/25, 3/3/25, and 3/4/25. All shifts listed above had at least one triple assignment and as many as seven triple assignments for the shift.

iii. A document review of the Divert and Pause Logs for both Facility A and B revealed the facility inconsistently utilized the divert (when a hospital ED is temporarily closed to ambulance traffic) or admission pause protocol for surge and capacity management and instead, while RNs cared for triples in the ICU, the units also admitted additional patients for care.

Additionally, document review of the daily assignment sheets revealed staff inconsistently escalated their staffing concerns. When nursing staff escalated their concerns for staffing shortages, the charge nurses documented no resolution or leadership denied divert for the staffing concerns.

Furthermore, the document review of the daily assignment sheets revealed the units continued to admit patients to the units, despite the number of intubated patients (patients who required breathing tubes) and patients on vasopressors (medication used to treat critically low blood pressures), even when admissions caused a triple assignment.

This was in contrast to the Surge and Capacity Management policy which read, ED staff should have evaluated and stabilized patients in the ED and transferred to an appropriate facility when the facility did not have the required resources to care for the patients. Additionally, this was in contrast to the staffing guidelines policy which read, whenever staff made the clinical nursing staff aware of emergent staffing concerns and complaints, they escalated the complaints and concerns up through leadership.

iv. A review of the facility's previous deficiencies cited for failure to ensure minimum staffing requirements revealed the facility was cited on 1/11/24 and again on 3/20/24.

C. Interviews

i. Interviews were conducted with staff over the course of the survey between 3/3/25 and 3/12/25. RN #1 stated triple assignments in the ICU happened regularly and had increased in frequency over the past few months. RN #1 stated they did not feel safe with some of the assignments because they could not complete all tasks and had a difficult time managing all patient care necessary for an ICU level patient. RN #1 stated when they felt unsafe, they escalated concerns to the charge nurse, however, the assignments did not change due to lack of staffing. RN #1 stated short staffing affected patient outcomes such as when patients self-extubated (pulled out their breathing tube) or when RNs had medication errors during the care of their patients.

ii. An interview was conducted with RN #2. RN #2 stated they had concerns with the frequency of triple assignments in the ICU and the lack of interventions by leadership. RN #2 stated they had access to the unit staffing grid, however, leadership focused on accepting patients in order to stay off of divert. RN #2 stated when leadership placed the ICU on divert, it did not always help because divert only applied to patients who needed intubation or vasopressors. RN #2 stated they still admitted patients with other diagnoses who needed ICU level care and these admissions resulted in triple assignments. RN #2 stated triple assignments put patients at risk for harm. RN #2 stated ICU patients' conditions changed rapidly and adverse events, such as a deteriorated condition or self-extubation, could occur if the patients were not monitored closely.

iii. An interview was conducted with RN #3. RN #3 stated they had triple assignments several times while they worked as a new graduate nurse. RN #3 stated their assignment included three ICU level patients and one of those patients needed to be intubated due to a deteriorated condition. RN #3 stated they were also assigned a new admission on another shift, but received no support because the other nurses had triple assignments as well. RN #3 stated they were not able to complete tasks for patients when they had a triple assignment, such as wound care, bathing, or skin care.

iv. An interview was conducted with RN #4. RN #4 stated they had concerns about the lack of support new graduate nurses had when they had a triple assignment. RN #4 stated when RNs had triple assignments, the new graduate nurses missed things, such as a tourniquet left on a patient's arm or that the RN did not fully know the patient's condition. RN #4 stated they knew about the escalation process, however, the escalations did not result in a resolution for staffing concerns.

v. An interview was conducted with RN #5. RN #5 stated charge nurses followed the unit matrix (staffing grid) when they made assignments. RN #5 stated the ICU matrix called for a 1:2 ratio and frequently, staff were assigned more than two patients because they did not have adequate numbers of staff. RN #5 stated the charge nurses would inform the house supervisor, staffing office, and unit manager to request more nurses. RN #5 stated frequently they did not get additional staff to prevent triple assignments. Additionally, RN #5 stated unsafe triple assignments resulted when the facility could not provide nurses that met the staffing matrix requirements.

vi. On 3/11/25 at 12:42 p.m., an interview was conducted with ICU manager (Manager) #6. Manager #6 stated the ICU staffing goal was a 1:2 ratio of ICU level patients. Manager #6 stated the charge nurses considered the acuity of the patients in the RN assignments. Manager #6 stated they were hiring new staff that would accommodate the increased census and turnover on the unit, but in the meantime, they used staff from the float pool, the acuity tool, patient downgrades from ICU level status, and divert to keep the triple assignments to a minimum and to keep patients safe. Manager #6 stated they consulted with the chief nursing officer (CNO) when the staff had valid concerns and could not move patients to a lower level of care. Manager #6 stated they would go on divert if staff had valid concerns and patients could not relocate to another unit. Manager #6 stated the facility took divert very seriously and the decision to go on divert was made on a case-by-case basis.

vii. An interview was conducted on 3/10/25 at 4:21 p.m. with CNO #7 and CNO #8. CNO #7 stated they did not consider the triple assignments in ICU to be true triples when the RN had one ICU level patient and two downgraded level patients. CNO #7 stated there was no policy or matrix adjustments that supported this practice. CNO #7 stated the staff escalated their concerns up the chain of command and leadership made the decision to pause admissions or to initiate intubation-vasopressor divert for ICU. CNO #8 stated it was not the decision of the facility to put the ED on divert to prevent triple assignments in the ICU. CNO #8 stated the local emergency medical services (EMS) made the decision to bring patients to the facility if the patient needed to be stabilized. CNO #8 further stated once at the facility, the patients were admitted to the ICU, and at times, this caused triple assignments. CNO #8 stated providers determined the level of acuity, such as ICU or downgraded level, and the facility used acuity levels in the master staffing plan to guide the charge nurses when they made assignments.

These interviews were in contrast to the surge and capacity management policy which read, patients were evaluated and stabilized in the ED and transferred to an appropriate facility when the facility did not have the required resources to care for the patients. Additionally, the interviews were in contrast to the CCR 1011-1 Chapter Four, Part 14.7 Nurse Staffing Plans regulations which read, a master nurse staffing plan included guidance and a process to reduce nurse-to-patient assignments to align with the demand based on patient acuity. Additionally, the interviews were in contrast to the master staffing plan which read, the facility had detailed unit staffing plans that guided appropriate staffing for each census level. The unit staffing plan provided clear guidance to the number of caregivers needed at each patient census level.

Based on observations, interviews, and document review, the facility failed to ensure patients were continuously monitored in accordance with facility policy in order to meet physician ordered pulse oximetry (pulse ox) (a medical device used to measure the saturation of oxygen carried in red blood cells) ranges ordered to identify a change in a patient's condition in one of two patient care units observed.

Findings include:

Facility policies:

The Cardiac and Pulse Oximetry Monitoring policy read, communication from telemetry technician to nursing associates on the unit included changes in pulse oximetry outside of set parameters. Communication chain of command response to the alarm was the assigned certified nursing assistant (CNA), registered nurse (RN), house supervisor, or hospital specific rapid response team (a team that responds to a patient's deteriorated condition) or code blue process (a team who provides advanced life care support in the event the patient's heart stops beating).

Appendix A to the Cardiac and Pulse Oximetry Monitoring policy read, a CNA could respond to a non-urgent alarm such as low battery, partial leads off, or poor quality pulse oximeter waveform. An RN responded to an urgent alarm, such as a pulse oximeter reading (SPO2) of less than 85%, a pause greater than three seconds, a ventricular tachycardia (a dangerous heart rhythm) of less than five seconds, a heart rate greater than 140 beats per minute or less than 40 beats per minute, or a change in the heart rhythm. An RN responded to an emergent alarm of a pulse oximeter reading of less than or equal to 80%, an SPO2 probe off or not reading, a lethal arrhythmia, a dead battery, or all leads off. The algorithm read for the technician to call the RN or charge nurse for emergent alarms. If the RN could check on the patient, the RN was to stay on the phone with the technician until the RN had direct eye contact with the patient. If the RN or charge nurse was unable to check the patient, the algorithm directed the technician to call a rapid response or code blue.

The Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy read, reassessment of the hospitalized patient is a continuous, ongoing process based upon department specific assessment parameters as well as in response to changes in diagnosis, treatments, procedures, and the plan of care. Patient condition and ongoing changes in status warrant more frequent reassessment and documentation of specific system changes. Notes should be used to document any actions/observations that do not have an appropriate or corresponding documentation section.

1. The facility failed to ensure patients were continuously monitored in accordance with facility policy in order to meet physician ordered pulse oximetry ranges.

A. Observations

i. On 3/6/25 at 9:55 a.m., observations were conducted in the IMC unit. Observations revealed IMC manager (Manager) #9 and charge nurse (RN) #10 talking at the nursing station while a continuous alarm sounded for Patient #6. Further observation revealed RN #11 walked behind the nurses' station, looked at the monitors, and briskly walked down the hall to room 701, Patient #6's room.

At 9:57 a.m., observations were conducted in room 701. Observations revealed Patient #6 was slouched in the bed, gray in color, and showed visible signs of respiratory distress. Patient #6 was noted to have labored breathing and was unable to speak in full sentences. Further observations revealed the patient had pulled their oxygen off, and their pulse oximetry was 83%.

According to the document review of the pulse ox machine strips for this timeframe, Patient #6 had low oxygenation saturations from 9:49 a.m. through 9:58 a.m.

This was in contrast to the Telemetry Monitoring Alarm Notification and Escalation Process policy, which instructed the telemetry technician to immediately notify the patient's nurse or charge nurse if the patient's pulse oximetry was less than 85%. The nurse was to stay on the phone with the telemetry tech until entering the patient ' s room to confirm eyes on the patient. If the telemetry technician could not reach the nurse or charge nurse, the telemetry technician was then expected to call a rapid response or a code blue.

B. Document review

i. Medical record review for Patient #6 was conducted on 3/6/25. The medical record review revealed Patient #6 was an 85 year old who presented to the emergency department (ED) on 2/27/25 with abnormal lab values. Medical record review revealed Patient #6 had acute pneumonia (a lung infection) and respiratory failure and was admitted to the intermediate care (IMC) unit on 2/28/25. Medical record review revealed a provider order on 2/27/25 to titrate oxygen to keep saturation above 90%, which was changed on 3/1/25 to titrate oxygen to keep saturation above 86%.

Review of Patient #6's oxygenation documentation on 3/7/25 revealed at 9:01 a.m., the monitor alarms showed the pulse ox was off and the telemetry monitoring technician (Tech) notified the RN. The medical record showed no indication that the staff responded to the alarm. At 9:28 a.m., the medical record revealed Patient #6's oxygen saturation was low at 85% and the Tech notified the RN. The medical record showed no indication that the staff responded to the alarm. At 9:55 a.m., the medical record revealed Patient #6's oxygen saturation was low at 84% and the Tech notified the RN. The medical record showed no indication staff responded to the alarm, however, the documentation time corresponded to the observation of Patient #6 in room 701.

This was in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, staff should have continuously reassessed the patient in an ongoing process based on department specific assessment parameters, as well as in response to change in treatments and procedures. The policy instructed staff to use notes to document any actions/observations that did not have a corresponding documentation section.

ii. A review of the pulse ox machine strips for Patient #6 revealed at 8:50 a.m., the pulse ox probe was off. At 8:51 a.m., Patient #6's pulse ox was 83%. At 8:52 a.m., Patient #6's pulse ox was 82%. The record review revealed no indication the Tech had notified any staff on the unit per facility policy, or that staff had responded to the low oxygen saturation levels.

The review of the pulse ox machine strips also revealed at 8:55 a.m., Patient #6's probe was off and remained off in documented one-minute increments until 9:11 a.m., for a total of 16 minutes. Patient #6's medical record review revealed the Tech had notified the RN at 9:01 a.m.

Further review of the pulse ox machine strips revealed Patient #6's oxygen saturation dropped again at 9:41 a.m. to 84% and stayed below 87% until 9:47 a.m. with no indication the telemetry monitoring technician notified any staff on the unit per facility policy or that staff had responded to the low oxygen saturation levels. Additionally, the review revealed Patient #6's oxygen saturation was 85% at 9:49 a.m. and remained low (81%-85%) until 10:02 a.m., 13 minutes later. The medical record review revealed the Tech notified staff at 9:55 a.m. and RN #11 documented Patient #6's vital signs at 10:00 a.m.

This was in contrast to the provider order placed on 3/1/25, which instructed staff to keep Patient #6's oxygen saturation above 86%.

This was also in contrast to the Telemetry Monitoring Alarm Notification and Escalation Process policy, which instructed the telemetry technician to immediately notify the patient's nurse or charge nurse if the patient's pulse oximetry was less than 85%. The nurse was to stay on the phone with the telemetry tech until entering the patient ' s room to confirm eyes on the patient. If the telemetry technician could not reach the nurse or charge nurse, the telemetry technician was then expected to call a rapid response or a code blue.

Additionally, this was in contrast to the Assessment, Reassessment, Vital Signs, and Documentation of Patient Care policy which read, staff should have continuously reassessed the patient in an ongoing process based on department specific assessment parameters, as well as in response to change in treatments and procedures. The policy instructed staff to use notes to document any actions/observations that did not have a corresponding documentation section.

C. Interviews

i. On 3/6/25 at 3:28 p.m., an interview was conducted with telemetry monitoring technician (RN) #13. RN #13 stated they documented the times staff were notified of low oxygen saturation levels in Patient #6's medical record. RN #13 stated they had called RN #11 several times during the shift, but did not ask RN #11 to stay on the phone until they had eyes on the patient after the pulse ox probe came off as required by facility policy. RN #13 stated as long as the RN acknowledged the need to check the patient, the telemetry monitoring technicians did not remain on the phone. RN #13 stated they had an abundance of alarms that required calls to the staff, so they only ensured staff were notified. RN #13 stated staff should have checked on the patient when the pulse ox probe came off to ensure the patient had not deteriorated.

ii. On 3/10/25 at 3:26 p.m., an interview was conducted with Manager #9. Manager #9 stated the telemetry monitoring unit monitored Patient #6 remotely and the pulse oximeter machine also showed on the monitor at the unit's nurses' station. Manager #9 stated once the RN received a call from the telemetry monitoring technician, the primary nurse was expected to check on the patient; if the primary nurse could not check the patient, then the charge nurse was expected to check on the patient. Manager #9 stated CNAs could check on patients when pulse ox probes came off. The CNAs escalated issues they did not know how to handle and escalated issues of patient distress to the RN. Manager #9 stated they reviewed Patient #6's incident of desaturation and stated the CNA had checked on the patient because RN #11 and RN #10 could not check on the patient at the time the probe was off of Patient #6.

iii. On 3/1/25 at 1:27 p.m., an interview was conducted with the cardiovascular and telemetry units manager (Manager) #14. Manager #14 stated the telemetry monitoring technicians called CNAs with green alarms such as a low battery, or if the patient had one telemetry lead off but had a visible heart rhythm. Manager #14 stated the telemetry monitoring technicians called RNs for yellow alarms such as vital signs which were outside of parameters. They called the unit charge nurse when RNs could not respond. Manager #14 stated the telemetry monitoring technician called RNs for red alarms, such as when pulse oximetry probes were off of the patient. They called rapid responses or code blues for lethal arrhythmias (a life-threatening irregular heartbeat) or when the RN did not respond or check on the patient. Manager #14 stated the telemetry monitoring technicians were expected to follow the escalation process.

This was in contrast to the medical record review and review of the pulse ox machine strips which revealed the patient had a 16 minute episode in which the probe was off six minutes before the RN was notified and remained off an additional 10 minutes while the CNA changed the probe.

Additionally, Manager #14 stated telemetry monitoring technicians did not stay on the phone with the staff when oxygen probes came off the patients. Manager #14 stated they would continue to the next call because they had constant alarms in the monitoring room.

This was in contrast to the Telemetry Monitoring Alarm Notification and Escalation Process policy, which instructed the nurse to stay on the phone with the telemetry tech until entering the patient ' s room to confirm eyes on the patient. If the telemetry technician could not reach the nurse or charge nurse, the telemetry technician was then expected to call a rapid response or a code blue.

iv. On 3/10/25 at 4:21 p.m., an interview was conducted with CNO #8. CNO #8 stated they performed a full investigation of the Patient #6 incident of desaturation and learned CNA #12 went into Patient #6's room after RN #11 called them to check on the patient. CNO #8 stated CNA #12 saw Patient #6 did not show signs of distress, so obtained a new pulse ox probe. CNO #8 stated this happened from 9:11 a.m. to 9:28 a.m., a total of 17 minutes.