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Based on review of hospital policies and procedures, facility documents, medical record review and staff and physician interviews, the hospital's governing body failed to provide oversight and have systems in place to ensure the protection and promotion of patient's rights to ensure a patient was evaluated for signs of life and assessed by nursing for provision of emergency treatment.

Findings include:

1. The hospital failed to promote and protect a patient's rights by failing to ensure laboratory staff evaluated a patient for signs of life and notified nursing staff of a need to assess a patient.

~cross refer to 482.13 Patient Rights' Condition: Tag 0115

2. The hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations to ensure a patient received safe delivery of care by failing to assess and monitor a patient with early warning signs of decompensation.

~cross refer to 482.23 Nursing Services Condition: Tag 0385.

Based on review of hospital policies and procedures, medical record review and staff and physician interviews, the hospital failed to promote and protect a patient's rights by failing to ensure laboratory staff evaluated a patient for signs of life and notified nursing staff of a need to assess a patient.

Findings include:

The hospital staff failed to provide care in a safe setting to a patient by failing to recognize the patient's emergent need for assessment when the lab staff member found the patient cold and non-responsive to verbal, touch or painful stimuli. Laboratory staff failed to assess the patient for signs of life and failed to notify nursing for assessment and treatment

~cross refer to 482.13(c)(2) Patient Rights' Standard: Tag A0144

Based on review of hospital policies and procedures, medical record review and staff and physician interviews the hospital staff failed to provide care in a safe setting to a patient by failing to recognize the patient's emergent need for assessment when the lab staff member found the patient cold and non-responsive to verbal, touch or painful stimuli. Laboratory staff failed to assess the patient for signs of life and failed to notify nursing for assessment and treatment.

Findings include:

Review on 08/12/2020 of the hospital's policy and procedure titled "Patient Rights & (and) Responsibilities" adopted 10/2014 revealed " ...Our staff is committed to meeting your needs and delivering the highest quality of patient care ... As a patient, you have a right to: ... Expect good quality care and high professional standards that are continually maintained and reviewed ... Expect to feel safe while in the hospital ..."

Review on 08/11/2020 of the hospital's policy titled "Nursing Process and Physical Assessment Standards" with an effective date of 10/18/2018 revealed " ... Medical/Surgical/Telemetry Departments ... A full assessment will be documented at least once during a standard 12-hour shift. Focused reassessments will be performed and documented as dictated by patient condition and/or physician order ... Vital signs, including temperature, pulse, respirations and blood pressure. Oxygen saturation ... monitoring as indicated. 'Routine' or 'qshift (every shift)' vital signs are defined as q (every) 8 hours ..."

Review on 08/11/2020 of the closed medical record for Patient #4 revealed a 52-year-old female who presented to the facility emergency department by EMS (Emergency Medical Services - ambulance) on 05/03/2020 at 1055 with complaints of AMS (altered mental status - confusion) and SOB (shortness of breath). Medical record review revealed Patient #4 was admitted on 05/03/2020 at 1725 with a diagnosis of Pneumonia (an infection of the air sacs in one or both lungs) to a medical/surgical observation status on a progressive care unit. Review of the History and Physical note dated 05/03/2020 at 1721 revealed Patient #4 had a past medical history of Asthma (respiratory disease), Chronic Bronchitis (respiratory disease), Arnold-Chiari malformation Type II (congenital condition of the central nervous system), and Anxiety (fear or apprehension ). Review of the Physician order dated 05/03/2020 at 1651 revealed an order for "Vital Signs Frequency: Routine Per Unit Routine 05/03/2020 1648 - Until Specified ..." Review of the "Vital Sign Flowsheet" revealed Patient #4's vital signs on 04/03/2020 at 1726 were BP (blood pressure) 157/113, HR (heart rate) 109, R (respirations) 22, Oxygen saturation 100% on RA (room air), T (temperature) "cannot get temperature to read pt (patient) warm to touch." Review of the "Vital Sign Flowsheet" at 2300 revealed BP 109/63; HR 103; R 24; Oxygen saturation 94% on RA; T 100.3; Pain 0 (no pain). Review of the MAR (Medication Administration Record) revealed Zanaflex (muscle relaxer) was administered orally to Patient #4 on 04/04/2020 at 0228. Review of a nursing note dated 05/04/2020 at 1049 revealed "Received report from night shift RN (Registered Nurse) between 7:15am and 7:30am. Shortly thereafter, lab technician asked for RN presence in the room. Upon entering, patient had no palpable radial or carotid pulse. Code blue (resuscitation code) pulled in room and compressions begun immediately ..." Review of the "Cardiopulmonary Resuscitation Record" dated 05/04/2020 at 0737 revealed CPR (cardiopulmonary resuscitation) started. Review revealed Patient #4 expired on 05/04/2020 at 0758. Review of the Discharge Summary note dated 05/04/2020 at 1041 revealed MD #5 responded to a CODE BLUE page. Review revealed Patient #4 was found unresponsive, without a pulse or spontaneous respiration and it was unknown how long Patient #4 had been without a pulse prior to being found. Review revealed Patient #4 never regained consciousness, Patient #4 never regained a pulse, Patient #4 never had a perfusing rhythm, and never regained spontaneous respirations. Review revealed Patient #4's daughter was contacted by telephone and updated while CPR was in progress. Review revealed Patient #4's date and time of death were recorded as 05/04/2020 at 0758. Review of the Referral/Evaluation for Donation of an Anatomical Gift form dated 05/04/2020 at 1100 revealed "... Cause of death: Cardiac arrest ..."

Telephone interview on 08/12/2020 at 1542 with MD #6 revealed she was the Admitting Hospitalist physician for Patient #4. Interview revealed MD #6 remembered Patient #4. Interview revealed Patient #4 came in to the Emergency Department (ED) in respiratory distress (acute illness that affects the lungs) and hypoxic (insufficient oxygen). Interview revealed Patient #4 did well in the ED and was thought to have Pneumonia (infection in one or both lungs). Interview revealed a decision was made to admit Patient #4 as a Med (Medical)/Surg (Surgical) patient in Observation status (stay in the hospital usually less than 48 hours). Interview revealed the plan of care was to give Patient #4 IV (intravenous) fluids, antibiotics (medication for infection), and monitor Patient #4. Interview revealed MD #6 did not receive any calls overnight regarding Patient #4.

Interview on 08/14/2020 at 0835 with RN (Registered Nurse) #4 revealed she was the primary nurse assigned to Patient #4 on 05/03/2020 1900 to 05/04/2020 0700. Review revealed the nurse was working with a preceptor as she was on her last day of orientation. Interview revealed she remembered Patient #4 was alert and able to communicate her needs. Interview revealed RN #4 did not see any significant change in her (Patient #4) vital signs. RN #4 reported she gave Patient #4 the scheduled oral dose of Zanaflex (muscle relaxer) at 0228 and Patient #4 had no difficulties with taking the medication.

Interview on 08/13/2020 at 1050 with a Lab Manager revealed when a laboratory technician attempts a blood draw on a patient there is an electronic computer tracking time stamp that records the times of the interaction and the patient involved. Interview revealed the Lab Manager had reviewed the times of interactions recorded with Patient #4. Interview revealed Lab Tech (Technician) #1 had the first interaction with Patient #4 on 05/04/2020 at 0609. Interview revealed the Lab Tech #2 had the second interaction with Patient #4 at 0709.

Interview on 08/12/2020 at 1610 with Lab Tech #1 revealed she was unable to remember Patient #4.

Interview on 08/13/2020 at 1136 with Lab Tech #2 revealed he remembered Patient #4. Interview revealed Lab Tech #2 entered Patient #4's room, called her by name and introduced himself and stated he was there to draw her labs. Interview revealed Patient #4 did not respond. Interview revealed Lab Tech #2 remembered Patient #4 being "very cold" so he held a heat pack on her hand for 10-15 minutes before his first attempt to draw labs. Interview revealed his first attempt was unsuccessful and Lab Tech #2 reapplied the heating pack for an addition 2 minutes then attempted to draw labs a second time. Interview revealed the second attempt was unsuccessful. Interview revealed Patient #4 did not respond to voice, touch, or painful stimulus of lab draw. Lab Tech #2 stated, "I never checked to see if she was alive or not. She never talked with me. I did not hear her breathing. She never spoke. Her eyes were open and she was laying on her back. It never came across my mind that she might be dead. I have never dealt with that before." Interview revealed Lab Tech #2 left Patient #4's room and continued on to his next patient.

Telephone interview on 08/13/2020 at 1100 with Lab Tech #3 revealed she went into Patient #4's room and introduced herself. Interview revealed Patient #4 did not respond, so Lab Tech #4 "shook her (Patient #4) shoulder with no response. Her mouth was open. She was cold to touch. I jostled her and hit the call button. I checked her pulse. No pulse. I could not see her chest rise." Interview revealed Lab Tech #4 notified Patient #4's RN. Interview revealed a CODE (alert staff of medical emergency) was called.
Telephone interview on 08/12/2020 at 1111 with RN (Registered Nurse) #8 revealed she was the primary nurse for Patient #4 on 05/04/2020 0700 to 1900 and remembered the patient. Interview revealed RN #8 received report from RN #4 in Patient #4's doorway and Patient #4 did not appear to be in any distress. Interview revealed they did not go in the room to the bedside for report. Interview revealed with the report RN #8 received she assumed Patient #4 was going to be a stable patient. Interview revealed RN #8 was sitting at the nurses station when a lab tech asked if patient #4 "always looked that way". Interview revealed RN #8 went to Patient #4's room. Interview revealed Patient #4 did not have a lot of color, the color was drained from her face, she (Patient #4) was cool to touch, and she was tucked into her bed covers. Interview revealed RN #8 checked for a carotid pulse (heartbeat felt on either side of the front of the neck just below the jaw line) and a femoral pulse (heartbeat felt on the inner thigh halfway to the pubic area), no pulses were palpable. Interview revealed RN #8 pushed the CODE button in Patient #4's room and started CPR (cardiopulmonary resuscitation). RN #8 stated "She was cool to touch. She was not breathing. I was concerned based on the temperature of her skin how long she might have been arrested. It takes a while to get to the body temperature that she was. She was a light skin African American woman. She was drained of most of her color."

Telephone interview on 08/12/2020 at 1031 with MD (Medical Doctor) #5 revealed he was Hospitalist physician for Patient #4 on 05/04/2020 and involved in the CODE. Interview revealed he remembered Patient #4's case. Interview revealed MD #5 had just come on shift and was reviewing the sign out from the previous provider when he received a page around 0740 indicating a CODE BLUE in Patient #4's room number. Interview revealed MD #5 went to the room where the CODE BLUE team was performing CPR. Interview revealed it was unclear how long Patient #4 had been in asystole (no electrical or mechanical activity of the heart - flatline), unclear how long Patient #4 had no pulse and unclear how long Patient #4 had not been breathing.

In summary, facility staff failed to ensure safe delivery of care to Patient #4. Laboratory staff failed to assess the patient for signs of life and failed to notify nursing for assessment and treatment.

Based on review of hospital policies and procedures, facility documents, medical record review and staff and physician interviews, the hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations to ensure a patient received safe delivery of care by failing to assess and monitor a patient with early warning signs of decompensation.

The findings include:

Nursing staff failed to assess and monitor a patient according to the hospital MEWS (Modified Early Warning Score) guidelines and bedside shift reporting policy for 1 of 3 sampled patients (Patient #4). The patient was found without a pulse and respirations and subsequently expired.

~cross refer to 482.23(b)(3) Nursing Standard: Tag A0395

Based on review of hospital policies and procedures, facility documents, medical record review and staff and physician interviews, nursing staff failed to assess and monitor a patient according to the hospital MEWS (Modified Early Warning Score) guidelines and bedside shift reporting policy in 1 of 3 sampled patients (Patient #4).

Findings include:

Review on 08/11/2020 of the hospital's policy titled "Nursing Process and Physical Assessment Standards" with an effective date of 10/18/2018 revealed " ... Medical/Surgical/Telemetry Departments ... A full assessment will be documented at least once during a standard 12-hour shift. Focused reassessments will be performed and documented as dictated by patient condition and/or physician order ... Vital signs, including temperature, pulse, respirations and blood pressure. Oxygen saturation ... monitoring as indicated. 'Routine' or 'qshift (every shift)' vital signs are defined as q (every) 8 hours ..."

Review on 08/14/2020 of the hospital provided power point titled "RN (Registered Nurse) Nurse Bundle Bedside Shift Report and Whiteboards" (not dated) revealed "Bedside Shift Report Ensure the safe handoff of care between nurses by involving patient and family ... Bedside Shift Report - Key Components 1. Active Patient ID [identification] (Wrist Band/DOB [date of birth]) for SAFETY * Oncoming RN must verify patient name and DOB ... 2. Manage up oncoming RN for TRUST * Off going RN introduce new RN and ensure patient he/she is in good hands ... 3. Invite patient into the conversation ... 4. Use of SBAR [type of reporting that includes situation,background, assessment and recommendation] (or your standard format) to organize report ... 5. Safety/Quality Checks for patient SAFETY .... 6. Use and update whiteboard as you give report ..."

Review on 08/14/2020 of the hospital provided power point titled "The New & (and) Improved Modified Early Warning Score (MEWS) dated Jan (January) 2020 revealed "What is MEWS? Modified Early Warning Score (MEWS) is a tool used to identify patients at risk for deterioration based on physiologic components: -Systolic BP (blood pressure) -Heart rate -Respiratory rate -Temperature -Level of consciousness How is the MEWS score calculated? Points assigned based on values of each vital sign measurement and totaled to give cumulative score ..."

Review on 08/14/2020 of the hospital provided information sheet titled "New and Improved Modified Early Warning Score (MEWS) Go Live with dates for (Hospital name) of January 28-31, 2020 revealed "Why: To save lives and improve inpatient mortality by early recognition of patient changes to prevent failure to rescue (FTR), codes, or transfers to higher level of care ...Validation of the MEWS show patients with a medium (yellow) to high (red) score during their admission were 87 times more likely to die compared to patients with low scores ... Go live will include: *Implement new MEWS workflow and a standardized nursing response *Adding new MEWS flowsheets and RN (Registered Nurse) documentation expectations *Adding MEWS to the Philips vital signs monitor screen."

Review on 08/12/2020 of the hospital's policy and procedure titled "MEWS (Modified Early Warning Score) Guidelines" last updated 01/17/2020 revealed "Green - Likely stable ... Yellow - At risk for Deteriotation (sic) - 1. Go to room and assess patient 2. Validate data, is this patient baseline? If data confirmed: 3. Is this an acute change? 4. Administer prn (as needed) meds (medications)/treatments as ordered. 5. Note Sepsis score. 6. Review goals of care. 7. Notify Charge Nurse and Provider. 8. Call RRT (rapid response team) nurse as needed. 9. Document patient condition/interventions/response. 10. Increase frequency of vital signs and focused assessments to at least q2h (every two hours) x2 (times two). -If stable, then q4h (every 4 hours) x2 and then q8h (every 8 hours) or dept. (department) routine. -If unstable, contact MD (Medical Doctor) and RRT nurse and prepare for possible transfer. 11. Add entry in progress notes using smart phrase 'MEWS' ..."

Review on 08/11/2020 of the closed medical record for Patient #4 revealed a 52-year-old female who presented to the facility emergency department by EMS (Emergency Medical Services - ambulance) on 05/03/2020 at 1055 with complaints of AMS (altered mental status - confusion) and SOB (shortness of breath). Medical record review revealed Patient #4 was admitted on 05/03/2020 at 1725 with a diagnosis of Pneumonia (an infection of the air sacs in one or both lungs) to a medical/surgical observation status on a progressive care unit. Review of the History and Physical note dated 05/03/2020 at 1721 revealed Patient #4 had a past medical history of Asthma (respiratory disease), Chronic Bronchitis (respiratory disease), Arnold-Chiari malformation Type II (congenital condition of the central nervous system), and Anxiety (fear or apprehension ). Review of the Physician order dated 05/03/2020 at 1651 revealed an order for "Vital Signs Frequency: Routine Per Unit Routine 05/03/2020 1648 - Until Specified ..." Review of the "Vital Sign Flowsheet" revealed Patient #4's vital signs on 04/03/2020 at 1726 were BP (blood pressure) 157/113, HR (heart rate) 109, R (respirations) 22, Oxygen saturation 100% on RA (room air), T (temperature) "cannot get temperature to read pt (patient) warm to touch." Review of the "MEWS (Modified Early Warning Score - a computer calculated predictor score that provides an early warning indicator of a patient's likelihood of decompensation) Flowsheet" dated 04/03/2020 at 1726 revealed a "Yellow" MEWS score color. Review in the electronic medical record revealed a pop up box with the actions for the"yellow" score result. Review of the "MEWS Flowsheet" at 1800 revealed a MEWS score color of "Yellow". Review of the "Vital Sign Flowsheet" at 2300 revealed BP 109/63; HR 103; R 24; Oxygen saturation 94% on RA; T 100.3; Pain 0 (no pain). Review of the "MEWS Flowsheet" at 2300 revealed a "Yellow" MEWS score color. Review of the MAR (Medication Administration Record) revealed Zanaflex (muscle relaxer) was administered orally to Patient #4 on 04/04/2020 at 0228. Review of a nursing note dated 05/04/2020 at 1049 revealed "Received report from night shift RN (Registered Nurse) between 7:15am and 7:30am. Shortly thereafter, lab technician asked for RN presence in the room. Upon entering, patient had no palpable radial or carotid pulse. Code blue (resuscitation code) pulled in room and compressions begun immediately ..." Review of the "Cardiopulmonary Resuscitation Record" dated 05/04/2020 at 0737 revealed CPR (cardiopulmonary resuscitation) started. Review revealed Patient #4 expired on 05/04/2020 at 0758. Review of the Discharge Summary note dated 05/04/2020 at 1041 revealed MD #5 responded to a CODE BLUE page. Review revealed Patient #4 was found unresponsive, without a pulse or spontaneous respiration and it was unknown how long Patient #4 had been without a pulse prior to being found. Review revealed Patient #4 never regained consciousness, Patient #4 never regained a pulse, Patient #4 never had a perfusing rhythm, and never regained spontaneous respirations. Review revealed Patient #4's daughter was contacted by telephone and updated while CPR was in progress. Review revealed Patient #4's date and time of death were 05/04/2020 at 0758. Review of the Referral/Evaluation for Donation of an Anatomical Gift form dated 05/04/2020 at 1100 revealed "... Cause of death: Cardiac arrest ..."

Interview on 08/13/2020 at 1050 with a Lab Manager revealed when a laboratory technician attempts a blood draw on a patient there is an electronic computer tracking time stamp that records the times of the interaction and the patient involved. Interview revealed the Lab Manager had reviewed the times of interactions recorded with Patient #4. Interview revealed Lab Tech (Technician) #1 had the first interaction with Patient #4 on 05/04/2020 at 0609. Interview revealed Lab Tech #2 had the second interaction with Patient #4 at 0709.

Interview on 08/12/2020 at 1610 with Lab Tech #1 revealed she was unable to remember Patient #4.

Interview on 08/13/2020 at 1136 with Lab Tech #2 revealed he remembered Patient #4. Interview revealed Lab Tech #2 entered Patient #4's room, called her by name and introduced himself and stated he was there to draw her labs. Interview revealed Patient #4 did not respond. Interview revealed Lab Tech #2 remembered Patient #4 being "very cold" so he held a heat pack on her hand for 10-15 minutes before his first attempt to draw labs. Interview revealed his first attempt was unsuccessful and Lab Tech #2 reapplied the heating pack for an addition 2 minutes then attempted to draw labs a second time. Interview revealed the second attempt was unsuccessful. Interview revealed Patient #4 did not respond to voice, touch, or painful stimulus of lab draw. Lab Tech #2 stated, "I never checked to see if she was alive or not. She never talked with me. I did not hear her breathing. She never spoke. Her eyes were open and she was laying on her back. It never came across my mind that she might be dead. I have never dealt with that before." Interview revealed Lab Tech #2 left Patient #4's room and continued on to his next patient.

Telephone interview on 08/13/2020 at 1100 with Lab Tech #3 revealed she went into Patient #4's room and introduced herself. Interview revealed Patient #4 did not respond, so Lab Tech #3 "shook her (Patient #4) shoulder with no response. Her mouth was open. She was cold to touch. I jostled her and hit the call button. I checked her pulse. No pulse. I could not see her chest rise." Interview revealed Lab Tech #4 notified Patient #4's RN. Interview revealed a CODE (alert staff of medical emergency) was called.

Telephone interview on 08/12/2020 at 1542 with MD #6 revealed she was the Admitting Hospitalist physician for Patient #4. Interview revealed MD #6 remembered Patient #4. Interview revealed Patient #4 came in to the Emergency Department (ED) in respiratory distress (acute illness that affects the lungs) and hypoxic (insufficient oxygen). Interview revealed Patient #4 did well in the ED and was thought to have Pneumonia (infection in one or both lungs). Interview revealed a decision was made to admit Patient #4 as a Med (Medical)/Surg (Surgical) patient in Observation status (stay in the hospital usually less than 48 hours). Interview revealed the plan of care was to give Patient #4 IV (intravenous) fluids, antibiotics (medication for infection), and monitor Patient #6. Interview revealed MD #6 did not receive any calls overnight regarding Patient #4.

Interview on 08/14/2020 at 0835 with RN (Registered Nurse) #4 revealed she was the primary nurse assigned to Patient #4 on 05/03/2020 1900 to 05/04/2020 0700. Review revealed the nurse was working with a preceptor as she was on her last day of orientation. Interview revealed she remembered Patient #4 was alert and able to communicate her needs. Interview revealed RN #4 did not see any significant change in her (Patient #4) vital signs. RN #4 reported she gave Patient #4 the scheduled oral dose of Zanaflex (muscle relaxer) at 0228 and Patient #4 had no difficulties with taking the medication. Interview revealed RN #4 was not familiar with the MEWS protocol and did not know what actions were to be implemented when Patient #4 had a yellow color MEWS score. RN #4 reported the nurses do an end of shift report at the bedside to introduce the oncoming nurse to the patient, discuss the patient's status and plan of care. Interview revealed RN #4 could not remember if the report to RN #8 on 05/04/2020 at 0700 was performed at the bedside.

Telephone interview on 08/12/2020 at 1111 with RN (Registered Nurse) #8 revealed she was the primary nurse for Patient #4 on 05/04/2020 0700 to 1900 and remembered the patient. Interview revealed RN #8 received report from RN #4 in Patient #4's doorway and Patient #4 did not appear to be in any distress. Interview revealed they did not go in the room to the bedside for report. Interview revealed with the report RN #8 received she assumed Patient #4 was going to be a stable patient. Interview revealed RN #8 was sitting at the nurses station when a lab tech asked if patient #4 "always looked that way". Interview revealed RN #8 went to Patient #4's room. Interview revealed Patient #4 did not have a lot of color, the color was drained from her face, she (Patient #4) was cool to touch, and she was tucked into her bed covers. Interview revealed RN #8 checked for a carotid pulse (heartbeat felt on either side of the front of the neck just below the jaw line) and a femoral pulse (heartbeat felt on the inner thigh halfway to the pubic area), no pulses were palpable. Interview revealed RN #8 pushed the CODE button in Patient #4's room and started CPR (cardiopulmonary resuscitation). RN #8 stated "She was cool to touch. She was not breathing. I was concerned based on the temperature of her skin how long she might have been arrested. It takes a while to get to the body temperature that she was. She was a light skin African American woman. She was drained of most of her color." Telephone interview on 08/14/2020 at 1005 with RN#8 revealed a MEWS score provided an objective reason to escalate care. Interview revealed a yellow score would warrant reassessment of the patient. Interview revealed vital signs should be checked and she would review trends to see if she needed to call the physician. Interview revealed the nurse would have to look at the protocol to see what actions would need to do done. She stated she did not know the frequency of vital signs and assessment for a yellow score. Interview revealed she remembered that the bedside shift report was done at the doorway for Patient #4 at 0700 on 05/04/2020. The nurse stated she could visualize the patient and she looked like she was sleeping. She remembered the report stating that the patient was a med surg patient on room air with an acute respiratory illness. It was reported that she had a history of asthma and was morbidly obese. Interview revealed the report was that her last vital signs were stable.

Telephone interview on 08/12/2020 at 1031 with MD (Medical Doctor) #5 revealed he was Hospitalist physician for Patient #4 on 05/04/2020 and involved in the CODE. Interview revealed he remembered Patient #4's case. Interview revealed MD #5 had just come on shift and was reviewing the sign out from the previous provider when he received a page around 0740 indicating a CODE BLUE in Patient #4's room number. Interview revealed MD#5 went to the room where the CODE BLUE team was performing CPR. Interview revealed it was unclear how long Patient #4 had been in asystole (no electrical or mechanical activity of the heart - flatline), unclear how long Patient #4 had no pulse and unclear how long Patient #4 had not been breathing.

Interview on 08/13/2020 at 1350 with NM #7 revealed she was the nursing manager on the 2W unit which was a progressive pulmonary care unit. Interview revealed Patient #4 was located on 2W. Interview revealed the unit included patients at varying levels of care that included medical surgical, telemetry and step down levels of care. Interview revealed the level of care was designated on admission by a physician's order. Interview revealed Patient #4 was admitted with a medical surgical status and vitals signs and a nursing assessment would be done every shift or every eight hours. Interview revealed there was an expectation that rounding was done every two hours and all patients would be checked on every two hours. Interview revealed the assessment and vital signs should be done more frequently when the patient's MEWS (Modified Early Warming Score) turned yellow. Interview revealed the last MEWS score for Patient #4 on 05/03/2020 at 2300 was yellow and the nurse should have notified the charge nurse and the physician, increased the frequency of vital signs to every 2 hours for at least two hours. Interview revealed the MEWS protocol should be followed and there was no indication the provider nor the charge nurse were notified. Interview revealed the MEWS protocol was not followed. Interview revealed the normal staffing ratio was 1 nurse to 3.5 patients and that night there was 1 nurse to 5 patients. NM #7 stated the nurse had "four extremely heavy load and one med surg, (Patient #4), with one transfer to ICU (Intensive Care Unit) at the beginning of the shift. I have concerns that (Patient #4) was not checked on as frequently as others due to her med surg status." Interview revealed nurses are expected to do a beside handoff report at shift change. Interview revealed the offgoing nurse and the oncoming nurse go to the patient's bedside and talk with the patient, check intravenous lines, discuss care plans and verify the patient's status. Interview revealed the handoff shift report for Patient #4 on 05/04/2020 at 0700 was done at the doorway and not done at the bedside.

NC00165162; NC00165572