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Based on clinical record review, policy and procedure review and interview, it was determined the facility failed to prevent actual harm to one of one patient (#15) in the Intensive Care Unit (ICU) who had a change in vital signs and there was no evidence the nurse took action. Failure to monitor the patient for changes and take action as needed did not ensure care was provided in a safe setting and in accordance with ICU standards of care. Findings included:

A. Review of the ICU Standards of Care on 05/16/18 showed patients are to be assessed every four hours and as needed (PRN) unless condition warrants more frequent observation.

B. Clinical record review on 05/16/18 showed Patient #15's vital signs while in the Intensive Care Unit (ICU) on 04/13/18 at 1:30 AM as blood pressure 160/85, pulse 98, respirations 15 and Sp02 (peripheral capillary oxygen saturation) 96%. The next set of vital signs on 04/13/18 at 1:45 AM showed a blood pressure of 206/114, pulse 114, respirations of 40 and SpO2 of 69%. The vital signs were acknowledged by the primary care nurse taking care of Patient #15. There was no documentation in the clinical record of any nurse actions relating to the change in vital signs.

C. The Vice President of Patient Care Services was interviewed on 05/16/18 at 12:41 PM and confirmed there was no evidence in the clinical record of any follow-up to the vital signs documented on 04/13/18 at 1:45 AM.

Based on clinical record review, policy and procedure review and interview, it was determined the facility failed to meet the Condition of Participation for Nursing Services in that there was an Immediate Jeopardy to patient health and safety that resulted in actual harm. The facility failed to assure the nurse assessed the patient's care needs and their health status related to a change in vital signs and failed to follow Intensive Care Unit (ICU) standards of care and plan of care as evidenced by:

1) Failed to prevent actual harm to one of one patient (#15) in the Intensive Care Unit (ICU) in that there was no evidence the nurse assessed the patient's care needs or their health status related to a change in vital signs prior to the patient being found unconscious. (Refer to A-0395)

2) Failed to follow Intensive Care Unit standards of care and the care plan to assure Patient #15 was monitored for change in condition; the electrocardiogram (ECG) was assessed for possible rhythm change; all alarm limits were assessed for a change in condition, or that all monitor alarms were audible both at the desk and in the room. (Refer to A-0396)

The cumulative effect of these failed practices resulted in an Immediate Jeopardy to patient health and safety in that the facility failed to protect patient #15 from actual harm.

The Immediate Jeopardy was abated with the following plan on 05/17/18 at 3:05 PM:
The following actions and processes have been put in place effective immediately:
1. Patients will be evaluated at the frequency of the monitoring required for the patient's level of care.
2. Ensure recorded vital signs are accurate
3. Established parameters with the electronic medical record (EMR) contain visual alerts for the nurse to evaluate the vital signs that coincide with patient condition. The nurse will then acknowledge the vital signs in the EMR.
4. Interventions will be carried out in accordance to patient condition and physician orders and interventions will be documented in the EMR in a timely manner.
5. The staff was trained on the process for appropriate vital signs monitoring and interventions including proper documentation in the EMR through mandatory read and sign education and email to all clinical staff on 05/17/18 and 05/24/18.
6. ICU Manager or designee will audit 10 random critical care charts daily for six weeks, then 10 charts per week for four weeks. Goal is to reduce failure rate by 30% weekly with a ultimate goal of 100 percent compliance sustained for one month. Results will be reported by ICU Manager to PI Steering Committee and Patient Safety Committee Monthly.
7. Patient will be individually assessed for fall risk. Appropriate care plan with interventions will be documented in the "EMR. If applicable, a bed alarm will be utilized and assessed at the beginning of each shift that alarm is on and audible to the staff. ICU Manager completed education regarding proper connectivity related to bed alarms to ensure that alarms are audible to the nurses' station. Completed 04/29/18. Education on management of alarms will be reinforced to staff by ICU manager during unit staff meeting and email on 05/17/18 and 05/24/18.
8. Staff will be educated that anytime abnormal activity or missing parameters are absent from the monitoring station, the nurse will be notified. ICU Managers will meet individually with each monitor technician of education regarding reporting variances relating to patient monitoring. The ICU Manager provided education regarding the importance of timely evaluation of patients when there is a missing parameter or abnormal activity. This was completed 04/26/18. Suspension and or silencing of all alarms are to only occur at the patient's bedside during active assessment and or interventions. Mandatory read and sign education completed by 05/24/18.

Based on review of clinical record, standards of care for the Intensive Care Unit (ICU), and interview, it was determined the facility failed to prevent actual harm to one of one Patient (#15) in the ICU in that there was no evidence the nurse assessed the patient's care needs or their health status related to a change in vital signs prior to the patient being found unconscious. Without an assessment of the patients change in vital signs, it could not be assured changes in the health status of Patient #15 were identified for intervention. The failed practice resulted in actual harm to Patient #15 and was likely to affect all ICU patients. Findings included:

A. Review of the ICU Standards of Care on 05/16/18 showed patients are to be assessed every four hours and as needed (PRN) unless condition warrants more frequent observation; an Electrocardiogram (ECG) strip will be obtained, analyzed and placed in the chart every 12 hours and as needed (rhythm changes); all alarm limits are assessed and documented at the beginning of each shift and as the patient's condition changes; and all monitor alarms must be audible both at the desk and in the room.

B. Clinical record review on 05/16/18 showed Patient #15's vital signs while in the Intensive Care Unit (ICU) on 04/13/18 at 1:30 AM as blood pressure 160/85, pulse 98, respirations 15 and Sp02 (peripheral capillary oxygen saturation) 96%. The next set of vital signs on 04/13/18 at 1:45 AM showed a blood pressure of 206/114, pulse 114, respirations of 40 and SpO2 of 69%. The vital signs were acknowledged by the primary care nurse taking care of Patient #15. There was no documentation in the clinical record of any nurse actions relating to the change in vital signs.

C. The Vice President of Patient Care Services was interviewed on 05/16/18 at 12:41 PM and confirmed there was no evidence in the clinical record of any follow-up to the vital signs documented on 04/13/18 at 1:45 AM.

Based on clinical record review, review of Intensive Care Unit (ICU) Standards of Care and interview, it was determined the facility failed to assess and monitor the nursing care needs of Patient #15 for any change in condition. Failure to assure care was provided in accordance with the multidisciplinary plan of care did not ensure any changes in the patients vital signs, electrocardiogram (ECG), or fall risk would be identified and that harm to Patient #15 would be prevented. The failed practice affected Patient #15 and was likely to affect all patients who received care in the ICU. Findings included:

A. Review of the ICU Standards of Care showed that patients will be assessed every two hours for the first 24 hours, then every four hours and as necessary unless condition warrants more frequent assessment; that "all alarm limits" are assessed and documented at the beginning of each shift and as the patient's condition changes, and that all monitor alarms must be audible both at the desk and in the rooms.

B. Respiratory Therapist #1 was interviewed by telephone on 05/16/18 at 11:09 AM and stated she observed Patient #15 face down on the floor beside the bed in ICU on 04/13/18 at approximately 3:00 AM when entering Patient #15's room to provide a breathing treatment. Upon entering the room the patient monitor leads were observed on the bed, oxygen, and vital signs monitor was laying on the bed and the patient was not in the bed. Respiratory Therapist #1 stated on 05/16/18 at 11:18 AM that no patient alarms were going off. The door to the ICU room was partially closed but the curtain was not closed. The patient's nurse was sitting just to the left of his room outside the door and "a half dozen people" were at the nurse's station, approximately eight feet from the room at the center desk. "Every lead was off the patient and laying on the bed and there were no alarms going off."

C. Review of the clinical record on 05/15/18 showed vital signs were acknowledged (electronic initials) by Patient #15's nurse on 04/13/18 as follows: 1:45 AM blood pressure 206/114, pulse 114, Respirations 40, Sp02 69%. The vital signs were marked with and exclamation mark as an alert. There was no evidence a nurse took action to address the vital signs. In addition, there was no evidence in the clinical record that additional assessment or intervention was performed until Patient #15 was found unresponsive and in the floor of the ICU room at approximately 3:00 AM on 04/13/18. This was confirmed on 05/15/18 at 12:03 PM at the time of clinical record review by Registered Nurse #1 and at 12:21 PM by Registered Nurse #2.

D. Review of the clinical record on 05/15/18 showed the interventions on the interdisciplinary plan of care for Patient #15 included a fall risk alert and bed alarm as an intervention. Flowsheet documentation included documentation at 8:00 PM on 04/12/18 that the bedside cardiac monitor was on and audible and bedside cardiac alarms were set.