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Based on facility policies and procedures, review of medical records (MR), Inpatient Request Logs, and interviews with radiology, nursing, transport and management staff it was determined the facility failed to ensure:

1. Patients were transported off/on the nursing unit in a safe manner with oxygen/monitoring according to facility policies.

2. Staff documented the time patients left and returned to the unit.

3. Radiology staff notified nursing and/or the physician of patient's shortness of breath and inability to lie flat which resulted in inability to perform the ordered test.

4. Staff followed the facility policy and procedure for Hand-Off Communication.

This affected 1 out of 6 MRs reviewed including Patient Identifier # 1 and had the potential to affect all patients admitted to the facility.

Findings include:

Refer to A 144 for findings.

Based on facility policies and procedures, review of medical records (MR), Inpatient Request Logs, and interviews with radiology, nursing, transport and management staff it was determined the facility failed to ensure:

1. Patients were transported off/on the nursing unit in a safe manner with oxygen/monitoring according to facility policies.

2. Staff documented the time patients left and returned to the unit.

3. Radiology staff notified nursing and/or the physician of patient's shortness of breath and inability to lie flat which resulted in inability to perform the ordered test.

4. Staff followed the facility policy and procedure for Hand-Off Communication.

This affected 1 out of 6 MRs reviewed including Patient Identifier (PI) # 1 and had the potential to affect all patients admitted to the facility.

Findings include:

Policy and Procedure
Telemetry Monitoring
PolicyStat ID: 3631602
Last Revised: 05/2017

Purpose:
The purpose of the policy is to establish cardiac monitoring admission, transport, and discharge criteria.

High Risk for a Cardiac Event during Transport
If a patient requires transport off the nursing unit for test or procedures, the patient should be transported with continuous cardiac monitoring and accompanied by a Licensed Health Care Provider.

Policy and Procedure
Oxygen Protocol
PolicyStat ID: 3346254
Last Revised: 04/2014

AARC (American Association for Respiratory Care) Clinical Practice Guideline
Oxygen Therapy for Adults in the Acute Care Facility--2002 Revision and Update

OT-AC (Oxygen Therapy Acute Care) 1.0 Procedure:
The procedure addressed is the administration of oxygen therapy in the acute care facility other than with mechanical ventilators and hyperbaric chambers.

OT-AC 2.0 Definition/Description:
Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of hypoxia.

OT-AC 11.0 Monitoring:
A. Patient
1. Clinical assessment including but not limited to cardiac, pulmonary, and neurologic status
B. Equipment
3. Care should be taken to avoid interruption of oxygen therapy in situations including ambulation or transport for procedures.

OT-AC 12.0 Frequency:
Oxygen therapy should be administered continuously unless the need has been shown to be associated only with specific situations (eg, exercise and sleep).

Policy and Procedure
Hand-Off Communication
PolicyStat ID: 4891775
Last Revised: 05/2018

Purpose:
The primary objective of a "hand-off" communication is to provide accurate information about a patient's care, treatment, and services, current condition and any recent or anticipated changes...

Responsibility:
It is the responsibility of all persons providing care to ensure that safe hand-off communication takes place when a patient passes from their care into the care of another even if only for a short period of time.

Transport Hand-Off Process:
1. The Ticket to Ride form will be completed by a nurse when a patient is being transported by non-clinical staff off of a unit for tests and procedures. Information on the Ticket to Ride includes the patient's fall risk, code status, need for oxygen, and IV's. Staff in the diagnostic or treatment area will add information to the form and send it back to the nurse. The receiving nurse will have an opportunity to ask questions and clarify information.

1. PI # 1 was admitted to the facility medical/surgical unit from the Emergency Department (ED) on 4/14/18 with diagnoses including Chronic Obstructive Pulmonary Disease and Acute on Chronic Systolic Congestive Heart Failure.

Review of the physician's orders dated and signed 4/14/18 at 10:34 AM revealed Oxygen Therapy 2 l/m nasal cannula O2 sat goal 92. Cardiac Monitoring: Telemetry, Cardiac Monitoring Required for Transport? Hi Risk Trans (transport)/Monitor Req (required).

Review of the nursing narrative dated 4/19/18 at 1335 (1:35 PM) revealed "patient was scheduled for MRI (magnetic resonance imaging) this morning. went to room to ask the patient if (he/she) preferred to go down in a stretcher or wheelchair. patient stated (he/she) could go in a wheelchair.(Employee name) the transporter for radiology department came to take patient down to get the test done and brought (him/her) back to the room and noticed (he/she) was short of breath so we let (him/her) sit in the wheelchair for a minute until we could get (him/her) back in the bed. one (once) in bed patient was placed on O2 via NC. I went to get the vital machine to check (his/her) pulse ox (oxygen) and it was 85, it then came up to 87. respiratory was immediately called to check the orders for the O2 level and see when was the last breathing treatment given, which it was stated (he/she) just had one. noticed shortly after that the patient lips started turning blue so (staff name) called a code 99 and called the primary MD (medical doctor), who gave orders. UAB family medicine MD's and residents responded and ran the code."
The above narrative documentation failed to include the time these events happened. Review of the entire medical record revealed no documentation of the time the patient left the unit to go to radiology, how he/she was transported and no documentation of O2 / monitor in use during the transport. There was no documentation of the time PI # 1 returned to the unit from radiology and no documentation of oxygen / monitor in use during the transport.

The surveyor requested documentation of the events from 9:30 AM on 4/19/18 (respiratory therapy gave treatment) to 11:00 AM when the documentation revealed PI # 1 was in ICU (Intensive Care Unit) and placed on a ventilator. No documentation was provided to the surveyor.

Review of the MR revealed PI # 1 was transferred to ICU on 4/19/18 at 11:00 AM and placed on a ventilator, Code Blue was called 2 more times after admission to ICU and PI # 1 expired at 12:03 PM.

The surveyor requested the Ticket to Ride documentation for transport of PI # 1 on 4/19/18. The Ticket to Ride could not be produced.

An interview conducted 7/26/18 at 10:00 AM with Employee Identifier (EI) # 2, Radiology Coordinator, confirmed the Ticket to Ride forms are kept in the radiology department for about a week then shredded.

EI # 2 was asked if there was documentation anywhere in the radiology department of the date and time inpatients enter and leave the radiology department. EI # 2 stated there was an inpatient request log.

EI # 2 was asked if there was any place else where the departure time for PI # 1 was documented. The answer was no, stating that when the ordered test is started Meditech (the electronic medical record) date and time stamped the beginning and end of the procedure. Because the MRI was not started on PI # 1 there was no tracking of the patient in Meditech.

EI # 2 was asked if the radiology tech would document that the test was not completed and why and the answer was no, since the test was not started there was no place in Meditech they could document.

EI # 2 was asked what the process was if the test could not be completed. The answer was for inpatients, the radiology tech would notify the nurse and/or the doctor the test could not be performed and why. The surveyor asked if it was documented in the MR. The answer was no, because if the test is not started there is no area in Meditech for them to document. Once the test is started they have a place to document comments.

Review of the Inpatient Request Log dated 4/19/18 revealed PI # 1 was on the log which documented the transport method as W/C (wheelchair), Sent For 0921 (9:21 AM) Picked Up 10:35 AM and Arrived - no time just employee initials.

Further review of the Inpatient Request Log dated 4/19/18 revealed the Ready for Return and Departed Initials spaces were blank.

An interview was conducted on 7/26/18 at 3:10 PM with Employee Identifier (EI) # 4, Patient Transporter. EI # 4 was asked to verify the Inpatient Request Log information for PI # 1 dated 4/19/18. EI # 4 stated the Sent For time was the time the radiology tech brought the Ticket to Ride and placed it in the tray for him. The Picked Up time of 10:35 AM was the time he picked up the Ticket to Ride not the time the patient was picked up.

EI # 4 was asked why the Ready for Return area on the Inpatient Request Log was blank on 4/19/18 for PI # 1 and the answer was "I'm not sure."

An interview conducted 7/30/18 at 1:00 PM with Employee Identifier # 1, Registered Nurse Quality, confirmed there was no documentation in the MR of when and how PI # 1 was transported off the nursing unit and back and no documentation the facility policies were followed.

Based on facility policies and procedures, review of medical records (MR), review of Code 99/Code Blue Critique Worksheets, and interviews with facility staff it was determined the facility failed to ensure nursing staff:

1. Followed the physician's orders for oxygen therapy.

2. Followed the facility policies for Telemetry Monitoring, Oxygen Protocol and Hand-Off Communication.

3. Ensured patients were transported off/on the nursing unit in a safe manner with oxygen/monitoring according to the physician orders and facility policies.

4. Documented when patients leave and return to the nursing unit.

5. Assessed and documented a respiratory assessment to include oxygen therapy each shift.

6. Interpreted a change in rhythm for patients on telemetry monitoring according to facility policy.

7. Documented events / interventions that occurred during a Code 99 and Code Blue.

This affected 1 out of 6 MRs reviewed affecting Patient Identifier # 1 and had the potential to affect all patients admitted to the facility.

Findings include:

Refer to A 392 for findings.

Based on facility policies and procedures, review of medical records (MR), review of Code 99/Code Blue Critique Worksheets, and interviews with facility staff it was determined the facility failed to ensure nursing staff:

1. Followed the physician's orders for oxygen therapy.

2. Followed the facility policies for Telemetry Monitoring, Oxygen Protocol and Hand-Off Communication.

3. Ensured patients were transported off/on the nursing unit in a safe manner with oxygen/monitoring according to the physician orders and facility policies.

4. Documented when patients leave and return to the nursing unit.

5. Assessed and documented a respiratory assessment to include oxygen therapy each shift.

6. Interpreted a change in rhythm for patients on telemetry monitoring according to facility policy.

7. Documented events / interventions that occurred during a Code 99 and Code Blue.

This affected 1 out of 6 MRs reviewed affecting Patient Identifier (PI) # 1 and had the potential to affect all patients admitted to the facility.

Findings include:

Policy and Procedure
Telemetry Monitoring
PolicyStat ID: 3631602
Last Revised: 05/2017

Purpose:
The purpose of the policy is to establish cardiac monitoring admission, transport, and discharge criteria.

High Risk for a Cardiac Event during Transport
If a patient requires transport off the nursing unit for test or procedures, the patient should be transported with continuous cardiac monitoring and accompanied by a Licensed Health Care Provider.

Daily Monitoring of Patients on Telemetry

C. The patient's primary nurse will document a baseline rhythm strip at the beginning of each shift and every 4 hours with pertinent rate or rhythm changes. If changes occur, the patients' primary nurse will assess the patients and notify the primary physician immediately.

H. When being monitored by telemetry, the nursing care is the responsibility of the primary nurse. The interpretation of the strip is the responsibility of the nurse every 8 Hrs. (hours) and with any rhythm change.
a. Documentation of the cardiac rhythm should include interpretation of the strip to include, rate, and rhythm.

Policy and Procedure
Oxygen Protocol
PolicyStat ID: 3346254
Last Revised: 04/2014

AARC (American Association for Respiratory Care) Clinical Practice Guideline
Oxygen Therapy for Adults in the Acute Care Facility--2002 Revision and Update

OT-AC (Oxygen Therapy Acute Care) 1.0 Procedure:
The procedure addressed is the administration of oxygen therapy in the acute care facility other than with mechanical ventilators and hyperbaric chambers.

OT-AC 2.0 Definition/Description:
Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of hypoxia.

OT-AC 11.0 Monitoring:
A. Patient
1. Clinical assessment including but not limited to cardiac, pulmonary, and neurologic status
B. Equipment
3. Care should be taken to avoid interruption of oxygen therapy in situations including ambulation or transport for procedures.

OT-AC 12.0 Frequency:
Oxygen therapy should be administered continuously unless the need has been shown to be associated only with specific situations (eg, exercise and sleep).

Policy and Procedure
Hand-Off Communication
PolicyStat ID: 4891775
Last Revised: 05/2018

Purpose:
The primary objective of a "hand-off" communication is to provide accurate information about a patient's care, treatment, and services, current condition and any recent or anticipated changes...

Responsibility:
It is the responsibility of all persons providing care to ensure that safe hand-off communication takes place when a patient passes from their care into the care of another even if only for a short period of time.

Transport Hand-Off Process:
1. The Ticket to Ride form will be completed by a nurse when a patient is being transported by non-clinical staff off of a unit for tests and procedures. Information on the Ticket to Ride includes the patient's fall risk, code status, need for oxygen, and IV's. Staff in the diagnostic or treatment area will add information to the form and send it back to the nurse. The receiving nurse will have an opportunity to ask questions and clarify information.

Policy and Procedure
Code 99 Team
PolicyStat ID: 3887565
Last Revised: 08/2017

Purpose:
To provide early and rapid intervention in order to promote better outcomes such as...

Procedure:
6. Staff nurse responsibilities:
Complete Code 99 critique form and place in red notebook

9. Department Director, House Supervisor, or designee responsibilities:
Ensure documentation is complete along with insuring appropriate physician is notified...

Domentation:
A. Process Intervention / Patient Notes, physician orders:

1. Patient Notes:
a. Assessment findings and observations
b. Interventions / actions
c. Reassessment and follow up

5. Code 99 forms

Policy and Procedure
Code Blue
PolicyStat ID: 1975439
Last Revised: 07/2015

Purpose:
The Code Blue policy and procedure has been established by Vaughan Regional Medical Center to facilitate and organize personnel in caring for individuals in a life-threatening situation in order to affect maximum care with minimum time elapse.

Duties of Personnel Responding to the Code Blue:

D. Nursing Supervisor
3. The Primary Nurse for the patient will complete the Code Critique Form. The completed Code Critique Form will be placed in the red notebook...

1. PI # 1 was admitted to the facility medical/surgical unit from the Emergency Department (ED) on 4/14/18 with diagnoses including Chronic Obstructive Pulmonary Disease and Acute on Chronic Systolic Congestive Heart Failure.

Review of the medical record on 7/25/18 revealed PI # 1 was on oxygen (O2) at 2 liters per minute (l/m) at home, became increasingly short of breath (SOB) and dizzy and called 911. The ambulance report documented PI # 1's oxygen saturation (sat) was in the low 60's at 2 l/m and the patient was placed on 4 l/m and the O2 saturation increased to 91%. PI # 1 was transported to the ED on 4/14/18, treated and then admitted to the medical/surgical floor.

Review of the ED documentation dated 4/14/18 revealed the patient was on O2 at 4 l/m while in the ED.

Review of the physician's orders dated and signed 4/14/18 at 10:34 AM revealed Oxygen Therapy 2 l/m nasal cannula O2 sat goal 92. Cardiac Monitoring: Telemetry, Cardiac Monitoring Required for Transport? Hi Risk Trans (transport)/Monitor Req (required).

Review of the ED record documentation on 4/14/18 at 11:40 AM revealed PI # 1 was on O2 at 4 l/m and O2 saturation was 96. The patient was transported to 2nd floor via stretcher and oxygen. There was no documentation the patient was transported with cardiac monitoring.

Review of the nursing admission assessment dated 4/14/18 at 11:57 AM revealed bilateral breath sounds crackles (rales), respirations regular and unlabored, O2 on at 4 l/m per nasal cannula, not 2 l/m as ordered. There was no documentation the nurse contacted the physician to confirm the oxygen order of 2 l/m.

Review of the physician's order dated 4/15/18 at 0109 (1:09 AM) revealed "Nursing Text O2 at 2L/NC (nasal cannula)."

Review of the order history data provided by the facility revealed the physician's order dated 4/15/18 at 1:09 AM was entered by nursing. The supplemental text was edited by Respiratory Therapy on 4/16/18 at 1441 (2:41 PM) to state "from O2 at 2L/NC to O2 at 4L/NC." There was no documentation of why the order dated 4/15/18 was changed.

Review of the vital signs recorded by the PCT (patient care technician) on 4/15/18 at 8:00 AM revealed blood pressure (BP) 96/51, Pulse 58, respirations 26, and O2 sat 82; comment: O2 sat low notified nurse (employee name).

Review of the MR revealed no documentation by the nurse regarding the low O2 sat reported by the PCT on 4/15/18 at 8:00 AM.

Review of the nursing shift assessment dated 4/15/18 at 8:30 AM revealed wheezes bilateral to all lung fields, respiratory pattern: dyspnea, uneven and labored, O2 at 2 l/m nasal cannula. There was no documentation the nurse assessed PI # 1's oxygen saturation. There was no documentation of cardiac rhythm.

Review of the nursing shift assessment dated 4/15/18 at 2000 (8:00 PM) revealed no documentation of respiratory and cardiac assessments even though these systems were documented as not within defined parameters.

Review of the nursing shift assessment dated 4/16/18 at 9:00 AM revealed no documentation of respiratory and cardiac assessments and no documentation of the cardiac rhythm.

Review of the telemetry rhythm strip dated 4/19/18 at 06:02 AM revealed HR (heart rate) 40 and rhythm sinus brady. There was no documentation by the nurse of the change in cardiac rhythm and no documentation the rhythm strip was interpreted by the nurse according to the facility policy.

Review of the nursing documentation dated 4/19/18 at 8:00 AM revealed vital signs pulse 59, respirations 24, blood pressure 142/81 and O2 sat 95, breath sounds clear, respiratory pattern dyspnea on exertion, O2 on at 4 l/m per nasal cannula and cardiovascular assessment normal sinus rhythm.

The record revealed a respiratory therapy treatment was provided to PI # 1 at 9:27 AM on 4/19/18. The next documentation was 4/19/18 at 11:00 AM by respiratory therapy for ventilator set up.

The next documentation was a nursing narrative dated 4/19/18 at 1335 (1:35 PM) which revealed "patient was scheduled for MRI (magnetic resonance imaging) this morning. went to room to ask the patient if (he/she) preferred to go down in a stretcher or wheelchair. patient stated (he/she) could go in a wheelchair. (Employee name) the transporter for radiology department came to take patient down to get the test done and brought (him/her) back to the room and noticed (he/she) was short of breath so we let (him/her) sit in the wheelchair for a minute until we could get (him/her) back in the bed. one (once) in bed patient was placed on O2 via NC. I went to get the vital machine to check (his/her) pulse ox (oxygen) and it was 85, it then came up to 87. respiratory was immediately called to check the orders for the O2 level and see when was the last breathing treatment given, which it was stated (he/she) just had one. noticed shortly after that the patient lips started turning blue so (staff name) called a code 99 and called the primary MD (medical doctor), who gave orders. UAB family medicine MDs and residents responded and ran the code."

The above narrative documentation failed to include the time these events happened. Review of the entire medical record revealed no documentation of the time the patient left the unit to go to radiology, how he/she was transported and no documentation of O2/monitor in use during the transport. There was no documentation of the time PI # 1 returned to the unit from radiology and no documentation of oxygen/monitor in use during the transport.

Further, the narrative documentation by the nurse failed to include the times and sequence of events during the Code 99 and subsequent Code Blue that occurred after PI # 1 returned to the nursing unit from radiology.

Review of the Code 99/Code Blue Critique Worksheet revealed no date and time recorded.

The Code Blue section of the Code 99/Code Blue Critique Worksheet form revealed incomplete data such as the date and time the Code Blue began, time of intubation, size ET (endotracheal) tube used and who performed the intubation.

The time the Code Blue ended was recorded as 10:55 AM per the Code 99/Code Blue Critique Worksheet.

The surveyor requested documentation of the events on 4/19/18 from 9:27 AM to 11:00 AM when the record shows PI # 1 in ICU (Intensive Care Unit) on a ventilator. No documentation was provided to the surveyor.

Review of the MR revealed PI # 1 was transferred to ICU on 4/19/18 at 11:00 AM and placed on a ventilator, Code Blue was called 2 more times after admission to ICU and PI # 1 expired at 12:03 PM.

An interview conducted 7/30/18 at 1:00 PM with Employee Identifier # 1, Registered Nurse Quality, confirmed the above findings.

Based on review of policy and procedure, medical records (MR), and interviews with facility staff it was determined the facility failed to ensure the staff:

1. Documented cardiac and respiratory assessments on all patients on telemetry and supplemental oxygen.

2. Documented rhythm strip interpretation with a change in rhythm.

3. Documented the date and time patients left the nursing unit, reason, and when they returned.

4. Documented accurately on the radiology Inpatient Tracking Log.

5. Completed a Code Blue form each time a Code Blue was called.

6. Documented the date, time, and interventions provided during a Code 99.

7. Followed the facility policy for editing and correcting late documentation.

This affected 1 out of 6 MRs reviewed including Patient Identifier # 1 and had the potential to affect all patients admitted to the facility.

Findings include:

Refer to A 449 for findings.

Based on review of policy and procedure, medical records (MR), and interviews with facility staff it was determined the facility failed to ensure the staff:

1. Documented cardiac and respiratory assessments on all patients on telemetry and supplemental oxygen.

2. Documented rhythm strip interpretation with a change in rhythm.

3. Documented the date and time patients left the nursing unit, reason, and when they returned.

4. Documented accurately on the radiology Inpatient Tracking Log.

5. Completed a Code Blue form each time a Code Blue was called.

6. Documented the date, time, and interventions provided during a Code 99.

7. Followed the facility policy for editing and correcting late documentation.

This affected 1 out of 6 MRs reviewed including Patient Identifier (PI) # 1 and had the potential to affect all patients admitted to the facility.

Findings include:

Policy and Procedure
Telemetry Monitoring
PolicyStat ID: 3631602
Last Revised: 05/2017

Purpose:
The purpose of the policy is to establish cardiac monitoring admission, transport, and discharge criteria.

High Risk for a Cardiac Event during Transport
If a patient requires transport off the nursing unit for test or procedures, the patient should be transported with continuous cardiac monitoring and accompanied by a Licensed Health Care Provider.

Daily Monitoring of Patients on Telemetry
C. The patient's primary nurse will document a baseline rhythm strip at the beginning of each shift and every 4 hours with pertinent rate or rhythm changes...

H. When being monitored by telemetry, the nursing care is the responsibility of the primary nurse. The interpretation of the strip is the responsibility of the nurse every 8 Hrs. (hours) and with any rhythm change.
a. Documentation of the cardiac rhythm should include interpretation of the strip to include, rate, and rhythm.

Policy and Procedure
Oxygen Protocol
PolicyStat ID: 3346254
Last Revised: 04/2014

OT-AC (Oxygen Therapy Acute Care) 1.0 Procedure:
The procedure addressed is the administration of oxygen therapy in the acute care facility other than with mechanical ventilators and hyperbaric chambers.

OT-AC 11.0 Monitoring:
A. Patient
1. Clinical assessment including but not limited to cardiac, pulmonary, and neurologic status

Policy and Procedure
Code 99 Team
PolicyStat ID: 3887565
Last Revised: 08/2017

Purpose:
To provide early and rapid intervention in order to promote better outcomes such as...

Procedure:
6. Staff nurse responsibilities:
Complete Code 99 critique form and place in red notebook

9. Department Director, House Supervisor, or designee responsibilities:
Ensure documentation is complete along with insuring appropriate physician is notified...

Domentation:
A. Process Intervention / Patient Notes, physician orders:

1. Patient Notes:
a. Assessment findings and observations
b. Interventions / actions
c. Reassessment and follow up

5. Code 99 forms

Policy and Procedure
Code Blue
PolicyStat ID: 1975439
Last Revised: 07/2015

Purpose:
The Code Blue policy and procedure has been established by Vaughan Regional Medical Center to facilitate and organize personnel in caring for individuals in a life-threatening situation in order to affect maximum care with minimum time elapse.

Duties of Personnel Responding to the Code Blue:

D. Nursing Supervisor
3. The Primary Nurse for the patient will complete the Code Critique Form. The completed Code Critique Form will be placed in the red notebook...

Policy and Procedure Entering, Editing Correcting Late Documentation
Effective Date: 04/01/06

Purpose:
to describe procedures for entering late documentation, editing documentation and correcting errors.

3. To Enter/Edit/Undo Late Documentation Greater Than 24-48 Hours Old
a. Intervention
The first line of text in the note should record the date and time of occurrence. Also the note should document the reason for the late entry...

1. PI # 1 was admitted to the facility medical/surgical unit from the Emergency Department (ED) on 4/14/18 with diagnoses including Chronic Obstructive Pulmonary Disease and Acute on Chronic Systolic Congestive Heart Failure.

Review of the physician's orders dated and signed 4/14/18 at 10:34 AM revealed Oxygen Therapy 2 l/m nasal cannula O2 sat goal 92. Cardiac Monitoring: Telemetry, Cardiac Monitoring Required for Transport? Hi Risk Trans (transport)/Monitor Req (required).

Review of the ED record documentation on 4/14/18 at 11:40 AM revealed PI # 1 was on O2 at 4 l/m and O2 saturation was 96. The patient was transported to 2nd floor via stretcher and oxygen. There was no documentation the patient was transported with cardiac monitoring.

Review of the nursing admission assessment dated 4/14/18 at 11:57 AM revealed bilateral breath sounds crackles (rales), respirations regular and unlabored, O2 on at 4 l/m per nasal cannula, not 2 l/m as ordered. There was no documentation the nurse contacted the physician to confirm the oxygen order of 2 l/m.

Review of the physician's order dated 4/15/18 at 0109 (1:09 AM) revealed "Nursing Text O2 at 2L/NC (nasal cannula)."

Review of the order history data provided by the facility revealed the physician's order dated 4/15/18 at 1:09 AM was entered by nursing. The supplemental text was edited by Respiratory Therapy on 4/16/18 at 1441 (2:41 PM) to state "from O2 at 2L/NC to O2 at 4L/NC." There was no documentation of why the order dated 4/15/18 was changed.

Review of the vital signs recorded by the PCT (patient care technician) on 4/15/18 at 8:00 AM revealed blood pressure (BP) 96/51, Pulse 58, respirations 26, and O2 sat 82; comment: O2 sat low notified nurse (employee name).

Review of the MR revealed no documentation by the nurse regarding the low O2 sat reported on 4/15/18 at 8:00 AM.

Review of the nursing shift assessment dated 4/15/18 at 8:30 AM revealed wheezes bilateral to all lung fields, respiratory pattern: dyspnea, uneven and labored, O2 at 2 l/m nasal cannula. There was no documentation the nurse assessed PI # 1's oxygen saturation. There was no documentation of cardiac rhythm as directed by facility policy.

Review of the nursing shift assessment dated 4/15/18 at 2000 (8:00 PM) revealed no documentation of respiratory and cardiac assessments even though these systems were documented as not within defined parameters.

Review of the nursing shift assessment dated 4/16/18 at 9:00 AM revealed no documentation of respiratory and cardiac assessments and no documentation of the cardiac rhythm.

Review of the telemetry rhythm strip dated 4/19/18 at 06:02 AM revealed HR (heart rate) 40 and rhythm sinus brady. There was no documentation of interpretation by the nurse of this change in rhythm as directed by the facility policy.

The record revealed a respiratory therapy treatment was provided to PI # 1 at 9:27 AM on 4/19/18. The next documentation was 4/19/18 at 11:00 AM by respiratory therapy for ventilator set up. There was no documentation of what happened between 9:27 AM and 11:00 AM on 4/19/18.

The next documentation was a nursing narrative dated 4/19/18 at 1335 (1:35 PM) which revealed "patient was scheduled for MRI (magnetic resonance imaging) this morning. went to room to ask the patient if (he/she) preferred to go down in a stretcher or wheelchair. patient stated (he/she) could go in a wheelchair. (Employee name) the transporter for radiology department came to take patient down to get the test done and brought (him/her) back to the room and noticed (he/she) was short of breath so we let (him/her) sit in the wheelchair for a minute until we could get (him/her) back in the bed. one (once) in bed patient was placed on O2 via NC. I went to get the vital machine to check (his/her) pulse ox (oxygen) and it was 85, it then came up to 87. respiratory was immediately called to check the orders for the O2 level and see when was the last breathing treatment given, which it was stated (he/she) just had one. noticed shortly after that the patient lips started turning blue so (staff name) called a code 99 and called the primary MD (medical doctor), who gave orders. UAB family medicine MDs and residents responded and ran the code."

The above narrative documentation failed to include the time these events happened. Review of the entire medical record revealed no documentation of the time the patient left the unit to go to radiology, how he/she was transported and no documentation of O2/monitor in use during the transport. There was no documentation of the time PI # 1 returned to the unit from radiology and no documentation of oxygen/monitor in use during the transport.

Further, the narrative documentation by the nurse failed to include the times and sequence of events during the Code 99 and subsequent Code Blue that occurred after PI # 1 returned to the nursing unit from radiology.

Review of the Code 99/Code Blue Critique Worksheet provided by the facility revealed no date and time recorded.

The Code Blue section of the Code 99/Code Blue Critique Worksheet form revealed incomplete data such as the date and time the Code Blue began, time of intubation, size ET (endotracheal) tube used and who performed the intubation.

The time the Code Blue ended was recorded as 10:55 AM per the Code 99/Code Blue Critique Worksheet.

The surveyor requested documentation of the events on 4/19/18 from 9:27 AM to 11:00 AM when the record shows PI # 1 in ICU (Intensive Care Unit) on a ventilator. No documentation was provided to the surveyor.

During chart review on 7/26/18 at 3:00 PM EI # 1, RN Quality, provided a nursing narrative note dated 5/8/18 and stated it was an amendment to the nursing narrative dated 4/19/18. EI # 5, Medical Records, who was also present, stated the nursing narrative dated 5/8/18 would not be part of the official medical record.

Review of the nursing narrative note provided by the facility dated 5/8/18 revealed "on 4/19 patient was scheduled for an MRI. (name) the transporter came to the room to take (him/her) down for the scheduled test. (He/she) came with a wheelchair and an oxygen tank. (He/she) transported the patient via wheelchair on 4L (liters) of oxygen. (He/she) took (him/her) down and brought (him/her) back and stated that the radiology team stated that the patient was unable to complete the test because (he/she) was too short of breath. (He/she) then transported (him/her) back to the floor and told me that the test did not get completed because the patient was short of breath. We allowed the patient to sit in the wheelchair until we felt (he/she) could move to the bed. Once we got (him/her) back in (his/her) bed we discontinued the portable oxygen tank and hooked (him/her) up to the oxygen on the wall and tried to get (him/her) stable. We noticed (his/her) lips started turning blue (name) RN called for a code 99."

There was no time documented when these events took place and no reason why the documentation was amended 19 days after the patient expired.

An interview conducted 7/30/18 at 1:00 PM with Employee Identifier # 1, Registered Nurse Quality, confirmed the above findings.