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Based on a review of medical records, medical staff rules and regulations, policies/procedures, hospital documents and interviews, it was determined the governing authority failed to:

A0049:

1. require that the medical staff was held to the provision in the Medical Staff Rules and Regulations that requires the physician to be available to direct care to 1 of 1 patient for whom the physician was aware the patient's condition had changed from the previous day and failed to respond to a call from the registered nurse for one hour (Pt #5);

2. ensure the medical staff provided evaluation, service, and/or referral as defined in the hospital's patient rights when 2 of 3 medical records reviewed revealed the patients' conditions required evaluation and service by a physician to stabilize their condition prior to resuscitation, during resuscitation, and prior to transfer to a higher level of care (Pt #'s 5 and 1); and

3. require the same level of medical oversight and responsibility for inpatient emergencies as for patients who present with emergencies, as evidenced by 2 of 2 code arrests not having physician direction when physicians were present in the hospital during the emergency/code arrest and knowingly allow the RN, who initiated the code, to continue to direct the code arrest for Pt #'s 1 and 5.

The cumulative effect of these systemic deficient practices resulted in the hospital's failure to meet the requirements for the Condition of Participation for the Governing Body.

Based on review of medical records, hospital documents, medical staff rules and regulations and interviews, it was determined the medical staff failed to require

A0353:

1. the medical staff completed the medical records according to the medical staff time-frame requirements and take action as required in the medical staff Rules and Regulations as evidenced in 2 of 2 patient discharge summaries documented and signed as completed with blanks remaining in the transcribed discharge summary (Pt #'s 1 and 5); and

A0347:

2. the Medical Director for wound care assessed Pt #3 on a weekly basis and signed physician orders within 48 hours.

The cumulative effect of these systemic deficient practices resulted in the hospital's failure to meet the requirements for the Condition of Participation for the Medical Staff.

Based on medical record review, document review and interview, it was determined the nursing executive failed to require:

A0395:

1. the registered nurses (RN's) reassessed patients when a change of condition occurred as evidenced in 2 of 2 patients reviewed with changes in condition (Pt #'s 1 and 4);

2. the registered nurses ensure vital signs are taken and documented as required by hospital policy and procedure(Pt #5);

3. the wound care nurse and the RN notified the physician with a patients change of condition or complication from a procedure in one of one patients with a debridement (Pt #4);

4. the RN followed physician orders in 1 of 3 patient records reviewed for orders (Pt #4);

5. the RNs documented reassessments of oxygen saturations, complete vital signs, and reassessments for Pt #8 who had two rapid responses initiated on 05/11/13, at 1110 and 2000 hours, requiring an unexpected transfer to an acute care hospital; and

6. the RN correctly interpreted the telemetry rhythm for Pt #7.

The cumulative effect of these systemic deficient practices resulted in the hospital's failure to meet the requirements for the Condition of Participation for Nursing Services.

Based on a review of medical records, medical staff rules and regulations, policies/procedures, hospital documents and interviews, it was determined the governing authority failed to ensure the medical staff was accountable for the quality of care provided to patients as evidenced by:

1. 0412: failing to require that the medical staff was held to the provision in the Medical Staff Rules and Regulations that requires the physician to be available to direct care to 1 of 1 patient for whom the physician was aware the patient's condition had changed from the previous day and failed to respond to a call from the registered nurse for one hour (Pt #5);

2. 0293: failing to ensure the medical staff provided evaluation, service, and/or referral as defined in the hospital's patient rights when 2 of 3 medical records reviewed revealed the patients' conditions required evaluation and service by a physician to stabilize their condition prior to resuscitation, during resuscitation, and prior to transfer to a higher level of care (Pt #'s 5 and 1); and

3. 0417: failing to require the same level of medical oversight and responsibility for inpatient emergencies as for patients who present with emergencies, as evidenced by 2 of 2 code arrests not having physician direction when physicians were present in the hospital during the emergency/code arrest and knowingly allow the RN, who initiated the code, to continue to direct the code arrest for Pt #'s 1 and 5.

Findings include:

1. The Medical Staff Rules and Regulations under C. Continued Stay Management included the following: "...2. All physicians shall provide for appropriate physician coverage for their patients when they are not available to ensure safe and adequate overall quality medical care for their patients. 3. If the attending or alternate cannot be reached to provide needed patient care, the on call physician, President of the Medical Staff, or the Medical Director will assume responsibility until the attending can be reached. Failure to meet these responsibilities will be reviewed by the Medical Executive Committee...."

Patient #5's medical record revealed the patient was assessed by the registered nurse (RN) at 0700 on 05/02/2013. The RN's notes included the patient's pupils were unequal and sluggish. This was a change in the patient's previous pupil assessment. The previous day documentation revealed the patient's pupils were brisk and reactive with both being size 5.

The physician was notified of this change, and ordered the staff to take hourly neurological checks. The physician was at the patient's bedside at 0945.

At 1100 the RN documented the patient was restless, breathing shallow and rapid pulse. The charge nurse was contacted and was at the bedside. The pulse oximetry was documented at 88%, which was a decrease for the patient. The oxygen saturation level improved to 94% with the patient's change in position. The patient's blood pressure dropped to 80/40; the physician was notified and normal saline bolus was ordered. At 1140 the physician was at the bedside. The patient was placed in Trendelenburg and a normal saline bolus was initiated. The patient blood pressure improved with the saline to 92/53.

At 1200 on the same date the right pupil was described as size 7 and sluggish. The left pupil was size 8 and sluggish. At 1600 the right pupil was a 7 and sluggish, and the left a size 8 and sluggish.

The physician documented at 1145 he was called due to the patient's blood pressure dropping "90-55" with heart rate of 120 and temperature 101. The physician documented the plan was to give intravenous fluids, monitor vital signs and discuss with pulmonary. There was no further documentation by the physician regarding the pulmonary discussion. There was no documented evidence of a pulmonary physician involved with the patient's care on 05/02/2013.

At 1230 the patient's blood pressure decreased and a second bolus of normal saline was started. The RN documented a page was placed to the physician at 1245 without a response by 1300. A second call was placed and the physician did not respond to the call until 1340, one hour after the patient's condition was continuing to change with the blood pressure dropping.

The physician ordered a Levophed drip which was initiated, however the patient's blood pressure continued to drop. Calls were placed to the physician at 1545 and 1630 related to the patient's condition. The physician ordered each time to increase the Levophed. The physician did not respond to the bedside to evaluate the patient.

All of the Levophed orders were telephone orders.

The patient coded at 1715.

The Medical Director stated, during an interview on 06/18/2013, he had not reviewed the case and was not aware of the physician's delay in responding to a call for a patient's change in condition.

The medical record was reviewed with the Chief Clinical Officer who confirmed the findings as stated from the medical record.

2. The Patient Rights and Responsibilities provided to patients at Cornerstone Hospital includes: "...Provision of Care...The patient has the right to reasonable access to care, treatment and services...The patient has the right to expect that, within its capacity, the hospital will make a reasonable response to the request of a patient for services. The hospital must provide evaluation, service and/or referral as indicated by the urgency of the care...."

Patient #5's medical record revealed the patient was assessed by the registered nurse (RN) at 0700 on 05/02/2013. The RN's notes included the patient's pupils were unequal and sluggish. This was a change in the patient's previous pupil assessment. The previous day documentation revealed the patient's pupils were brisk and reactive with both being size 5.

The physician was notified of this change and ordered the staff to take hourly neurological checks. The physician was at the patient's bedside at 0945. The physician was again notified of the patient's condition at 1140, and documentation revealed the physician was at the patient's bedside at 1140. The patient's condition continued to deteriorate and a call was placed to the physician at 1245. The physician did not respond until 1345, one hour after the original call was placed.

The physician ordered a Levophed drip which was initiated, however the patient's blood pressure continued to drop. Calls were placed to the physician at 1545 and 1630 related to the patient's condition. The physician ordered each time to increase the Levophed. The physician did not respond to the bedside to evaluate the patient.

The patient coded at 1715 and was transported to an acute care hospital. There was no documented evidence the attending physician or physician, who was available in house at the time of the code, provided evaluation and service to the patient at the time of the code. The attending physician delayed responding to the patient's change of condition after being notified twice by the nursing staff. The physician failed to come to the facility and evaluate the patient when the patient condition continued to deteriorate hemodynamically and neurologically from 1345 through 1715 when the patient coded.

There was no documentation the hospital personnel followed a chain of command by requesting the Chief Medical Officer to be involved or contacting administration so that the patient's continued deterioration of condition could be addressed prior to the patient requiring resuscitation and emergency intervention.

Patient #1's medical record notes documented by the RN revealed: "...PT seen through window. (Director of Nursing stated patient was in isolation due to the MRSA and VRE) PT pale blue/yellow in color. RT...paged STAT to room. Upon assessment of PT, PT was unresponsive and pulseless. Code called...0840 CPR initiated...." The RN documented at 0910 blood pressure 105/51, heart rate 90's -126 and various heart rhythms; including Sinus Tachycardia, Atrial fibrillation and paced rhythm. At 0915 the patient blood pressure was documented at 94/53, heart rate 111, respirations 27; 0925 blood pressure 89/48, pulse 110; 0930 blood pressure 80/48 pulse 105 and patient with agonal breaths; 0935 blood pressure 77/42 and pulse 101. The last documented vitals signs prior to transfer was blood pressure 69/38 and pulse of 85 with intravenous fluids "wide open."

There were no orders documented by the physician, there was no notes in the progress notes or dictated notes by the physician present at the code. The order for transfer of the patient was provided as a telephone order from an attending physician who was not present at the code. There was no documentation that the attending physician was aware of the patient's hemodynamic status. There is no evidence provided to the surveyor at the time of the investigation that indicated the patient's condition was evaluated and managed by a physician or that the hospital personnel reported patient's condition to the physician to ensure the reasonable care was being provided to the patient prior to the transfer of the patient to an acute care hospital.

The Medical Director stated during interview on 06/18/2013, he had not reviewed these records and could not comment on the care provided at the time of the survey process.

The Chief Clinical Officer stated, during interview on 06/13/2013, that the RNs run the codes and will ask for assistance from a physician if the RN feels it is necessary.

There is no documented evidence the administrator and medical staff provided the patients reasonable access to care, treatment and services.

3. The Medical Staff Bylaws revealed at 2.2 Purposes and Responsibilities: "...The purposes and responsibilities of the Organized medical Staff are:...2.2.2. To provide patients with the quality of care that is commensurate with acceptable standards and available community resources...."

The Plan for the Provision of Patient Care revealed under Emergency Services the following: "...D. Medical Oversight 1. The hospital shall be responsible for ensuring adequate medical coverage for emergency services. Qualified physicians or licensed independent practitioners shall be available either in person or telephonically to determine whether the patient has an emergency medical condition and direct the next course of action. 3. A physician or licensed independent practitioner shall be responsible for all patients who present for emergency services. 4. All medications and treatments shall be provided under the direction and order of a physician or licensed independent practitioner...6. The hospital shall maintain a list of physicians who are on call to provide the initial screening, evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition...."

The plan for the Provision of Patient Care Emergency Services C. revealed: "...A registered nurse shall be on site twenty-four (24) hours a day. The on-site registered nurse shall have received training in advanced life support techniques and be deemed competent to initiate treatment of the emergency patient...."

The Provision of Care described the care for emergency patient was to be directed by a physician once initiated by the registered nurse. This same level of care was not available or required for the inpatients who have an emergency condition.

The Medical Director was interviewed on 06/18/2013. The Medical Director stated in the interview that he changed the hospital policy so that the RNs could conduct the codes. The physician's had the option to become involved with a code situation or not.

The hospital policy on Emergency Protocols, dated 08/06/2013, revealed: "...Procedure: 1. ACLS Protocols will be initiated as appropriate...3. The protocols are to be initiated at the discretion of the nurse until a physician is contacted. Any protocols carried out will require physician review and orders as soon as possible...4. If the attending or the attendings on call coverage is unable to be reached within 5 minutes of a stat call and 15-20 minutes for a routine call, the Chief of Staff or designee can be called for assistance. In the absence of a physician, the After Hours Physician - when on duty - can be summoned for immediate patient contact during an urgent or emergent change in the patient's status...."

The Chief Clinical Officer was asked who conducts the code arrests when a physician is present at the code arrests. The Director of Nursing stated, in the interview on 06/12/2013, the registered nurse who is the designated team leader conducts the code. The surveyor asked for clarification with the following question: When a physician is documented as being present at the code arrest the registered nurse conducts the code ordering the interventions to include the medications and interventions? The response by the Director of Nursing was yes this is true.

Interview was conducted on 06/12/2013 with the registered nurse (RN), charge nurse, who was identified on the code records as the Team Leader of the code arrest. The RN confirmed that she conducted the code arrests providing the direction and the interventions when a physician was present.

The code record for Pt #'s 1, 4 and 5 were reviewed with the Medical Director.

These records revealed a physician was present at the codes. The Medical Director was one of the physicians identified as being present for the code arrest for Pt #5. The Medical Director stated that he only "poked" his head in the room and asked if the RN had the code under control and the RN responded yes, so he left.

The Medical Director confirmed he did not order interventions nor would he consider himself present at the code and his name should not appear on the code record.

In summary, the Medical Director revealed the RNs who are "ACLS" (advanced cardiac life support) certified are the individuals responsible for conducting the code arrests at the hospital even when a physician is present in the building and has the knowledge and experience to conduct a code on a patient in an emergent situation. The medical staff has delegated the direction for an inpatient emergency condition to an RN.

The Code Arrest Policy revealed under #10 of the Procedure that the physician must sign the Emergency Cardio-Pulmonary Record.

There was no identified signature of a physician on the Emergency Cardio-Pulmonary Record for Pt #'s 1 and 5.

A physician was documented as being present at two of the three codes and did not assume the responsibility of directing the code arrest, and did not sign the code arrest forms as required by the policy.

Patient #1's medical record notes documented by the RN revealed: "...PT seen through window. (Director of Nursing stated patient was in isolation due to the MRSA and VRE) PT pale blue/yellow in color. RT...paged STAT to room. Upon assessment of PT, PT was unresponsive and pulseless. Code called...0840 CPR initiated...."

The RN documented at 0910 blood pressure 105/51, heart rate 90's -126 and various heart rhythms; including Sinus Tachycardia, Atrial fibrillation and paced rhythm. At 0915 the patient blood pressure was documented at 94/53, heart rate 111, respirations 27; 0925 blood pressure 89/48, pulse 110; 0930 blood pressure 80/48 pulse 105 and patient with agonal breaths; 0935 blood pressure 77/42 and pulse 101. The last documented vitals signs prior to transfer was blood pressure 69/38 and pulse of 85 with intravenous fluids "wide open."

The medical record contained documentation a physician was present at the code. There were no orders documented by the physician, there were no progress notes or dictated notes by the physician. The order for transfer of the patient was provided as a telephone order from an attending physician.

Patient #5's medical record revealed the patient coded at 1715 on 05/02/2013. The code record included documentation a physician was present at 1718. The patient was in "...PEA/ST at 1715, 1716, and 1718...." The rhythm was then documented at 1720 as Sinus Tachycardia.

The vital signs were documented as follows: 1715 blood pressure 64/49 no pulse, respirations 46; 1716 blood pressure 70/51, pulse with compressions, respirations 24; 1718 blood pressure 70/40, pulse with compressions, respirations 21, and 1720 blood pressure 76/51. pulse documented as check mark sign indicating "yes," respirations 24.

There was no documented physician's signature on the code record on 06/12/2013 when the record was reviewed. There was no documented progress note by the physician on the record and there was no documented dictation by the physician as to the events of the code arrest.

There was a documented telephone order to transfer the patient to another hospital for further blood pressure management and hemodynamic monitoring.

The two physicians who were present in the building at the time of the codes were physicians who manage patient care on a daily basis.

Based on interview, review of clinical records, review of hospital policies and procedures, and review of other hospital records, it was determined for 1 of 1 patient (Patient #13) with physical restraints, the hospital failed to ensure the least restrictive intervention was used.

Findings include:

The hospital's policy and procedure titled Restraints used in the Provision of Medical and Surgical Care included the following: "The purpose of this policy is to ensure the safety of the patient in restraints for his/her immediate physical safety with the goal of being a restraint-free hospital to the extent possible consistent with patient and staff safety...The Hospital's restraint program shall comply with the requirements set forth by the Center for Medicare and Medicare Services (CMS)...Hospital Leadership will support limited and justified use of restraints through its Performance Improvement Program and through ensuring staff competency. The critical components of the program are as follows: 1. Patients have the right to be free from both physical restraints and drugs used as a restraint (chemical restraints). Restraints will only be used when necessary and not used as coercion, discipline, convenience or retaliation. 2. Restraints will only be used when less restrictive interventions have been determined to be ineffective...Possible alternatives to use of restraints may include but are not limited to:..sitters."

Patient #13 was admitted to the hospital on 4/23/2013. A review of the clinical record revealed the patient had a tracheostomy tube, ventilator, nasogastric tube with tube feedings for nourishment, colostomy with a large abdominal wound requiring a wound vacuum, and a peripherally inserted central catheter (PICC) for intravenous medication and fluid administration.

A nursing note, dated 5/3/2013 at 5:30 p.m., revealed the patient pulled his PICC line out while the IV was running. The Registered Nurse (RN) contacted the physician and requested an order for a physical restraint which was received. Documentation in the record revealed soft restraints were placed on the patient's right and left wrist. Soft wrist restraints and/or mittens were used daily from 5/3/2013 to 5/23/2013. During that period of time, there were seven occurrences of the patient decannulating himself, and two occurrences of the patient pulling off the wound vacuum and/or pulling off his abdominal dressings.

A section of the reports staff used to document the incident include a section: "What could have been done to prevent this incident?"

Documentation on those reports included the following:

5/9/2013 at 10:30 a.m.: "Frequent checks on patient. 1 on 1 sitter"
5/15/2013 at 2:15 p.m.: "One-to-one sitter"
5/20/2013 at 11:15 a.m.: "Sitter could keep patient from pulling at vac, PEG and trach button when RN in another patient room. Patient appears to need supervision any time while awake to prevent removal of dressings and treatment equipment."
5/29/2013 at 5:20 a.m.: "Physical, chemical restraints, sitter in room w/ pt."

There was no documentation in the clinical record that the hospital attempted to provide one-to-one-supervision of the patient.

The Chief Clinical Officer stated, during an interview on 6/20/2013, that a one-to-one sitter was tried but the patient still pulled his lines out. The surveyor requested documentation that a one-to-one sitter was provided, however, he was not able to locate it. He later stated that he did not have staff availability to provide for a one to one sitter, and that there was no staff available in the community.

Based on document review, and staff interviews, it was determined the facility failed to ensure the Medical Director for wound care:

1. assessed the patient (Pt #3) on a weekly basis; and

2. signed physician orders within 48 hours.

Findings include:

The hospital policy titled Wound Management Program Overview required: "...Purpose: To provide patients with individualized, comprehensive wound management plan. To design a multidisciplinary wound management plan that will positively affect the outcome of care, teaching and rehabilitation of those with select disorders of the integumentary system. The team includes: the physician, Wound Care Certified Nurse (WCCN), Clinical Dietician, Pharmacist, Physical Therapist, Occupational Therapist, Speech/Language Pathologist, Case Managers and nursing staff...The wound care nurse will perform and document a comprehensive skin assessment on all patients upon admission and weekly, thereafter, on patients with wounds or skin breakdown. The Wound Care Nurse and the patient's physician will develop a plan of care based on the assessment findings . The WCN and the patient's physician will develop a plan of care based on the assessment findings. The WCN and the patient's physician, who directs the plan of care, will review the treatment plan and the patient's response at least weekly and revise, as needed...The wound care team will perform a comprehensive wound assessment and photographic Documentation (if possible) within 24 hours of admission , or when a wound is first identified on existing patients. Wound assessment and photographic documentation will be performed each week, thereafter by the Wound Care Team...."

The hospital policy titled Wound Care Team policy required: "...B. Medical Director...." The Wound Care Nurse verified in an interview conducted on 06/19/13, the physician on the interdisciplinary team is the Wound Care Medical Director. There are 2 general surgeons that are contracted by the facility to be the Wound Care Medical Directors. She verified they alternate weeks to participate in the interdisciplinary wound care team conferences.

1. Patient #3 was admitted to the facility on 05/28/2013, from an acute care hospital. Diagnoses were: Cerebral Vascular Accidents (CVA) x 2; Dementia; Dysphagia; Aphasia; Chronic Kidney Disease (CKD) with dialysis twice per week; Hypertension; Diabetes; Dyslipidemia; Coccidiomycosis; Peripheral Artery Disease; Peripheral Neuropathy; non-STEMI (non ST elevation Myocardial infarction); Diabetic ulcer of the left foot in multiple spots; Left bundle branch block; PEG (percutaneous endoscopic gastrostomy) tube.

The history and physical revealed: Patient #3 had debridement of the diabetic ulcers down to the level of the bone by a Podiatrist during an outpatient procedure prior to hospitalization.
The patient also had drainage from the exit site of the PEG tube which was cultured on admission to the facility. The Family Nurse Practitioner H&P revealed: The patient was stabilized and sent to Cornerstone for continued therapies and antibiotic therapy..."The wound (wd) cultures done on the drainage from around the PEG, but sources (sic) most likely secondary to an osteomyelitis with open bone." Patient #3 received Rocephin and Vancomycin for the wounds. He had a temperature of 103.3 on 05/30/13. A white blood count (wbc) of 19.1 on 05/29/13, which increased to 32.4 on 6/6/13. Normal wbc is 4.5 to 10.0 per microliter.

The wound care nurse photographic documentation done on 05/29/13, included multiple ulcers on the left foot; the left first toe; the left second toe; a pressure ulcer on the left 3rd toe; and the left 5th toe with bone exposed. Patient #3 had a small skin tear on the right forearm and a small nodule on the upper back. On 06/03/13, the WCN had photographs of these areas plus wounds on the right buttock and coccyx. Wound/skin care team conference documentation on 06/06/13 included the program director physician wound care note: "This is futile. He needs hospice. Ethics committee consulted."

The WCN acknowledged the wound care team physician had not seen Patient #3 until the ninth day after admission.

2. The Medical Staff Rules and Regulations, dated 03/16/09, required: "...telephone order must be authenticated by signature of a practitioner with date and time within 48 hours...."

The Wound Care Nurse had written orders on 05/29/13, at 0950 hours: Xeroform to wounds on L foot (double over on each wd), wrap with cling wrap, change (symbol) Q (every) M, W, F, & prn (as needed). Allevyn Gentle Border to skin tear R FA (forearm) (symbol) change Q M, Th, & PRN. Float heels. Low-air mattress. TO (Telephone Order) RB (Read Back) Dr______( Medical Director of Wound Care). It was signed by the Medical Director of Wound Care on 06/06/13.

The Wound Care Nurse had written orders on 06/04/13, at 1120 hours: "EPC cream to wd on R buttock near anus Bid (twice per day) & prn. Allevyn Gentle Border to wd on coccyx/sacral area change (symbol) Q M. Th, & PRN." TO. RB. Dr.______ Wound Care Medical Director. The order was not signed off by the physician when the medical record was reviewed by the surveyor on 06/18/13.

The Quality Director verified in an interview conducted on 06/19/13, telephone orders should be signed by the physicians within 48 hours.

Based on review of medical records, documentation, and interview, it was determined the governing authority failed to require that the medical staff completed the medical records according to the medical staff time-frame requirements and take action as required in the medical staff Rules and Regulations as evidenced in 2 of 2 patient discharge summaries documented and signed as completed with blanks remaining in the transcribed discharge summary (Pt #'s 1 and 5).

Findings include:

The Medical Staff Rules and Regulations under Medical Records Requirements #8 included: "... If the record still remains incomplete 30 days after discharge and if all essential reports have been received, the CEO shall notify the physician by mail, return receipt requested, that they have 72 hours to complete their records or their privileges shall be suspended until the records have been completed. Admitting shall be notified of this action...."

The medical record policy revealed all records are to be completed within 30 days post discharge.

Review of Pt #1's medical record revealed the patient was discharged to an acute care hospital on 03/10/13. The medical record contained a discharge summary dictated and transcribed on 02/27/13, which was 12 days prior to the patient ' s actual discharge. The discharge summary contained a physician ' s signature that was not dated or timed, and the content had multiple blank spaces that were not completed.

Patient #1's record remains incomplete as of 06/11/2013. This is 3 months or 90 days from the date of discharge.

The Director of Medical Records confirmed during an interview conducted on 06/11/2013, that the discharge summary contained blanks, the wrong discharge date, and had not been completed within 30 days as required by the medical staff rules and regulations.

Review of Pt #5 ' s medical record revealed the patient was discharged on 05/02/13. The discharge summary dated and signed on 05/04/13, did not include the patient ' s transfer medication list and remains incomplete as of 06/11/13.

The Medical Records Director confirmed during an interview on 06/11/2013, that the record was initially flagged for the physician to complete and when not completed this was reported to the medical staff for further action and follow up. The Director confirmed she was not aware if there was follow up.

The Chief Executive Officer was notified of these findings on 06/12/13. The Medical Director was notified on 06/18/13, and explained he had not been informed there were incomplete and inaccurate discharge summaries.

The hospital could not provide documentation to support that the governing authority took action for the incomplete and inaccurate discharge summaries.

Based on medical record review, document review and interview, it was determined the nursing executive failed to require:

1. the registered nurses (RN's) reassessed patients when a change of condition occurred as evidenced in 2 of 2 patients reviewed with changes in condition (Pt #'s 1 and 4);

2. the registered nurses ensure vital signs are taken and documented as required by hospital policy and procedure(Pt #'s 4 and 5);

3. the wound care nurse and the RN notified the physician with a patients change of condition or complication from a procedure in one of one patients with a debridement (Pt #4);

4. the RN followed physician orders in 1 of 3 patient records reviewed for orders (Pt #4);

5. the RNs documented reassessments of oxygen saturations, complete vital signs, and reassessments for Pt #8 who had two rapid responses initiated on 05/11/13, at 1110 and 2000 hours, requiring an unexpected transfer to an acute care hospital; and

6. the RN correctly interpreted the telemetry rhythm for Pt #7.

Findings include:

1. The Nursing Services policy on Reassessment Nursing with a revised date of September 2011 revealed the following: "...A registered nurse will reassess each patient according to the patient needs and as needed...The reassessment should include but not be limited to: review of compromised systems, vital signs, safety/fall risks, and skin assessment, pain assessment, and nutritional intake...In addition, the patient is reassessed to determine the patient's response to treatment (i.e. response to PRN medication or respiratory treat), when a significant change occurs in the patient's condition or behavior...."

Patient #1's medical record revealed the RN documented at 0420 on 03/10/2013 the patient was resting quietly in bed, eyes closed, easily aroused, no sign or symptoms of distress and with no acute changes in assessment.

The night shift respiratory therapist documented at 0541 on 03/10/2013 the patient was taken off the ventilatory and placed the patient on the T-Mask with the FIO2 at 50%. The therapist documented the patient had "an ok" night on vent, with lots of suctioning of thick secretions with no respiratory distress.

The day shift respiratory therapist documented at 0705 on 03/10/2013, the patient was found on 100% T-Mask. The respiratory therapist documented that the RN stated "...the patient desated to 84% and was suctioned and placed on 100%...."

There was no documentation by nursing as to when the oxygen saturation level decreased to 84%. There was no documentation of a nursing assessment with the patient's change of condition when the 84% oxygen saturation level was reported and the ventilator changes made.

There was no assessment of the patient by the RN on the night shift from 0450 to the time the day shift RN documented at 0750. The RN documented at 0750 the patient was on T-Mask at 70%. Patient resting with eyes closed, somewhat easily arousable. The patient nods to yes/no question, denies pain/discomfort, no signs or symptoms of distress, and respiration even and unlabored.

There was no evidence of an RN assessment of the patient from 0750 to 0838. At 0838 03/10/2013, the RN documented: "...RN to check on PT. PT seen through window. PT pale blue/yellow in color. RT...paged STAT to room. Upon assessment of PT, PT was unresponsive and pulseless. Code called...0840 CPR initiated...."

The RN documented at 0910 a blood pressure 105/51, heart rate 90's -126 and various heart rhythms; including Sinus Tachycardia, Atrial fibrillation and paced rhythm. At 0915 the patient's blood pressure was documented at 94/53, heart rate 111, respirations 27; 0925 blood pressure 89/48, pulse 110; 0930 blood pressure 80/48 pulse 105 and patient with agonal breaths; 0935 blood pressure 77/42 and pulse 101. The last documented vitals signs prior to transfer to another hospital was blood pressure 69/38 and pulse of 85 with intravenous fluids "wide open."

There was no documented evidence of a nursing reassessment other than vital signs during the time from 0915 through time of transport at 0946.

There was no documentation of a physician being notified of the patient's vital signs at the time of transport. There was no documented evidence of a nursing assessment with the patient's change in vital signs.

The Chief Clinical Officer and the Quality Director confirmed in an interview conducted on 06/10/2013, that they could not identify documentation of the respiratory or nursing assessments related to the patient's decrease in the 84% saturation level sometime between 0541 and 0705.

Patient #4's medical record revealed there was no documented assessments by nursing, for Patient #4, who had a significant change from the patient's previous status from 2330 05/15/2013 until 0100 05/16/2013. Oneand one half hours later at 0100, the blood pressure was 76/54.

The RN documented at 0200 regarding the patient: "...breathing still labored @ 32 (with) use of accessory abd. muscles. Retrained to breathe deeply (with) nostrils..." There was no further documentation of cardio-pulmonary assessment for the patient.

There was no further documentation of vital signs until 0440, when the RN documented the patient was non responsive to verbal or tactile stimulation and eyes fixed on roof. The RN documentation also identified the following: patient had thick crackles in the right lung lobe and audible secretions in the throat, respiration increased and rapid with excessive use of abdominal accessory muscles to breathe, color pale, waxy and skin diaphoretic.

The patient coded at 0455 and was transported to an acute care hospital at 0541.

2. The hospital policy on Reassessment revealed the following: "...1. The registered nurse will reassess each patient according to the patient needs and as needed...3. The reassessment should include but not be limited to: review of compromised systems, vital signs...4. In addition, the patient is reassessed to determine the patient's response to treatment...when a significant change occurs in the patient's condition or behavior...."

Patient #4's medical record revealed the physician was at the bedside at 2240 on 05/15/2013, due to being called for the patient's changes in vital signs, cold extremities, color waxy and pale, and labored respirations.

The physician ordered continuous pulse oximetry monitoring of the oxygen saturation level to keep > or equal to 90%, and to call if the oxygen level needed to be adjusted greater than 4 liters per nasal cannula. The orders also included to call the physician for a systolic blood pressure less than 90 or greater than 130.

The vital signs were documented at 0100 hours, on 5/16/13, two hours and 20 minutes after the previous vital signs and assessment. The documented blood pressure was 76/54.

The RN then documented at 0200 hours and revealed "... breathing still labored @ 32 (with) use of accessory abd. Muscles. Retrained to breathe deeply (with) nostrils...."

The RN doccumented at 0400, the pulse oximetry was 82% and the respirations were 50, two hours after the previous assessment.

The RN documented at 0440: "...Pt nonresponsive to verbal or tactile stimulation...Eyes fixed on roof...Pt has thick crackles in Rt lobe lung & audible secretions in throat. Resp are (increased) rapid (with) excessive use of abd accessory muscles to breathe. Color is very pale, waxy & skin diaphoretic...."

Patient #4 had a complication from a wound debridement, that resulted in significant bleeding, a change in respiratory status, and blood pressure. The physician ordered specific vital sign parameters to be monitored and the physician to be notified of patient's inability to maintain within the parameters. The RN failed to monitor and assess the patient with changing vital signs, and request intervention as ordered by the physician.

Patient #5's medical record revealed the patient was placed on a vasopressor agent, Levophed. The hospital policy titled Vital Signs, required for patient's on Vasopressor agents that the pulse rate and blood pressure be taken and recorded every 15 minutes.

A review of Pt #5's record revealed the physician ordered the patient be placed on a Levophed drip at 1345 on 05/02/2013. The initial Levophed drip was initiated at 1 microgram per minute with the blood pressure at 62/52. The patient maintained on the 1 microgram/minute until 1535 when the physician ordered to increase to 2 micrograms for a blood pressure of 68/40. There was no documented blood pressure on the flow sheet until 1600 (25 minutes later) when the blood pressure was documented at 77/58.

The next blood pressure was at 1715, one hour and 15 minutes later, which was documented at 69/49, and the Levophed was increased to 3 micrograms/minute. The Levophed was increased to 10 micrograms/minute at 1720, when the blood pressure was documented at 70/51.

There was no blood pressure documented until 40 minutes later when it was 60/30 and the Levophed was increased to 15 micrograms/minute.

There was no documented evidence the patient's blood pressure and pulse were taken and documented every 15 minutes as required by hospital policy.

Interview with the Director of Nursing on 06/12/2013, confirmed the vital signs were not documented every 15 minutes according to hospital policy and procedure.

3. Patient # 4's medical record revealed the physician had orders on 05/15/2013, for the wound care nurse to perform a conservative sharp debridement of the patient's pressure ulcer on the buttock.

The wound care nurse documented the debridement was completed at 1700, and included the following: "... slough cap removed exposing non-viable loose tissue. moderate amount of bleeding from distal portion of wound. Pressure held for approximately 20 minutes. Bleeding sufficiently stopped so drsy applied and pt positioned so that pressure would be held palliatively. Pt's beside RN informed of complications. Pt vitals stable WNL @ this time...wound appears 100% slough over...."

The documented vital signs on the Vital Sign record at 1700, revealed a blood pressure of 125/83, pulse 100 and respirations 20.

There was no notification to the physician of a complication of bleeding from the debridement procedure that required 20 minutes of pressure.

The RN documented on 05/15/2013 at 1900, the patient complained of dizziness. The blood pressure was documented as 96/60, pulse 105 and respiration 28. The RN documented the patient's extremities were cool. The RN pulled back the top sheet covering the patient and found a bed soaked from the waist down with blood. The RN documented the wound on the right buttock was weeping blood profusely and when the RN stripped the bed and cleaned the mattress the RN documented, "blood dripped onto the floor." The documented blood loss identified by the RN, was approximated as 1 unit.

There was no documented evidence a physician was notified of the patient's condition related to the blood loss or the patient's complaint of dizziness and changing vital signs.

At 1700 hours, the patient started exhibiting signs and symptoms of complications following the debridement. At 1900, the patient had approximately 1 unit of blood loss. The RN documented at 2200, having trouble getting an accurate oxygen saturation level via the oximetry machine. At 2240 the patient had labored breathing at 42/minute with a pulse of 120. The patient's color was waxy and pale, and extremities cold. RN also documented the patient was feeling like he was having a panic attack and hard to communicate with the patient. RN identified patients' pulses in radials were very faint and rapid, and unable to get a blood pressure on the patient with both automatic and manual blood pressure on all 4 extremities. The physician was notified five hours and 40 minutes after the bleeding began post debridement, and the patient had changes in vital signs.

4. Patient #4's medical record revealed the physician ordered an x-ray, arterial blood gases and to call results, normal saline 125 cc/hour for 2 liters and continuous pulse oximetry to keep Oxygen saturation greater than 90% and to call if the oxygen needed to be greater than 4 liters per nasal cannula. The orders also included an order to call the physician for a systolic blood pressure less than 90 or greater than 130.

There was no documented assessment by nursing for Patient #4 who had a significant change in patient condition with orders from the physician to monitor the patient's oxygen saturation and blood pressure to maintain the patients oxygen and blood pressure as stated above. At 0100 05/16/2013 the documented blood pressure was 76/54. There was no documented evidence of notification to the physician as ordered.

The RN documented at 0200 the patient: "...breathing still labored @ 32 (with) use of accessory abd. Muscles. Retrained to breathe deeply (with) nostrils. There continued to be no documented notification to the physician."

The vital sign record indicated at 0400 the pulse oximetry was at 82% and the respirations were 50. There was no documentation the physician was notified at 0400 with the pulse oximetry being recorded at less than 90%.

The physician ordered at 2240 parameters that he wanted to be notified if the patient's condition changed. The patient met these parameters at 0100 for the blood pressure and then at 0400 for the oxygen saturation and there still was no notification. The patient went at least 3 hours with parameters that the physician wanted to be notified of and then the patient's condition deteriorated to a crisis situation at 0440.

The RN documented at 0440: "...Pt nonresponsive to verbal or tactile stimulation...Eyes fixed on roof...Pt has thick crackles in Rt lobe lung & audible secretions in throat. Resp are (increased) rapid (with) excessive use of abd accessory muscles to breathe. Color is very pale, waxy & skin diaphoretic."

A code arrest was called at 0440 and the patient was transferred to a higher level of care.

5. The hospital policy titled Assessment - Reassessment Nursing required: "...A registered nurse will reassess each patient according to the patient needs and as needed...Reassessment is performed...PRN changes...."

The hospital policy titled Vital Signs required: "...Vital signs...will be taken and documented as follows:...Any time there is a change in the patient's condition...Vital signs are Blood Pressure, Pulse Rate, Respiratory Rate, and Temperature...."

Patient # 8 was admitted on 05/08/13 with the following diagnoses: Respiratory failure; Pneumonia; Panhypopituitarism; Hypoxic encephalopathy; Delirium; Anemia; Dysphagia; and history of a pituitary tumor resection.

Patient # 8 had two rapid response team (RRT) interventions on 05/11/13 at 1110 and 2000 hours.

A physician's order was written on 05/10/13 at 2350 hours which included: "...Titrate to keep oxygen saturation above 90%...."

Nursing documentation included the following for 05/11/13:

0800: "...Pt sounds very congested. On oximeter at 11 L (liters) (of oxygen) Sat 84%...."

1110: "...Pt O2 sat dropped to 72%. Attempt to suction pt failed: pt would not open the mouth or allow suctioning. Pt was suctioned through the nares by Resp therapist thick white phlegm collected...."

Nursing documentation did not include interventions taken by the nurse from 0800 until 1110 hours, for the patient's low oxygen saturation of 84%. No vital signs were taken between 0800 until the rapid response at 1110 hours.

The Director of Quality Management confirmed in an interview on 06/19/13 at 1040 hours, that nursing did not document interventions for the low O2 saturations, and did not document a reassessment of the oxygen saturations for over 3 hours.

Patient #8 was started on bi-pap and moved to the high intensity unit at 1120 hours, after a rapid response and a change in condition.

Nursing documentation after the first rapid response on 05/11/13 included:

1930: Assessment...pt appears lethargic and responds to pain only with no verbal response. Pupil pinpoint sluggish @ 3-4 mm (millimeters)...Spoke to on-call MD and will come to assess pt...."

Patient #8 had a second rapid response initiated on 05/11/13 at 2000 hours.

2000: "...Dr. (name) seen (sic) pt and evaluated wants pt be (sic) evaluated @ (name of acute care hospital)...."

2100: "...Tucson fire came and collected pt...left building...."

Nursing documented vital signs once on the high observation unit at 1430 hours. No other vital signs were documented until the second rapid response was called, five and a half hours later at 2000 hours.

Nursing did not document vital signs for 5 and a half hours, after 1430 until the rapid response at 2000 hours. Nursing did not document an assessment after 1600 hours until 4 hours later when a rapid response was called.

The Director of Quality Management confirmed in an interview on 06/19/13 at 1040 hours, that nursing documented one set of vital signs while the patient was in the high observation unit, prior to the second rapid response call for this patient.

6. The hospital policy titled Cardiac Monitor: Telemetry required: "...Documentation:...the patient's rhythm will be documented by the nurse in the assessment/reassessment nursing notes...."

Patient #7 was admitted on 6/12/13 for care of chronic problems. The patient had a new cardiac pacemaker for a high-degree heart block (electrical conductivity problem). The patient also had the following diagnosis: heart transplant 2007, diabetes, chronic obstructive pulmonary disease, hypertension, chronic kidney disease requiring dialysis, myocardial infarction and coronary artery bypass graft.

Review of the medical record on 6/18/13 at 1300 hours revealed the following:

On 6/16/13 at 1200 hours, RN # 12 documented on the nursing notes: "...1200 assessment completed. No acute changes. VSS (vital signs stable), V (ventricular)-paced rate 80...."

On 6/16/13 at 1200 hours, the monitor tech recorded the patient's cardiac rhythm as: "...V-paced with a rate of 80...."

Interviews on 6/19/13 with employee #'s 2, 8, 11, 15, 16 and provider # 7 confirmed the monitor cardiac rhythm was not V-paced.

The Chief Clinical Officer (CCO) confirmed in an interview conducted on 10/20/13, the interpretation of the monitor telemetry record for 6/16/13 at 1200 hours was not V-paced.