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Based on observation, interview, and record review, the facility failed to maintain a Quality Assurance Program (QAPI) designed to identify and monitor ongoing deficiencies in nursing care.

The facility's Quality Assurance Program Improvement (QAPI) program failed identify and monitor quality of care for issues with vital sign monitoring and intravenous fluid administration for 5 (#1, #7, #8, #9, and #10) of 10 telemetry patients reviewed (Refer to A-0273).

The cumulative effect of these systemic problems resulted in the facility's inability to identify quality of care concerns and ensure the provision of quality health care in a safe environment.

Based on record review and interview the facility's Quality Assurance Program Improvement (QAPI) program failed to monitor quality of care for vital sign monitoring and intravenous fluid administration for 5 (#1, #7, #8, #9, and #10) of 10 telemetry patients reviewed.

Findings included:

1. A review of the "Discharge Summary Report" dated 3/3/20 by Physician Staff F noted on 3/2/20 around 9:51 p.m. Patient #1 had a blood pressure of 74/55 and a heart rate of 115 beats per minute. A call was placed to Physician Assistant (PA) Staff A and orders were obtained to give intravenous (IV) fluids. PA Staff A also asked to be notified if there was no improvement in blood pressure. On 3/3/20 at 12:43 a.m. the monitor tech notified the Rapid Response Team after being unable to reach anyone to alert that Patient #1 was asystole (no heart rhythm). After a couple minutes a code blue was called. The resuscitation was unsuccessful, and Patient #1 was pronounced dead on 3/3/20 at 1:00 a.m. The report continues "I would like to note that during her stay, I had to repeatedly ask that her blood pressures be obtained with vital signs as this was not occurring. I spoke with nursing and the Nursing Director about that." " ...I cannot see that the bag was ever scanned or hung. The vitals were never rechecked and [RN Staff C] stated she was too busy and unable to get back to doing it."

A review of the Medication Administration Record for Patient #1 revealed no documentation Patient #1 was administered IV fluids.

On 5/11/12 at 9:45 a.m., in an interview, former Risk Manager (RM) Staff D verified she had no investigation regarding the lack of the fluid bolus being administered to Patient #1 or vital signs not being retaken on the patient. No interview was completed with RN Staff C who documented Patient #1 had a blood pressure of 74/55 or had spoken with the members of the rapid response team to find out what they had found when they arrived at the patient's room. RM Staff D verified no one had spoken with Physician Staff F regarding issues with vital signs occurring at the hospital. RM Staff D verified there was no documentation of RN Staff C ever rechecking Patient #1's blood pressure.

On 5/13/21 at 11:30 a.m., in an interview, the Chief Quality Officer verified the events surrounding Patient #1's death had not been reviewed in QAPI since the incident occurred.

Based on observation, interview and record review the hospital failed to ensure provision of an organized nursing service as it relates to following physician orders for the administration of intravenous fluids and monitoring of vital signs on telemetry patients.

The facility failed to administer intravenous fluids in accordance with physician orders for 2 (#1 and #8) of 10 patients sampled, and monitor vital signs for 4 (#1, #7, #9, and #10) of 10 patients sampled (Refer to A0392).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality nursing care in a safe environment.

Based on record review and interview, the facility failed to administer intravenous fluids in accordance with physician orders for 2 (#1 and #8) of 10 patients sampled, and monitor vital signs for 4 (#1, #7, #9, and #10) of 10 patients sampled.

The findings included:

1. A review of the clinical record for Patient #1 revealed, on 3/2/20 at 9:51 p.m., Patient #1 had a documented blood pressure of 74/55.

A review of the physician's orders for Patient #1 revealed, on 3/2/20 at 10:03 p.m. an order was received to administer normal saline (NS) 1000 milliliters (ml) bolus then 75 ml per hour today.

A review of the Medication Administration Record for Patient #1, revealed no documentation of a normal saline bolus or continuous infusion at 75ml/hr.

A review of the "Cardiopulmonary Resuscitation Report", dated 3/3/20, shows cardiopulmonary resuscitation was started on Patient #1 and she was noted to be pulseless at 12:45 a.m. This was noted to be 2 hours and 54 minutes after RN Staff C had assessed a blood pressure of 74/55 with a heart rate of 115. There is no documentation RN Staff C ever rechecked Patient #1's blood pressure.

A review of the "Discharge Summary Report," dated 3/3/20, by Physician Staff F noted on 3/2/20 around 9:51 p.m. Patient #1 had a blood pressure of 74/55 and a heart rate of 115 beats per minute. A call was placed to Physician Assistant (PA) Staff A and orders were obtained to give intravenous (IV) fluids. PA Staff A also asked to be notified if there was no improvement in blood pressure. On 3/3/20 at 12:43 a.m. the monitor tech notified the Rapid Response Team after being unable to reach anyone to alert that Patient #1 was asystole (no heart rhythm). After a couple minutes a code blue was called. The resuscitation was unsuccessful, and Patient #1 was pronounced dead on 3/3/20 at 1:00 a.m. The report continues "I would like to note that during her stay, I had to repeatedly ask that her blood pressures be obtained with vital signs as this was not occurring. I spoke with nursing and the Nursing Director about that." " ...I cannot see that the bag was ever scanned or hung. The vitals were never rechecked and [RN Staff C] stated she was too busy and unable to get back to doing it."

On 5/11/21 at 11:15 a.m., in an interview, Physician Assistant (PA) Staff A said she remembers there were issues with getting nurses to take routine vital signs. PA Staff A said it is an on-going issue. She gave an order for Patient #1 to receive a bolus and she asked the nurse to call her back with the patient's response, did not hear back. She stated she found out the next day Patient #1 had expired.

On 5/11/21 at 1:15 p.m., in an interview, Physician Staff F said, she was the doctor assigned to Patient #1 during her stay in the hospital. She verified she could not see where the IV fluids were scanned or hung. She verified the vital signs were never rechecked. Issues with patients not receiving IV fluids at the hospital persisted until she left the hospital in May of 2020.

2. A review of the medical record for Patient #8, on 5/12/21, revealed Patient #8's "Medication Administration Record" had an active order to receive IV fluids at 125 milliliters hourly with a start time of 5/8/21 at 6:00 a.m. and no stop date. The Fourth Floor Unit Manager was observed calling the pharmacy and verifying the order was an active order.

On 5/12/21 at 10:35 a.m., The Fourth Floor Unit Manager said she could not explain why the physician's order was not being followed or clarified with a physician.

On 5/12/21 at 10:40 a.m. RN Staff E said she had started caring for Patient #8 at 7:30 a.m. in the morning. RN Staff E said she had received report regarding Patient #8 form the nurse and it was not reported to her that Patient #8 had IV fluids ordered. After reviewing Patient #8's MAR, RN Staff E said Patient #8 did have a order for continuous IV fluids at 125 milliliters hourly.

On 5/11/21 at 10:55 a.m. Patient #8 was observed in the hospital bed. The patient was observed with no IV fluids hanging. The patient said he had been transferred to the floor on 5/10/21 and he had been receiving IV antibiotics, but he had not had continuous fluids since being transferred.

3. A review of the medical record for Patient #7, on 5/12/21, revealed Patient #7 was admitted on the telemetry unit on 5/10/21. Patient #7 had gone 8 hours between 5/10/21 at 7:48 p.m. to 5/11/21 at 4:23 a.m. without having his vitals assessed.

On 5/12/21 at 10:40 a.m., in an interview, the Fourth Floor Unit Manager could not explain why Patient #7 had not had his vitals obtained every 4 hours.

4. A review of the medical record for Patient #9, on 5/12/21, revealed Patient #9 was admitted on telemetry on 5/7/21. Patient #9 had gone for an eight-hour period between 8 p.m. on 5/7/21 to 4 a.m. on 5/8/21 without having vitals taken. Patient #9 had also gone from 8 p.m. on 5/8/21 to 4 a.m. on 5/9/21 without having vital signs assessed.

On 5/12/21 at 10:10 a.m., in an interview, The Fourth Floor Unit Manager could not explain why the patient had not had his vitals obtained every four hours.

5. A review of the medical record for Patient #10, on 5/12/21, revealed Patient #10 was admitted to the hospital on 5/9/21. The Patient had physician's orders for telemetry monitoring. A physician's order dated 5/10/21 at 8:19 a.m., for "vital signs Q [every] 4 hours". The vital sign record for Patient #10 went from 5/10/21 at 7:48 a.m. to 5/11/21 4:02 a.m. without having his vital signs taken.

On 5/12/21 at 9:45 a.m. The Fourth Floor Unit Manager said the standard of care for patients on telemetry was that they would have their vital signs taken every 4 hours. The Fourth Floor Unit Manager said she could not explain why the patient's blood pressure had not been taken every 4 hours during that time frame.