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Based on interview, record review and policy review the facility failed to:
- Ensure staff appropriately and timely recognized, assessed and notified the physician to a change of condition for one patient (#10) of one patient reviewed, who experienced a change in condition following a colonoscopy (a procedure to examine the inside of the colon using a lighted camera) and later died; (C-0296)
- Recognize the death of Patient #10 as a sentinel event (a patient safety event that results in an unexpected outcome including death), immediately investigate with the completion of a Root Cause Analysis (RCA, method of problem solving used for identifying the root causes of faults or problems) in a timely manner; (C-0292) and
- Provide immediate education to nursing staff regarding appropriate assessment and reporting of symptoms to the physician for one patient (#10) of one patient reviewed for a change of condition following a colonoscopy. (C-0296)

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Provision of Services. The facility had performed 348 colonoscopies from 08/01/18 to 11/27/18. The facility census was 12.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 11/29/18, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

As of 11/30/18, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Immediately reassessed all inpatients to ensure their needs were being met.
- Clinical Educator provided education to staff related to change of condition with timely appropriate assessment including vital signs, timely appropriate notification of physician and informing the physician of all symptoms relating to the change of condition.
- Staff P will receive one to one training by the unit charge nurse beginning with the next scheduled shift (11/30/18 night shift) and continue until the state agency approves of her competencies. Staff P will not be allowed to work independently until competencies are achieved and the state agency approves.
- Staff I, Inpatient Services Director will receive one to one re-education regarding patient change of conditions, nurse assessment, reassessment, recognizing what a sentinel event is and the process to contact a physician.
- All hospital staff including physicians received education related to the facility policy Sentinel Event Hospital Directive with the focus on recognition of a sentinel event.
- Staff B, Risk, Patient Safety and Stroke Manager will receive one to one education regarding sentinel events with focus on what a sentinel event is, how and who to report an event.
- Unscheduled/unannounced observed mock scenario drills for patient change of conditions to all nursing staff starting with the clinical staff on the Medical/Surgical inpatient unit.

Based on interview, record review and policy review, the facility failed to:
- Recognize a sentinel event (actual event that could or did cause patient harm) after the death of one patient (#10) following a colonoscopy (a procedure to examine the inside of the colon using a lighted camera);
- Initiate an immediate investigation of the event;
- Complete a Root Cause Analysis (RCA, method of problem solving used for identifying the root causes of faults or problems) in a timely manner; and
- Provide immediate education to nursing staff to identify a change of condition, complete a thorough assessment and report all patient symptoms to the physician.
These failures had the potential to place all patients in the facility at risk for their health and safety. The facility had performed 348 colonoscopies from 08/01/18 to 11/27/18. The facility census was 12.

Findings included:

1. Review of the facility policy titled, "Sentinel Events," revised 07/25/18, showed:
- The definition of a sentinel event was a patient safety event (not primarily related to the natural course of the patient's illness or underlying condition) that reaches a patient and results in death, permanent harm or severe temporary harm;
- A RCA should be completed for all reportable sentinel events within 45 days of becoming aware of the event; and
- Following completion of the RCA, improvements to reduce risk shall be identified and implemented.

A delay in completing an RCA for 45 days can lead to repeat sentinel events, if the event that occurred was related to care, or lack or care, provided to the patient

Review of Patient #10's medical record showed:
- She was an 83 year old female who had a colonoscopy on 08/02/18 by Staff CC, Medical Doctor (MD) and General Surgeon.
- The colonoscopy was completed without difficulty or complications.
- The patient had a change of condition at 10:15 PM (twelve hours post procedure), that included an increased pain level (seven), new onset of pain in the left shoulder and that she had not passed any gas since the procedure.
- The change in condition was not reported to the physician.
- At 2:10 AM, the patient complained that she was nauseated and was unable to take a deep breath. The patient attempted to vomit with no success.
- At 2:40 AM, Staff CC was notified of the nausea and difficulty to take a deep breath. Orders received to obtain an Electrocardiogram (EKG, test to check for problems with the electrical activity of your heart) and a set of cardiac enzymes (blood test to evaluate heart function).
- At 4:00 AM, the patient was noted to be very pale with garbled speech and held the left side of her forehead. Staff CC was notified and a Computed Tomography (CT, X-ray test that produces images of the body using those X-rays and a computer) was ordered of the head.
- At 4:30 AM, a rapid response (RR, a medical emergency team that responds to hospitalized patients with early signs of deterioration to prevent respiratory or cardiac arrest) was called and the patient was very restless, and grabbed at her chest and left upper quadrant. The CT of the head with the addition of abdomen and pelvis were completed.
- At 4:50 AM, during transport to the Intensive Care Unit (ICU) the patient had agonal (abnormal pattern of breathing accompanied by strange vocalizations) respirations and sternal rubs (application of a painful stimulus with the knuckles of a closed fist to the center of the chest of a patient who is not alert and does not respond to verbal stimuli to check the level of consciousness) was performed.
- At 4:55 AM a code blue (emergency situation where a patient's heart or breathing stopped, and staff quickly respond with a process specific to restoring the heartbeat or breathing) was called and the patient was pronounced dead at 5:14 AM.

Review of facility document titled, "Event Report," dated 08/03/18 at 4:55 AM described the event of Patient #10's RR during her transport from CT to the ICU with a code blue initiated at 4:55 AM and time of death at 5:14 AM.

Review of the facility complaint/grievance log showed Patient #10's family had phoned the facility on 08/07/18 to inquire about her death.

Review of a typed letter dated 08/08/18 to Patient #10's daughter and signed by Staff B, Risk, Patient Safety and Stroke Manager showed the documentation "based on your call, an investigation will be conducted."

2. Review of Staff B's handwritten note, related to the event, showed that on 09/20/18, she interviewed the nursing staff that cared for Patient #10 (approximately 48 days after the patient's death).

3. Review of the undated RCA identified that the Situational, Background, Assessment and Recommendation (SBAR, a technique used to facilitate prompt and appropriate communication) report to the physician was incomplete, but the patient assessment, as completed by the nurse, was appropriate.

Review of Patient #10's record showed that she was not thoroughly assessed when she had a change of condition even though the RCA findings stated that the patient assessments were completed appropriately.

During an interview on 11/28/18 at 10:30 AM, Staff B, Risk, Safety and Stroke Manager stated that she:
- Learned of the event when she reported to work on the morning of the event;
- Received the event report on the following Monday (three days after the event).
- Initially viewed the event as a "patient concern" and didn't consider it a sentinel event until after the patient's daughter had called to question the patient's death on 08/07/18.
- Was involved in the RCA that took place on approximately 09/10/2018 or 09/11/2018 (approximately 38 days after the patient's death).

Staff B received and reviewed the event report on 08/06/18 but failed to recognize the event as a sentinel event and failed to immediately initiate an investigation that included the completion of an RCA until the middle of September, which was greater than 30 days past the date after the event.

During an interview on 11/29/18 at 4:45 PM, Staff D, Chief Executive Officer, CEO stated that he was first aware of the event the following Tuesday 08/07/18. The event was discussed at a Board of Trustees meeting in 09/2018 or 10/2018 and at that time a board member suggested some training be done to the staff.

4. During an interview on 11/28/18 at 2:00 PM, Staff I, Inpatient Services Director stated that he educated staff during a staff meeting "sometime" in September. The education was related to hypovolemia (a condition in which the liquid portion of the blood [plasma] is too low) issues and complete SBAR reported to physicians.

The facility failed to identify the educational need and immediately implement that education to staff on the failures that occurred when Patient #10 had a change of condition until greater than one month after the patient's death.

Based on interview, record review and policy review, the facility failed to ensure staff appropriately and thoroughly assessed and reported a change of condition for one patient (#10) of one patient reviewed with a change of condition that resulted in death. The facility also failed to educate nursing staff in a timely manner, to ensure thorough assessments were completed, and a complete report of the patient were reported to a physician, in the event of a change of patient condition. These failures had the potential to place all patients in the facility at risk for their health and safety should they experience a change of condition. The facility had performed 348 colonoscopies from 08/01/18 to 11/27/18. The facility census was 12.

Findings included:

1. Even though requested the facility failed to provide a nursing assessment policy.

Review of Patient #10's medical record showed
- A History and Physical (H&P) dated 07/20/18, which documented that the patient was an 83 year old female with recent weight loss and anemia (a condition in which blood doesn't have enough health red blood cells), with a plan for a colonoscopy (a procedure to examine the inside of the colon using a lighted camera).
- A Colonoscopy Procedure Report dated 08/02/18, by Staff CC, Medical Doctor (MD) and Surgeon, documented that the procedure started at 7:55 AM and ended at 8:10 AM with no complications.
- Post procedural nursing notes at 8:49 AM, by Staff EE, Registered Nurse (RN), documented that the patient complained of abdominal pain and was guarded (to tense the abdominal muscles to protect them from pain that results from pressure applied to the abdomen), abdomen non-tender, but slightly firm.
- An X-ray at 9:08 AM, of the Kidney, ureter, and bladder (KUB, radiography test to assess the abdominal area for causes of abdominal pain) ordered by Staff CC, documented no obvious evidence of free air (presence of air within the abdominal cavity that could be indicative of a bowel perforation or injury) noted and that the bowel gas pattern appeared unremarkable.

Review of nursing notes showed the following documentation by Staff O, RN:
- On 08/02/18 at 9:10 AM, Patient #10 returned to her pre-procedure room on the Medical/Surgical unit with abdominal pain rated at a five (pain scale used to determine a patient's level of pain with zero indicating no pain and 10 being the worst pain). The patient informed the nurse that she was wheezing. The patient's abdomen was soft with hypoactive (decreased or absent) bowel sounds, per nurse assessment.
- At 9:35 AM, the patient was encouraged by nursing staff to get up and walk to help pass gas, but the patient refused.
- At 9:40 AM, Staff CC was notified of the patient's continued complaints of abdominal pain and wheezing, with an order received for Respiratory Therapy (RT) to evaluate the patient's wheezing.
- At 10:02 AM, RT evaluated the patient and did not recommend respiratory treatments at that time.
- At 1:36 PM, the patient walked in the hallway with a cane, steady gait, with decreased pain. The patient only felt pain with deep breaths.
- At 5:09 PM, the patient was seated on the edge of her bed eating supper, stated that the pain was tolerable with rating of three in her left upper quadrant.

Review of nursing notes dated 08/02/18 at 10:15 PM, showed the following by Staff P, RN:
- Documentation that the patient reported having left upper quadrant abdominal pain with left shoulder pain, rated at a seven.
- No documentation that she palpated (examination with the hands) the patient's abdomen.
- No indication that she notified the physician of the patient's continued abdominal pain that increased in intensity, or of the new onset of left shoulder pain.

Review of vital sign documentation showed that no vital signs (clinical measurements specifically pulse rate, temperature, respiration rate and blood pressure that indicate the state of a patient's essential body functions) were documented for Patient #10 from 8:00 PM on 08/02/18 to 2:10 AM on 08/03/18.

During an interview on 11/28/18 at 2:52 PM, Staff P, RN stated that:
- Patient #10's pain increased to seven at approximately 10:00 PM.
- She palpated her abdomen and it was soft (Staff P verified that this was not documented in her nursing notes).
- She didn't feel there were any red flags at that time, so she didn't feel she needed to call the doctor.
- Patient's vital signs were to be checked every eight hours unless otherwise ordered by the physician to be checked more frequently

During an interview on 11/29/18 at 12:10 PM, Staff CC, and Surgeon, stated that he was not notified that the patient had a change of condition at 10:15 PM on 08/02/18.

Staff P, RN failed to perform a thorough assessment of Patient #10 at 10:15 PM, which included vital signs, when the patient experienced a change in clinical condition. Staff P failed to notify Staff CC of the patient's condition, which could have provided an opportunity for the physician to order further testing.

Review of nursing notes dated 08/03/18 showed that Staff P documented between 2:10 AM and 4:50 AM, the patient had complaints of nausea, pain and inability to take a deep breath. At 2:35 AM, the physician was notified, who ordered a 12 lead Electrocardiogram (EKG, test to check for problems with the electrical activity of your heart) and a set of cardiac enzymes (blood test to evaluate heart). The patient became cold and clammy, vomited and had garbled speech (speech that is unable to be understood), grabbed at her chest and abdomen, and became unresponsive with abnormal breathing. A Rapid Response (team of health care providers that respond to hospitalized patients with early signs of deterioration, to prevent death) was called, and the patient was transferred to the Intensive Care Unit (ICU).

Review of nursing notes dated 08/03/18 at 6:15 AM, showed Staff EE documented that the patient arrested (emergency situation where a patient's heart or breathing stopped), but attempts to resuscitate the patient were unsuccessful, and the patient died.

During an interview on 11/29/18 at 12:10 PM, Staff CC stated that:
- He was not informed of the patient's continued abdominal pain or that it had increased to a level of seven.
- He was only aware of her chest pain and had he known (about the patient's continued abdominal pain) he would at a minimum ordered another KUB.
- He was shocked when he was notified that the patient had died, as it was unexpected.

During an interview on 11/28/18 at 2:00 PM, Staff I, Inpatient Manager, stated that he didn't have any concerns with Staff P's assessment of Patient #10 at 10:15 PM, or that she failed to call the physician at that time, and felt that "nothing was missed."

During an interview on 11/28/18 at 10:30 AM Staff B, Risk, Patient Safety and Stroke Manager, stated that she felt Staff P failed to do a thorough assessment when Patient #10 had an increase in pain;

During an interview on 11/29/18 at 4:25 PM, Staff A, Chief Nursing Officer, CNO stated that she expected Staff P, RN, to have called the physician when Patient #10's pain escalated to a seven.

2. During an interview on 11/28/18 at 2:00 PM, Staff I, Inpatient Manager, stated that he didn't educate staff regarding appropriate and complete patient assessments until "sometime" in 09/2018, after a root cause analysis (method of problem solving used to identify the root cause of faults or problems) was completed related to Patient #10's death. Staff I added that the education was informal and without documentation of who attended.

Based on interview, record review and policy review, the facility failed to ensure nursing staff correctly followed a pain medication order for one discharged patient (#10) out of one discharged patient reviewed with medication orders for pain. This failure had the potential to place all patients at risk for unrelieved pain. The facility census was 12.

Findings included:

1. Review of the facilities policy titled, "Medication Management - Ordering & Transcribing," dated 03/12/18, showed that medications will be prepared and administered in accordance with the orders of a licensed independent practitioner responsible for the patient's care and in accordance with law and regulation.

Review of Patient #10's medication orders showed an order dated 08/02/18 by Staff CC, Medical Doctor (MD) and Surgeon, for Acetaminophen (pain reliever) 650 milligrams (mg. a measure of dosage strength) per os (PO, by mouth) every six hours as needed for mild pain, rated one to three on a pain scale (scaled used to assess whether pain is increasing or decreasing, one is minimal pain and 10 is the worst pain).

Review of Patient #10's Medication Administration Record (MAR) showed that Staff P, Registered Nurse, (RN) administered Acetaminophen 650 mg at 10:15 PM on 08/02/18, for complaints of left upper quadrant (left upper portion of the abdomen) pain and left shoulder area pain, with a pain scale of seven.

During an interview on 11/28/18 at 2:52 PM, Staff P, RN stated that she administered Acetaminophen to Patient #10 in accordance to the physicians order. Staff P confirmed that the pain level associated with the order was for pain one to three, and that Patient #10's reported pain level was a seven.

During an interview on 11/29/18 at 4:25 PM, Staff A, Chief Nursing Officer, CNO stated that she expected Staff P to have called the physician for another medication order for the patient's pain level, when it was rated a seven.