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Based on interviews and record review (RR), the facility failed to ensure patient (P)3 representative's right to be informed of the patient's health status.

Findings include:

P5 is a 71-year-old male who was admitted to the hospital on 06/13/22 and had secondary diagnosis of quadriplegia secondary to prior hemorrhagic stroke, contractures of upper both hands, contractures of joint of hand, controlled type 2 diabetes mellitus, paroxysmal atrial fibrillation, aphasia (late effect of stroke), morbid obesity, and primary hypertension. P3 was under the care of an infectious disease doctor (IDD)3 for a wound culture positive for Staphylococcus Aureas (MSSA). P3 was scheduled for discharge to a long-term care facility on 06/13/23, however, the patient experienced respiratory distress and the Rapid Response Team was activated. P3's Patient Representative (PR)1 and family member (FM) were not given sufficient information regarding the patient's medical situation.

1) Reviewed P3's records (nursing notes, respiratory notes, vitals flowsheet, respiratory flow sheet, social work notes, and MD notes) which included, but not limited to the following:

-06/13/23 08:32 AM, Social Work note- P3 pending discharge awaiting authorization.

-06/13/23 12:50 PM, hospitalist program progress note, Medical Doctor (MD)5 documented, "-6/13/23 Just before scheduled transfer to ...(LTC facility), the pt (P3) developed hypoxia and tachycardia (tachycardia). Likely aspiration. Plan/Pending issues: Likely aspiration. It is possible he might develop pneumonia in near future. Will discuss with ID consultant ...(IDM3) Addendum The pt (P3) continued to have labored breathing throughout the day. SPO2 wave form is not capturing pulse week, but SPO2 showed 80s while on Oxymask. CTA chest was done which seemed to be negative for massive PE (pulmonary embolism) but showed b/l (bilateral) lower lobe infiltration. Likely aspiration. -After discussed with.. (IDD3) ...antibiotic was broadened to Zosyn. -Discussed with RT (respiratory Therapy). Will consider to obtain ABG (arterial blood gas) if difficult to assess oxygenation due to poor SPO2 wave form. - NPO (nothing by mouth) for now. IV (intravenous) hydration therapy gingerly. -The writer called both phone numbers of .... (PR and FM8)..which went to VM (voicemail). "Await to call back to give update."

-06/13/23 at 3:59 PM nursing progress notes, Registered Nurse (RN)6- P3 ate 85% of breakfast with assistance. Assessment, audible crackles noted, lungs with rhonchi when auscultated. Breathing 30 breaths per minute, heart rate tachy (rapid). P3 refused medications and requested the head of the bed (HOB) be lowered, despite RN6 informing the patient an elevated HOB is recommended to ease breathing. P3's oxygen saturation low 80s on 3 Liters (L) of air, placed on 15 L non-rebreather at that time. EKG and portable chest x-ray completed, Respiratory therapist called to assist, deep suctioning performed by RT at that time. Oxygen saturation 93-95% on 8L Oxymask. IV team at bedside to insert PIV for CTA. MD5 at bedside this afternoon prior to transport to CTA, placed on 15L non-rebreather for CTA.

-06/13/23 at 05:17 PM, nursing progress note by Crisis Registered Nurse (CRN)1- Called via phone to assist RN22 and care of P3. Rapid Response Team activated for the following criteria: Respiratory distress, Tachypnea (rapid breathing), and decreased oxygen saturation. Oxygen was administered and suctioning. MD5 notified of P3's status, to remain on the unit. Called for oxygen desaturation throughout the day, with increased work of breathing. Overnight patient on room air saturating at 98%. At time of call, P3 on 15L FIO2 via non-rebreather mask. Respirations shallow. Possible morning aspiration per MD note. RT at bedside suctioning copious amounts of tan secretion. Oxygen improving post suctioning, able to wean FIO2 to 10 L via Oxymask-O2 sat remaining greater that 95%. Respiratory rate 28-32 breaths per minute. Post suctioning lungs CTA. BP at 5:07 PM, blood pressure (BP) 87/63 Pulse (P) 70. MD5 notified- fluid bolus ordered and started. ABG drawn- MD5 aware of results and up to bedside to evaluate patient. Patient continues to need frequent suctioning- improved oxygenation and respiratory status immediately post suctioning; however, audible crackles noted as time progresses. Impressed upon primary RN of relaying to oncoming shift need for suctioning to be done in tandem with overnight respiratory therapist as large amount of thick tan secretions continues to be an issue. O3 sat remaining >95% on 10 L Oxymask. BP improving at this time.

- 06/13/23 at 08:08 PM, nursing progress note by RN22- "Outcome Evaluation: Lungs + coarse crackles, tachypneic, RR (respiration rate) 32, desat to 86-88 despite with nonrebreather mask at 15L. Deep suctioning done with large amount of secretions. RT & Crisis RN came to assist at bedside. Frequent deep suctioning done. 1700 (5:00 PM) noted BP down to 87/63, HR 72-80's MD5 notified, gave 500 cc NS bolus as ordered. BP went up 122/79 post NS bolus. O2 sat improved after frequent deep suctioning done. Nonrebreather mask changed to Oxymizer by RT, current O2 sat 99=100%, RR 22-24."

- 06/14/23 at 03:45 AM, nursing progress note by RN43- P3 is alert and oriented to person and place, still on nonbreather at 10 L with stable SPO2. Deep suction performed q4h (every four hours). Sputum culture sent to lab. 0500: P3 was found unresponsive and pulseless. Code blue and DART team called and came to bedside. No interventions done. On call hospitalist notified.

- 06/14/23 at 11:49 AM, nursing progress note by RN6- "(P3) expired at 0630 this morning...Family present..."

2) Conducted interviews and concurrent review of P3's Electronic Medical Record (EMR), when available, to include, but not limited to MD5, RN6, RN22, and the Operation Manager (OM)9 for contracted paging services (PS).

- Conducted a telephone interview with MD5 on 06/15/23 at 08:28 AM regarding P5's medical condition and notification of P3's representative and/or FM of P3's Change in Condition (CIC). MD stated, in the morning P3 was okay and is on 1:1 assistance for meals. After breakfast, MD5 received a call from RN6 that P3 had become hypoxic (low level of oxygen in the blood). Aspiration pneumonia was suspected since P3's symptoms started after breakfast. MD5 ordered a chest x-ray which came back clear, it was then suspected P3 may have had a pulmonary embolism (PE) which was later discounted and the results of multiple test and signs/symptoms were positive for aspiration pneumonia. MD5 was informed at 06:00 PM by a call from RN22 that a Code was called, for P3, due to tachypneic (rapid, shallow breathing). Inquired if the physician had contacted PR1 and/or FM1 after P3's had a change in condition and activation of the Rapid Response Team on 06/13/23. MD5 replied, between 6:30 PM and 07:00 PM, called PR1, there was no answer and left a voicemail to contact MD5 through a PS. Then FM1 was called and left a voicemail to contact physician through the same service and/or the unit. MD5 stated FM1 called the unit, but MD5 did not receive a page from PS for PR1 or FM1. Physician stated the next day, family members were saying their good-byes, FM1 inquired why did he/she did not respond to attempts to contact MD5 through PS. MD5 stated Fm1 was informed that no message was received from FM1 through the service, however, when MD5 reviewed the service log, the service log documented FM1 did attempt to contact MD5 and this was the first time MD5 became aware of FM1's missed call.

On 06/14/23 at 04:10 PM, conducted a telephone interview with RN22 regarding notification of PR1 and FM1 of P3's change in condition after the Rapid Response Team was activated. RN22 reported receiving hand-off communication with RN6 and was informed of possible aspiration and P3 had returned from testing and became tachpneic, rapid response was called, and respiratory therapy performed deep suctioning. Inquired if RN22 spoke with either PR1 or FM1 regarding P3's change in medical condition. RN22 confirmed he/she spoke to FM1 and informed FM1 him/her that P3 had aspirated and looked better after receiving suctioning, more alert, but did not go into details or inform FM1 that a rapid response was called and the team responded. Inquired if the information given to FM1 regarding P3's change in condition was sufficient enough to convey the seriousness of P3's change in medical condition. RN22 stated he/she did not talk to FM1 at length and just answered questions FM1 asked. RN22 confirmed the information provided to FM1 did not convey the seriousness of P3's medical condition and due to the lack of information, FM1 did not understand the implications of P3's change in condition.

On 06/16/23 at 09:17 AM, conducted a telephone interview with the Operations Manager (OM)9 of the facility's contracted paging system (PS). OM9 reviewed MD5's call log and confirmed a call from FM1's number was received by PS at 04:41 PM and MD5 was paged at 04:43 PM, but there was no follow-up or response from MD5. MD5 did not answer the call despite answering all other calls 15 minutes prior to and 20 minutes after FM1's initial call.

Based on interviews and record review (RR), the nursing staff did not supervise and facilitate one patient (P)1's care needs. On 11/29/2023, P1's condition changed and the response to provide an order for nebulizer treatment was delayed. The nursing staff did not follow the facility policy of calling a rapid response for the condition change, which would have brought the resources needed to the bedside immediately. In addition, the RN assigned to P1 to supervise her care, was not aware that P1 did not receive the scheduled nebulizer treatment on 11/28/2022 at 07:00 PM.

Findings include:

1) P1 is a 83 year old female with pertinent medical history of Chronic Obstructive Pulmonary Disease (COPD-lung condition that restricts airflow and causes difficulty breathing), asthma, and thoracic aortic aneurysm. She speaks primarily Cantonese, and lived with her daughter and granddaughter, who were very involved with her care. On 11/28/2022, P1's family took her to the Emergency Department (ED) because her SpO2 (oxygen level in tissue) had decreased and she was having shortness of breath. P1 was admitted for further care for COPD exacerbation, hyponatremia (low blood sodium level) and multifocal ectopic atrial beats (cardiac arrthymia).

P1's admission orders placed on 11/28/2023 at 03:00 PM included but not limited to: 1."albuterol sulfate 2.5 mg (milligrams)/.05 nebulizer (changes liquid medicine into mist form that is inhaled through a mouthpiece or mask) soln (solution) 2.5 mg. and atrovent 0.5 mg QID (four times a day) (07, 11, 15, 19)," which works by opening your airways to make breathing easier. 2. "oxygen supplementation prn (as needed) (goal saturation (oxygen) 88-92%)."

2) Reviewed P1's records (nursing notes, respiratory notes, vitals flowsheet, respiratory flow sheet and physician (MD) notes.), which included but not limited to the following:
- 11/28/2022 04:50 PM, P1 received one nebulizer (albuterol and atrovent) treatment in the Emergency Department at 04:50 PM. The hospitalist wrote the admission order as above.
- 11/28/2022 07:36 PM, Nursing note: "Pt (P1) admitted in the unit via gurney accompanied by ED RN (registered nurse). Pt appears agitated but was able to console by her granddaughter,who is at bedside. Tachypeic [sic] (rapid shallow breathing) in the 30's upon arrival but was able to recover saturation to 90's, on 2L(liters)/NC (nasal cannula)
- 11/28/2022 08:31 PM, Respiratory Therapy (RT) progress note: "Patient seen at 08:15 (PM) for scheduled breathing treatments (scheduled at 07:00 PM), treatments refused by family members at the bedside. Patient eating, RT will attempt later again."
- 11//28/2022 08:54 PM, RT note: "2nd attempt - Patient seen again for scheduled breathing treatments, treatments refused by family members at the bedside. Patient needs more time to eat. RT will return in 20 min, (minutes)."
- 11/28/2022 09:38 PM, RT note: "3rd Attempt -Attempt to see patient again for scheduled breathing treatments at 1900 (07:00 PM), treatment refused by family member at the bedside. Patient is now on the bedside commode. HR (heart rate) at 115 (normal 80-100 beats per minute). On NC (nasal cannula). RT will MAR (medication administration record) meds for now."
- 11/29/2022 00:33 AM, Nursing note: Removing O2 cannula and pulse ox (oximeter-equipment placed on patient to measure oxygen saturation (SpO2) in tissue). Desat (desaturation-% of SpO2 decreased) during oxygen removal.
- 11/29/2022 02:04 AM, Nursing Note: Notified MD of Sod (Sodium) levels. Dc (discontinue) Fluids
- 11/29/2022 03:34 AM, Nursing Note: CP (Chest pain) 5/10 (scale 1-10 with 10 being the worst), MD called.
SpO2 low 80's (%), increased to 90, labored breathing, crackles. CP protocol. ABG (arterial blood gas) refused.
Paged EKG.
- 11/29/2022 03:51 AM, Nursing Note: P117, O2 (SpO2) 78 (%).
- 11/29/2022 03:52 AM: P112 P94 SPO2 95%.
- 11/29/2022 04:36 AM: MD2 modified the nebulizer order for a treatment now and then QID
- 11/29/2022 05:25 AM: 100% (SpO2 on 4l)
- 11/29/2022 05:53 AM: Nebulizer treatment given by RT.

3) Reviewed the policy titled "Adult Rapid Response System Policy, 674-21-792-A, last revised 04/2021. The policy included:
"Rapid Response Team has been created to: Assist the staff member in assessing and stabilizing the patient condition, Assist the staff member in organizing information to be communicated to the patients physician, educate and support the staff as they care for the patient, if circumstances warrant, assist with patient transfer to a higher level of care. The following protocol will be utilized to provide rapid response consultation to patients within the hospital (H)1. The Rapid Response Team (RRT) may include the: crisis nurse, ICU (intensive care unit)/Telemetry nurse, respiratory therapist, Medical Officer of the Day, Surgical Officer of the the Day (H1) only, and can be activated 24 hours a day, 7 days a week. ..."

Rapid Response Criteria. "The following criteria will be utilized unless otherwise clarified by the physician:
"1. Staff concern for patient: 1. "Something isn't right'. or 2. For patients not meeting activation criteria with changes in patient's baseline:"
"2. Respiratory status: 1. Changes from baseline of patient 2. Respiratory rate < 8 or > 30. 3. Oxygen saturation < 90% despite supplemental oxygen 4. Increased oxygen requirements 5. Secretion and/or airway management : ..." "...Rapid Response System (RRS) activation will not delay an attempt to promptly notify Attending physician with acute changes of the patient. ..."

4) On 06/16/2023 at 11:20 AM, during an interview with the nursing unit manager (NM), she said if a patient has a condition change, as P1 did, she would expect them to notify the MD and Rapid Response Team. When asked if P1 met the criteria for a Rapid Response call, on 11/29/2022 when the RN documented P1 had new onset of CP, SpO2 in low 80's, labored breathing and crackles on auscultation, NM said it would depend on P1's code status. After informed NM P1 was a "full code (if heart stopped and/or stopped breathing, all resuscitation procedures to be provided)" at that time, she said, "Yes, she (P1) met the criteria."

5) Cross Reference A-1160 Respiratory Services:
On 11/29/2023, the facility failed to: 1) provide a "now" respiratory nebulizer treatment in a timely manner as ordered by the physician. 2) document nursing was notified P1 did not get a nebulizer treatment after three attempts because she was eating, and then on the commode. 3) facility did not have a policy/procedure that addresses what staff should do if a patient is unavailable for a scheduled treatment, and 4) RT did not complete an event report for missed treatment.

Based on interviews and record review, the facility failed to: 1) provide a "now" respiratory nebulizer treatment in a timely manner as ordered by the physician. 2) did not document nursing was notified one patient (P)1 did not get her 110/28/2022 07:00 PM nebulizer treatment after three attempts because she was eating, and then on the commode, 3) facility did not have a guidelines or policy/procedure that addressed what staff should do if a patient is unavailable for a scheduled treatment, and 4) RT did not complete an event report for missed treatment. As a result of these deficiencies, there is the potential patients who do not get ordered respiratory treatments will have a negative outcome.

Findings include:

1) P1 is a 83 year old female with pertinent medical history of Chronic Obstructive Pulmonary Disease (COPD-lung condition that restricts airflow and causes difficulty breathing), asthma, and thoracic aortic aneurysm. She speaks primarily Cantonese, and lived with her daughter and her granddaughter, who were involved with her care. The family could check her SPO2 (percentage of blood saturated oxygen) at home using a pulse oximeter, and had oxygen available (typically did not use) as needed. On 11/28/2023, P1's family took her to the Emergency Department (ED) because her SPO2 had decreased and she was having shortness of breath. P1 was admitted for further care for COPD exacerbation, hyponatremia (low blood sodium level) and multifocal ectopic atrial beats (cardiac arrthymia). P1 expired on 11/29/2023.

2) Review of P1's records revealed the following:
11/28/2022 04:57 PM, Hospitalist history and physical: Respirations (R) 26, weight 70#, SpO2 93%, "increased RR (respiratory rate) and work of breathing." Assessment/Plan: ...#Probable COPD exacerbation, #Acute on chronic respiratory failure with hypercapnia (too much carbon dioxide (CO2) in your blood) and now hypoxemia (too little oxygen in blood), #Asthma Oxygen saturation 80% on RA (room air) on presentation (to the ED), VBG (venous blood gas) and BMP (basic metabolic panel/labs) confirm chronic CO2 retention. "- Telemetry - continue steroids - albuterol/ipratropium nebulizers (combination therapy to relax and open airway) - oxygen supplementation prn (as needed) (goal saturation 88-92%)"
"Code Status and Discussion: Full Support"

11/28/2022 07:36 PM, Nursing Progress notes: "Pt (P1) Admitted in the unit via gurney ... Pt appears agitated but was able to console by her grand daughter who is at the bedside. Tachypneic (abnormally rapid breathing) in the 30's upon arrival but was able to recover saturation to 90's, on 2L(liters)/NC (nasal cannula). ...Per daughter pt was very hypoxic at home that she's becoming more confused. ...Grand daughter is requesting if she can stay overnight since pt is able to appear more calm when grand daughter at bedside."

11/28/2022 08:31 PM, Respiratory notes by RT1: "Patient (P1) seen at 20:15 for scheduled breathing treatments, treatments refused by family members at the beside. Patient is eating, RT will attempt later again."
11/28/2022 08:54 PM, Respiratory notes by RT1: "Second Attempt-Patient seen again for scheduled breathing treatments, treatments refused by family members at the bedside. Patient needs more time to eat. RT will return in 20 min."
11/28/2022 09:37 PM, Respiratory notes by RT1: "Third Attempt- Attempt to see patient again for scheduled breathing treatments at 1900, treatment refused by family member at the bedside. Patient is now on the commode. HR (heart rate) noted at 115 (normal 80-100 beats per minute). On NC."
There was no documentation the RT notified the RN (registered nurse) of the elevated HR or that the treatment had not been given. In addition, there was no documentation P1's family was informed of the risks if P1 did not get the nebulizer treatment.

11/29/2023 0033 AM, Nursing note by RN1: "...Pt has behavior of removing nasal cannula and SPO2. Pt was able to settle down after dinner meal. Pt with noted desaturation due to removal of nasal cannula to low 80's but increased after applying oxygen. - 02:04 AM: "MD1 informed of sodium levels ....Per MD to d/c (discontinue) fluids and BMP (basic metabolic panel) labs at 04:00."
- 03:56 AM: "Informed MD regarding noted increase in HR (heart rate), pt c/o (complained of) 5/10 chest discomfort/tightness to midsternum area, noted desaturation to low 80's but increased to 90's, noted labored breathing, and crackles to bases (lungs not inflating correctly or fluid inside). Chest pain protocol initiated. Per MD ordered labs including troponin, EKD was done, I stat ABG (arterial blood gas) per granddaughter, per POA (Power of attorney) daughter does not want pt to have istat ABF. MD aware okay to not do."

11/29/2022 04:37 AM, order by MD1: Nebulizer order discontinued (and modified). New order entered by MD1: "albuterol sulfate 2.5 mg/.05 nebulizer soln 2.5 mg. QID (07, 11, 15, 19), "Include Now."

11/29/2022 05:53 AM Respiratory Flowsheet:"Albuterol 2.5 mg. and Atrovent 0.5 mg. nebulizer treatment given.
SpO2 78%, P117
The "Now" order was not completed in a timely manner. It took over one hour after the order was written.

4) Reviewed the policy titled "Administration and Monitoring of Respiratory Medications last revised 06/28/2021. The policy included the following, "12. Monitor and document the response to treatment on the appropriate flow sheets in Epic (electronic record) ... Make a progress note in Epic of any significant event, such as patient refusing treatment or adverse reactions, and notify RN and/or physician."

Reviewed the policy titled "Guidelines for the Selection and Procurement, Storage, Ordering Preparing and Dispensing, Administration and Monitoring of Medications, 674-22-713-A, last revised 03/2022. The policy included order type of Stat (urgent, immediately, ASAP (as soon as possible) and Routine (standard administration times) orders. The policy included "7.3 Standard administration times," which provided the expected time frame of first doses of medication to arrive on the unit and to be administered": Stat order-within 15 minutes of order received by pharmacy and expected time frame to be given to the patient was five minutes of medication arrival on unit.

5) On 06/15/2023, during an interview with the Pharmacy Manager (PM), she said the pharmacy does not use the order type "now", but she would consider the that to be a "stat" order. Reviewed the timeline of when the nebulizer order was entered by the MD2 on 11/29/2023 (04:37 AM), and when the nebulizer treatment was given (05:53 AM). The PM agreed there was a delay in administration of the medication by respiratory services.

On 06/16/2023 at 09:30 AM, conducted an interview with the Respiratory Therapy Manager (RTM). She said if the RT documented patient is "unavailable" for treatment, it could mean they are off the unit in another department i.e. radiology, or they could be eating or in the bathroom. The RTM said the RT would document in the progress note or MAR (medication administration record). She said the department did not have a policy regarding refused or unavailable treatments that provides guidelines that would include the number of times to return to give the treatment, or informing patient/family of risk of refusal of treatment. The RTM said it would be the expectation the RT notify the RN the treatment was not done. She went on to say on the RT department has has a secretary on the day shift that processes orders and notifies the RT of a stat (now) treatment and sometimes the Charge Nurse or nursing unit secretary will call the RT cell phone directly. A review of P1's record was completed. The RTM confirmed MD2 entered the order for a now nebulizer treatment and then four times a day on 11/28/2022 at 04:37 AM. RN1 acknowledged the order at 04:50 AM, and the treatment was given at 05:53 AM. She confirmed there was no documentation the RT notified the RN the treatment was not done.

On 06/16/2023 at 11:20 AM, during a telephone interview with the Nurse Manager (NM), inquired how new orders are processed. She said the unit does not have a unit secretary on the night shift, but "the Charge Nurse steps in and as part of the role is to help make phone calls and facilitate new orders." The NM went on to say they carry cell phones and have the direct number for respiratory. She could not say how or who notified RT that night and was unaware of the delay. When asked the NM how she would interpret the order "nebulizers now," she said she had not seen an order written like that before, but "would interpret it as stat," and would expect RT response to be 15-30 minutes.