HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to have an organized nursing service that provides 24-hour nursing services by failing to ensure nursing care was provided to patients as needed. for 2 of 2 units, Intensive Care Unit (ICU) and Acute Care Unit (ACU), the Hospital failed to ensure staffing provided adequate nursing services. This potentially places any patient in ICU and ACU at risk for harm, serious injury, or death. As a result, the Condition for Participation 42 CFR 482.23, Nursing Services, was not in compliance.

Findings include:

1. The Hospital failed to ensure adequate staffing to provide nursing care to patients as needed on the Intensive Care Unit (ICU) and Acute Care Unit (ACU). See deficiency at A-392.

The Immediate Jeopardy (IJ) was identified on 7/7/2022, at 42 CFR 482.23, Nursing Services, due to the Hospital's failure to ensure adequate staffing for critical care patients. And subsequently, Pt #1 was found unresponsive and expired on 6/19/2022. The Immediate Jeopardy was announced on 7/7/2022 at 3:35 PM in a meeting with the Chief Executive Officer, the Vice President of Quality and Compliance and the Senior Vice President of Patient Care. The IJ was not removed by the survey exit date of 7/12/2022.




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Based on document review and interview, it was determined that for 2 of 2 units, Intensive Care Unit (ICU) and Acute Care Unit (ACU), the Hospital failed to ensure adequate staffing for critical care patients to ensure nursing care was provided to the patients as needed. Subsequently, Pt #1 was found unresponsive and expired on 6/19/2022.

Findings include:

1.On 7/6/2022, the Hospital's policy titled, "Standards of Nursing Care" (revision date September, 2020) was reviewed and required,
"Cardiac patient with heart disease can expect the following from critical care nursing service ...Continuous cardiac monitoring until discharged or transferred from unit ...vital signs every two hours or more frequently as indicated or ordered and documented ...rhythm strip in chart every shift and cardiac rhythm documented ...

2. On 7/6/2022, the Hospital's staffing matrix for ICU and ACU was reviewed and required:

ICU: Census 7 - 4 RNs days, evenings and nights
Census 5-6 - 3 RNs days, evenings and nights
Census 4 - 2 RNs days, evenings and nights
Census 1-2 - 2 RNs days, evenings and nights


ACU: Census 17 - 5 RNs, 1 Charge Nurse days, evenings and nights
Census 16, 15, 14 & 13 - 4 RNs, 1 Charge Nurse days, evenings and nights
Census 12, 11, 10 & 9 - 3 RNs, 1 Charge Nurse days, evenings and nights
Census 8, 7, 6, 5 & 4 - 2 RNs, 1 Charge Nurse days, evenings and nights


3. On 7/6/2022, the Hospital's policy titled, "Staffing" (August 2006) was reviewed and required, "Purpose - to assure an adequate number of caregivers to provide to patients...Unplanned staffing vacancies will be filled..."

4. On 7/6/2022, Pt #1's clinical record, dated 6/17/2022 to 6/19/2022, was reviewed. Pt #1 was admitted to the Hospital's ACU on 6/17/2022. Pt #1's admitting order dated 6/17/2022 noted "Admit ICU - diagnosis CHF (congestive heart failure, coumadin (blood thinner medication) excess." Pt #1 was admitted to the ACU on 6/17/2022 with ICU status. (ICU status means ICU nurses care for Pt #1 on the ACU according to E #2 (ACU/ICU Director). Daily staffing sheets dated 6/17/2022, 6/18/2022 and 6/19/2022 noted ICU - "closed." Z1 (ICU RN) was assigned to the care of Pt #1 on 6/19/2022 from 7:00am - 7:00pm) Pt #1 was on continuous EKG monitoring, on 100% bipap (machine for assistance with breathing). Pt #1's vital sign monitoring record dated 6/19/2022 noted that Pt #1's respiratory status was not assessed by Z1 between 8:00am and 12:00pm (4 hours). The last assessment documented by Z1 was 12:00 PM. Pt #1's code blue record, dated 6/19/2022, noted "unwitnessed arrest," CPR started at 2:10 PM. Pt #1's time of death was 2:41 PM on 6/19/2022.

5. On 7/6/2022, the Daily Staffing Sheets for ICU and ACU, dated 6/19/2022, were reviewed and included:
- 1 Registered Nurse from 7am to 1 pm for ICU - census 7 (should have 4 RNs as required by the matrix) and 2 RNs from 1pm to 7pm for ICU - census 7 (should have 4 RNs as required by the matrix).
- 1 Registered Nurse from 7am-7pm for ACU - census 9 (as opposed to 3 RNs required by the matrix).

6. On 7/6/2022, the Daily Staffing Sheets from April, May, June and July were reviewed. The Daily Staffing Sheets noted the following dates when ICU was closed due to combining staff and lack of staff especially on 6/18/2022 & 6/19/2022 according to interview with the ICU/ACU Director (see interview below) and patients were moved to ACU:
-4/15/2022, 4/16/2022, 4/29/2022, 4/30/2022
-6/3/2022, 6/4/2022, 6/5/2022, 6/6/2022, 6/7/2022, 6/8/2022, 6/9/2022, 6/10/2022, 6/11/2022, 6/13/2022, 6/14/2022, 6/15/2022, 6/17/2022, 6/18/2022, 6/19/2022, 6/20/2022, 7/3/2022 & 7/4/2022

Following the staffing shortage on ICU and ACU and Pt #1's death on 6/19/2022, staffing shortages resulting in the closure of the ICU, and ICU patients being moved from the ICU to the ACU (ACU is located on the same floor of the Hospital, next unit down the hall from ICU) occurred again on the following dates:
6/20/2022 - 7am to 3:30pm - ICU closed -ICU census 6 with 3 RNs. ICU open on 6/20/2022 3:00 pm -7:00 pm - census 5 with 3 RNS & 1 Charge Nurse
ICU -7:00 PM -7:00 AM - census 5 - 1 RN (should have 3 RNs) and 1 Charge Nurse

6/20/2022 - ACU 7am to 3:30pm - census 8 with 1 RN and 1 Charge Nurse (should have 2 RNs)
3:00 pm -7:00pm - census 10 with 1 RN and 1 Charge Nurse (should have 3 RNs)
7:00pm -7:00am - census 8 with 1 RN and 1 Charge Nurse (should have 2 RNs)

7/3/2022 -7am-3pm- ICU open with census 1 and 1 RN (should have 2 RNs)
3:00pm - 7:00pm - ICU - census 1 with 1 RN (should have 2 RNs)
7:00pm -11:00pm - ICU -census 1 with 1RN (should have 2 RNs)
11:00pm - 7:30am - ICU closed with 1 patient in ACU (4 RNs on ACU)

7/3/2022 - 7am-3pm - ACU - census 12 with 2 RNs (should have 3 RNs)
3:00pm-7:00pm - ACU - census 12 with 2 RNs (should have 3 RNs)

7/4/2022 - 7:00am-3:30pm - ICU closed - ICU census 2 - patients moved to ACU with 2 ICU RNs
3pm-7pm -ICU closed - ICU census 2 (patients in ACU) with 2 RNs
7pm-11pm - ICU open with census 2 and 1 RN & 1 Charge Nurse
11pm-7am - ICU open with census 2 and 1 RN & 1 Charge Nurse

7. Clinical records for the other 6 ICU patients who were in ACU on 6/19/2022 (Pt #12, Pt #13, Pt #14, Pt #15, Pt #16 and Pt #17) were reviewed on 7/7/2022, and included the following:

Pt #12 was an ICU patient in ACU on 6/19/2022. Pt #12 was admitted on 6/8/2022 with diagnosis of hypotension, unspecified.
-Assessments on 6/19/2022 - Pt#12 was assessed at 6am and then not reassessed until 5pm (11 hours later). Pt #12's blood pressure at 5pm was 86/58 (low blood pressure lower than 90/lower than 60) and heart rate 112 (normal 60-100). The following medications were not given on 6/19/2022 and there were no physician's orders to hold these medications - Sevelamer (phosphate binder) 400 mg four times a day (none given on 6/19/2022); Pantoprazole (gastric reflux medication) 40 mg twice a day; Tamsulosin (for urinary retention) 0.4mg daily; Eliquis (blood thinner) 5 mg twice a day; Insulin (diabetes medication) sliding scale three times a day before meals.

Pt #13's admitting order was admit to ICU on 6/15/2022 with diagnoses of hyponatremia and dehydration. Pt #13 was an ICU patient on ACU.
-Assessments on 6/19/2022 - Pt #13 was assessed on 6/18/2022 at 10:00PM and then not again until 6/19/2022 at 12:00 noon (14 hours later). The following medication was not given on 6/19/2022 and there were no physician's orders to hold this medication - Baclofen (for muscle spasms) 10 mg three times a day.

Pt #14 was admitted on 6/18/2022 with bed request for ICU with diagnosis of atrial fibrillation with rapid ventricular response. Pt #14 was an ICU patient on the ACU. Pt #14 was assessed on 6/19/2022 at 4:00 AM and then not again until 4:30 PM on 6/19/2022 (12 hours later). The following medications were not given on 6/19/2022 and there were no physician's orders to hold these medications - Amlodipine (high blood pressure medicine) 5 mg once a day; Rocephin (antibiotic) 1 gram IVPB every 24 hours; Furosemide (diuretic) 20 mg once a day; Propranolol (high blood pressure medicine) 10 mg twice a day.

Pt #15 was admitted on 6/17/2022 with bed request for ICU with diagnosis of hypernatremia and hyperkalemia. Pt #15 was an ICU patient on the ACU. Pt #15 was assessed on 6/19/2022 at 12:00 PM and then not again until 6/20/2022 at 4:46 AM (16 hours later). The following medications was not given and there were no physician's orders to hold this medication - Hydrochlorothiazide (diuretic) 25 mg once a day.

Pt. #16 was admitted on 6/17/2022 to the Intensive Care Unit (ICU) with the diagnoses of acute diabetic ketoacidosis (elevated blood glucose) and hypokalemia (low blood potassium). On 6/19/2022, Pt. #16's vital signs were not monitored between 6:09 AM and 9:22 PM (15 hours and 13 minutes). Pt. #16 did not have nursing assessments on 6/19/2022, between 4:10 AM and 9:01 PM (14 hours and 51 minutes). Pt. #16's clinical record included an order for Levofloxacin 500 milligrams (antibiotic) every 24 hours. Pt. #16 did not receive Levofloxacin on 6/19/2022, as ordered, and there was no physician's order to hold.

Pt. #17 was admitted on 6/10/2022 to the ICU with the diagnoses of acute respiratory distress, and acute asthma exacerbation. Pt. #17's vital signs were not monitored on 6/19/2022, between 7:09 AM and 7:18 PM (12 hours and 9 minutes). Pt. #17 did not have nursing assessments on 6/19/2022, between 6:54 AM and 9:29 PM (14 hours and 23 minutes). Pt. #17's clinical record included an order for theophylline 200 milligrams every 12 hours. Pt. #17's theophylline was scheduled for 9:00 AM and 9:00 PM. On 6/19/2022, Pt. #17 received the medication at 3:00 PM instead of 9:00 AM.

8. On 7/6/2022 at 9:30 AM, an interview was conducted with the ACU Registered Nurse (E #6).
E #6 stated that she worked in the ACU on 6/19/2022. E #6 stated that she was the only nurse from 7am to 7pm for 9 patients in the ACU. E #6 stated that Pt #1 was in the ACU but had "ICU status." E #6 stated that Pt #1 was cared for by an agency nurse (Z1) assigned to care for the ICU patients (including Pt #1) that were on the ACU. E #6 stated that Z1 had 3 ICU patients but 4 other ICU patients (all on the ACU) did not have any nursing oversight from 7 am to 1 pm on 6/19/2022. E #6 stated she was responsible for 9 ACU patients. E #6 stated that she was on her lunch break around 2:00 PM on 6/19/2022 and a nurse technician (E #7) came in the break room and said to come look at Pt #1. E #7 said that Pt #1 was not looking too good. E #6 stated that she went into Pt #1's room and noted that Pt #1 was not breathing. E #6 stated that she did a sternal rub and did not get a response. E #6 stated that the heart rate monitor was 20 (normal range 60-100 beats per minute). E #6 stated that she left Pt #1's room and told the nurse technician (E #7) to call a code. E #6 stated that E #7 was on the job for about 2 weeks, so E #7 did not know what a code was. E #6 stated that she then found Z1 in the hallway to call a code. E #6 stated that she went to get the crash cart and by the time she got back to Pt #1's room, physicians were in Pt #1's room doing CPR. E #6 stated that she left Pt #1's room again to go find a suction machine because E #6 had borrowed Pt #1's suction machine for another patient. E #6 stated that she got the suction machine and set it up in Pt #1's room.

9. On 7/6/2022 at 10:00 AM, an interview was conducted with MD #1 (Pt #1's physician). MD #1 stated Pt #1 was admitted for ICU critical care but was on the ACU. MD #1 stated that this is not the first time the Hospital has put an ICU patient on the ACU. MD #1 stated that she spoke with the Director of Nursing (E #9) about her concern regarding placing ICU patients in the ACU. MD #1 stated that she was told by E #9 that ICU patients were cared for in the ACU because of staffing issues. MD #1 stated that the Medical Director (MD #2) of the ICU is also aware of this concern. MD #1 stated that MD #1 saw Pt #1 the morning of 6/19/2022 (Pt #1 expired at 2:00 PM on 6/19/2022). MD #1 stated that Pt #1 was improving. MD #1 stated that Pt #1 had a cardiac arrest on 6/19/2022.

10. On 7/6/2022 at 10:30AM, an interview was conducted with the Director of ICU/ACU (E #2). E #2 stated on the week before June 19th, ICU census started going up, so we moved ICU patients to ACU. E#2 stated that we just didn't have enough staff. E #2 stated that she was called on 6/19/2022 in the morning when there was only 1 RN for ICU patients and 1 RN for ACU patients. E #2 stated that Z1 refused to care for the 7 ICU patients and told her she was only going to care for 3 (Pt #1, Pt #13, and Pt #17) of the 7 ICU patients. E #2 stated that the 4 other ICU patients did not have a RN caring for them from 7am to 1pm, when another agency nurse came to work. E #2 stated that there was only 1 Registered Nurse (E #6) for 9 ACU patients. E #2 stated that the ICU nurses all had critical care training. E #2 stated that moving ICU patients to ACU happens on a regular basis for staffing issues.

11. On 7/6/2022 at 11:30 AM, an interview was conducted with the Nurse Technician (E #10). E #10 stated that she cared for Pt #1 the day Pt #1 expired (6/19/2022). E #10 stated that Pt #1's bipap (a type of ventilator - a device that helps with breathing) was taken off by Z1 when Pt #1 was being fed lunch by E #10 at 11:00 am. E #10 stated that she has only worked at the Hospital for one month. E #10 stated that she told Z1 that Pt #1 was finished with her lunch at noon. E #10 stated that she took Pt #1's vital signs at noon. E #10 stated that the next time she checked on Pt #1 was at 2:00 PM, and Pt #1 was not responsive. E #10 stated that she is CPR certified. E #10 stated that Pt #1 did not have her bipap connected. E #10 stated that the bipap tubing was next to Pt #1. E #10 stated that she went and told E #6 (around 2:00 PM) to come take a look at Pt #1. E #10 stated that Z1 came in Pt #1's room and started doing CPR.

12. On 7/6/2022 at 3:00 PM, an interview was conducted with the Director of Nursing (E #9). E #9 stated that the Hospital is experiencing a nursing shortage just like the entire nation. E #9 stated that nurses don't want to work at this Hospital. E #9 stated that she hired staffing coordinators for each shift in response to the issue on 6/19/2022. E #9 stated that the staffing coordinators will call agencies and any staff available to come to work in there are call off or vacancies. E #9 stated that when the ICU census is low, the patients are moved to ACU to combine staffing. E #9 stated that the Hospital uses agency nurses and is in the process of recruiting nurses to fill the vacancies.

Based on document review and interview, it was determined that for 1 of 11 (Pt #4) patients' clinical records reviewed, the Hospital failed to ensure the registered nurse supervised and evaluated the nursing care for each patient by not ensuring the completion of assessments and vital signs, in accordance with policy and physician's orders.

Findings include:

1. On 7/7/2022, the Hospital's policy titled, "Clinical Care Station Charting and Documentation" (revised 2/2009), was reviewed. The policy requires, "III. Procedures ...D. Graphic Vital Signs, Weights, Intake/output & Nursing Flowsheets: ... All Physician and nursing treatments that are ongoing should be entered on the action list. Vital Signs are to be charted every four (4) hours unless otherwise specified by the attending. The Charge Nurse, Team Leader or RN [Registered Nurse] responsible for the patient is to review the action list for completeness and final evaluation of data at the end of the shift."

2. On 7/6/202, Pt. #4's clinical record was reviewed. Pt. #4 was admitted on 6/3/2022 to 2E Respiratory Care Unit with the diagnoses of Sepsis (infection), Multiple Decubitus (Deeply injured tissue) Ulcers. Pt. #4's physician's orders, dated 6/3/2022 at 6:32 PM, included vital signs to be done Q4 Hours (every 4 hours). Pt #4 was then transferred to 3 south Stepdown unit on 6/16/2022, with the same vital sign orders of Q4 hours. The clinical Record lacked documentation of vital signs on the following dates and times:
- 6/19/2022 for 12:00 AM and 4:00 AM;
- 6/20/2022 for 12:00 AM, 4:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM; and
- 6/21/2022 for 12:00 AM, 4:00 AM, 12:00 PM, and 4:00 PM.
-Pt #4's Clinical record lacked any documentation of Vital signs or nurse progress notes from 9:32 AM on 6/20/2022 until 6/21/2022 at 9:00 AM (24 hours). On 6/23/2022 at 8:56 PM, Pt #4 was transferred to the Intensive Care Unit (ICU) for worsening hemodynamic (blood circulatory system) and respiratory conditions.

3. On 7/6/2021 at approximately 9:45 AM, an interview was conducted with the Nursing Informatics Registered Nurse (E#11). E #11 agreed that there was no record of vital signs being recorded in the patient's clinical record and stated, "I spoke with Medical records and no paper records exist for vital signs on the patient, we just missed them."