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Based on record review and interview the hospital failed to meet the Condition of Participation for Governing Body by failing to ensure medical staff adopt and enforce bylaws regarding physician's availability/response time when"'on call" (for the admitting physician's practice) resulting in a failure on the part of Physician S10 to respond to a page regarding a significant change in the condition of Patient #3 for 2 (two) hours (See findings cited at A0353).

An immediate jeopardy situation was identified on 2/08/2010 at 4:25 p.m. and reported to the hospital's Vice President of Nursing and Vice President of Medical Affairs. The immediate jeopardy was a result of the hospital's failure to adopt and enforce bylaws regarding physician's availability/response time when "on call" resulting in a failure on the part of Physician S10 to respond to a page regarding a significant change in the Condition of Patient #3 for two hours. Physician S10 was paged at 2:15 a.m. and did not return the call to the hospital until 4:15 a.m. Patient #3 expired later that morning (pronounced dead at 7:40 a.m. on 11/19/09).

A corrective action plan was submitted by the hospital on 2/09/2010 to address the immediate jeopardy situation which reveled the hospital had notified the Medical Staff of a new policy titled, "Physician Notification Protocol, adopted 2/08/2010" via e-mail and fax sent on 2/08/2010. Review of this policy revealed in part, "Non Critical Situation: Call (Office/Answering Service). If no response in 20 minutes repeat call and inform Charge Nurse. If no response in 10 minutes, call House Supervisor. (House Supervisor) to recall or consider another number. If no response in 15 minutes (House Supervisor) to notify Administrator on Call who will direct call to Department Chair or Chief of Staff as applicable. Critical Situation: Call Medical Emergency Team. . . ." Clinical Staff had been educated on the new protocol on 2/08/2010 via e-mail. A flow chart was posted on all nursing units outlining the protocol to utilize when attempting to reach physicians for non-critical situations and critical situations. Nursing staff on duty were interviewed and verbalized awareness of the new policy for contacting physicians as follows: Registered Nurse (RN) S18 on 2/09/2010 at 9:10 a.m., RN S19 on 2/09/2010 at 9:15 a.m., RN S20 on 2/09/2010 at 9:20 a.m., and RN S21 on 2/09/2010. As a result of the hospital's action plan, the Immediate Jeopardy situation was removed on 2/09/2010 at 9:40 a.m.

Based on record review and interview the hospital failed to ensure the Medical Staff was accountable to the governing body for quality of care provided to patients as evidence by failing to adopt and enforce bylaws regarding physician's availability/response time when"'on call (related to patients admitted to their practice)", resulting in a failure on the part of Physician S10 to respond to a page regarding a significant change in the condition of Patient #3 for 2 (two) hours (Findings).

Review of Patient #3's medical record revealed the patient was admitted to the hospital on 11/13/09 with diagnoses that included Severe Cardiomyopathy, Severe Peripheral Vascular Disease with Limb Threatening Ischemia, Ischemic Heart Disease, Acute on Chronic Renal Insufficiency, and Acute on Chronic Respiratory Insufficiency. Review of Patient #3's Graphic Sheet from the dates of 11/13/09 through 11/17/09 revealed the patient's heart rate ranged from a low of 56 to a high of 85.

Review of Nursing Documentation by Registered Nurse (RN) S11 dated 11/18/09 -11/19/09 revealed Patient #3 was examined by Physician S10 (Cardiologist) on 11/18/09 at 1342 (1:42 p.m.). Patient #3's nursing documentation revealed he had a hematoma to his right groin area the "approximate size of a grapefruit" with the last hematocrit 26.1. Patient #3 was documented as alert and speaking with his wife on the phone at 2130 (9:30 p.m.). Further review revealed Patient #3's vital signs at 2:15 a.m. (11/19/09) to indicate a heart rate of 201, blood pressure of 99/64, Respirations of 24, Pulse Ox of 87% on 2 liters of oxygen. Documentation revealed a page was placed to Physician S10 at 2:15 a.m. in regards to these changes in condition. Further review revealed Physician S10 did not respond to the page until 4:15 a.m. (2 hours after the nurse paged the physician at 2:15 a.m.). Documentation at 4:15 a.m. revealed Physician S10 ordered lab (a stat hematocrit, hemoglobin and stat chem 7) and for the patient to be transfused with 1 unit of blood if the patient's hematocrit was less than 25. Blood Pressure was documented as 95/61 with a heart rate of 132 at that time (4:15 a.m.). Further review revealed 5:45 a.m. hematocrit results of 25.4 were noted by RN S11 and Physician S10 was paged. Physician S10 was documented as being paged again at 6:20 a.m. At 6:52 a.m. Patient #3 was found unresponsive and unarousable. A Nurse Aide was documented as calling for help at 6:53 a.m. Cardio Pulmonary Resuscitation was started at 6:54 a.m. Physician S10 called and was notified of Patient 3's status at 6:54 a.m. (1 hour and 9 minutes after being paged at 5:45 a.m.) A Code Blue was called at 6:55 a.m.

Review of Patient #3's Code Blue documentation revealed the code was begun at 6:55 a.m. with the initial assessment of Pulseless Electrical Activity. Advance Cardiac Life Support was provided from 6:55 a.m. until 7:40 a.m. when the patient was pronounced dead. The code was run by Emergency Physician S22 at 7:40 a.m.

During a face to face interview on 2/08/2010 at 9:30 a.m., Registered Nurse (RN) S11 indicated she was the nurse that provided care to Patient #3 on the dates of 11/18/09 through the morning of 11/19/09. RN S11 indicated Patient #3 had a significant change in his condition at 2:15 a.m. when his heart rate increased to 201 and his oxygen saturations dropped to 87%. RN S11 indicated she paged the "on call" physician (S10) at 2:15 a.m. RN S11 indicated she was very concerned about Patient #3 and the physician was not calling her back. S11 indicated she informed the House Supervisor (S13) of the problem with contacting Physician S10 at 2:30 a.m. and notified her charge nurse (S9) at 2:45 a.m. RN S11 indicated it was not until 4:15 a.m. that Physician S10 responded to her page. (2 hours after the initial page). RN S11 indicated she called the physician's number more than once; however, she had also been providing care to another unstable patient (assigned to her care) during the same time (Patient #9) and did not document all attempts to reach Physician S10 before 4:15 a.m.. RN S11 indicated at the time Physician S10 responded to her call (4:15 a.m.) regarding Patient #3, that Patient #9 was trying to pull out his IV (Intravenous Line) and by the time she completed the phone call, #9 had pulled his IV out. Review of Patient #9's medical record revealed the patient pulled his line out at 4:25 a.m. (confirming the time frame in which RN S11 indicated Physician S10 responded to her 2:15 a.m. page).

During a face to face interview on 2/08/2010 at 10:25 a.m., Physician S10 (Cardiologist) indicated the documentation by RN S11 was incorrect. When asked to provide the surveyor with his answering services' log for the dates of 11/18/09 - 11/19/09, Physician S10 refused.

During a face to face interview on 2/05/2010 at 2:20 p.m., Physician S8 (Cardiologist and partner of S10) indicated when "on call", a physician should respond to pages/phone calls immediately and should be available "on site" to provide care to the patient within one hour as needed.

Review of the hospital's Medical Staff Bylaws and Rules/Regulations revealed no documented evidence of rules/regulations regarding what was expected of the hospital's physicians in regards to availability and/or response times to pages for patients under their care when "on call".

During a face to face interview on 2/08/2010 at 2:20 p.m., Physician S13, Vice President of Medical Affairs, confirmed there were no rules and regulations in the Medical Staff Bylaws regarding what response times were expected from physicians when on call. Physician S13 indicated the hospital's medical staff had previously identified the need to implement a policy regarding physician response time; however, there had been no policy or rule implemented at the time of the survey. Physician S13 indicated a 2 hour response time to a page was too long.

Based on record review and interview the hospital failed to ensure an effective process was in placed for addressing grievances for 1 of 3 sampled patients reviewed for the hospital's procedure to handle grievances (#3). Findings:

During a telephone interview on 2/05/2010 at 12:00 p.m., Patient #3's wife indicated she had called the hospital shortly after her husband had died (death 11/19/09 at 7:40 a.m.) to file a grievance. #3 indicated she had never been called by the hospital to inform her that her husband had taken a turn for the worse on the night before he died. #3 indicated she had been married for 40 years. She further indicated she was extremely disturbed and hurt that her husband had to die alone with no family members at his bedside. #3's wife indicated she was connected per telephone with Patient Relations Manager S7 when she called the hospital to make a complaint (grievance). #3's wife spelled S7's name for the surveyor. #3 indicated S7 listened to her complaint and informed her that she would have to investigate the incident and would respond to her in writing within 7 - 14 days. S7 indicated it had been over a month since she had made the complaint and had never received any information from S7 or the hospital regarding their investigation (See findings cited at A0395).

Review of the hospital's grievance log revealed no documented evidence of any grievance filed by Patient #3's wife.

During a face to face interview on 2/05/2010 at 12:30 a.m., Patient Relations Manager S7 indicated she had no recall of anyone, to include Patient #3's wife, making a complaint/grievance regarding failure of the hospital to notify family of a significant change in condition. S7 indicated it could be possible that someone else answered the phone identifying themselves as "the office of S7" (using her name). S7 indicated all calls to her office with complaints and/or grievances should be documented and the procedure for either a complaint or grievance should be followed as indicated.

Review of the hospital policy titled, "Patient Grievance and Complaints, #K81738-PI101, Reviewed 6/2009" presented by the hospital as their current policy revealed in part, "A patient grievance is a written or verbal complaint by a patient, or the patient's representative, regarding the patient's care . . . All grievances with be addressed as quickly as possible. If unable to resolve within 7 days from receipt, a written notice of acknowledgment, including an estimated time for the final response, will be sent to the patient or their representative. A formal written response should be sent to the patient within 30 days of receipt of the grievance. . ."

Based on record review and interview the hospital failed to meet the Condition of Participation for Nursing Services by:
1) failing to ensure Supervisory Nursing Staff intervene when a Registered Nurse reported the inability to reach a physician for a patient exhibiting a significant change in condition.
2) failing to ensure Supervisory Nursing Staff provided immediate assessment of staffing needs with reassignment of staff as needed when patient acuity levels significantly increased over a short period of time for 1 of 1 shift reviewed where a Registered Nurse (RN S11)complained to supervisors that her assigned patient load was greater than she was capable of handling (11/18/09 -11/19/09). (See findings cited at A0392)

An immediate jeopardy situation was identified on 2/08/2010 at 4:25 p.m. and reported to the hospital's Vice President of Nursing and Vice President of Medical Affairs. The immediate jeopardy was a result of the hospital's failure:
1) to ensure supervisory nursing staff intervene when a Registered Nurse (S11) reported to Charge Nurse (S12) and House Supervisor (S13) on 11/19/09 at 2:30 a.m. and 2:45 a.m. that Physician S10 was not responding to pages to address a significant change in condition for Patient #3, and
2) to ensure supervisory nursing staff provided immediate assessment of staffing needs and reassignments of staff to cover the telemetry unit when Registered Nurse S11 reported to Charge Nurse S12 that she was overwhelmed and unable to meet the needs of the 5 patients assigned to her care when 2 of the patients were in crisis at the same time (11/19/09 from 2:00 a.m. until 7:00 a.m.) Patient #9 was transferred to the Intensive Care Unit at 5:40 a.m. Patient #3 Coded at 6:55 a.m.

A corrective action plan was submitted by the hospital on 2/09/2010 to address the immediate jeopardy situation which revealed the hospital had adopted a new policy titled, "Physician Notification Protocol, adopted 2/08/2010" Review of this policy revealed in part, "Non Critical Situation: Call (Office/Answering Service). If no response in 20 minutes repeat call and inform Charge Nurse. If no response in 10 minutes, call House Supervisor. (House Supervisor) to recall or consider another number. If no response in 15 minutes (House Supervisor) to notify Administrator on Call who will direct call to Department Chair or Chief of Staff as applicable. Critical Situation: Call Medical Emergency Team. . . ." Clinical Staff had been educated on the new protocol on 2/08/2010 vial e-mail. A flow chart was posted on all nursing units outlining the protocol to utilize when attempting to reach physicians for non-critical situations and critical situations. An assigned mandatory computer based learning module was implemented on 2/08/2010. Nursing staff on duty were interviewed and verbalized awareness of the new policy for contacting physicians as follows: Registered Nurse (RN) S18 on 2/09/2010 at 9:10 a.m., RN S19 on 2/09/2010 at 9:15 a.m., RN S20 on 2/09/2010 at 9:20 a.m., and RN S21 on 2/09/2010. As a result of the hospital's action plan, the Immediate Jeopardy situation was removed on 2/09/2010 at 9:40 a.m. Further review of the corrective action plan revealed a revised Policy titled, "Staffing Assignments, Telemetry, Review Date: February 2010". Review of this policy revealed in part, "Assignment Guidelines: Review of patient acuity is the first consideration. If a patient experiences an acute change, the staff nurse updates the Operational Coordinator to more accurately describe the care the patient requires.. . Assignments are written in pencil After assignments are made, they may be readjusted before or during the shift changes as the need arises. If a nurse feels the staffing assignment needs to be adjusted because of changes in patient acuity or workload, the staff will notify the (Charge Nurse) The (Charge Nurse) will make staffing adjustments as appropriate. The House Supervisor will be notified". Charge Nurses and House Supervisors were educated via e-mail on 2/08/2010. An assigned mandatory computer based learning module was implemented on 2/08/2010. As a result of the hospital's action plan, the Immediate Jeopardy situation was removed on 2/09/2010 at 9:40 a.m.

Based on record review and interview the hospital failed ensure nursing staff were available to meet the needs of the patient by:
1) failing to ensure Supervisory Nursing Staff intervene when a Registered Nurse reported the inability to reach a physician for a patient exhibiting a significant change in condition for 1 of 9 sampled patients (#3).
2) failing to ensure Supervisory Nursing Staff provided immediate assessment of staffing needs with reassignment of staff as needed when patient acuity levels significantly increased over a short period of time for 1 of 1 shift reviewed where a Registered Nurse (RN S11)complained to supervisors that her assigned patient load was greater than she was capable of handling (11/18/09 -11/19/09). Findings:


1) failing to ensure Supervisory Nursing Staff intervene when a Registered Nurse reported the inability to reach a physician for a patient exhibiting a significant change in condition for 1 of 9 sampled patients (#3).

Review of Patient #3's medical record revealed the patient was admitted to the hospital on 11/13/09 with diagnoses that included Severe Cardiomyopathy, Severe Peripheral Vascular Disease with Limb Threatening Ischemia, Ischemic Heart Disease, Acute on Chronic Renal Insufficiency, and Acute on Chronic Respiratory Insufficiency. Review of Patient #3's Graphic Sheet from the dates of 11/13/09 through 11/17/09 revealed the patient's heart rate ranged from a low of 56 to a high of 85.

Review of Nursing Documentation by Registered Nurse (RN) S11 dated 11/18/09 -11/19/09 revealed Patient #3 was examined by Physician S10 (Cardiologist) on 11/18/09 at 1342 (1:42 p.m.). Patient #3's nursing documentation revealed #3 had a hematoma to his right groin area the "approximate size of a grapefruit" with his last hematocrit- 26.1. Patient #3 was documented as alert and speaking with his wife on the phone at 2130 (9:30 p.m.). Further review revealed Patient #3's vital signs at 2:15 a.m. (11/19/2010) to include a heart rate of 201, blood pressure of 99/64, Respirations of 24, Pulse Ox of 87% on 2 liters of oxygen. Documentation revealed S11 paged Physician S10 at 2:15 a.m. in regards to these changes in the patient's condition. Further review revealed RN S11 notified the House Supervisor (RN S13) at 2:30 a.m. of Patient #3's condition and the lack of response to pages to Physician S10 from her 2:15 a.m. page. Review revealed RN S11 notified the Charge Nurse (RN S9) at 2:45 a.m. that she had not received a return call from Physician S10. Physician S10 did not respond to the page until 4:15 a.m. (2 hours after the nurse paged the physician).

During a face to face interview on 2/08/2010 at 9:30 a.m., Registered Nurse (RN) S11 indicated she was the nurse that provided care to Patient #3 on the dates of 11/18/09 through the morning of 11/19/09. RN S11 indicated Patient #3 had a significant change in his condition at 2:15 a.m. when his heart rate increased to 201 and his oxygen saturations dropped to 87%. RN S11 indicated she paged the "on call" physician (S10) at 2:15 a.m. RN S11 indicated she was very concerned about Patient #3 and the physician's failure to respond timely when paged. S11 indicated she informed House Supervisor S13 of the problem with contacting Physician S10 at 2:30 a.m. and notified her charge nurse (S9) at 2:45 a.m. RN S11 indicated it was not until 4:15 a.m. that Physician S10 responded to her page. (2 hours after the initial page). RN S11 indicated she called the physician's number more than once; however, she had also been providing care to another unstable patient (assigned to her care) during the same time (Patient #9) and did not document all attempts to reach Physician S10 before 4:15 a.m.. RN S11 indicated she received some help from other nurses in providing care to one of the two patients in crisis (#9) but remained the primary nurse responsible for the care of 5 patients which included the two patients in crisis (#3 and #9). RN S11 indicated at no time did supervisory Nursing Staff intervene when she was unable to reach Patient #3's physician from 2:15 a.m. until the physician responded at 4:15 a.m..

During a face to face interview on 2/08/09, RN S9 (Charge Nurse) indicated she was aware that RN S11 was having difficulty getting Physician S10 to respond to pages on 11/19/09. RN S11 indicated she believed RN S9 was "on top of the situation" and handled things appropriately by making attempts to reach the physician and monitor the patient while awaiting a response by the physician. RN S9 indicated she had instructed RN S11 to contact the House Supervisor and make her aware of the difficulty in reaching Physician S10. RN S11 indicated S9 carried out her instructions and there was nothing else that could be done at the time. RN S11 confirmed that she did not intervene to provide assistance with contacting Physician S10. RN S9 confirmed that RN S11 was assigned to to the care of 5 patients and that two of the patients were in crisis (#3, #9).

During a telephone interview on 2/08/2010 at 12:25 p.m., House Supervisor, RN S13, indicated she had never received any reports from RN S11 claiming that she could not reach Patient #3's physician. RN S13 confirmed she did not intervene or assist RN S13 with contacting Physician S10.

During a telephone interview on 2/08/2010 at 12:50 p.m., RN S11 indicated she did speak with House Supervisor RN S13 as documented in the medical record of Patient #3 at 2:30 a.m. RN S11 indicated she did this because she was very concerned about the change in condition of Patient #3 and her inability to reach the patient's physician. RN S11 indicated she made it very clear to the Charge Nurse and House Supervisor that she could not reach Physician S10 to provide care to Patient #3 who was having vital sign changes indicating a Significant Change in his Condition. RN S11 indicated there was no assistance offered by either the Charge Nurse or the House Supervisor in reaching Physician S10 from 2:15 a.m. until the physician contacted her at 4:15 a.m.


2) failing to ensure Supervisory Nursing Staff provided immediate assessment of staffing needs with reassignment of staff as needed when patient acuity levels significantly increased over a short period of time for 1 of 1 shift reviewed where a Registered Nurse (RN S11)complained to supervisors that her assigned patient load was greater than she was capable of handling (11/18/09 -11/19/09).

Review of the assignment sheet accompanied with an interview of the RN Manager of Telemetry (S15) on 2/18/2010 at 2:10 p.m. revealed RN S11 was assigned to the care of Patients #3 (Severe Cardiomyopathy, Severe Peripheral Vascular Disease with Limb Threatening Ischemia, Ischemic Heart Disease, Renal Insufficiency, Chronic Respiratory Insufficiency) , #9 (Chronic Obstructive Pulmonary Disease Exacerbation, Alcohol Abuse), R1 (Status Post Peripheral Angiogram), R2 (Hemoptysis, Hypertension, Diabetes, Chronic Obstructive Pulmonary Disease, and Lung Cancer) , and R3(Cholelichiatis) on the night of 11/18/09 through the morning of 11/19/09. S15 confirmed that another patient was assigned to RN S11 at the beginning of the shift but the patient was discharged home and Patient #9 was admitted to her care later in the shift (1:45 a.m.).

Record review revealed all nursing documentation for Patient #3 and Patient #9 on the morning of 11/19/2010 was done by RN S11.

Review of Patient #9 ' s nursing notes (the other patient in crisis assigned to the care of RN #S11) as documented by RN S11 revealed the patient arrived on the floor at 1:45 a.m. (the documented initial change in patient #3 ' s condition began at 2:15 a.m.), pulse ox noted at 88% at 2:30 a.m. (respiratory paged for treatment), pulled out his IV at 4:25 a.m. at the same time as a new order for Ativan IVP was received, Code White (behavior management code) was called at 4:30 a.m., new order for Ativan IVP at 4:50 a.m., soft restraints applied at 5:10 a.m., stat Arterial Blood Gases and order to transfer to Intensive Care Unit (ICU) at 5:20 a.m., transferred to ICU by RN S11 at 5:40 a.m., and family (patient #9 ' s) was notified of transfer/change in condition at 5:55 a.m.

Review of Nursing Documentation by Registered Nurse (RN) S11 dated 11/18/09 -11/19/09 revealed Patient #3 was examined by Physician S10 (Cardiologist) on 11/18/09 at 1342 (1:42 p.m.). Patient #3's nursing documentation revealed he had a hematoma to his right groin area the "approximate size of a grapefruit" with the last hematocrit 26.1. Patient #3 was documented as alert and speaking with his wife on the phone at 2130 (9:30 p.m.). Further review revealed Patient #3's vital signs at 2:15 a.m. (11/19/09) to indicate a heart rate of 201, blood pressure of 99/64, Respirations of 24, Pulse Ox of 87% on 2 liters of oxygen. Documentation revealed a page was placed to Physician S10 at 2:15 a.m. in regards to these changes in condition. Further review revealed Physician S10 did not respond to the page until 4:15 a.m. (2 hours after the nurse paged the physician at 2:15 a.m.). Documentation at 4:15 a.m. revealed Physician S10 ordered lab (a stat hematocrit, hemoglobin and stat chem 7) and for the patient to be transfused with 1 unit of blood if the patient's hematocrit was less than 25. Blood Pressure was documented as 95/61 with a heart rate of 132 at that time (4:15 a.m.). Further review revealed 5:45 a.m. hematocrit results of 25.4 were noted by RN S11 and Physician S10 was paged. Physician S10 was documented as being paged again at 6:20 a.m. At 6:52 a.m. Patient #3 was found unresponsive and unarousable. A Nurse Aide was documented as calling for help at 6:53 a.m. Cardio Pulmonary Resuscitation was started at 6:54 a.m. Physician S10 called and was notified of Patient 3's status at 6:54 a.m. (1 hour and 9 minutes after being paged at 5:45 a.m.) A Code Blue was called at 6:55 a.m.

Review of Patient #3's Code Blue documentation revealed the code was begun at 6:55 a.m. with the initial assessment of Pulseless Electrical Activity. Advance Cardiac Life Support was provided from 6:55 a.m. until 7:40 a.m. when the patient was pronounced dead. The code was run by Emergency Physician S22 at 7:40 a.m.

(S11 was also assigned to the care of R1, R2, R3 all of which were in stable condition with minimal care):

During a face to face interview on 2/08/2010 at 8:40 a.m., Registered Nurse S9 indicated she was the Charge Nurse on the night of 11/18/09 through the morning of 11/19/09. S9 indicated it was an extremely busy night and unusual because there had been more than one patient in crisis at the same time. S9 indicated as Charge Nurse, she had no patients assigned to her care. S9 indicated she oversaw any work performed by Licensed Practical Nurses and was there to assist the Registered Nurses as needed. S9 indicated she took over the care of Patient #9, in order for RN S11 to focus on Patient #3.

During a face to face interview on 2/08/2010 at 9:30 a.m., Registered Nurse S11 (graduated from nursing school 1 year and 9 months prior to the interview) indicated she was overwhelmed on the night of 11/18/09 into the morning of 11/19/09 when her assignment resulted in her having 5 patients, with 2 in crisis at the same time, on the telemetry unit. RN S11 indicated she asked the Charge Nurse (S9) to change the assignment because she could not keep up. S11 indicated she was extremely busy and was unsure of when the request was made. RN S11 indicated the Charge Nurse had assisted her with the Code White (Behavior Code) called for Patient #9, which required several staff's intervention; however, she remained the primary nurse for all 5 patients assigned to her care, to include Patient #3 and Patient #9 who were both in crisis requiring frequent assessments, interventions, and/or calls to their physicians. RN S11 indicated there were no changes in the assignment and she was overwhelmed. RN S11 indicated she had to leave the bedside of Patient #3 when she transported Patient #9 to ICU (Intensive Care Unit). RN S11 indicated there was no time when she was relieved of her assignment as primary care nurse for Patient #9 (as indicated by RN S9).

Record review revealed all nursing documentation for Patient #3 and Patient #9 on the morning of 11/19/09 was done by RN S11.

During a telephone interview on 2/08/2010 at 12:25 p.m., House Supervisor S13 indicated she was on duty the night of 11/18/09 into the morning of 11/19/09. S13 indicated the only complaint that she received from RN S11 was that Physician S10 had been verbally abusive to her on the phone. RN S11 indicated there had been no request for a change of assignment.

Based on record review and interview the hospital failed to ensure a Registered Nurse (RN) supervise and evaluate the nursing care for each patient by:
1) Failing to ensure family members were notified of a significant change in condition for 1 of 9 sampled patients (#3).
2) Failing to ensure the Medical Emergency Team was activated when a patient experienced a significant change in condition for 1 of 9 sampled patients (#3). Findings:

1) Failing to ensure family members were notified of a significant change in condition.

Review of Patient #3's Graphic Sheet from the dates of 11/13/09 through 11/17/09 revealed the patient's heart rate ranged from a low of 56 to a high of 85. Further review of Patient 3's medical record revealed the following: On the morning of 11/19/09 at 2:15 a.m., Patient #3 had a significant change in condition with an increase in his heart rate to 201, blood pressure of 99/64, and pulse ox on 2 liters of oxygen of 87% (translation of nursing notes provided by the Vice President of Nursing, S6, due to illegibility of handwriting). Patient #3 was found on the floor in his hospital room at 4:45 a.m. At 5:45 a.m. Patient #3's hematocrit returned with a result of 25.4 (normal 40 - 54). At 6:55 a.m. a Code Blue was called for Patient #3 and the patient was pronounced dead at 7:40 a.m. Review of the entire medical record revealed no documented evidence of any attempts to notify Patient #3's wife until after the patient was pronounced dead. This finding was confirmed by RN S11 who was assigned to the care of Patient #3 on the night of 11/18/09 through the morning of 11/19/09.

During a face to face interview on 2/08/2010 at 8:40 a.m., Charge Nurse S9 indicated she did not make any attempts to notify Patient #3's family of a significant change in his condition.

During a face to face interview on 2/08/2010 at 9:30 a.m., RN S11 indicated she made no attempts to notify Patient #3's family when the patient experienced a change of condition on 11/19/09 at 2:15 a.m. Further she indicated no attempts were made to reach any family member until after the patient was pronounced dead on 11/19/09 at 7:40 a.m. Review of the hospital policy titled, "Disclosure: Outcome requiring notification Disclosure, last revised 10/01/07" presented by the hospital as their current policy revealed in part, "When appropriate, the patient and their family are promptly informed about outcomes of care that changes their initial plan of care due to unanticipated outcomes."

Review of the hospital policy titled, "Patient Rights and Responsibilities, last revised 1/03/08" presented by the hospital as their current policy revealed in part, "The patient (has) the right to obtain, from his/her physician, complete, current information concerning diagnosis, treatment, and prognosis in terms the patient can reasonable be expected to understand. When it is not medically advisable to give such information to the patient, the information should be made available to an appropriate person in his/her behalf. . . The dying patient has the right to comfort and dignity through treatment of primary and secondary symptoms that respond to therapies as desired by the patient or surrogate decision-maker. Psychological and spiritual concerns of the patient and the family regarding dying shall be acknowledged along with his/her individual and corporate expression of grief."

Review of the hospital policy titled, "Medical Emergency Team, last revised 8/07" presented by the hospital as their current policy revealed in part, "House Supervisor assures MD (medical doctor) called and family notified as needed. Charge Nurse or Unit Director assists in notification of family and MD prn (as needed)."

2) Failing to ensure the Medical Emergency Team was activated when a patient experienced a significant change in condition.

Review of the hospital's 2008 Medical Emergency Team (MET) Education printout revealed in part, "When to call the MET(?). Staff is worried about patient. Unstable patient requiring a lot of intervention (even if responding), acute change in heart rate to less than 40 or greater than 130, acute change in systolic blood pressure to less than 90 systolic, acute change in respiratory rate to less than 8 or greater than 30, acute change in pulse oximetry saturation to less than 90% on oxygen, acute change in conscious state, acute change in urinary output to less than 50 milliliters in 4 hours, acute symptoms indicative of stroke. Note: Call for any situation requiring a response to attend to a patient with a change in condition or a worsening of condition."

Review of Patient #3's Nursing Documentation dated 11/19/2009 revealed the following:
At 2:15 a.m. the patient's heart rate was documented as 201.
At 5:35 a.m. the patient's blood pressure was documented as 88/65.

Review of the November 2009 Code Blue Log presented by the hospital as the log that reveals any time a Code Blue is called or the MET team is requested revealed no documented evidence of the MET team being called to Patient #3's bedside prior to his cardiac arrest at 6:58 a.m. This finding was confirmed by the hospital's Vice President of Nursing S6 on 2/09/2010 at 8:40 a.m. Patient #3 ' s heart rate at 2:15 a.m. on 11/19/09 was documented as 201. Patient #3's blood pressure was documented as 88/65 at at 5:35 a.m. S6 indicated a heart rate of 201 or a blood pressure of 88/65 should have triggered the nurse caring for Patient #3 to call the MET team for assessment, interventions as per Emergency protocols, and assistance in caring for Patient #3.