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The Condition of Participation for Patient Rights has not been met.

Based on medical record reviews, review of Hospital policies, review of Hospital documentation and interviews for five of fifteen patients whose medical conditions required the use of continuous oxygen, the Hospital failed to ensure patients, on multiple occasions, were provided care in a safe setting when continuous oxygen was not administered as ordered resulting in a decrease in the patients' oxygen saturation rates.


Please see A144

Based on medical record reviews, review of Hospital policies, review of Hospital documentation and interviews for five of fifteen patients whose medical conditions required the use of continuous oxygen, the Hospital failed to ensure patients, on multiple occasions, were provided care in a safe setting when continuous oxygen was not administered as ordered resulting in a decrease in the patients' oxygen saturation rates. The findings include:


a. P #1 was admitted to the Hospital on 10/2/19 with diagnoses that included COPD (chronic obstructive pulmonary disease) and emphysema.

Physician orders dated 10/2/19 directed oxygen via nasal cannula starting at 2 LPM (liters/minute) to maintain an oxygen saturation (SpO2) goal of 90% to 95%.

A transport summary dated 10/8/19 at 12:22 PM identified that P#1 was transported to advanced endoscopy for a bronchoscopy and was transported back to the unit (E9-5) by Transport Aide #1 at 2:45 PM.

Nursing flow records dated from 10/8/19 at 7:55 PM to 10/9/19 at 7:48 AM identified that P #1's SpO2 ranged from 91 to 93% on 3 LPM of oxygen via nasal cannula.

Hospital documentation dated 10/9/19 noted that on 10/9/19 at 8:30 AM, P #1 was found with the nasal oxygen cannula attached to an empty portable oxygen tank instead of the wall oxygen. Facility documentation further indicated that the last time P #1 utilized the portable oxygen tank was when P #1 returned to the unit from the bronchoscopy procedure the day prior (10/8/19 at 2:35 PM). The length of time P #1 was without nasal oxygen was unable to be accurately determined.

The Hospital failed to ensure that P #1 received continuous oxygen in accordance with physician order over an undetermined length of time. Review of SpO2 documentation between 10/8/19 and 10/9/19 identified that P #1 did not experience a decrease in SpO2.

Interview with RN #1 (Clinical Outcomes Leader) on 10/21/19 at 10:13 AM identified that RN's #2 and #3 cared for P #1 on 10/8/19 and 10/9/19 and although they saw the nasal oxygen tubing in place, they never followed the tubing from the patient to the oxygen source and did not realize that P #1 was not receiving oxygen via the nasal cannula. RN #1 further noted that RN #2 was responsible to reconnect the nasal cannula to the wall oxygen unit upon return to the unit.

Interview with Transport Aide (TA) #1 on 10/21/19 at 2:20 PM identified that he informed the unit's Business Associate of Patient #1's return on 10/8/19 and a nurse or PCA (patient care assistant) came into the room upon P #1's return. Transport Aide #1 further noted that his practice at the time of the incident was to leave the portable oxygen tank with the patient after transport in case it was needed again.


b. P #4 was admitted to the Hospital on 9/16/19 with diagnoses that included COPD and emphysema. P #4 was subsequently diagnosed with respiratory failure and pneumonia.

Physician orders dated 10/16/19 directed oxygen via nasal cannula starting at 2 LPM to maintain a SpO2 goal of 90% to 95%.

Nursing flow records dated 10/16/19 at 8:06 AM and 8:30 AM identified that Patient #4's SPO2 was 92% on 4 LPM of oxygen via nasal cannula.

Transport documentation indicated that P #4 was transported to Interventional Radiology on 10/16/19 at 4:34 PM and returned to the unit (E 9-5) at 6:52 PM, transported by Transport Aide #2.

Nursing flow records dated 10/16/19 at 9:55 PM identified that P #4's SpO2 was 91% and the flow records lacked documentation of oxygen administration.

Hospital documentation dated 10/17/19 identified that on 10/16/19 at 10:32 PM, P #4 was found connected to an empty portable oxygen tank instead of the wall oxygen and his/her SpO2 was 81% at that time. The patient was placed on oxygen at 4 LPM and recovered, although a specific SpO2 was not documented.

Interview with the Patient Safety Coordinator on 10/21/19 at 11:35 AM indicated that on 10/16/19 at 6:52 PM TA #2 informed the unit's Business Associate of P #4's return. A text message was sent to RN #5 and PCA #1, and PCA #2 went to provide care for P #4. The Patient Safety Coordinator further noted that the incident occurred at the change of shift and RN #5 never heard the text sent by the unit's Business Associate. On 10/16/19 at 10:32 PM RN #6 discovered that P #4 was connected to an empty portable oxygen tank.

The Hospital failed to ensure that P #4 received continuous oxygen which resulted in a below normal oxygen saturation level which was not in accordance with physician order over an undetermined length of time.


c. P #5 was admitted to the Hospital on 11/27/19 with diagnoses that included COPD and atrial fibrillation.

Physician orders dated 11/27/19 directed oxygen via nasal cannula starting at 2 LPM to maintain a SpO2 goal of 90% to 95%.

Review of P #5's clinical record identified that P #5 had a CT scan of the head on 12/4/19 which started at 11:34 AM and ended at 11:44 AM.

Nursing flow records dated 12/4/19 identified that the patient's SpO2's were 98% to 100% from 12:00 PM to 1:30 PM and 91% to 94% from 2:10 PM to 2:40 PM.

Review of a respiratory therapy (RT) note dated 12/4/19 at 3:00 PM identified that as RT #1 was walking by P#5's room he/she heard an alarm going off. RT #1 identified that he/she found Patient #5 with a SpO2 in the 70's with notable cyanosis (SpO2 values under 90 are considered low, according to Mayo Clinic). RT #1 identified that P #5 had nasal oxygen prongs in place but they were hooked up to an empty oxygen tank. RT #1 identified that he/she quickly placed the patient on wall oxygen and increased the liter flow to 6 LPM. RT#1 identified that when the patient's "sats were in the 90's" he/she went and informed the nurse (RN #6).

The Hospital failed to ensure that P #5 received continuous oxygen which resulted in a below normal oxygen saturation level which was not in accordance with physician order over an undetermined length of time.

Review of a hospital adverse event report dated 12/10/19 identified that on 12/4/19, P #5, who required continuous oxygen, was transported via bed and portable oxygen to Diagnostic Imaging. Post diagnostic imaging the portable oxygen tank was noted to be empty and the patient was noted to have desaturation of oxygenation which recovered when connected to the wall oxygen system.

Review of Hospital documentation (Provision of Care Event) dated 12/12/19 identified that the cause of the 12/4/19 incident where P #5 was connected to an empty oxygen tank was attributed to staff's failure to follow policy and procedure.

Interview with RN #6 on 12/18/19 at 10:30 AM identified that on 12/4/19 sometime before 12:00 PM he/she and TA #3 brought P #5 to Diagnostic Imaging. RN #6 stated that P #5 was connected to portable oxygen for the transport and when the procedure was over RN #6 and TA #3 brought the patient back to his/her room. RN #6 indicated that he/she reconnected P #5's monitors and settled the patient. RN #6 stated that it is his/her usual practice to connect patients to wall oxygen, however he/she must have inadvertently left the patient connected to the portable oxygen tank on returned to his/her room. RN #6 was unable to recall if TA #3 mentioned that he had to remove the portable oxygen tank from the patient's room.

RN #6 failed to ensure that P #5 was reconnected to wall oxygen on return to the unit to ensure P #5 received oxygen in accordance with physician order.

Interview with TA #3 on 12/13/19 at 11:30 AM identified that on 12/4/19 he/she and RN #6 brought P #5 back to his/her room after a transport from CT scan. TA #3 stated that he/she waited for the nurse to hook the patient up to the wall oxygen so that he/she could take the portable tank out of the room and return it to the storage area. TA #3 acknowledged he/she was educated on this new process back in October 2019 and he/she should have been sure to take the tank out the patient's room but while he/she was waiting for the nurse to finish, he/she got sidetracked and forgot to 'get the tank'.

Interview with the Transport Director on 12/13/19 at 11:50 AM identified the Facility's "Patient Transport Department Oxygen Policy" was revised in October 2019 and directed that when the nurse transfers the oxygen from the portable tank to the wall outlet, the transport staff removes the oxygen tank and holder from the bed and room and places the tank in the nearest designated oxygen tank storage. The Transport Director identified that initially, the process focused on one specific inpatient unit and was rolled out hospital wide via a practice alert on 12/4/19. The Transport Director identified that all transport staff had been educated in October 2019 and it was the expected practice for all transports. The Transport Director identified that TA#3 was aware of the process and should have followed the process on 12/4/19.


d. P# 6 was admitted to the Hospital on 12/8/19 with diagnoses that included hypoxemic respiratory failure and left sided hemothorax with chest tube placement (12/28/19).

Physician orders dated 12/21/19 directed oxygen via nasal cannula starting at 2 LPM to maintain an oxygen saturation goal of 90% to 95%. The order directed titrate flow rate at 1 liter/minute.

Nursing flow records dated 12/30/19 from 9:00 AM to 1:00 PM identified that that P #6's SpO2 was 92% on 4 LPM of oxygen via nasal cannula and was transitioned to 2 LPM at 1:00 PM. Review of the flow records from 1:00 PM to 4:00 PM identified that P #6's SpO2 were maintained at 97%-100 %.

Review of a Handoff report dated 12/30/19 identified that P #6 was transported to Diagnostic Imaging and a right heart catheterization was performed and the sheaths were removed at 6:48 PM.

Although P #6's clinical record failed to identify the time that P #6 returned to the medical floor, review of P #6's Nursing flow record dated 12/30/19 from 8:00 PM to 10:00 PM identified that P #6's SpO2 was 97%-98% on 2 LPM of oxygen via nasal cannula.

Review of a Hospital adverse event report dated 1/4/20 identified that on 12/30/19, a portable oxygen tank was used during P #6's transportation via bed to Diagnostic Imaging. Post diagnostic imaging P #6 was noted to have desaturation of oxygenation which recovered when connected to the wall oxygen system. The portable oxygen tank was noted to be empty.

Review of the clinical record failed to identify that P #6's desaturation episode including an assessment of SpO2 and oxygen requirements were documented in the clinical record.

The facility failed to ensure that P #6 received continuous oxygen to maintain normal oxygen saturation levels in accordance with physician order over an undetermined length of time.

Interview with RN #7 on 1/24/20 at 2:45 PM identified that on 12/30/19 she was assigned to care for P #6 from 7:00 AM to 7:00 PM. RN #7 stated that P #6 was scheduled for a procedure in Diagnostic Imaging and at approximately 4:45 PM she was informed that they were ready for the patient. RN #7 stated that she transferred the patient to a portable oxygen tank and oxygen monitor, and RN #7 and TA #5 took the patient to the "Cath lab" (Diagnostic Imaging). RN #7 was unable to specify the exact time but indicated that the "Cath lab" called near the end of her shift (about 7:00 PM) and informed her that the patient was ready to return to the floor. RN #7 identified that she and TA #5 transported P #6 back to his/her room and she reconnected P #6's monitor lines, adjusted his/her chest tube and settled the patient. RN #7 stated that she was aware that she should not have left the patient on the portable oxygen and indicated that it was her usual practice to transfer a patient's oxygen from the portable tank to the wall oxygen. However, as she was focusing on P #6's chest tubes, she must have forgot to switch the portable oxygen to wall oxygen. RN #7 stated that she reported off to RN #8, who took over P#6's care.

RN #7 failed to ensure that P #6 was reconnected to wall oxygen on return to the unit to ensure P #6 received oxygen to maintain normal oxygen saturation levels in accordance with physician order.

Interview with RN #8 on 1/24/20 at 7:50 AM identified that on 12/30/19 she was assigned to care for P#6 from 7:00 PM to 12/31/19 at 7:00 AM. RN #8 identified that on the evening of 12/30/19 when she arrived for her shift she observed P #6 being transported to his/her room and the "day nurse" went into the room and settled the patient. RN #8 stated that she went into P #6's room, saw that P #6 had been settled and she and RN #7 went into the hall way and she received report ( handoff). RN #8 stated that she monitored P #6 throughout the next few hours and the patient was stable, with SpO2's in the 90's and had normal sinus rhythm. RN #8 stated that she noted that P #6 was receiving oxygen via nasal cannula, however she did not notice that P #6 was still connected to the portable oxygen until later in the evening (about 11:30-11:45 PM) when P #6's oxygen monitor sounded and P #6's saturations were slowly dropping (to 84%). RN #8 stated that she checked P #6's chest tubes and as she was assessing, the charge nurse came to the room and noted that P #6 was connected to the portable oxygen tank that was empty. RN #8 stated that she immediately connected the patient to wall oxygen and the patient's saturations returned to the mid 90's.

RN #8 failed to ensure that P #6 was connected to wall oxygen to ensure P #6 received oxygen to maintain normal oxygen saturation levels to maintain normal oxygen saturation levels in accordance with physician order.


e. P #7 was admitted to the Emergency Department (ED) on 1/20/20 with complaints of abdominal pain, nausea and vomiting and a history of COPD.

Physician orders dated 1/27/19 directed oxygen via nasal cannula starting at 2 LPM to maintain a SpO2 goal of 90% to 95%. The order directed titrate flow rate at 1 LPM.

A Nursing flow record dated 1/21/20 at 11:29 AM identified that P #7's SpO2 was 97% on 3 LPM of oxygen.

Review of P #7's ED clinical record dated 1/21/20 at 3:16 PM identified that P #7 was transported to Interventional Radiology for a biopsy.

Review of an Interventional Radiology note dated 1/21/20 at 4:59 PM identified that P #7 underwent a liver biopsy with no complications.

An Interventional Radiology nurse's note dated 1/21/20 at 7:00 PM identified that P #7 was received in Interventional Radiology with oxygen at 3 LPM with stable vital signs.
Review of a Hospital adverse event report dated 1/22/20 identified that on 1/21/20, P #7 was transferred from the ED to Interventional Radiology with portable oxygen. The report identified that the Interventional Radiology RN (RN #9) identified that P #7's oxygen tank was empty upon initial assessment of the patient. P #7 was placed on wall oxygen and underwent the procedure as planned. The report did not specify an assessment of the patient. The adverse event report noted that based on the Hospital's investigation, it was found that there was a lack of standardized process to ensure portable oxygen tanks had an adequate supply of oxygen prior to transporting patients.

The Hospital failed to ensure that P #7 received continuous oxygen to maintain normal oxygen saturation levels in accordance with physician order over an undetermined length of time on 1/21/20.

Interview with RN #9 on 1/24/20 at 8:40 AM identified that on 1/21/20 P #7 was received in Interventional Radiology from the ED at about 3:15 PM. RN #9 identified that when she entered the procedure room she observed P#7 alone in the room on the stretcher with a nasal cannula. RN #9 stated that P #7 voiced no complaints but appeared winded. RN #9 stated that P #7's SpO2 was 86%, and when she checked the portable oxygen tank it was empty. RN #9 stated that she placed P #7 on wall oxygen and P #7's SpO2 increased to 90%-95 %. RN #9 stated that P #7's transport person should not have left the procedure room until Interventional Radiology staff was present.

Interview with RN #10 on 1/24/20 at 11:25 AM identified that on 1/21/20 he was assigned to care for P #7 while he/she was in the ED. RN #10 identified that earlier on 1/21/19, P #7 was transported to Endoscopy, returned to the ED at 12:06 PM, and RN #10 switched the oxygen from the portable tank to wall oxygen. RN #10 was unable to recall the specific oxygen flow rate or P #7's SpO2. RN #10 indicated that the information would be documented in P #7's record, however the record failed to identify documentation of P #7's oxygen flow rate or SpO2 from 12:00 PM to 5:00 PM. RN #10 identified that later in the afternoon P #7 was scheduled for an Interventional Radiology procedure and when transport arrived, RN #10 transferred P #7's oxygen to the portable tank that was still on the stretcher from the previous transport. RN #10 indicated that he looked at the tank and thought there was enough oxygen. RN 10 was unable to identify why P #7's tank was empty at the time he/she arrived at Interventional Radiology.

RN #10 failed to document P #7's oxygen liter flow or SpO2 and failed to ensure that the portable tank was full and sufficient to deliver the prescribed oxygen to maintain normal oxygen saturation levels.

Interview with TA #4 on 1/24/20 at 2:10 PM identified on 1/21/20 he transported P #7 from the ED to Interventional Radiology via stretcher with portable oxygen. TA #4 was unable to identify the amount of oxygen in the portable tank as he did not look at the oxygen tank gauge. TA #4 stated that when he arrived to Interventional Radiology with P # 7 he knocked on the control room door and announced that P #7 was there. TA #4 stated that he was directed to P #7's Room. TA #4 stated that he brought P #7 in, locked and lowered the stretcher and as he turned to leave he heard a staff person say hello to P #7. TA #4 acknowledged that he did not perform a physical handoff of P #7 and although he stated that he heard a staff person acknowledged P #7, he could not say that he saw the "nurse".

Interview with the Transport Manager on 1/24/20 at 2:20 PM identified that TA #4 was expected to check the portable oxygen tank gauge prior to transport and was expected to stay with P #7 until the nurse arrived (physical handoff).

The Hospital policy entitled "Patient Transport Department Oxygen Policy" (Undated) identified that when the nurse transfers the oxygen from the portable tank to the wall outlet, return and secure the oxygen tank to the storage cabinet if not needed for the next patient.

The Hospital did not have a nursing policy regarding patient transport. The facility RN Job Description identified responsibilities to include patient assessment and implementation of interventions.

The Condition of Participation for Nursing Services has not been met.

Based on medical record reviews, review of Hospital policies, review of Hospital documentation and interviews for five of fifteen patients (P) who utilized oxygen (P #1, P #4, P #5, P #6 and P#7), the Hospital failed to ensure on multiple occasions that continuous oxygen was administered in accordance with physician orders and to maintain safe oxygen saturation levels resulting in a decrease in the patients' oxygen saturation rates.


Please see A395 and A410

Based on medical record reviews, review of Hospital policies, review of Hospital documentation and interviews for five of fifteen patients (P) who utilized oxygen (P #1, P #4, P #5, P #6 and P#7), the Hospital failed to ensure on multiple occasions that continuous oxygen was administered in accordance with physician orders and to maintain safe oxygen saturation levels resulting in a decrease in the patients' oxygen saturation rates. The finding includes:


a. P #1 was admitted to the Hospital on 10/2/19 with diagnoses that included COPD (chronic obstructive pulmonary disease) and emphysema.

Physician orders dated 10/2/19 directed oxygen via nasal cannula starting at 2 LPM (liters/minute) to maintain an oxygen saturation (SpO2) goal of 90% to 95%.

A transport summary dated 10/8/19 at 12:22 PM identified that P#1 was transported to advanced endoscopy for a bronchoscopy and was transported back to the unit (E9-5) by Transport Aide #1 at 2:45 PM.

Nursing flow records dated from 10/8/19 at 7:55 PM to 10/9/19 at 7:48 AM identified that P #1's SpO2 ranged from 91 to 93% on 3 LPM of oxygen via nasal cannula.

Hospital documentation dated 10/9/19 noted that on 10/9/19 at 8:30 AM, P #1 was found with the nasal oxygen cannula attached to an empty portable oxygen tank instead of the wall oxygen. Documentation further indicated that the last time P #1 utilized the portable oxygen tank was when P #1 returned to the unit from the bronchoscopy procedure the day prior (10/8/19 at 2:35 PM). The length of time P #1 was without nasal oxygen was unable to be accurately determined.

The Hospital failed to ensure that P #1 received continuous oxygen in accordance with physician order over an undetermined length of time. Review of SpO2 documentation between 10/8/19 and 10/9/19 identified that P #1 did not experience a decrease in SpO2.

Interview with RN #1 (Clinical Outcomes Leader) on 10/21/19 at 10:13 AM identified that RN's #2 and #3 cared for P #1 on 10/8/19 and 10/9/19 and although they saw the nasal oxygen tubing in place, they never followed the tubing from the patient to the oxygen source and did not realize that P #1 was not receiving oxygen via the nasal cannula. RN #1 further noted that RN #2 was responsible to reconnect the nasal cannula to the wall oxygen unit upon return to the unit.

Interview with Transport Aide (TA) #1 on 10/21/19 at 2:20 PM identified that he informed the unit's Business Associate of Patient #1's return on 10/8/19 and a nurse or PCA (patient care assistant) came into the room upon P #1's return. Transport Aide #1 further noted that his practice at the time of the incident was to leave the portable oxygen tank with the patient after transport in case it was needed again.


b. P #4 was admitted to the Hospital on 9/16/19 with diagnoses that included COPD and emphysema. P #4 was subsequently diagnosed with respiratory failure and pneumonia.

Physician orders dated 10/16/19 directed oxygen via nasal cannula starting at 2 LPM to maintain a SpO2 goal of 90% to 95%.

Nursing flow records dated 10/16/19 at 8:06 AM and 8:30 AM identified that Patient #4's SPO2 was 92% on 4 LPM of oxygen via nasal cannula.

Transport documentation indicated that P #4 was transported to Interventional Radiology on 10/16/19 at 4:34 PM and returned to the unit (E 9-5) at 6:52 PM, transported by Transport Aide #2.

Nursing flow records dated 10/16/19 at 9:55 PM identified that P #4's SpO2 was 91% and the flow records lacked documentation of oxygen administration.

Hospital documentation dated 10/17/19 identified that on 10/16/19 at 10:32 PM, P #4 was found connected to an empty portable oxygen tank instead of the wall oxygen and his/her SpO2 was 81% at that time. The patient was placed on oxygen at 4 LPM and recovered, although a specific SpO2 was not documented.

Interview with the Patient Safety Coordinator on 10/21/19 at 11:35 AM indicated that on 10/16/19 at 6:52 PM TA #2 informed the unit's Business Associate of P #4's return. A text message was sent to RN #5 and PCA #1, and PCA #2 went to provide care for P #4. The Patient Safety Coordinator further noted that the incident occurred at the change of shift and RN #5 never heard the text sent by the unit's Business Associate. On 10/16/19 at 10:32 PM RN #6 discovered that P #4 was connected to an empty portable oxygen tank.

The Hospital failed to ensure that P #4 received oxygen which resulted in a below normal oxygen saturation level which was not in accordance with physician order over an undetermined length of time.


c. P #5 was admitted to the Hospital on 11/27/19 with diagnoses that included COPD and atrial fibrillation.

Physician orders dated 11/27/19 directed oxygen via nasal cannula starting at 2 LPM to maintain a SpO2 goal of 90% to 95%.

A Nursing flow record dated 12/4/19 at 8:00 AM identified that P #5's SpO2 was 97% on 2 LPM of oxygen via nasal cannula.

Review of P #5's clinical record identified that P #5 had a CT scan of the head on 12/4/19 which started at 11:34 AM and ended at 11:44 AM.

Nursing flow records dated 12/4/19 from 12:00 PM to 2:40 PM identified that the patient's SpO2's were 98% to 100 % from 12:00 PM to 1:30 PM and 91% to 94% from 2:10 PM to 2:40 PM.

Review of a respiratory therapy (RT) note dated 12/4/19 at 3:00 PM identified that as RT #1 was walking by P#5's room he/she heard an alarm going off. RT #1 identified that he/she found Patient #5 with an SpO2 in the 70's with notable cyanosis (SpO2 values under 90 are considered low, according to Mayo Clinic). RT #1 identified that P #5 had nasal oxygen prongs in place but they were hooked up to an empty oxygen tank. RT #1 identified that he/she quickly placed the patient on wall oxygen and increased the liter flow to 6 LPM. RT#1 identified that when the patient's "sats were in the 90's" he/she went and informed the nurse (RN # 6).

The Hospital failed to ensure that P #5 received oxygen which resulted in a below normal oxygen saturation level which was not in accordance with physician order over an undetermined length of time.

Review of Hospital documentation (Provision of Care Event) dated 12/12/19 identified that the cause of the 12/4/19 incident where P #5 was connected to an empty oxygen tank was attributed to staff's failure to follow policy and procedure.

Review of a hospital adverse event report dated 12/10/19 identified that on 12/4/19, P #5, who required continuous oxygen, was transported via bed and portable oxygen to Diagnostic Imaging. Post diagnostic imaging the portable oxygen tank was noted to be empty and the patient was noted to have desaturation of oxygenation which recovered when connected to the wall oxygen system.

Interview with RN # 6 on 12/18/19 at 10:30 AM identified that on 12/4/19 sometime before 12:00 PM he/she and TA #3 brought P #5 to Diagnostic Imaging. RN #6 stated that P #5 was connected to portable oxygen for the transport and when the procedure was over RN #6 and TA #3 brought the patient back to his/her room. RN #6 indicated that he/she reconnected P #5's monitors and settled the patient. RN #6 stated that it is his/her usual practice to connect patients to wall oxygen, however he/she must have inadvertently left the patient connected to the portable oxygen tank on returned to his/her room. RN #6 was unable to recall if TA #3 mentioned that he had to remove the portable oxygen tank from the patient's room.

RN #6 failed to ensure that P #5 was reconnected to wall oxygen on return to the unit to ensure P #5 received oxygen in accordance with physician order.

Interview with TA #3 on 12/13/19 at 11:30 AM identified that on 12/4/19 he/she and RN #6 brought P #5 back to his/her room after a transport from CT scan. TA #3 stated that he/she waited for the nurse to hook the patient up to the wall oxygen so that he/she could take the portable tank out of the room and return it to the storage area. TA #3 acknowledged he/she was educated on this new process back in October 2019 and he/she should have been sure to take the tank out the patient's room but while he/she was waiting for the nurse to finish, he/she got sidetracked and forgot to 'get the tank'.

Interview with the Transport Director on 12/13/19 at 11:50 AM identified the Facility's "Patient Transport Department Oxygen Policy" was revised in October 2019 and directed that when the nurse transfers the oxygen from the portable tank to the wall outlet, the transport staff removes the oxygen tank and holder from the bed and room and places the tank in the nearest designated oxygen tank storage. The Transport Director identified that initially, the process focused on one specific inpatient unit and was rolled out hospital wide via a practice alert on 12/4/19. The Transport Director identified that all transport staff had been educated in October 2019 and it was the expected practice for all transports. The Transport Director identified that TA#3 was aware of the process and should have followed the process on 12/4/19.


d. P# 6 was admitted to the Hospital on 12/8/19 with diagnoses that included hypoxemic respiratory failure and left sided hemothorax with chest tube placement (12/28/19).

Physician orders dated 12/21/19 directed oxygen via nasal cannula starting at 2 LPM to maintain an oxygen saturation goal of 90% to 95%. The order directed titrate flow rate at 1 liter/minute.

Nursing flow records dated 12/30/19 from 9:00 AM to 1:00 PM identified that that P #6's SpO2 was 92% on 4 LPM of oxygen via nasal cannula and was transitioned to 2 LPM at 1:00 PM. Review of the flow records from 1:00 PM to 4:00 PM identified that P #6's SpO2 were maintained at 97% -100 %.

Review of a Handoff report dated 12/30/19 identified that P #6 was transported to Diagnostic Imaging and a
right heart catheterization was performed and the sheaths were removed at 6:48 PM.

Although P #6's clinical record failed to identify the time that P #6 returned to the medical floor, review of P #6's Nursing flow record dated 12/30/19 from 8:00 PM to 10:00 PM identified that P #6's SpO2 was 97% - 98% on 2 LPM of oxygen via nasal cannula.

Review of a Hospital adverse event report dated 1/4/20 identified that on 12/30/19, a portable oxygen tank was used during P #6's transportation via bed to Diagnostic Imaging. Post diagnostic imaging P #6 was noted to have desaturation of oxygenation which recovered when connected to the wall oxygen system. The portable oxygen tank was noted to be empty.

Review of the clinical record failed to identify that P #6's desaturation episode including an assessment of SpO2 and oxygen requirements were documented in the clinical record.

The facility failed to ensure that P #6 received oxygen to maintain normal oxygen saturation levels in accordance with physician order over an undetermined length of time.

Interview with RN #7 on 1/24/20 at 2:45 PM identified that on 12/30/19 she was assigned to care for P #6 from 7:00 AM to 7:00 PM. RN #7 stated that P #6 was scheduled for a procedure in Diagnostic Imaging and at approximately 4:45 PM she was informed that they were ready for the patient. RN #7 stated that she transferred the patient to a portable oxygen tank and oxygen monitor, and RN #7 and TA #5 took the patient to the "Cath lab" (Diagnostic Imaging). RN #7 was unable to specify the exact time but indicated that the "Cath lab" called near the end of her shift (about 7:00 PM) and informed her that the patient was ready to return to the floor. RN # 7 identified that she and TA #5 transported P #6 back to his/her room and she reconnected P #6's monitor lines, adjusted his/her chest tube and settled the patient. RN #7 stated that she was aware that she should not have left the patient on the portable oxygen and indicated that it was her usual practice to transfer a patient's oxygen from the portable tank to the wall oxygen. However, as she was focusing on P #6's chest tubes, she must have forgot to switch the portable oxygen to wall oxygen. RN #7 stated that she reported off to RN #8, who took over P#6's care.

RN #7 failed to ensure that P #6 was reconnected to wall oxygen on return to the unit to ensure P #6 received oxygen to maintain normal oxygen saturation levels in accordance with physician order.

Interview with RN #8 on 1/24/20 at 7:50 AM identified that on 12/30/19 she was assigned to care for P#6 from 7:00 PM to 12/31/19 at 7:00 AM. RN #8 identified that on the evening of 12/30/19 when she arrived for her shift she observed P #6 being transported to his/her room and the "day nurse" went into the room and settled the patient. RN #8 stated that she went into P #6's room, saw that P #6 had been settled and she and RN #7 went into the hall way and she received report ( handoff). RN #8 stated that she monitored P #6 throughout the next few hours and the patient was stable, with SpO2's in the 90's and had normal sinus rhythm. RN #8 stated that she noted that P #6 was receiving oxygen via nasal cannula, however she did not notice that P #6 was still connected to the portable oxygen until later in the evening (about 11:30 - 11:45 PM) when P #6's oxygen monitor sounded and P #6's saturations were slowly dropping (to 84%). RN #8 stated that she checked P #6's chest tubes and as she was assessing, the charge nurse came to the room and noted that P #6 was connected to the portable oxygen tank that was empty. RN #8 stated that she immediately connected the patient to wall oxygen and the patient's saturations returned to the mid 90's.

RN #8 failed to ensure that P #6 was connected to wall oxygen to ensure P #6 received oxygen to maintain normal oxygen saturation levels to maintain normal oxygen saturation levels in accordance with physician order.


e. P #7 was admitted to the Emergency Department (ED) on 1/20/20 with complaints of abdominal pain, nausea and vomiting and a history of COPD.

Physician orders dated 1/27/19 directed oxygen via nasal cannula starting at 2 LPM to maintain a SpO2 goal of 90% to 95%. The order directed titrate flow rate at 1 LPM.

A Nursing flow record dated 1/21/20 at 11:29 AM identified that P #7's SpO2 was 97% on 3 LPM of oxygen.

Review of P #7's ED clinical record dated 1/21/20 at 3:16 PM identified that P #7 was transported to Interventional Radiology for a biopsy.

Review of an Interventional Radiology note dated 1/21/20 at 4:59 PM identified that P #7 underwent a transjugular liver biopsy with no complications.

An Interventional Radiology nurse's note dated 1/21/20 at 7:00 PM identified that P #7 was received in Interventional Radiology with oxygen at 3 LPM with stable vital signs.

Review of P #7's ED Nursing flow records dated 1/21/20 from 8:15 PM to 12:00 AM identified that P #7's SpO2 was 94 %-100 % with oxygen at 3 LPM via nasal cannula.

Review of a Hospital adverse event report dated 1/22/20 identified that on 1/21/20, P #7 was transferred from the ED to Interventional Radiology with portable oxygen. The report identified that the Interventional Radiology RN (RN #9) identified that P #7's oxygen tank was empty upon initial assessment of the patient. P #7 was placed on wall oxygen and underwent the procedure as planned.

The Hospital failed to ensure that P #7 received oxygen to maintain normal oxygen saturation levels in accordance with physician order over an undetermined length of time on 1/21/20.

Interview with RN #9 on 1/24/20 at 8:40 AM identified that on 1/21/20 P #7 was received in Interventional Radiology from the ED at about 3:15 PM. RN #9 identified that when she entered the procedure room she observed P#7 alone in the room on the stretcher with a nasal cannula. RN #9 stated that P #7 voiced no complaints but appeared winded. RN #9 stated that P #7's SpO2 was 86%, and when she checked the portable oxygen tank it was empty. RN #9 stated that she placed P #7 on wall oxygen and P #7's SpO2 increased to 90% - 95 %. RN #9 stated that P #7's transport person should not have left the procedure room until Interventional Radiology staff was present.

Interview with RN #10 on 1/24/20 at 11:25 AM identified that on 1/21/20 he was assigned to care for P #7 while he/she was in the ED. RN #10 identified that earlier on 1/21/19, P #7 was transported to Endoscopy, returned to the ED at 12:06 PM, and RN #10 switched the oxygen from the portable tank to wall oxygen. RN #10 was unable to recall the specific oxygen flow rate or P #7's SpO2. RN #10 indicated that the information would be documented in P #7's record, however the record failed to identify documentation of P #7's oxygen flow rate or SpO2 from 12:00 PM to 5:00 PM. RN #10 identified that later in the afternoon P #7 was scheduled for an Interventional Radiology procedure and when transport arrived, RN #10 transferred P #7's oxygen to the portable tank that was still on the stretcher from the previous transport. RN #10 indicated that he looked at the tank and thought there was enough oxygen. RN 10 was unable to identify why P #7's tank was empty at the time he/she arrived at Interventional Radiology.

RN #10 failed to document P #7's oxygen liter flow or SpO2 and failed to ensure that the portable tank was full and sufficient to deliver the prescribed oxygen to maintain normal oxygen saturation levels.

Interview with TA #4 on 1/24/20 at 2:10 PM identified on 1/21/20 he transported P #7 from the ED to Interventional Radiology via stretcher with portable oxygen. TA #4 was unable to identify the amount of oxygen in the portable tank as he did not look at the oxygen tank gauge. TA #4 stated that when he arrived to Interventional Radiology with P # 7 he knocked on the control room door and announced that P #7 was there. TA #4 stated that he was directed to P #7's Room. TA #4 stated that he brought P #7 in, locked and lowered the stretcher and as he turned to leave he heard a staff person say hello to P #7. TA #4 acknowledged that he did not perform a physical handoff of P #7 and although he stated that he heard a staff person acknowledged P #7, he could not say that he saw the "nurse".

Interview with the Transport Manager on 1/24/20 at 2:20 PM identified that TA #4 was expected to check the portable oxygen tank gauge prior to transport and was expected to stay with P #7 until the nurse arrived (physical handoff).

The Hospital policy entitled "Patient Transport Department Oxygen Policy" (Undated) identified that when the nurse transfers the oxygen from the portable tank to the wall outlet, return and secure the oxygen tank to the storage cabinet if not needed for the next patient.

The Hospital did not have a nursing policy regarding patient transport. The facility RN Job Description identified responsibilities to include patient assessment and implementation of interventions.

Based on clinical record review, interview and review of Hospital policy for one of three patients (P) who required a blood transfusion (P #13) the Hospital failed to ensure that the transfusion was administered as directed in the physician's order and failed to ensure that the patient's clinical record was complete and accurate to address the patient's transfusion. The finding included:


Patient #13's diagnoses included anemia.

A physician's order dated 1/21/20 directed to transfuse one unit of red blood cells (RBC), transfuse over two (2) hours.

Review of P #13's transfusion record dated 1/21/20 at 10:30 PM identified that the patient's vital signs were obtained and one unit of Red Blood Cells (RBC)/Lactate Ringers (LR) in 350 ml's was hung and set to infuse at a rate of 175 ml/hr. The record identified that at 11:45 PM the transfusion was stopped with 350 ml's infused. Review of P #13's electronic medical record (EMR) Blood Administration Flow Sheet identified that P #13's infusion was completed in one hour and fifteen minutes and the patient had no reaction.

P #13's record failed to identify that the transfusion was delivered within the ordered time frame of two hours.

Interview with RN #12 on 1/24/20 at 2:50 PM identified that on 1/21/20 she administered one unit of RBC's to Patient #13. RN #12 indicated that prior to administering the blood, she verified that P #13 and the blood matched, obtained vital signs and slowly infused the blood (per procedure) to ensure the patient had no reaction. The RBC's were then infused via gravity at a steady drip until the entire unit was infused. RN #12 stated that she could not recall if she documented the details in P #13's record however, P #13 needed the transfusion "somewhat" immediately and had also been started on "pressors". RN #12 indicated that she needed to infuse the RBC's as expediently as possible in order to get the patient's "pressors" started as soon as possible. RN #12 stated that the physician and the PA (physician assistant) were present during the transfusion and were aware that P #13's blood was infused with no reaction in less than 2 hours.

The physician was not available for interview.

Interview with PA #5 on 1/24/20 at 1:40 PM identified that he/she cared for P #13 on 1/21/20 and verified that P #13 had no adverse effects from the transfusion being infused less in than 2 hours.

Review of the Hospital's Administration of Blood policy (date unknown) directed that a provider order is required for the administration of blood/blood products and once initiated, a blood product transfusion is completed in the timeframe outlined per provider order.


b. Review of P #13's clinical record included a "paper" transfusion record dated 1/21/20 that identified that P#13's transfusion started at 10:40 PM and ended at 11:40 PM and the entire unit was given. However, the patient's Blood Administration Flow Sheet in the EMR identified that that P #13's transfusion started at 10:30 PM and was stopped at 11:45 PM. Additionally, although P #13's electronic flow record identified that P #13 had no transfusion reaction, the "paper" transfusion record inaccurately indicated the patient had a transfusion reaction when "yes" was checked.

P #13's record failed to identify accurate and consistent documentation of the patient's blood transfusion.

Interview with RN #12 on 1/24/20 at 2:50 PM identified that when she completed the paper transfusion record, she must have misinterpreted the section for transfusion reaction and erroneously checked yes. RN #12 identified that P #13 did not have a reaction from the transfusion. Additionally, RN #12 acknowledged that she should have documented the reason that the patient's blood was infused in less than the prescribed time.

Review of the Hospital's Administration of Blood policy (date unknown) directed that a provider order is required for the administration of blood/blood products and once initiated, a blood product is completed in the timeframe outlined per provider order. Additionally the policy directed to complete the Blood Administration Flow in the patient's EMR including, in part, reaction or no reaction.