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Based on record review, staff interview, staff signed statement review, physician signed statement review, and policy and procedure review, the facility failed to protect and promote one (1) of seven (7) patients reviewed, the right to be free from neglect (Patient #1). The CONDITION OF PARTICIPATION - Patient Rights was not met.

Findings include:

Cross-refer to A-0145 for the facility's failure to ensure that Patient #1 was afforded the right to be free from neglect.


Cross Refer to A-0395 for the facility's failure to ensure that a Registered Nurse assessed and evaluated significant changes in Patient #1's blood pressure, failure to notify the physician of Patient #1's significant blood pressure changes, failure to reassess, evaluate and monitor Patient #1's blood pressure, and failure of the nursing staff to inform and communicate the significant blood pressure changes to unit nursing staff.

Based on medical record review, staff interview, staff's signed statement review, physician's signed statement review, and policy and procedure review, the facility failed to ensure that Patient #1, one (1) of seven (7) patients reviewed, was provided the right to be free from neglect. The facility failed to ensure assessment and evaluation by a Registered Nurse (RN) of significant changes in the patient's blood pressure, failed to notify the physician, and failed to ensure a RN reassessed, evaluated and monitored the patient's condition.

Findings include:

Review of Patient #1's 11/17/2010 Admission History and Physical revealed that the patient was a 56 year old who presented to the primary physician's office on 11/16/2010 with complaints of persistent nausea, vomiting and diarrhea for two (2) days. The patient was given two (2) liters of normal saline. The nausea and vomiting persisted even with the use of an anti-emetic.

Patient #1 was admitted to the facility on 11/17/2010 with the chief complaint of abdominal pain. The patient also complained of upper abdominal and back pain. The patient's medical history included diagnoses of Type II Diabetes Mellitus, Hypertension (high blood pressure), Hyperlipidemia, previous CVA (Cardiovascular Accident), and Depression. The admission diagnoses were Intractable Nausea and Vomiting. Review of the physician's 11/17/10 admission orders revealed that there was no medication ordered to treat the patient's blood pressure until 11/20/2010. At that time the medication "Clonidine 0.1 milligrams (mg) po (by mouth) twice a day, give one now and one later this p.m." was ordered by the physician. Another physician's order was written on 11/21/2010 to "Increase Clonidine to 0.2 mg po bid (twice a day)." There was no other documented evidence that the nurse informed the physician of the patient's significant changes in blood pressure readings.


Review of the patient's nurse's notes (NN) revealed: Patient #1's blood pressure spiked to 190/103 millimeters/mercury on 11/17/2010; 205/107 mm/Hg on 11/18/2010; 200/98 mm/Hg on 11/19/2010; 210/115 mm/Hg on 11/20/2010; 213/98 mm/Hg on 11/21/2010; 217/103 mm/Hg on 11/22/2010; and 202/103 mm/Hg on 11/23/2010. The patient's blood pressure on 11/24/2010 was 205/94 mm/Hg at 12:40 a.m. and 187/67 mm/Hg at 8:00 a.m. At 4:10 p.m. the patient's blood pressure was 69/46 mm/Hg with a pulse of 126 beats/minute. There was no documented evidence that the blood pressure readings from 11/17/10 thru 11/23/10 were rechecked/reassessed. There was no documented evidence that the physician had been notified of these significant high and low blood pressure readings, that the charge nurse was notified, or that the patient's condition was assessed, evaluated and monitored by a Registered Nurse (RN).

Review of Patient #1's November 2010 Medication Administration Record (MAR) revealed that RN #2 gave the patient Morphine two (2) milligrams (mg) intravenously (IV) on 11/24/10 at 4:35 p.m. for complaints of pain.

NN signed by RN #1 on 11/24/2010 revealed, "5:05 p.m. Found unresponsive. No resp (respirations) or pulse noted. Code 9 called." and at 5:25 p.m. "Transferred to ICU (intensive care unit)."

RN #1 provided the following signed statement on 12/21/2010 at 11:20 a.m. "The evening of 11/24/10 @ (at) 1610 (4:10 p.m.) patient was assessed by myself. She was aware & (and) alert. Requests pain medication. Family was present. I informed her I would check her chart first. I proceeded with checking my next two patients, one which took longer than expected. About 1655 to 1700 (4:55 p.m. to 5:00 p.m.) I made it back to the nurse's station to check charts. Her chart was checked first to compare previous blood pressures. After noting a difference, I informed our charge nurse (RN #2) who informed me that she just gave the patient Morphine. I leave the station to re-check patient BP (blood pressure) and patient was found unresponsive in bed. Mouth cyanotic and not breathing. Emergency bell pulled. I went to get crash cart from nurse's station. (RN #2) said she was going to start compressions. A back board was retrieved from a different floor. Somebody started bagging her. After pulse and rhythm established, she was transferred to ICU."

RN #2 provided the following signed statement on 12/21/2010 (no time). "Patient called out about 1620 (4:20 p.m.) on call bell requesting IV (intravenous) pain medication. Patient had a history of having high blood pressure on this admit & (had) been told during report that afternoon that her blood pressure was running high that day. I had seen the patient on several occasions after receiving Morphine and knew about her diagnosis & had made rounds with (doctor) to see her. Patient was awake, alert, & oriented when I went in the room at 1630 (4:30 p.m.). Patient was sitting up, eating. I gave the Morphine 2 mg IV push over 4 (four) minutes. Her daughter came in & I visited with her for a few minutes. The patient & her daughter were joking around about her daughter's work. The patient commented that her daughter would like my watch. I left the room at 1635 (4:35 p.m.). Her nurse (RN #1) came in at 1705 (5:05 p.m.) & the patient was not breathing. A code was called. I went immediately in the room & started CPR (Cardiopulmonary Resuscitation). After the code, after the patient was in the unit, I informed (doctor) that I had given her Morphine 2 mg IV 35 minutes before she coded. I had given the Morphine for her nurse because she was out making rounds on her other patients & I didn't want the patient to have to wait."

The attending physician provided the following signed statement on 12/21/2010 at 3: 50 p.m.: "I admitted (Patient #1) on 11/17/10. She had experienced several days of N/V (nausea/vomiting). Pt had RUQ (right upper quadrant) pain @ time of admission which lead me to believe she had something other than viral gastroenteritis, which had been prominent in the community. Pt had CT of her abdomen on 11/18/10 revealing complex mass @ apex of R (right) kidney concerns for renal or adrenal CA (cancer). Gen (general) Surgery was consulted and MRI performed suggested adrenal source of mass was most likely. There was a concern that this may represent a pheochromocytoma (rare tumor). 24 hr. urine for VMA/Metanephrine was ordered on 11/20/10 and these results were pending. Pt suffered a cardioresp (cardiorespiratory) arrest on 11/24/10. Apparently suffered significant anoxic brain damage. Pt did not wish to live on medical support and family decided to withdraw life support as (Patient #1) had expressed in the past."

A physician consult dated 11/24/2010 stated: "(Patient #1) is a 56 year old female who came in one week ago with apparent nausea, vomiting, and abdominal discomfort. Reportedly, she's had flank pain problems requiring significant IV (intravenous) narcotics. She reportedly has an adrenal mass that's being considered for surgical intervention. She apparently was reasonably stable until this morning other than persistent hypertension with systolic BP near 200 mmHg...She reportedly had ventricular fibrillation (abnormal heart rhythm) and was cardio-converted by the code team with CPR being applied."

A physician consult dated 11/25/2010 stated, "She has been stable since yesterday but yesterday even (evening) she coded with rapid ventricular fibrillation and she was cardio-converted by the code team. Last night was reported that she might have had one or two seizures and she dropped her blood pressure a good bit requiring Synephrine and Dopamine. Her BP is up now and she's requiring Labetalol prn to control blood pressure but is staying 180 systolic and 80's diastolic...Neurologically she is on Diprivan and sedated but when off of that, she is withdrawing extremities on painful stimuli some. Pupils are equally reactive to light. Doll's head eye movements are positive. No facial asymmetry seen. Reflexes are depressed and cerebella function and gait cannot be evaluated. Impression: 1. Status post cardiopulmonary arrest with likely mild hypoxic Encephalopathy and Brain injury. 2. Seizures, likely secondary to #1. 3. History of narcotic use and some adrenal dysfunction."

Review of Patient #1's Death Certificate revealed the date and time of death was December 4, 2010 at 11:10 a.m. The cause of death was: (a) Aortic Encephalopathy (b) Cardiopulmonary arrest (c) Ventricular Tachycardia. (d) Aspiration.

Adverse effects of Morphine include: Circulatory Depression, Flushing, Shock, Bradycardia (slow heart rate), Hypotension (low blood pressure) and Atrial Fibrillation (abnormal heart rhythm).

Review of the facility's Hospital-wide Assessment Policy #10077.1 page one (1) revealed: "A patient will be assessed by the various disciplines in the hospital according to the following assessment protocol. Each patient's physical, psychological and social status are assessed. Additional assessment data will be collected depending on the patient's immediate and emerging needs and the setting in which care will be provided."

Review of the facility's Medical Record Documentation Policy #10335.2 page one (1) revealed: "Assessments are made and documented by a registered nurse on admission, at the beginning of each eight (8) hour shift and PRN (as needed) as the condition of the patient changes."

Review of the facility's Incident Reporting Policy and Procedure Number: #10004.3, revision date 9/2003, page two (2) number 4.1.3 revealed, "All incidents involving patient injury should immediately be reported to the risk management department. If the incident has extreme circumstances, the risk manager should be notified by telephone in addition to the usual reporting mechanism. In the absence of the risk manager, the administrator on call should be notified."

Based on medical record review, staff interview, signed staff statement review, signed physician statement review, documentation review, and policy and procedure review, the facility failed to ensure that their performance improvement and quality assurance activities included tracking the adverse events of neglect and subsequent deterioration and death of Patient #1, one (1) of seven (7) patients reviewed. The CONDITION OF PARTICIPATION - Quality Assessment and Performance Improvement Program was not met.

Findings include:

Cross Refer to A-0286 for the facility's failure to ensure that their Performance Improvement and Quality Assurance activities included tracking the adverse events of neglect and subsequent deterioration and death of Patient #1.

Based on staff interview, signed staff statement review, signed physician statement review, record review and policy and procedure review, the facility failed to ensure that their Performance Improvement activities included tracking adverse events of neglect and subsequent deterioration and death of Patient #1, one (1) of seven (7) patients reviewed.

Findings include:

Review of Patient #1's 11/17/2010 Admission History and Physical revealed that the patient was a 56 year old who was admitted to the facility on 11/17/2010 with the chief complaint of Abdominal Pain. The patient also complained of N/V (nausea/vomiting), and back pain. The admission diagnoses were Intractable Nausea and Vomiting. The patient's medical history included the following diagnoses: Type II Diabetes Mellitus, Hypertension (high blood pressure), Hyperlipidemia, previous CVA (Cardiovascular Accident), and Depression. The patient's home medications were ordered, but review of the physician's 11/17/2010 admission orders revealed that there was no medication ordered to treat the patient's blood pressure until 11/20/2010. At that time the medication Clonidine 0.1 milligrams (mg) twice a day was ordered. Another physician's order was written on 11/21/10 to "Increase Clonidine to 0.2 mg po (by mouth) bid (twice a day)."

Review of nurse's notes (NN) revealed that Patient #1's blood pressure spiked to 190/103 millimeters/mercury (Hg) on 11/17/2010; 205/107 mm/Hg on 11/18/2010; 200/98 mm/Hg on 11/19/2010; 210/115 mm/Hg on 11/20/2010; 213/98 mm/Hg on 11/21/2010; 217/103 mm/Hg on 11/22/2010; and 202/103 mm/Hg on 11/23/2010. The patient's blood pressure on 11/24/2010 was documented as 205/94 mm/Hg at 12:40 a.m. and 187/67 mm/Hg at 8:00 a.m. At 4:10 p.m. Patient #1's blood pressure was documented as 69/46 mm/Hg with a pulse of 126 beats/minute. There was no documented evidence that: the abnormal blood pressure readings from 11/17/10 thru 11/23/10 were rechecked or reassessed by a Registered Nurse (RN). There was no documented evidence that the physician had been notified of these significant high and low blood pressure readings, that the charge nurse was notified, or that the patient's condition was assessed, evaluated and monitored by a RN.

Review of Patient #1's November 2010 Medication Administration Record (MAR) revealed that RN #2 gave Patient #1 Morphine two (2) milligrams (mg) intravenously (IV) on 11/24/10 at 4:35 p.m. for complaints of pain.

Adverse effects of Morphine include: Circulatory Depression, Flushing, Shock, Bradycardia (slow heart rate), Hypotension (low blood pressure) and Atrial Fibrillation (abnormal heart rhythm).

Review of 11/24/10 NN revealed that RN #1 found Patient #1 with no vital signs and unresponsive at 5:06 p.m. RN #1 called a code at that time. Patient #1 was transferred to Intensive Care Unit (ICU) on 11/24/10 at 5:25 p.m.

RN #1 provided the following signed statement on 12/21/2010 at 11:20 a.m. "The evening of 11/24/10 @ (at) 1610 (4:10 p.m.) patient was assessed by myself. She was aware & alert. Requests pain medication. Family was present. I informed her I would check her chart first. I proceeded with checking my next two patients, one which took longer than expected. About 1655 to 1700 (4:55 p.m. to 5:00 p.m.) I made it back to the nurse's station to check charts. Her chart was checked first to compare previous blood pressures. After noting a difference, I informed our charge nurse (RN #2) who informed me that she just gave the patient Morphine. I leave the station to re-check patient BP (blood pressure) and patient was found unresponsive in bed. Mouth cyanotic and not breathing. Emergency bell pulled. I went to get crash cart from nurse's station. (RN #2) said she was going to start compressions. A back board was retrieved from a different floor. Somebody started bagging her. After pulse and rhythm established, she was transferred to ICU."

RN #2 provided the following signed statement on 12/21/2010 (no time). "Patient called out about 1620 (4:20 p.m.) on call bell requesting IV (intravenous) pain medication. Patient had a history of having high blood pressure on this admit & had been told during report that afternoon that her blood pressure was running high that day. I had seen the patient on several occasions after receiving Morphine and knew about her diagnosis & had made rounds with (doctor) to see her. Patient was awake, alert, & oriented when I went in the room at 1630 (4:30 p.m.). Patient was sitting up, eating. I gave the Morphine 2 mg IV push over 4 (four) minutes. Her daughter came in & I visited with her for a couple minutes. The patient & her daughter were joking around about her daughter's work. The patient commented that her daughter would like my watch. I left the room at 1635 (4:35 p.m.). Her nurse (RN #1) came in at 1705 (5:05 p.m.) & the patient was not breathing. A code was called. I went immediately in the room & started CPR (Cardiopulmonary Resuscitation). After the code, after the patient was in the unit, I informed (doctor) that I had given her Morphine 2 mg IV 35 minutes before she coded. I had given the Morphine for her nurse because she was out making rounds on her other patients & I didn't want the patient to have to wait."

The attending physician provided the following signed statement on 12/21/2010 at 3: 50 p.m.: "I admitted (Patient #1) on 11/17/10. She had experienced several days of N/V (nausea/vomiting). Pt had RUQ (right upper quadrant) pain @ time of admission which lead me to believe she had something other than viral gastroenteritis, which had been prominent in the community. Pt had CT of her abdomen on 11/18/10 revealing complex mass @ apex of R (right) kidney concerns for renal or adrenal CA (cancer). Gen (general) Surgery was consulted and MRI performed suggested adrenal source of mass was most likely. There was a concern that this may represent a pheochromocytoma (rare tumor). 24 hr. urine for VMA/Metanephrine was ordered on 11/20/10 and these results were pending. Pt suffered a cardioresp (cardiorespiratory) arrest on 11/24/10. Apparently suffered significant anoxic brain damage. Pt did not wish to live on medical support and family decided to withdraw life support as (Patient #1) had expressed in the past."

A physician consult dated 11/24/2010 stated: "(Patient #1) is a 56 year old female who came in one week ago with apparent nausea, vomiting, and abdominal discomfort. Reportedly, she's had flank pain problems requiring significant IV (intravenous) narcotics. She reportedly has an adrenal mass that's being considered for surgical intervention. She apparently was reasonably stable until this morning other than persistent hypertension with systolic BP near 200 mmHg...She reportedly had ventricular fibrillation (abnormal heart rhythm) and was cardio-converted by the code team with CPR being applied."

A physician consult dated 11/25/2010 stated, "She has been stable since yesterday but yesterday even (evening) she coded with rapid ventricular fibrillation and she was cardio-converted by the code team. Last night was reported that she might have had one or two seizures and she dropped her blood pressure a good bit requiring Synephrine and Dopamine. Her BP is up now and she's requiring Labetalol prn to control blood pressure but is staying 180 systolic and 80's diastolic...Neurologically she is on Diprivan and sedated but when off of that, she is withdrawing extremities on painful stimuli some. Pupils are equally reactive to light. Doll's head eye movements are positive. No facial asymmetry seen. Reflexes are depressed and cerebella function and gait cannot be evaluated. Impression: 1. Status post cardiopulmonary arrest with likely mild hypoxic Encephalopathy and Brain injury. 2. Seizures, likely secondary to #1. 3. History of narcotic use and some adrenal dysfunction."

Review of Patient #1's Death Certificate revealed the date and time of death was December 4, 2010 at 11:10 a.m. The cause of death was documented as: (a) Aortic Encephalopathy (b) Cardiopulmonary arrest (c) Ventricular Tachycardia. (d) Aspiration.

Review of the facility's Hospital-wide Assessment Policy #10077.1 page one (1) revealed: "A patient will be assessed by the various disciplines in the hospital according to the following assessment protocol. Each patient's physical, psychological and social status are assessed...Additional assessment data will be collected depending on the patient's immediate and emerging needs and the setting in which care will be provided."

Review of the facility's Medical Record Documentation Policy #10335.2 page one (1) revealed: "Assessments are made and documented by a registered nurse on admission, at the beginning of each eight (8) hour shift and PRN (as needed) as the condition of the patient changes."

Review of the facility's Incident Reporting Policy and Procedure Number
#10004.3, revision date 9/2003, page two (2) number 4.1.3 revealed, "All incidents involving patient injury should immediately be reported to the risk management department. If the incident has extreme circumstances, the risk manager should be notified by telephone in addition to the usual reporting mechanism. In the absence of the risk manager, the administrator on call should be notified."

During an interview on 12/22/10 from 8:30 a.m. to 8:45 a.m. the Chief Quality Officer revealed that no action regarding the incident had been addressed by Quality Assurance and Performance Improvement. She stated that she has not yet obtained staff statements or counseled the two (2) RNs involved in the incident. She also stated that the nurses failed to complete an incident report regarding the incident and that the case would be reviewed by Quality Assurance and Performance Improvement (QAPI) in January of 2011.

Based on record review, documentation review, staff interview, physician statement review, staff statement review, and policy and procedure review, the facility failed to ensure that that the 24 hour nursing services provided was adequately monitored by a Registered Nurse (RN) and that communication among nursing staff and medical staff occurred when a significant change in condition occurred for one (1) of seven (7) patients reviewed (Patient #1). The CONDITION of PARTICIPATION - Nursing Services was not met.

Findings include

Cross refer to A-0145 for the facility's failure to ensure that Patient #1 was provided the right to be free from neglect.

Cross refer to A-0395 for the facility's failure to ensure that a RN assessed, evaluated and monitored Patient #1's significant high and significant drop in blood pressure, that communication occurred among unit nursing staff related to the patient's condition, and that the physician was notified of the patient's significant change in condition.

Based on medical record review, staff interview, policy review, review of staff signed statements and review of physician's signed statement, the facility failed to ensure that Registered Nurses (RNs) assessed, evaluated and monitored significant changes in the patient's blood pressure; failed to reassess the patient's abnormal blood pressures; to inform and communicate among unit nursing staff of the significant blood pressure changes, and failure to notify the physician of the significant change in condition for one (1) of seven (7) patients reviewed (Patient #1).

Findings include:

Review of Patient #1's 11/17/2010 Admission History and Physical revealed that the patient was a 56 year old who was admitted to the facility on 11/17/2010 with the chief complaint of Abdominal Pain. The patient also complained of back pain. The patient's medical history included: Type II Diabetes Mellitus, Hypertension (high blood pressure), Hyperlipidemia, previous CVA (Cardiovascular Accident), and Depression. The admission diagnosis was Intractable Nausea and Vomiting. The patient's home medications were ordered but review of the physician's 11/17/10 admission orders revealed that there was no medication ordered to treat the patient's blood pressure until 11/20/2010. At that time the medication Clonidine 0.1 milligrams (mg) twice a day was ordered. Another physician's order was written on 11/21/10 to "Increase Clonidine to 0.2 mg po (by mouth) bid (twice a day)."


Review of nurse's notes (NN) revealed that Patient #1's blood pressure spiked to 190/103 on 11/17/2010; 205/107 on 11/18/2010; 200/98 on 11/19/2010; 210/115 on 11/20/2010; 213/98 on 11/21/2010; 217/103 on 11/22/2010; and 202/103 on 11/23/2010. The patient's blood pressure on 11/24/2010 was 205/94 at 12:40 a.m. and 187/67 at 8:00 a.m. At 4:10 p.m. the patient's blood pressure was documented as 69/46 and she had a pulse of 126. There was no documented evidence that the blood pressure readings from 11/17/10 thru 11/23/10 were rechecked, that the physician had been notified of these significant high and low blood pressure readings, that the charge nurse was notified, or that the patient's condition was assessed, evaluated and monitored by a RN.

Review of Patient #1's November 2010 Medication Administration Record (MAR) revealed that RN #2 gave the patient Morphine two (2) milligrams (mg) intravenously (IV) on 11/24/10 at 4:35 p.m. for complaints of pain.

Review of Patient #1's 11/24/10 NN revealed that RN #1 found the patient with no vital signs at 5:06 p.m. RN #1 called a code at that time. Patient #1 was transferred to the Intensive Care Unit (ICU) on 11/24/10 at 5:25 p.m.

RN #1 provided the following signed statement on 12/21/2010 at 11:20 a.m. "The evening of 11/24/10 @ (at) 1610 (4:10 p.m.) patient (Patient #1) was assessed by myself. She was aware & alert. Requests pain medication. Family was present. I informed her I would check her chart first. I proceeded with checking my next two patients, one which took longer than expected. About 1655 to 1700 (4:55 p.m. to 5:00 p.m.) I made it back to the nurse's station to check charts. Her chart was checked first to compare previous blood pressures. After noting a difference, I informed our charge nurse (RN #2) who informed me that she just gave the patient Morphine. I leave the station to re-check patient BP (blood pressure) and patient was found unresponsive in bed. Mouth cyanotic and not breathing. Emergency bell pulled. I went to get crash cart from nurse's station. (RN #2) said she was going to start compressions. A back board was retrieved from a different floor. Somebody started bagging her. After pulse and rhythm established, she was transferred to ICU."

RN #2 provided the following signed statement on 12/21/2010 (no time). "Patient called out about 1620 (4:20 p.m.) on call bell requesting IV (intravenous) pain medication. Patient had a history of having high blood pressure on this admit & had been told during report that afternoon that her blood pressure was running high that day. I had seen the patient on several occasions after receiving Morphine and knew about her diagnosis & had made rounds with (doctor) to see her. Patient was awake, alert, & oriented when I went in the room at 1630 (4:30 p.m.). Patient was sitting up, eating. I gave the Morphine 2 mg IV push over 4 (four) minutes. Her daughter came in & I visited with her for a couple minutes. The patient & her daughter were joking around about her daughter's work. The patient commented that her daughter would like my watch. I left the room at 1635 (4:35 p.m.). Her nurse (RN #1) came in at 1705 (5:05 p.m.) & (and) the patient was not breathing. A code was called. I went immediately in the room & started CPR (Cardiopulmonary Resuscitation). After the code, after the patient was in the unit, I informed (doctor) that I had given her Morphine 2 mg IV 35 minutes before she coded. I had given the Morphine for her nurse because she was out making rounds on her other patients & I didn't want the patient to have to wait."

The attending physician provided the following signed statement on 12/21/2010 at 3: 50 p.m. "I admitted (Patient #1) on 11/17/10. She had experienced several days of N/V (nausea/vomiting). Pt had RUQ (right upper quadrant) pain @ time of admission which lead me to believe she had something other than viral gastroenteritis, which had been prominent in the community. Pt had CT of her abdomen on 11/18/10 revealing complex mass @ apex of R (right) kidney concerns for renal or adrenal CA (cancer). Gen (general) Surgery was consulted and MRI performed suggested adrenal source of mass was most likely. There was a concern that this may represent a pheochromocytoma (rare tumor). 24 hr. urine for VMA/Metanephrine was ordered on 11/20/10 and these results were pending. Pt suffered a cardioresp (cardiorespiratory) arrest on 11/24/10. Apparently suffered significant anoxic brain damage. Pt did not wish to live on medical support and family decided to withdraw life support as (Patient #1) had expressed in the past."

A physician consult dated 11/24/2010 stated: "(Patient #1) is a 56 year old female who came in one week ago with apparent nausea, vomiting, and abdominal discomfort. Reportedly, she's had flank pain problems requiring significant IV (intravenous) narcotics. She reportedly has an adrenal mass that's being considered for surgical intervention. She apparently was reasonably stable until this morning other than persistent hypertension with systolic BP near 200 mmHg...She reportedly had ventricular fibrillation (abnormal heart rhythm) and was cardio-converted by the code team with CPR being applied."

A physician consult dated 11/25/2010 stated, "She has been stable since yesterday but yesterday even (evening) she coded with rapid ventricular fibrillation and she was cardioverted by the code team. Last night was reported that she might have had one or two seizures and she dropped her blood pressure a good bit requiring Synephrine and Dopamine. Her BP is up now and she's requiring Labetalol prn (as needed) to control blood pressure but is staying 180 systolic and 80's diastolic...Neurologically she is on Diprivan and sedated but when off of that, she is withdrawing extremities on painful stimuli some. Pupils are equally reactive to light. Doll's head eye movements are positive. No facial asymmetry seen. Reflexes are depressed and cerebella function and gait cannot be evaluated. Impression: 1. Status post cardiopulmonary arrest with likely mild hypoxic Encephalopathy and Brain injury. 2. Seizures, likely secondary to #1. 3. History of narcotic use and some adrenal dysfunction."

Review of Patient #1's Death Certificate revealed the date and time of death was December 4, 2010 at 11:10 a.m. The cause of death was documented as: (a) Aortic Encephalopathy (b) Cardiopulmonary arrest (c) Ventricular Tachycardia. (d) Aspiration.

Adverse effects of Morphine include: Circulatory Depression, Flushing, Shock, Bradycardia (slow heart rate), Hypotension (low blood pressure) and Atrial Fibrillation (abnormal heart rhythm).

Review of the facility's Hospital-wide Assessment Policy #10077.1 page one (1) revealed: "A patient will be assessed by the various disciplines in the hospital according to the following assessment protocol. Each patient's physical, psychological and social status are assessed. Additional assessment data will be collected depending on the patient's immediate and emerging needs and the setting in which care will be provided."

Review of the facility's Medical Record Documentation Policy #10335.2 page one (1) revealed: "Assessments are made and documented by a registered nurse on admission, at the beginning of each eight (8) hour shift and PRN (as needed) as the condition of the patient changes."

Review of the facility's Incident Reporting Policy and Procedure Number: #10004.3, revision date 9/2003, page two (2) number 4.1.3 revealed, "All incidents involving patient injury should immediately be reported to the risk management department. If the incident has extreme circumstances, the risk manager should be notified by telephone in addition to the usual reporting mechanism. In the absence of the risk manager, the administrator on call should be notified."

During an interview on 12/22/10 from 8:30 a.m. to 8:45 a.m. the Chief Quality Officer revealed that no action regarding the incident had been addressed by Quality Assurance and Performance Improvement. She stated that she had not yet obtained staff statements or counseled the two (2) RNs involved in the incident. She also stated that the nurses failed to complete an incident report regarding the incident and that the case would be reviewed by Quality Assurance and Performance Improvement (QAPI) in January of 2011.