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Based on observation, interview, and record review, the facility failed to monitor 1 (P-1) of 10 patients reviewed, resulting in a delayed response to patient decline. Findings include:

See tag A-0144 Failure to provide patient monitoring.

Based on observation, interview, and record review, the facility failed to monitor 1 (P-1) of 10 patients reviewed, resulting in a delayed response to patient decline. Findings include:

Review of "Chief Complaint for P-1," dated 02/18/25 revealed, "Patient presents with shortness of breath, and cough. (P-1) is a 95-year-old female presenting with upper respiratory symptoms, cough, fever, and increased oxygen requirements. Patient reports for the past 4 days, she has had upper respiratory symptoms, such as a hoarse voice, cough, and congestion. Today they noticed a fever of 100.6. They also noticed that her SpO2 (oxygenation) was low, to the 80s." Review of triage record dated 02/18/25 revealed that P-1 presented with the following vital signs: Blood pressure (BP) 142/72, Heart Rate (HR) 103, Respiratory rate (RR) 22, Oxygen saturation (O2) of 93% on 4 liters (L) via nasal cannula.

An interview with confidential informant 11 (CI-11) on 03/27/25 at 1022 revealed, (P-1) was triaged and placed into an exam room at 1609 on 02/18/25 and moved into hall bed "CCH-20" after approximately 10 minutes. CI-11 stated that the ED was full, and the staff were very busy. P-1 began to have more breathing distress, despite being placed on 4 liters of oxygen. CI-11 stated that they tried to get the attention of staff to re-examine P-1's condition. CI-11 spoke with an ED Technician and requested the physician to come. CI-11 stated they were told that P-1 had been admitted to an inpatient bed and that no ED doctor was "staffed" to her (P-1). CI-11 stated that they called a sibling and requested her to bring a portable pulse oxygenation detector (pulse ox) from home, so she could at least monitor P-1's oxygenation status. CI-11 stated that when P-1 was moved to the hall, there was no monitoring equipment available. CI-11 requested a "pulse-ox" and was told one was not available because the ED was so busy. After CI-11's sister arrived with her personal pulse-ox, CI-11 took a reading on P-1 and found her (P-1) to be oxygenating at 70%. CI-11 again requested a doctor and "Someone must have heard me; they moved P- into a room with three beds and then placed P-1 on a cardiac monitor, a BiPAP (non-invasive ventilator) and continuous pulse ox.

Review of "Patient Care Timeline," dated 02/18/25 at 2250 revealed P-1's vital signs recorded as BP 101/53, HR 81, RR 39 (2x normal), O2 95% on non-rebreather.

Review of "ED Notes," dated 02/18/25 at 2302 revealed, "Rapid response called due to patient desaturation to 85%. Patient moved to a room and rapid called. Rapid response came to bedside." The next note at 2316 revealed, "Patient's arterial blood gas requires bipap (bi-level positive airway pressure). Respiratory at bedside."

A tour of the Emergency Department was conducted on 03/26/25 at 0930 with ED manager (Staff H). Staff H was questioned how many patients can be boarded in the halls? Staff H stated that he had 19 hallcarts in Critical Care and 30 in Acute Care. Staff H stated that the department has 5 telemetry (heart monitoring) packs available for hallcart patients. Staff H was then requested to demonstrate the equipment available to monitor the patients placed in halls. After a quick tour of the ED and Acute care areas, 3 portable pulse oximeter machines, and 4 'Dynamaps' (blood pressure, pulse ox and heart rate) monitoring machines were observed and available for the 67 beds in Critical care, and 3 Dynamaps were available for Acute Care, with 24 beds and an additional 30 hall beds. Staff H was next questioned how often patients are 'boarded' (no inpatient bed available so the patient remains in the ED) overnight? Staff H replied, "Every day." Staff H was next questioned if the unit has enough equipment to monitor cardiac or respiratory patients when the boarding beds are full? Staff H replied, "There is not enough. If we had a lot of telemetry (patients requiring heart monitoring), we would have a shortage. We currently have to swap patients rooms or equipment to manage."

Based on observation and interview, the facility failed to ensure that nursing personnel adhered to the facility's policy and procedure regarding the placement of colored "fall risk" identification bands on 4 ( P-4, P-5, P-6, P-7) of 4 patients assessed for increased fall risk, resulting in the increased potential for patient falls for all patients screened for risk, and the facility failed to ensure that nursing personnel performed daily CHG (chlorhexidine gluconate) baths for 1 (P-2) of 10 patients reviewed for nursing care, resulting in the potential for negative outcomes for patients receiving nursing services. Findings include:

During bedside interview on 03/26/25 at 1110 with the daughter of (P-4), the daughter stated that P-4 had an "assisted fall" hours earlier that day. P-4 was noted to not be wearing a wrist band colored to indicate risk of falls.

An interview was conducted with P-4's nurse, (Staff N) on 03/26/25 at 1120. Staff N was questioned if her patients, wear wrist bands to communicate fall risks? Staff N replied, "Yes." Staff N was next asked to verify that P-4 was at risk for falls, and if they should have a fall-band in place? Staff N verified the fall risk status and absence of the fall band. She then placed a fall risk ID band on P-4.

During tour of the Oncology (4300) unit on 04/27/25 at approximately 1243, patient rooms for P-5,P-6, and P-7 were observed to have magnetic signs on the door frames. An interview was conducted with RN (Staff O) at 1245 on 04/27/25. Staff O was questioned about the magnetic signage and she stated that the magnets communicate fall risks to staff. Yellow socks and wrist bands are also used. Staff O was next asked to verify that current patients (P-5, P-6, and P-7) were wearing fall bands. Staff O assessed the three patients and stated that all three had been identified as a fall risk and required fall bands. None of the three patients were were identified by Staff O as wearing colored fall risk identification bands.

Review of "Protocol/Care Plan for the Management of The Patient at Risk for Falls, (no date, no rev.) revealed that all patients, (low, moderate or high risk) are to wear bands. The procedure states under "Low Risk (score 7-10) 1. Initiate universal fall precautions (UFPs). 2. Individualize Fall protocol. 3. Place FALL RISK patient ID band on Patient. "Moderate" and "High" risk patients have additional precautions in addition to the low risk measures. All levels of fall risk wear the same fall risk band.


Review of "Orders," demonstrated that P-2 was ordered to receive daily baths using chlorhexidine gluconate (CHG/antimicrobial) wipes on 02/24/25 at 2111.

Medical record review for P-2 did not have documentation of a daily CHG bath as ordered for 02/27/25, 02/28/25, 03/01/25, 03/02/25 and 03/03/25.