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Based on staff interview, review of medical records, and review of an autopsy report, it was determined the hospital failed to ensure all nursing requirements were met. There lacked evidence nursing staff provided the necessary assessment, monitoring, and nursing measures to ensure adequate respiratory management for 1 of 3 sample patients (#6) with respiratory distress. This lack of appropriate nursing care likely resulted in the patient's death. In addition, the hospital failed to ensure staff provided adequate assessment, monitoring and nursing measures to prevent or relieve pain for 3 (#5, #7, #9) of 6 sample patients who experienced pain. The combined results of these systems failures resulted in the inability of the hospital to ensure nursing assessments, monitoring and nursing measures were adequately and appropriately provided for all patients (A395).

Based on staff interview, medical record review, and review of an autopsy report, the facility lacked evidence nursing staff provided the necessary assessments, monitoring, and nursing measures to ensure adequate respiratory management for 1 (#6) of 3 sample patients who experienced respiratory distress. This lack of adequate monitoring likely contributed to the patient's death. In addition, the facility failed to ensure adequate pain management for 3 (#5, #7, #8) of 6 sample residents who had pain. The findings were:

1. Review of the medical record for 17 year old patient #6 showed s/he was admitted with pneumonia and hypoxia on 2/8/09 at 10:25 AM. Review of the 2/8/09 admission history showed the patient was transferred from another hospital because the transferring physician believed s/he required a higher level of care and possibly a ventilator due to the severity of his/her illness. The following concerns were identified:
a. Review of the 2/8/09 nursing notes timed at 11:14 PM showed the patient's family member told nursing staff the patient was short of breath. Nursing then called respiratory therapy and a therapist arrived sixteen minutes later. The respiratory therapist's assessment showed the patient had coarse lung fields with no wheezes. The respiratory therapist further stated there were no treatments ordered that would relieve the patient's shortness of breath. The nurse told the patient's family to keep the patient in an upright position and left the room. Interview with the DON on 8/27/10 at 8:30 AM revealed the respiratory therapist later stated what she meant was the patient had no current orders for treatment to relieve the patient's shortness of breath; not that there were no treatments available. She further confirmed she did not think to call the physician to request an order for the appropriate treatment.
b. Review of the 2/9/09 nursing note timed at 1:18 AM showed the patient had taken the oxygen mask off and was experiencing increased shortness of breath. Review revealed the patient's oxygen saturation rate at that time was 68% (normal is equal to or greater than 90%). Interview with the director of nurses on 8/27/10 at 8:30 AM revealed the patient was very restless and anxious because of the shortness of breath and s/he would take off the oxygen mask due to feeling suffocated. Review of the medical record showed the physician was not contacted by staff to report the patient's declining condition or to request additional orders to treat his/her deterioration.
c. Review of the 2/9/09 nursing notes timed at 3:45 AM showed the patient's telemetry unit was not on the patient and the nurse asked a CNA to apply it. At 3:55 AM, the nurse entered the patient's room to hang an IV (intravenous therapy) and noted the telemetry unit was still off. At 4 AM the nurse again asked the CNA to place the telemetry unit back on the patient. Review of the 5:15 AM nursing note showed the CNA was again asked to hook up the telemetry unit because the technician was unable to monitor the patient and she needed to print strips. The telemetry unit was off the patient at least from 3:45 AM until 5:15 AM (one and one-half hours) so the patient was not monitored during that time.
d. Review of the 2/9/09 nursing notes timed at 4:09 showed the patient's pulse had increased to 123 beats per minute (60 to 80 beats per minute is normal), his/her respirations were increased to 36 (normal is 12 to 20 per minute) and his/her oxygen saturation was 89%. Review of the medical record showed the physician was not notified of the continued decline in the patient's condition.
e. Review of the 2/9/09 nursing notes timed at 5:55 AM showed the CNA reported to the nurse that the patient had vomited and his/her oxygen was off again. The nurse checked the patient and s/he was not breathing. A code blue (cardiopulmonary pulmonary resuscitation) was called, but the patient expired at 6:46 AM on 2/9/09. According to the physician's progress notes, he was not notified of the patient's decline in condition until 6:30 AM.
f. Review of the patient's 3/19/09 autopsy report showed the patient died as a result of complications of pneumonia including ARDS (acute respiratory distress syndrome).
g. Interview with the administrator, DON and the quality assurance staff on 8/27/10 at 8:30 AM revealed they believed the nursing care of this patient was poor and probably contributed to his/her death. They expressed their concern regarding the incident and stated a safety management company was consulted after the patient's death. The administrator said the consultant recommendations were implemented to prevent future events such as this one.

2. Review of the admission history and physical for patient #5 showed s/he was admitted with diagnoses including tongue cancer. Review of the 8/24/10 pain assessment that was performed at 2:01 AM showed the patient was experiencing pain in his/her tongue rated 7 on a scale of 0 to 10, with 10 being the worst (7/10). In addition, the patient was anxious. Further review showed the patient was administered 2 milligrams (mg) of Morphine Sulfate (MS) for the pain. At 2:45 AM the patient continued to have pain and the physician was called. However, according to the record, the patient did not receive any additional medication or pain relief interventions until 7:31 AM (5 hours 30 minutes later) when s/he again received 2 mg of MS. Interview with RN #1 on 8/26/10 at 4:30 PM revealed she was unable to locate any documentation showing a follow-up pain re-assessment was done prior to that time. She further stated the expectation was for a re-assessment to be done within one hour after administration of a PRN (as needed) medication.

3. Review of the 8/17/10 admission history and physical for patient #8 showed s/he was admitted with diagnoses including rheumatoid arthritis and a recent fall. Review of the 8/23/10 consultation showed the patient had a dislocated hip fracture which was in need of surgical repair. Review of the 8/20/10 pain assessment performed at 2:29 PM showed the patient had hip pain rated 5/10, and the patient was clutching at him/herself and grimacing. Further review showed the patient received two Lortabs (pain medication) at that time. Continued review showed the patient received an additional two Lortabs at 3:18 AM, but there was no evidence an assessment was performed again until 7:11 AM on 8/21/10 (16 hours and 12 minutes). Interview with RN #2 on 8/27/10 at 12 noon revealed she was unable to locate any earlier pain assessment.

4. Review of the 8/15/10 admission history and physical for patient #7 showed s/he presented to the emergency room in acute respiratory distress and had a known history of chronic obstructive pulmonary disease (COPD) and atrial fibrillation. Review of the 8/16/10 pain assessment performed at 9:16 PM showed the patient expressed s/he had pain in the back that was at an unacceptable level. The patient was medicated with Tylenol for the pain. Continued review showed the patient's pain level was not re-assessed to determine the effectiveness of the pain medication until 4:35 AM the next morning (7 hours 19 minutes later). Interview with RN #2 on 8/27/10 at 12 noon revealed there was no other information concerning the patient's pain.