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Based on review of facility policy and medical records (MR) and staff (EMP) interview, it was determined the facility failed to follow their approved policy regarding discussion of the patient's wishes regarding resuscitation prior to surgery in two of four applicable MRs reviewed (MR5 and MR7) and failed to request a copy of an advance directive in one of four applicable MRs reviewed (MR6).

Findings include:

Review on June 1, 2022, of facility policy "Advanced Directives," last reviewed May 19, 2022, revealed "...Policy...Prior to any interventional procedures, including those requiring anesthesia or moderate sedation, any existing directives to limit the use of resuscitation procedures (do not resuscitate orders and/or advance directives) should be reviewed with the patient or designated surrogate as part of the informed consent process. As a result of this review, the status of these directives should be clarified or modified based on the preferences of the patient and documented in the medical record ...Process Depending Upon Care Setting: ...B. What Information Should Geisinger Providers Obtain and Record Regarding Advanced Directives? 1. During each admission, Geisinger providers should be requesting copies of existing living wills, durable powers of attorney, POLST, or other decision-making preference documents within the patient ' s possession. Copies of these documents should be placed within the patient's medical record. ...Responsibility: Nursing Staff ...2. ...If the patient has a Living Will or Durable Power of Attorney or POLST and does not have the document with him/her, the nursing staff will remind the family to bring the patient's advance directive to the hospital. Attempts to have family provide the documents will be made on admission, day three, and day five of the hospital stay, and documented in the medical record..."

Review of MR5 on June 1, 2022, revealed MR5 had a surgical procedure on May 31, 2022, and was admitted following the procedure. Nursing documentation prior to the procedure revealed staff did not discuss his/her advance directive with MR5. There was no provider documentation in MR5 of a discussion of his/her wishes regarding an advance directive or resuscitation.

Interview with EMP19 on June 1, 2022, at 1000 confirmed there was no documentation by nursing staff or the provider of a discussion of MR5's wishes regarding an advance directive or resuscitation prior to the surgical procedure.

Review of MR7 on June 1, 2022, revealed MR7 had a surgical procedure on May 31, 2022, and was admitted following the procedure. Nursing documentation prior to the procedure revealed staff did not discuss his/her advance directive with MR7. There was no provider documentation in MR7 of a discussion of his/her wishes regarding an advance directive or resuscitation.

Interview with EMP19 on June 1, 2022, at 1015 confirmed there was no documentation by nursing staff or the provider of a discussion of MR7's wishes regarding an advance directive or resuscitation prior to the surgical procedure.

Review of MR6 on June 1, 2022, revealed documentation on the day of admission, May 28, 2022, confirmed MR6 had an advance directive but it was not available. There was no documentation of a follow up request to family for a copy of MR6's advance directive on day three of his/her hospital stay.

Interview with EMP19 on June 1, 2022, at 1009 confirmed there was no documentation in MR6 a follow up request to family for a copy of MR6's advance directive.

Based on review of medical records (MR) and staff (EMP) interview, it was determined the facility failed to ensure a patient was given the opportunity to have a family member or representative notified of his/her admission in one of four applicable MRs reviewed (MR5) and failed to ensure a family member or representative was notified of a patient ' s admission when requested in two of four applicable MRs reviewed (MR6 and MR7).

Findings include:

Request on June 1, 2022, for a policy regarding notification of a family member or representative of his or her choice and his or her own physician notified upon admission to the hospital revealed the facility did not have a policy.

Interview with EMP8 on June 1, 2022, at 1430 confirmed the facility did not have a policy to address notification of a patient's family member or representative or physician upon a patient's admission to the hospital.

Review on June 1, 2022, revealed there was no documentation MR5 was given the opportunity to have a family member or representative of his or her choice notified of his/her admission.

Interview with EMP19 on June 1, 2022, at 1000 confirmed there was no documentation MR5 was given the opportunity to have a family member or representative of his or her choice notified of his/her admission.

Review on June 1, 2022, revealed MR6 requested notification of his/her admission to his/her emergency contact. There was no documentation in MR6 of notification of his/her emergency contact and no documentation MR6's emergency contact was present during the admission process.

Interview with EMP19 on June 1, 2022, at 1009 confirmed there was no documentation in MR6 of notification of his/her emergency contact.

Review on June 1, 2022, revealed MR7 requested notification of his/her admission to his/her emergency contact. There was no documentation in MR7 of notification of his/her emergency contact and no documentation MR7's emergency contact was present during the admission process.

Interview with EMP19 on June 1, 2022, at 1015 confirmed there was no documentation in MR7 of notification of his/her emergency contact.

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The facility failed to ensure physician orders for oxygen were followed in two of two applicable medical records (MR) reviewed (MR1 and MR2) which resulted in an adverse outcome (cardiac/respiratory arrest) and potentially led to patient's demise in one of two medical records reviewed (MR1); and failed to adequately supervise the nursing care in one of twelve records reviewed as demonstrated by the failure to ensure oxygen needs of the patient were met during hand off to ancillary departments which resulted in an adverse outcome (cardiac/respiratory arrest) and potentially led to patient's demise in one of two applicable medical records reviewed (MR1).

A discussion took place with the survey team and the facility's administrative staff (EMP5, EMP7, EMP8, EMP9, EMP10 and EMP28) regarding the survey team's concerns related to Nursing on June 2, 2022 at 1014.

Cross reference
482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient.
482.23(c) Standard: Preparation and Administration of Drugs.

Based on review of facility policy and documentation, medical record (MR) reviews and staff (EMP) interview, it was determined the facility failed to adequately supervise the nursing care as demonstrated by the failure to ensure oxygen needs of the patient were met during hand off to ancillary departments which resulted in an adverse outcome (cardiac/respiratory arrest) and potentially led to patient ' s demise in one of twelve medical records reviewed (MR1).

Findings include:
Review of facility policy, "Hand Off Communication," last reviewed September 16, 2021 revealed "The policy of Hand Off Communication to ensure a standardized approach to "hand off" communication when permanent or temporary responsibility is assumed for the patient. Definitions Hand off Communication- refers to a contemporaneous process of passing patient information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient's care... Hand Off Communication Process: 1. Hand offs should be verbal or face to face whenever possible. ... 5. Hand offs should occur minimally at the following times: a. Change of shift or responsibility b. Change of care of the hospital, including when patients are sent for procedures or treatments. ... 7. The "Patient Passport" is to be used whenever a patient is transported for a procedure or treatment. ..."
Review of facility policy, "Patient Passports," last reviewed April 26, 2022, revealed "Purpose The purpose of the Patient Passports Policy is to provide ... a continuous loop of Patient Information from the Nursing Unit to the Patients [sic] destination and finally back to the Patients original Nursing Unit ... Procedure 1. ... to ensure optimum patient safety, all patients who are transported must have a Patient Passport ..."

Review of a "Patient Passport" hand off communication form on May 31, 2022 at 1030, confirmed this form contains oxygen and flow rate instructions.

Review of MR1 on May 31, 2022 at 1100, June 1, 2022 at 1040 and 1315, and June 2, 2022 at 0910 revealed the physician orders on May 20, 2022 at 0315 included the patient was on a titrating oxygen administration of 0- 6 LPM [liters per minute] via nasal cannula to maintain pulse oximetry [SPO2] between 91- 96% with an initial flow rate of 2 LPM and orders to titrate up/down by 1 LPM. The last documented time the patient had oxygen on was May 21, 2022 at 0745 and was receiving oxygen 4 L/min via nasal cannula with pulse oximetry at 91%. The patient was scheduled for a Magnetic Resonance Imaging test on May 21, 2022.

Interview with EMP21 on June 1, 2022 at 1125 confirmed they had switched the patient from CPAP (continuous positive airway pressure) mask to nasal cannula oxygen on May 21, 2022 when the vital signs were taken at 0745. EMP21 revealed when radiology was ready for the patient, they were caring for another patient, and asked EMP23 to get the patient ready for transport. EMP21 related having explained to EMP23 the patient needed oxygen.

It is unknown the exact circumstances of when/how the oxygen became removed.

Interview with EMP22 on June 1, 2022 at 1135 related that they were working as a team with EMP21 that day, and had not yet seen the patient prior to his/her leaving the nursing unit early for MRI testing. EMP22 stated patients that are ot primary assigned patients, but rather patients he/she is supervising, are seen at least once or twice a shift.

Interview with EMP23 on June 1, 2022 at 1145 related the nursing unit received a call from Magnetic Resonance Imaging that they were ready for the patient. They were asked by EMP21 to get the patient ready and then obtained an MRI (Magnetic Resonance Imaging)-safe gown. EMP23 related that EMP21 had already related information to the unit desk clerk so that transport was aware that the patient needed oxygen. EMP23 gave EMP24 the gown and asked them to get the patient ready.

Interview with EMP11 on June 1, 2022 at 1150 clarified the unit desk clerk is responsible for entering the transport request and information for oxygen (clicking on the oxygen box on the Patient Passport form) to communicate this to transport. Transport then obtains the printed Patient Passport form from the unit desk clerk. Further interview with EMP11 stated they know the oxygen section was completed on this form. Nursing assistants and transport staff may physically obtain oxygen tanks but switching the patient over to oxygen is the nurse's responsibility.

Interview with EMP24 on June 1, 2022 at 1418 revealed they were asked to change the patient into an MRI-safe gown. EMP24 did not recall the patient having oxygen on. They do recall transport arriving to pick up the patient as he/she was leaving the room.

Interview with EMP26 on June 2, 2022 at 0950 confirmed the patient was not on oxygen when arrived to the Magnetic Resonance Imaging unit.

Based on review of facility policy, medical record (MR) review and staff (EMP) interview, it was determined the facility failed to ensure physician orders for oxygen were followed in two of two applicable medical records reviewed (MR1 and MR2) which resulted in an adverse outcome (cardiac/respiratory arrest) and potentially led to patient's demise in one of two applicable medical records reviewed (MR1).
Findings include:
Review of facility policy "Oxygen Administration," last reviewed by the facility on March 11, 2022 revealed "Policy... II. Oxygen will be administered via (simple devices) Nasal Cannula, Intermittent Nasal Cannula, Simple Mask, Venturi Mask, Non-Rebreathing Mask, Transtracheal Catheter, or Trach Adapter ... III. Oxygen administration requires a provider order."
Review of MR1 on May 31, 2022 at 1100, June 1, 2022 at 1040 and 1315, and June 2, 2022 at 0910 revealed the physician orders on May 20, 2022 at 0315 included the patient was on a titrating oxygen administration of 0- 6 LPM [liters per minute] via nasal cannula to maintain pulse oximetry [SPO2] between 91- 96% with an initial flow rate of 2 LPM and orders to titrate up/down by 1 LPM. The last documented time the patient of MR1 had oxygen on was on May 21, 2022 at 0745 and was receiving oxygen 4 L/min via nasal cannula with pulse oximetry at 91%. The patient was scheduled for a Magnetic Resonance Imaging test on May 21, 2022. The testing started at 0912. At 1007, the patient was in cardiac/respiratory arrest and coded. At 1022, the patient had a return of spontaneous circulation and the code was stopped. The patient later expired at 1515.

Interview with EMP12 on June 1, 2022 at 1034, confirmed the patient was off the nursing unit on May 21, 2022 at 0851.

Interview with EMP21 on June 1, 2022 at 1123 revealed they had switched the patient over from the CPAP (continuous positive airway pressure) mask to oxygen via nasal cannula at 4 LPM at time vital signs were taken on May 21, 2022 at 0745. EMP21 related they didn ' t feel the patient was unstable at that time and would not have been assigned this patient if he/she had been unstable.

It is unclear when/how the patient of MR1's oxygen was removed.

Interview with EMP23 on June 1, 2022 at 1145 related the nursing unit received a call from Magnetic Resonance Imaging that they were ready for the patient. EMP 21 asked EMP23 to get the patient ready. EMP23 obtained an MRI (Magnetic Resonance Imaging)-safe gown. EMP23 revealed that EMP21 had already related information to the unit desk clerk so that transport was aware that the patient needed oxygen. EMP23 gave EMP24 the gown and asked them to get the patient ready.

Interview with EMP24 on June 1, 2022 at 1418 related they were asked to change the patient into an MRI-safe gown. They didn't recall the patient having oxygen tubing on and were not aware the patient had oxygen. Transport came to pick the patient up as they were leaving the room.

Interview with EMP26 on June 2, 2022 at 0950 confirmed the patient was not on oxygen upon arrival to the Magnetic Resonance Imaging unit.

Review on June 1, 2022, of facility documentation regarding MR2 revealed the facility had been called on March 22, 2022, by the skilled nursing facility (SNF) receiving MR2 following an inpatient admission. The SNF representative stated s/he was called by the ambulance transport team because the patient was to be on continuous oxygen and was discharged from the facility without supplemental oxygen and the patient's daughter was upset.

Review on June 1, 2022, of MR2 revealed the patient was discharged from the facility to a SNF via ambulance on March 22, 2022. The provider discharge summary documented the patient was on chronic oxygen supplementation. Discharge orders included continuous oxygen administration of one to six liters/minute via nasal cannula to maintain an oxygen saturation of 91-95%. Further review of MR2 revealed discharge nursing documentation indicated the patient did not require supplemental oxygen and there was no documentation the patient was discharged on oxygen.

Interview with EMP28 on June 1, 2022, at approximately 1115, confirmed an investigation regarding the complaint filed on behalf of MR2 revealed there was a miscommunication between the patient's primary care nurse and the nurse discharging the patient. EMP28 advised a conversation with the discharging nurse confirmed the patient was discharged without supplemental oxygen.

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The facility failed to follow its established policy for 30-minute assessments which resulted in an adverse outcome (respiratory/cardiac arrest) and potentially led to patient's demise on May 21, 2022. (MR1)

A discussion took place with the survey team and the facility's administrative staff (EMP5, EMP7, EMP8, EMP9, EMP10 and EMP28) regarding the survey team's concerns related to Radiology on June 2, 2022 at 1014.

Cross reference
482.26(b) Standard: Safety for Patients and Personnel

Based on review of medical records (MR), facility policy and documentation, and staff (EMP) interview, it was determined the facility failed to assess patient condition at 30 minutes as per the policy and the patient had an adverse outcome (cardiac/respiratory arrest) which potentially led to patient's demise in one of one applicable medical record reviewed. (MR1).

Findings include:

Review of facility policy, "Magnetic Resonance Safe Practices," last reviewed on March 15, 2022, revealed "Patient Safety Rules ... 5. For those exams or series of exams that require a scanning time > 45 minutes, Level 2 MR [Magnetic Resonance] Personnel shall stop scanning at 30 minutes to question the patient for any feeling of warmth or unusual feeling and if required, inspect the patient for any change in their condition."

Review of MR1 on May 31, 2022 at 1100, June 1, 2022 at 1040 and 1315, and June 2, 2022 at 0910 revealed the physician orders on May 20, 2022 at 0315 noted the patient was on a titrating oxygen administration of 0- 6 LPM [liters per minute] via nasal cannula to maintain pulse oximetry [SPO2] between 91- 96% with an initial flow rate of 2 LPM and orders to titrate up/down by 1 LPM. The last documented time the patient had oxygen on was on May 21, 2022 at 0745 and was receiving oxygen 4 L/min via nasal cannula with pulse oximetry at 91%. The patient was scheduled for a Magnetic Resonance Imaging test on May 21, 2022. It is unknown the exact circumstances of when/how the oxygen became removed.

Review of the imaging portion of MR1 on June 1, 2022 at 1315 indicated the patient had a series of tests for Magnetic Resonance Imaging for the cervical and thoracic spine areas with and without contrast. Testing started at 0912 and continued through non-contrast studies of the cervical and thoracic spine. There was no documented check at 30 minutes into the test. At 0951, the patient was given contrast and continued with contrast studies of the thoracic and cervical spine. Further review noted, the start of the code was on May 21, 2022 at 1007. At 1022, the patient had a return of spontaneous circulation and the code was stopped. The patient later expired in the cardiac intensive care unit on May 21, 2022, at 1515.

Interview with EMP16 and EMP14 on June 1, 2022 at 1315 confirmed there was no documented 30-minute assessment in MR1 as per policy.

Interview with EMP26 on June 2, 2022 at 0950 confirmed the patient was not on oxygen upon arrival to the Magnetic Resonance Imaging unit. EMP26 and EMP27 were working as a team. EMP26 clarified role was there for support. The patient had not appeared in distress at time received to the unit, and the patient did not ring the call bell while in the Magnetic Resonance Imaging machine. Staff usually check with the patient every couple of sequences and have never been told to document these checks. The patient was unresponsive when removed from the Magnetic Resonance Imaging machine. A code was call with immediate initiation of resuscitative efforts.

EMP27 was unavailable for interview on May 31, 20222, June 1, 2022 and June 2, 2022.

Based on review of facility documents and staff (EMP) interviews, it was determined the facility failed to ensure the infection control program was integrated into its hospital wide Quality Assurance and Performance Improvement (QAPI) program.

Findings include:

Review on May 31, 2022, of the facility's Infection Control Committee meeting minutes for January 26, 2022, March 30, 2022, and May 25, 2022, revealed no documentation the infection control information was reported to the QAPI Committee meetings.

Interview with EMP3 and EMP4, on May 31, 2022, at 1330, confirmed there was no documentation the facility ' s Infection Control Committee meeting minutes for January 26, 2022, March 30, 2022, and May 25, 2022, were reported to the QAPI Committee meetings. EMP3 and EMP4 confirmed the infection control information was to be reported to the Patient Safety Committee and the QAPI Committee meetings.

Interview with EMP5, on May 31, 2022, at 1425, confirmed the infection control information is reviewed at the Infection Control Committee meetings, reported to the Patient /Safety Committee meetings, reported to the Clinical Leadership Council meetings, and is then to be reported at the QAPI Committee meetings.

Review on May 31, 2022, of the Quality Improvement Committee meeting minutes of August 19, 2021, September 16, 2021, October 21, 2021, November 18, 2021, January 20, 2022, February 17, 2022, March 17, 2022, April 21, 2022, and May 19, 2022, revealed no documentation the Infection Control Committee or Infection Control information was reviewed.

Interview with EMP4, on May 31, 2022, at 1400, confirmed there was no documentation the infection control information was reviewed by the Quality Improvement Committee.