HospitalInspections.org

Based on interview, record review, and policy review, the provider failed to ensure identification, tracking, analysis of root causes, and implementation of preventive interventions for one of one sampled patient's (1) adverse medical event. Findings include:

1. Review of patient 1's electronic medical record (EMR) revealed:
*There was an incident on 5/24/16 at 3:43 p.m. that involved the following documentation:
-"Trach out and difficulties with reinsertion. Same accomplished via RT [respiratory therapy] as first in the room."
*There was no further documentation in the EMR.
*There were no vital signs documented (blood pressure, pulse, and respirations).
*There was no documentation of oxygen saturation during the adverse event.

Interview on 7/18/16 at 5:10 p.m. with registered nurse (RN) E regarding patient 1 revealed:
*She agreed the documentation for the adverse event on 5/24/16 was not fully documented.
*The patient had gone to an appointment outside the hospital for a cranial scan.
*The trach had dislodged, and he had turned blue. The ambulance had to be called and he was taken to the emergency room (ER) for reinsertion of his trach tube.
*The RT would document any treatments or trach changes during the day, and then the nurses would document in the RT documentation area when they completed treatments or trach changes on the patients.
*"The charting is not perfect."
*In an event the patient's trach would dislodge the nurses should have completed an assessment, vital signs, oxygen saturation levels, and then documented in the patient's medical record.
*It was not uncommon for patient's trachs to become dislodged.
*Patient 1 was "very fragile" and would not be able to tolerate having his trach out for any period of time.

Interview on 7/18/16 at 5:45 p.m. with certified nursing assistant (CNA) A regarding an incident with patient 1 revealed:
*She had been employed at the facility for six years, but had just started working in the hospital unit since August of last year.
*She had concerns about particular nurses not answering ventilator alarms when they were sounding for patient 1.
*The alarms on the ventilators were loud.
*The alarm was sounding in patient 1's room, and there was no one visible on the floor.
*She approached an RN who had been patient 1's nurse in regards to the sounding alarms. The RN's comment to her, "It is going to be at least a half hour I have medications to give."
*When she was scheduled on the floor and had to transport patients there was no one that covered her shift while she was absent from the floor. The CNAs were instructed to ask the RNs for assistance when the CNA was gone on a transport outside the hospital with a patient. The RNs were reluctant to assist the CNAs as needed, because they were busy with their own duties.

Interview on 7/19/16 at 9:04 a.m. with RN care coordinator F regarding dislodged patient's trachs and staffing concerns revealed:
*Her biggest role was discharge planning and patient referrals.
*She worked Monday through Friday eight hour shifts.
*She did all the scheduling for the nursing staff.
*She had never been directly involved in an incident where a patient's trach had dislodged, and the patient had become cyanotic.
*She had never been scared when a patient's trach had become dislodged.
*She stated there had been no issues with nursing staff not attending patient's dislodged trachs.
*There had been no issues brought to her attention about patient 1's trach care or any issues with his trach.
*The patient's trachs were going to come out, because the patients were young and quite active.
*She would have expected the nurses to have taken care of the patient first when a trach had dislodged and came out.
*There should have been detailed documentation of the event. The vital signs, oxygen saturation, nursing assessment, and patient's condition should have been documented for any abnormal and unexpected event.
*The nurses should have followed nursing practice standards. There were no policy and procedures to ensure consistent documentation by the nursing staff.
*The nursing staff documented by exception, but there was no policy that directed nursing staff on what needed to have been documented.
*She agreed there should have been more documentation on patient 1's event on May 24, 2016.

Interview on 7/19/16 at 10:30 a.m. with RT D regarding the dislodging of patient 1's trach on May 24, 2016 revealed:
*She heard the alarms sounding in his room. She was down the hall from his room walking toward the classroom, and turned around to investigate the alarm sounding.
*RN E was sitting at the desk when she entered patient 1's room.
*The patient's trach had become dislodged and he was bluish in color.
*She then pounded on the glass window to get the attention of RN E who was still sitting at the nurses's station.
*Care coordinator F also entered the patient's room.
*She thought the patient's oxygen saturation had dropped to the 80s (normal was 90 to 100%) but was not sure.
*The ventilator alarms were very loud.
*Staff would have been expected to check any alarms that were sounding in the patient's rooms.
*She thought she had documented the re-insertion of his trach but was not sure.
*She would have expected the RN to thoroughly document the event in the patient's EMR.

Interview on 7/19/16 at 12:30 p.m. with the director of nursing regarding all the above concerns revealed:
*She had reviewed the nursing documentation.
*She had no criteria to follow for monitoring nursing staff for appropriate documentation on the EMR.
*There was no system in place to ensure consistent tracking of accurate and complete documentation.
*She would have expected the staff who had grievances, complaints, or concerns regarding staffing issues when scheduled staff needed to go out of the building on a patient appointment to come to her with those issues. She would have asked the staff to problem solve.
*She stated no grievance, complaints, or concerns had been brought to her attention.
*When direct care staff were out on an appointment with patients outside of the hospital depending on the particular situation, whomever would leave on that transport needed to communicate that to the staff. The staff on the floor would have decided what steps/or assistance would have been needed when that staff person was absent from the floor.
*Staff needs were based on census not the acuity of the patients.
*Her expectation would have been the staff needed to communicate their needs to the care coordinator.
*There was no formal monitoring of the staff.
*There was no policy or procedure for staffing guidelines to ensure patients had the appropriate staff to care for their needs.
*There was no monitoring of direct care staff regarding patient care. Quality assurance addressed ventilators, fractures, adverse drug events, and transfers under and over seventy-two hours.
*She had not really considered staffing to have been an issue.
*Nursing staff meetings have improved with attendance by nursing staff.
*She felt as though management promoted communication and encouraged staff to come to them with concerns. She worked the floor with nursing staff at times.
*When she attended nursing report there was good communication between staff.
*When she was out on the floor "realtime" she would ask staff how things were going.
*There was no way to track which staff members had read new policy and procedures.
*She agreed she needed to have criteria to monitor thorough documentation of nursing staff and other disciplines.
*She had been made aware of events when the patients trach had become dislodged and had fallen out. There was a particular event in May 2016 with patient 1 that was brought to her attention..
*RN care coordinator F had informed her of the event regarding patient 1's incident in May 2016. The care coordinator had told her the patient's oxygen saturation had been quite low, and there was difficulty reinserting the trach tube after it had dislodged. The patient had turned blue in color.
There was an e-mail sent out after the incident to the staff in regards to having a nurse present in the patient's room when performing activities of daily living. She stated RN care coordinator F had documented a summary of the event on May 24, 2016 involving patient 1.
*She agreed the documentation of the event on May 24, 2016 was incomplete and should have been more thorough.

Interview on 7/19/16 at 2:25 p.m. with RN care coordinator F regarding her interview at 9:04 a.m. regarding patient 1's event on 5/24/16 revealed:
*She stated she was not sure what the survey team had been asking her in regards to patient 1.
*There was no investigation or summary completed as the director of nursing had informed us in her earlier interview.
*The patient's oxygen saturation had not been registering, so it was unknown what the oxygen level was for him.
*She was scared at that particular time on May 24, but she dealt with trachs and unstable "kids" all the time.
*The patient was blue when she arrived in the patient's room.
*She was not aware of what professional standards the provider followed for nursing care. The staff would have referred to the facility's policy and procedures.

Review of the provider's 7/10/15 Quality Assessment and Performance Improvement Plan (QAPI) policy revealed:
*The purpose of the QAPI was to have a well-defined, organized program designed to reduce medical errors, improve safety, quality of care, and positive outcomes for patients. Clinical outcomes were a top priority.
*The QAPI program would incorporate quality indicator data, analysis of trends, and implementation of action plans and mechanisms that included communication, feedback, and learning.
*Team participation would have provided staff with the experience of collaborating with other team members to make needed improvements.
*All findings of measures and plans of actions would have been shared with (provider name) staff on an ongoing basis, utilizing communication boards, and department meeting formats.
*The director of quality and compliance might facilitate team projects as needed and would have acted as a liaison between teams and the QAPI committee, and monitored team progress while providing guidance to attain the desired outcome.

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A. Based on observation, interview, record review, and policy review, the provider failed to ensure:
*Complete and thorough documentation in the electronic medical record (EMR) for one of one sampled patient (1) who had his tracheal (trach) tube dislodged, the patient was cyanotic, and there was follow-up investigation by the director of nursing or care coordinator F after the patient's incident on May 24, 2016.
*Appropriate coverage of staff on the floor when scheduled staff had to leave the floor and transport/accompany patients to appointments outside the hospital.
Findings include:

1. Review of patient 1's EMR revealed:
*There was an incident on 5/24/16 at 3:43 p.m. that involved the following documentation:
-"Trach out and difficulties with reinsertion. Same accomplished via RT [respiratory therapy] as first in the room."
*There was no further documentation in the EMR.
*There were no vital signs documented (blood pressure, pulse, and respirations).
*There was no documentation of oxygen saturation during the adverse event.

Interview on 7/18/16 at 5:10 p.m. with RN E regarding patient 1 revealed:
*She agreed the documentation for the adverse event on 5/24/16 was not fully documented.
*The patient had gone to an appointment outside the hospital for a cranial scan, the trach had dislodged, and he had turned blue. The ambulance had to be called, and he was taken to the emergency room (ER) for reinsertion of his trach tube.
*The RT would document any treatments or trach changes during the day, and then they would document in the RT documentation area when the nurses completed treatments or trach changes on the patients.
*"The charting is not perfect."
*In an event the patient's trach would dislodge, the nurses should have completed an assessment, vital signs, oxygen saturation levels, and then documented in the patient's medical record.
*It was not uncommon for patient's trachs to become dislodged
*Patient 1 was "very fragile" and would not be able to tolerate having his trach out for any period of time.

Interview on 7/18/16 at 5:45 p.m. with CNA A regarding an incident with patient 1 revealed:
*She had been employed at the facility for six years, but had just started working in the hospital unit since August of last year.
*She had concerns about particular nurses not answering ventilator alarms when they were sounding for patient 1.
*The alarms on the ventilators were loud.
*The alarm was sounding in patient 1's room and there was no one visible on the floor.
*She approached an RN who had been patient 1's nurse in regards to the sounding alarms. The RNs comment to her, "It is going to be at least a half hour I have medications to give."
*When she was scheduled on the floor and had to transport patients, there was no one that covered her shift while she was absent from the floor. The CNAs were instructed to ask the RNs for assistance when the CNA was gone on a transport outside the hospital with a patient. The RNs were reluctant to assist the CNAs as needed because they were busy with their own duties.

Interview on 7/19/16 at 8:35 a.m. with RN G regarding patient's trachs dislodging and nursing documentation revealed:
*If a patient's trach dislodged and came out, the alarms would sound.
*She would assist with artificial respirations and get oxygen started until the new trach was re-inserted.
*She would monitor vital signs and oxygen saturations until the patient was considered stable again.
*She agreed the following documentation should have been included in the EMR:
-Date/time/size of the trach inserted.
-How the child tolerated the procedure.
-Oxygen saturations.
-Nursing assessments during the adverse event and until the patient was stable again.
-The staff charted by exception meaning only significant or abnormal events were charted in the patient's EMR.
-The documentation on patient 1's adverse event on May 24, 2016 should have been charted in the EMR and she agreed the information in the chart was very limited.

Interview on 7/19/16 at 9:04 a.m. with RN care coordinator F regarding dislodged patient's trachs and staffing concerns revealed:
*Her biggest role was discharge planning and patient referrals.
*She worked Monday through Friday eight hour shifts.
*She did all the scheduling for the nursing staff.
*She had never been directly involved in an incident where a patient's trach had dislodged, and the patient had become cyanotic.
*She had never been scared when a patient's trach had become dislodged.
*She stated there had been no issues with nursing staff not attending patient's dislodged trachs.
*There had been no issues brought to her attention about patient 1's trach care or any issues with his trach.
*The patient's trachs were going to come out, because the patients were young and quite active.
*She would have expected the nurses to have taken care of the patient first when a trach had dislodged and came out.
*There should have been detailed documentation of the event. The vital signs, oxygen saturation, nursing assessment, and patient's condition should have been documented for any abnormal and unexpected event.
*The nurses should have followed nursing practice standards. There were no policy and procedures to ensure consistent documentation by the nursing staff.
*The nursing staff documented by exception, but there was no policy that directed nursing staff on what needed to have been documented.
*She agreed there should have been more documentation on patient 1's event on May 24, 2016.

Interview on 7/19/16 at 10:30 a.m. with RT D regarding the dislodging of patient 1's trach on May 24, 2016 revealed:
*She heard the alarms sounding in his room. She was down the hall from his room walking toward the classroom and turned around to investigate the alarm sounding.
*RN E was sitting at the desk when she entered patient 1's room.
*The patient's trach had become dislodged and he was bluish in color.
*She then pounded on the glass window to get the attention of RN E who was still sitting at the nurse's station.
*Care coordinator F also entered the patient's room.
*She thought the patient's oxygen saturation had dropped to the 80s (normal was 90 to 100%) but was not sure.
*The ventilator alarms were very loud.
*Staff would have been expected to check any alarms that were sounding in the patients rooms.
*She thought she had documented the re-insertion of his trach, but was not sure.
*She would have expected the RN to thoroughly document the event in the patient's EMR.

Interview on 7/19/16 at 12:30 p.m. with the director of nursing regarding all the above concerns revealed:
*She had reviewed the nursing documentation.
*She had no criteria to follow for monitoring nursing staff for appropriate documentation on the EMR.
*There was no system in place to ensure consistent tracking of accurate and complete documentation.
*She would have expected the staff who had grievances, complaints, or concerns regarding staffing issues when scheduled staff needed to go out of the building on a patient appointment to come to her with those issues. She would have asked the staff to problem solve.
*She stated no grievance, complaints, or concerns had been brought to her attention.
*When direct care staff were out on an appointment with patients outside of the hospital depending on the particular situation, whomever would leave on that transport needed to communicate that to the staff. The staff on the floor would have decided what steps/or assistance would have been needed when that staff person was absent from the floor.
*Staff needs were based on census not the acuity of the patients.
*Her expectation would have been the staff needed to communicate their needs to the care coordinator.
*There was no formal monitoring of the staff.
*There was no policy or procedure for staffing guidelines to ensure patients had the appropriate staff to care for their needs.
*There was no monitoring of direct care staff regarding patient care. Quality assurance addressed ventilators, fractures, adverse drug events, and transfers under and over seventy-two hours.
*She had not really considered staffing to have been an issue.
*Nursing staff meetings have improved with attendance by nursing staff.
*She felt as though management promoted communication and encouraged staff to come to them with concerns. She worked the floor with nursing staff at times.
*When she attended nursing report there was good communication between staff.
*When she was out on the floor "realtime" she would ask staff how things were going.
*There was no way to track which staff members had read new policy and procedures.
*She agreed she needed to have criteria to monitor thorough documentation of nursing staff and other disciplines.
*She had been made aware of events when the patients trach had become dislodged and had fallen out. There was a particular event in May 2016 with patient 1 that was brought to her attention..
*RN care coordinator F had informed her of the event regarding patient 1's incident in May 2016. The care coordinator had told her the patient's oxygen saturation had been quite low, and there was difficulty reinserting the trach tube after it had dislodged. The patient had turned blue in color.
There was an e-mail sent out after the incident to the staff in regards to having a nurse present in the patient's room when performing activities of daily living. She stated RN care coordinator F had documented a summary of the event on May 24, 2016 involving patient 1.
*She agreed the documentation of the event on May 24, 2016 was incomplete and should have been more thorough.

Interview on 7/19/16 at 2:25 p.m. with RN care coordinator F regarding her interview at 9:04 a.m. regarding patient 1's event on 5/24/16 revealed:
*She stated she was not sure what the survey team had been asking her in regards to patient 1.
*There was no investigation or summary completed as the director of nursing had informed us in her earlier interview.
*The patient's oxygen saturation had not been registering, so it was unknown what the oxygen level was for him.
*She was scared at that particular time on May 24, but she dealt with trachs and unstable "kids" all the time.
*The patient was blue when she arrived in the patient's room.
*She was not aware of what professional standards the provider followed for nursing care. The staff would have referred to the facility's policy and procedures.

Review of the provider's 8/1/14 General Event Report policy revealed the policy had not addressed incidents that had not caused injury such as the incident on May 24, 2016.

Review of the provider's undated Documentation for Nursing revealed:
*The current policy replaced the 2008 policy.
*Nursing documentation would occur in the EMR for all "parties" [patients] in the specialty hospital.
*Charting by exception that included flowsheets and charting what was abnormal for the patient in the EMR.
*The policy had not addressed the expectations of charting for the nursing staff in an emergent or an adverse event.

Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 8th Ed., St. Louis, Mo., 2013, pp. 348 and 868, revealed:
*"Nursing documentation must be accurate, comprehensive, and flexible, enough to retrieve clinical data, maintain continuity of care, track patient outcomes,and reflect current standards of nursing practice. Information in the patient record provides a detailed account of the level of quality care delivered to the patients."
*Unexpected extubation of the tracheal tube.
-Call for assistance while remaining with the patient.
-Assist respirations with bag-valve mask as needed.
-Assess patient for airway patency, spontaneous breathing, and vital signs.
-Prepare of reintubation.

2. Observation and interview on 7/18/16 at 1:35 p.m. with registered nurse (RN) E regarding staffing of the floor revealed:
*There were two RNs on from 7:00 a.m. to 7:00 p.m., and two certified nursing assistants (CNA) usually on from 7:00 a.m. to 7:00 p.m. Some CNAs worked eight hour shifts, and there would be short shifts other CNAs would fill as needed.
*There was an RT on Monday through Friday who worked 6:00 a.m. to 6:00 p.m.
*There was a full-time health unit coordinator who was also an RN who worked eight hours shifts Monday through Friday.
*The current hospital census was seven patients and six out of the seven patients were ventilator dependent.

Interview on 7/18/16 at 3:00 p.m. with RN E regarding staffing and scheduled patient appointments outside the hospital revealed:
*There have been times when patient's outside appointments had to be rescheduled because of staffing concerns.
*"Trying to get enough staff to help got hairy at times."
*If patients needed to go to the ER the scheduled staff could be off the floor for extended periods of time.
*The RNs attempted to divide the patients evenly in aspects to their care and appointments.
*They had a health unit coordinator who worked eight hours during the day, but she had been on leave due to personal issues. So she was not available to assist the staff due to her absence from the floor.
*There have been issues on the weekends, the RN would notify the leader-on-call, and that person would attempt to find extra help. There were instances where they worked short staffed and leadership on call would not come in to assist.

Interview on 7/18/16 at 3:10 p.m. with RN G regarding staffing issues on the floor revealed:
*She was extra assistance for nursing care needed on the floor.
*Her role was not nursing care.
*She was the health unit coordinator (HUC).
*She would go on trips to appointments with patients outside the hospital.
*When an RN went on a transport outside the hospital she would attempt to cover for that RN while she was absent from the floor.

Interview on 7/18/16 at 3:55 p.m. with the director of nursing regarding staffing issues on the hospital floor revealed:
*There was no policy or procedure for patient acuity and staffing.
*The staffing on days was two RNs, two CNAs, and the HUC.
*She did not feel there were any issues with staffing. Either the care coordinator, herself, or the HUC would assist on the floor when scheduled staff were out on patient appointments. They were in their offices, and she would have expected staff to ask for assistance if they needed help on the floor.

Review of the provider's April 4, 2016 through July 17, 2016 appointment calendar revealed:
*The following dates patients had appointments off campus that removed a scheduled CNA from their scheduled floor duties with no coverage identified:
-April 4.
-April 14.
-April 20.
-May 19.

Review of the provider's 4/11/16 staff meeting revealed:
*"With our new budget there will be open positions for hospital RN. This is to staff with 3 nurses on during day shifts and a 7-11 pm on nights for a census greater than 10 if the acuity is there. If the census does not allow for 3 nurses, staff will be expected to float to where the need is. If there is not a need staff will need to take vacation. Updated Scheduling policy to follow soon. Nursing staff will be expected to sign off on the policy."

3. Interview on 7/19/16 at 9:04 a.m. with RN care coordinator F regarding dislodged patient's trachs and staffing concerns revealed:
*Her biggest role was discharge planning and and patient referrals.
*She worked Monday through Friday eight hour shifts.
*She did all the scheduling for the nursing staff.
*She had never been directly involved in an incident where a patient's trach had dislodged, and the patient had become cyanotic.
*She has never been scared when a patient's trach has become dislodged.
*She stated there has been no issues with staff not attending patient's dislodged trachs.
*There had been no issues brought to her attention about patient 1's trach care or any issues with his trach.
*The patient's trachs were going to come out because the patient's were young and quite active.
*She would have expected the nurses to have taken care of the patient first when a trach had dislodged and had come out.
*There should have been detailed documentation of the event. The vital signs, oxygen saturation, nursing assessment, and patient's condition should have been documented for any abnormal and unexpected event.
*The nurses should have followed nursing practice standards. There were no policy and procedures to ensure consistent documentation by the nursing staff.
*The nursing staff documented by exception, but there was no policy that directed nursing staff on what needed to have been documented.
*She agreed there should have been more documentation on patient 1's event on May 24, 2016.

Interview on 7/19/19 at 9:15 a.m. with CNA B regarding staffing and patient's trachs dislodging on the the hospital floor revealed:
*It was not uncommon for patient trachs to become dislodged. Patient's rolled over and were active in their crib or bed.
*There was an incident that happened once when she had found patient 2 with the trach dislodged, she quickly notified RN C, and was told by RN C that she "was busy." She yelled that she needed a nurse now, because the patients trach was out. Then RN E came to assist.
*She stated that other staff had taken their concerns to management about RN C, but nothing had ever been addressed as far as she had known.
*She had concerns about communication within the department. She had no training in regards to ventilator alarms, feeding alarms, and pulse oximetry alarms. She has obtained her information and training from other CNAs she worked with.
*She was concerned about not getting timely updates on current patient's conditions and what was expected of her. She would come in after the 7:00 a.m. shift had started so she would get report from the other CNA.
*When patient's were scheduled for appointments outside the hospital the social worker was supposed to assist with the transfers, but she was always attending meetings and was unable to assist with transfers. The CNA working with her for that day would have been expected to go on the transfer, and that would have left her working by herself on the floor.
*She stated the lack of staffing had been brought up in the past. The concern of working short when the other CNA had to go on a transport had been a concern since she started her employment over a year ago.
*She felt as though communication between management and nurses needed improvement.

Interview on 7/19/16 at 12:30 p.m. with the director of nursing regarding all the above concerns revealed:
*She would have expected the staff who had grievances, complaints, or concerns regarding staffing issues when scheduled staff needed to go out of the building on a patient's appointments would have come to her with those issues. She would have asked the staff to problem solve.
*She stated no grievance, complaints, or concerns had been brought to her attention.
*When direct care staff were out on an appointment with patient's outside of the hospital depending on the particular situation, whomever would have left on that transport needed to communicate that to the staff. The staff on the floor would have decided what steps/or assistance would have been needed when that staff person was absent from the floor.
*Staff needs were based on census not the acuity of the patients.
*Her expectation would have been the staff needed to have communicated their needs to the care coordinator.
*There was no formal monitoring of the staff.
*There was no policy or procedure for staffing guidelines to ensure patient's had the appropriate staff to care for their needs.
*There was no monitoring of direct care staff regarding patient care. Quality assurance addressed ventilators, fractures, adverse drug events, and transfers under and over seventy-two hours.
*She had not really considered staffing to have been an issue.
*Nursing staff meetings have improved with attendance by nursing staff.
*She felt as though management promoted communication and encouraged staff to come to them with concerns. She worked the floor with the nursing staff at times.
*When she attended nursing report there was good communication between staff.
*She was out on the floor "realtime" she would have asked staff how things were going.
*There was no way to track which staff members had read new policy and procedures.
*She had been made aware of events when the patient's trach had become dislodged and had fallen out. There was a particular event in May 2016 with patient 1 that had been brought to her attention..
*RN care coordinator F had informed her of the event regarding patient 1's incident in May 2016. The care coordinator told her that the patients oxygen saturation was quite low and there was difficulty reinserting the trach tube after it had dislodged. The patient had turned blue in color.
There was an e-mail that was sent out to the staff after the incident in regards to having the RNs present in the patient's room when performing activities of daily living. She stated RN care coordinator F had documented a summary of the event on May 24, 2016 involving patient 1.
*She agreed the documentation of the event on May 24, 2016 was incomplete and should have been more thorough.

Review of the provider's 9/22/14 Direct Support Professional/CNA job description revealed:
*The position provided care and support for children or adults with disabilities.
*Assist with transportation needs of individuals as needed.
*Assist with individual medical needs communicating with the appropriate medical staff.
*Assist in emergencies.
*Attend, complete, and maintain training's as required.
*Communicate significant changes/concerns in the individual's life to team members.

Review of the provider's 8/18/14 Registered Nurse job description revealed:
*The position was responsible to assess the health status of patients in accordance with the organization's Mission and Core Values.
*Provided respiratory care/support.
*Evaluated the quality and effectiveness of nursing interventions.
*Documented per shift in the Electronic Medical Record and/or paper charts.
*Provided leadership to support staff.
*Promoted health and safety.
*Used critical thinking skills.

Review of the provider's 1/14/15 Care Coordinator job description revealed:
*The position assisted in the supervision of nursing and direct support staff within the Specialty Hospital in accordance with the organization's Mission and Core Values.
*Provided clinical support, mentoring and leadership to nursing staff and direct support staff.
*Responded to and troubleshoots routine questions/issues during daily operations.
*Reported/communicated regularly with nursing staff and support staff.
*Conducted performance reviews on direct reports.
*Ensured quality and service standards were met.
*Determined and monitored work schedules.
*Used critical thinking skills.
*Knowledge of South Dakota Rules and regulations for Speciality Hospitals.
*Performed tasks required of the unit at a high level, and showed ability to communicate effectively with the team.
*Might be required to work in an assigned area based on coverage needs.

Review of the provider's 1/14/15 Director of Nursing job description revealed:
*The position was responsible to manage and supervise nursing services in the Specialty Hospital in accordance with organization's Mission and Core Values.
*Promoted professional nursing practice, and quality patient care initiatives.
*Provided effective training, coaching, and mentoring to ensure the nursing services staff had the required competencies necessary to fulfill their role.
*Assisted in the development and collection of clinical outcomes and clinical quality improvement projects.
*Worked closely with the director of quality and compliance to ensure quality standards were met across nursing programs.
*Collaborate with other directors to ensure communication between clinical leaders and staff to ensure consistency in services.
*Oversees nursing documentation and processes related to electronic health records.
*Monitored compliance with organizational standards of practice and documentation.
*Monitored compliance with state and federal laws and regulations.
*Proven management and supervisory skills.
*Knowledge guidelines and requirements of applicable regulatory and licensing agencies.
*Knowledge of nursing practices.
*Knowledge of best practices across nursing services.
*Ability to communicate effectively to various levels of staff and build an effective team.
*Staff feedback.

B. Based on record review, policy review, and interview, the provider failed to ensure:
*One of one sampled patient (2) had the appropriate size tracheal tube inserted during an emergent event.
*Five of eight sampled patients (2, 6, 7, 8, and 9) with tracheotomies had tracheostomy changes performed in accordance with their physician's order.
Findings include:

1. Review of patient 2's EMR revealed:
*He was eighteen months old.
*His diagnoses included respiratory failure and laryngomalacia.
*He had a tracheostomy.
*On 5/18/16 at 5:36 p.m. "Noted that patient had a 3.0 emergency trach in place rather than the ordered 3.5 cuffed trach. RT to change to the 3.5 cuffed trach after patient eats."

Interview on 7/19/16 at 4:55 p.m. with RN clinical coordinator F regarding the above concern revealed:
*There was no physician notification regarding the wrong size trach inserted on 5/18/16.
*There was no documentation in the EMR for the reasoning of the 3.0 cuffed trach placement.
*She was unsure how long the wrong sized trach had been in the patient.
*There was no policy and procedure for physician notification.

2. Review of patient 2's EMR revealed:
*He had been admitted on 2/15/16.
*The diagnoses were respiratory failure and laryngomalacia.
*He had a physician's order to change the trach every Monday.
*There was no documentation found for trach changes on 6/13/16 and 6/27/16.

3. Review of patient 6's EMR revealed:
*She had been admitted on 12/16/15.
*The diagnoses were cerebral palsy, laryngomalacia, and epilepsy.
*She had a physician's order to change the trach every Thursday.
*There were multiple Thursday's from 6/16/16 through 7/09/16 where there was no documentation of the physician's ordered trach change.

4. Review of patient 7's medical record revealed:
*He had been admitted on 1/18/16 with a diagnosis of tracheomalacia, congenital bronchomalacia, and bronchopulmonary dysphagia.
*His 7/1/16 tracheostomy physician's order stated to change the tracheostomy every Tuesday.
*The provider's staff had changed his tracheostomy on the following dates.
-6/14/16.
-6/20/16.
-6/21/16.
-7/12/16.
-7/19/16.
*His parents had changed the tracheostomy on 7/2/16.

Interview on 7/19/16 at 4:00 p.m. with clinical coordinator F revealed she was unable to find documentation of any other tracheostomy changes having been performed.

5. Review of patient 8's EMR revealed:
*His diagnoses included: dystonia, dysphagia, neuromuscular scoliosis, seizures, and obstructive sleep apnea.
*He had an endotracheal tube (trach).
*On 12/23/15 there was a physician's order to change the trach every two weeks on Wednesdays with the parents present.
*There was no documentation in the EMR that the parents had been present during the changing of the trach.
*There was no documentation the trach had been changed between 6/9/16 and 7/10/16.

6. Review of patient 9's EMR revealed:
*His diagnoses included: severe intellectual disability, seizure disorder, anoxic brain injury, and cardiomyopathy.
*He had a trach.
*On 7/1/15 there was a physician's order to change the trach weekly on Mondays.
*There was no documentation for trach changes having been done on the following dates:
-6/13/18.
-7/4/16.
-7/18/16.

Interview on 7/19/16 at 4:00 p.m. with clinical coordinator F revealed she was unable to find documentation of any other tracheostomy changes having been performed.

7. Interview on 7/19/16 at 10:30 a.m. with RT H and RN clinical coordinator F regarding the above trach change documentation concerns revealed there was inconsistent documentation regarding nursing staff and RT staff documenting trach changes.

Interview on 7/19/16 at 12:30 p.m. with the director of nursing regarding all the above concerns revealed:
*She had reviewed nursing documentation.
*She had no criteria to follow for monitoring nursing staff for appropriate documentation on the EMR.
*There was no system in place to ensure consistent tracking of accurate and complete documentation.
*She agreed she needed to have criteria to monitor thorough documentation of nursing staff and other disciplines.

Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 8th Ed., St. Louis, Mo., 2013, p. 305, revealed:
*"The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe the orders are in error or harm patients. Therefore, you need to assess all orders."