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Based on document review and interview, it was determined the facility's quality assurance program failed to analyze data and implement systemic corrective measures to improve patient outcomes.

Findings include:

The facility's "Performance Improvement Plan 2019" states, "Quality improvement involves two primary activities:
(1) Measuring and assessing performance of services provided through the collection and analysis of data and
(2)Conducting quality improvement initiatives and taking action where indicated, including the design of new services, and/or the improvement of existing services."

Review of the Mortality Review for Patient #1 revealed the facility identified there was a delay in activating the rapid response team on 5/18/19 and identified care related issues.
There was no documented evidence that the facility developed and implemented systemic corrective measures.

Review of facility document titled "Rapid Response Team and Resuscitation Outcomes," January 2018 to May 2019, revealed the facility collected data for rapid response activations. For example:
Activations in 2019:
January 2019 - 73
February 2019 - 71
March 2019 - 76
April 2019 - 93
May 2019 - 86
There was no documented evidence that the facility analyzed the data to determine timeliness and outcomes of activation of the rapid response team.

During an interview conducted on 7/9/19 at 3:15 PM with Staff H, RN Educator, Critical Care, she acknowledged the data was not analyzed to determine timeliness and outcomes of the activation of the rapid response team.

Based on medical record review, document review and interview, in three (3) of 16 medical records reviewed, the facility failed to conduct ongoing assessment of patients with deteriorating medical condition, and implement its Rapid Response Team, as per facility policy, for patient's O2 saturation of less than 90%.

This failure placed all patients at risk for harm and death.

Findings Include:

Review of the medical record for Patient #1 identified: A 74 year old who was admitted on 5/14/19 for right lung mass, shortness of breath. The patient was placed on oxygen therapy for oxygen saturating (O2 sat) at 89 % (normal 95-100% on room air) and was admitted to the Medical Surgical Unit. During the course of her hospitalization the patient's O2 sat fluctuated between 83% and 95%, with changes in her respiratory rate and mental status.
On 5/18/19, the patient became unstable exhibiting marked oxygen desaturation intermittently during the day with a drop in the O2 sat to 85% at 5:47 PM. A Rapid Response was initiated at 8:55 PM. The patient was pronounced dead at 10:20 PM.



Review of medical record for Patient #2 identified: A 78 year old patient was sent to the facility on 6/11/19 at the recommendation of a visiting nurse service for redness and infection at a Mediport (catheter for chemotherapy) site. On admission she was started on oxygen therapy for O2 sat of 99%. During the patient's hospitalization she had intermittent shortness of breath (SOB) and fluctuating O2 saturation.
On 6/23/19 the O2 sat decreased further while on oxygen. A Rapid Response was called at 4:24 AM. The patient was pronounced dead at 4:55 AM following attempts at resuscitation.

Review of Medical Record for Patient #3 identified a 63 year old female was admitted to the Step Down unit on 4/2/19 for increased heart rate, shortness of breath, fatigue and a cough. She was started on O2 therapy. On 4/7/19, the patient's condition continued to deteriorate and the O2 sat dropped to 78%. At 10:07 AM, the patient suffered a cardiac arrest and was pronounced dead at 11:07 AM.

The nursing staff failed to document ongoing re-assessment and failed to initiate a Rapid Response, as per facility policy.


See TAG A395

Based on medical record review, document review and interview, in three (3) of 16 medical records reviewed, it was determined the facility failed to ensure that the nursing staff (a) conduct ongoing assessment of patients with deteriorating medical condition, and (b) activate a Rapid Response protocol as per facility's policy. (Patient #1, #2, #3).

These failures resulted in patient harm and death.


Findings include:

Review of facility's policy titled "Rapid Response Team" last reviewed 08/21/2017 states: "The patient's primary nurse is responsible for performing focused assessment of the patient including vital signs, mental status, pertinent lab results. If the patient meets criteria or the nurse is concerned about the patient the nurse should activate the RRT. The Rapid Response Team will be activated by the staff nurse or any employee of the hospital if the patient has an acute change in one or more of the following criteria: Heart rate less than 40 or greater than 150 beats per minute ...O2 saturation less than 90% despite O2 therapy ...respiratory rate below 8 or greater than 28...change in conscious state."

Review of the Medical Record for Patient #1 identified: This 74 year-old was admitted to the Medical Surgical Telemetry unit on 5/14/19 with complaints of shortness of breath and elevated troponin (a protein in the blood that detects heart injury). On 5/16/19 at 12:33 PM, physician documented that the patient was confused and did not recall who he (physician) was or why she was admitted. The patient's oxygen saturation (O2 sat) had dropped to
83 % (normal between 95% and 100% on room air) and the patient's oxygen therapy was changed. A Rapid Response Team was not activated.

On 5/18/19, the patient began to exhibit intermittent decrease in her O2 saturation. For example: Nursing documentation at 11:15 AM, O2 sat was 88%; at 11:30 AM O2 sat was 89%; at 11:35 AM O2 sat was 95%.
There was no documentation of a reassessment of of the patient's respiratory rate, heart rate or pulse.
A Rapid Response was not initiated timely for this decompensating patient who was exhibiting an O2 sat of below 90% while on oxygen therapy.

At 12:40 PM, Physician documentation noted Hypoxemic Respiratory Failure (an inability to inhale enough oxygen in the lungs leading to decreased oxygen in the blood) and her oxygen therapy was changed.
At 1:37 PM, pulmonologist documented: "Acute dyspnea (shortness of breath) while speaking with her neighbor." and the patient's oxygen therapy was adjusted.
At 2:00 PM, Nurse Tech documented O2 sat 91%, Respiratory Rate 22 (normal 12-20 breaths per minute), Heart Rate 84 (normal 60-100 beats per minute).
At 5:47 PM, Nurse Tech documented O2 sat 85%, Respiratory Rate 22, Heart Rate 57, and RN informed.
There was no documentation that the patient was reassessed after the 5:47 PM vital signs were reported to the RN.

At 8:55 PM, approximately two hours later, a Rapid Response was called for "worsening repiratory distress and oxygen saturation in the 80s." The patient suffered a cardiac arrest at 9:25 pm while being transferred to the Intensive Care Unit. She was pronounced dead at 10:20 PM following attempts to revive her.


Review of medical record for Patient #2 identified: This 78 year old patient was sent to the facility on 6/11/19 at the recommendation of a visiting nurse service for redness and infection at a Mediport (catheter for chemotherapy) site. On admission, she was started on oxygen therapy for oxygen saturation (O2 sat) of 99%. During the patient's hospitalization she had intermittent shortness of breath while on oxygen therapy and her O2 sat ranged from 91% -99%.

On 6/23/19 at midnight the oxygen saturation decreased to 92% while on oxygen. At 2:12 AM, the patient now had difficulty breathing at rest and on exertion despite increased oxygen concentration.
There was no documentation that the patient's vital signs and O2 sat were rechecked until 3:13 AM, when the O2 sat was at 91%. At 3:19 AM, a physician was called and O2 therapy was adjusted and Lasix (to eliminate fluid retention) was ordered (given at 4:02 AM).
On 6/23/19 at 5:03 AM, a physician documented, "RRT (Rapid Response Team) was called at 4:24 am. When I arrived patient was unresponsive and agonally breathing (gasping, labored breathing)." A Code Blue (cardiac arrest activation) was activated at 4:30 PM and the patient was pronounced dead at 4:55 AM.

The reason for activating the RRT at that time was not documented and is not evident in the medical record.


Review of Medical Record for Patient #3 identified: This 63 year old patient was admitted to the step-down unit on 4/2/19 with a rapid heart rate, progressive shortness of breath, fatigue and a cough. The patient was placed on oxygen therapy.
On 4/6/19 at 2:49 AM, a nurse practitioner documented that the patient had worsening Bilateral Pneumonia with increasing white blood cells. A nurse documented at 10: 00 PM that the patient had shallow breathing and difficulty breathing with exertion.

On 4/7/19 at 4:00 AM, a nurse documented that the patient's vital signs were Heart Rate 123 (normal 60 - 100), Respiration 24 (normal 12 -20), and that the oxygen saturation had decreased to 92 % (normal range 96% -100% on room air).

At 6:30 AM, a nurse documented that the oxygen saturation was 84 - 86%, and that the patient was tachypneic (breathing rapidly). This note also indicated a physician was called and he stated: "call after 10 minutes."
At 7:20 AM, a nurse documented "O2 saturation 78%. Unable to obtain vital signs related to patient's condition and restlessness.
At 7:40 AM, patient was seen by a pulmonary specialist who documented that the patient was more hypoxic (had less oxygen circulating), more short of breath and that his plan was to increase oxygen therapy.
At 8:00 AM, Heart Rate of 155 was documented. Patient was intubated (inserting a breathing tube through the mouth and then into the airway) at 8:55 AM, she sustained a cardiac arrest at 10:07 AM, and was pronounced dead at 11:03 AM when resuscitative measures failed.

The nursing staff failed to call a rapid response when the patient's condition was deteriorating, as per facility policy.

Review of facility's policy titled "Organizational Structure for Patient Assessment and Reassessment," last reviewed 4/2018 states; "Patients are reassessed after treatment, therapy or educational sessions to determine effectiveness (extent of improvement) of the interventions undertaken by the healthcare team."

These findings were shared with Staff B, the Director of Nursing , on 7/11/19 at approximately 10:00 AM.

Based on medical record review, document review and interview, in one (1) of 16 medical records reviewed, it was determined the nursing staff failed to formulate a nursing care plan to address the patient's difficulty breathing. (Patient #2).

Findings include:

Review of medical record for Patient #2 identified: This 78 year old patient was sent to the facility on 6/11/19 at the recommendation of a visiting nurse service for redness and infection at a Mediport (catheter for chemotherapy) site. The patient's past medical history included hypoxemic (low oxygen) respiratory failure.

The patient was started on oxygen 3 liters (L) via a nasal cannula upon admission and the oxygen saturation was 99% (normal range is 96% - 100% on room air). The patient's oxygen saturation fluctuated and ranged from 91 % - 99% on oxygen therapy during the course of her hospitalization. For example the following findings were noted while the patient was on oxygen:
6/16/19 at 5:52 PM - oxygen saturation 94 %. At 11:03 PM the patent had rapid and shallow breathing, with rales, crackles and wheezing in both lungs.
6/17/19 at 7:15 PM - oxygen saturation 93%.
6/22/17 at 6:37 AM - oxygen saturation 93%
6/23/19 at 3:13 AM - oxygen saturation 91 %
The patient's respiratory difficulties continued to deteriorate, she sustained a cardiac arrest at 4:30 AM on 6/23/19, and she died at 4:55 AM that morning.

There was no documentation in the medical record that the nursing staff formulated a nursing care plan throughout the patient's hospitalization to address the patient's difficulty with breathing, which was noted upon admission and throughout her hospitalization.

The policy titled "Inpatient Interdisciplinary Plan of Care" which was last reviewed 05/06/2019 states "documentation of the care plan must be initiated by an RN within one hour of admission." The policy also states "the care plan must be kept updated based on the patient's current status and condition."

These findings were shared with Staff B, the Director of Nursing, on 7/3/19 at approximately 3:10 PM.