HospitalInspections.org

Based on interview and record review, the hospital's Governing Body (GB) failed to effectively govern the hospital, provide safe and quality care to all patients, and ensure compliance with federal regulations, as evidenced by:

1. The GB failed to ensure compliance with the statutorily mandated Condition of Participation for Nursing Services when it failed to ensure the facility's nursing services were well organized to meet the needs of patients in a safe and effective manner. This included inadequate staffing, on a repeated basis, to all areas of the hospital including the Intensive Care Unit (ICU) and Emergency Department (ED), resulting in and/or contributing to serious decline in patients' conditions, as well as an inability to respond to emergencies throughout the hospital; and the routine assignment of untrained nurses to high acuity areas with the potential to result in serious patient decline and adverse events. Refer to A 392 Findings 1 through 5, A 397 Findings 1 through 3, and A 398 Findings 1 through 3.

2. The GB failed to ensure the hospital had developed, implemented and maintained an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program, despite numerous prior regulatory deficiencies having been cited. Refer to A 273 Findings 1 through 5 and A 308.

The cumulative effect of these systemic problems resulted in the hospital's inability to comply with the statutorily mandated Condition of Participation: Governing Body.

Based on staff interview and document review, the hospital's Governing Body (GB) failed to ensure the hospital had developed, implemented and maintained an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program.

1. The quality program did not include processes of care and operations that were measured, tracked, and analyzed regarding areas where prior regulatory violations had been identified. Refer to A 273 Findings 1 through 5.

2. The QAPI program did not include indicators for areas where the facility had been issued repeated past deficiencies and resulted in nursing services that were unsafe and ineffective. Refer to A 308.

These failures put patients at risk for substandard care, adverse events, and negative outcomes. The cumulative effect of these systemic problems resulted in the inability of the hospital to comply with the statutorily-mandated Condition of Participation for Quality Assessment and Performance Improvement.

Based on interview and record review, the hospital failed to ensure that processes of care and operations were measured, analyzed, and tracked as quality indicators to demonstrate implementation of corrective actions and sustaining safe care practices. Documented evidence was lacking to show the following care processes were effectively evaluated and tracked when continued evidence of regulatory violations were identified.

1. The inability of charge nurses in the Intensive Care Unit (ICU) to respond to rapid responses (ICU charge nurse and respiratory therapist provide early and rapid intervention for patients demonstrating signs of imminent clinical deterioration) throughout the hospital due to inadequate staffing was not being tracked. Refer to A 392 Finding 1 b and Finding 3 a.

2. The number of patient falls during periods of inadequate staffing was not being tracked. Refer to A 392 Finding 4.

3. Competency and training of staff prior to patient assignment as well as related negative patient outcomes was not being tracked. Refer to A 397 Finding 1, 2, and 3.

4. Elopements for behavioral/mental health patients were not being tracked or analyzed. Refer to A 392 Finding 5.

5. Hospital wide inadequate staffing and associated negative patient outcomes were not tracked and analyzed.

These failures resulted in continued care practices that jeopardized patient outcomes and safety.

Findings:

1. During an interview on 11/15/22 at 4 pm, the incidents involving the inability of the charge nurses to respond to rapid responses, on 7/27/22 and again on 10/14/22, was discussed with the ICU Director (ICUD). She said she has quality measures for code blues (called when a patient's heart or breathing stops) and rapid responses but did not review all of them. ICUD said she was aware there was usually communication between the charge nurse and house supervisor if the charge nurse had patients and was unable to respond to a rapid. She said when the charge nurse responded to a rapid the documentation was given to her for review, but if the charge nurse did not respond to a rapid because she/he has patients, then she would not know about these and would not review or track them.

During an interview on 11/16/22 at 3 pm, the lack of attention to review of rapids and situations where rapids were called, but the ICU charge nurse can't respond due to inadequate staffing, was discussed with the Chief Nursing Officer (CNO). He said this issue can be rolled into the resuscitation committee but they have not done this so far.

During an interview on 11/17/22 at 9:50 am, the Director of Performance Improvement (DPI) confirmed there had been a disconnect between the unit directors and Performance Improvement including, no tracking of rapids that didn't get called or an increase in rapids, due to inadequate staffing, or delay of care for ICU patients who stayed in the Emergency Department waiting, for ICU beds.

2. During an interview on 11/17/22 at 9 am, the Ortho/Neuro Director (OND) said he tracked falls for Quality Improvement. He said he looked at how the fall took place, if there had been hourly rounding by staff, physical therapy notes if any, neurological assessment, witnesses, any injuries, and tests like x-rays. OND said he has not related falls to staffing and has not tracked falls when staffing was out of ratio, to see if there was an increase in the number of falls.

During an interview on 11/17/22 at 9:50 am, DPI confirmed there had been a disconnect between the unit directors and Performance Improvement as they were not tracking outcomes such as an increase in falls when there was short staffing.

3. During an interview on 11/15/22 at 4 pm, floating of Telemetry (Tele, continuous remote monitoring of the patient's heart rate and rhythm) nurses to ICU was discussed with ICUD. She said she worked with their current educator getting new Tele hires to have ICU orientation for three days during their hospital orientation and there was a separate check off list for Tele nurses for the ICU. She said this did not apply for existing Tele nurses that float to ICU because there was not enough staff to allow for that.

During a concurrent interview and record review on 11/15 at 3:33 pm, the DPI stated the facility's staff were responsible for monitoring staff competency and training. DPI generated a Behavioral Violence Prevention (VPH) course (required upon hire and annually) completion report for all staff who currently work at the facility's Center for Behaioral Health (CBH) unit. DPI verified that 16 of 49 (10.88%) of CBH staff have completed the mandatory BVP training.

During a record review and concurrent interviews on 11/16/22 at 10:20 am and 11/17/22 at 9:50 am, competency and training of staff was discussed with DPI. She said "corporate" decided they did not need an educator and eliminated their education department, so there was no educator for the hospital for around eight months and then corporate let us hire only one educator, even though we had a back log of staff, that needed training and competencies. DPI said nobody, neither the department director or their educator, knew if a certain nurse was competent for their floor/unit or if they're competent to be floated to another unit, because no one has that nurses's competency list. DPI agreed the orientation should be done by the educator but unit specific competencies need the involvement of the unit directors.

4. During a concurrent interview and record review on 11/16/22 at 10:20 am, DPI said elopements were patients who have been placed on an involuntary hold and leave the hospital, as opposed to voluntary patients, who leave Against Medical Advice (AMA). She confirmed there was no log to track elopements for Mental Health patients. Their electronic record system included elopements in with patients who left AMA.

During an interview on 11/16/22 at 3 pm, the Chief Nursing Officer confirmed that security officers assist with mental health patients when outdoors and the standard was two security guards with nursing staff and the patient. Elopement was part of the security notes so the log of which patients elope was very difficult to obtain and elopements were not tracked.

5. During interviews on 11/16/22 at 10:20 am and 11/17/22 at 9:50 am, inadequate staffing throughout the hospital was discussed with DPI. She said the hospital went a year without a RN contract until last month when it was ratified, so the other hospitals in town paid nurses more, but they have now started rehire bonuses for nurses to return to work. DPI said no one was keeping track of how many shifts were out or ratio and not in accordance with their policy for staffing and patient acuities were not being done per their policy.

Based on interview and document review, the hospital's Governing Body (GB) failed to ensure that the Quality Assessment and Performance Improvement (QAPI) program reflected the all aspects of the hospital's services. The QAPI program did not include indicators for areas where the facility had been issued repeated past deficiencies and resulted in nursing services that were unsafe and ineffective.

Findings:

During a concurrent interview and document review on 11/16/22 at 3 pm, issues regarding inadequate staffing and inadequately trained staff, resulting in negative patient outcome and numerous deficiencies cited in the past two years, was discussed with the Chief Executive (CEO) and the Chief Nursing Officer (CNO). They produced orders for traveler nurses for the winter surge plan which included Emergency Department nurses and Telemetry nurses that were now at the hospital but none yet for the Intensive Care Unit (ICU). The CNO said five ICU nurses were set to start by 11/28/22. Their current core staffing for night shift was four regular nurses for ICU which was inadequate when their ICU patient census was full.

CNO said they had been without an educator for eight months and their current educator has been in the job for about four months. He was then asked how only one educator could get all the backlog up to date. He said they have regional educators from corporate, but they have not, as of yet helped. CNO confirmed there was an overall gap with their nursing competencies. CNO said there were different styles between their current educator and their prior educator that may have contributed to this ongoing problem. He said their current educator will be stepping down from that position so the hospital has now posted an educator position to replace her.

Both the CEO and CNO said recruiting was part of their GB minutes but there was nothing about nurses floating to other units and staff competencies in these minutes.

The ongoing problem with insufficient staffing on the Telemetry (Tele, continuous remote monitoring of the patient's heart rate and rhythm) unit including inadequately trained medical-surgical nurses floating to Telemetry, even while this survey was going on was discussed. They were asked how safe quality care was provided to all patients at all times given the chronic long term staffing and lack of competently trained staff. They confirmed there was a problem and a gap.

Based on interview and record review, the hospital failed to ensure that nursing services were furnished by a registered nurse and consistent with nationally accepted standards of practice as evidenced by:

1. The facility failed to implement its "Staffing for Critical Care," policy when it did not maintain a nurse to patient ratio in the ICU (Intensive Care Unit) of 1:2 at all times. On 7/27/22, the facility's Administration allowed two elective (non- emergency), scheduled open heart surgeries to proceed, with the knowledge that there was inadequate staffing in the ICU, which posed a threat to the safety of the ICU patients. The Administration also had no plan for staffing should an emergency arise, such as the need to admit a patient to ICU from the floor (another unit of the hospital), due to a decline in their condition. Refer to A 392 Finding 1 a.

2. The facility failed to implement its "Rapid Response Team" policy when the rapid response team (members including the ICU Charge nurse that assess and treat deteriorating patients to prevent further decline), could not respond to emergencies, due to inadequate and unsafe staffing in the ICU. Refer to A 392 Finding 1 b.

3. The facility continued to fail to implement its "Staffing for Critical Care," policy when it did not maintain a nurse to patient ratio in ICU of 1:2 at all times, on 9/22/22. Refer to A 392 Finding 2.

4. The facility continued to fail to implement its "Staffing for Critical Care," policy when it did not maintain a nurse to patient ratio in ICU of 1:2, and "Staffing Plan for Telemetry," policy when it did not maintain a nurse to patient ratio of 1:4, at all times on 10/14/22. Refer to A 392 Finding 3 a.

5. The facility continued to fail to implement its "Staffing Plan for Telemetry," policy during the time of this survey. Refer to Finding A 398 Finding 3.

6. The facility failed to implement its "Staffing Plan for Emergency Department," policy when it did not maintain a nurse to patient ratio of 1:2 for critical patients and 1:4 for general acute patients. Refer to A 392 Finding 3 b.

7. The facility failed to implement its "Staffing Plan for Surgical/Ortho Neuro," policy when it did not maintain a nurse to patient ratio of 1:5. Refer to A 392 Finding 4.

8. The facility failed to provide appropriate ongoing patient assessments to meet the immediate safety needs and care of CBH patients. Refer to A 392 Finding 5.

9. The facility failed to ensure its "Transport of Monitored Patient," policy was implemented when a critical patient was improperly transferred from the Telemetry unit (Tele, continuous remote monitoring of the patient's heart rate and rhythm) to the ICU. Refer to A 398 Finding 1.

10. The facility failed to fully implement its "Targeted Temperature Management," policy in the ED. Refer to A 398 Finding 2.

11. The facility failed to implement its "Patient Classification-Telemetry," policy when it did not use a patient acuity system for staffing. Refer to A 398 Finding 3.

12. The facility failed to ensure competency of staff prior to patient care assignment when no system for determining competency on each unit was implemented and maintained. Refer to A 397 Findings 1 through 3.

The cumulative effect of these systemic problems caused, contributed or compromised the decline in patients' health and had the potential to compromise the health and safety of patients throughout the hospital due to inadequate staffing, the inability to implement nursing policies and provide care as needed to all patients, and resulted in the inability of the hospital to comply with the statutorily-mandated Condition of Participation for Nursing Services.

Based on interview and record review, the facility failed to have adequate numbers of nurses and other staff to provide assessments, safe and effective care as needed by the patients, and implement its staffing policies, to patients in the intensive care unit (ICU), Telemetry unit (Tele, continuous remote monitoring of the patient's heart rate and rhythm), Emergency Department (ED), Ortho/neuro units (a floor for general acute patients) and Center for Behavioral Health (CBH).

1.a. The facility failed to implement its "Staffing for Critical Care" policy when it did not maintain a nurse to patient ratio in the ICU of 1:2 at all times. On 7/27/22, the facility's Administration allowed two elective (non emergency), scheduled open heart surgeries to proceed, with the knowledge that there was inadequate staffing in the ICU, which posed a threat to the safety of the ICU patients. The Administration also had no plan for staffing should an emergency arise, such as the need to admit a patient to ICU from the floor (another unit of the hospital), due to a decline in their condition. This had the potential to result in a decline in the condition of all patients in the ICU and hospital.

1.b. On 7/27/22, the facility failed to implement its "Rapid Response Team" policy when the rapid response team (members including the ICU Charge nurse that assess and treat deteriorating patients to prevent further decline), could not respond, due to inadequate and unsafe staffing in the ICU. As a result, Patient 1 who was on the Telemetry unit, went into septic shock (a life threatening condition caused by a severe localized or system-wide infection that required immediate medical attention) and had to wait several hours before receiving necessary medications (vasopressors which are drugs given for septic shock that does not respond to fluids and aims at improving blood pressure and organ perfusion) that were specifically needed for her condition and ordered by the physician, before being transferred to ICU. These failures contributed to a significant decline, including inadequate organ perfusion (oxygen deficiency) to Patient 1, who later expired on 8/2/22.

2. The facility continued to fail to implement its "Staffing for Critical Care," policy when it did not maintain a nurse to patient ratio in ICU of 1:2 at all times, on 9/22. This failure continued to pose a safety hazard to patients in the ICU and hospital.

3. a. The facility continued to fail to implement its "Staffing for Critical Care," policy when it did not maintain a nurse to patient ratio in ICU of 1:2, and "Staffing Plan for Telemetry" policy when it did not maintain a nurse to patient ratio of 1:4, at all times on 10/14/22. This failure continued to pose a safety hazard to patients in the ICU, Telemetry, and throughout the hospital.

3. b. The facility failed to implement its "Staffing Plan for Emergency Department," policy when it did not maintain a nurse to patient ratio of 1:2 for critical patients and 1:4 for general acute patients. As a result the staff were unable to fully implement the facility's "Targeted Temperature Management" policy and there was a delay in the care provided for Patient 4, while he remained in the ED.

4. The facility failed to implement its "Staffing Plan for Surgical/Ortho Neuro," policy when it did not maintain a nurse to patient ratio of 1:5. This failure contributed to or caused Patient 5 to suffer a fall, when nurses did not answer her call light, and she got out of bed and fell. As a result of the fall, she suffered a cut to her head and had to stay in the hospital one extra night.

5. The facility failed to provide appropriate ongoing patient assessments, including evaluations related to appropriateness of outdoor activities and elopement risk, to meet the immediate safety needs and care of all CBH patients. This resulted in Patient 28, being permitted to attend an outdoor activity while exhibiting combative and erratic behavior, as well as up to five more CBH patients, including Patient 27, without the facility's usual public safety officer supervision. This compromised patient safety for all the patients who were attending the outdoor activity and contributed to Patient 27's elopement (unauthorized departure from the hospital) during outdoor activity unsupervised by public safety officers.

Findings:

1. a. The facility's "Staffing Plan for Critical Care" policy, dated 9/2018 was reviewed. It indicated the licensed nurse to patient ratio in Critical Care shall not be more than 1:2 at all times.

The California Department of Public Health (CDPH) received three complaints regarding understaffing in ICU on the night shift on 7/27/22, and allegations that Administration knew of this problem and proceeded with two open heart surgeries instead of rescheduling them, causing some nurses in the ICU, to have three patients instead of two assigned to them, and resulting in an unsafe situation.

During confidential interviews from 8/16/22 through 8/18/22 at 7:35 am, Registered Nurse (RN) 1, 2, 3, and 4 all confirmed the ICU was understaffed on 7/27/22 on night shift, with only three nurses scheduled for night shift. There were two patients who were scheduled to have open heart surgeries on 7/27/22. Both these open heart cases were not emergent so the hospital had the option of canceling these surgeries but went ahead with the surgeries anyway, despite only having three nurses scheduled in ICU on night shift. The surgeon and Administration knew the facility did not have enough staff to safely care for these patients. RN 3 said the charge nurse on night shift was taking care of four patients for part of the shift.

During a concurrent interview and record review on 8/17/22 at 9:30 am, the Director of Performance Improvement (DPI) confirmed there were three nurses including the charge nurse, scheduled for night shift, on 7/27/22 in the ICU. The nurses were out of ratio and the charge nurse had patients.

During an interview on 8/17/22 at 1:25 pm, House Supervisor (HS, ensures patients have adequate care coverage by coordinating staffing) 1 was the hospital supervisor on day shift on 7/27/22. She said, "we knew we were short staffed and the ICU Director (ICUD) called staff and a notification was sent to staff asking for help, so one day shift staff nurse stayed over until midnight and ICUD came in after midnight, and another nurse came in early at 3 am the next day, on 7/28/22". HS 1 said the first patient who had open heart surgery the morning of 7/27/22 was still a 1:1 patient (very critical and unstable and was a ratio of one nurse to one patient). She said, "he had heart valve surgery and we thought he would be off 1:1 by night shift but he wasn't. Although he should have remained 1:1 we didn't have enough staff so we had to go to 1:2." HS 1 said the Tele unit nurses already were maxed out (the Tele staffing sheet indicated each nurse had been assigned to care for five patients instead of four patients) so none of those nurses could float to help out in ICU.

During an interview on 8/17/22 at 1:45 pm, HS 2 (night shift house supervisor on 7/27/22) said they were extremely short staffed in ICU. She said the staffing issue started the day before, on 7/26/22. She said "we were short staffed and we probably should not be doing the open heart cases, but was told the surgeon was going out of town and needed to do it." She said when she started her shift the ICU charge nurse (CN) had patients and they were out of ratio at 1:3. HS 2 said the Cardiovascular OR crew (staff) and the surgeon knew staffing was not enough on night shift. Both these two open heart cases went to ICU where there were already patients on ventilators (tube inserted into the lungs and on a breathing machine) and where there was the Charge Nurse with only two other nurses scheduled for night shift. She said another patient from Tele declined and needed to go to ICU so she called the Administrator on call, who was the CEO (Chief Executive Officer). He advised her to call the Recovery Room (RR) staff which she did. The RR staff declined to come in because they were on call, had no critical care experience, and were scheduled to work the next day. HS 2 called the CEO again a couple times but he did not answer.

During an interview on 8/18/22 at 12:53 pm, RN 5 said she was the ICU charge nurse on night shift on 7/27/22. She said she started off the shift caring for three ICU patients. At one point she had four patients to care for, for three hours, from midnight until 3 am. RN 5 said during the period when she cared for four patients, three of the patients were on ventilators and they were receiving 27 intravenous (IV) medication drips between them. She said three of the patients were over 300 pounds and they did not get turned as they should have, which could lead to pressure sores. RN 5 said she also called the CEO, to ask for help, but he did not answer her calls.

During an interview on 8/17/22 at 1:55 pm, the ICU Director (ICUD) confirmed that the ICU charge nurse cared for four ICU patients for a brief period of time.

During a concurrent interview and record review on 8/22/22 at 9:20 am, DPI reviewed the records for the patients in ICU. DPI confirmed there were eight patients at the start of the night shift (6 pm). Two of them were stable and not on the ventilator, two were open heart patients whose surgeries had been performed that day who were on the ventilator with multiple tubes (tubes in the chest to drain blood and in the bladder to drain urine), lines (lines in the pulmonary artery to measure heart function, blood flow, and pressures in the heart) and IV medication drips (to maintain blood pressure and cardiac output, and sedatives), and three other patients also on the ventilator with one or more IV medication drips. Patient 2 was the eighth patient and had been on a regular medical-surgical floor. Patient 2 developed low oxygen saturations during the day and physician was notified on 7/27/22. The nursing notes indicated at 11:34 am, Patient 2 was awaiting an ICU bed. DPI said they had ICU beds but not enough staff so Patient 2 was not transferred to ICU until after 4:15 pm. After transfer to ICU, Patient 2 was intubated (breathing tube put down into the lungs) and placed on a ventilator.

1. b. A copy of the facility's "Rapid Response Team" policy, dated 6/2021, was reviewed. The purpose was, "the multidisciplinary team consists of a critical care nurse and respiratory therapist. The team will arrive within 10 minutes to assess and treat patients with deteriorating conditions." The policy was, "1. The goal is to provide early and rapid intervention, for patients demonstrating signs of imminent clinical deterioration, thus preventing intubations, admissions to ICU, cardiac arrest and death." The facility's "Rapid Response" policy, dated 11/2015 was reviewed. The procedures were, "1. The critical care nurse and respiratory therapist will assess the patient and provide the appropriate treatment as indicated on the standardized procedure to stabilize the patient... 2. A member of the team will stay with the patient until stable or transferred to a higher level of care."

A review of Patient 1's record indicated she was admitted through the Emergency Room on 7/24/22, to the Tele unit, with diagnoses that included acute on chronic respiratory failure, chronic obstructive lung disease (COPD), and heart failure. The following lab tests were done and were within normal limits: White Blood Cell (WBC) count was 8.7 (normal 4.5 - 11, high levels indicate infection), BUN/Creatinine 17 and 0.92 (normal 7-18 and 0.40-0.90, tests used to evaluate kidney function).

On 7/27/22 Patient 1's lab values were grossly abnormal indicating sepsis and altered kidney function. On 7/27/22 at 5:31 am, Patient 1's WBC were elevated at 22.8 and by 10:26 pm, the WBC was 31.3. Her BUN/Creatinine levels at 5:31 am were still within normal range but the levels were high by 10:26 pm, and BUN was 26 and Creatinine 2.57. Patient 1's Lactic Acid (indicates how serious septic shock is and when higher than 2 has been associated with mortality rates of 28.4%) was 2.9 (normal range 0.4-2.0) at 9:09 pm and went up to 3.8 by 10:06 pm. Patient 1's Procalcitonin level on 7/27/22 at 9:09 pm was 109.51 (normal range 0-0.5, procalcitonin levels of greater than two indicate a high probability of systemic bacterial infection and risk for progression to sepsis or septic shock), and was 146.78 by 10:26 pm.

During an interview on 8/25/22 at 4:55 pm, Tele RN (TRN) said she cared for Patient 1 in Tele on 7/27/22, before her transfer to ICU. She said she was told in report Patient 1 had hypotension (low blood pressure) and had been treated with a bolus (small amount given in a short time) of IV fluids but her blood pressure (BP) was still in the 70's and Mean Arterial Pressure was less than 60 (MAP, normal range 70-100 and indicates that there's enough consistent pressure in your arteries to deliver blood throughout your body, MAP is considered a better indictor of perfusion to vital organs than systolic BP). She said she notified Patient 1's physician that Patient 1 was not responding to fluids and he ordered another bolus of IV fluids which was given. She said they called a rapid response and the Tele charge nurse spoke to the ICU charge nurse, who was the rapid nurse for that night, and she gave instructions over the phone, because the ICU nurse was unable to come to the Tele unit to assess Patient 1. Another 1000 milliliters (ml) bolus IV fluids was given and labs were done. The physician was notified again who said he would call ICU about a transfer. The labs had critical values including critically high WBC count, lactic acid, procalcitonin and potassium. She said Patient 1 needed to be transferred to ICU but there was no ICU nurse to care for her. At one point she said she lost IV access and the Emergency Room physician came up and inserted a CVP line (IV line access in a major large vein). TRN said she started dobutamine (blood pressure medication) at 5 mcg/kg/min and inserted a foley (tube into the bladder to drain urine) but there was hardly any urine output. TRN said Patient 1 had no response to the dobutamine but they "can't start vasopressors (powerful medication to increase blood pressure) like Dopamine or Levophed (also known as Norepinephrine) and titrate (adjust the dose) them on the Tele unit". TRN said there were physician orders for vasopressors, including dopamine and Norepinephrine but they were not started until the ICU Director came in around 1 am and assumed care of this patient when she was transferred to ICU.

During an interview on 8/23/22 at 5:03 pm, RN 5 said she was the ICU charge nurse on 7/27/22. She said the charge nurse usually responds to a rapid response (called if a patient declines) or code blue (patient needs life saving resuscitative measures) on the floor. At the beginning of the shift she told the house supervisor that she would be unable to respond to any rapid or code blue because she was caring for three patients and none of the other nurses could watch her patients because they were already caring for too many patients. RN 5 said the charge nurse on Tele knew she couldn't come to Tele to help with a rapid response but needed help, so she called RN 5. The Tele nurse was concerned about Patient 1 and thought she might suffer a code blue without intervention. Patient 1's BP was in the 70's and MAP was below 60. RN 5 said she and Patient 1's physician tried to provide care for this patient without physically leaving ICU to go to the Tele unit. She said the Emergency Room physician went to Tele and put in a central line. She said "we knew we needed the central line to start vasopressor drips". Patient 1 had labs drawn around 9 pm and 10 pm and the lactic and procalcitonin levels were very high which indicated severe sepsis and Patient 1 belonged in ICU but she could not take another patient. The Tele nurse had tried dobutamine which is a medication they can give on Tele but that was not the right drug for this patient. Patient 1 needed dopamine and/ or Levophed which can only be given and titrated in ICU. "Patient 1 had a low BP and MAP for about six hours that caused inadequate perfusion to her organs and she was very sick by the time she got to us and ended up passing away a few days later."

During an interview on 8/22/22 at 7:25 am, RN 1 said if a patient's MAP is less than 60 they're not perfusing organs such as the kidneys and there is diminished perfusion to the tissues and brain. "That's why we have rapid responses, to give patients the treatment they need and if necessary, transfer them to ICU."

Further review of Patient 1's record indicated on 7/27/22 at 7 pm, her BP was 77/50 with MAP 59 and at 10 pm, Patient 1's BP was 72/48 and MAP 56. The ER physician went to Tele and inserted a inserted the central line in the right femoral vein on Patient 1. Afterwards he dictated a note on 7/27/22 at 10:29 pm. In this note, he indicated he had been called to place a central line in Patient 1 who was in respiratory distress with hypotension. He noted Patient 1 to have systolic BPs of approximately 60 with MAPs of approximately 40. The procedure required multiple sticks (needles inserted) in the right groin secondary (due) to no palpable (feel by touch) femoral pulse.

The ICU MD's admit note on 7/28/22 at 1:40 am indicated Patient 1 was a 57 year old with reported history of mitral and aortic valve (heart) surgery, COPD on home oxygen of 2 liters who was admitted a few days ago. She became hypotensive and was feeling more short of breath, unable to lie flat. WBC was increasing and lactic acid was elevated and renal functioning was worsening. Antibiotics were started and 4 liters IV fluids were given but the patient did not respond and continued to have low BP. His assessment was shock: suspect sepsis secondary to leukocytosis (elevated WBC). . . AKI (acute kidney injury) due to shock, hyperkalemia (high potassium level).

During concurrent interviews and record reviews on 8/22/22 at 9:20 am and 10:40 am, DPI reviewed Patient 1's record and said she was transferred from Tele to ICU around 1 am on 7/28/22. Vasopressor drips were then started to treat low BP and MAP upon admission to ICU. DPI said dopamine was not started until Patient 1 got to ICU and explained that titratable (dosages are adjusted frequently according to patient needs and vital signs) drugs such as dopamine are not given in Tele. She said there were physician orders on 7/27/22 to start dopamine at 11:10 pm and titrate dose every 10 minutes to maintain MAP 65 and Norepinephrine ordered at 7/28/22 at 12:10 am, titrate dose every 5 minutes to maintain MAP 65. Although dopamine was ordered 11:10 pm, it was not started for two hours, until Patient 1 got to ICU. DPI said even though it's not documented it looks like there was a delay in getting Patient 1 to ICU due to lack of staffing in ICU. Patient 1 was made comfort care on 8/1/22 and died the next day.

2. During an interview on 10/13/22 at 10:30 am, RN 12 said the hospital frequently staffs the ICU without enough nurses. He said the charge nurse often has to take patients. According to their policy the charge nurse must respond to any rapid response or code blue on other floors in the hospital. RN 12 explained this may take as little as 20 minutes or as long as 1 1/2 hours. If a charge nurse has patients then they are unable to respond to rapid responses and code blues, which impacts patient safety.

During an interview on 11/2/11 at 9:55 am, the Ortho/Neuro Director (OND) reviewed the staffing and assignment sheets for the night shift in ICU, on 9/13/22. He confirmed there were two patients that were extremely critical and those patients were assigned 1:1 (one patient to one nurse) so the charge nurse was assigned to care for two patients.

During an interview on 10/26/22 at 1:55 pm, OND and TD both confirmed the ICU charge nurse responds to rapid responses and code blues on the other floors in the hospital.

3. a. During an interview on 10/26/22 at 1:50 pm, the Tele Director (TD) reviewed the staffing sheets for Tele for night shift on 10/14/22 and said they were out of ratio. She said all the nurses except one were assigned to care for five patients when it should have been four patients.

During an interview on 10/20/22 at 9:40 am, the Chief Nurse Officer (CNO) reviewed the staffing sheets for ICU for the night shift on 10/14/22. He confirmed one nurse received a third patient that night and the other nurses including the Charge Nurse (CN) had two patients. He was requested to provide the names of patients who had rapid responses or code blues that night. He provided this information on 10/26/22 and it included the name of Patient 3.

A review of Patient 3's record indicated she had been admitted on 10/11/22 and had open heart surgery on 10/12/22. After surgery she was in the ICU, until the day shift on 10/14/22, when she was transferred to the Tele unit. At 5:15 pm her BP was 80/40 and MAP was 53 and at 5:30 pm her BP was 73/41 and MAP 52. A noted dated 10/14/22 at 5:56 pm indicated the physician had been notified of Patient 3's BP of 70/38 and gave an order for IV Albumin (used to treat low blood volume). A noted dated 10/14/22 at 7:32 pm indicated the cardiac surgeon was notified again that the patient's sustained BP was below 90 and ordered Albumin 100 ml IV. Patient 3's BP at 8 pm was 79/41, MAP 54. At 8:45 pm, Patient 3's BP was 73/33 and MAP 46. The next BP recorded was at 10 pm and was 71/34 with MAP 46. The Tele nurse notified the cardiac surgeon of the continued low BP and he wanted Patient 3 transferred back to ICU. A noted charted by the ICU charge nurse dated 10/14/22 at 11 pm, indicated she had been called by the Tele charge nurse to assess Patient 3 for transfer back to ICU. Upon arrival to the patient's room, Patient 3 stated she felt like she was dying, BP 73/40, heart rate in 50's. Patient 3 was transferred to ICU at 11:07 pm and Dopamine drip was started immediately. Patient 3 was in critical condition and remained in ICU until 10/17/22 at 7:31 pm, when she was transferred back to the Tele unit.

During a concurrent interview and record review on 11/2/22 at 10:30 am, TD said Patient 3 had been transferred from ICU to Tele on day shift on 10/14/22, with a "soft BP" (borderline normal) with low MAP. She reviewed Patient 3's BPs and confirmed they were in the 70's and MAPs in the 40's from 8 pm until Patient 3 was transferred at 11 pm. She confirmed these were below normal.

During an interview on 10/31/22 at 4:26 pm, RN 7 said she was charge nurse (CN) in ICU, on the night shift on 10/14/22, and was assigned to care for two patients. She said she told the HS she would not be able to respond to a rapid response or code blue because she had a patient assignment. RN 7 said one of her two patients was a patient who had open heart surgery that morning, was still on a ventilator, and should have been a 1:1 patient. Later in the shift around 11 pm the Tele CN called her, and even though she had told HS that she would not be able to respond to a code blue or rapid, she did go to Tele briefly to see Patient 3, whose surgeon wanted her moved back to ICU. She did not stay with Patient 3 and transfer her back to ICU, because she was unable to do so, due to her patient assignment. She told RN 1, who was working in ICU, she would have to take a third patient who needed dopamine.

3. b. During an interview on 10/31/22 at 4:26 pm, RN 7 said the house supervisor for the hospital also had to function as the charge nurse, in the ED on night shift, on 10/14/22. She said Patient 4 was a critically ill ED patient who had physician orders to be admitted to ICU, but had to remain in the ED the entire night shift on 10/14/22, due to no ICU nurse being available to care for that patient. She said the ED nurse who cared for Patient 4 also had three more patients to care for that night, when Patient 4, who was very critical, should have been a 1:1 (one patient to one nurse).

A review of the staffing sheets for ICU on 10/15/22, confirmed once Patient 4 was transferred to ICU, he was made a 1:1 for the day shift and night shift on 10/15/22, because he was extremely critical.

During a concurrent interview and record review on 10/26/22 at 1:30 pm, the ED director (EDD) reviewed staffing assignment sheets and ED logs (contains patient names and where transferred) for night shift on 10/14/22, and confirmed the nurses were out of ratio. She said Patient 4 came in to ED at 5:20 pm on 10/14/22, was admitted to ICU but stayed all night in ED. She said the RN (RN 8) who cared for this patient also had three other patients assigned to him. He should have had only two patients since this one was an ICU patient. The other ED nurses were assigned to care for five patients, instead of four, and since they had no charge nurse, the house supervisor (HS 2) had to function as the charge nurse in ED as well as house supervisor for the hospital. EDD confirmed Patient 4 was on a ventilator, had been started on cooling measures and had numerous IV drips for his heart, BP, and sedation.

During an interview on 11/7/22 at 12:55 pm, HS 2 confirmed she was both the house supervisor and the ED charge nurse on night shift on 10/14/22. She said the ED charge nurse has to direct patient traffic through the ED and be immediately available to answer all radio calls from ambulances.

The facility's "Targeted Temperature Management" policy, dated 5/2022, was reviewed. The purpose was "to guide the patient receiving Targeted Temperature Management (TTM) post cardiac arrest with return of ROSC in an effort to improve neurologic outcome." Pathophysiology - TTM decreased the cerebral (brain) metabolic rate by 6% for every 1 degree C drop in core body temperature thus reducing cerebral oxygen demand. Oxygen supply to the ischemic areas of the brain improves when blood flow increases subsequent to the reduction of the metabolic rate. Additional benefits include a decrease in intracranial pressure (inside the head) and potential protection against seizures. Policy - Cooling should be done rapidly for all patients whether they are in the ED or ICU, within 1-2 hours to achieve maximum effectiveness, and should be initiated as soon as possible after ROSC (return of spontaneous circulation, the resumption of a sustained heart rhythm that perfuses the body after cardiac arrest). Documentation included the patient's temperature, water temperature, cooling blanket settings with each change, shivering assessments, level of sedation. . .

A review of Patient 4's record indicated he suffered a witnessed cardiac arrest at home and was brought to the ED by ambulance on 10/14/22 at 5:18 pm. The ED physician noted he intubated Patient 4 and after ROSC, cooling measures were started. An ED nurse's note at 6:05 pm, indicated cooling measures were initiated with a goal temperature of 35 degrees C (Celsius) per physician order, Arctic Sun (device used to lower patients' temperatures). Patient 4's temperature on 10/14/22 at 5:52 was noted to be 96.6 F or 35.889 Celsius. The next temperature recorded was six hours later on 10/15/22 at 1 am when the temperature was 96 F or or 35.55 Celsius. Hourly temperatures from 2 am until 5:06 am were 96 F to 96.5 F. On 10/15/22 at 6 am, Patient 4's temperature was 95 F or 35 Celsius. It took 12 hours to cool Patient 4 to the goal temperature as opposed to one to two hours as indicated in the TTM policy. There was no hourly documentation of Patient 4's temperature, and no documentation of water temperature, cooling blanket settings, and shivering assessments. Patient 4 was transferred to ICU on 10/15/22 around 9 am. He was later made comfort care and expired on 10/18/22.

During a concurrent interview and record review on 11/7/22 at 9 am, the EDD confirmed there was a communication between the physician and the RN to start cooling measures with a goal temperature by use of the Arctic Sun. She said we don't use the Arctic Sun that often in ED because the patient usually goes right up to ICU.

During an interview on 11/7/22 at 1:46 pm, RN 8 said the other ED nurses were assigned to care for five patients, on night shift on 10/14/22. He said he was assigned to care for four patients but one of them was Patient 4, who was an ICU patient they were keeping in the ED. He said they started the cooling measures with the Arctic Sun. He said he has had no special training with this device and TTM but the Arctic Sun instructions were easy to follow. He was aware there was a policy for targeted temperature monitoring, but said he would not have had time to read it, given his assignment. He said he used Precedex (IV sedation for ventilator patients) initially but the patient was still restless so he started another drip. RN 8 said he was aware he needed to chart temperatures every hour and thought he had done so. He said the patient was not shivering although this was not charted. RN 8 said he was also assigned to care for three other patients who were not seriously ill. He said, I think they were giving me easier patients in the other three beds but that just meant I had to discharge one patient then get another patient.

During an interview on 11/15/22 at 8:30 am, the Clinical Educator said TTM training was not done in other areas outside the ICU.

During a concurrent interview and record review on 11/15/22 at 8 am the Director of Performance Improvement (DPI) confirmed the patient's temperature was recorded at 5:52 pm and not again until 1 am, it was 12 hours before target temperature was reached, and water temperature and shivering assessments were not recorded.

4. During a concurrent interview and record/document review on 9/28/22 at 3:10 pm, OND confirmed the ratio, on the Ortho/Neuro unit was five patients to one nurse, unless a patient was on Tele monitoring (continuous remote monitoring of the patient's heart rate and rhythm), then it should be four patients to one nurse. OND confirmed on 9/14/22, on the day shift, two RNs had six patients instead of five patients and on the night shift one nurse was assigned to care for six patients.

On 9/15/22 at 1:50 pm, RN 11 said she worked on the day shift on 9/14/22, on the Ortho/Neuro floor. She said they were out of ratio and understaffed, as usual, when one patient (Patient 5) who was alert and oriented, had her call light on for a long time. None of the nurses could get to her and the patient got up by herself and fell and hit her head and injured it. She said this patient had just had knee surgery the day before.

On 10/4/22, OND provided the names of three patients who had fallen from 9/13/22 through 9/16/22, which included three patients including Patient 5.

During an interview on 10/17/22 at 1:20 pm, Patient 5 confirmed she had fallen during her recent hospitalization. She said she went in on 9/13/22 for a complete knee replacement and was kept overnight. She said she was in a private room and had trouble with her bladder, and needed to go to the bathroom about every two hours. She said on 9/14/22, she put on her call light but no one came. There was a portable commode against the wall, so she got out of bed and tried to get on it, but when she reached for it, she fell and hit her head on the edge of the bed. Patient 1 said while she was laying on the floor she had to yell for help, because still no one came, and finally four people showed up to help her. She said her head started bleeding and they did a CT (computed tomography, detailed pictures of inside the body) scan of her head and got a knee X-ray and kept her overnight for one more night. She said she fell late morning or early afternoon and it was not until that evening, when a nursing student was assigned to care for her, did someone change her bloody pillowcase and offer to clean her hair, which had blood in it. Patient 1 said prior to the fall she had been out of bed but only with help. She said she had been told to use the call light when she needed to get up and she did as she had been told to do, but no one came. She said she did not know how long she had the call light on but she did not wait until the last minute before putting it on. Patient 1 also said no one from the hospital ever called her after the discharge to see how she was doing, which she would have expected, since she fell in the hospital, when no one answered her call light.

During a concurrent interview and review of Patient 1's record on 10/17/22 at 4:15 pm,

Based on interview and record review, the facility failed to ensure competency of staff prior to patient care assignment when no system for determining competency on each unit was implemented and maintained.

This failure had the potential to result in significant harm including death when the assigned nurse does not have established competencies to care for the assigned patients.

Findings:

1. During an interview on 11/15/22 at 8:25 am with the Clinical Educator (CE), CE stated that she was in the process of defining the orientation process. Her plan was for both a general orientation to the hospital and unit specific orientations to units that staff may float to. CE stated that she oversees and ensures that general orientation was completed and the department directors ensure that unit specific orientations and competency validations were completed and tracked. CE stated that it was her understanding that no nurse should float to another unit and be given a patient assignment until they have completed competency validation for that unit.

During a concurrent interview and record review on 11/15/22 at 9:45 am with the Orthopedic Neuro Director (OND), and CE, CE stated that the determination of unit based competency was done by the unit director and a record was kept on the unit. OND stated that he did not complete unit based competency validation on his staff and had no record of this. When asked how he determined competency to work on the unit, he stated that the preceptor did that but that there was no record kept. OND stated that he did not have any competencies on file for any of his nurses and understood that the Education Department did this. CE stated that she did general orientation for all new hires and the unit director did the unit specific competency validation. When asked if he saw a disconnect in this process, OND stated that he did see that there was a disconnect.

A review of the facility's policy titled, "General Orientation," revised 1/2017 indicated that for the "Department/Unit based Orientation: It is the responsibility of each department head/director/manager/supervisor or designee to assist the new employee with this portion of the orientation process."

A review of facility's document titled, "Telemetry Unit Daily Assignment Sheet," indicated that Registered Nurse (RN)18 was assigned to a full patient load (four patients) on the Telemetry unit (Tele, continuous remote monitoring of the patient's heart rate and rhythm) on 11/10/22.

A review of RN 18's personnel file indicated that RN 18 was hired as a medical/surgical floor nurse on 8/17/22, and her nursing license was issued, for the first time, on 6/24/22. No orientation checklist to the Telemetry floor could be found in her file.

During an interview on 11/16/22 at 8:45 am, Registered Nurse (RN) 19 stated that she had been floated on 11/10/22 to the Telemetry unit. She was hired as a orthopedic/neuro unit nurse. She has been with the facility and floated often. RN 19 stated that on 11/10/22, she saw the staffing assignment when she came on duty. The assignment indicated that two nurses from the medical/surgical/ortho group needed to float to telemetry (tele) that night. RN 19 volunteered as she had worked there often. After she arrived on the unit, she was surprised to see that RN 18 also arrived to work there with a full patient assignment of telemetry level patients. RN 18 told RN 19 that she had never worked on telemetry and had never been oriented to the unit. RN 19 knew RN 18 to be a newly graduated RN without much experience and was concerned about the assignment. RN 19 told the charge nurse, RN 21 that RN 18 would need assistance since she was inexperienced on the unit. RN 21 told RN 19, "you can just help her." RN 19 pointed out that she had been assigned to orient another nurse on that shift as well as have her own patient assignment and needed RN 21 to assist RN18. RN 19 stated that during the shift, RN 18 came to her often for help with many tasks that she needed assistance with, and was increasingly anxious and upset during the shift. At one point RN 19 saw RN 21 have a private 1:1 conversation with RN 18, but did not see RN 21 assist RN 18, at all during the shift. RN 21 was often seated at the nursing station while others attempted to assist RN 18.


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2. During an interview on 11/15/22, at 10 am, the Director of Telemetry (TD) said she didn't not know if the nurses that were floated to her department from other units in the hospital had completed the necessary competencies to work in her department, or if the nurses assigned to work on the Telemetry Unit had completed all of the staff competencies. TD confirmed she did not have any of her staffs' competencies and thought the clinical educator had them.

During an interview on 11/15/22 at 11 am, the House Supervisor (HS) 1 said she did not know which nurses have completed their competencies to float. HS 1 said she did know who was competent to work where. The Director of each department was supposed to let the house supervisors who can and cannot float and to what department.

A review of facility's document titled, "Telemetry Unit Daily Assignment Sheet" indicated RN 14 (floated from another floor without orientation and training) was assigned to a full patient load (four patients) on the Telemetry unit on 11/10/22.

During an interview on 11/15/22, at 8 pm, HS 3 said she staffs the units based on what the charge nurses told her. HS 3 said she didn't know if the nurse she assigned to float to telemetry on 11/10/22, was deemed competent to float to that unit.

During an interview on 11/16/22, at 3:15 pm, RN 23 said the Telemetry unit did not follow patient ratios. She said she was often assigned five patients per shift, as opposed to four. RN 23 said on 11/16/22 she was given five patients. One of the patients she was assigned to care for was on a cardiac drip (medication given intravenously) for heart arrythmias (irregular heart rate). She said she was told by the charge nurse (RN) 21 that she didn't need to know anything about this cardiac medication because the patient was on it at home. RN 23 said she did not feel it was a safe assignment. RN 23 also said she often did not get her breaks during the day because she was so busy and there was no one to relieve her.

During an interview on 11/16/22, at 3:45 pm, RN 24 said today (11/14/22) she was given five patients, one of whom was on a cardiac drip for blood pressure (a medication to regulate blood pressure). RN 24 said she spoke up and told the charge nurse (RN 21) that it was not safe. RN 21 told her it was not that much work. RN 24 said she often does not get her break during her shift.

During an interview on 11/16/22 at 4 pm, RN 25 said her shifts usually start with five patients and she felt it was not safe. When RN 25 told the charge nurse (RN 21), she was told she has to do it anyway. RN 25 stated she often did not get her breaks.






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3. A review of the facility's policy titled, "Staffing and Organizational Structure, Behavioral Health Program," dated 12/2017, indicated that all licensed and certified staff members were required to provide annual documentation demonstrating they have maintained the qualifications of training, experiences, and competency needed to function in their position.

A review of the facility's job description, "Behavioral Health Registered Nurse," revised 1/2014, indicated that the education, experience, and training required for a registered nurse and/or licensed vocational nurse to provide safe patient care in the CBH department included a Behavioral Violence Prevention (BVP) certificate within 6 months of hire and maintained current (annually).

A review of the facility's policy titled, "Code Gray, Behavioral Health Program," dated 12/2018, indicated that a Code Gray emergency requires CBH staff to provide facility support when a patient in the general facility becomes abusive or assaultive. The policy mandated that all staff assigned to CBH complete BVP training.

A review of the facility's corporate form, "Orientation for the Director of Psychiatric/Behavioral Health Services," undated, indicated the director of CBH must demonstrate competency in the responsibility for oversight of employee competency assessments and promote staff accountability for completing department training requirements.

During a concurrent interview and record review on 11/15/22 at 8:54 am, CE stated that licensed nurses and support staff hired to the CBH were required to complete a department specific BVP training upon initial hire and annually. CE reported that the facility's department directors were responsible for providing department specific trainings and ensuring that staff maintain job-specific competencies. CE verified the "Behavioral Violence Prevention Class Focus Outline," undated, included the following core competencies required, for CBH staff to deliver safe care to patients suffering from mental illness or psychiatric emergency: verbal de-escalation of psychiatric crisis, effectively and safely placing a patient in restraints, physical techniques to optimize safety with aggressive and/or violent behavior, understanding mental health laws, dealing with patients who suffer from mental health illness in the least restrictive manner, maintaining the safety of staff and patients when dealing with patients who are upset, agitated, aggressive, or in psychiatric crisis. CE stated prior to Covid-19 restrictions, BVP training was provided in a live, face to face format, to verify staff were comfortable and confident with CBH's core competencies. Since Covid-19, the facility converted BVP training to the facility's on-line educational portal 'Health Streams'. CE reported it was the responsibility of each department director to ensure their staff are assigned and completing mandatory trainings.

During an interview on 11/15/22 at 10 am, RN 16 stated they transferred to the facility's CBH department approximately two years. RN 16 had no previous mental health or behavioral health work experience and had not attended or completed a BVP training since their department orientation two years ago. RN16 reported they did not feel proficient in applying physical restraints or administering chemical restraints (the use of medication to subdue, sedate, or restrain an individual) to CBH patients in psychiatric crisis. These techniques were covered throughly in the BVP training.

During an interview on 11/15/22 at 11:42 am, BHA reported he transferred to the facility's CBH department two years ago. BHA had not attended or completed a BVP training since his department orientation two years ago. BHA stated BVP training was very valuable and covered new safety techniques on how to talk patients in crisis down, deescalate violent patients, and apply restraints if necessary. The BVP training helped BHA understand the symtpoms of mental illness and feel safe while keeping patients safe.

During an interview on 11/15/22 at 12 pm, RN 14 reported they work as a charge nurse on the CBH unit. RN 14 had not attended or completed BVP training since 2019. RN 14 stated prior to Covid-19 restrictions the training was offered in a live face-to-face format. Since Covid-19 restrictions the facility has not offered annual BVP training to current employees. RN 14 stated BVP training was imperative for staff to feel proficient and safe with de-escalation techniques and restraint use.

During an interview on 11/15/22 at 12:18 pm, Center for Behavioral Health Director (CBHD) confirmed that BVP training was required annually and stated the training covered critical components that "CBH staff use every minute of every day". CBHD stated he did not keep record or monitor if CBH staff have completed mandatory department trainings. CBHD reported either the corporate educators, the facility's human resource department, or the facility's one clinical educator were responsible for ensuring CBH staff maintain department specific competencies. If an employee was not current on their mandatory trainings, the facility's timeclock will not allow the staff member to proceed with work.

During an interview on 11/15/22 at 12:38 pm, Chief Nursing Officer (CNO) verified that BVP was required for all CBH staff at the time of hire and annually. CNO stated that the facility's directors were responsible for knowing that their staff were competent in and "cleared to work" safely. The facility did not utilize timeclock accountability for unit specific competencies.

During a concurrent interview and record review on 11/15 at 3:33 pm, the Director of Performance Improvement (DPI) stated the corporate educators develop curriculum and revamped trainings to be rolled out to the facilities. The facility's staff were responsible for monitoring staff competency and training. DPI generated a BVP course completion report for all staff who currently worked at the facility's CBH unit. DPI verified that currrently 16 of 49 (10.88%) CBH staff members have completed the mandatory BVP training.

Based on interview and record review:

1. The facility failed to ensure its "Transport of Monitored Patient," policy was implemented when two non-licensed patient care techs transferred Patient 3 from the Telemetry unit (Tele, continuous remote monitoring of the patient's heart rate and rhythm) to the Intensive Care Unit (ICU) and did not use a portable monitor. As a result, if Patient 3 had a life threatening arrhythmia (abnormal heart rhythm) during the transport, it would have gone unrecognized and untreated until her arrival to ICU.

2. The facility failed to implement its "Staffing Plan for Emergency Department," policy when it did not maintain a nurse to patient ratio of 1:2 for critical patients and 1:4 for general acute patients. As a result the staff were unable to fully implement its "Targeted Temperature Management," policy and there was a delay in the care provided for Patient 4 while he remained in the ED.

3. The facility failed to implement its "Staffing Plan for Telemetry," policy and its "Patient Classification-Telemetry," policy when it did not maintain a nurse to patient ratio of 1:4 and use a patient acuity system for staffing. This had the potential to result in a decline in the condition of all patients on this unit.


Findings:

1. The facility's "Transport of Monitored Patient" policy, dated 6/2022 was reviewed. It indicated its purpose was to set a standard that promotes safety for the monitored patients being transported from one unit to another. Any patient on the telemetry unit that is considered unstable or on a continuous IV (intravenous) drug infusion will have an ACLS (Advanced Cardiac Life Support) RN (Registered Nurse) accompany the patient with a portable bedside monitor when being transported.

A review of Patient 3's record indicated she had been admitted on 10/11/22 and had open heart surgery on 10/12/22. Afterwards she was in the ICU until the day shift on 10/14/22, when she was transferred to the Tele unit. Her condition declined and the surgeon ordered her to be transferred back to ICU. Her record included a nursing note which indicated on 10/14/22 at 11:07 pm, the patient had been transferred to ICU from Tele, by two patient care techs (unlicensed staff) on a tele monitor (monitor that is watched in a remote location in the hospital).

During an interview on 10/31/22 at 8:10 am, RN 1 said Patient 3 was transferred from Tele to ICU by two patient care techs not a RN. They used the tele monitor and not a portable cardiac monitor that would have been visible during the transport. She said the tele monitor was remote monitoring done in another location. If the patient had a life threatening heart rhythm, during the transport or in the elevator, the techs would not have even known about it, due to the lack of a portable monitor. RN 1 said according to their transport policy, it must be by a RN with a portable monitor.

During an interview on 11/1/22 at 8 am, RN 9 said she was the Tele nurse who cared for Patient 3 on 10/14/22. She said she did not go with Patient 3, when she was transferred to ICU. She said their unit was understaffed and since she had been busy with Patient 3 for a while, she went to check on her other patients. While she was checking her other patients, a patient care tech from ICU with a Tele tech took the pt to ICU, without her knowledge. She then went to ICU and gave report on the patien to the ICU RN.

2. The facility's "Targeted Temperature Management" policy, dated 5/2022, was reviewed. The purpose was "to guide the patient receiving Targeted Temperature Management (TTM) post cardiac arrest with return of ROSC in an effort to improve neurologic outcome." Pathophysiology - TTM decreased the cerebral (brain) metabolic rate by 6% for every 1 degree C drop in core body temperature thus reducing cerebral oxygen demand. Oxygen supply to the ischemic areas of the brain improves when blood flow increases subsequent to the reduction of the metabolic rate. Additional benefits include a decrease in intracranial pressure (inside the head) and potential protection against seizures. Policy - Cooling should be done rapidly for all patients whether they are in the ED or ICU, within 1-2 hours to achieve maximum effectiveness, and should be initiated as soon as possible after ROSC (return of spontaneous circulation, the resumption of a sustained heart rhythm that perfuses the body after cardiac arrest). Documentation included the patient's temperature, water temperature, cooling blanket settings with each change, shivering assessments, level of sedation.

A review of Patient 4's record indicated he suffered a witnessed cardiac arrest at home and was brought to the ED by ambulance on 10/14/22 at 5:18 pm. The ED physician noted he intubated Patient 4 and after ROSC cooling measures were started. An ED nurse's note at 6:05 pm, indicated cooling measures initiated, goal temperature of 35 degrees C (Celsius) per physician order, Arctic Sun (device used to lower patients' temperatures). Patient 4's temperature on 10/14/22 at 5:52 was noted to be 96.6 F or 35.889 Celsius. The next temperature recorded was six hours later on 10/15/22 at 1 am when the temperature was 96 F or or 35.55 Celsius. Hourly temperatures from 2 am until 5:06 am were 96 F to 96.5 F. On 10/15/22 at 6 am, Patient 4's temperature was 95 F or 35 Celsius. It took 12 hours to cool Patient 4 to the goal temperature as opposed to 1 to 2 hours as indicated in the TTM policy. There was no hourly documentation of Patient 4's temperature, and no documentation of water temperature, cooling blanket settings, and shivering assessments.

During a concurrent interview and record review on 11/15/22 at 8 am the Director of Performance Improvement (DPI) confirmed the patient's temperature was recorded at 5:52 pm and not again until 1 am, it was 12 hours before target temperature was reached and the shivering assessment not recorded.






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3. During a concurrent interview and record review on 11/14/22 at 10 a.m., with Director of Telemetry (TD), the "Telemetry Unit Night shift Daily Assignment Sheets (TNDAS)," dated November 1, 4, 8, and 13, 2022 were reviewed. The NDAS indicated the nursing staff were out of compliance when each nurse was assigned five patients instead of four patients. TD confirmed the staffing ratio for those days was out of compliance.

During a concurrent interview and record review on 11/14/22 at 10:30 a.m., with TD, the "Telemetry Unit Day shift Daily Assignment Sheets (TDDAS)," dated November 6, 9, and 11, 2022 were reviewed. The TDDAS indicated the nursing staff were out of compliance when each nurse was assigned five patients instead of four. TD confirmed the staffing ratio for those days was out of compliance.

During a concurrent interview and record review on 11/15/22 at 10 am, with House Supervisor (HS 1), the facility's policy and procedure (P&P) titled, "Staffing Plan for Telemetry," dated 9/18, was reviewed. The P&P indicated, "The licensed nurse-to-patient ratio in Telemetry shall be no greater than 1:4 at all times." HS 1 confirmed they did not follow their P&P titled "Staffing Plan for Telemetry."

During a concurrent interview and record review on 11/14/22 at 10:40 a.m., with HS 3, the Telemetry Unit Patient Classification Variance (TUPCV, includes acuity levels of each patient to assist in determining the number of staff needed) forms, dated for the month of November 2022, were reviewed. The TUPCV indicated acuity level 5 patients were one licensed nurse to three patients. HS 3 confirmed they did not base their staffing on acuity levels.

During a review of the facility's P&P titled, "Patient Classification-Telemetry," dated 4/21, the P&P indicated, a Patient Classification system shall be used from shift to shift to determine the number of staff required to meet the needs of critical care patients. The staffing ratio shall be 1:4 ratio at all times.