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Based on the manner and degree of the standard-level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 Condition of Participation: NURSING SERVICES was out of compliance.

A-0405 Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care, and accepted standards of practice: Based on observations, interviews, and document review, the facility failed to ensure patients with respiratory concerns received oxygen and monitoring in accordance with recognized standards and provider orders to ensure the safety of patients in one out of one patients who received continuous oxygen titration. (Patient #1)

Based on observations, interviews, and document review, the facility failed to ensure patients with respiratory concerns received oxygen and monitoring in accordance with recognized standards and provider orders to ensure the safety of patients in one out of one patients who received continuous oxygen titration. (Patient #1)

Findings include:

Facility policies:.

The Oxygen/Therapeutic Gas Administration and Humidification policy read, a respiratory therapist or registered nurse will review daily the need and appropriateness of oxygen therapy and follow all provider orders for titration and discontinuation of oxygen therapy. Supplemental O2 may be increased as clinically indicated by respiratory or nursing staff only. If the prescribed oxygen produces an saturation of peripheral oxygen (SpO2) less than 90% (unless the physician's order specifies otherwise), the liter flow or FiO2 needed to achieve an SpO2 of 90% is determined by adjusting the flow or percentage of oxygen and measuring the clinical response via pulse oximetry. The physician will be contacted when the results of the oxygen therapy assessment indicate a need to increase the liter flow by three liters or more to achieve the same SpO2.

The Assessment and Reassessment policy read, reassessment is to be ongoing and may be triggered by pertinent data that may include, but are not limited to: early physiological monitoring systems, acute change in patient condition and/or change in diagnosis, response to plan of care/treatment plan. This may necessitate the need for other disciplines (i.e.: dietary, therapies, respiratory, case management) to be notified

The Clinical Assessment and Reassessment Guideline policy read, problem focused reassessment every shift (can be delegated to a designee with required RN assessment required daily) and as the patient ' s condition warrants.

References:

The patient care technician (PCT) job description read, the PCT delivers high quality, patient-centered care by performing a variety of delegated basic patient care services related to common nursing functions and activities of daily living. Participates in the implementation of nursing care plans by performing direct and indirect patient care under the supervision of the licensed nurse. Provides or assists with non-medicated support care, including non-sterile dressing changes, skin protection, application of heat or ice, and venous compression devices

The State Board of Nursing certified nurse aide (CNA) scope of practice read, the CNA, when deemed competent by a registered nurse (RN) or advanced practice registered nurse (APRN), in good faith may perform the following tasks only for clients/patients with stable health conditions and who are not considered high risk: (5) Administration of oxygen as authorized by a health care provider.

The Colorado Revised Statutes, ARTICLE 255: NURSES AND NURSE AIDES read, in no event may a registered nurse or certified midwife delegate to another person the authority to select medications if the person is not, independent of the delegation, authorized by law to select medications. Delegated tasks must be within the area of responsibility of the delegating nurse or certified midwife and must not require any delegatee to exercise the judgment required of a nurse or certified midwife. The delegating nurse or certified midwife is solely responsible for determining the required degree of supervision the delegatee will need, after an evaluation of the appropriate factors, which include but are not limited to the following: (a) The stability of the condition of the patient; (d) Whether the delegated task has a predictable outcome.

1. The facility failed to ensure patients received oxygen according to a provider's order, documented interventions and change in the patient's condition, and ensured continuous pulse oximetry monitoring was provided to high risk patients. Additionally, the facility failed to ensure staff performed care within their scope of practice.

A. Observations

i. On 7/10/24 at 2:25 p.m., observations were conducted in the progressive care unit (PCU). Observations revealed patient care technician (PCT) #1 at the nursing station. PCT #1 reported to the nursing staff they were concerned about walking Patient #1. PCT #1 stated they had been titrating Patient #1's oxygen for most of the shift related to the patient's pulse oximetry and shortness of breath.

ii. On 7/10/24 at 2:28 p.m., observations were conducted in room 4309. Observation revealed PCT #1 unhooked Patient #1's nasal cannula from the wall supplied oxygen and placed the patient on a portable oxygen tank.

The observations on 7/10/24 were in contrast to the PCT job description which read, the PCT participated in the implementation of nursing care plans and performed direct and indirect patient care under the supervision of the licensed nurse. Provided or assisted with non-medicated support care.

The observations on 7/10/24 were also in contrast to the Oxygen/Therapeutic Gas Administration and Humidification policy read, supplemental O2 may be increased as clinically indicated by respiratory or nursing staff only.

The observations on 7/10/24 were also in contrast to the State Board of Nursing certified nurse aide (CNA) scope of practice which reach read, the CNA when deemed competent by a RN or APRN in good faith may have performed the following tasks only for clients/patients who had stable health conditions and who are not considered high risk: administration of oxygen as authorized by a health care provider.

B. Document Review

i. Medical record review revealed Patient #1 was admitted to the ICU on 7/3/24 for community-acquired pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation (a sudden worsening of breathing) and was transferred to the progressive care unit (PCU) on 7/8/24. Further review of the medical record review revealed, on 7/3/24 at 11:55 a.m., Patient #1 had an active order for heated high flow oxygen. There was no evidence in the medical record the patient had an order to titrate oxygen.

This was in contrast to the observation on 7/10/24 which showed the patient on wall supplied oxygen rather than heated high flow oxygen. Wall-supplied oxygen was delivered through hospital outlets at low to moderate flow rates without heating or humidification, while heated high-flow oxygen was delivered via specialized system at high flow rates with heating and humidification

ii. Review of Patient #1's telemetry record revealed on 7/10/24 between the hours of 12:00 a.m. and 3:00 p.m. the patient's SpO2 dropped below 87% 11 times. There was no evidence in the medical record that medical interventions had been documented, the provider had been notified, or the nurse had performed a reassessment.

Further review of the telemetry record revealed a gap in continuous pulse oximetry on 7/9/24 for approximately 40 minutes. There was no evidence in the medical record the telemetry department notified the patient nurse.

This was in contrast to the Assessment and Reassessment policy which read, reassessment was ongoing and could be triggered by pertinent data, including early physiological monitoring systems, acute changes in patient condition or diagnosis, and response to the plan of care or treatment plan.

This was also in contrast to the Clinical Assessment and Reassessment Guideline policy which read, a problem focused reassessment was conducted every shift and as the patient ' s condition warranted.

C. Interviews

i. On 7/11/24 at 8:30 a.m., an interview was conducted with Patient #1. Patient #1 stated they had difficulty breathing and shortness of breath since their admission. Patient #1 stated PCT #1 and RN #3 titrated their 02 the day prior with little to no relief. Patient #1 stated they continued to have shortness of breath and was concerned that their care was not progressing.

ii. On 7/10/24 at 2:35 p.m., an interview was conducted with PCT #1. PCT #1 stated they titrated Patient #1 oxygen throughout the shift and would report the change to the RN. PCT #1 stated they titrated the patient's oxygen from five liters to nine liters during lunch due to the patient experiencing shortness of breath. PCT #1 stated they had told the nurse after they had titrated the oxygen and it was the responsibility of the nurse to document the change. PCT #1 stated it was common practice for PCTs to titrate oxygen. PCT #1 stated they were unaware of any risks for oxygen administration.

iii. On 7/10/24 at 2:50 p.m., an interview was conducted with RN #3. RN #3 stated Patient #1 had an order for high flow oxygen. RN #3 stated Patient #1's pulse oximetry was not stable and required the staff to titrate the oxygen throughout the shift. RN #3 stated they were busy during their shift and did not always have time to access Patient #1 when their pulse oximetry was low. RN #3 stated when they were busy they allowed experienced PCTs titrate oxygen. RN #3 stated they titrated Patient #1 oxygen throughout the shift and did not document the titration in the patient's medical record.

iv. On 7/11/24 at 9:15 a.m., an interview was conducted with PCT #2. PCT #2 stated they would titrate the oxygen by one liter at a time and continued to increase the oxygen until the shortness of breath subsided. PCT #2 stated they would change the patient from nasal to a simple face mask if the increased amount of oxygen failed to stabilize their pulse oximetry. PCT #2 stated it was common practice for PCTs to titrate oxygen. PCT #2 stated they would not document the titration of the oxygen as that was the nurse's responsibility. PCT #2 stated they would only document the oxygen with the patient's routine vital signs.

The interviews with PCT #1, PCT #2, and RN #3 were in contrast to the PCT's job description which read, the PCT participated in the implementation of nursing care plans and performed direct and indirect patient care under the supervision of the licensed nurse. Provided or assisted with non-medicated support care

The interviews with PCT #1, PCT #2, and RN #3 were also in contrast to the Oxygen/Therapeutic Gas Administration and Humidification policy which read, supplemental O2 may be increased as clinically indicated by respiratory or nursing staff only. The physician was contacted when the results of the oxygen therapy assessment indicated a need to increase the liter flow by three liters or more to achieve the same SpO2.

The interviews with PCT #1, PCT #2, and RN #3 were also in contrast to the State Board of Nursing certified nurse aide (CNA) scope of practice which reach read, the CNA, when deemed competent by a RN or APRN, in good faith may have performed the following tasks only for clients/patients who had stable health conditions and who are not considered high risk: administration of oxygen as authorized by a health care provider.

The interviews with PCT #1, PCT #2, and RN #3 were in contrast to the Colorado Revised Statutes, ARTICLE 255: NURSES AND NURSE AIDES which read, the registered nurse could not delegate the authority to select medications to another person if that person was not independently authorized by law to select medications. Delegated tasks needed to be within the delegating nurse area of responsibility and could not require the delegatee to exercise the judgment of a nurse. The delegating nurse was solely responsible for determining the necessary degree of supervision for the delegatee after evaluating factors such as the stability of the patient's condition and the predictability of the delegated task's outcome.

v. On 7/11/24 at 12:12 p.m., an interview was conducted with RN #4. RN #4 stated oxygen should not be titrated without an order. RN #4 stated PCTs were not allowed to titrate oxygen. RN #4 stated PCTs were not clinically trained to titrate the patients oxygen. RN #4 stated PCTs could administer too much oxygen to the patient, which decreased their respiratory drive, which could lead to retained carbon dioxide and respiratory arrest. RN #4 stated it was important to document changes in oxygen administration to see trends in how the patient was doing. RN #4 stated providers needed to see if the patient's oxygen had been changed to evaluate the patient's response to their treatment. RN #4 stated if the nursing staff did not document the change in the patient's condition, the healthcare team might not provide appropriate interventions and the patient could decompensate.

vi. On 7/10/24 at 4:12 p.m., an interview was conducted with respiratory manager (Manager) #5. Manager #5 stated oxygen was considered a medication. Manager #5 stated that increasing the rate of flow and amount of oxygen for a COPD patient could decrease the respiratory drive and cause the patient to go into respiratory arrest.

vii. On 7/10/24 at 3:05 p.m., an interview was conducted with the director of telemetry (Director) #6. Director #6 stated that patients should have had the correct oxygen order. Director #6 stated patients should have a titrated oxygen order. Director #6 stated it was outside of the PCTs' scope of practice to titrate the patients' oxygen. Director #6 stated PCTs did not have the clinical knowledge to assess the patient and determine the patient's oxygen needs. Director #6 stated it was the nurse's responsibility to titrate the patient's oxygen, evaluate the intervention, and document the response in the medical record.

viii. On 7/11/24 at 3:50 p.m., an interview was conducted with the director of patient safety (Director) #9. Director #9 stated Patient #1 did not have an order to titrate oxygen. Director #9 stated that the patient's medical record had lacked documentation indicating that the oxygen for Patient #1 had been titrated during the day shift on 7/10/24. Director #9 stated that the telemetry department had informed nursing staff of a gap in continuous pulse oximetry monitoring on 7/9/24 at 10:00 p.m. because Patient #1's battery had died and needed to be replaced. Director #9 stated the gap in continuous pulse oximetry had been estimated at 40 minutes.

The interview with Director #9 was in contrast with the telemetry notification log, which did not show that the telemetry department had notified the nursing staff about the need to replace the continuous pulse oximetry monitor battery.

ix. On 7/11/24 at 12:39 p.m., an interview was conducted with hospitalist (Provider) #7. Provider #7 stated oxygen should only have been titrated by the respiratory therapist, registered nurse, or provider. Provider #7 stated it was important for patients to receive oxygen as ordered by the prescriber. Provider #7 stated that patients on oxygen should have had an oxygen titration order. Provider #7 stated if staff did not document the titration and delivery of oxygen, they would not have been able to assess the patient's response to treatment, potentially affecting the care received. Additionally, Provider #7 stated without being notified of changes in the patient's condition, they would not have been able to effectively treat the patient.

x. On 7/15/24 at 10:54 a.m., an interview was conducted with chief nursing officer (CNO) #8. CNO #8 stated all PCTs at the facility were required to have a CNA certification. CNO #8 stated that oxygen was considered a medication. CNO #8 stated patients should have had the correct oxygen order. CNO #8 stated patients should have had a titrated oxygen order. CNO #8 stated only the nurse or respiratory therapist should have titrated the patient's oxygen, with documentation in the medical record. CNO #8 stated the physician should have been contacted when the oxygen therapy assessment indicated a need to increase the liter flow by three liters within a 12-hour shift. CNO #8 stated if the patient was off continuous pulse oximetry, the telemetry department should have called the nurse to notify them. CNO #8 stated that the facility's telemetry escalation pathway required immediate intervention within five minutes. CNO #8 stated that it was important to maintain continuous pulse oximetry to monitor the patient and identify changes in condition.

Interviews with the hospital leadership were in contrast to the observations performed on 7/10/24 where PCT #1 reported titrating Patient #1's oxygen.

Interview with the hospital leadership was in contrast the the interviews with PCT #1, PCT #2, and RN #3 who stated PCTs routinely titrated patients' oxygen levels.