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Based on interview and record review the facility failed to ensure Registered Nurse (RN) care met the professional standards when:

1. A change in condition notification to Medical Doctor (MD) was not done per Policy and Procedure (P&P) titled, "ASSESSMENT AND REASSESSMENT OF PATIENTS" for one of 31 sampled patients (Patient 30).

2. Vitals signs (heart rate, breathing rate, pain, oxygen level, and blood pressure) were not done every 15 minutes for one of 31 sampled patients (Patient 30) during an administration of an intravenous (IV- medication delivery into a vein) medication Norepinephrine (medication to increase blood pressure).

3. The facility's P&P titled, "STANDARDIZED PROCEDURE: RAPID RESPONSE TEAM RRT MANAGEMENT OF PATIENTS" was not followed for respiratory distress (difficulty breathing) for one of 31 sampled patients (Patient 30).

These failures resulted in a disruption in the continuity of quality care nursing services, providers not being updated on patient care changes and outcomes for Patient 30.

Findings:

1. During a concurrent interview and record review on 9/26/24 at 9:16 a.m. with Quality Safety Registered Nurse (QSRN), Patient 30's "Vitals Section (VS)," dated 4/30/24 was reviewed. The VS indicated on, 4/30/24, at 1:34 a.m., Patient 30's heart rate was 140 (normal heart rate 60 to 100 beats per min[ute]-bpm) and breathing rate was 56 (normal breathing rate 12 to 22) breathes per minute. QSRN stated, Patient 30 was breathing fast, admitted for Sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection or injury, causing organ dysfunction) and was "very sick." QSRN stated the facility process for change in condition was not followed and MD should have been contacted regarding Patient 30's increased respiratory rate of 56 and heart rate of 140 bpm. QSRN stated on 4/30/24, at 4:12 a.m., Patient 30's heart rate was 121 bpm, breathing rate was 30, and pulse oximetry (measurement of oxygen level) was 81% (normal oxygen level greater than or equal to 92%) with supplemental oxygen at 10 liters/minutes delivery via nasal cannula (a tube device used to deliver oxygen through the nose). QSRN stated MD was not notified of Patient 30's condition for respiratory distress and should have been.

During a concurrent interview and record review on 9/26/24 at 9:18 a.m. with QSRN, the facility's P&P titled, "ASSESSMENT AND REASSESSMENT OF PATIENTS," dated 11/27/18 was reviewed. The P&P indicated, "A. The following processes will be followed to identify and deliver the proper patient care, treatment, and services. . . H. INTERVENTION- 1. The planning and delivery of patient care shall reflect all elements of the nursing process. . . 4. RNs play the predominant role in the timely communication of the patient's response or lack of response to treatment to others, such as the physician." QSRN stated MD should have been notified of Patient 30's change in condition.

During a concurrent interview and record review on 9/26/24 at 1:33 p.m. with MD. Patient 30's medical record (MR), dated 4/30/24 was reviewed. There was no indication of MD being notified of Patient 30's respiratory distress condition. MD stated Patient 30's respiratory distress should have been reported to her.

2. During a concurrent interview and record review on 9/25/24 at 3:32 p.m. with QSRN, Patient 30's "Physician Order (PO)," dated 4/30/24 was reviewed. The PO indicated, "Norepinephrine drip 8 mg (milligram) + (plus) Sodium Chloride 0.9% premix diluent titrate." QSRN stated the facility P&P included vitals signs for Norepinephrine were to be obtained and assessed every 15 minutes with an infusion of Norepinephrine.

During a concurrent interview and record review on 9/25/24 with QSRN at 3:36 p.m. Patient 30's "Medication Administration Record (MAR)," dated 4/30/24 was reviewed. The MAR indicated Norepinephrine drip was started on 4/30/24, at 5:37 a.m. QSRN stated there were no vitals prior to the administration or every 15 minutes after being initiated.

During a concurrent interview and record review on 9/30/24 at 11:17 a.m. with QSRN, the facility's P&P titled, "ASSESSMENT AND REASSESSMENT OF PATIENTS," dated 11/27/18 was reviewed. The P&P indicated, "F. VITAL SIGN ASSESSMENT- 1. Vital signs include the following: Temperature, blood pressure, pulse, respirations, and level of pain. . . 3. The frequency of vital signs throughout a shift is based on clinical area and the patient's condition. a. Critical Care: Blood pressure, pulse, respiratory rate, and other hemodynamic measurements should be monitored and recorded. . . Frequent VS, e.g., every 15 minutes, may be required according to specific care/treatment guidelines, medications, and interventions." QSRN stated there were no vitals signs obtained every 15 minutes for Patient 30. QSRN stated the facility's P&P should have been followed.

3. During a concurrent interview and record review on 9/25/24 at 3:27 p.m. with QSRN, Patient 30's "Rapid Response Team (RRT) note," dated 4/30/24 was reviewed. The RRT note indicated on, 4/30/24, at 4:40 a.m., Patient 30 had respiratory distress and a RRT call was placed for a critical care trained nurse evaluation. QSRN stated there was 28 minutes from the time Patient 30 had a drop in his oxygen level to when the RRT was implemented. QSRN stated the facility process is to call a RRT when there is a decrease in oxygenation below 92%, increased respirations, changes in heart rate, and a nurse concern for the patient condition. QSRN stated Patient 30 had physician orders that included to monitor and maintain an oxygen saturation level equal to or greater than 92%. QSRN stated Patient 30 had an oxygen level of 81% with supplemental oxygen in use of 10 liters/minute via nasal cannula with a breathing rate of 30, and that was criteria for a Rapid Response.

During a concurrent interview and record review on 9/25/24 at 3:41 p.m., with QSRN, the facility's P&P titled, "STANDARDIZED PROCEDURE: RAPID RESPONSE TEAM RRT MANAGEMENT OF PATIENTS," dated 12/29/2020 was reviewed. The P&P indicated, "STANDARDIZED PROCEDURE SUMMARY/INTENT. . . for safe and appropriate management by the Rapid Response Team (RRT) for patients exhibiting signs and symptoms of impending respiratory and/or cardiovascular collapse. . . C. Circumstances under which the RN may perform the function: 1. . . . The RRT may be activated in all situations where rapid patient evaluation is needed including but not limited to the following signs/symptoms. . . a. Circulation: Acute change in. . . heart rate. . . > [greater than] 130 bpm. . . b. Airway: Respiratory distress and/or threatened airway. C. Breathing: Acute change in respiratory rate > 30. . . SpO2 < 90% despite oxygen use. . . f. Staff concern: Nurse or other hospital staff members are worried or concerned about patient. . . failure to respond to treatment, increasing level of care or acuity." QSRN stated Patient 30's oxygen saturation was critically low, and a RRT should not have taken 28 minutes to call.

During an interview on 9/26/24 at 1:56 p.m. with MD, MD stated, "30 minutes or so is a long time, we cannot put the person [Patient 30] at risk." MD stated Patient 30 met rapid response criteria.

Based on interview and record review the facility failed to ensure completeness of a medical record (MR) for one of 31 sampled patients (Patient 30) when a heart monitoring tracing strip was not included in the MR for one of 31 sampled patients (Patient 30). This failure resulted in an incomplete medical record for Patient 30.

Findings:

During a concurrent interview and record review on 9/26/24 at 9:27 a.m. with Quality Safety Registered Nurse (QSRN), Patient 30's "Telemetry (heart monitoring) Tracings (TR)," dated 4/29/24 to 4/30/24 was reviewed. The TR indicated, on 4/30/24 Patient 30 had no documented telemetry tracing other than the code blue (medical emergency) telemetry tracing. QSRN stated Patient 30 was admitted to a telemetry care area with heart monitoring ordered, and there should be a telemetry tracing rhythm strip in his MR. QSRN stated the facility process included the registered nurse (RN) to review, sign, and have the telemetry tracing rhythm strip scanned into the MR. QSRN stated Patient 30 had no telemetry tracing documentation to provide from the telemetry care area.

During a concurrent interview and record review on 9/26/24 at 4:30 p.m. with QSRN, the facility's P&P titled, "MEDICAL RECORD CONTENT AND COMPLETENESS", dated 12/28/22 was reviewed. The P&P indicated, "POLICY SUMMARY/INTENT. . . Assure the medical record contains patient specific data and information to . . . support the diagnosis, facilitate patient care, treatment of services. . . support decision analysis, justify treatment. . . to provide a medical record for all patients that is timely, meaningful, an authentic and legible description of the patient's clinical condition and hospital course. . . define a complete and properly documented patient medical record that supports patient care. . . E. The patient medical record shall include. . . 3. Any findings of assessments and reassessments. . . 9. Any observations relevant to care, treatment, and service." QSRN stated, "All documentation for Patient 30's care should be in the MR, and not documented is incomplete and not done."

During a concurrent interview and record review on 9/26/24 at 5:04 p.m. with QSRN, the facility's P&P titled, "REMOTE CARDIAC TELEMETRY MONITORING & AUTOSTOP PROCEDURE", dated 2/22/23 was reviewed. The P&P indicated, "C. PROCEDURE. . . 13. Telemetry tracings, trends, and alarm reviews will be reviewed . . . The strips will be placed in the medical record by the RN after reviewing, signing, dating and timing it. . . a. Any significant arrhythmia events observed between routine 12-hour reviews and tracings will be documented by running a strip and documenting in the chart."

During an interview on 9/30/24 at 3:39 p.m. with Chief Medical Officer (CMO), CMO stated Patient 30's chart had a lack of documentation and "not documented is not done." CMO stated all staff was to follow policy, and that included complete and accurate documentation of the care provided.