HospitalInspections.org

Based on clinical record review, video review, document review and interviews it was revealed the governing body failed to ensure the day to day operations and policies and procedures of the hospital were followed. The governing body failed to ensure medical staff evaluate the quality of patient care provided to patients by nursing staff and failed to ensure nursing staff follow facility policy to initiate cardiopulmonary resuscitation (CPR) for emergency services of patient #5 without a pulse or respirations. This failure was revealed in one (1) out of eleven (11) patient cases reviewed. This failure has the potential for all patients to be at risk for an adverse event (see tags A 049 and A 093).

Based on clinical record review, video review, document review and interviews it was revealed the governing body failed to ensure medical staff is accountable for the quality of patient care provided to patients and ensures nursing staff follow facility policy to initiate cardiopulmonary resuscitation (CPR) for emergency services of patient #5 without a pulse or respirations. This failure was revealed in one (1) out of eleven (11) patient cases reviewed. This failure has the potential for all patients to be at risk for an adverse event.

Findings include:

1. A review of patient #5's clinical record revealed a "Nursing Progress Note" dated 06/07/21 at 4:57 a.m., documented by Registered Nurse (RN) #1, that states in part: "Licensed Practical Nurse (LPN) was preparing to do a CIWA/COWS (Clinical Institute Withdrawal Assessment/Clinical Opiate Withdrawal) assessment when patient found-stating ... did not think the patient was breathing, RN evaluated patient, who was cold, mottled, eyes open and fixed, no respirations, no pulse, no cardiac sounds present. Patient was last awake at 2315 (11:15 p.m.). Patient was documented as being asleep at subsequent face checks. RN notified on-call provider, on-call admissions, on-call Family Practice Care (FPC) provider, Assistant Chief Executive Officer and Assistant Chief Nursing Executive (ACNE). Patient was pronounced by physician #1."

2. A video recording was reviewed from the date of 06/06/21 at approximately 11:35 p.m. through 06/07/21 till approximately 1:48 a.m. of Unit A6. On 06/06/21 at 11:55 p.m. LPN #1 was seen documenting face checks, enters and leaves patient #5's room and continues completing face checks. On 06/07/21 at approximately 12:09 a.m. LPN #1 was seen completing face checks, entered patient #5's room and at 12:14 a.m. leaves the room and walks to the nurse's station. At 12:14 a.m. RN #1 and LPN #1 go back to patient #5's room. During the course of the review, no crash cart was seen taken to the patient's room, nor were there any staff seen rushing to the patient #5's room on the unit.

3. A review of the "Morbidity and Mortality Committee" meeting minutes dated 06/10/21 of patient #5's case review states in part: "In review of all records, all evaluations and assessments were done in a timely manner. In summary, it was the consensus that the care provided to the patient was appropriate; and no probable cause for the hospital." A review of the CPR/Code Blue response was not evaluated.

4. A review of the "Code Call Sheet" from 06/01/21 through 06/14/21 revealed a Code Blue was not documented being called on 06/06/21 or 06/07/21 for patient #5.

5. A review of staff's "Basic Life Support" certifications for CPR revealed all staff working on the Unit A6 on 06/06/21 at the time of the event had active CPR certifications.

6. A review of facility policy, "Unit Face Checks/Security Checks," revised/reviewed 07/30/19, states in part: "The face check person should always look for "signs of life" including, but not limited to breathing; chest and/or abdominal rises; snoring; and/or any kind of body movements. ... Be aware of the special problems that patients may have, conditions such as cardiac, diabetes, epilepsy, and what to do if an emergency occurs."

7. A review of facility policy, "Patient Death in Hospital," revised/reviewed 02/16/17, states in part: "When any patient is found unconscious without respiration or pulse, CPR shall be instituted immediately, and a code blue (call to the Switchboard) shall be made unless the patient has a "do not resuscitate" (DNR) order. ... The Emergency Medical Services (EMS) will be expected to transport the person to a local emergency room. ... Mortality Review: Committee members shall thoroughly review the circumstances of the patient's death. All records shall be examined to evaluate the patient's care. Should the EMS believe that death has occurred and refuse to transport the person; a determination of death must be made by the licensed independent provider called in accordance with accepted medical standards. The time of the exam is the time of death."

8. A review of facility policy, "Patient's Rights and Responsibilities," effective 09/24/19, states in part: "While you are in this hospital, you or your guardian/representative (if clinically indicated) have the right: ... to a sanitary and humane living environment, and reasonable safety in so far as the hospital practices and environment are concerned ... to receive prompt and adequate psychiatric and medical treatment ... to be free from: neglect; exploitation; verbal, mental, physical, and sexual abuse; harassment; and any form of corporal punishment."

9. A review of facility policy, "Behavioral Code of Conduct," revised/reviewed 05/27/10, states in part: "Each employee assumes responsibility to identify and report any behavior that threatens patient safety or impedes the delivery of quality patient care. Individuals in a leadership capacity have the additional responsibility to ensure that appropriate mechanisms are used to ensure patient and employee confidentiality and safety once incidents of misbehavior are reported. ... employees will ... report any condition or infraction of law, safety standard, etc. to appropriate level of leadership; protect the confidentiality, safety and dignity of patients ... identify errors in work and strive to correct the errors and set up procedures to ensure they do not reoccur ... adhere to safety policies and procedures and report safety violation to the appropriate level of leadership."

10. A review of facility policy, "Patient Abuse/Neglect or Exploitation," effective 02/21/19, states in part: "It is the responsibility of all hospital staff to ensure protection of all patients from physical and verbal abuse or any other infringement of their civil, human or legal rights and from neglect. ... ensures a timely, thorough and objective investigation of all allegations of abuse, neglect or harassment. ... will suspend any employee accused of abuse or neglect pending outcome of investigation."

11. A review of facility policy, "Handling of Patient Complaint/Grievances," effective 03/20/20, states in part: "Complaints alleging abuse, neglect, endangerment or misappropriation of property are given top priority, are reviewed immediately by the Legal Aid Patient Advocate with immediate interventions taken as necessary to safeguard the patient, and the matter referred at once to Administration for further management. Any allegation of abuse or neglect will be referred to Adult Protective Services (APS) immediately. When a complaint or grievance has been received by the Legal Aid Patient Advocate, they shall approach resolution with assistance from appropriate staff/Department Manager(s) and administration."

12. A review of facility policy, "Identification, Assessment, and Referral of Possible Cases of Abuse, Neglect, or Exploitation," revised/reviewed 10/30/14, states in part: "Neglect: Negligent, reckless, or intentional failure to meet the needs of a client ... criteria for suspicion of neglect: ...18. Nonaction which results in abuse of any form. ... Procedure: 1. All patients will be assessed for the potential of abuse, neglect, or exploitation as a part of the admission process. ... 4. In the event that a patient's potential for abuse/neglect or exploitation is not identified in the initial assessments, a referral can be made at any point during the treatment when these issues are recognized. ... 6. A referral will be made to Adult Protective Services (APS) immediately on the patient's behalf. The individual recognizing the issue will be responsible for notifying APS ....

13. An interview was conducted on 09/15/21 at approximately 11:25 p.m. with RN #1. When asked about patient #5's death and if CPR was provided, RN #1 stated in part, "The LPN that was doing face to face checks came to me and said they didn't think patient #5 was breathing. (States LPN #1 name) who told me. I went in to check the patient. The patient was gray and mottled and cool to the touch. I got a stethoscope and there was not breath sounds or cardiac sounds. I worked at Hospice and seen a lot of patients die. From past experience, I didn't see the benefit and it was not started." When asked about the CPR policy and CPR is only held for DNR patients, the RN stated in part, "True. The patient was not a DNR." When asked if a report was filed, the RN stated in part, "Yes, I did a report. I'm not aware an APS was done."

14. An interview was conducted on 09/15/21 at approximately 1:15 p.m. with Licensed Practical Nurse #1. When asked about finding patient #5 and if CPR was performed, the nurse stated in part, "I found the patient deceased. I was on face checks. ... I noticed the patient's eyes were open and fixed. I shook the patient and there was no response, so I went to the nurse, the RN that night. ... (States RN #1's name) and I both went back there and the RN checked the patient's pulse. I went and got a scope and the RN checked the patient. I then went back to doing the face checks and the RN called who needed to be called. The Medical Examiner came." When asked why CPR was not started, the nurse stated in part, "I can't answer that. I don't know." The first thing I thought was to tell the RN the patient wasn't breathing." When discussing the CPR policy and the policy and if they were told to do CPR, the nurse stated in part, "No." When asked if they had a CPR certification, the nurse stated in part, "Yes."

15. An interview was conducted on 09/16/21 at approximately 11:30 a.m. with the ACNE. When asked about patient #5 not receiving CPR when found, the ACNE stated in part, "I know the policy and the nurse knows the policy. ... I don't feel we did anything wrong, but that we didn't follow our policies. I know the mind set, but I know the policy here." ... When asked if the patient was neglected, the ACNE concurred.

16. An interview was conducted on 09/15/21 at approximately 10:38 a.m. with the Chief Compliance Officer. When asked if CPR was provided to patient #5, the CCO stated in part, "It wasn't done. I can't answer that."

17. An interview was conducted on 09/15/21 at approximately 11:06 a.m. with Chief Executive Officer (CEO). When asked about patient #5's death, the CEO agreed CPR was not provided for the patient. The CEO concurred staff didn't follow the policy of the hospital and stated, "If it's not charted, it didn't happen."

Based on clinical record review, video review, document review and interviews it was revealed the governing body failed to ensure medical staff evaluate and appraise emergency patient services and care for patient #5 and ensure nursing staff follow facility policy to initiate cardiopulmonary resuscitation (CPR) for emergency services patients without a pulse or respirations. This failure was revealed in one (1) out of eleven (11) patient cases reviewed. This failure has the potential for all patients to be at risk for an adverse event.

Findings include:

1. A review of patient #5's clinical record revealed a "Nursing Progress Note" dated 06/07/21 at 4:57 a.m., documented by Registered Nurse (RN) #1, that states in part: "Licensed Practical Nurse (LPN) was preparing to do a CIWA/COWS (Clinical Institute Withdrawal Assessment/Clinical Opiate Withdrawal) assessment when patient found-stating ... did not think the patient was breathing, RN evaluated patient, who was cold, mottled, eyes open and fixed, no respirations, no pulse, no cardiac sounds present. Patient was last awake at 2315 (11:15 p.m.). Patient was documented as being asleep at subsequent face checks. RN notified on-call provider, on-call admissions, on-call Family Practice Care (FPC) provider, Assistant Chief Executive Officer and Assistant Chief Nursing Executive (ACNE). Patient was pronounced by physician #1."

2. A video recording was reviewed from the date of 06/06/21 at approximately 11:35 p.m. through 06/07/21 till approximately 1:48 a.m. of Unit A6. On 06/06/21 at 11:55 p.m. LPN #1 was seen documenting face checks, enters and leaves patient #5's room and continues completing face checks. On 06/07/21 at approximately 12:09 a.m. LPN #1 was seen completing face checks, entered patient #5's room and at 12:14 a.m. leaves the room and walks to the nurse's station. At 12:14 a.m. RN #1 and LPN #1 go back to patient #5's room. During the course of the review, no crash cart was seen taken to the patient's room, nor were there any staff seen rushing to the patient #5's room on the unit.

3. A review of the "Morbidity and Mortality Committee" meeting minutes dated 06/10/21 of patient #5's case review states in part: "In review of all records, all evaluations and assessments were done in a timely manner. In summary, it was the consensus that the care provided to the patient was appropriate; and no probable cause for the hospital." A review of the CPR/Code Blue response was not evaluated.

4. A review of the "Code Call Sheet" from 06/01/21 through 06/14/21 revealed a Code Blue was not documented being called on 06/06/21 or 06/07/21 for patient #5.

5. A review of staff's "Basic Life Support" certifications for CPR revealed all staff working on the Unit A6 on 06/06/21 at the time of the event had active CPR certifications.

6. A review of facility policy, "Unit Face Checks/Security Checks," revised/reviewed 07/30/19, states in part: "The face check person should always look for "signs of life" including, but not limited to breathing; chest and/or abdominal rises; snoring; and/or any kind of body movements. ... Be aware of the special problems that patients may have, conditions such as cardiac, diabetes, epilepsy, and what to do if an emergency occurs."

7. A review of facility policy, "Patient Death in Hospital," revised/reviewed 02/16/17, states in part: "When any patient is found unconscious without respiration or pulse, CPR shall be instituted immediately, and a code blue (call to the Switchboard) shall be made unless the patient has a "do not resuscitate" (DNR) order. ... The Emergency Medical Services (EMS) will be expected to transport the person to a local emergency room. ... Mortality Review: Committee members shall thoroughly review the circumstances of the patient's death. All records shall be examined to evaluate the patient's care. Should the EMS believe that death has occurred and refuse to transport the person; a determination of death must be made by the licensed independent provider called in accordance with accepted medical standards. The time of the exam is the time of death."

8. A review of facility policy, "Patient's Rights and Responsibilities," effective 09/24/19, states in part: "While you are in this hospital, you or your guardian/representative (if clinically indicated) have the right: ... to a sanitary and humane living environment, and reasonable safety in so far as the hospital practices and environment are concerned ... to receive prompt and adequate psychiatric and medical treatment ... to be free from: neglect; exploitation; verbal, mental, physical, and sexual abuse; harassment; and any form of corporal punishment."

9. A review of facility policy, "Behavioral Code of Conduct," revised/reviewed 05/27/10, states in part: "Each employee assumes responsibility to identify and report any behavior that threatens patient safety or impedes the delivery of quality patient care. Individuals in a leadership capacity have the additional responsibility to ensure that appropriate mechanisms are used to ensure patient and employee confidentiality and safety once incidents of misbehavior are reported. ... employees will ... report any condition or infraction of law, safety standard, etc. to appropriate level of leadership; protect the confidentiality, safety and dignity of patients ... identify errors in work and strive to correct the errors and set up procedures to ensure they do not reoccur ... adhere to safety policies and procedures and report safety violation to the appropriate level of leadership."

10. A review of facility policy, "Patient Abuse/Neglect or Exploitation," effective 02/21/19, states in part: "It is the responsibility of all hospital staff to ensure protection of all patients from physical and verbal abuse or any other infringement of their civil, human or legal rights and from neglect. ... ensures a timely, thorough, and objective investigation of all allegations of abuse, neglect, or harassment. ... will suspend any employee accused of abuse or neglect pending outcome of investigation."

11. A review of facility policy, "Handling of Patient Complaint/Grievances," effective 03/20/20, states in part: "Complaints alleging abuse, neglect, endangerment or misappropriation of property are given top priority, are reviewed immediately by the Legal Aid Patient Advocate with immediate interventions taken as necessary to safeguard the patient, and the matter referred at once to Administration for further management. Any allegation of abuse or neglect will be referred to Adult Protective Services (APS) immediately. When a complaint or grievance has been received by the Legal Aid Patient Advocate, they shall approach resolution with assistance from appropriate staff/Department Manager(s) and administration."

12. A review of facility policy, "Identification, Assessment, and Referral of Possible Cases of Abuse, Neglect, or Exploitation," revised/reviewed 10/30/14, states in part: "Neglect: Negligent, reckless, or intentional failure to meet the needs of a client ... criteria for suspicion of neglect: ...18. Nonaction which results in abuse of any form. ... Procedure: 1. All patients will be assessed for the potential of abuse, neglect, or exploitation as a part of the admission process. ... 4. In the event that a patient's potential for abuse/neglect or exploitation is not identified in the initial assessments, a referral can be made at any point during the treatment when these issues are recognized. ... 6. A referral will be made to Adult Protective Services (APS) immediately on the patient's behalf. The individual recognizing the issue will be responsible for notifying APS ....

13. An interview was conducted on 09/15/21 at approximately 11:25 p.m. with RN #1. When asked about patient #5's death and if CPR was provided, RN #1 stated in part, "The LPN that was doing face to face checks came to me and said they didn't think patient #5 was breathing. It was (states LPN #1s name) who told me. I went in to check the patient. The patient was gray and mottled and cool to the touch. I got a stethoscope and there was not breath sounds or cardiac sounds. I worked at Hospice and seen a lot of patients die. From past experience, I didn't see the benefit and it was not started." When asked about the CPR policy and CPR is only held for DNR patients, the RN stated in part, "True. The patient was not a DNR." When asked if a report was filed, the RN stated in part, "Yes, I did a report. I'm not aware an APS was done."

14. An interview was conducted on 09/15/21 at approximately 1:15 p.m. with LPN #1. When asked about finding patient #5 and if CPR was performed, the nurse stated in part, "I found the patient deceased. I was on face checks. ... I noticed the patient's eyes were open and fixed. I shook the patient and there was no response, so I went to the nurse, the RN that night. ...(States RN #1's name) and I both went back there, and the RN checked the patient's pulse. I went and got a scope, and the RN checked the patient. I then went back to doing the face checks and the RN called who needed to be called. The Medical Examiner came." When asked why CPR was not started, the nurse stated in part, "I can't answer that. I don't know." The first thing I thought was to tell the RN the patient wasn't breathing." When discussing the CPR policy and the policy and if they were told to do CPR, the nurse stated in part, "No." When asked if they had a CPR certification, the nurse stated in part, "Yes."

15. An interview was conducted on 09/16/21 at approximately 11:30 a.m. with the ACNE. When asked about patient #5 not receiving CPR when found, the ACNE stated in part, "I know the policy and the nurse knows the policy. ... I don't feel we did anything wrong, but that we didn't follow our policies. I know the mind set, but I know the policy here." ... When asked if the patient was neglected, the ACNE concurred.

16. An interview was conducted on 09/15/21 at approximately 10:38 a.m. with the Chief Compliance Officer. When asked if CPR was provided to patient #5, the CCO stated in part, "It wasn't done. I can't answer that."

17. An interview was conducted on 09/15/21 at approximately 11:06 a.m. with Chief Executive Officer (CEO). When asked about patient #5's death, the CEO agreed CPR was not provided for the patient. The CEO concurred staff didn't follow the policy of the hospital and stated, "If it's not charted, it didn't happen."

Based on clinical record review, video review, document review and interviews it was determined the facility failed to protect patient rights to ensure the facility followed the grievance policy, provide care in a safe setting and to ensure patients are free of neglect to ensure nursing staff follow facility policy to initiate cardiopulmonary resuscitation (CPR) for emergency services of patient #5 without a pulse or respirations. This failure was identified in one (1) out of eleven (11) patient records. These findings have the potential for all patients to be at risk for serious injury, harm, or death. (See tags A 120, A 144, and A 145).

A. Noncompliance: An Immediate Jeopardy (IJ) for Patient Rights, to receive care in a safe setting and to be free of neglect, and Nursing Services, failing to evaluate a patient and follow policy and procedures, was called on 09/15/21 at 12:36 p.m. because the facility failed to ensure the nursing staff-initiated CPR of patient #5 who was found in their room not breathing and not having a pulse.

B. Harm or Potential Harm: The patient was found without a heartbeat, pulse or respirations on 06/07/21 at approximately 12:08 a.m. and CPR was not initiated. This practice places all patients at risk for serious injury, harm or death.

C. Immediacy: The facility needs to correct their processes to ensure all staff recognize and provide CPR immediately when finding patients who are not breathing and pulseless.

D. A remedial plan of correction was received and sent to the Interim State agency Program Director. The plan was accepted and the facility abated the IJ on 09/15/21 at 6:04 p.m. by immediately educating all department nursing staff in person upon arrival to their next shift to ensure all staff follow the following: any patient found unresponsive without a pulse or respirations must immediately have CPR performed by CPR qualified staff; must call audibly for help and initiate a "Code Blue" upon discovery of any unresponsive patient without a pulse or respirations; continue CPR until arrival of the Emergency Medical Services (EMS) team or a physician orders to cease CPR and the patient is not left alone until EMS or appropriate individuals removes the patient from the facility. The facility reviewed and revised three (3) Code Blue policies to remove conflicting directives, re-educate direct care staff who have not worked in the immediate action period and conduct mock code blues one (1) time per month on each shift on random units until all units have been included and will be monitored by nursing administration and supervisors. The data will be reported to the Quality Assurance Performance Improvement (QA/PI) Committee for tracking and trending for six (6) months.

Based on clinical record review, video review, document review and interviews it was determined the facility failed to protect patient rights to ensure the facility followed the grievance policy to ensure the facility staff report neglect of patient #5 and failed to submit an Adult Protective Services (APS) report in accordance with West Virginia State law. This failure was identified in one (1) out of eleven (11) patient records. These findings have the potential for all patients to be at risk for serious injury, harm, or death.

Findings include:

1. A review of patient #5's clinical record revealed a "Nursing Progress Note" dated 06/07/21 at 4:57 a.m., documented by Registered Nurse (RN) #1, that states in part: "Licensed Practical Nurse (LPN) was preparing to do a CIWA/COWS (Clinical Institute Withdrawal Assessment/Clinical Opiate Withdrawal) assessment when patient found-stating ... did not think the patient was breathing, RN evaluated patient, who was cold, mottled, eyes open and fixed, no respirations, no pulse, no cardiac sounds present. Patient was last awake at 2315 (11:15 p.m.). Patient was documented as being asleep at subsequent face checks. RN notified on-call provider, on-call admissions, on-call Family Practice Care (FPC) provider, Assistant Chief Executive Officer and Assistant Chief Nursing Executive (ACNE). Patient was pronounced by physician #1."

2. A video recording was reviewed from the date of 06/06/21 at approximately 11:35 p.m. through 06/07/21 till approximately 1:48 a.m. of Unit A6. On 06/06/21 at 11:55 p.m. LPN #1 was seen documenting face checks, enters and leaves patient #5's room and continues completing face checks. On 06/07/21 at approximately 12:09 a.m. LPN #1 was seen completing face checks, entered patient #5's room and at 12:14 a.m. leaves the room and walks to the nurse's station. At 12:14 a.m. RN #1 and LPN #1 go back to patient #5's room. During the course of the review, no crash cart was seen taken to the patient's room, nor were there any staff seen rushing to the patient #5's room on the unit.

3. A review of the "Administrator on Call Log" dated 06/2021 revealed an APS report was not documented as filed.

4. A review of the "Administrator On-Call Log," documented by the Assistant Chief Executive Officer, revealed they were notified of patient #5's death at 12:14 a.m. and to complete all required paperwork.

5. An email dated 09/16/21 at 9:26 a.m. from Patient Advocate #1 states in part: "There was not an investigation completed by Legal Aid."

6. A review of facility policy, "Patient's Rights and Responsibilities," effective 09/24/19, states in part: "While you are in this hospital, you or your guardian/representative (if clinically indicated) have the right: ... to a sanitary and humane living environment, and reasonable safety in so far as the hospital practices and environment are concerned ... to receive prompt and adequate psychiatric and medical treatment ... to be free from: neglect; exploitation; verbal, mental, physical, and sexual abuse; harassment; and any form of corporal punishment."

7. A review of facility policy, "Identification, Assessment, and Referral of Possible Cases of Abuse, Neglect, or Exploitation," revised/reviewed 10/30/14, states in part: "Neglect: Negligent, reckless, or intentional failure to meet the needs of a client ... criteria for suspicion of neglect: ...18. Nonaction which results in abuse of any form. ... Procedure: 1. All patients will be assessed for the potential of abuse, neglect, or exploitation as a part of the admission process. ... 4. In the event that a patient's potential for abuse/neglect or exploitation is not identified in the initial assessments, a referral can be made at any point during the treatment when these issues are recognized. ... 6. A referral will be made to APS immediately on the patient's behalf. The individual recognizing the issue will be responsible for notifying APS ....

8. A review of facility policy, "Patient Abuse/Neglect or Exploitation," effective 02/21/19, states in part: "It is the responsibility of all hospital staff to ensure protection of all patients from physical and verbal abuse or any other infringement of their civil, human or legal rights and from neglect. ... ensures a timely, thorough, and objective investigation of all allegations of abuse, neglect, or harassment. ... will suspend any employee accused of abuse or neglect pending outcome of investigation."

9. A review of facility policy, "Handling of Patient Complaint/Grievances," effective 03/20/20, states in part: "Complaints alleging abuse, neglect, endangerment or misappropriation of property are given top priority, are reviewed immediately by the Legal Aid Patient Advocate with immediate interventions taken as necessary to safeguard the patient, and the matter referred at once to Administration for further management. Any allegation of abuse or neglect will be referred to APS immediately. When a complaint or grievance has been received by the Legal Aid Patient Advocate, they shall approach resolution with assistance from appropriate staff/Department Manager(s) and administration."

10. A review of facility policy, "Behavioral Code of Conduct," revised/reviewed 05/27/10, states in part: "Each employee assumes responsibility to identify and report any behavior that threatens patient safety or impedes the delivery of quality patient care. Individuals in a leadership capacity have the additional responsibility to ensure that appropriate mechanisms are used to ensure patient and employee confidentiality and safety once incidents of misbehavior are reported. ... employees will ... report any condition or infraction of law, safety standard, etc. to appropriate level of leadership; protect the confidentiality, safety and dignity of patients ... identify errors in work and strive to correct the errors and set up procedures to ensure they do not reoccur ... adhere to safety policies and procedures and report safety violation to the appropriate level of leadership."

11. A review of the "Analysis of Adverse Patient Event," analysis undated, conducted by RN #1 and reviewed by ACNE, states in part: "It was the 0015 (12:15 a.m.) round when LPN noted pillow was over patient's nose/mouth at this time she moved it and noted that patient wasn't breathing. ... Findings of Review: Staff responded quickly and appropriately, per RN assessment, cardiopulmonary resuscitation (CPR) was not started due to the coolness, mottling, hyper flexion of neck and eyes dilated/fixed, this was reported to provider and supported by provider. Medical Examiner (ME) office to complete autopsy. Conclusion, including if this event was preventable: Nothing preventable noted at this time. Corrective Action: None noted at this time."

12. An interview was conducted on 09/15/21 at approximately 11:25 p.m. with RN #1. When asked if a report was filed, the RN stated in part, "Yes, I did a report. I'm not aware an APS was done." When asked if all staff with CPR training know to start CPR and call for help, the RN stated in part, "I don't know if all staff know to do it. But if it is unexpected, we don't think about it. All staff are educated for CPR but don't think about it."

13. An interview was conducted on 09/16/21 at approximately 10:24 a.m. with Patient Advocate #1. When asked if an investigation was completed for patient #5, the Advocate stated in part, "For those situations, our stance is that in a death, if there were signs of neglect or abuse, we leave it to law enforcement or the medical examiner to determine or if an APS had been filed then we investigate."

14. An interview was conducted on 09/16/21 at approximately 11:20 a.m. with Patient Advocate #1. When asked about the follow up if an investigation was completed for patient #5, the Advocate stated in part, "I went back and reviewed the chart. We didn't have any questions for CPR. We saw the patient was seen by the medical examiner. I raised no concerns to do an investigation."

15. An interview was conducted on 09/16/21 at approximately 11:30 a.m. with the ACNE. When asked if the reports were reviewed at Quality Assurance Performance Improvement (QA/PI), the ACNE stated in part, "The QA/PI Committee didn't get the report to review." When asked if the patient was neglected, the ACNE concurred.

Based on clinical record review, video review, document review and interviews it was determined the facility failed to protect patient rights to ensure the nursing staff provide care in a safe setting and follow facility policy to initiate cardiopulmonary resuscitation (CPR) for emergency services of patient #5 without a pulse or respirations. This failure was identified in one (1) out of eleven (11) patient records. These findings have the potential for all patients to be at risk for serious injury, harm or death.

Findings include:

1. A review of patient #5's clinical record revealed a "Nursing Progress Note" dated 06/07/21 at 4:57 a.m., documented by Registered Nurse (RN) #1, that states in part: "Licensed Practical Nurse (LPN) was preparing to do a CIWA/COWS (Clinical Institute Withdrawal Assessment/Clinical Opiate Withdrawal) assessment when patient found-stating ... did not think the patient was breathing, RN evaluated patient, who was cold, mottled, eyes open and fixed, no respirations, no pulse, no cardiac sounds present. Patient was last awake at 2315 (11:15 p.m.). Patient was documented as being asleep at subsequent face checks. RN notified on-call provider, on-call admissions, on-call Family Practice Care (FPC) provider, Assistant Chief Executive Officer and Assistant Chief Nursing Executive (ACNE). Patient was pronounced by physician #1."

2. A video recording was reviewed from the date of 06/06/21 at approximately 11:35 p.m. through 06/07/21 till approximately 1:48 a.m. of Unit A6. On 06/06/21 at 11:55 p.m. LPN #1 was seen documenting face checks, enters and leaves patient #5's room and continues completing face checks. On 06/07/21 at approximately 12:09 a.m. LPN #1 was seen completing face checks, entered patient #5's room and at 12:14 a.m. leaves the room and walks to the nurse's station. At 12:14 a.m. RN #1 and LPN #1 go back to patient #5's room. During the course of the review, no crash cart was seen taken to the patient's room, nor were there any staff seen rushing to the patient #5's room on the unit.

3. A review of staff's "Basic Life Support" certifications for CPR revealed all staff working on the Unit A6 on 06/06/21 at the time of the event had active CPR certifications.

4. A review of the "Administrator On Call Log" dated 06/2021 revealed an Adult Protective Services (APS) report was not documented as filed.

5. A review of facility policy, "Unit Face Checks/Security Checks," revised/reviewed 07/30/19, states in part: "The face check person should always look for "signs of life" including, but not limited to breathing; chest and/or abdominal rises; snoring; and/or any kind of body movements. ... Be aware of the special problems that patients may have, conditions such as cardiac, diabetes, epilepsy, and what to do if an emergency occurs."

6. An email dated 09/16/21 at 9:26 a.m. from Patient Advocate #1 states in part, "There was not an investigation completed by Legal Aid."

7. A review of the "Code Call Sheet" from 06/01/21 through 06/14/21 revealed a Code Blue was not documented being called on 06/06/21 or 06/07/21 for patient #5.

8. A review of facility policy, "Patient Death in Hospital," revised/reviewed 02/16/17, states in part: "When any patient is found unconscious without respiration or pulse, CPR shall be instituted immediately, and a code blue (call to the Switchboard) shall be made unless the patient has a "do not resuscitate" (DNR) order. ... The Emergency Medical Services (EMS) will be expected to transport the person to a local emergency room. ... Mortality Review: Committee members shall thoroughly review the circumstances of the patient's death. All records shall be examined to evaluate the patient's care. Should the EMS believe that death has occurred and refuse to transport the person; a determination of death must be made by the licensed independent provider called in accordance with accepted medical standards. The time of the exam is the time of death."

9. A review of facility policy, "Patient's Rights and Responsibilities," effective 09/24/19, states in part: "While you are in this hospital, you or your guardian/representative (if clinically indicated) have the right: ... to a sanitary and humane living environment, and reasonable safety in so far as the hospital practices and environment are concerned ... to receive prompt and adequate psychiatric and medical treatment ... to be free from: neglect; exploitation; verbal, mental, physical, and sexual abuse; harassment; and any form of corporal punishment."

10. A review of facility policy, "Behavioral Code of Conduct," revised/reviewed 05/27/10, states in part: "Each employee assumes responsibility to identify and report any behavior that threatens patient safety or impedes the delivery of quality patient care. Individuals in a leadership capacity have the additional responsibility to ensure that appropriate mechanisms are used to ensure patient and employee confidentiality and safety once incidents of misbehavior are reported. ... employees will ... report any condition or infraction of law, safety standard, etc. to appropriate level of leadership; protect the confidentiality, safety and dignity of patients ... identify errors in work and strive to correct the errors and set up procedures to ensure they do not reoccur ... adhere to safety policies and procedures and report safety violation to the appropriate level of leadership."

11. A "Face Check" rounding sheet for Unit A6 was presented for review for the requested date of 06/06/21 through 06/07/21. The document revealed patient #5 was checked every fifteen (15) minutes from 7:00 p.m. through 12:00 a.m. but was not documented from 12:15 a.m. through 6:45 a.m.

12. An interview was conducted on 09/15/21 at approximately 10:38 a.m. with the Chief Compliance Officer. When asked if CPR was provided to patient #5, the CCO stated in part, "It wasn't done. I can't answer that."

13. An interview was conducted on 09/15/21 at approximately 11:25 p.m. with RN #1. When asked about patient #5's death and if CPR was provided, RN #1 stated in part, "The LPN that was doing face to face checks came to me and said they didn't think patient #5 was breathing. (States LPN #1's name) who told me. I went in to check the patient. The patient was gray and mottled and cool to the touch. I got a stethoscope and there was not breath sounds or cardiac sounds. I worked at Hospice and seen a lot of patients die. From past experience, I didn't see the benefit and it was not started." When asked about the CPR policy and CPR is only held for DNR patients, the RN stated in part, "True. The patient was not a DNR." When asked if a report was filed, the RN stated in part, "Yes, I did a report. I'm not aware an APS was done."

14. An interview was conducted on 09/15/21 at approximately 1:15 p.m. with LPN #1. When asked about finding patient #5 and if CPR was performed, the nurse stated in part, "I found the patient deceased. I was on face checks. ... I noticed the patient's eyes were open and fixed. I shook the patient and there was no response, so I went to the nurse, the RN that night. ...(States RN #1's name) and I both went back there and the RN checked the patient's pulse. I went and got a scope and the RN checked the patient. I then went back to doing the face checks and the RN called who needed to be called. The Medical Examiner came." When asked why CPR was not started, the nurse stated in part, "I can't answer that. I don't know." The first thing I thought was to tell the RN the patient wasn't breathing." When discussing the CPR policy and the policy and if they were told to do CPR, the nurse stated in part, "No." When asked if they had a CPR certification, the nurse stated in part, "Yes."

15. An interview was conducted on 09/16/21 at approximately 11:30 a.m. with the ACNE. When asked about patient #5 not receiving CPR when found, the ACNE stated in part, "I know the policy and the nurse knows the policy. ... I don't feel we did anything wrong, but that we didn't follow our policies. I know the mind set, but I know the policy here." ... When asked if the patient was neglected, the ACNE concurred.

16. An interview was conducted on 09/15/21 at approximately 11:06 a.m. with Chief Executive Officer (CEO). When asked about patient #5's death, the CEO agreed CPR was not provided for the patient. The CEO concurred staff didn't follow the policy of the hospital and stated, "If it's not charted, it didn't happen."

Based on clinical record review, video review, document review and interviews it was determined the facility failed to protect patient rights to ensure patients are free of neglect and ensure nursing staff follow facility policy to initiate cardiopulmonary resuscitation (CPR) for emergency services of patient #5 without a pulse or respirations. This failure was identified in one (1) out of eleven (11) patient records. These findings have the potential for all patients to be at risk for serious injury, harm or death.

Findings include:

1. A review of patient #5's clinical record revealed a "Nursing Progress Note" dated 06/07/21 at 4:57 a.m., documented by Registered Nurse (RN) #1, that states in part: "Licensed Practical Nurse (LPN) was preparing to do a CIWA/COWS (Clinical Institute Withdrawal Assessment/Clinical Opiate Withdrawal) assessment when patient found-stating ... did not think the patient was breathing, RN evaluated patient, who was cold, mottled, eyes open and fixed, no respirations, no pulse, no cardiac sounds present. Patient was last awake at 2315 (11:15 p.m.). Patient was documented as being asleep at subsequent face checks. RN notified on-call provider, on-call admissions, on-call Family Practice Care (FPC) provider, Assistant Chief Executive Officer and Assistant Chief Nursing Executive (ACNE). Patient was pronounced by physician #1."

2. A video recording was reviewed from the date of 06/06/21 at approximately 11:35 p.m. through 06/07/21 till approximately 1:48 a.m. of Unit A6. On 06/06/21 at 11:55 p.m. LPN #1 was seen documenting face checks, enters and leaves patient #5's room and continues completing face checks. On 06/07/21 at approximately 12:09 a.m. LPN #1 was seen completing face checks, entered patient #5's room and at 12:14 a.m. leaves the room and walks to the nurse's station. At 12:14 a.m. RN #1 and LPN #1 go back to patient #5's room. During the course of the review, no crash cart was seen taken to the patient's room, nor were there any staff seen rushing to the patient #5's room on the unit.

3. A review of staff's "Basic Life Support" certifications for CPR revealed all staff working on the Unit A6 on 06/06/21 at the time of the event had active CPR certifications.

4. A review of the "Administrator On Call Log" dated 06/2021 revealed an Adult Protective Services (APS) report was not documented as filed.

5. A review of the "Administrator On-Call Log," documented by the Assistant Chief Executive Officer, revealed they were notified of patient #5's death at 12:14 a.m. and to complete all required paperwork.

6. A review of facility policy, "Unit Face Checks/Security Checks," revised/reviewed 07/30/19, states in part: "The face check person should always look for "signs of life" including, but not limited to breathing; chest and/or abdominal rises; snoring; and/or any kind of body movements. ... Be aware of the special problems that patient may have, conditions such as cardiac, diabetes, epilepsy, and what to do if an emergency occurs."

7. An email dated 09/16/21 at 9:26 a.m. from Patient Advocate #1 states in part, "There was not an investigation completed by Legal Aid."

8. A review of the "Code Call Sheet" from 06/01/21 through 06/14/21 revealed a Code Blue was not documented being called on 06/06/21 or 06/07/21 for patient #5.

9. A review of facility policy, "Patient Death in Hospital," revised/reviewed 02/16/17, states in part: "When any patient is found unconscious without respiration or pulse, CPR shall be instituted immediately, and a code blue (call to the Switchboard) shall be made unless the patient has a "do not resuscitate" (DNR) order. ... The Emergency Medical Services (EMS) will be expected to transport the person to a local emergency room. ... Mortality Review: Committee members shall thoroughly review the circumstances of the patient's death. All records shall be examined to evaluate the patient's care. Should the EMS believe that death has occurred and refuse to transport the person; a determination of death must be made by the licensed independent provider called in accordance with accepted medical standards. The time of the exam is the time of death."

10. A review of facility policy, "Patient's Rights and Responsibilities," effective 09/24/19, states in part: "While you are in this hospital, you or your guardian/representative (if clinically indicated) have the right: ... to a sanitary and humane living environment, and reasonable safety in so far as the hospital practices and environment are concerned ... to receive prompt and adequate psychiatric and medical treatment ... to be free from: neglect; exploitation; verbal, mental, physical, and sexual abuse; harassment; and any form of corporal punishment."

11. A review of facility policy, "Behavioral Code of Conduct," revised/reviewed 05/27/10, states in part: "Each employee assumes responsibility to identify and report any behavior that threatens patient safety or impedes the delivery of quality patient care. Individuals in a leadership capacity have the additional responsibility to ensure that appropriate mechanisms are used to ensure patient and employee confidentiality and safety once incidents of misbehavior are reported. ... employees will ... report any condition or infraction of law, safety standard, etc. to appropriate level of leadership; protect the confidentiality, safety and dignity of patients ... identify errors in work and strive to correct the errors and set up procedures to ensure they do not reoccur ... adhere to safety policies and procedures and report safety violation to the appropriate level of leadership."

12. A review of facility policy, "Identification, Assessment, and Referral of Possible Cases of Abuse, Neglect, or Exploitation," revised/reviewed 10/30/14, states in part: "Neglect: Negligent, reckless, or intentional failure to meet the needs of a client ... criteria for suspicion of neglect: ...18. Nonaction which results in abuse of any form. ... Procedure: 1. All patients will be assessed for the potential of abuse, neglect, or exploitation as a part of the admission process. ... 4. In the event that a patient's potential for abuse/neglect or exploitation is not identified in the initial assessments, a referral can be made at any point during the treatment when these issues are recognized. ... 6. A referral will be made to APS immediately on the patient's behalf. The individual recognizing the issue will be responsible for notifying APS ....

13. A review of facility policy, "Patient Abuse/Neglect or Exploitation," effective 02/21/19, states in part: "It is the responsibility of all hospital staff to ensure protection of all patients from physical and verbal abuse or any other infringement of their civil, human or legal rights and from neglect. ... ensures a timely, thorough and objective investigation of all allegations of abuse, neglect or harassment. ... will suspend any employee accused of abuse or neglect pending outcome of investigation."

14. A review of facility policy, "Handling of Patient Complaint/Grievances," effective 03/20/20, states in part: "Complaints alleging abuse, neglect, endangerment or misappropriation of property are given top priority, are reviewed immediately by the Legal Aid Patient Advocate with immediate interventions taken as necessary to safeguard the patient, and the matter referred at once to Administration for further management. Any allegation of abuse or neglect will be referred to APS immediately. When a complaint or grievance has been received by the Legal Aid Patient Advocate, they shall approach resolution with assistance from appropriate staff/Department Manager(s) and administration."

15. A review of the Quality Assurance Performance Improvement (QAPI) Committee meeting minutes dated 07/29/21 revealed there were not any "Mortality Reviews" reported in the month of June, zero (0) code blues and zero (0) resuscitations were conducted. The report provided by the Compliance Officer on behalf of Nursing Administration states in part, "there were no root cause analysis conducted in the month of June 2021."

16. A review of the "Analysis of Adverse Patient Event," analysis undated, conducted by RN #1 and reviewed by ACNE, states in part, "It was the 0015 (12:15 a.m.) round when LPN noted pillow was over patient's nose/mouth at this time she moved it and noted that patient wasn't breathing. ... Findings of Review: Staff responded quickly and appropriately, per RN assessment, CPR was not started due to the coolness, mottling, hyper flexion of neck and eyes dilated/fixed, this was reported to provider and supported by provider. Medical Examiner (ME) office to complete autopsy. Conclusion, including if this event was preventable: Nothing preventable noted at this time. Corrective Action: None noted at this time."

17. A "Face Check" rounding sheet for Unit A6 was presented for review for the requested date of 06/06/21 through 06/07/21. The document revealed patient #5 was checked every fifteen (15) minutes from 7:00 p.m. through 12:00 a.m. but was not documented from 12:15 a.m. through 6:45 a.m.

18. A review of the "Morbidity and Mortality Committee" meeting minutes dated 06/10/21 of patient #5's case review states in part: "In review of all records, all evaluations and assessments were done in a timely manner. In summary, it was the consensus that the care provided to the patient was appropriate; and no probable cause for the hospital." A review of the CPR/Code Blue response was not evaluated.

19. An interview was conducted on 09/15/21 at approximately 10:38 a.m. with the Chief Compliance Officer. When asked if CPR was provided to patient #5, the CCO stated in part, "It wasn't done. I can't answer that."

20. An interview was conducted on 09/15/21 at approximately 11:06 a.m. with Chief Executive Officer (CEO). When asked about patient #5's death, the CEO agreed CPR was not provided for the patient. The CEO concurred staff didn't follow the policy of the hospital and stated, "If it's not charted, it didn't happen."

21. An interview was conducted on 09/15/21 at approximately 11:25 p.m. with RN #1. When asked about patient #5's death and if CPR was provided, RN #1 stated in part, "The LPN that was doing face to face checks came to me and said they didn't think patient #5 was breathing. (States LPN #1's name) who told me. I went in to check the patient. The patient was gray and mottled and cool to the touch. I got a stethoscope and there was not breath sounds or cardiac sounds. I worked at Hospice and seen a lot of patients die. From past experience, I didn't see the benefit and it was not started." When asked about the CPR policy and CPR is only held for DNR patients, the RN stated in part, "True. The patient was not a DNR." When asked if a report was filed, the RN stated in part, "Yes, I did a report. I'm not aware an APS was done."

22. An interview was conducted on 09/15/21 at approximately 1:15 p.m. with LPN #1. When asked about finding patient #5 and if CPR was performed, the nurse stated in part, "I found the patient deceased. I was on face checks. ... I noticed the patient's eyes were open and fixed. I shook the patient and there was no response, so I went to the nurse, the RN that night. ...(States RN #1's name) and I both went back there and the RN checked the patient's pulse. I went and got a scope and the RN checked the patient. I then went back to doing the face checks and the RN called who needed to be called. The Medical Examiner came." When asked why CPR was not started, the nurse stated in part, "I can't answer that. I don't know." The first thing I thought was to tell the RN the patient wasn't breathing." When discussing the CPR policy and the policy and if they were told to do CPR, the nurse stated in part, "No." When asked if they had a CPR certification, the nurse stated in part, "Yes."

23. An interview was conducted on 09/16/21 at approximately 10:24 a.m. with Patient Advocate #1. When asked if an investigation was completed for patient #5, the Advocate stated in part, "For those situations, our stance is that in a death, if there were signs of neglect or abuse, we leave it to law enforcement or the medical examiner to determine or if an APS had been filed then we investigate."

24. An interview was conducted on 09/16/21 at approximately 11:20 a.m. with Patient Advocate #1. When asked about the follow up if an investigation was completed for patient #5, the Advocate stated in part, "I went back and reviewed the chart. We didn't have any questions for CPR. We saw the patient was seen by the medical examiner. I raised no concerns to do an investigation."

25. An interview was conducted on 09/16/21 at approximately 11:30 a.m. with the ACNE. When asked about patient #5 not receiving CPR when found, the ACNE stated in part, "I know the policy and the nurse knows the policy. ... I don't feel we did anything wrong, but that we didn't follow our policies. I know the mind set, but I know the policy here." ... When asked if the patient was neglected, the ACNE concurred.

25. An interview was conducted on 09/16/21 at approximately 11:30 a.m. with the ACNE. When asked about patient #5 not receiving CPR when found, the ACNE stated in part, "We did an AAP (Analysis of Adverse Patient Event) and RCA (Root Cause Analysis). I don't feel we did anything wrong, but that we didn't follow our policies. I know the mind set, but I know the policy here." When asked if the reports were reviewed at QA/PI, the ACNE stated in part, "The QA/PI Committee didn't get the report to review." When asked if the patient was neglected, the ACNE concurred.

Based on clinical record review, video review, document review and interviews it was revealed the governing body failed to ensure the Quality Assurance Performance Improvement (QA/PI) Program measure, evaluate, analyze and monitor the effectiveness and safety of quality care and analyze and track adverse patient events for failure to initiate cardiopulmonary resuscitation (CPR) for emergency services of patient #5 without a pulse or respirations. This failure was revealed in one (1) out of eleven (11) patient cases reviewed. This failure has the potential for all patients to be at risk for an adverse event (see tags A 273 and A 286).

Based on clinical record review, video review, document review and interviews it was revealed the governing body failed to ensure the Quality Assurance Performance Improvement (QA/PI) Program measure, evaluate, analyze, and monitor the effectiveness and safety of quality care for failure to initiate cardiopulmonary resuscitation (CPR) for emergency services of patient #5 without a pulse or respirations. This failure was revealed in one (1) out of eleven (11) patient cases reviewed. This failure has the potential for all patients to be at risk for an adverse event.

Findings include:

1. A review of patient #5's clinical record revealed a "Nursing Progress Note" dated 06/07/21 at 4:57 a.m., documented by Registered Nurse (RN) #1, that states in part: "Licensed Practical Nurse (LPN) was preparing to do a CIWA/COWS (Clinical Institute Withdrawal Assessment/Clinical Opiate Withdrawal) assessment when patient found-stating ... did not think the patient was breathing, RN evaluated patient, who was cold, mottled, eyes open and fixed, no respirations, no pulse, no cardiac sounds present. Patient was last awake at 2315 (11:15 p.m.). Patient was documented as being asleep at subsequent face checks. RN notified on-call provider, on-call admissions, on-call Family Practice Care (FPC) provider, Assistant Chief Executive Officer and Assistant Chief Nursing Executive (ACNE). Patient was pronounced by physician #1."

2. A video recording was reviewed from the date of 06/06/21 at approximately 11:35 p.m. through 06/07/21 till approximately 1:48 a.m. of Unit A6. On 06/06/21 at 11:55 p.m. LPN #1 was seen documenting face checks, enters and leaves patient #5's room and continues completing face checks. On 06/07/21 at approximately 12:09 a.m. LPN #1 was seen completing face checks, entered patient #5's room and at 12:14 a.m. leaves the room and walks to the nurse's station. At 12:14 a.m. RN #1 and LPN #1 go back to patient #5's room. During the course of the review, no crash cart was seen taken to the patient's room, nor were there any staff seen rushing to the patient #5's room on the unit.

3. A review of the "Administrator on Call Log" dated 06/2021 revealed an Adult Protective Services (APS) report was not documented as filed.

4. An email dated 09/16/21 at 9:26 a.m. from Patient Advocate #1 states in part, "There was not an investigation completed by Legal Aid."

5. A review of facility policy, "Patient Death in Hospital," revised/reviewed 02/16/17, states in part: "When any patient is found unconscious without respiration or pulse, CPR shall be instituted immediately, and a code blue (call to the Switchboard) shall be made unless the patient has a "do not resuscitate" (DNR) order. ... The Emergency Medical Services (EMS) will be expected to transport the person to a local emergency room. ... Mortality Review: Committee members shall thoroughly review the circumstances of the patient's death. All records shall be examined to evaluate the patient's care. Should the EMS believe that death has occurred and refuse to transport the person; a determination of death must be made by the licensed independent provider called in accordance with accepted medical standards. The time of the exam is the time of death."

6. A review of facility policy, "Behavioral Code of Conduct," revised/reviewed 05/27/10, states in part: "Each employee assumes responsibility to identify and report any behavior that threatens patient safety or impedes the delivery of quality patient care. Individuals in a leadership capacity have the additional responsibility to ensure that appropriate mechanisms are used to ensure patient and employee confidentiality and safety once incidents of misbehavior are reported. ... employees will ... report any condition or infraction of law, safety standard, etc. to appropriate level of leadership; protect the confidentiality, safety and dignity of patients ... identify errors in work and strive to correct the errors and set up procedures to ensure they do not reoccur ... adhere to safety policies and procedures and report safety violation to the appropriate level of leadership."

7. A review of facility policy, "Handling of Patient Complaint/Grievances," effective 03/20/20, states in part: "Complaints alleging abuse, neglect, endangerment or misappropriation of property are given top priority, are reviewed immediately by the Legal Aid Patient Advocate with immediate interventions taken as necessary to safeguard the patient, and the matter referred at once to Administration for further management. Any allegation of abuse or neglect will be referred to APS immediately. When a complaint or grievance has been received by the Legal Aid Patient Advocate, they shall approach resolution with assistance from appropriate staff/Department Manager(s) and administration."

8. A review of the QA/PI Committee meeting minutes dated 07/29/21 revealed there were not any "Mortality Reviews" reported in the month of June, zero (0) code blues and zero (0) resuscitations were conducted. The report provided by the Compliance Officer on behalf of Nursing Administration states in part, "there were no root cause analysis conducted in the month of June 2021."

9. A review of the "Analysis of Adverse Patient Event," analysis undated, conducted by RN #1 and reviewed by ACNE, states in part, "It was the 0015 (12:15 a.m.) round when LPN noted pillow was over patient's nose/mouth at this time she moved it and noted that patient wasn't breathing. ... Findings of Review: Staff responded quickly and appropriately, per RN assessment, cardiopulmonary resuscitation (CPR) was not started due to the coolness, mottling, hyper flexion of neck and eyes dilated/fixed, this was reported to provider and supported by provider. Medical Examiner (ME) office to complete autopsy. Conclusion, including if this event was preventable: Nothing preventable noted at this time. Corrective Action: None noted at this time."

10. A review of the "Morbidity and Mortality Committee" meeting minutes dated 06/10/21 of patient #5's case review states in part: "In review of all records, all evaluations and assessments were done in a timely manner. In summary, it was the consensus that the care provided to the patient was appropriate; and no probable cause for the hospital." A review of the CPR/Code Blue response was not evaluated.

11. An interview was conducted on 09/15/21 at approximately 11:25 p.m. with RN #1. When asked about patient #5's death and if CPR was provided, RN #1 stated in part, "The LPN that was doing face to face checks came to me and said they didn't think patient #5 was breathing. (States LPN #1's name) who told me. I went in to check the patient. The patient was gray and mottled and cool to the touch. I got a stethoscope and there was not breath sounds or cardiac sounds. I worked at Hospice and seen a lot of patients die. From past experience, I didn't see the benefit and it was not started." When asked about the CPR policy and CPR is only held for DNR patients, the RN stated in part, "True. The patient was not a DNR." When asked if a report was filed, the RN stated in part, "Yes, I did a report. I'm not aware an APS was done."

12. An interview was conducted on 09/16/21 at approximately 10:24 a.m. with Patient Advocate #1. When asked if an investigation was completed for patient #5, the Advocate stated in part, "For those situations, our stance is that in a death, if there were signs of neglect or abuse, we leave it to law enforcement or the medical examiner to determine or if an APS had been filed then we investigate."

13. An interview was conducted on 09/16/21 at approximately 11:20 a.m. with Patient Advocate #1. When asked about the follow up if an investigation was completed for patient #5, the Advocate stated in part, "I went back and reviewed the chart. We didn't have any questions for CPR. We saw the patient was seen by the medical examiner. I raised no concerns to do an investigation."

14. An interview was conducted on 09/16/21 at approximately 11:30 a.m. with the ACNE. When asked about patient #5 not receiving CPR when found, the ACNE stated in part, "We did an AAP (Analysis of Adverse Patient Event) and RCA (Root Cause Analysis). I don't feel we did anything wrong, but that we didn't follow our policies. I know the mind set, but I know the policy here." When asked if the reports were reviewed at QA/PI, the ACNE stated in part, "The QA/PI Committee didn't get the report to review." When asked if the patient was neglected, the ACNE concurred.

Based on clinical record review, video review, document review and interviews it was revealed the governing body failed to ensure the Quality Assurance and Performance Improvement (QA/PI) Program analyze and track adverse patient events for failure to initiate cardiopulmonary resuscitation (CPR) for emergency services of patient #5 without a pulse or respirations. This failure was revealed in one (1) out of eleven (11) patient cases reviewed. This failure has the potential for all patients to be at risk for an adverse event.

Findings include:

1. A review of patient #5's clinical record revealed a "Nursing Progress Note" dated 06/07/21 at 4:57 a.m., documented by Registered Nurse (RN) #1, that states in part: "Licensed Practical Nurse (LPN) was preparing to do a CIWA/COWS (Clinical Institute Withdrawal Assessment/Clinical Opiate Withdrawal) assessment when patient found-stating ... did not think the patient was breathing, RN evaluated patient, who was cold, mottled, eyes open and fixed, no respirations, no pulse, no cardiac sounds present. Patient was last awake at 2315 (11:15 p.m.). Patient was documented as being asleep at subsequent face checks. RN notified on-call provider, on-call admissions, on-call Family Practice Care (FPC) provider, Assistant Chief Executive Officer and Assistant Chief Nursing Executive (ACNE). Patient was pronounced by physician #1."

2. A video recording was reviewed from the date of 06/06/21 at approximately 11:35 p.m. through 06/07/21 till approximately 1:48 a.m. of Unit A6. On 06/06/21 at 11:55 p.m. LPN #1 was seen documenting face checks, enters and leaves patient #5's room and continues completing face checks. On 06/07/21 at approximately 12:09 a.m. LPN #1 was seen completing face checks, entered patient #5's room and at 12:14 a.m. leaves the room and walks to the nurse's station. At 12:14 a.m. RN #1 and LPN #1 go back to patient #5's room. During the course of the review, no crash cart was seen taken to the patient's room, nor were there any staff seen rushing to the patient #5's room on the unit.

3. A review of the "Administrator on Call Log" dated 06/2021 revealed an Adult Protective Services (APS) report was not documented as filed.

4. An email dated 09/16/21 at 9:26 a.m. from Patient Advocate #1 states in part, "There was not an investigation completed by Legal Aid."

5. A review of the "Code Call Sheet" from 06/01/21 through 06/14/21 revealed a Code Blue was not documented being called on 06/06/21 or 06/07/21 for patient #5.

6. A review of facility policy, "Patient Death in Hospital," revised/reviewed 02/16/17, states in part: "When any patient is found unconscious without respiration or pulse, CPR shall be instituted immediately, and a code blue (call to the Switchboard) shall be made unless the patient has a "do not resuscitate" (DNR) order. ... The Emergency Medical Services (EMS) will be expected to transport the person to a local emergency room. ... Mortality Review: Committee members shall thoroughly review the circumstances of the patient's death. All records shall be examined to evaluate the patient's care. Should the EMS believe that death has occurred and refuse to transport the person; a determination of death must be made by the licensed independent provider called in accordance with accepted medical standards. The time of the exam is the time of death."

7. A review of facility policy, "Patient's Rights and Responsibilities," effective 09/24/19, states in part: "While you are in this hospital, you or your guardian/representative (if clinically indicated) have the right: ... to a sanitary and humane living environment, and reasonable safety in so far as the hospital practices and environment are concerned ... to receive prompt and adequate psychiatric and medical treatment ... to be free from: neglect; exploitation; verbal, mental, physical, and sexual abuse; harassment; and any form of corporal punishment."

8. A review of facility policy, "Behavioral Code of Conduct," revised/reviewed 05/27/10, states in part: "Each employee assumes responsibility to identify and report any behavior that threatens patient safety or impedes the delivery of quality patient care. Individuals in a leadership capacity have the additional responsibility to ensure that appropriate mechanisms are used to ensure patient and employee confidentiality and safety once incidents of misbehavior are reported. ... employees will ... report any condition or infraction of law, safety standard, etc. to appropriate level of leadership; protect the confidentiality, safety and dignity of patients ... identify errors in work and strive to correct the errors and set up procedures to ensure they do not reoccur ... adhere to safety policies and procedures and report safety violation to the appropriate level of leadership."

9. A review of facility policy, "Identification, Assessment, and Referral of Possible Cases of Abuse, Neglect, or Exploitation," revised/reviewed 10/30/14, states in part: "Neglect: Negligent, reckless, or intentional failure to meet the needs of a client ... criteria for suspicion of neglect: ...18. Nonaction which results in abuse of any form. ... Procedure: 1. All patients will be assessed for the potential of abuse, neglect, or exploitation as a part of the admission process. ... 4. In the event that a patient's potential for abuse/neglect or exploitation is not identified in the initial assessments, a referral can be made at any point during the treatment when these issues are recognized. ... 6. A referral will be made to APS immediately on the patient's behalf. The individual recognizing the issue will be responsible for notifying APS ....

10. A review of facility policy, "Patient Abuse/Neglect or Exploitation," effective 02/21/19, states in part: "It is the responsibility of all hospital staff to ensure protection of all patients from physical and verbal abuse or any other infringement of their civil, human or legal rights and from neglect. ... ensures a timely, thorough, and objective investigation of all allegations of abuse, neglect, or harassment. ... will suspend any employee accused of abuse or neglect pending outcome of investigation."

11. A review of facility policy, "Handling of Patient Complaint/Grievances," effective 03/20/20, states in part: "Complaints alleging abuse, neglect, endangerment or misappropriation of property are given top priority, are reviewed immediately by the Legal Aid Patient Advocate with immediate interventions taken as necessary to safeguard the patient, and the matter referred at once to Administration for further management. Any allegation of abuse or neglect will be referred to APS immediately. When a complaint or grievance has been received by the Legal Aid Patient Advocate, they shall approach resolution with assistance from appropriate staff/Department Manager(s) and administration."

11. A review of the "Analysis of Adverse Patient Event," analysis undated, conducted by RN #1 and reviewed by ACNE, states in part, "It was the 0015 (12:15 a.m.) round when LPN noted pillow was over patient's nose/mouth at this time she moved it and noted that patient wasn't breathing. ... Findings of Review: Staff responded quickly and appropriately, per RN assessment, cardiopulmonary resuscitation (CPR) was not started due to the coolness, mottling, hyper flexion of neck and eyes dilated/fixed, this was reported to provider and supported by provider. Medical Examiner (ME) office to complete autopsy. Conclusion, including if this event was preventable: Nothing preventable noted at this time. Corrective Action: None noted at this time."

12. A review of the QA/PI Committee meeting minutes dated 07/29/21 revealed there were not any "Mortality Reviews" reported in the month of June, zero (0) code blues and zero (0) resuscitations were conducted. The report provided by the Compliance Officer on behalf of Nursing Administration states in part, "there were no root cause analysis conducted in the month of June 2021."

13. A review of the "Analysis of Adverse Patient Event," analysis undated, conducted by RN #1 and reviewed by ACNE, states in part, "It was the 0015 (12:15 a.m.) round when LPN noted pillow was over patient's nose/mouth at this time she moved it and noted that patient wasn't breathing. ... Findings of Review: Staff responded quickly and appropriately, per RN assessment, cardiopulmonary resuscitation (CPR) was not started due to the coolness, mottling, hyper flexion of neck and eyes dilated/fixed, this was reported to provider and supported by provider. Medical Examiner (ME) office to complete autopsy. Conclusion, including if this event was preventable: Nothing preventable noted at this time. Corrective Action: None noted at this time."

14. A review of the "Morbidity and Mortality Committee" meeting minutes dated 06/10/21 of patient #5's case review states in part: "In review of all records, all evaluations and assessments were done in a timely manner. In summary, it was the consensus that the care provided to the patient was appropriate; and no probable cause for the hospital." A review of the CPR/Code Blue response was not evaluated.

15. An interview was conducted on 09/15/21 at approximately 10:38 a.m. with the Chief Compliance Officer (CCO). When asked if CPR was provided to patient #5, the CCO stated in part, "It wasn't done. I can't answer that."

16. An interview was conducted on 09/15/21 at approximately 11:06 a.m. with Chief Executive Officer (CEO). When asked about patient #5's death, the CEO agreed CPR was not provided for the patient. The CEO concurred staff didn't follow the policy of the hospital and stated, "If it's not charted, it didn't happen."

17. An interview was conducted on 09/15/21 at approximately 11:25 p.m. with RN #1. When asked about patient #5's death and if CPR was provided, RN #1 stated in part, "The LPN that was doing face to face checks came to me and said they didn't think patient #5 was breathing. (States LPN #1's name) who told me. I went in to check the patient. The patient was gray and mottled and cool to the touch. I got a stethoscope and there was not breath sounds or cardiac sounds. I worked at Hospice and seen a lot of patients die. From past experience, I didn't see the benefit and it was not started." When asked about the CPR policy and CPR is only held for DNR patients, the RN stated in part, "True. The patient was not a DNR." When asked if a report was filed, the RN stated in part, "Yes, I did a report. I'm not aware an APS was done."

18. An interview was conducted on 09/16/21 at approximately 10:24 a.m. with Patient Advocate #1. When asked if an investigation was completed for patient #5, the Advocate stated in part, "For those situations, our stance is that in a death, if there were signs of neglect or abuse, we leave it to law enforcement or the medical examiner to determine or if an APS had been filed then we investigate."

19. An interview was conducted on 09/16/21 at approximately 11:20 a.m. with Patient Advocate #1. When asked about the follow up if an investigation was completed for patient #5, the Advocate stated in part, "I went back and reviewed the chart. We didn't have any questions for CPR. We saw the patient was seen by the medical examiner. I raised no concerns to do an investigation."

20. An interview was conducted on 09/16/21 at approximately 11:30 a.m. with the ACNE. When asked about patient #5 not receiving CPR when found, the ACNE stated in part, "I know the policy and the nurse knows the policy. I got out the policy and went over the policy. We did an AAP (Analysis of Adverse Patient) and RCA (Root Cause Analysis). I don't feel we did anything wrong, but that we didn't follow our policies. I know the mind set, but I know the policy here." When asked if the reports were reviewed at QA/PI, the ACNE stated in part, "The QA/PI Committee didn't get the report to review." When asked if the patient was neglected, the ACNE concurred.

Based on clinical record review, video review, document review and interviews the facility failed to ensure the Registered Nurse (RN) supervise and evaluates patient care and follows nursing policies and procedures to initiate cardiopulmonary resuscitation (CPR) for emergency services of patient #5 without a pulse or respirations. The facility failed to ensure all staff follow their cardio resuscitation policy. This failure was revealed in one (1) out of eleven (11) patient cases reviewed. This failure has the potential for all patients to be at risk for an adverse event (see tags A 395 and A 398).

A. Noncompliance: An Immediate Jeopardy (IJ) for Patient Rights, to receive care in a safe setting and to be free of neglect, and Nursing Services, failing to evaluate a patient and follow policy and procedures, was called on 09/15/21 at 12:36 p.m. because the facility failed to ensure the nursing staff initiated CPR of patient #5 who was found in their room not breathing and not having a pulse.

B. Harm or Potential Harm: The patient was found without a heartbeat, pulse or respirations on 06/07/21 at approximately 12:08 a.m. and CPR was not initiated. This practice places all patients at risk for serious injury, harm or death.

C. Immediacy: The facility needs to correct their processes to ensure all staff recognize and provide CPR immediately when finding patients who are not breathing and pulseless.

D. A remedial plan of correction was received and sent to the Interim State agency Program Director. The plan was accepted and the facility abated the IJ on 09/15/21 at 6:04 p.m. by immediately educating all department nursing staff in person upon arrival to their next shift to ensure all staff follow the following: any patient found unresponsive without a pulse or respirations must immediately have CPR performed by CPR qualified staff; must call audibly for help and initiate a "Code Blue" upon discovery of any unresponsive patient without a pulse or respirations; continue CPR until arrival of the Emergency Medical Services (EMS) team or a physician orders to cease CPR and the patient is not left alone until EMS or appropriate individuals removes the patient from the facility. The facility reviewed and revised three (3) Code Blue policies to remove conflicting directives, re-educate direct care staff who have not worked in the immediate action period and conduct mock code blues one (1) time per month on each shift on random units until all units have been included and will be monitored by nursing administration and supervisors. The data will be reported to the Quality Assurance Performance Improvement (QA/PI) Committee for tracking and trending for six (6) months.

Based on clinical record review, video review, document review and interviews the facility failed to ensure the Registered Nurse (RN) supervise and evaluates patient care and failed to initiate cardiopulmonary resuscitation (CPR) for emergency services of patient #5 without a pulse or respirations. The facility failed to ensure all staff follow their cardio resuscitation policy This failure was revealed in one (1) out of eleven (11) patient cases reviewed. This failure has the potential for all patients to be at risk for an adverse event.

Findings include:

1. A review of patient #5's clinical record revealed a "Nursing Progress Note" dated 06/07/21 at 4:57 a.m., documented by RN #1, that states in part: "Licensed Practical Nurse (LPN) was preparing to do a CIWA/COWS (Clinical Institute Withdrawal Assessment/Clinical Opiate Withdrawal) assessment when patient found-stating ... did not think the patient was breathing, RN evaluated patient, who was cold, mottled, eyes open and fixed, no respirations, no pulse, no cardiac sounds present. Patient was last awake at 2315 (11:15 p.m.). Patient was documented as being asleep at subsequent face checks. RN notified on-call provider, on-call admissions, on-call Family Practice Care (FPC) provider, Assistant Chief Executive Officer and Assistant Chief Nursing Executive (ACNE). Patient was pronounced by physician #1."

2. A video recording was reviewed from the date of 06/06/21 at approximately 11:35 p.m. through 06/07/21 till approximately 1:48 a.m. of Unit A6. On 06/06/21 at 11:55 p.m. LPN #1 was seen documenting face checks, enters and leaves patient #5's room and continues completing face checks. On 06/07/21 at approximately 12:09 a.m. LPN #1 was seen completing face checks, entered patient #5's room and at 12:14 a.m. leaves the room and walks to the nurse's station. At 12:14 a.m. RN #1 and LPN #1 go back to patient #5's room. During the course of the review, no crash cart was seen taken to the patient's room, nor were there any staff seen rushing to the patient #5's room on the unit.

3. A "Face Check" rounding sheet for Unit A6 was presented for review for the requested date of 06/06/21 through 06/07/21. The document revealed patient #5 was checked every fifteen (15) minutes from 7:00 p.m. through 12:00 a.m. but was not documented from 12:15 a.m. through 6:45 a.m.

4. A review of staff's "Basic Life Support" certifications for CPR revealed all staff working on the unit A6 on 06/06/21 at the time of the event had active CPR certifications.

5. A review of facility policy, "Unit Face Checks/Security Checks," revised/reviewed 07/30/19, states in part: "The face check person should always look for "signs of life" including, but not limited to breathing; chest and/or abdominal rises; snoring; and/or any kind of body movements. ... Be aware of the special problems that patients may have, conditions such as cardiac, diabetes, epilepsy, and what to do if an emergency occurs."

6. A review of the "Code Call Sheet" from 06/01/21 through 06/14/21 revealed a Code Blue was not documented being called on 06/06/21 or 06/07/21 for patient #5.

7. A review of facility policy, "Patient Death in Hospital," revised/reviewed 02/16/17, states in part: "When any patient is found unconscious without respiration or pulse, CPR shall be instituted immediately, and a code blue (call to the Switchboard) shall be made unless the patient has a "do not resuscitate" (DNR) order. ... The Emergency Medical Services (EMS) will be expected to transport the person to a local emergency room. ... Mortality Review: Committee members shall thoroughly review the circumstances of the patient's death. All records shall be examined to evaluate the patient's care. Should the EMS believe that death has occurred and refuse to transport the person; a determination of death must be made by the licensed independent provider called in accordance with accepted medical standards. The time of the exam is the time of death."

8. A review of facility policy, "Patient's Rights and Responsibilities," effective 09/24/19, states in part: "While you are in this hospital, you or your guardian/representative (if clinically indicated) have the right: ... to a sanitary and humane living environment, and reasonable safety in so far as the hospital practices and environment are concerned ... to receive prompt and adequate psychiatric and medical treatment ... to be free from: neglect; exploitation; verbal, mental, physical, and sexual abuse; harassment; and any form of corporal punishment."

9. A review of facility policy, "Behavioral Code of Conduct," revised/reviewed 05/27/10, states in part: "Each employee assumes responsibility to identify and report any behavior that threatens patient safety or impedes the delivery of quality patient care. Individuals in a leadership capacity have the additional responsibility to ensure that appropriate mechanisms are used to ensure patient and employee confidentiality and safety once incidents of misbehavior are reported. ... employees will ... report any condition or infraction of law, safety standard, etc. to appropriate level of leadership; protect the confidentiality, safety and dignity of patients ... identify errors in work and strive to correct the errors and set up procedures to ensure they do not reoccur ... adhere to safety policies and procedures and report safety violation to the appropriate level of leadership."

10. A review of facility policy, "Identification, Assessment, and Referral of Possible Cases of Abuse, Neglect, or Exploitation," revised/reviewed 10/30/14, states in part: "Neglect: Negligent, reckless, or intentional failure to meet the needs of a client ... criteria for suspicion of neglect: ...18. Nonaction which results in abuse of any form. ... Procedure: 1. All patients will be assessed for the potential of abuse, neglect, or exploitation as a part of the admission process. ... 4. In the event that a patient's potential for abuse/neglect or exploitation is not identified in the initial assessments, a referral can be made at any point during the treatment when these issues are recognized. ... 6. A referral will be made to Adult Protection Services (APS) immediately on the patient's behalf. The individual recognizing the issue will be responsible for notifying APS ....

11. A review of facility policy, "Patient Abuse/Neglect or Exploitation," effective 02/21/19, states in part: "It is the responsibility of all hospital staff to ensure protection of all patients from physical and verbal abuse or any other infringement of their civil, human or legal rights and from neglect. ... ensures a timely, thorough, and objective investigation of all allegations of abuse, neglect, or harassment. ... will suspend any employee accused of abuse or neglect pending outcome of investigation."

12. An interview was conducted on 09/15/21 at approximately 10:38 a.m. with the Chief Compliance Officer (CCO). When asked if CPR was provided to patient #5, the CCO stated in part, "It wasn't done. I can't answer that."

13. An interview was conducted on 09/15/21 at approximately 11:06 a.m. with Chief Executive Officer (CEO). When asked about patient #5's death, the CEO agreed CPR was not provided for the patient. The CEO concurred staff didn't follow the policy of the hospital and stated, "If it's not charted, it didn't happen."

14. An interview was conducted on 09/15/21 at approximately 11:25 p.m. with RN #1. When asked about patient #5's death and if CPR was provided, RN #1 stated in part, "The LPN that was doing face to face checks came to me and said they didn't think patient #5 was breathing. (States LPN #1's name) who told me. I went in to check the patient. The patient was gray and mottled and cool to the touch. I got a stethoscope and there was not breath sounds or cardiac sounds. I worked at Hospice and seen a lot of patients die. From past experience, I didn't see the benefit and it was not started." When asked if the patient was checked in the previous fifteen (15) minutes and was breathing, then couldn't have been long, the nurse stated in part, "True. The way patient #5 was found, looked like she/he was sleeping last time." When asked about the CPR policy and CPR is only held for DNR patient, the RN stated in part, "True. The patient was not a DNR." When asked if the patient gray, cold and mottled the patient may not have been dead for only fifteen (15) minutes, the RN stated in part, "I felt that way also. I didn't feel rigor mortis had set in." When asked if a report was filed, the RN stated in part, "Yes, I did a report. I'm not aware an APS was done." When asked if all staff with CPR training know to start CPR and call for help, the RN stated in part, "I don't know if all staff know to do it. But if it is unexpected, we don't think about it. All staff are educated for CPR but don't think about it."

15. An interview was conducted on 09/15/21 at approximately 1:15 p.m. with LPN #1. When asked about finding patient #5 and if CPR was performed, the nurse stated in part, "I found the patient deceased. I was on face checks. The patient was laying on their left side facing the wall. I noticed the pillow was down around the nose, so I went to move the pillow form the patient's face. When I moved the pillow, I noticed the patient's eyes were open and fixed. I shook the patient and there was no response, so I went to the nurse, the RN that night. I said "this isn't good and told the RN they need to come back and the patient was not responsive and is deceased. (States RN #1's name) and I both went back there, and the RN checked the patient's pulse. I went and got a scope, and the RN checked the patient. I then went back to doing the face checks and the RN called who needed to be called." When asked why CPR was not started, the nurse stated in part, "I can't answer that. I don't know. The first thing I thought was to tell the RN the patient wasn't breathing." When discussing the CPR policy and the policy and if they were told to do CPR stated in part, "No." When asked if they had a CPR certification, the nurse stated in part, "Yes."

16. An interview was conducted on 09/16/21 at approximately 11:30 a.m. with the ACNE. When asked about patient #5 not receiving CPR when found, the ACNE stated in part, "I know the policy and the nurse knows the policy ... we didn't follow our policies. I know the mind set, but I know the policy here." When asked if the patient was neglected, the ACNE concurred.

Based on clinical record review, video review, document review and interviews the facility failed to ensure the nursing staff follows nursing policies and procedures to initiate cardiopulmonary resuscitation (CPR) for emergency services of patient #5 without a pulse or respirations. The facility failed to ensure all staff follow their cardio resuscitation policy This failure was revealed in one (1) out of eleven (11) patient cases reviewed. This failure has the potential for all patients to be at risk for an adverse event.

Findings include:

1. A review of patient #5's clinical record revealed a "Nursing Progress Note" dated 06/07/21 at 4:57 a.m., documented by Register Nurse (RN) #1, that states in part: "Licensed Practical Nurse (LPN) was preparing to do a CIWA/COWS (Clinical Institute Withdrawal Assessment/Clinical Opiate Withdrawal) assessment when patient found-stating ... did not think the patient was breathing, RN evaluated patient, who was cold, mottled, eyes open and fixed, no respirations, no pulse, no cardiac sounds present. Patient was last awake at 2315 (11:15 p.m.). Patient was documented as being asleep at subsequent face checks. RN notified on-call provider, on-call admissions, on-call Family Practice Care (FPC) provider, Assistant Chief Executive Officer and Assistant Chief Nursing Executive (ACNE). Patient was pronounced by physician #1."

2. A video recording was reviewed from the date of 06/06/21 at approximately 11:35 p.m. through 06/07/21 till approximately 1:48 a.m. of Unit A6. On 06/06/21 at 11:55 p.m. LPN #1 was seen documenting face checks, enters and leaves patient #5's room and continues completing face checks. On 06/07/21 at approximately 12:09 a.m. LPN #1 was seen completing face checks, entered patient #5's room and at 12:14 a.m. leaves the room and walks to the nurse's station. At 12:14 a.m. RN #1 and LPN #1 go back to patient #5's room. During the course of the review, no crash cart was seen taken to the patient's room, nor were there any staff seen rushing to the patient #5's room on the unit.

3. A "Face Check" rounding sheet for Unit A6 was presented for review for the requested date of 06/06/21 through 06/07/21. The document revealed patient #5 was checked every fifteen (15) minutes from 7:00 p.m. through 12:00 a.m. but was not documented from 12:15 a.m. through 6:45 a.m.

4. A review of staff's "Basic Life Support" certifications for CPR revealed all staff working on the unit A6 on 06/06/21 at the time of the event had active CPR certifications.

5. A review of facility policy, "Unit Face Checks/Security Checks," revised/reviewed 07/30/19, states in part: "The face check person should always look for "signs of life" including, but not limited to breathing; chest and/or abdominal rises; snoring; and/or any kind of body movements. ... Be aware of the special problems that patients may have, conditions such as cardiac, diabetes, epilepsy, and what to do if an emergency occurs."

6. A review of the "Code Call Sheet" from 06/01/21 through 06/14/21 revealed a Code Blue was not documented being called on 06/06/21 or 06/07/21 for patient #5.

7. A review of facility policy, "Patient Death in Hospital," revised/reviewed 02/16/17, states in part: "When any patient is found unconscious without respiration or pulse, CPR shall be instituted immediately, and a code blue (call to the Switchboard) shall be made unless the patient has a "do not resuscitate" (DNR) order. ... The Emergency Medical Services (EMS) will be expected to transport the person to a local emergency room. ... Mortality Review: Committee members shall thoroughly review the circumstances of the patient's death. All records shall be examined to evaluate the patient's care. Should the EMS believe that death has occurred and refuse to transport the person; a determination of death must be made by the licensed independent provider called in accordance with accepted medical standards. The time of the exam is the time of death."

8. A review of facility policy, "Patient's Rights and Responsibilities," effective 09/24/19, states in part: "While you are in this hospital, you or your guardian/representative (if clinically indicated) have the right: ... to a sanitary and humane living environment, and reasonable safety in so far as the hospital practices and environment are concerned ... to receive prompt and adequate psychiatric and medical treatment ... to be free from: neglect; exploitation; verbal, mental, physical, and sexual abuse; harassment; and any form of corporal punishment."

9. A review of facility policy, "Behavioral Code of Conduct," revised/reviewed 05/27/10, states in part: "Each employee assumes responsibility to identify and report any behavior that threatens patient safety or impedes the delivery of quality patient care. Individuals in a leadership capacity have the additional responsibility to ensure that appropriate mechanisms are used to ensure patient and employee confidentiality and safety once incidents of misbehavior are reported. ... employees will ... report any condition or infraction of law, safety standard, etc. to appropriate level of leadership; protect the confidentiality, safety and dignity of patients ... identify errors in work and strive to correct the errors and set up procedures to ensure they do not reoccur ... adhere to safety policies and procedures and report safety violation to the appropriate level of leadership."

10. A review of facility policy, "Identification, Assessment, and Referral of Possible Cases of Abuse, Neglect, or Exploitation," revised/reviewed 10/30/14, states in part: "Neglect: Negligent, reckless, or intentional failure to meet the needs of a client ... criteria for suspicion of neglect: ...18. Nonaction which results in abuse of any form. ... Procedure: 1. All patients will be assessed for the potential of abuse, neglect, or exploitation as a part of the admission process. ... 4. In the event that a patient's potential for abuse/neglect or exploitation is not identified in the initial assessments, a referral can be made at any point during the treatment when these issues are recognized. ... 6. A referral will be made to Adult Protection Services (APS) immediately on the patient's behalf. The individual recognizing the issue will be responsible for notifying APS ....

11. A review of facility policy, "Patient Abuse/Neglect or Exploitation," effective 02/21/19, states in part: "It is the responsibility of all hospital staff to ensure protection of all patients from physical and verbal abuse or any other infringement of their civil, human or legal rights and from neglect. ... ensures a timely, thorough, and objective investigation of all allegations of abuse, neglect, or harassment. ... will suspend any employee accused of abuse or neglect pending outcome of investigation."

12. An interview was conducted on 09/15/21 at approximately 10:38 a.m. with the Chief Compliance Officer (CCO). When asked if CPR was provided to patient #5, the CCO stated in part, "It wasn't done. I can't answer that."

13. An interview was conducted on 09/15/21 at approximately 11:06 a.m. with Chief Executive Officer (CEO). When asked about patient #5's death, the CEO agreed CPR was not provided for the patient. The CEO concurred staff didn't follow the policy of the hospital and stated, "If it's not charted, it didn't happen."

14. An interview was conducted on 09/15/21 at approximately 11:25 p.m. with RN #1. When asked about patient #5's death and if CPR was provided, RN #1 stated in part, "The LPN that was doing face to face checks came to me and said they didn't think patient #5 was breathing. (States LPN #1's name) who told me. I went in to check the patient. The patient was gray and mottled and cool to the touch. I got a stethoscope and there was not breath sounds or cardiac sounds. I worked at Hospice and seen a lot of patients die. From past experience, I didn't see the benefit and it was not started." When asked if the patient was checked in the previous fifteen (15) minutes and was breathing, then couldn't have been long, the nurse stated in part, "True. The way patient #5 was found, looked like she/he was sleeping last time." When asked about the CPR policy and CPR is only held for DNR patient, the RN stated in part, "True. The patient was not a DNR." When asked if the patient gray, cold and mottled the patient may not have been dead for only fifteen (15) minutes, the RN stated in part, "I felt that way also. I didn't feel rigor mortis had set in." When asked if a report was filed, the RN stated in part, "Yes, I did a report. I'm not aware an APS was done." When asked if all staff with CPR training know to start CPR and call for help, the RN stated in part, "I don't know if all staff know to do it. But if it is unexpected, we don't think about it. All staff are educated for CPR but don't think about it."

15. An interview was conducted on 09/15/21 at approximately 1:15 p.m. with LPN #1. When asked about finding patient #5 and if CPR was performed, the nurse stated in part, "I found the patient deceased. I was on face checks. The patient was laying on their left side facing the wall. I noticed the pillow was down around the nose, so I went to move the pillow form the patient's face. When I moved the pillow, I noticed the patient's eyes were open and fixed. I shook the patient and there was no response, so I went to the nurse, the RN that night. I said "this isn't good and told the RN they need to come back and the patient was not responsive and is deceased.(States RN #1's name) and I both went back there, and the RN checked the patient's pulse. I went and got a scope, and the RN checked the patient. I then went back to doing the face checks and the RN called who needed to be called." When asked why CPR was not started, the nurse stated in part, "I can't answer that. I don't know. The first thing I thought was to tell the RN the patient wasn't breathing." When discussing the CPR policy and the policy and if they were told to do CPR stated in part, "No." When asked if they had a CPR certification, the nurse stated in part, "Yes."

16. An interview was conducted on 09/16/21 at approximately 11:30 a.m. with the ACNE. When asked about patient #5 not receiving CPR when found, the ACNE stated in part, "I know the policy and the nurse knows the policy ... we didn't follow our policies. I know the mind set, but I know the policy here." When asked if the patient was neglected, the ACNE concurred.

Based on clinical record review and document review the facility failed to ensure medical and nursing staff contact the Kentucky Organ Donor Affiliates of patient #5 ' s death following facility policy and procedures. The facility failed to ensure all staff followed their policy for notifying the organ procurement organization of the patient ' s death to determine suitability for organ donation. This failure was revealed in one (1) out of eleven (11) patient cases reviewed. This failure has the potential for all patients' wishes for organ donation to not be followed.

Findings include:

1. A review of patient #5 ' s clinical record, revealed a "Nursing Progress Note," dated 06/07/21 at 4:57 a.m., documented by Registered Nurse (RN) #1, states in part, "Licensed Practical Nurse (LPN) was preparing to do a CIWA/COWS (Clinical Institute Withdrawal Assessment/Clinical Opiate Withdrawal) assessment when patient found -stating ... did not think the patient was breathing, RN evaluated the patient, who was cold, mottled, eyes open and fixed, no respirations, no pulse, no cardiac sounds present. Patient was last awake at 2315 (11:15 p.m.). Patient was documented as being asleep at subsequent face checks. RN notified on-call provider, on-call admissions, on-call Family Practice Care (FPC) provider, Assistant Chief Executive Officer, and Assistant Chief Nurse Executive. Patient was pronounced by Physician #1."

2. A review of Patient #5 ' s clinical record revealed there was not any documentation the Kentucky Organ Donor Affiliates was notified of the patient ' s death.

3. A "Face Check" rounding sheet was presented for review for the requested date of 06/06/21 through 06/07/21 of unit A6. The document revealed patient #5 was checked every fifteen (15) minutes from 7:00 p.m. through 12:00 a.m. and was not documented from 12:15 a.m. through 6:45 a.m.

4. A review of facility policy, "Unit Face Checks/Security Checks," revised/reviewed 07/30/19, states in part, "The face check person should always look for "signs of life" including, but not limited to breathing; chest and/or abdominal rises; snoring; and/or any kind of body movements. ... Be aware of the special problems that patients may have, conditions such as cardiac, diabetes, epilepsy, and what to do if an emergency occurs."

6. A review of the "Code Call Sheet" from 06/01/21 through 06/14/21, revealed a Code Blue was not documented being called on 06/06/21 or 06/07/21 for patient #5.

7. A review of facility policy, "Patient Death in Hospital," revised/reviewed 02/16/17, states in part, "If a patient expires in the Hospital, Kentucky Organ Donor Affiliates (KODA) will be notified by the physician in attendance."

8. A review of the "Morbidity and Mortality Committee" meeting minutes, dated 06/10/21, of patient #5 ' s case review, states in part, "In review of all records, all evaluations and assessments were done in a timely manner. In summary, it was the consensus that the care provided to the patient was appropriate; and no probable cause for the hospital." A review of the physician failing to notify the organ procurement organization was not evaluated.

9. A review of facility policy, "Behavioral Code of Conduct," revised/reviewed 05/27/10, states in part, "Each employee assumes responsibility to identify and report any behavior that threatens patient safety or impedes the delivery of quality patient care. Individuals in a leadership capacity have the additional responsibility to ensure that appropriate mechanisms are used to ensure patient and employee confidentiality and safety once incidents of misbehavior are reported. ... employees will ... report any condition or infraction of law, safety standard, etc. to appropriate level of leadership; protect the confidentiality, safety and dignity of patients ... identify errors in work and strive to correct the errors and set up procedures to ensure they do not reoccur ... adhere to safety policies and procedures and report safety violations to the appropriate level of leadership."

10. An interview was conducted on 09/15/21 at approximately 11:06 a.m. with the CEO. When asked about patient #5 ' s death, the CEO agreed CPR was not provided for the patient and the organ procurement organization, KODA, was not notified. The CEO stated in part, "I concur staff didn ' t follow the policy of the hospital. If it ' s not charted, it didn ' t happen."

11. An interview was conducted on 09/16/21 at approximately 11:30 a.m. with the Assistant Chief Nursing Executive (ACNE). When asked about patient #5 not receiving CPR when found, the ACNE stated in part, "I know the policy and the nurse knows the policy ... we didn ' t follow our policies. I know the mind set, but I know the policy here." When asked if the patient was neglected, the ACNE concurred.