HospitalInspections.org

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance.

A-0144 The patient has the right to receive care in a safe setting. Based on interviews and document review the facility failed to ensure a safe patient care environment. Specifically, the facility failed to provide continuous monitoring required to monitor a patient's status and the patient expired.

Based on interviews and record review, the facility failed to provide care in a safe setting. Specifically, the facility failed to provide the continuous monitoring required to monitor a patient's status and the patient expired. (Cross-reference A-0395)

Facility policies:

Continuous Cardiac Telemetry Monitoring Policy and Procedure (Telemetry policy) dated 1/13/20 read, the purpose is to provide a standard workflow for Registered Nurses (RN) and Telemetry Technicians (Tele Techs) caring for patients on continuous cardiac telemetry monitoring, ensure safe care for patients on continuous cardiac telemetry monitoring and provide a mechanism for timely recognition and treatment of cardiac abnormalities. In the event of equipment failure of the telemetry system, the provider will be notified and will assist with prioritizing which patients will be placed on a portable monitor, which patients will have continuous cardiac telemetry monitoring discontinued and which patients will be transferred elsewhere for closer observation. All patients with an order for continuous cardiac telemetry monitoring will be monitored at all times. The RN responsible for the patient will obtain the telemetry unit from the Tele Tech in ICU. The Tele Tech will admit the patient into the main telemetry monitoring system in the ICU and verify the patient's information on the display. While the patient is on continuous telemetry monitoring, the Tele Tech is observing the monitor at the ICU nurse's station for any changes in the patient's rhythm, abnormal tracings or poor quality tracing. In the event of changes in the patient's rhythm, abnormal tracings or poor quality tracing, the Tele Tech will immediately notify the RN responsible for the patient or the Charge Nurse on the unit where the patient is roomed. If the Tele Tech is unable to reach anyone, they should call a Rapid Response to the patient's room.

The Capnography (method of monitoring of respiratory status) Guidelines for Use dated 4/2016 read, the monitoring can be initiated at nurse discretion for any clinical condition where ventilation status is of a concern or a change in patient condition in a critical care area. Any patient requiring continuous capnography needs to be in a critical care area.

1. The facility failed to ensure patient care equipment monitored a patient's heart rhythm and oxygen levels continuously as required. As a result, the staff was unaware of the change in the status of Patient #2 who then expired.

a. Interview with staff revealed patients requiring continuous monitoring for cardiac and respiratory status were cared for in rooms using equipment without direct communication to the nurses' station. Patients were not continuously monitored when equipment failed to transmit wirelessly.

i. On 2/9/21 at 2:01 p.m., Registered Nurse (RN) #5 was interviewed. RN #5 stated Intensive Care Unit (ICU) patients were placed in Medical Surgical (Med Surg) unit rooms. She stated the Med Surg rooms lacked the equivalent monitoring of ICU rooms. Specifically, in the ICU rooms, the telemetry, pulse oximetry and blood pressure monitoring was directly wired to transmit information regarding patient status to the nurses' station. Information transmitted to the nurses' station included the automatic recordings regarding the patient's blood pressure readings, heart rate, heart rhythm, respiratory rate and oxygen saturation level. If the monitoring system detected change in a patient's status or readings were out of the programmed ranges, alarms would sound at the nurses' station. Nurse #5 stated alarms from telemetry or pulse oximetry monitors in ICU sounded at the nurses' station and staff would assess the patient. RN #5 stated the risk to patients was death if monitors did not transmit to nurses' station due to staff not being alerted to a change in the status of the patient, such as not having a pulse or not breathing.

RN #5 stated the equipment used for telemetry monitoring and pulse oximetry monitoring in Med Surg rooms was wireless yet the monitoring equipment often failed to sync, or transmit, which resulted in the required information regarding change in patient status to not be displayed to the nurses' station.

RN #5 stated she cared for Patient #2 on 2/1/21. She stated the continuous telemetry and pulse oximetry monitors worked in the room but failed to sync to the nurses' station. RN #5 stated she remained with Patient #2 due to the failure of the monitoring system and concern for the patient. She was required to assess and administer medications to other patients and left the room for 10 minutes. Patient #2 was found unresponsive and without a pulse upon her return. Patient #2 was unable to be resuscitated and expired.

ii. On 2/10/21 at 9:15 a.m., Nurse Director (Director) #11 was interviewed. Director #11 stated her role was to directly supervise registered nurses, patient care techs and tele techs on the Med Surg and ICU units. She stated patients were at risk if cared for in a Med Surg room and required continuous telemetry and pulse oximetry monitoring because the monitors were not hardwired as they were in the ICU rooms. She stated the patient was at risk of a delay in care or untimely intervention due to the lack of monitoring. During a subsequent interview with Director #11 on 2/17/21 at 1:29 p.m., she stated patients were at risk of decline in condition or death if nurses did not hear the alarm in a patient room.

iii. On 2/8/21 at 2:23 p.m., RN #6 was interviewed. RN #6 stated telemetry and pulse oximetry monitors fail to sync frequently on the Med Surg unit. She stated the monitoring system in the ICU was better due to the telemetry and pulse oximetry monitoring transmitting directly to the nurses' station which allowed for staff monitoring and notification of alarms which may indicate a change in patient status.

iv. On 2/9/21 at 1:45 p.m., Provider #15 was interviewed. Provider #15 stated continuous telemetry and pulse oximetry was ordered to monitor patient status if the patient was very ill or had low oxygen. He stated continuous monitoring was important and if monitors failed to sync to the nurses' station staff would be unable to monitor for change in patient status.

2. The facility failed to follow their policy regarding continuous cardiac telemetry monitoring.

a. The Telemetry policy read, all patients with an order for continuous cardiac telemetry monitoring will be monitored at all times. While the patient is on continuous telemetry monitoring, the Tele Tech is observing the monitor at the ICU nurse's station for any changes in the patient's rhythm, abnormal tracings or poor quality tracing.

i. On 2/8/21 at 11:08 a.m., Telemetry Monitor Technician (Tech #1) was interviewed. Tech #1 stated a Tele Tech was not present every shift to monitor telemetry and pulse oximetry at the nurses' station. She stated the facility used to have a Tele Tech on the schedule 24 hours a day and seven days a week.

ii. On 2/9/21 at 2:01 p.m., Registered Nurse (RN) #5 was interviewed. RN #5 stated she had difficulty syncing telemetry monitors to transmit information regarding patient status to the nurses' station. RN #5 stated this was a common issue with the monitors on the Med Surg unit. She stated the patients who required telemetry and pulse oximetry monitoring on the Med Surg unit were at risk for staff to not be alerted to a patient change in status, such as not breathing or not having a pulse.

iii. On 2/17/21 at 1:29 p.m., Director #11 was interviewed. She stated the Med Surg unit had an issue with the telemetry monitors not communicating to the nurses' station. She stated nurses attempted to remain close to a patient's room in order to hear an alarm but due to caring for other patients it was not always possible. She stated the patient was at risk of a delay in care or untimely intervention due to the lack of monitoring.

iv. On 2/17/21 at 2:58 p.m., Chief Nursing Officer (CNO) #19 was interviewed. CNO #19 stated the facility's policy regarding telemetry monitoring fails to address continuous monitoring without a Tele Tech.

3. The facility failed to follow their policy regarding monitoring for respiratory status for patients.

a. The Capnography Guidelines for Use read, the monitoring can be initiated at nurse discretion for any clinical condition where ventilation status is of a concern or a change in patient condition in a critical care area.

i. On 2/9/21 at 2:01 p.m., RN #5 was interviewed. RN #5 stated capnography (CAP) machines in Med Surg rooms were used to continuously monitor patients' oxygen levels. She stated the CAP machines in Med Surg rooms were not hard-wired and required syncing to the nurses' station. Nurses had to manually enter patient information at the nurses' station. RN #5 stated the CAP machines often failed to sync and patients were not continuously monitored unless the nurse remained in the patient room. She stated patients were at risk of death if the patient had a change in status, such as no pulse and not breathing, if the monitoring system did not transmit to the nurses station to alert staff. RN #5 stated monitors for oxygen levels in the ICU were hard-wired and synced without difficulty.

ii. On 2/17/21 at 1:29 p.m., Director #11 was interviewed. Director #11 stated the Med Surg unit had issues with monitors not syncing to the nurses' station. She stated on the Med Surg unit, nurses had to remain close to patient rooms in order to hear alarms on monitors if not synced. Director #11 stated patients were at risk for a delay in care, decline in condition or death if nurses did not hear an alarm from the monitors.

Based on the manner and degree of standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.21 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM was out of compliance.

A-0286 -(a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities .....(2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. Based on interviews and document review, the facility failed to identify causative factors surrounding patient safety events and implement preventative actions. Specifically, the facility failed to analyze potential causes and implement preventative measures for three of three adverse patient events reviewed with the quality department.

Based on interviews and document review, the facility failed to identify causative factors surrounding patient safety events and implement preventative actions. Specifically, the facility failed to analyze potential causes and implement preventative measures for three of three adverse patient events reviewed with the quality department.

Findings include:

Facility policies:

The Clinical Quality Assessment, Patient Safety, and Process Improvement Plan for 2020 read, the purpose of the plan is to provide a framework for continual improvement in the delivery of safe patient care. The plan requires leaders, associates and providers to work collaboratively. The quality department collects and analyzes data for identification of opportunities of improvement. Additionally the quality department facilitates patient safety event reviews, reports safety trends and develops and implements action plans.

The Quality and Safety Plan, dated 4/20/17 read, the quality and safety department will measure and monitor performance outcomes and will implement process changes. The analysis of data to identify areas of improvement and on-going risk assessments will be used as guidelines. Priority will be given to high-risk and problem-prone areas. Resources used to identify areas of improvement include: event reporting system, serious safety events, hospital acquired conditions and infection prevention surveillance.

1. The facility failed to ensure investigation of patient safety events, identification of causes and contributing factors, and ongoing communication and monitoring to ensure preventive actions were implemented to prevent reoccurrence of the patient safety events.

A. Review of patient safety events.
Review of the facility's patient safety event log revealed the following:

a. On 9/5/20 a report titled "Saturday was dangerous" was entered. A review of the report revealed, staff had concerns with staffing number and indicated training was inadequate to deal with situation on the unit. The report further revealed other issues on the day of the event to include equipment failure and missing supplies.

i. The investigation of the event was completed by the director of the unit (Director #24). In the investigation report, Director #24 documented she spoke with staff who had worked on 9/5/20. The report stated drills and education continue to be provided to staff.

ii. Review of the unit meeting minutes from 9/9/20 indicated there was a discussion the drills were needed to be done, however evidence was not provided by the facility to confirm the education had occurred. Additionally, there was no evidence of preventative measures to address the equipment malfunction issues.

iii. Review of the September serious safety event committee data read, the above incident was discussed and the committee determined the follow up was adequate, but there was no evidence the facility addressed the concerns of staffing numbers, inadequate training of staff, the equipment failures or the missing supplies identified 9/5/20.
This was five months after the incident has occurred.

b. On 10/14/20 an event pertaining to the medical-surgical unit was entered. A review of the report revealed, a patient was admitted to the medical-surgical unit at 4:30 a.m. with a positive toxicology screen and had a backpack with a lock on it. The patient's belongings were not searched in the emergency department or upon admission to the medical surgical unit. The patient gave permission for the bag to be searched later in the day at 3:30 p.m. Upon the search of the belongings, multiple knives, razor blades, and drug paraphernalia were discovered.

i. The investigation of the event was completed by Registered Nurse (RN #8) who was also the nurse manager for the medical-surgical and intensive care units. In the investigation report, RN #8 documented an email was sent to admitting nursing staff to remind them of the procedure around patient belongings.

ii. The facility was unable to provide evidence the education was provided hospital wide in order to educate all nurses to prevent reoccurrence. Additionally, the facility did not provide evidence of the education nor what the appropriate procedure was when patient's belongings were to be searched.

iii. On 11/25/20, a similar event occurred where a patient's belongings were not search upon admission. The facility was unable to provide any evidence to ensure patient belongs were searched as required and to prevent any further reoccurrence of a similar event.

c. On 2/3/21, an event occurred which involved the delay in placing a chest tube was entered. A review of the report revealed a chest x-ray (CXR) had been ordered for a patient on 1/31/21. The CXR was not read until the evening of 1/31/21. The CXR showed a left pneumothorax. Once it was noted the CXR showed pneumothorax, a physician arrived with a radiology tech and a stat CXR was completed. The stat CXR confirmed the patient had a left pneumothorax. After pneumothorax was confirmed, a chest tube was placed. The report read the CXR was thought to be for an outpatient and was not read immediately causing a delay in treatment.

i. On 2/17/21, the investigation for the event was reviewed. Review of the report's investigation revealed there was no documentation of an investigation or preventative measures implemented in order to prevent re-occurrence nor were other factors identified or investigated.

B. Interviews:

a. On 2/17/21 at 10:44 a.m., an interview was conducted with the Safety and Quality Director (Director #21). Director #21 stated patient safety events were events reported which could cause harm to patients and were used to identify ways to prevent harm. Director #21 stated managers and directors were responsible to investigate and provide follow-up. The follow-up was to be completed within 30 days. Director #21 stated the facility "had not been the best at documenting the actions taken". Director #21 stated if managers and directors did not investigate patient safety events, there was a continued risk to future patients.

i. Patient safety event #1 was reviewed with Director #21. Director #21 stated she was not sure if staffing was looked at as a causative factor in relation to the patient safety event, even though staffing had been mentioned as a concern in the initial report. Director #21 stated she would expect staffing to be investigated after an event like this had occurred.

ii. Patient safety event #2 was reviewed with Director #21. Director #21 stated there had not been adequate follow-up for patient safety event #2 and was unaware if there was a policy regarding patient's belongings being searched.

iii. Patient safety event #3 was reviewed with Director #21. Director #21 stated the patient safety event had not been completed yet since it had not been 30 days. Director #21 confirmed there had been no follow-up completed for the event as of 2/17/21. Director #21 stated it was concerning there had not been follow-up and needed to be reviewed shortly after the incident occurred.

b. On 2/17/21 at 2:58 p.m., an interview was conducted with Chief Nursing Officer (CNO #19). CNO #19 stated she had oversight of the directors who completed the investigation and documented follow-up for the patient safety events. CNO #19 stated at times, there had been inappropriate follow-up and implementation of appropriate actions. CNO #19 stated it was important to investigate patient safety events and implement preventative measures in order to provide quality patient care and prevent re-occurrence of events.

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

A-0395 A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and record review, the facility failed to provide supervision, assessment and monitoring in one of one medical records of patients who required continuous monitoring who subsequently expired. Specifically, the nursing staff failed to continuously monitor the patient's oxygen levels and heart rhythm as ordered.

A-0397 A registered nurse must make all patient care assignments. The director of the nursing service and the hospital are to ensure that nursing personnel with the appropriate education, experience, licensure, competence and specialized qualifications are assigned to provide nursing care for each patient in accordance with the individual needs of each patient. Based on document review and interviews, the facility failed to ensure staff with the necessary experience and training cared for patients to delivery safe patient care.

Based on interviews and record review, the facility failed to provide supervision, assessment and monitoring in one of one medical records of patients who required continuous monitoring who subsequently expired. Specifically, the nursing staff failed to continuously monitor the patient's oxygen levels and heart rhythm as ordered. (Cross-reference A-0144)

Findings include:

Facility policies:

Continuous Cardiac Telemetry Monitoring Policy and Procedure (Telemetry policy) dated 1/13/20 read, the purpose is to provide a standard workflow for Registered Nurses (RN) and Telemetry Technicians (Tele Tech) caring for patients on continuous cardiac telemetry monitoring, ensure safe care for patients on continuous cardiac telemetry monitoring and provide a mechanism for timely recognition and treatment of cardiac abnormalities. In the event of equipment failure of the telemetry system, the provider will be notified and will assist with prioritizing which patients will be placed on a portable monitor, which patients will have continuous cardiac telemetry monitoring discontinued and which patients will be transferred elsewhere for closer observation. All patients with an order for continuous cardiac telemetry monitoring will be monitored at all times. The RN responsible for the patient will obtain the telemetry unit from the Tele Tech in ICU. The Tele Tech will admit the patient into the main telemetry monitoring system in the ICU and verify the patient's information on the display. While the patient is on continuous telemetry monitoring, the Tele Tech is observing the monitor at the ICU nurse's station for any changes in the patient's rhythm, abnormal tracings or poor quality tracing. In the event of changes in the patient's rhythm, abnormal tracings or poor quality tracing, the Tele Tech will immediately notify the RN responsible for the patient or the Charge Nurse on the unit where the patient is roomed. The Tele Tech is unable to reach anyone, they should call a Rapid Response to the patient's room.

The Assignment of Patient Care Policy (Patient Care policy) dated 1/9/18 read, the purpose is to ensure an adequate number of staff members with appropriate experience and training that supports the delivery of safe patient care. The staff required for each shift is based upon the use of a staffing matrix that takes into consideration the nursing care needs and acuity of the patient population on the unit. In the event a charge nurse has a concern with staffing, the safety of a patient or feels a need for additional staff they are unable to obtain, they are to call the Director on Call for guidance and advice.

1. The facility failed to ensure the nursing staff continuously monitored the patient's cardiac rhythm and oxygen saturation according to the physician orders and the facility policy.

A. Document review

a. Policies were reviewed.

Telemetry policy dated 1/13/20 read, the purpose is to provide the RN and Tele Tech with a standard workflow and provide a mechanism for timely recognition and treatment of cardiac abnormalities. In the event of equipment failure of the telemetry system, the provider will be notified.

The Patient Care policy dated 1/9/18 read, the purpose is to ensure an adequate number of staff members with appropriate experience and training that supports the delivery of safe patient care. In the event a charge nurse has a concern with staffing or the safety of a patient, they are to call the Director on Call.

b. The staff tracker and call light log from night shift on 2/1/21 was reviewed.

Nurse #5 entered Patient #2's room at 10:01 p.m. and departed the room at 10:43 p.m. Nurse #5 returned to Patient #2's room at 10:44 p.m. and departed the room at 10:46 p.m.

Nurse #5 entered a different patient's room at 10:50 p.m. and departed at 10:51 p.m. Nurse #5 returned to the patient's room at 10:52 p.m. and departed at 10:53 p.m.

Nurse #5 entered Patient #2's room at 11:02 p.m. At 11:04 p.m., a Staff Emergency call was initiated from Patient #2's room. At 11:05 p.m., a Code Blue was called from Patient #2's room.

c. Patient #2's medical record was reviewed.

According to the History and Physical (H&P) by Provider #16 on 2/1/21, Patient #2 had a history of rheumatoid arthritis, gout, COPD (lung disease in which airflow is obstructed from the lungs) and lupus. Patient #2 was admitted on 2/1/21 at 8:16 p.m. with severe sepsis (a body's response to an infection), pneumonia, acute respiratory failure with hypoxia (low oxygen level), dehydration and acute renal failure.

On 2/1/21 at 9:05 p.m., Provider #14 ordered oxygen administration to maintain Patient #2's oxygen saturation (measurement of the balance of oxygen in the blood) to greater than 90%, pulse oximetry and cardiac telemetry monitoring.

On 2/1/21 at 8:16 p.m., RN #5 started an initial assessment of Patient #2. RN #5 documented Patient #2 was alert, speech was clear, breathing was shallow and labored. She documented the telemetry machine and Capnostream (portable bedside monitor for continuous monitoring of oxygen saturation, pulse rate and respiratory rate) failed to transmit information to the nurses' station.

There was no evidence RN #5 contacted the provider regarding the telemetry and Capnostream monitors failure to sync to the nurses' station.

On 2/1/21 at 8:32 p.m., Patient #2's Blood pressure (BP) was 135/76, pulse was 105, respiratory rate (RR) was 24 and temperature was 98.8 F. Patient #2 was on 5 liters per minute (LPM) of oxygen by nasal cannula and oxygen saturation was 100%.

On 2/1/21 at 10:10 p.m., Patient #2's BP was 107/61 and pulse was 116.

On 2/1/21 at 10:36 p.m., Patient #2's BP was 98/60, pulse was 116, RR 22, temperature was 97.8 F and oxygen saturation was 90 % on 5 LPM by nasal cannula.

On 2/1/21 at 11:10 p.m., Provider #14 documented the code blue. Provider #14 documented Patient #2 was in asystole, CPR was continued and to refer to additional documentation in record regarding medications and code timeline.

On 2/2/21 at 3:43 a.m., RN #5 documented she remained in Patient #2's room and "completed multiple tasks until 10:55 p.m."

On 2/2/21 at 7:06 a.m., RN #5 documented she returned to Patient #2's room on 2/1/21 at 11:11 p.m. to check on patient due to inability to monitor oxygen saturations from the nurses' station. RN #5 documented Patient #2 was found in bed with oxygen removed. Patient #2 was unresponsive and without a pulse. RN #5 activated a staff emergency and Code Blue (an emergency medical response within a hospital to assist a patient in need of resuscitation) and started cardiopulmonary resuscitation. RN #5 documented the code blue timeline.

RN #5 documented staff recording of the code started on 2/1/21 at 11:34 p.m. At 11:36 p.m., Provider #14 requested a pulse check. Patient #2 was in pulseless electrical activity (PEA) and CPR continued. Patient #2 required suctioning of secretions and use of a laryngeal mask airway (LMA) for continuous respirations. CPR continued, Patient #2 received fourth dose of epinephrine at 11:29 p.m. At 11:31 p.m., pulse and cardiac rhythm check indicated Patient #2 had shockable rhythm. Patient #2 received shock and CPR continued. At 11:36 p.m., Patient #2 without a pulse or rhythm. Provider #14 performed an ultrasound of Patient #2's heart at the bedside and no motion detected. CPR continued until time of death called by Provider #16 at 11:39 p.m.

There was no evidence Patient #2 was continuously monitored for changes in cardiac rhythm and oxygen saturation as ordered by the provider and facility policy from 10:46 p.m. to 11:02 p.m.

B. Interviews were conducted.

i. On 2/9/21 at 2:01 p.m., RN #5 was interviewed. RN #5 stated she was charge nurse and had a concern with staffing for the Med Surg unit the night of 2/1/21. RN #5 stated one of her three patients assigned to her was an ICU status. She stated the Med Surg unit had four ICU status patients and one of the nurses planned to leave in the middle of the shift. RN #5 stated the shift was busier than usual due to the care required by the patients. RN #5 stated she was notified of four potential admits during the night of 2/1/21.

RN #5 stated she notified the house supervisor regarding concerns of staffing and acuity of patients on the unit. RN #5 stated the house supervisor was instructed by the administrator on call to push the nurses to take six patients each.

RN #5 stated Patient #2 was assigned to her. She stated Patient #2 was very ill and breathing was labored. When Provider #16 was with Patient #2, RN #5 stated she stepped out to retrieve additional supplies for Patient #2. She was so concerned about Patient #2 she remained with Patient #2 until her other patients required medication and assessment. She stated she returned to Patient #2 after approximately 10 minutes and Patient #2 was unresponsive and without a pulse.

RN #5 stated the patient care tech notified her the telemetry and pulse oximetry monitors were not transmitting to the nurses' station. She stated the monitors worked in the room and she was able to view the information while in the room with Patient #2. RN #5 stated the unit was extremely busy and no one was able to remain with Patient #2 while she attended to other patients. RN #5 stated during her night shift on 2/1/21, no Tele Tech was scheduled.

Due to telemetry and pulse oximetry monitors not syncing to the nurses' station, Patient #2 was not monitored while RN #5 attended to other patients.

ii. On 2/8/21 at 2:33 p.m., RN #6 was interviewed. RN #6 reported she worked the night of 2/1/21 but did not care for Patient #2. RN #6 stated RN #5 remained with Patient #2 due to concerns of equipment not transmitting to the nurses' station. RN #6 stated Patient #2 would have received telemetry and pulse oximetry continuous monitoring if admitted to the intensive care unit as the monitors in ICU. She stated the monitors were hard-wired and transmitted to the nurses' station.

iii. On 2/9/21 at 1:45 p.m., Provider #15 was interviewed. Provider #15 stated any patient with pneumonia and hypoxia would require continuous telemetry and pulse oximetry monitoring. He stated the monitors had staff to monitor at the ICU nurses' station. Provider #15 stated decision whether for a patient to be admitted as a Med Surg patient or ICU patient made between the ED provider and hospitalist.

Provider #15 stated Patient #2 was under the care of Provider #16. Provider #15 stated Patient #2 was very sick with sepsis and bacteremia (infection in the blood). He learned of Patient #2's death at change of shift the next morning.

iv. On 2/10/21 at 9:15 a.m., Director #11 was interviewed. Director #11 stated the patients on the Med Surg unit the last several weeks were higher acuity than usual. She was aware charge nurses had voiced concerns regarding staffing to the house supervisor or administrator on call. Director #11 stated nine out of ten times the charge nurses were instructed to figure it out. Director #11 stated she worked additional hours to help the nurses as she was able.

v. On 2/10/21 at 10:39 a.m., House Supervisor #13 was interviewed. House Supervisor #13 stated he was aware of charge nurse concerns regarding staffing during some of their shifts. He stated ultimately the decision to accept an additional admit to the Med Surg unit was up to the administrator on call.

House Supervisor #13 stated he was involved in the bed request for inpatient admission for Patient #2. House Supervisor #13 stated he was concerned regarding admission status of Patient #2 as a Med Surg patient and not an ICU patient based on some lab values he reviewed. He stated he asked for clarification several times by Provider #14 and Provider #15. House Supervisor #13 stated both providers stated Patient #2 was a Med Surg status patient. He stated based on his own ICU experience as a nurse, Patient #2 should have been an ICU status patient.

vi. On 2/10/21 at 1:34 p.m., Chief Nursing Officer (CNO) #19 was interviewed. CNO #19 stated Patient #2 was not monitored while Nurse #5 attended to other patients. She stated the telemetry and pulse oximetry monitoring equipment did not sync to the nurses' station. She stated the facility lacked a policy to address monitoring while a Tele Tech was not scheduled.

Based on document review and interviews, the facility failed to ensure staff with the necessary experience and training cared for patients to delivery safe patient care.

Findings include:

Facility policy:

The Assignment of Patient Care policy read, the facility ensures an adequate number of staff members with appropriate experience and training that supports the delivery of safe patient care. The facility ensures a registered nurse is responsible for planning, supervising, evaluating and delegating the nursing care of each patient. Before delegating appropriate aspects of nursing care to nursing personnel or unlicensed ancillary staff, a registered nurse, designated as the charge nurse or team lead, will review the available data on the patients such as: shift report, direct observation, nursing rounds, and planned procedures.

Additionally, deployment of nursing staff members among various units or departments will take into consideration multiple factors in addition the patient's nursing care needs based on both patient acuity, patient intensity and patient population in the department. Also, the quantity and the skill mix of nursing personnel required to meet these identified needs. These will be indicated in the various staffing matrix based on volume as well as patient acuity and/or intensity.

1. The facility failed to ensure patients were assigned to nurses who were trained to care and meet the needs of those patients.

a. According to the facility policy, staffing assignments were made by the charge nurse by reviewing shift report, direct observation, nursing rounds, and planned procedures to ensure staff members with appropriate experience and training could delivery safe patient care.

b. On 2/11/21 at 10:37 a.m., interview was conducted with Educator #18. Educator #18 stated she was directed to develop an emergency critical care training class for nurses working on the Medical Surgical nursing unit. The training was planned as an emergency measure to handle staffing issues for the COVID-19 pandemic. Educator #18 said the class was three hours in length and was presented several times in April 2020.

c. On 2/9/21 at 2:01 p.m., an interview was conducted with Registered Nurse (RN) #5 who was hired to work with medical surgical level of patients. RN #5 stated she attended the emergency a one-and-a-half-hour critical care training program in April of 2020. RN #5 stated she did not feel the one-and-a-half-hours was enough education. She did not feel comfortable taking care of this level of patient and then confirmed she was assigned to intensive care level patients after the training.

RN #5 stated normal training for nurses who cared for critical care patients was six weeks of training which included shadow work shifts with an experienced critical care nurse. She stated this training allowed the trainee practice with their critical care nursing skills. RN #5 stated her one and a half hours of training included education on how to manage a patient who required a ventilator (a mechanical device used for patients with respiratory diseases who required artificial respiration). RN #5 stated she was not given a shadow shift with an experienced critical care nurse.

On 2/1/21 RN #5 was assigned to care for three patients. Patient's #1 and #2 were medical surgical patient care level and Patient #3 was an intensive care level patient.

According to the medical record, Patient #2 was admitted from the emergency department diagnosed with pneumonia, acute respiratory failure and sepsis. The patient had rapid respirations, an elevated heart rate, a fluctuating oxygen level, and decreased blood pressure.

During the interview with RN #5, she stated Patient #2 was very sick when he arrived from the emergency department. The nurse applied a cardiac monitor in the patient room. However, she was unable to synchronize the cardiac monitor to the central telemetry cardiac monitoring system (Telemetry monitoring allowed healthcare providers to monitor the electrical activity of the heart) RN #5 stated the patient was too sick to be left alone in his room, making him a critical patient.

During the interview with RN #5 she stated due to having two other patients assigned to her, she left Patient #2's room to provide nursing care to her other two patients; Patient's #1 and #3 who were located on the surgical nursing unit but were designated at both intensive care level and medical surgical level care. When Patient #2 was left alone in his room, the patient had a cardiac arrest. The emergency resuscitation team was unable to revive the patient and the patient subsequently died.

c. On 2/17/21 at 1:29 p.m., an interview was conducted with Director #11. Director #11 stated even though the training was meant to be an emergency solution to a forecasted surge of critically ill patients, there had been no additional follow up education provided to the medical surgical nurses since the institution of the emergency process which was implemented on 4/1/20, ten months after the implementation of the program.

d. Continued review of the daily staffing sheets for February of 2021, revealed other incidents in which nurses who attended the one-and-a-half-hour critical care training were assigned intensive care level patients.

i. On 2/1/21, the RN was assigned two medical surgical level patients and one intensive care level patients.

ii. On 2/14/21, the RN was assigned one medical surgical patient and one intensive care level patient.

iii. On 2/15/21, the RN was assigned one medical surgical patient and one intensive care level patient.

iv. On 2/16/21, the RN was assigned two intensive care level patients.

e. On 2/9/21 at 4:19 p.m., an interview was conducted with Registered Nurse (RN) #8. RN #8 stated she cared for medical surgical level of patients which were stable but since the COVID-19 pandemic, she had been required to care for intensive care level patients. RN #8 stated she attended a short intensive care level training class and then stated she had no formal checklist or education plan after the training. RN #8 stated she received five training shifts which was in contrast to RN #5 who received no shadow shifts with an experienced intensive care nurse.

f. Review of personnel files for both RN #5, RN #8 and RN #9 revealed there was no evidence of a competency evaluation was completed to ensure the RN's were trained and able to care for intensive care level patients.

This was in contrast to facility standards for training according to RN #5 and the facility policy which required the facility to ensure staff members with appropriate experience and training were available to delivery safe patient care.

g. On 2/17/21 at 12:47 p.m., an interview was conducted with Registered Nurse (RN) #9. RN #9 stated she attended the critical care training program for one and a half hours. RN #9 stated she did not have a shadow shift with an experienced intensive care nurse. RN #9 was the charge nurse for the medical surgical unit and stated it was her responsibility to assign both medical surgical and intensive care level patients to the nursing staff.

RN #9 was unable to identify a process for ensuring the nursing assignments followed facility policy to ensure the delivery of safe patient care.

h. On 2/17/21 at 1:29 p.m., an interview was conducted with Director #11 who had oversight of all nursing care provided by the medical surgical nurses. Director #11 stated the medical surgical staff nurses did not complete a skill competency list or complete shadow work shifts from an experienced critical care nurse to gain proficiency. Director #11 after review of the training, shift assignments and incident on 2/1/21 stated the nurses did not have enough training to ensure delivery of safe patient care.

i. On 2/17/21 at 2:58 p.m., an interview was conducted with Chief Nursing Officer (CNO) #19. CNO#19 stated she was aware of the emergency surge plan for training the medical surgical nurses to care for intensive care patients. CNO #19 stated she was surprised to learn the nurses continued to provide nursing care for intensive care level patients with the one-and-half-hour training program. CNO#19 stated without adequate training the medical surgical nurses would not be able to recognize a change in a patient's condition which could lead to a serious patient event.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.42, INFECTION PREVENTION AND CONTROL AND ANTIBIOTIC STEWARDSHIP PROGRAMS, was out of compliance.


A-0747 The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. Based on observations, interviews, and document reviews, the facility failed to employ methods to prevent and control the transmission of COVID-19 within the facility. Specifically, the facility failed to ensure healthcare personnel (HCP) wore the recommended personal protective equipment (PPE) during aerosol generating procedures (AGPs) in accordance with guidance from the Centers for Disease Control (CDC) and facility policy. This failure occurred in one of one observations of patients who had an AGP.

Based on observations, interviews, and document reviews, the facility failed to employ methods to prevent and control the transmission of COVID-19 within the facility. Specifically, the facility failed to ensure healthcare personnel (HCP) wore the recommended personal protective equipment (PPE) during aerosol generating procedures (AGPs) in accordance with guidance from the Centers for Disease Control (CDC) and facility policy. This failure occurred in one of one observations of patients who had an AGP.

Findings include:

Facility policy:

The facility document, Personal Protective Equipment (PPE) standards, outlined the following PPE to be worn by HCP in the absence of a negative COVID 19 test. HCP should don a N95 mask or a Powered air-purifying respirator (PAPR) a protective gown, gloves, and eye protection for patient care procedures which generate aerosols (aerosol-generating procedures/ (AGP).

AGPs are medical procedure performed for a patient that may induce aerosols of various sizes including droplet nuclei. High concentrations of aerosols or droplet nuclei increase the risk of the transmission of opportunist airborne pathogens. AGP patient procedures include the delivery of high flow oxygen treatments to patients for respiratory problems. The mechanical devices which deliver high flow oxygen include positive pressure ventilations such as Bi-level Positive Airway Pressure (BiPAP) and continuous positive airway pressure (CPAP) machines. The facility document required HCP staff don N95 mask during AGP procedures.

Reference:

The CDC Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/10/21 read, HCP should use N95 respirators or equivalent or higher-level respirators for all AGP. AGP procedures performed on patients are more likely to generate higher concentrations of potentially infectious respiratory aerosols. These aerosols put HCP and others at an increased risk for pathogen exposure and infection. AGP procedures include non-invasive ventilation such as BiPAP and CPAP mechanical ventilation techniques.

1. The facility failed to ensure HCP wore the CDC recommended PPE when care was provided to patients receiving AGPs.

a. According to the facility policy and CDC recommendations above, a N95 respirator should be worn for all AGP, which included caring for patients who used a BiPAP non-invasive ventilation used to support breathing through a mask. Air and oxygen is administered under positive pressure and the air pressure changes in response to a person breathing in or out.

b. On 2/11/21 at 9:00 a.m., Registered Nurse # 4 was observed provided nursing care to a patient diagnosed with pneumonia. The patient required a high-flow oxygen system through a BiPAP. The registered nurse (RN) stopped the BiPAP and removed the patient from the machine to administer oral medications to the patient. The RN wore a surgical mask. This was in contrast to the CDC recommendation and facility policy which read, a HCP should wear a N95 respirator or higher for AGPs.

c. On 2/17/21 at 12:47 p.m., an interview was conducted with RN #9. RN #9 stated she would wear a N95 mask while caring for patients diagnosed with COVID-19. RN #9 stated she did not know what type of mask she would wear if a patient was receiving an AGP. She repeated she would only wear a N95 mask when care was provided to a patient diagnosed with a COVID-19 infection.

d. On 2/17/21 at 12:49 p.m., interview was conducted with Infection Preventionist (IP) #17. IP #17 stated the minimum PPE to be worn during an AGP included a N95 or PAPR, face shield, gown and hair cover. IP #17 stated a BiPAP was an AGP treatment which spread respiratory secretions. IP#17 said she did not think the staff nurses understood what PPE was required when caring for patient who required a BiPAP.