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Based on a review of the medical record, facility ' s timelines of the investigation, interviews with staff, and review of policies and procedures, a review of the incident report submitted by the facility to the State Agency (SA) , and a review of state laws, it was determined that the facility failed to report an adverse event within twenty-four (24) or the next business day as required to be in compliance with state law.


Cross-reference A-0021 as it relates to the facility failure to comply with state law by not submitting an incident report within the required twenty-four (24) hour or one business day timeframe. The facility notified the state agency on 3/16/21 about the adverse event surrounding P#5 death.

Based on a review of the medical record, facility ' s timelines of the investigation, interviews with staff, and review of policies and procedures, a review of the incident report submitted by the facility to the State Agency (SA) , and a review of state laws, it was determined that the facility failed to report an adverse event within twenty-four (24) or the next business day as required to be in compliance with state law.

Findings:

Based on a review of the medical record, interviews with staff, a review of policies and procedures, observations made at the facility, a review of the facility ' s ED staffing schedule, and facility ' s analysis findings, it was determined that the governing body failed to ensure adequate staffing coverage and ensure the availability alarming devices to alert staff of declining patients, thereby causing a delay in care to one Patient (P) (P#5) out of five sampled patients. The lack of coverage and the facility ' s delay in patient care led to the facility ' s failure to immediately initiate lifesaving interventions for P#5, who was found unresponsive on 2/9/22 at 12:11 a.m. P#5 expired at the facility on 2/9/22 at 12:47 a.m.

Findings:

A review of Patient (P) #5 ' s medical record revealed that P#5 presented to the facility ' s Emergency Department (ED) on 2/8/22 at 11:44 a.m. with a chief complaint of abdominal pain. P#5 ' s past medical history included a gastrointestinal (abdominal) bleed, colitis (inflammation of the large intestine), high blood pressure, and myocardial infarction (heart muscle that began to die due to insufficient blood). Triage was started at 11:46 a.m. A review of the triage note revealed that P#5 reported abdominal pain and a bruise on the right lower section of his abdomen. P#5 stated he was weak and had reported constipation and bloating. P#5 was on a daily blood thinner. P#5 stated a pain score of 10 (highest).
At 11:49 am, Patient #5's vital signs at the ED were as follows:

Heart Rate (HR): 49 (normal range was normal 60-100)
Respiratory Rate (RR): 18 (normal range was 12-20)
Blood pressure (B/P): 86/56 (low) (normal range was 100-120/60-80)
Oxygen saturation (O2): 97% (normal range was 94-100%).

On 2/8/22 at 12:03 p.m. Medical Doctor (MD) CC was assigned to P#5. MD CC ' s orders included but were not limited to the following:
1. Complete blood count with differentials.
2. Troponin (cardiac marker to know if the heart is injured).
3. Comprehensive metabolic panel (CMP) (a helpful and common test that measures several important aspects of your blood).
4. Electrocardiography (EKG) (recorded the electrical signal from the heart to check for different heart conditions).
5. Cardiac Monitoring
6. Medication (morphine (pain medicine), ondansetron(antiemetic), piperacillin-tazobactam(antibiotics), normal saline).
7. Computerized Tomography (CT) (imaging of abdomen and pelvis)

On 2/8/22 at 3:23 p.m., a CT of the abdomen and pelvis was completed, and findings were compatible with acute left-sided colitis (inflammation of the large intestine).
On 2/8/22 at 4:26 p.m., MD CC consulted a colorectal surgeon, MD MM, and at 4:38 p.m., P#5 was admitted as an inpatient to the facility. MD BB was assigned as the admitting physician. MD BB ordered telemetry monitoring (monitoring of electrical activity of the heart), full code status (if a patient has no heartbeat and not breathing, all life-sustaining measures would be made), Diet-NPO (nothing by mouth), and blood and stool cultures.

A review of the consult notes by MD OO on 2/8/22 at 7:32 p.m. revealed that P#5 did not have a perforation and would need non-operative management. MD OO documented that P#5 should be placed on antibiotics, bowel rest, and NPO.

A review of the facility ' s space lab monitor rhythm revealed the following:

On 2/8/22 at 8:11 p.m., P#5 ' s rhythm on the monitor showed a normal sinus (normal heart rhythm); HR 59, RR 22.
On 2/8/22 at 8:24 p.m., P#5 ' s rhythm on the monitor showed a normal sinus; HR 62, RR 23.
On 2/8/22 at 8:59 p.m., P#5 ' s rhythm on the monitor showed a change to wide QRS complex (electrical abnormality in the heart); HR 67, RR 27.
On 2/8/22 at 9:07 p.m., P#5 ' s rhythm on the monitor showed that the wide QRS complex (electrical abnormality in the heart) continued; HR 66, RR 16.
On 2/8/22 at 11:52 p.m., P#5 ' s rhythm on the monitor showed a sinus rhythm with first-degree heart block (a rhythm where the electrical impulses move more slowly to reach the ventricles, the mildest type of heart block); HR 67, RR 27, O2 92%.

On 2/9/2022 at 12:00 a.m. P#5 ' s rhythm on the monitor showed a rhythm change to asystole (the cessation of electrical and mechanical activity of the heart).

The facility failed to document and perform any interventions during any of the forementioned abnormal heart rhythms. P#5 ' s cardiopulmonary arrest was unwitnessed.

A review of the Code Blue Flowsheet revealed that on 2/9/22 at 12:12 a.m., a cardiopulmonary arrest was recognized for P#5. MD KK, Registered Nurse (RN) GG, RN HH, and RN FF were present and responded to the Code Blue (emergency code for when a patient goes into cardiac arrest). During resuscitation efforts, P#5 received naloxone (opioid antagonist), lidocaine (vasodilator), epinephrine (vasoconstrictor and blood pressure support), and magnesium (vital mineral for heart function). P#5 was intubated by MD KK at 12:47 a.m. Resuscitation efforts were stopped, and the time of death was called at 12:47 a.m.

On 2/9/21 at 12:23 a.m. MD KK documented that P#5 was found unresponsive by the nursing staff, and MD KK was called to the bedside. The staff could not state how long it had been since P#5 was last seen responsive. MD KK noted that Cardiopulmonary Resuscitation (CPR) was in progress upon arrival at the bedside. MD JJ was paged, and a Code Blue was paged out.

A review of P#5 ' s Discharged Summary revealed that P#5 was discharged on 2/9/22 at 4:20 a.m. P#5 ' s discharge diagnosis was Respiratory Arrest and Pulseless Electrical Activity (PEA).

An interview with the Director of Emergency Department (DED) AA was conducted on 4/5/22 at 3:08 p.m. DED AA acknowledged he was aware of the event with P#5. DED AA stated that he heard about the incident during rounding the morning that P#5 had the cardiac arrest. DED AA said Charge Nurse (CN) FF said P#5 coded, and there were some issues with the case. DED AA said that he interviewed Registered Nurse (RN) GG and RN HH. RN GG told DED AA that she had left the POD to transport another patient to the floor, and when RN GG returned, RN GG heard the monitor alarm sounding, went to P#5 ' s room, and found him unresponsive. RN GG called for assistance immediately. DED AA said RN HH said he had left the ED POD to locate an infusion pump to administer blood. DED AA said CN FF was at the ambulance desk to allow a nurse to take a bathroom break. DED AA said CN FF immediately left the desk and went to assist with the code once she became aware. DED AA said they pulled the team together to discuss the incident, gather the data, and review the case. DED AA said they talked about the opportunity to improve communications between the staff. DED AA said they re-educated the nurses about the need to notify the charge nurse or resource nurse before leaving the POD. DED AA said the monitors were designed to connect to the spectra phones ( healthcare cellular communications device). Unfortunately, the staff did not have their phones with them. DED AA said a new process for collecting and distributing phones was implemented. DED AA said the staffing was adequate, but there were issues with communication and knowing where all resources were located. DED AA said all the ED staff were re-educated on available resources and how to get assistance.


An interview was conducted with the CN FF on 4/6/22 at 9:14 a.m. CN FF stated that the incident with P#5 occurred around 11:00 p.m. CN FF said that she was at the ambulance desk reliving a staff member who needed to use the restroom. CN FF said RN HH called on the phone to inform her that P#5 was about to code. RN HH said she immediately left the ambulance desk and went to the patient ' s room. CN FF stated there were already three staff members (MD KK, RN GG, and RN HH) in P#5 ' s room when she arrived. CN FF said the house supervisor performed chest compression on the patient while another staff member was administering medications. CN FF said she asked RN GG what had happened. RN GG said she was returning from transporting another patient to a nursing unit and heard the space lab monitor alarm sounding. RN GG immediately called for assistance. CN FF said P#5 was administered Narcan (opioid antidote) because the patient was previously on pain medication before he became unresponsive. P#5 was intubated and administered epinephrine, but he remained unresponsive. CN FF said at some point, the admitting doctor called the patient ' s family, explained to them what had happened, and called the time of death. CN FF said while investigating the event; they found out that the spectra phones that connected to the space lab monitor were not working correctly on the POD. They got new phones for everyone and put a new system for exchanging the phone during shift changes. CN FF said before signing off on the phone and handing them back out, they would make sure the phones were completed. CN FF said there was supposed to be a resource nurse on each POD, and before staff left the POD, they were supposed to notify someone to cover for them. CN FF said RN GG told her she notified RN HH before leaving the POD.

A telephone interview was conducted with RN GG on 4/6/22 at 10:30 a.m. RN GG stated she started providing care for P#5 around 7:00 p.m., on the day the event occurred. RN GG said P#5 was at the facility for colitis and had been in a lot of pain. RN GG said P#5 was alert and oriented and was given pain medications several times. RN GG stated she medicated P#5 around 10:30 p.m. RN GG said she informed RN HH that she was transporting a patient to the cardiac unit. Before leaving, she checked on all her patients. Her patients ' vital signs were okay, and their call bell alarms were in working order. RN GG said she left ED POD-C to transport another patient but could but not remember the actual time. RN GG said when she returned, she saw the red light flashing in P#5 ' s room, and she thought P#5 was probably disconnected from the monitor. She immediately went to P#5 ' s room and saw that P#5 was asystole. RN GG said she immediately alerted other staff that P#5 was unresponsive, and they started chest compression. RN GG said she did not receive a spectra phone for that shift. RN GG stated they went through safety meetings and education regarding communications and handing off the spectra phone since the incident occurred.


A telephone interview was conducted with the RN LL on 4/6/22 at 11:30 a.m. RN LL stated she was not the primary nurse for P#5. RN LL said she left POD-C to get an oxygen tank down the hall. RN LL said she came across RN GG in the hallway towards POD-C. RN LL stated that while she was coming from the hallway down to the door of POD C, RN GG said she needed help and that P#5 was unresponsive. RN LL said she immediately sat the oxygen tank down and went to P#5 ' s room to assist with resuscitating P#5. RN LL said the POD did not have a spectra phone assigned to them when the incident occurred.

A telephone interview was conducted with RN II on 4/6/22 at 12:09 p.m. RN II stated she was on her lunch break when the incident occurred, and RN HH was covering for her. RN II said that she went into P#5 ' s room when she returned to work, and chest compression had already started. RN II acknowledged there were no spectra phones assigned to them when the incident occurred.

A review of the facility ' s policy titled "Emergency Room Staffing," policy number 301-10, last reviewed 9/19, revealed that the purpose of the policy was to outline the staffing pattern utilized in the ED. Staffing standards at the facility ' s ED were based on historical volume and acuity.

A review of the facility ' s ED staffing schedule included the following:

Date: 2/7/22 - 2/8/22

POD A Number of Beds: 11
Charge Nurse: 1 Technicians: None
7:00 a.m. to 11:00 p.m.- 4 RNs
11:00 p.m. to 3:00 a.m.- 3 RNs
3:00 a.m. to 7:00 a.m.- 2 RNs

POD C Number of Beds: 12
Charge Nurse: 1 Technicians: None
7:00 a.m. to 7:00 p.m.- 4 RNs
7:00 p.m. to 7:00 a.m.- 3 RNs


POD F Number of Beds: 12
Charge Nurse:1 Technicians: None
7:00 a.m. to 11:00 p.m.- 4 RNs
11:00 p.m. to 7:00 a.m.- 3 RNs



Date: 2/8/22 - 2/9/22

POD A Number of Beds: 11
Schedules:
Charge Nurse: 1 Technician: None
7:00 a.m. to 3:00 a.m.- 4 RNs
3:00 a.m. to 7:00 a.m.-2 RNs

POD C Number of Beds: 12
Charge Nurse: 1 Technicians: None
7:00 a.m. to 11:00 p.m.- 4 RNs
11:00 p.m. to 7:00 a.m.- 3 RNs

POD F Number of Beds: 12
Charge Nurse:1 Technicians: None
7:00 a.m. to 7:00 p.m.- 4 RNs
7:00 p.m. to 3:00 a.m.- 3 RNs
3:00 a.m. to 7:00 a.m.- 2 RNs

A review of the facility ' s analysis findings revealed that the ideal staffing plan for a 12-bed POD is 3 primary RNs, 1 resource RN, and 1 ED tech. Further review revealed that from 2/8/22 at 11:30 p.m. to 2/9/22 at 7:00 a.m. there were only 3 primary RNs and 0 ED techs on POD -C.

A review of Health Facility Regulation Division (HFRD) Facility Incident Report Form revealed the facility reported the incident on 3/16/22. The incident report categorized the incident type as other. The facility specified the incident as an unanticipated death. The facility documented the incident occurred 2/9/22 at 12:12 a.m. The report documented there was a 9 minute delay in calling a code blue ( an alert to call attention to a patient experiencing a life threatening emergency).

A review of Georgia State Rule 111-8-40-.07 Hospital Inspections and Required Reports to the Department the following:
2. The hospital's peer review committee(s) shall make the self-report of the incident within twenty-four (24) hours or by the next regular business day from when the hospital has reasonable cause to believe an incident has occurred. The self-report shall be received by the Department in confidence and shall include at least:
(i) The name of the hospital;
(ii) The date of the incident and the date the hospital became aware that a reportable incident may have occurred;
(iii) The medical record number of any affected patient(s);
(iv) The type of reportable incident suspected, with a brief description of the incident; and
(v) Any immediate corrective or preventative action taken by the hospital to ensure against the replication of the incident prior to the completion of the hospital's investigation.

The facility failed to comply with state law by not submitting an incident report within the required twenty-four (24) hour or one business day timeframe. The facility notified the state agency on 3/16/21 about the adverse event surrounding P#5 death.

Based on a review of the medical record, interviews with staff, a review of policies and procedures, observations made at the facility, a review of the facility ' s ED staffing schedule, and facility ' s analysis findings, it was determined that the governing body failed to ensure adequate staffing coverage and ensure the availability alarming devices to alert staff of declining patients, thereby causing a delay in care to one Patient (P) (P#5) out of five sampled patients. The lack of coverage and the facility ' s delay in patient care led to the facility ' s failure to immediately initiate lifesaving interventions for P#5, who was found unresponsive on 2/9/22 at 12:11 a.m. P#5 expired at the facility on 2/9/22 at 12:47 a.m.

Cross-reference A-0063 as it relates to the governing body failed to ensure adequate staffing and proper technology were in place to ensure proper care for P#5. P#5 medical record documented that P#5 experienced cardiac events beginning 2/8/22 at 8:59 p.m. and escalated to P#5 experiencing asystole on 2/9/22 at 12:00 a.m. Documentation revealed that life saving measures were not initiated until 2/9/22 at 12:12 a.m. Interviews with staff confirmed the necessary devices (spectra phones) were not in place to alert staff of P#5 ' s deteriorating condition, furthermore interviews revealed that the emergency department Pod-C was not adequately monitored by staff leading to the delay in care for P#5.

Based on a review of the medical record, interviews with staff, a review of policies and procedures, observations made at the facility, a review of the facility ' s ED staffing schedule, and facility ' s analysis findings, it was determined that the governing body failed to ensure adequate staffing coverage and ensure the availability alarming devices to alert staff of declining patients, thereby causing a delay in care to one Patient (P) (P#5) out of five sampled patients. The lack of coverage and the facility ' s delay in patient care led to the facility ' s failure to immediately initiate lifesaving interventions for P#5, who was found unresponsive on 2/9/22 at 12:11 a.m. P#5 expired at the facility on 2/9/22 at 12:47 a.m.

Findings:

A review of Patient (P) #5 ' s medical record revealed that P#5 presented to the facility ' s Emergency Department (ED) on 2/8/22 at 11:44 a.m. with a chief complaint of abdominal pain. P#5 ' s past medical history included a gastrointestinal (abdominal) bleed, colitis (inflammation of the large intestine), high blood pressure, and myocardial infarction (heart muscle that began to die due to insufficient blood). Triage was started at 11:46 a.m. A review of the triage note revealed that P#5 reported abdominal pain and a bruise on the right lower section of his abdomen. P#5 stated he was weak and had reported constipation and bloating. P#5 was on a daily blood thinner. P#5 stated a pain score of 10 (highest).
At 11:49 am, Patient #5's vital signs at the ED were as follows:

Heart Rate (HR): 49 (normal range was normal 60-100)
Respiratory Rate (RR): 18 (normal range was 12-20)
Blood pressure (B/P): 86/56 (low) (normal range was 100-120/60-80)
Oxygen saturation (O2): 97% (normal range was 94-100%).

On 2/8/22 at 12:03 p.m. Medical Doctor (MD) CC was assigned to P#5. MD CC ' s orders included but were not limited to the following:
1. Complete blood count with differentials.
2. Troponin (cardiac marker to know if the heart is injured).
3. Comprehensive metabolic panel (CMP) (a helpful and common test that measures several important aspects of your blood).
4. Electrocardiography (EKG) (recorded the electrical signal from the heart to check for different heart conditions).
5. Cardiac Monitoring
6. Medication (morphine (pain medicine), ondansetron(antiemetic), piperacillin-tazobactam(antibiotics), normal saline).
7. Computerized Tomography (CT) (imaging of abdomen and pelvis)

On 2/8/22 at 3:23 p.m., a CT of the abdomen and pelvis was completed, and findings were compatible with acute left-sided colitis (inflammation of the large intestine).
On 2/8/22 at 4:26 p.m., MD CC consulted a colorectal surgeon, MD MM, and at 4:38 p.m., P#5 was admitted as an inpatient to the facility. MD BB was assigned as the admitting physician. MD BB ordered telemetry monitoring (monitoring of electrical activity of the heart), full code status (if a patient has no heartbeat and not breathing, all life-sustaining measures would be made), Diet-NPO (nothing by mouth), and blood and stool cultures.

A review of the consult notes by MD OO on 2/8/22 at 7:32 p.m. revealed that P#5 did not have a perforation and would need non-operative management. MD OO documented that P#5 should be placed on antibiotics, bowel rest, and NPO.

A review of the facility ' s space lab monitor rhythm revealed the following:

On 2/8/22 at 8:11 p.m., P#5 ' s rhythm on the monitor showed a normal sinus (normal heart rhythm); HR 59, RR 22.
On 2/8/22 at 8:24 p.m., P#5 ' s rhythm on the monitor showed a normal sinus; HR 62, RR 23.
On 2/8/22 at 8:59 p.m., P#5 ' s rhythm on the monitor showed a change to wide QRS complex (electrical abnormality in the heart); HR 67, RR 27.
On 2/8/22 at 9:07 p.m., P#5 ' s rhythm on the monitor showed that the wide QRS complex (electrical abnormality in the heart) continued; HR 66, RR 16.
On 2/8/22 at 11:52 p.m., P#5 ' s rhythm on the monitor showed a sinus rhythm with first-degree heart block (a rhythm where the electrical impulses move more slowly to reach the ventricles, the mildest type of heart block); HR 67, RR 27, O2 92%.

On 2/9/2022 at 12:00 a.m. P#5 ' s rhythm on the monitor showed a rhythm change to asystole (the cessation of electrical and mechanical activity of the heart).

The facility failed to document and perform any interventions during any of the forementioned abnormal heart rhythms. P#5 ' s cardiopulmonary arrest was unwitnessed.

A review of the Code Blue Flowsheet revealed that on 2/9/22 at 12:12 a.m., a cardiopulmonary arrest was recognized for P#5. MD KK, Registered Nurse (RN) GG, RN HH, and RN FF were present and responded to the Code Blue (emergency code for when a patient goes into cardiac arrest). During resuscitation efforts, P#5 received naloxone (opioid antagonist), lidocaine (vasodilator), epinephrine (vasoconstrictor and blood pressure support), and magnesium (vital mineral for heart function). P#5 was intubated by MD KK at 12:47 a.m. Resuscitation efforts were stopped, and the time of death was called at 12:47 a.m.

On 2/9/21 at 12:23 a.m. MD KK documented that P#5 was found unresponsive by the nursing staff, and MD KK was called to the bedside. The staff could not state how long it had been since P#5 was last seen responsive. MD KK noted that Cardiopulmonary Resuscitation (CPR) was in progress upon arrival at the bedside. MD JJ was paged, and a Code Blue was paged out.

A review of P#5 ' s Discharged Summary revealed that P#5 was discharged on 2/9/22 at 4:20 a.m. P#5 ' s discharge diagnosis was Respiratory Arrest and Pulseless Electrical Activity (PEA).

An interview with the Director of Emergency Department (DED) AA was conducted on 4/5/22 at 3:08 p.m. DED AA acknowledged he was aware of the event with P#5. DED AA stated that he heard about the incident during rounding the morning that P#5 had the cardiac arrest. DED AA said Charge Nurse (CN) FF said P#5 coded, and there were some issues with the case. DED AA said that he interviewed Registered Nurse (RN) GG and RN HH. RN GG told DED AA that she had left the POD to transport another patient to the floor, and when RN GG returned, RN GG heard the monitor alarm sounding, went to P#5 ' s room, and found him unresponsive. RN GG called for assistance immediately. DED AA said RN HH said he had left the ED POD to locate an infusion pump to administer blood. DED AA said CN FF was at the ambulance desk to allow a nurse to take a bathroom break. DED AA said CN FF immediately left the desk and went to assist with the code once she became aware. DED AA said they pulled the team together to discuss the incident, gather the data, and review the case. DED AA said they talked about the opportunity to improve communications between the staff. DED AA said they re-educated the nurses about the need to notify the charge nurse or resource nurse before leaving the POD. DED AA said the monitors were designed to connect to the spectra phones ( healthcare cellular communications device). Unfortunately, the staff did not have their phones with them. DED AA said a new process for collecting and distributing phones was implemented. DED AA said the staffing was adequate, but there were issues with communication and knowing where all resources were located. DED AA said all the ED staff were re-educated on available resources and how to get assistance.


An interview was conducted with the CN FF on 4/6/22 at 9:14 a.m. CN FF stated that the incident with P#5 occurred around 11:00 p.m. CN FF said that she was at the ambulance desk reliving a staff member who needed to use the restroom. CN FF said RN HH called on the phone to inform her that P#5 was about to code. RN HH said she immediately left the ambulance desk and went to the patient ' s room. CN FF stated there were already three staff members (MD KK, RN GG, and RN HH) in P#5 ' s room when she arrived. CN FF said the house supervisor performed chest compression on the patient while another staff member was administering medications. CN FF said she asked RN GG what had happened. RN GG said she was returning from transporting another patient to a nursing unit and heard the space lab monitor alarm sounding. RN GG immediately called for assistance. CN FF said P#5 was administered Narcan (opioid antidote) because the patient was previously on pain medication before he became unresponsive. P#5 was intubated and administered epinephrine, but he remained unresponsive. CN FF said at some point, the admitting doctor called the patient ' s family, explained to them what had happened, and called the time of death. CN FF said while investigating the event; they found out that the spectra phones that connected to the space lab monitor were not working correctly on the POD. They got new phones for everyone and put a new system for exchanging the phone during shift changes. CN FF said before signing off on the phone and handing them back out, they would make sure the phones were completed. CN FF said there was supposed to be a resource nurse on each POD, and before staff left the POD, they were supposed to notify someone to cover for them. CN FF said RN GG told her she notified RN HH before leaving the POD.

A telephone interview was conducted with RN GG on 4/6/22 at 10:30 a.m. RN GG stated she started providing care for P#5 around 7:00 p.m., on the day the event occurred. RN GG said P#5 was at the facility for colitis and had been in a lot of pain. RN GG said P#5 was alert and oriented and was given pain medications several times. RN GG stated she medicated P#5 around 10:30 p.m. RN GG said she informed RN HH that she was transporting a patient to the cardiac unit. Before leaving, she checked on all her patients. Her patients ' vital signs were okay, and their call bell alarms were in working order. RN GG said she left ED POD-C to transport another patient but could but not remember the actual time. RN GG said when she returned, she saw the red light flashing in P#5 ' s room, and she thought P#5 was probably disconnected from the monitor. She immediately went to P#5 ' s room and saw that P#5 was asystole. RN GG said she immediately alerted other staff that P#5 was unresponsive, and they started chest compression. RN GG said she did not receive a spectra phone for that shift. RN GG stated they went through safety meetings and education regarding communications and handing off the spectra phone since the incident occurred.


A telephone interview was conducted with the RN LL on 4/6/22 at 11:30 a.m. RN LL stated she was not the primary nurse for P#5. RN LL said she left POD-C to get an oxygen tank down the hall. RN LL said she came across RN GG in the hallway towards POD-C. RN LL stated that while she was coming from the hallway down to the door of POD C, RN GG said she needed help and that P#5 was unresponsive. RN LL said she immediately sat the oxygen tank down and went to P#5 ' s room to assist with resuscitating P#5. RN LL said the POD did not have a spectra phone assigned to them when the incident occurred.

A telephone interview was conducted with RN II on 4/6/22 at 12:09 p.m. RN II stated she was on her lunch break when the incident occurred, and RN HH was covering for her. RN II said that she went into P#5 ' s room when she returned to work, and chest compression had already started. RN II acknowledged there were no spectra phones assigned to them when the incident occurred.

A review of the facility ' s policy titled "Emergency Room Staffing," policy number 301-10, last reviewed 9/19, revealed that the purpose of the policy was to outline the staffing pattern utilized in the ED. Staffing standards at the facility ' s ED were based on historical volume and acuity.

A review of the facility ' s ED staffing schedule included the following:

Date: 2/7/22 - 2/8/22

POD A Number of Beds: 11
Charge Nurse: 1 Technicians: None
7:00 a.m. to 11:00 p.m.- 4 RNs
11:00 p.m. to 3:00 a.m.- 3 RNs
3:00 a.m. to 7:00 a.m.- 2 RNs

POD C Number of Beds: 12
Charge Nurse: 1 Technicians: None
7:00 a.m. to 7:00 p.m.- 4 RNs
7:00 p.m. to 7:00 a.m.- 3 RNs


POD F Number of Beds: 12
Charge Nurse:1 Technicians: None
7:00 a.m. to 11:00 p.m.- 4 RNs
11:00 p.m. to 7:00 a.m.- 3 RNs



Date: 2/8/22 - 2/9/22

POD A Number of Beds: 11
Schedules:
Charge Nurse: 1 Technician: None
7:00 a.m. to 3:00 a.m.- 4 RNs
3:00 a.m. to 7:00 a.m.-2 RNs

POD C Number of Beds: 12
Charge Nurse: 1 Technicians: None
7:00 a.m. to 11:00 p.m.- 4 RNs
11:00 p.m. to 7:00 a.m.- 3 RNs

POD F Number of Beds: 12
Charge Nurse:1 Technicians: None
7:00 a.m. to 7:00 p.m.- 4 RNs
7:00 p.m. to 3:00 a.m.- 3 RNs
3:00 a.m. to 7:00 a.m.- 2 RNs

A review of the facility ' s analysis findings revealed that the ideal staffing plan for a 12-bed POD is 3 primary RNs, 1 resource RN, and 1 ED tech. Further review revealed that from 2/8/22 at 11:30 p.m. to 2/9/22 at 7:00 a.m. there were only 3 primary RNs and 0 ED techs on POD -C.

The governing body failed to ensure adequate staffing and proper technology were in place to ensure proper care for P#5. P#5 medical record documented that P#5 experienced cardiac events beginning 2/8/22 at 8:59 p.m. and escalated to P#5 experiencing asystole on 2/9/22 at 12:00 a.m. Documentation revealed that life saving measures were not initiated until 2/9/22 at 12:12 a.m. Interviews with staff confirmed the necessary devices (spectra phones) were not in place to alert staff of P#5 ' s deteriorating condition, furthermore interviews revealed that the emergency department Pod-C was not adequately monitored by staff leading to the delay in care for P#5.

Based on a review of the medical record, staff interviews, policies and procedures, observations, facility's ED staffing schedule, and facility's analysis findings, it was determined that the facility failed to provide adequate staffing coverage thereby causing a delay in care to one patient out of 5 sampled (Patient #5). The lack of coverage and facility's delay in patient care led to the facility's failure to immediately initiate a life saving interventions for P#5 who was found unresponsive on 2/9/22 at 12:11 am. P#5 expired at the facility on 2/9/22 at 12:47 am.

Findings:
Cross- reference to A-0392 as it relates to the facility's failure to provide adequate staffing coverage. Specifcally, P#5 was left unmonitored. P#5 experienced a life threating arrythmia (irregular heartbeat) at 12:00 a.m. on 2/9/22. Lifesaving measures were not documented to be initiated until 12:12 a.m. P#5 was unsupervised by with an asystole arrhythmia (no electrical heart activity) for 12 minutes.

Based on a review of the medical record, interviews with staff, a review of policies and procedures, observations made at the facility, a review of the facility ' s ED staffing schedule, and facility ' s analysis findings, it was determined that the facility failed to provide adequate staffing coverage thereby causing a delay in care to one Patient (P) (P#5) out of five sampled patients. The lack of coverage and the facility ' s delay in patient care led to the facility ' s failure to immediately initiate lifesaving interventions for P#5, who was found unresponsive on 2/9/22 at 12:11 a.m. P#5 expired at the facility on 2/9/22 at 12:47 a.m.

Findings:

A review of Patient (P) #5 ' s medical record revealed that P#5 presented to the facility ' s Emergency Department (ED) on 2/8/22 at 11:44 a.m. with a chief complaint of abdominal pain. P#5 ' s past medical history included a gastrointestinal (abdominal) bleed, colitis (inflammation of the large intestine), high blood pressure, and myocardial infarction (heart muscle that began to die due to insufficient blood). Triage was started at 11:46 a.m. A review of the triage note revealed that P#5 reported abdominal pain and a bruise on the right lower section of his abdomen. P#5 stated he was weak and had reported constipation and bloating. P#5 was on a daily blood thinner. P#5 stated a pain score of 10 (highest).
At 11:49 am, Patient #5's vital signs at the ED were as follows:

Heart Rate (HR): 49 (normal range was normal 60-100)
Respiratory Rate (RR): 18 (normal range was 12-20)
Blood pressure (B/P): 86/56 (low) (normal range was 100-120/60-80)
Oxygen saturation (O2): 97% (normal range was 94-100%).

On 2/8/22 at 12:03 p.m. Medical Doctor (MD) CC was assigned to P#5. MD CC ' s orders included but were not limited to the following:
1. Complete blood count with differentials.
2. Troponin (cardiac marker to know if the heart is injured).
3. Comprehensive metabolic panel (CMP) (a helpful and common test that measures several important aspects of your blood).
4. Electrocardiography (EKG) (recorded the electrical signal from the heart to check for different heart conditions).
5. Cardiac Monitoring
6. Medication (morphine (pain medicine), ondansetron(antiemetic), piperacillin-tazobactam(antibiotics), normal saline).
7. Computerized Tomography (CT) (imaging of abdomen and pelvis)

On 2/8/22 at 3:23 p.m., a CT of the abdomen and pelvis was completed, and findings were compatible with acute left-sided colitis (inflammation of the large intestine).
On 2/8/22 at 4:26 p.m., MD CC consulted a colorectal surgeon, MD MM, and at 4:38 p.m., P#5 was admitted as an inpatient to the facility. MD BB was assigned as the admitting physician. MD BB ordered telemetry monitoring (monitoring of electrical activity of the heart), full code status (if a patient has no heartbeat and not breathing, all life-sustaining measures would be made), Diet-NPO (nothing by mouth), and blood and stool cultures.

A review of the consult notes by MD OO on 2/8/22 at 7:32 p.m. revealed that P#5 did not have a perforation and would need non-operative management. MD OO documented that P#5 should be placed on antibiotics, bowel rest, and NPO.

A review of the facility ' s space lab monitor rhythm revealed the following:

On 2/8/22 at 8:11 p.m., P#5 ' s rhythm on the monitor showed a normal sinus (normal heart rhythm); HR 59, RR 22.
On 2/8/22 at 8:24 p.m., P#5 ' s rhythm on the monitor showed a normal sinus; HR 62, RR 23.
On 2/8/22 at 8:59 p.m., P#5 ' s rhythm on the monitor showed a change to wide QRS complex (electrical abnormality in the heart); HR 67, RR 27.
On 2/8/22 at 9:07 p.m., P#5 ' s rhythm on the monitor showed that the wide QRS complex (electrical abnormality in the heart) continued; HR 66, RR 16.
On 2/8/22 at 11:52 p.m., P#5 ' s rhythm on the monitor showed a sinus rhythm with first-degree heart block (a rhythm where the electrical impulses move more slowly to reach the ventricles, the mildest type of heart block); HR 67, RR 27, O2 92%.

On 2/9/2022 at 12:00 a.m. P#5 ' s rhythm on the monitor showed a rhythm change to asystole (the cessation of electrical and mechanical activity of the heart).

The facility failed to document and perform any interventions during any of the forementioned abnormal heart rhythms. P#5 ' s cardiopulmonary arrest was unwitnessed.

A review of the Code Blue Flowsheet revealed that on 2/9/22 at 12:12 a.m., a cardiopulmonary arrest was recognized for P#5. MD KK, Registered Nurse (RN) GG, RN HH, and RN FF were present and responded to the Code Blue (emergency code for when a patient goes into cardiac arrest). During resuscitation efforts, P#5 received naloxone (opioid antagonist), lidocaine (vasodilator), epinephrine (vasoconstrictor and blood pressure support), and magnesium (vital mineral for heart function). P#5 was intubated by MD KK at 12:47 a.m. Resuscitation efforts were stopped, and the time of death was called at 12:47 a.m.

On 2/9/21 at 12:23 a.m. MD KK documented that P#5 was found unresponsive by the nursing staff, and MD KK was called to the bedside. The staff could not state how long it had been since P#5 was last seen responsive. MD KK noted that Cardiopulmonary Resuscitation (CPR) was in progress upon arrival at the bedside. MD JJ was paged, and a Code Blue was paged out.

A review of P#5 ' s Discharged Summary revealed that P#5 was discharged on 2/9/22 at 4:20 a.m. P#5 ' s discharge diagnosis was Respiratory Arrest and Pulseless Electrical Activity (PEA).

An interview with the Director of Emergency Department (DED) AA was conducted on 4/5/22 at 3:08 p.m. DED AA acknowledged he was aware of the event with P#5. DED AA stated that he heard about the incident during rounding the morning that P#5 had the cardiac arrest. DED AA said Charge Nurse (CN) FF said P#5 coded, and there were some issues with the case. DED AA said that he interviewed Registered Nurse (RN) GG and RN HH. RN GG told DED AA that she had left the POD to transport another patient to the floor, and when RN GG returned, RN GG heard the monitor alarm sounding, went to P#5 ' s room, and found him unresponsive. RN GG called for assistance immediately. DED AA said RN HH said he had left the ED POD to locate an infusion pump to administer blood. DED AA said CN FF was at the ambulance desk to allow a nurse to take a bathroom break. DED AA said CN FF immediately left the desk and went to assist with the code once she became aware. DED AA said they pulled the team together to discuss the incident, gather the data, and review the case. DED AA said they talked about the opportunity to improve communications between the staff. DED AA said they re-educated the nurses about the need to notify the charge nurse or resource nurse before leaving the POD. DED AA said the monitors were designed to connect to the spectra phones ( healthcare cellular communications device). Unfortunately, the staff did not have their phones with them. DED AA said a new process for collecting and distributing phones was implemented. DED AA said the staffing was adequate, but there were issues with communication and knowing where all resources were located. DED AA said all the ED staff were re-educated on available resources and how to get assistance.


An interview was conducted with the CN FF on 4/6/22 at 9:14 a.m. CN FF stated that the incident with P#5 occurred around 11:00 p.m. CN FF said that she was at the ambulance desk reliving a staff member who needed to use the restroom. CN FF said RN HH called on the phone to inform her that P#5 was about to code. RN HH said she immediately left the ambulance desk and went to the patient ' s room. CN FF stated there were already three staff members (MD KK, RN GG, and RN HH) in P#5 ' s room when she arrived. CN FF said the house supervisor performed chest compression on the patient while another staff member was administering medications. CN FF said she asked RN GG what had happened. RN GG said she was returning from transporting another patient to a nursing unit and heard the space lab monitor alarm sounding. RN GG immediately called for assistance. CN FF said P#5 was administered Narcan (opioid antidote) because the patient was previously on pain medication before he became unresponsive. P#5 was intubated and administered epinephrine, but he remained unresponsive. CN FF said at some point, the admitting doctor called the patient ' s family, explained to them what had happened, and called the time of death. CN FF said while investigating the event; they found out that the spectra phones that connected to the space lab monitor were not working correctly on the POD. They got new phones for everyone and put a new system for exchanging the phone during shift changes. CN FF said before signing off on the phone and handing them back out, they would make sure the phones were completed. CN FF said there was supposed to be a resource nurse on each POD, and before staff left the POD, they were supposed to notify someone to cover for them. CN FF said RN GG told her she notified RN HH before leaving the POD.

A telephone interview was conducted with RN GG on 4/6/22 at 10:30 a.m. RN GG stated she started providing care for P#5 around 7:00 p.m., on the day the event occurred. RN GG said P#5 was at the facility for colitis and had been in a lot of pain. RN GG said P#5 was alert and oriented and was given pain medications several times. RN GG stated she medicated P#5 around 10:30 p.m. RN GG said she informed RN HH that she was transporting a patient to the cardiac unit. Before leaving, she checked on all her patients. Her patients ' vital signs were okay, and their call bell alarms were in working order. RN GG said she left ED POD-C to transport another patient but could but not remember the actual time. RN GG said when she returned, she saw the red light flashing in P#5 ' s room, and she thought P#5 was probably disconnected from the monitor. She immediately went to P#5 ' s room and saw that P#5 was asystole. RN GG said she immediately alerted other staff that P#5 was unresponsive, and they started chest compression. RN GG said she did not receive a spectra phone for that shift. RN GG stated they went through safety meetings and education regarding communications and handing off the spectra phone since the incident occurred.


A telephone interview was conducted with the RN LL on 4/6/22 at 11:30 a.m. RN LL stated she was not the primary nurse for P#5. RN LL said she left POD-C to get an oxygen tank down the hall. RN LL said she came across RN GG in the hallway towards POD-C. RN LL stated that while she was coming from the hallway down to the door of POD C, RN GG said she needed help and that P#5 was unresponsive. RN LL said she immediately sat the oxygen tank down and went to P#5 ' s room to assist with resuscitating P#5. RN LL said the POD did not have a spectra phone assigned to them when the incident occurred.

A telephone interview was conducted with RN II on 4/6/22 at 12:09 p.m. RN II stated she was on her lunch break when the incident occurred, and RN HH was covering for her. RN II said that she went into P#5 ' s room when she returned to work, and chest compression had already started. RN II acknowledged there were no spectra phones assigned to them when the incident occurred.

A review of the facility ' s policy titled "Emergency Room Staffing," policy number 301-10, last reviewed 9/19, revealed that the purpose of the policy was to outline the staffing pattern utilized in the ED. Staffing standards at the facility ' s ED were based on historical volume and acuity.

A review of the facility ' s ED staffing schedule included the following:

Date: 2/7/22 - 2/8/22

POD A Number of Beds: 11
Charge Nurse: 1 Technicians: None
7:00 a.m. to 11:00 p.m.- 4 RNs
11:00 p.m. to 3:00 a.m.- 3 RNs
3:00 a.m. to 7:00 a.m.- 2 RNs

POD C Number of Beds: 12
Charge Nurse: 1 Technicians: None
7:00 a.m. to 7:00 p.m.- 4 RNs
7:00 p.m. to 7:00 a.m.- 3 RNs


POD F Number of Beds: 12
Charge Nurse:1 Technicians: None
7:00 a.m. to 11:00 p.m.- 4 RNs
11:00 p.m. to 7:00 a.m.- 3 RNs



Date: 2/8/22 - 2/9/22

POD A Number of Beds: 11
Schedules:
Charge Nurse: 1 Technician: None
7:00 a.m. to 3:00 a.m.- 4 RNs
3:00 a.m. to 7:00 a.m.-2 RNs

POD C Number of Beds: 12
Charge Nurse: 1 Technicians: None
7:00 a.m. to 11:00 p.m.- 4 RNs
11:00 p.m. to 7:00 a.m.- 3 RNs

POD F Number of Beds: 12
Charge Nurse:1 Technicians: None
7:00 a.m. to 7:00 p.m.- 4 RNs
7:00 p.m. to 3:00 a.m.- 3 RNs
3:00 a.m. to 7:00 a.m.- 2 RNs

A review of the facility ' s analysis findings revealed that the ideal staffing plan for a 12-bed POD is 3 primary RNs, 1 resource RN, and 1 ED tech. Further review revealed that from 2/8/22 at 11:30 p.m. to 2/9/22 at 7:00 a.m. there were only 3 primary RNs and 0 ED techs on POD -C.

The facility failed to provide adequate staffing to ensure proper care for P#5. P#5 medical record documented that P#5 experienced cardiac events beginning 2/8/22 at 8:59 p.m. and escalated to P#5 experiencing asystole on 2/9/22 at 12:00 a.m. Documentation revealed that life saving measures were not initiated until 2/9/22 at 12:12 a.m. Interviews with staff confirmed the necessary devices (spectra phones) were not in place to alert staff of P#5 ' s deteriorating condition, furthermore interviews revealed that the emergency department Pod-C was not adequately monitored by staff leading to the delay in care for P#5