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Based on review of medical records (MR), review of facility documents and interview with staff (EMP) it was determined that the facility failed to protect and promote each patient's right as evidence by: failure to fully informed of their rights in advance of furnishing or discontinuing of patient care (A0117): failure to ensure consent to provide treatment was obtained at the time of admission (A0131): failure to ensure patients receive care in a safe setting (A0144): And, failure to ensure patients are free from neglect (A0145).

Based on review of facility documentation, record review (MR), and interview (EMP), it was determined the facility failed to ensure patients were fully informed of their rights in advance of furnishing or discontinuing of patient care for 10 of 10 medical records (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, and MR10) reviewed.

Findings include:

On January 7, 2022, a review of the facility policy, "Admission of Patients, last approved date March 1, 2020," revealed, "Administration A. Admission Consent forms will be executed at the time of admission or as soon as possible in emergency situations, by written or verbal consent...B. Patient Rights, Advance Directive, and HIPAA will be reviewed as part of the admission interview process."

On January 7, 2022, a review of the facility policy, "Patient Rights and Responsibilities, last approved date May 24, 2021," revealed, "Patient Rights...A Communication...B. Informed Decisions...C. Visitation...D. Advance Directives...E. Care Planning...F. Care Delivery...G. Privacy and Confidentiality...H. Hospital Bills...I. Complaints, Concerns, and Questions."

On January 7, 2022, a review of the facility booklet titled, "Your hospital stay ..." was reviewed. On page 10 of this booklet was, "Understanding your rights and responsibilities...You have the right to: Treatment without discrimination. Safe, respectful, and dignified care at all times. Instructions and information you can understand. Participate in decisions about your care. Care that supports you and your family. Access to your billing and medical records...For a complete list of your rights and responsibilities as a patient, please visit https://www.ahn.org/patients-visitors-information/patient-privacy-rights."

Record reviews were completed on January 6 and 7, 2022. MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, and MR10 revealed the nurses documented, " admission guide provided. "

During an interview on January 6, 2022, at 1:50 PM, EMP 3 confirmed that all patients are provided with a packet of information at the time of admission including the admission guide booklet that included patient rights and responsibilities.

During an interview on January 7, 2022, at 9:30 AM, EMP 1 confirmed that the patient guide does not fully inform the patient of their rights and responsibilities and they are furnished care without being fully informed.

Based on a review of facility policy, medical records (MR). personnel files (PF), and staff interview (EMP), it was determined that the facility failed to ensure patients receive care in a safe setting by permitting two staff under investigation to work in the same capacity and provide care to patients during a 16-day investigation which resulted in the termination of their employment (PR1 and PR3).

Findings Include:

On January 7, 2022, a review of the facility's Patient Rights and Responsibilities, last reviewed on 5/24/2021, stated, "Patient Rights. Care Delivery: You have the right to:
2. Receive care in a safe setting free from any form of abuse, harassment, and neglect."

On January 7, 2022, a review of the facility's Allegation of Patient Abuse Policy, last approved on 10/1/2020, states, "Abuse: Intentional mistreatment or the willful infliction of infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physician harm....... This includes staff neglect.....Neglect: the failure to provide goods, resources, and services necessary to meet basic needs.... ."


On January 7, 2022, a review of MR1 revealed that the patient had prolonged hospitalization since July 2021 due to extensive 54% TBSA second and third-degree burns involving his face, neck, bilateral upper extremities, left lower extremity, left hemi abdomen. Further review revealed that MR1 underwent numerous debridement and grafting procedures and underwent a left trans humeral amputation. While admitted to inpatient rehabilitation, the patient had two abnormal blood pressure readings on the morning of December 21, 2022. The patient then noted to be fatigued during morning when assessed by therapy assistants. During occupational therapy session an acute change of condition was noted and a rapid response was initiated then transitioned to code blue, however MR1 ceased to breathe.

On January 5, 2022, EMP1 reported the incident as gross misconduct on behalf of the nursing care staff for this patient.

On January 7, 2022 EMP5 reported being made aware of the incident and reporting it to her supervisor and human resources and that the investigation of three nurses responsible for the care of MR1. During the interview EMP5 was asked about the investigation process.
EMP5 explained that the employees were union covered employees and that the employees were permitted to work in the same capacity during the investigation.

On January 7, 2022 the nursing schedules reviewed that PF1 and PF3 provide care to patients during the 16-day investigation which resulted in the termination of their employment.


On January 7, 2022, at 1:40PM, EMP9 acknowledged that permitting staff to provide care to patient while under investigation for patient neglect is a violation of Patient Rights, and that patients have the right to receive care in a safe setting.

Based on a review of facility policy and medical records (MR) and staff interview (EMP), it was determined that the facility failed to ensure patients are free from neglect by permitted a staff to care for patients after admitting to inadequately providing medical care to a patient the staff deemed as being difficult.

Findings Include:

On January 7, 2022, a review of the facility's Patient Rights and Responsibilities, last reviewed on 5/24/2021, stated, "Patient Rights. Care Delivery: You have the right to:
2. Receive care in a safe setting free from any form of abuse, harassment, and neglect."

On January 7, 2022, a review of the facility's Allegation of Patient Abuse Policy, last approved on 10/1/2020, states, "Abuse: Intentional mistreatment or the willful infliction of infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physician harm....... This includes staff neglect.....Neglect: the failure to provide goods, resources, and services necessary to meet basic needs.... ."


On January 7, 2022, a review of MR1 revealed that the patient had prolonged hospitalization since July 2021 due to extensive 54% TBSA second and third-degree burns involving his face, neck, bilateral upper extremities, left lower extremity, left hemi abdomen. Further review revealed that MR1 underwent numerous debridement and grafting procedures and underwent a left trans humeral amputation. While admitted to inpatient rehabilitation, the patient had two abnormal blood pressure readings on the morning of December 21, 2022. The patient then noted to be fatigued during morning when assessed by therapy assistants. During occupational therapy session an acute change of condition was noted and a rapid response was initiated then transitioned to code blue, however MR1 ceased to breathe.

On January 5, 2022, EMP1 reported the incident as gross misconduct on behalf of the nursing care staff for this patient.

EMP5 explained that after reviewing the incident and the hours leading up to MR1's death, EMP5 immediately saw red flags. EMP5 further explained that staff made a bad judgement and understood what staff failed to do but found the patient to be too diffuclt.

On January 7, 2022, during an interview EMP5 confirmed that staff was permitted to care for other patients after admitting to inadequately providing medical care to a patient acting in a difficult manner.

Based on a review of facility documents, medical record review (MR), and staff interview (EMP), it was determined the facility failed to ensure that the nursing staff adhered to the policies and procedures of the hospital for 2 of 2 medical records reviewed (MR1 and MR10).
Findings include:
On January 7, 2022, the facility policy, "Rapid Response Team, Last Revised Date November 1, 2019," revealed, "Administration A. Any person may initiate the Rapid Response Team by calling the Operator and asking for Rapid Response to be announced and the location. The Rapid Response should be used to prevent a crisis or any time that a critical care response is desired. The following guidelines should be used to assist in decision-making in situations where it is reasonable to initiate a Rapid Response. Bedside clinicians should use their best judgment specific to the circumstances and situations that may arise ...3. Blood Pressure a. <80 or >200 systolic ...with symptoms such as neurological change ..."
1. Review of MR1 revealed the patient was admitted on 7/31/2021 to the Burn Unit following 54% total body surface area flash burns to his face, neck, bilateral upper extremities, left lower extremity, left hemisphere of abdomen. On 11/16/2021, MR1was admitted to the Rehabilitation Unit for comprehensive inpatient rehabilitation, with a planned discharge to home with family.
Review of MR1 revealed the following vital signs:
-On 12/20/2021, at 6:13 PM: blood pressure (BP) was 128/87
-On 12/21/2021, at 6:20 AM: BP was 74/48; at 6:21 AM: BP was 68/42

Further review of MR1 did not reveal any nurse's notes/clinical notes by either PF1 or PF3 regarding MR1's low BP or escalation of the same to the physician.

During an interview with EMP5 on January 6, 2022, at 1155 AM, EMP5 explained that on the morning of 12/21/2021, the Occupational Therapist noted that the patient was not at baseline and noted a decrease in respiratory rate, shallow breathing, pale lips, and lethargy. This change in condition was reported to PF1.

At 12:10 PM, PF1 noted that MR1's BP was 72/48. At 12:11 PM, an RRT was called and the patient's pulse was lost shortly thereafter.

At 12:11 PM, MR1 was found pulseless and a Code Blue was announced. A note by the attending physician, entered on 12/21/2021 at 3:38PM, revealed: " Code Blue called due to patient being found unresponsive. ... Patient was in persistent PEA (pulseless electrical activity) without ROSC (return of spontaneous circulation). Family arrived and decision was made to stop further CPR. TOD (time of death) 12:45."

During an interview with EMP5 on January 6, 2022, at approximately 12:00 PM, EMP stated she was concerned that there was no escalation of the patient ' s condition/low BP.
2. On January 7, 2022, a review of a facility document revealed an incident occurred for MR10 on September 28, 2021, where the patient's blood pressure dropped and the rapid response was initiated. The investigation for this incident was requested, none was provided.
A review of MR10 revealed the patient was admitted to the rehab unit on September 16, 2021. On September 28, 2021, at 6:01 AM, the blood pressure (BP) was 167/72, Temperature (T) 102.4, heart rate (HR) 102, oxygen saturation 94% on room air. At 6:18 AM on the same date, MR10's BP dropped to 68/44. At 6:25 AM the BP was 66/48, HR 104. At 7:38 AM BP 63/36, T 102.4.
A nursing note for MR10 dated September 28, 2021, at 7:19 AM revealed, "RN tried to wake Pt for morning vitals and noticed that he is not responding and lethargic, febrile with low BP. Hospitalist informed and new order given. Continue to monitor Pt." There were no nursing notes timed at the time the BP was first noted at 6:18 AM. The next nursing note was at 7:40 AM that revealed, "Rapid response called."
The first drop in BP was noted at 6:18 AM on September 28, 2021, and the BP remained low and continued to drop to 63/36 at 7:38 AM. The rapid response was not called until 7:40 AM, one hour and 22 minutes later.
During an interview on January 7, 2022, at 1:45PM, EMP5 confirmed the staff failed to follow facility policy for initiating a rapid response.