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Based on review of facility policy, medical record review, review of facility documentation, and interviews, the facility failed to honor a patient's right to request treatment for one patient (#1) of 8 records reviewed for advanced directives.

The findings included:

During the investigation it was found Patient #1 was admitted to the facility on 12/2/18 with diagnoses including Displaced Gastrostomy Tube (feeding tube), Pneumonia (infection in the lung), Pneumonitis (inflammation of the lung tissue) to the Lower Lung Lobes, and Splenomegaly (enlarged spleen). Further review revealed the patient's advanced directive status was Full Code (life-saving measures to be implemented). The patient was taken to the Peri-Operative Unit (unit where patients are prepared for surgery) on 12/6/18 for a Percutaneous Endoscopic Gastrostomy (PEG) tube and Ash catheter (alternative vascular access for those patients in need of hemodialysis) insertion. Anesthesia evaluated the patient and found the patient was unstable for the surgical procedure and was concerned the patient would not be able to be weaned from the ventilator. The surgeon was notified by the staff and the patient was prepared to return to the medical surgical unit by the nursing staff. The patient's cardiac monitor was removed; he was placed on a portable oxygen tank, and prior to the transport the physician asked the nurses to wait until he had spoken with the patient's family. The nursing staff left the patient in the room, unmonitored, while providing care to two additional patients. The transport team was contacted to take the patient back to the medical surgical unit at 7:11 PM, and upon their arrival to the Peri-Operative Unit at 8:10 PM, the patient was found by the transporter with no pulse, not breathing, and cyanotic (bluish color to the skin and mucous membranes). The nurse was notified and confirmed the patient was pulseless and no Code Blue (facility's notification of a cardiac or respiratory arrest) was initiated for the patient. Two Registered Nurses (RN's) witnessed the patient had expired and notified the anesthesia provider by phone and did not convey the emergent situation to the provider.

During a conference with the Administrator, the Chief Nursing Officer (CNO), the Risk Manager (RM), the Cooperative Director of Quality Management, the Chief Medical Officer (CMO), and the Chief Operating Officer (COO) on 3/26/19 at 3:30 PM, in the conference room, the facility was informed of an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation, has caused, or is likely to cause injury, harm, impairment, or death) at 42 CFR PART 482.13 Condition of Participation, Patient Rights.

During a conference with the Administrator, the CNO, the CMO, the COO, the RM, the Corporate Director of Quality Management, and the Director of Peri-Operative Services on 3/27/19 at 1:55 PM, in the conference room, the facility presented an Immediate Action Plan for the Immediate Jeopardy. Review of the Immediate Action Plan, which removed the Immediate Jeopardy on 3/27/19, revealed the following actions were implemented:

1. CPR (cardiopulmonary resuscitation), Code Blue, documentation, and monitoring of the Peri-Operative patient education

Education
A. Will be provided to all Peri-Operative Team Members to include Registered Nurses (RN), Licensed Practical Nurses (LPN), Scrub Technicians (trained staff who assist the surgeon during the surgical procedure), Resource Technicians (individuals who ensure equipment is readily available in the operating room, Anesthesia Technicians, Mobile Radiology Technicians, Clerical, Supply Technicians, Phlebotomist (individuals who are trained to draw blood), and Chart Coordinators (individuals who prepare the surgery patients medical records) on the initiation of CPR on patients who experience cardiac and/or respiratory arrest. The education included: the clinical team will initiate Code Blue response; all patients in pre-op (peri-operative) will be attached to a cardiac monitor with vital signs obtained at least every 30 minutes throughout the entirety of the stay; in the event a patient's procedure is cancelled or postponed, the documentation will continue through the entirety of the patient's pre-op stay; all Peri-Operative patient's will have nursing assessment, care, and interventions documented within the electronic documentation software until the patients are discharged from the care area.
B. Education will be provided by the Director of Peri-Operative Service, Nurse Managers (NM) of the Peri-Operative Services, and the Peri-Operative Educator.
C. Any Peri-Operative Team Member that does not complete the education will not be allowed to work until the education is complete.
D. Anesthesiologists will be provided education on a cardiac monitor and documentation requirements for cancellation of cases. Education will be provided by e-mail with a return read receipt, written signature or written attestation. Surgeons will receive education on documentation requirements for cancelled cases. Education will be provided by e-mail with a return read receipt, written signature or written attestation.
E. Education will be provided to the Certified Registered Nurse Anesthetists (CRNA) on cardiac monitoring. Education will be provided by e-mail with a return read receipt, written signature or written attestation.
F. Completion Date: Education started on 3/26/19 and will be completed by 4/2/19. Review of sign-in sheet revealed 95 of 161 members of the Peri-Operative Unit had completed the training.

Monitoring and tracking
a. Assessments, documentation, and Cardiac Monitoring have been developed that will review 70 cases per month for 4 consecutive quarters. Monitoring start date is 3/27/19 and ongoing.
b. Monitors for assessment will be completed by assigned Short Stay and PACU (Post Anesthesia Care Unit) Nursing staff.
c. If compliance is met at 80% after four consecutive quarters the monitor will be reevaluated. The results will be reviewed at the QA/PI (quality assurance/performance improvement) meeting, Medical Staff Quality Review Committee (MSQRC), and the Governing Body.

Title of Person Responsible
The CNO, Director of Peri-Operative Services, and CMO

2. Portable Oxygen (O2) Education

Education
a. The nurse will assume responsibility of ensuring the transport O2 tank has sufficient volume (greater than 500 psi-pounds per square inch) for transport and hook the patient to the O2. In the event the transport is delayed the patient will remain on the wall O2.
b. Education will be provided to all Peri-Operative Service Team Members, Registered Nurses, Licensed Practical Nurses, Scrub Technicians, Resource Technicians, Anesthesia Technicians, Mobile Radiology Technicians, Clerical, Supply Technicians, Phlebotomist, and Chart Coordinators.
c. Education will be provided by the Director of Peri-Operative Service, NM of Peri-Operative Services, or the Peri-Operative Educator.
d. Any Peri-Operative staff that does not complete the education will not be allowed to work until the education is complete.
e. Education will be provided to Anesthesiologists on ensuring the transport O2 tank has sufficient volume (greater than 500 psi) for transport and hook the patient to the O2. In the event the transport is delayed the patient will remain on the wall O2. Education will be provided via e-mail with a return read receipt, written signature, or written attestation.
f. Education will be provided to CRNA's ensuring the transport O2 tank has sufficient volume (greater than 500 psi) for transport and hook the patient to the O2. In the event the transport is delayed the patient will remain on the wall O2. Education will be provided via e-mail with a return read receipt, written signature, or written attestation.

Completion Date
a. Education started on 3/26/19 and will be completed by 4/2/19 for current team members.
b. New team members will have education completed prior to the end of orientation. This will be ongoing for any team members hired.

Monitoring and Tracking Procedures
Portable Oxygen Monitor has been developed that will review 70 tanks per month for 4 consecutive quarters.

Title or Person Responsible
The CNO, Director of Peri-Operative Services, and CMO

3. Hand-Off Communication

Education
a. When patients are transported from a clinical area to another area, hand off communication should occur between the giver and the receiver of patient information by the hand off communication tool, SBAR (situation, background, assessment, and recommendations), phone and/or face to face communication and will be documented in the clinical record.
b. Completion date: education started 3/26/19 and will be completed by 4/2/19 for current team members. New members will receive the education completed prior to the end of orientation. Will be ongoing for any team member hired.

Monitoring and Tracking Procedures
Hand off communication Monitors have been developed that will review 70 cases per month for 4 consecutive quarters and ongoing and completed by assigned Short Stay and PACU Nursing staff. If compliance is met at 80% after four consecutive quarters the monitor will be evaluated. The results of the monitor will be reviewed at the QA/PI Meeting, Medical Staff Quality Review Committee (MSQRC), and to the Governing Body.

Responsible Party
CNO and Director of Peri-Operative Services

4. Combination of Pre-Op and PACU Areas

Education
a. After regular business hours, as well as on weekends and holidays, the Pre-Op and PACU staff will combine staff and patient care to one location to increase the level of patient support. This combining of staff and areas will be documented on the daily OR (Operating Room) Operations Report.

Completion date: Combination of Pre-Op and PACU staff after regular hours, as well as on weekends and holidays started 3/27/19.

Monitors and Tracking
Will be completed by Operating Room Shift Charge Nurse. The results of the monitor will be reviewed at the QA/PI Meeting, Medical Staff Quality Review Committee (MSQRC), and to the Governing Body.

Responsible Party: CNO and Director of Peri-Operative Services

5. Bio-Medical Work Orders

Education
a. Critical element equipment related to patient care equipment will require a work order for tracking purposes.
b. Completion date: Start 3/27/19 and ongoing

Monitoring and Tracking Procedures
Report of all peri-operative repairs will be sent to the Director of Peri-Operative Services on a monthly basis for verification of the work order completion. Any changes to cardiac monitor parameters will be initiated by a work order and approved by the Director of Peri-Operative Services and the Director of Bio-Medical Services. Report will be initiated by Bio-Medical Services and forwarded to the Director of Peri-Operative Services on a monthly basis. The results of the monitor will be reviewed at the QA/PI Meeting, Medical Staff Quality Review Committee (MSQRC), and to the Governing Body.

Responsible Party: CNO and Director of Peri-Operative Services

Interview with the Cooperative Director of Quality Management and the RM on 3/27/19 at 1:15 PM, in the conference room, revealed the facility had implemented immediate actions related to Advanced Directives for patients and the initiation of immediate resuscitative measures for patients who have a full code status. All staff in the Peri-Operative Service was required to complete the training. Education was provided to RN's, LPN's, Scrub Technicians, Resource Technicians, Anesthesia Technicians, Mobile Radiology Technicians, Clerical, Supply Technicians, Phlebotomist, and Chart Coordinators. Anesthesiologist, CRNA's and Surgeons were included in the mandatory training. The facility has implemented ongoing monitoring tools for ensuring immediate resuscitation to any patient with full code status who suffers cardiac or respiratory arrest and ensuring a safe environment in the Peri-Operative Service Line which will be reported in the QA/PI Meeting, Medical Staff Quality Review Committee (MSQRC), and the Governing Board.

Review of the Immediate Jeopardy Action Plan revealed immediate actions were implemented by the facility and the Immediate Jeopardy was removed on 3/27/19. The facility remains out of compliance at 42 CFR PART 482.13, Conditions of Participation, Patient Rights (Condition).

Please refer to A-0132

Based on review of facility policy, medical record review, review of facility documentation, and interviews, the facility failed honor a patient's right to request resuscitative measures for one patient (#1) of 8 records reviewed for advanced directives.

The findings included:

Review of facility policy "Do Not Resuscitate Orders (DNR)" last reviewed 2/22/17 revealed "...CPR [cardiopulmonary resuscitation] is to be initiated immediately on a patient who experiences cardiac and/or respiratory arrest unless a DNR has been written or the patient has a valid Universal DNR order..."

Review of facility policy "Cardiopulmonary Resuscitation-Code Blue Adult and Pediatric" last reviewed 2/8/18 revealed "...the person recognizing a cardiac and/or respiratory arrest shall immediately summon help and begin cardiopulmonary resuscitation..."

Medical record review revealed the Patient #1 was admitted to the facility on 12/2/18 with diagnoses including Displaced Gastrostomy Tube (feeding tube), Pneumonia (infection in the lung), Pneumonitis (inflammation of the lung tissue) to the Lower Lung Lobes, and Splenomegaly (enlarged spleen). The patient expired on 12/6/18.

Medial record review of an Admission History and Physical dated 12/2/18 at 6:13 PM revealed the patient reported pain around his Gastrostomy tube (G-Tube). Further review revealed a computed tomography (CT) indicated the tube was superficial to the abdominal wall and surgery was consulted for possible replacement of the tube. Continued review revealed the patient had a previous history of Myasthenia Gravis (chronic autoimmune neuromuscular disease that causes weakness in the skeletal muscles responsible for breathing and moving parts of the body, including the arms and legs), Sleep Apnea, and Idiopathic Thrombocytopenia Purpura (ITP) (disorder that can lead to easy or excessive bruising and bleeding) and a previous Tracheostomy (surgically created hole in the windpipe that provides an alternative airway for breathing) which had been closed.

Medical record review of a Physician's Order dated 12/2/18 at 6:39 PM revealed the patient was a Full Code (implement life-saving measures) and the physician ordered the Adult Oxygen (O2) Protocol for Patient #1. Review of the Adult Oxygen Protocol revealed "...Target saturation: 92% or greater...Unless otherwise ordered, oxygen is initiated via nasal cannula at 2 L/min [liters per minute]. If patient does not have continuous pulse oximetry ordered, Respiratory Therapy to place order for Pulse Ox [pulse oximetry]...If oxygen protocol initiated via nasal cannula, titrate at 1 L/min up to 4 L/min to reach target oxygen saturation range...Once patient has achieved target or greater oxygen saturation: oxygen may be decreased by 1 L/min as tolerated to maintain target oxygen saturation until weaned to room air...Discontinue oxygen when: Room air oxygen saturation is greater than target oxygen saturation AND Respiratory rate is within 12-20 breathes [breaths] per minute AND patient does not de-saturate below the target oxygen saturation with exertion if applicable..."

Medial record review of a Physician's Order dated 12/4/18 at 12:54 AM revealed continuous cardiac telemetry monitoring was ordered for the patient.

Medical record review of a General Surgery Progress Note dated 12/4/18 at 6:46 AM revealed "...possible PEG [Percutaneous Endoscopic Gastrostomy] tube placement today in OR [Operating Room] if respiratory status stable..."

Medical record review of an Anesthesia Pre-op Record dated 12/6/18 at 4:04 PM revealed a pre-procedure assessment was performed by the Anesthesiologist. Further review revealed "... 5:22 PM: anesthesia note: patient in pulmonary edema [excess fluid in the lungs], obtunded [altered level of consciousness], unable to sign consent. Family unavailable. Case cancelled..."

Medical record review of a Discharge Summary dated 12/6/18 revealed "...patient was taken downstairs to have PEG tube replaced. While awaiting surgery, he was found unresponsive with no heart rate, no pulse, no respirations, and was pronounced [deceased]...cause of death: acute respiratory failure...this was 12/6/18 at 8:42 PM..."

Medical record review of the Nurses Notes dated 12/6/18 revealed no nursing documentation of the patient's death, no documentation of CPR, no documentation of the activation of a Code Blue (code to activate the response team for the resuscitation of a patient in cardiac/respiratory arrest), or no documentation the patient's physician or Anesthesiologist was notified.

Review of facility documentation, with no date or time, revealed "...admitted to [the facility] on 12/2/18 with abdominal wall cellulitis from PEG tube. Patient's respiratory status continued to decline during his visit. 12/6/18, patient was taken to short stay surgery for PEG replacement and EGD [Esophagogastroduodenoscopy - tube to view the throat and stomach]. Anesthesia cancelled surgery due to patient's underlying respiratory status. Short stay staff planned to transport patient back to floor, when another patient arrived to short stay. The nurse was unable to leave the unit. Nurse unhooked monitor to transport the patient but never hooked it back up. Transport requested to take patient back to the floor. Transport arrived and noted the patient appeared not to be breathing. He notified the nurse. Nurse never initiated code blue, no CPR or any life-saving measures. She called another nurse from her break. Second nurse arrived at bedside and also failed to intervene. RN [Registered Nurse] never initiated any life-saving measures..."

Interview with the Nurse Manager (NM) of Peri-Operative Services on 3/22/19 at 2:50 PM, in the NM's office, revealed the patient was an inpatient and came to the peri-operative unit for a PEG tube and Ash catheter (alternative vascular access for those patients in need of hemodialysis) insertion on 12/6/18. Continued interview revealed the patient was a full code. Further interview revealed the Anesthesiologist evaluated the patient and found the patient's respiratory status was too severe and the Anesthesiologist was concerned the patient would not be able to be weaned off the ventilator after surgery. It was decided to cancel the patient's surgery. Further interview revealed the nurse was getting ready to take the patient back to his room. She had removed the patient's heart monitor and placed the patient on a portable oxygen tank. The surgeon stopped them and told them to wait until he could speak with the family. The nurse took the patient back into the room but did not place the patient back on the monitor or on the oxygen on the wall. At this point, another patient came into the unit and the RN started preparing the other patient for surgery. Around 8:00 PM, the transporter came to the peri-operative unit to take the patient to the floor. The transporter asked RN #1 if the patient was ready to go the floor and she told him the patient was ready. The transporter went to the patient's bedside and noticed the patient did not look good. He went and got the nurse and they both went to the patient's bedside. They realized the patient had expired. She did not call a Code. "...No CPR was started for the patient. There was no Code called or CPR started by the staff..." The nurse called the Anesthesiologist to notify him. She left him a message to come to the unit but did not indicate the emergent situation to the provider. When the Anesthesiologist came to the unit he was still not aware the patient had expired. He went to Patient #1's bedside and the nurses informed him of the situation. The Anesthesiologist pronounced the patient's death at that time.

Interview with the Anesthesiologist on 3/22/19 at 3:00 PM, in the NM office, revealed the patient was deemed not appropriate for surgery on 12/6/18 related to his respiratory status and the patient was in pulmonary edema. Further interview revealed "...I knew the patient was a full code and that is one of the reason's I did not want to intubate him because the surgery was not a critical surgery. I went out and asked the nurses what was going on and they told me the patient had expired. I asked [named nurses] why they did not call a Code Blue...he was pulseless and not breathing. I hooked the patient up to the monitor and there was no cardiac activity..."

Interview with Transporter #1 on 3/22/19 at 3:35 PM, in the NM office, revealed "...when I got to the Holding Room there was only one nurse in the unit at that time. I asked the nurse if the patient was ready to go and she said he was ready to go. The curtain was pulled and when I rounded the corner of the room, he did not look good. I asked the nurse if she was sure the patient was ready to go and asked her to come into the room. When she came into the room and looked at the patient, she said 'Oh Shit, he is dead.' There was no monitor on the patient and his oxygen was hooked up to the portable tank. There was no Code Blue called and CPR was not started..."

Interview with the Director of Peri-Operative Services on 3/25/19 at 10:35 AM, in the Risk Managers office, revealed she received a call from the charge nurse informing her Patient #1 had expired in the Short Stay Unit and CPR was not performed and a Code Blue was not called. Further interview revealed "...I asked her to go to the unit and confirm what was going on. I could not believe a patient who a full code was not coded and I thought the story had got mixed up. I told her I would come to the facility and for her to call me back. When I arrived the patient was already pronounced by anesthesia. The nurses were confused about why this was such a big deal. They said the patient was already dead and there was no reason to code the patient but he was a full code. [RN #1] did finally agree that she should have called a code...he was found around 8:10 PM. The nurse did not activate a code or start CPR. The patient was not on the monitor and was on the portable O2 tank. They called anesthesia but did not tell [Anesthesiologist] the patient had expired and activate the emergency notification...there was no Code Blue called, the patient was not hooked back on the cardiac monitor, he was left on a portable O2 tank, and no documentation was found indicating they called the physician..." Further interview confirmed the facility failed to initiate CPR and failed to honor the patient's Advanced Directive Status.

Interview with the Risk Manager (RM) on 3/25/19 at 1:15 PM, in the conference room, revealed the RM was notified by the Director of Peri-Operative Services on 12/6/18 of the event. Further interview revealed "...the nursing staff got busy providing care to two other patients and around 8:10 PM the patient was found by the nursing staff in the Peri-Operative Unit without a pulse and not breathing..." Continued interview revealed Patient #1 was a full code and resuscitative measures were not performed for the patient resulting in the patient's death. Further interview confirmed the facility's policy was not followed.

Refer to A-951

Based on review of facility policy, review of the Association of the Peri-Operative of Registered Nurses (AORN) guidelines, medical record review, review of facility documentation, and interviews, the facility failed to provide high quality of care according to acceptable standards of practice for a nonresponsive patient (#1) of 8 surgery records reviewed.

The findings included:

During the investigation it was found Patient #1 was admitted to the facility on 12/2/18 with diagnoses including Displaced Gastrostomy Tube (feeding tube), Pneumonia (infection in the lung), Pneumonitis (inflammation of the lung tissue) to the Lower Lung Lobes, and Splenomegaly (enlarged spleen). Further review revealed the patient's advanced directive status was Full Code (life-saving measures to be implemented). The patient was taken to the Peri-Operative Unit (unit where patients are prepared for surgery) on 12/6/18 for a Percutaneous Endoscopic Gastrostomy (PEG) tube and Ash catheter (alternative vascular access for those patients in need of hemodialysis) insertion. Anesthesia evaluated the patient and found the patient was unstable for the surgical procedure and was concerned the patient would not be able to be weaned from the ventilator. The surgeon was notified by the staff and the patient was prepared to return to the medical surgical unit by the nursing staff. The patient's cardiac monitor was removed; he was placed on a portable oxygen tank, and prior to the transport the physician asked the nurses to wait until he had spoken with the patient's family. The nursing staff left the patient in the room, unmonitored, while providing care to two additional patients. The transport team was contacted to take the patient back to the medical surgical unit at 7:11 PM, and upon their arrival to the Peri-Operative Unit at 8:10 PM, the patient was found by the transporter with no pulse, not breathing, and cyanotic (bluish color to the skin and mucous membranes). The nurse was notified and confirmed the patient was pulseless and no Code Blue (facility's notification of a cardiac or respiratory arrest) was initiated for the patient. Two Registered Nurses (RN's) witnessed the patient had expired and notified the anesthesia provider by phone and did not convey the emergent situation to the provider.

During a conference with the Administrator, the Chief Nursing Officer (CNO), the Risk Manager (RM), the Cooperative Director of Quality Management, the Chief Medical Officer (CMO), and the Chief Operating Officer (COO) on 3/26/19 at 3:30 PM, in the conference room, the facility was informed of an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation, has caused, or is likely to cause injury, harm, impairment, or death) at 42 CFR PART 482.51, Conditions of Participation, Surgical Services (Condition).

During a conference with the Administrator, the CNO, the CMO, the COO, the RM, the Corporate Director of Quality Management, and the Director of Peri-Operative Services on 3/27/19 at 1:55 PM, in the conference room, the facility presented an Immediate Action Plan for the Immediate Jeopardy. Review of the Immediate Action Plan, which removed the Immediate Jeopardy on 3/27/19, revealed the following actions were implemented:

1. CPR (cardiopulmonary resuscitation), Code Blue, documentation, and monitoring of the Peri-Operative patient education

Education
A. Will be provided to all Peri-Operative Team Members to include Registered Nurses (RN), Licensed Practical Nurses (LPN), Scrub Technicians (trained staff who assist the surgeon during the surgical procedure), Resource Technicians (individuals who ensure equipment is readily available in the operating room, Anesthesia Technicians, Mobile Radiology Technicians, Clerical, Supply Technicians, Phlebotomist (individuals who are trained to draw blood), and Chart Coordinators (individuals who prepare the surgery patients medical records) on the initiation of CPR on patients who experience cardiac and/or respiratory arrest. The education included: the clinical team will initiate Code Blue response; all patients in pre-op (peri-operative) will be attached to a cardiac monitor with vital signs obtained at least every 30 minutes throughout the entirety of the stay; in the event a patient's procedure is cancelled or postponed, the documentation will continue through the entirety of the patient's pre-op stay; all Peri-Operative patient's will have nursing assessment, care, and interventions documented within the electronic documentation software until the patients are discharged from the care area.
B. Education will be provided by the Director of Peri-Operative Service, Nurse Managers (NM) of the Peri-Operative Services, and the Peri-Operative Educator.
C. Any Peri-Operative Team Member that does not complete the education will not be allowed to work until the education is complete.
D. Anesthesiologists will be provided education on a cardiac monitor and documentation requirements for cancellation of cases. Education will be provided by e-mail with a return read receipt, written signature or written attestation. Surgeons will receive education on documentation requirements for cancelled cases. Education will be provided by e-mail with a return read receipt, written signature or written attestation.
E. Education will be provided to the Certified Registered Nurse Anesthetists (CRNA) on cardiac monitoring. Education will be provided by e-mail with a return read receipt, written signature or written attestation.
F. Completion Date: Education started on 3/26/19 and will be completed by 4/2/19. Review of sign-in sheet revealed 95 of 161 members of the Peri-Operative Unit had completed the training.

Monitoring and tracking
a. Assessments, documentation, and Cardiac Monitoring have been developed that will review 70 cases per month for 4 consecutive quarters. Monitoring start date is 3/27/19 and ongoing.
b. Monitors for assessment will be completed by assigned Short Stay and PACU (Post Anesthesia Care Unit) Nursing staff.
c. If compliance is met at 80% after four consecutive quarters the monitor will be reevaluated. The results will be reviewed at the QA/PI (quality assurance/performance improvement) meeting, Medical Staff Quality Review Committee (MSQRC), and the Governing Body.

Title of Person Responsible
The CNO, Director of Peri-Operative Services, and CMO

2. Portable Oxygen (O2) Education

Education
a. The nurse will assume responsibility of ensuring the transport O2 tank has sufficient volume (greater than 500 psi-pounds per square inch) for transport and hook the patient to the O2. In the event the transport is delayed the patient will remain on the wall O2.
b. Education will be provided to all Peri-Operative Service Team Members, Registered Nurses, Licensed Practical Nurses, Scrub Technicians, Resource Technicians, Anesthesia Technicians, Mobile Radiology Technicians, Clerical, Supply Technicians, Phlebotomist, and Chart Coordinators.
c. Education will be provided by the Director of Peri-Operative Service, NM of Peri-Operative Services, or the Peri-Operative Educator.
d. Any Peri-Operative staff that does not complete the education will not be allowed to work until the education is complete.
e. Education will be provided to Anesthesiologists on ensuring the transport O2 tank has sufficient volume (greater than 500 psi) for transport and hook the patient to the O2. In the event the transport is delayed the patient will remain on the wall O2. Education will be provided via e-mail with a return read receipt, written signature, or written attestation.
f. Education will be provided to CRNA's ensuring the transport O2 tank has sufficient volume (greater than 500 psi) for transport and hook the patient to the O2. In the event the transport is delayed the patient will remain on the wall O2. Education will be provided via e-mail with a return read receipt, written signature, or written attestation.

Completion Date
a. Education started on 3/26/19 and will be completed by 4/2/19 for current team members.
b. New team members will have education completed prior to the end of orientation. This will be ongoing for any team members hired.

Monitoring and Tracking Procedures
Portable Oxygen Monitor has been developed that will review 70 tanks per month for 4 consecutive quarters.

Title or Person Responsible
The CNO, Director of Peri-Operative Services, and CMO

3. Hand-Off Communication

Education
a. When patients are transported from a clinical area to another area, hand off communication should occur between the giver and the receiver of patient information by the hand off communication tool, SBAR (situation, background, assessment, and recommendations), phone and/or face to face communication and will be documented in the clinical record.
b. Completion date: education started 3/26/19 and will be completed by 4/2/19 for current team members. New members will receive the education completed prior to the end of orientation. Will be ongoing for any team member hired.

Monitoring and Tracking Procedures
Hand off communication Monitors have been developed that will review 70 cases per month for 4 consecutive quarters and ongoing and completed by assigned Short Stay and PACU Nursing staff. If compliance is met at 80% after four consecutive quarters the monitor will be evaluated. The results of the monitor will be reviewed at the QA/PI Meeting, Medical Staff Quality Review Committee (MSQRC), and to the Governing Body.

Responsible Party
CNO and Director of Peri-Operative Services

4. Combination of Pre-Op and PACU Areas

Education
a. After regular business hours, as well as on weekends and holidays, the Pre-Op and PACU staff will combine staff and patient care to one location to increase the level of patient support. This combining of staff and areas will be documented on the daily OR (Operating Room) Operations Report.

Completion date: Combination of Pre-Op and PACU staff after regular hours, as well as on weekends and holidays started 3/27/19.

Monitors and Tracking
Will be completed by Operating Room Shift Charge Nurse. The results of the monitor will be reviewed at the QA/PI Meeting, Medical Staff Quality Review Committee (MSQRC), and to the Governing Body.

Responsible Party: CNO and Director of Peri-Operative Services

5. Bio-Medical Work Orders

Education
a. Critical element equipment related to patient care equipment will require a work order for tracking purposes.
b. Completion date: Start 3/27/19 and ongoing

Monitoring and Tracking Procedures
Report of all peri-operative repairs will be sent to the Director of Peri-Operative Services on a monthly basis for verification of the work order completion. Any changes to cardiac monitor parameters will be initiated by a work order and approved by the Director of Peri-Operative Services and the Director of Bio-Medical Services. Report will be initiated by Bio-Medical Services and forwarded to the Director of Peri-Operative Services on a monthly basis. The results of the monitor will be reviewed at the QA/PI Meeting, Medical Staff Quality Review Committee (MSQRC), and to the Governing Body.

Responsible Party: CNO and Director of Peri-Operative Services

Interview with the Cooperative Director of Quality Management and the RM on 3/27/19 at 1:15 PM, in the conference room, revealed the facility had implemented immediate actions related to Advanced Directives for patients and the initiation of immediate resuscitative measures for patients who have a full code status. All staff in the Peri-Operative Service was required to complete the training. Education was provided to RN's, LPN's, Scrub Technicians, Resource Technicians, Anesthesia Technicians, Mobile Radiology Technicians, Clerical, Supply Technicians, Phlebotomist, and Chart Coordinators. Anesthesiologist, CRNA's and Surgeons were included in the mandatory training. The facility has implemented ongoing monitoring tools for ensuring immediate resuscitation to any patient with full code status who suffers cardiac or respiratory arrest and ensuring a safe environment in the Peri-Operative Service Line which will be reported in the QA/PI Meeting, Medical Staff Quality Review Committee (MSQRC), and the Governing Board.

Review of the Immediate Jeopardy Action Plan revealed immediate actions were implemented by the facility and the Immediate Jeopardy was removed on 3/27/19. The facility remains out of compliance at 42 CFR PART 482.13, Conditions of Participation, Surgical Services (Condition).

Please refer to A-0951

Based on review of facility policy, review of the Association of the Peri-Operative of Registered Nurses (AORN) guidelines, medical record review, review of facility documentation, and interviews, the facility failed to follow policies and procedures for assessments, documentation, perioperative care, and resuscitative measures for a nonresponsive patient (#1) of 8 surgery records reviewed.

The findings included:

Review of facility policy "Pre and Post-Operative/Procedural Care" last reviewed 4/6/15 revealed "...pre-operative procedural preparation for all invasive procedures includes assessment, initiation of care plans, pre procedure/operative education and completion of the pre-procedure check list...the pre-operative/invasive verification check list, which includes necessary information, is to be completed on each patient before he/she are released for surgery..."

Review of facility policy "Do Not Resuscitate Orders" last reviewed 2/22/17 revealed "...CPR [cardiopulmonary resuscitation] is to be initiated immediately on a patient who experiences cardiac and/or respiratory arrest unless a DNR [do not resuscitate] has been written or the patient has a valid Universal DNR order..."

Review of facility policy "Transfer/Transport of Patients" last reviewed 3/31/17 revealed "...patient transport: under the following circumstances licensed team member(s) are to accompany patient: patients returning from surgery...have had a procedural sedation...when the patient is being monitored with telemetry/cardiac monitoring...any time the Registered Nurse [RN] determines, based on assessed needs, that a licensed nurse should accompany the patient..."

Review of the "Procedure for Cancelling cases in the Surgery Information System (SIS)," with no date or time, revealed "...If case is cancelled in the Pre-op Holding it is important to finish charting all the interventions that you have done to the patient. You will choose the 'cancelled' check box on the Patient Information Tab...and sign out of the chart after you have finished all of the necessary charting...make sure anesthesia has finished their charting...you will choose the correct reason why case was cancelled and add a nurses note with details of why case was cancelled..."

Review of facility policy "Cardiopulmonary Resuscitation-Code Blue Adult and Pediatric" last reviewed 2/8/18 revealed "...the person recognizing a cardiac and/or respiratory arrest shall immediately summon help and begin cardiopulmonary resuscitation..."

Review of the AORN Guidelines for Peri-Operative Practice; Information Management dated 1/23/19 revealed "...as part of the legal health record, the perioperative patient health record should reflect the plan of care, including assessment, nursing diagnosis, outcome identification, planning, implementation of interventions, and evaluation of progress toward the expected outcomes...the perioperative RN should record the assessment of findings (physical, psychosocial) in the patient health care record...the healthcare record should include nursing interventions performed, the location of the care, and the name and the role of the person performing the care...the patient health record should reflect continuous reassessment and evaluation of perioperative nursing care and the patient's response to implemented nursing interventions...patient date must be collected concurrently with each assessment, reassessment, or evaluation and recorded in the patient health care record..."

Medical record review revealed Patient #1 was admitted to the facility on 12/2/18 with diagnoses including Displaced Gastrostomy Tube (feeding tube), Pneumonia (infection in the lung), Pneumonitis (inflammation of the lung tissue) to the Lower Lung Lobes, and Splenomegaly (enlarged spleen). The patient expired on 12/6/18.

Medial record review of an Admission History and Physical dated 12/2/18 at 6:13 PM revealed the patient reported pain around his Gastrostomy tube (G-Tube). Further review revealed a computed tomography (CT) indicated the tube was superficial to the abdominal wall and surgery was consulted for possible replacement of the tube. Continued review revealed the patient had a previous history of Myasthenia Gravis (chronic autoimmune neuromuscular disease that causes weakness in the skeletal muscles responsible for breathing and moving parts of the body, including the arms and legs), Sleep Apnea, and Idiopathic Thrombocytopenia Purpura (ITP) (disorder that can lead to easy or excessive bruising and bleeding) and a previous Tracheostomy (surgically created hole in the windpipe that provides an alternative airway for breathing) which had been closed.

Medical record review of a Physician's Order dated 12/2/18 at 6:39 PM revealed the patient was a Full Code (implement life-saving measures) and the physician ordered the Adult Oxygen (O2) Protocol for Patient #1. Review of the Adult Oxygen Protocol revealed "...Target saturation: 92% or greater...Unless otherwise ordered, oxygen is initiated via nasal cannula at 2 L/min [liters per minute]. If patient does not have continuous pulse oximetry ordered, Respiratory Therapy to place order for Pulse Ox [pulse oximetry]...If oxygen protocol initiated via nasal cannula, titrate at 1 L/min up to 4 L/min to reach target oxygen saturation range...Once patient has achieved target or greater oxygen saturation: oxygen may be decreased by 1 L/min as tolerated to maintain target oxygen saturation until weaned to room air...Discontinue oxygen when: Room air oxygen saturation is greater than target oxygen saturation AND Respiratory rate is within 12-20 breathes [breaths] per minute AND patient does not de-saturate below the target oxygen saturation with exertion if applicable..."

Medial record review of a Physician's Order dated 12/4/18 at 12:54 AM revealed continuous cardiac telemetry monitoring was ordered for the patient.

Medical record review of a General Surgery Progress Note dated 12/4/18 at 6:46 AM revealed "...possible PEG [Percutaneous Endoscopic Gastrostomy] tube placement today in OR [Operating Room] if respiratory status stable..."

Medical record review of an Interventional Radiology (IR) Consult dated 12/4/18 at 1:23 PM revealed "...pt. [patient] is going to surgery for PEG tube placement and we would recommend that the Ash Cath be placed at that time...surgery does not have a timeline on PEG tube placement as they are reevaluating on a daily basis until he is medically stable for surgery..."

Medical record review of a Physician's Progress Note dated 12/5/18 at 6:14 AM revealed "...no acute events overnight...was on a BiPap [Bilevel Positive Airway Pressure] overnight and has done well. This morning he was on nasal cannula with humidification at 3 LPM [liters per minute] with normal [oxygen] saturations...awaiting PEG tube placement today in OR if respiratory status stable..."

Medical record review of a Pulmonary Progress Note dated 12/6/18 at 2:39 PM revealed the patient was on 2 liters per minute (LPM) O2 via nasal cannula.

Medical record review of an Anesthesia Pre-op Record dated 12/6/18 at 4:04 PM revealed a pre-procedure assessment was performed by the Anesthesiologist. Further review revealed "... 5:22 PM: anesthesia note: patient in pulmonary edema [excess fluid in the lungs], obtunded [altered level of consciousness], unable to sign consent. Family unavailable. Case cancelled..."

Medical record review of a Nursing Pre-op Record dated 12/6/18 at 6:04 PM revealed the patient was admitted to the pre-operative unit for an insertion of an Ash Catheter and a PEG tube placement.

Medical record review of a Perioperative communication tool dated 12/6/18, with no time, revealed Patient #1's vital signs were as follows: Blood Pressure: 156/85, Pulse 118, Respirations 20, and oxygen saturations was 97% on 4 liters of oxygen. Further review revealed no further documentation of additional vital signs or a patient assessment.

Medical record review of a Discharge Summary dated 12/6/18 revealed "...patient was admitted with Cellulitis of his PEG tube and also PEG tube obstruction, pneumonia, hypertension, obstructive sleep apnea, chronic pain, and myasthenia gravis. He had been receiving plasmapheresis [process that filters the blood and removes harmful antibodies] on outpatient basis, this was continued here. Patient was taken downstairs to have PEG tube replaced. While awaiting surgery, he was found unresponsive with no heart rate, no pulse, no respirations, and was pronounced [deceased]...cause of death: acute respiratory failure...this was 12/6/18 at 8:42 PM..."

Medical record review of an Anesthesia Event note dated 12/6/18 at 8:47 PM revealed "...anesthesia note: became aware the patient had expired, unclear at this time, but likely over an hour ago. Patient pulseless on examination, no heart sounds on auscultation, not breathing. No response to painful stimuli, no cardiac activity on heart monitor. Patient declared dead..."

Medical record review of the Nurses Notes dated 12/6/18 revealed no nursing documentation of the patient's death, no documentation of CPR, no documentation of the activation of a Code Blue (code to activate the response team for the resuscitation of a patient in cardiac/respiratory arrest), or no documentation the patient's physician or Anesthesiologist was notified.

Review of facility documentation, with no date or time, revealed "...admitted to [the facility] on 12/2/18 with abdominal wall cellulitis from PEG tube. Patient's respiratory status continued to decline during his visit. 12/6/18, patient was taken to short stay surgery for PEG replacement and EGD [Esophagogastroduodenoscopy - tube to view the throat and stomach]. Anesthesia cancelled surgery due to patient's underlying respiratory status. Short stay staff planned to transport patient back to floor, when another patient arrived to short stay. The nurse was unable to leave the unit. Nurse unhooked monitor to transport the patient but never hooked it back up. Transport requested to take patient back to the floor. Transport arrived and noted the patient appeared not to be breathing. He notified the nurse. Nurse never initiated code blue, no CPR or any life-saving measures. She called another nurse from her break. Second nurse arrived at bedside and also failed to intervene. RN [Registered Nurse] never initiated any life-saving measures..."

Review of facility documentation of a Time Line revealed the patient arrived in the Short Stay Unit on 12/6/18 at 6:04 PM. The Registered Nurse (RN) began a pre-op assessment, attached the patient to the monitor, completed pre-op checklist.
6:25 PM: CRNA [Certified Registered Nnurse Anesthetist] checked patient. He called the Anesthesiologist and requested he see the patient. Patient was tachypneic [fast respirations] and short of breath. Patient was on monitor and vital signs were stable.
6:30 PM: Anesthesiologist at bedside. Patient was obtunded [decreased level of consciousness] and in full pulmonary edema.
6:35 PM: Anesthesiologist notified surgeon. Surgeon at bedside and discussed patient's condition.
6:40: Surgery cancelled
6:45 PM: RN #1 asked RN #2 to help transport patient back to the floor. The patient was unhooked from monitor and placed the patient on a portable oxygen [O2] tank.
6:52 PM: Another patient (#2) arrived for emergency EGD related to GI bleed. RN #1 started his preop admission and told RN #2 not to worry about transporting Patient #1. (The patient was left off the cardiac monitor and was left on the portable O2 tank and the O2 tank was not checked to ensure the level of oxygen available in the tank).
7:00 PM: RN #3 asked if she needed to do anything before she left to go eat. House transport was requested to transport the patient to the floor.
7:11 PM: Transport request put in the facility's automated system for transport services
7:30 PM: RN #1 said she checked on Patient #1, he was resting but eyes were open
8:10 PM: transporter arrived to get patient and asked nurse if patient was ok to go up. They walked to bedside together found patient had expired. Nurse made no effort to begin lifesaving measures. No code called. No compressions or respirations started.
8:12 PM: RN #2 arrived at bedside found patient cold, waxy, and unresponsive. She said 'he was dead.' Left message on the facility's surgery communication device for anesthesiologist to come to pre-op. (There was no emergent notification message left to inform anesthesia the patient had expired)
8:30-8:40 PM: Anesthesiologist arrived. Patient #4 in the bed next to Patient #1 told Anesthesiologist 'the nurse killed that patient. I'm afraid for her give me any meds [medications].' Anesthesiologist went to next curtained area, curtain was pulled. He checked the patient. Patient was stiff, no pulse, no respirations, attached to the bedside monitor to verify asystole (no heart contractions). Patient was pronounced.
8:30 PM: OR supervisor notified and was told by RN #2 the patient had expired. She questioned if a code was called and RN #2 responded '[Anesthesiologist] knows.'

Interview with the Nurse Manager (NM) of the Peri-Operative Services, on 3/22/19 at 2:50 PM, in the NM's office, revealed the patient was an inpatient and came to the peri-operative unit for a PEG tube and Ash catheter insertion on 12/6/18. The patient was evaluated in the peri-operative unit by the RN and the anesthesia provider. The Anesthesiologist evaluated the patient and found the patient's respiratory status was too severe and was concerned the patient would not be able to be weaned off the ventilator after surgery. Anesthesia and the surgeon discussed the patient's care it and it was decided to cancel the patient's surgery pending their discussion with the family. Further interview revealed RN #1 was getting ready to take Patient #1 back to his room. She had removed the patient's heart monitor and placed the patient on a portable oxygen tank. The surgeon stopped them and told them to wait until he could speak with the family. The nurse took the patient back into the room but did not place the patient back on the cardiac monitor or on the oxygen on the wall. At this point, another patient came into the unit and the RN started preparing the other patient for surgery. There were two RN's in the unit and both of them were providing care to other patients. Around 8:00 PM, the transporter came to the peri-operative unit to take Patient #1 to the floor. He asked the nurse if the patient was ready to go the floor and she told him the patient was ready. The transporter went to the patient's bedside and noticed the patient did not look good. He went and got RN #1 and they both went to the patient's bedside and when they got there, the transporter and the nurse realized the patient had expired. RN #1 did not call a Code. The patient was not a DNR (Do Not Resuscitate), he was a full code. No CPR was started for the patient. When RN #2 came to the unit she observed the patient was cold, had a blue color, and was stiff. There was no Code called or CPR started by the staff. The Anesthesiologist was called to notify him. He was in another procedure and could not answer the call. The RN left him a message to come to the unit but did not indicate the emergent situation to the provider. When the Anesthesiologist came to the unit he was still not aware the patient had expired. He went to another patient's bedside, which was the bay beside Patient #1, and Patient #4 told him Patient #1 had died and said 'that nurse killed that patient.' The Anesthesiologist went to Patient #1's bedside and the nurses informed him of the situation. The Anesthesiologist pronounced the patient's death at that time. Further interview confirmed the staff failed to follow the facility's policies related to Code Blue; failed to ensure the patient was placed back on the cardiac monitor and wall oxygen; failed to ensure a complete patient assessment was performed for a patient prior to a surgical procedure; and failed to maintain an accurate medical record for the patient.

Interview with Transporter #1 on 3/22/19 at 3:35 PM, in the NM office, revealed the transport was placed in the system by the nurse and it took about an hour for the transport to occur. Further interview revealed "...when I got to the Holding Room there was only one nurse in the unit at that time. I asked the nurse if the patient was ready to go and she said he was ready to go. The curtain was pulled and when I rounded the corner of the room, he did not look good. I asked the nurse if she was sure the patient was ready to go and asked her to come into the room. When she came into the room and looked at the patient, she said 'Oh shit, he is dead.' There was no monitor on the patient and his oxygen was hooked up to the portable tank. I don't know if the tank had oxygen in it. There was no Code Blue called and CPR was not started..."

Interview with the Director of Peri-Operative Services on 3/25/19 at 10:35 AM, in the Risk Managers office, revealed she received a call from the charge nurse informing her Patient #1 had expired in the Short Stay Unit and CPR was not performed and a Code Blue was not called. Further interview revealed "...when I arrived the patient was already pronounced by anesthesia. The nurses were confused about why this was such a big deal. They said the patient was already dead and there was no reason to code the patient but he was a full code. [RN #1] did finally agree that she should have called a code and got the physician up to the unit promptly..." Continued interview revealed the patient's surgery had been cancelled related to his respiratory status. The nurse had taken the patient off the monitor and placed him on O2 using the portable tank. RN #1 was going to take him back to the floor. At that point another patient with a Gastrointestinal bleed came in and she had to admit the patient and get him ready for emergent surgery. The nurse forgot to place Patient #1 back on the cardiac monitor and hook his O2 up to the wall oxygen. When transport came to take the patient back to the floor, he found the patient unresponsive, cold, and cyanotic. He notified the nurse and the patient had expired. The other patient came to the unit around 7:40 PM and Patient #1 was found around 8:10 PM. The nurse did not activate a code or start CPR. The patient was not on the cardiac monitor and was on the portable O2 tank. They called anesthesia but did not tell the provider the patient had expired and activate the emergency notification. They did not document anything in the patient's medical record. The Nurse Manager found the peri-operative information (nurse's documentation) in the shred box. There was no Code Blue called, the patient was not hooked back on the cardiac monitor, he was left on a portable O2 tank, and no documentation was found indicating they called the physician. Further interview confirmed the facility failed to initiate CPR; failed to ensure Patient #1 was placed on the cardiac monitor; failed to ensure a portable oxygen tank contained oxygen; and failed to ensure nursing documentation was completed and in the medical record.

Telephone interview with RN #3 on 3/25/19 at 10:55 AM revealed "...[RN #1] had asked me earlier if I could help her transport the patient to the floor. She had taken the patient off the monitor and placed him on a portable oxygen tank. Just as we were getting ready the surgeon told us to keep the patient and he would try to talk with the family. We thought it would be just a few minutes. She did not place the patient back on the monitor or the wall oxygen..."

Interview with the Risk Manager on 3/25/19 at 1:15 PM, in the conference room, revealed the patient's surgical case had been cancelled because he was too sick for the surgery. The physicians wanted to talk to the patient's family and asked the nursing staff to hold the patient in the pre-op unit. The patient's cardiac monitor had been removed and the patient was placed on a portable oxygen tank in anticipation of transfer back to the floor. The nursing staff got busy providing care to two other patients and around 8:10 PM the patient was found by the nursing staff in the Peri-Operative Unit without a pulse and not breathing. Continued interview revealed the facility completed a Root Cause Analysis on 1/16/19 (36 days after the patient expired), which identified several issues in relation to the event. The facility reviewed the case as a sentinel event (an unexpected occurrence involving death or serious physical or psychological injury). Continued interview revealed the facility failed to ensure the patient was placed back on the cardiac monitor, failed to place the patient back on the wall oxygen, and failed to initiate CPR for a patient who was a full code. Further interview confirmed the facility's policy was not followed.