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The hospital did not ensure the protection and promotion of patient rights for all patients requiring oximetry monitoring.

See findings under Tag 0144.

Based on medical record review, document review and interview, the hospital did not ensure Patient #1 was being cared for in a safe setting as evidenced by a delay in response to an oximeter (oxygen saturation and heart rate monitor) alarm.

Findings include:

Review of nursing clinical note dated 1/27/14 at 9:43am revealed that at approximately 7:30-7:32 am the pulse oximetry (ox) machine was alarming. On entry into the patient's room it was noted that the pulse ox was not reading. The patient was found to be "unresponsive and white in color" with the trach tube lying next to him. A code (cardiopulmonary resuscitative team) was called and compressions were started.

Interview with Staff #8, Staff RN, on 2/21/14 revealed that at approximately 5:45am, the patient's tracheostomy was suctioned. At approximately 6:40-6:50am, Staff #8 looked in the patient ' s room and noted readings were being displayed on the oximeter. Sometime between 7:15am and 7:30am while walking towards the patient ' s room from the opposite side of the hall with the on-coming nurse, an alarm was first heard by the on-coming nurse, who then went into the patient's room, following which a code was called.

Interview with Staff #9, Staff RN, on 2/21/14 revealed she began to hear an alarm, which increased in intensity, as she and another nurse approached the patient ' s room from the opposite hallway. On entry into the room, it was noted that the oximetry sensor was attached to the patient ' s right foot. The patient was pale in color and his tracheostomy tube was lying next to his right shoulder. Tracheostomy tubes are secured with a Velcro system and it appeared that one side of the Velcro had become undone.

Interview with Staff #4, Nurse Manager, on 2/21/14 revealed that shift change occurs at 7:00am. During shift change, the physicians and nurses listen to the full shift report, which is then followed by individual nurse to nurse report. When the code was called, Staff #4 entered the patient ' s room with the physicians. Staff #4 believes the time was close to 7:30am. Compressions had been started and the patient was being bagged via face mask. Staff #9 was in the process of inserting the tracheostomy tube.

Review of the cardiopulmonary resuscitation record dated 1/27/14 revealed the time of the event was recorded as 7:30am. The patient was resuscitated and at 7:45am the patient was transferred to the pediatric intensive care unit.

Interview with Staff #10, Respiratory Therapy Manager on 2/4/14 revealed that the oximeter used for Patient #1 was removed from service following the event. The oximeter was inspected by biomedical engineering and a printout of the patient's oxygen saturation and heart rate for the time period from 7:01am to 7:30am was obtained. During the inspection it was identified that the oximeter internal clock was 1 hour and 18 minutes ahead of the actual time therefore the printout indicates the time period to be 8:19am to 8:54am. Staff #10 indicated that the oximeter will alarm when oxygen saturation or heart rate fails to meet the predetermined parameters. Once the parameters are again met the alarm stops.

Review of the oximetry printout dated 1/27/14 from 8:19am to 8:54am (actual time 7:01am to 7:30am) revealed the oximeter alarmed on 5 occasions between 7:01am and 7:11am with each episode lasting 18 seconds, 24 seconds, 90 seconds, 44 seconds and 20 seconds respectively. At 7:16am the oximeter alarmed continuously for 3 minutes 43 seconds, initially with no pulse ox reading and a heart rate of 185. At 7:17am pulse ox is again picked up with a reading of 74. At 7:19am there is 16 seconds of no alarm with a pulse ox reading of 93 and heart rate of 166 and then a continuous alarm with pulse ox reading of 83 and a heart rate of 57 noted at 7:25am. At 7:26am the sensor was noted to be off with no further readings.

Interview with Staff #3, Risk Management on 2/3/14 revealed that the 10th floor is not equipped with centralized monitoring.

The hospital did not ensure tracheostomy care and/or nursing respiratory assessments are being documented on patients with tracheostomy tubes in place.

See findings under Tag # 0395

Based on medical record review, policy review and interview, the hospital did not ensure tracheostomy care and/or nursing respiratory assessments was being documented for 2 out of 5 patients with tracheostomy tubes in place (Patient #1 and 9).

Findings include:

Review of facility policy entitled " Tracheostomy Care Adult/Pediatric " effective 9/09 revealed tracheostomy care, which includes the cleaning of the tube, shall be performed every 8 hours and as needed.

Review of Artificial Airway flow sheets for Patient #1 dated 1/26-1/27/14 revealed tracheostomy care was documented at 8:04am on 1/26/14. At that time the tracheostomy was noted to be secure with the velcro holder intact. There is no evidence of tracheostomy care being performed for approximately 23 hours prior to the dislodgement of the patient's tracheostomy.

Review of Nursing Respiratory Assessment flow sheets for Patient #1 dated 1/27/14 at 4:00am revealed the patient was assessed by nursing with suctioning of the tracheostomy performed. There was no further documentation of nursing respiratory assessment prior to the dislodgement of the patient's tracheostomy.

Review of Artificial Airway flow sheets for Patient #9 revealed no evidence to indicate that the patient ' s inner cannula was cleaned between 1/30/14 at 6:00pm and 2/03/14 at 6:00pm.

Interview with Staff #1 on 2/3/14 confirmed there was no documented evidence that the inner cannula for Patient #9 were cleaned in accordance with facility policy during the above noted time frame.