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Based on review of records, policy / procedures review and interviews, the facility failed to ensure that care and treatment were based on the patient's identified needs and treatment priorities when physician orders were not reviewed or implemented for a nasogastric tube (NGT) insertion, transfer to higher level of care, critical care consult and no cardiac monitoring for several hours for 1 (SP#2) of 4 Sampled Patients.

Findings include:

Review of SP#2's record conducted on 5/08/2023 revealed the following documentation:

A General Surgery Consultation note by Resident3 on 03/24/2023 at 8:30 AM revealed SP#2 presented with diffuse abdominal and nausea and emesis non bloody, non-bilious. SP#2 reported last bowel movement was here in the Emergency Department (ED). Denies any constipation, diarrhea, fever, chills. General surgery consulted for partial small bowel obstruction. SP#2 seen, evaluated, labs and vitals reviewed. Will attempt conservative management with decompression and small bowel series.

Plan: Small bowel series - recommendations to follow: Nasogastric tube (NGT) if emesis; Bowel regimen; Serial abdominal exam; Electrolyte replacement; Limit narcotics; Fluid resuscitate; Will follow, rest of care per primary.

03/24/2023 at 12:23 PM - SP#2 admitted to 7 North Tower.

03/25/2023 at 3:52 AM - Nurse called physician. SP#2 vomiting tea colored vomit.

03/25/2023 at 3:54 AM: Blood pressure: 127/88, Heart rate: 96, Oxygen saturation 93%.

03/25/2023 at 3:58 AM - Nurse Practitioner (NP) called back with a telephone order to give SP#2 a one time dose of Zofran for nausea/vomiting.

03/25/2023 at 7:05 AM - Nurse notified NP about SP#2 sounding wet upper respiratory rhonchi. SP#2 is not in distress at this time. NP ordered Lasix and breathing treatment for SP#2.

03/25/2023 at 7:47 AM - General Surgery Progress Note documented SP#2 seen and examined at bedside. Emesis reported overnight. SP#2 reports feeling better, vomiting (overnight). No abdominal pain, nausea.

Plan: No acute surgical intervention; Recommend NGT if continued emesis; Diet as tolerated; Bowel regimen; Serial abdominal examinations; Electrolyte replacement; Medical and Pain Management per Primary Team.

03/25/2023 at 2:37 PM - Teaching Physician Attestation (1st visit without Resident 2): I have personally seen SP#2, performed the critical or key portions of the service, and participated in the management of SP#2. I have reviewed and agree with Resident 2's note, and have reviewed all labs, electrocardiograms (ECG's), and imaging studies or reports. I agree with this advance practitioner/resident 2 findings, exam, and plan. I, the attending (General surgery attending physician / MD4), was present and saw SP#2 with the advanced practitioner/resident 2 and agree with the findings except:

High grade small bowel obstruction (SBO) seen on small bowel series, however, SP#2 reporting flatus on rounds this AM. Unclear if SBO versus disutility/slow transit time; Abdominal x-ray in AM; Trial of clears; NT if continues emesis; Will follow.

03/25/2023 at 9:05 AM - SP#2's blood pressure 80/55. Record review revealed no documentation that the physician was notified.

03/25/2023 at 11:56 AM - SP#2's blood pressure 76/56. Record review revealed no documentation that the physician was notified.

03/25/2023 at 12:30 PM - Nurse placed call to NP on-call regarding SP#2's condition. SP#2 is hypotensive. NP stated to hold blood pressure medication. All blood pressure medications on hold per order.

03/25/2023 at 12:30 PM - Hospitalist (MD5) was rounding. While rounding on S#2, MD 5 assessed SP#2. Order received for bolus at the bedside which was carried out.

03/25/2023 at 2:53 PM - SP#2's blood pressure 84/60. Record review revealed no documentation that the physician was notified.

03/25/2023 at 3:30 PM - SP#2 stable watching TV with family at bedside. No apparent distress. Denied pain or discomfort at this moment. Call light within reach.

03/25/2023 at 5:20 PM - SP#2 stable in bed watching TV. Denied discomfort. No distress.

03/25/2023 at 6:06 PM - SP#2's blood pressure 100/64.

03/25/2023 at 6:18 PM - SP#2's bed alarm went off. Rushed to the room. Nurse found SP#2 leaning in the bed with difficulty breathing. Oxygen in place. Asking help from the secretary to call rapid response.

03/25/2023 at 6:19 PM - SP#2 became pulseless. Nurse initiated cardiopulmonary resuscitation (CPR), activated code blue intervention.

03/25/2023 at 6:23 PM - Code blue intervention team arrived at bedside.

Review of the Post Code Blue Note dated 03/25/2023 at 7:09 PM documented at approximately 6:26 PM a rapid response was called overhead which changed to a code blue at 6:29 PM. On arrival to the room, chest compressions were in progress and SP#2 was receiving air via bag-mask ventilation. SP#2 was noted with vomits being produced from mouth on arrival, suspected large volume aspiration with resultant cardiac arrest secondary to hypoxia. Advanced Cardiac Life Support (ACLS) was continued. Intravenous access (IV) was gained during the course of ACLS and SP#2 was intubated for better airway control. SP#2 underwent 23 further minutes of ACLS, 7 rounds of epinephrine, 2 doses of bicarbonate, however Return of Spontaneous Circulation (RSC) was unable to be obtained and rhythm continue to show asystole. SP#2 final rhythm asystole at 6:52 PM at which time SP#2 was pronounced deceased. Family was contacted. Surgery team was present at bedside. Primary team was informed.

The surveyor was provided with the Full Disclosure Report for telemetry (heart rhythm) monitoring (reproduction of every single heartbeat for every minute of the day) during SP#2's hospital stay. There was no display of heart rhythm prior to the call for the Rapid Response team on 03/25/2023 from 4:05 PM. To 6:50 PM. The report displayed scattered words indicating heartbeat irregularities.

Review of the facility policy and procedure "Telemetry Policy HEART Monitoring" last reviewed 06/14/2022 documented IV. Telemetry Escalation Process: (d - page 9) included, but was not limited to:

d. In the event that a patient's cardiac rhythm is not transmitting to the central monitoring station, the Telemetry Technician will contact the Primary nurse or patient care technician (PCT) for immediate resolution.
i. If the situation if not responded to / resolved within 2 minutes, the Telemetry Technician will escalate the notification to the secondary nurse or the unit's Charge RN.
ii. If immediate response / resolution is not reached following notification to the secondary nurse or the unit Charge RN, the Telemetry Technician will initiate an overhead/electronic "Telemetry Alert" to the patient bedside. Department staff will immediately respond to the patient room and the patient will be evaluated and/or address the transmission issue.
iii. The Telemetry Technician will record the notification(s) on the approved facility-specific Telemetry Notification log.

Interview with the Director of Patient Safety/Risk Manager on 05/08/2023 at 10:45 AM revealed / confirmed that there is no policy addressing the timeframe in which orders must be reviewed or implemented. The Director of Patient Safety/Risk Manager stated that each nurse is responsible for acknowledging orders for their assigned patients.

Interview with the Registered Nurse (RN2) on 05/08/2023 at 12:20 PM regarding the care provided to SP#2 revealed a call was placed to the Nurse Practitioner regarding the low blood pressure. RN2 stated the Nurse Practitioner gave a telephone order to call a Rapid Response. RN2 stated that MD5 was rounding and instructed not to call a Rapid Response but to give a normal saline bolus of 250 milliliters. RN2 stated that at that time, SP#2 pulled out the IV line. RN2 stated text sent to the IV PICC line service and asked another nurse to assist with starting a new IV line after unsuccessful attempts to restart IV. Stated the IV was started and the normal saline bolus was given (Nursing note indicated IV normal saline given at 12:36 PM).

RN2 stated that he was assigned to 6 or 7 patients which included 3 trauma patients and 1 patient with blood sugar out of control. RN2 stated around 5:30 PM, SP#2's spouse informed them of her departure. RN2 stated that SP#2 was assisted back to bed and alarm was activated. RN2 stated that the Patient Care Technician went in to take SP#2's blood pressure around 6:00 PM. RN2 stated that he spoke to SP#2's spouse and informed someone was taking SP#2's blood pressure. RN2 stated that he went into SP#2's room because the bed alarm sounded and found SP#2 with eyes rolled back, leaning in bed having difficulty breathing. RN2 stated that SP#2 was pulseless and called Rapid Response. RN2 stated that a Rapid Response was not called earlier because MD5 stated not to call. MD5 did not give additional verbal orders. RN2 stated the unit was short of nurses that day and there was no Charge Nurse to assist with care. RN2 stated that there is no timeframe for reviewing orders. RN2 stated some physicians will text or call the nurse when new orders are placed.

Interview with the Patient Safety Director/Risk Manager on 05/09/2023 revealed that upon speaking with the telemetry technician; the technician stated that if all the monitor leads are not attached to the patient, tracings will not be seen, however, abnormal cardiac episodes will be captured and documented within the report. The Patient Safety Director/Risk Manager stated there is no documentation for the absence of monitoring SP#2 on 03/25/2023.

Interview with the Director of Nursing Informatics on 05/09/2023 at 3:00 PM revealed that blank spaces on the full disclosure report probably indicated no telemetry was being picked up. Upon review of the telemetry monitoring from a different system, the Director of Nursing Informatics stated the last alert that documented "No TEEM" was at 3:40 PM which indicated SP#2 was taken off the monitor.

Review of Order's Audit Trail of Events documented MD5 placed orders on 03/25/2023:
11:52 AM for nasogastric tube to low intermittent suction (NGT to LIS)
3:40 PM for transfer to Stepdown unit
3:41 PM for critical care consult, hypotension, possible ICU management

Record review revealed no documentation that the above physician orders written on 03/25/2023 were reviewed or implemented by nursing staff prior to the expiration of SP#2 on 03/25/2023 at 6:52 PM.

The facility failed to provide minimum standard of care to SP#2.