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Based on review of patient records, approved hospital policy and procedure, and staff interview, the hospital failed to thoroughly investigate the facts and conditions surrounding a patient's cardiac and respiratory arrest, code, and eventual death in order to determine if the incident was preventable, and to protect patients by implementing actions to prevent a recurrence.

Failure to rigorously review an event resulting in an undesirable patient outcome risked patient health and safety.

Findings:

The hospital failed to investigate an undesirable patient outcome in a timely manner to identify contributing factors, and provide staff training and internal monitoring to ensure the incident would not recur as evidenced by the following:

Per record review, Patient #1 was an 84 year old who came to the Emergency Department by ambulance and was admitted to the medical floor for observation on 1/17/2010. Multiple diagnoses included congestive heart failure, gastro-intestinal bleeding, hypoxemia, and cancer with metastases. Per the record, staff received an order and transferred the patient to the special care unit at 10:35 a.m. after staff observed him/her to have labored breathing, lung congestion and a respiratory rate of 28 breaths per minute. The patient coded approximately 10 minutes later and died. There was no evidence that nursing staff had received report or assessed the patient.

This critical patient was not monitored and essentially left unattended in the special care unit. No heart monitor had been applied to monitor the patient's cardiac status or provide an alarm to alert staff of the patient's worsening condition.

Review of patient care plans and staff interviews on 6/22-23/2010 revealed that standard protocol for the special care unit included continuous cardiac monitoring.

Nursing notes dated 1/17/2010 at 12:14 p.m. from the special care unit evidenced that, "Nurse (Special Care Unit) had not had report on this (Patient #1) and had asked house supervisor to stay with the patient until the nurse was free to assess (him/her)." Neither the RN from the medical floor, nor the house supervisor stayed with the patient or gave report to the receiving RN to ensure a safe transfer.

The hospital approved policy and procedure "Incident Reporting" (#8610-I-3 dated 11/2006) was reviewed.
Under Procedure-Investigation, item 3 directed, "Appropriate investigation includes but is not limited to: Review of communication and handoffs; review of educational needs of parties involved; review of process to determine stability of processes involved and review of personnel issues such as staffing, behavioral issues and competency."
Under Definitions, Incident reporting was defined as, "An objective, factual description of an...adverse outcome...or any other event not considered a routine daily occurrence..." Under Procedure, item 7 directed, "The responsible party completes the report and responds with an action plan if appropriate within 72 hours."

Per interview with administrative staff members on 6/22-23/2010, no internal investigation had been done, and no action plan had been formulated, implemented or evaluated to prevent possible recurrence. There was no evidence that follow-up staff training or procedural review had been done following the event to ensure that staff were routinely implementing safe transfer practices and to ensure that no similar incident would occur.

Six months after the incident, the hospital had not acted regarding staff failure to provide Patient #1 with immediate bedside care. There was no evidence that administration took immediate action to identify and correct deficient issues with the existing system to hand off or transfer patients. There were no changes to procedures, effective directives, or staff training to prevent recurrence and protect patients.

CONDITION OF PARTICIPATION - NOT MET

Based on medical record review, review of facility policies and procedures, and staff interview, the hospital failed to ensure that a patient who was transferred from the medical floor to the special care unit due to deterioration in his/her condition was placed on a heart monitor and received immediate nursing care when needed in accordance with facility approved policies and procedures.

Refer to CFR 482.23(b) at tag A0392 regarding failure of staff to provide a safe transfer for a patient.

As demonstrated by examples documented in this report, the cumulative affect of these systemic problems resulted in the facility's inability to ensure the provision of quality heath care in a safe environment and is evidence that this Condition of Participation was NOT MET.

Based on review of patient records, approved hospital policy and procedures and staff interview, the hospital failed to ensure that nursing staff provided immediate attention, bedside care and monitoring to a critical patient who was transferred from the medical floor to the special care unit for 1 of 8 patient records reviewed (Patient #1).

Failure to provide a safe transfer and immediate bedside patient care by qualified staff risked patient health and safety.

Findings:

Per record review, Patient #1 was an 84 year old who came to the Emergency Department by ambulance and was admitted to the medical floor for observation on 1/17/2010. Multiple diagnoses included congestive heart failure, gastro-intestinal bleeding, hypoxemia, and cancer with metastases. Per the record, staff received an order and transferred the patient to the special care unit at 10:35 a.m. after staff observed him/her to have labored breathing, lung congestion and a respiratory rate of 28 breaths per minute. The patient coded approximately 10 minutes later and died. There was no evidence that nursing staff had received report or assessed the patient.

This critical patient was not monitored and essentially left unattended in the special care unit. No heart monitor had been applied to monitor the patient's cardiac status or provide an alarm to alert staff of the patient's worsening condition.

Review of patient care plans and staff interviews on 6/22-23/2010 revealed that standard protocol for the special care unit included continuous cardiac monitoring.

Nursing notes dated 1/17/2010 at 12:14 p.m. from the special care unit evidenced that, "Nurse (Special Care Unit) had not had report on this (Patient #1) and had asked house supervisor to stay with the patient until the nurse was free to assess (him/her)." Neither the RN from the medical floor, nor the house supervisor stayed with the patient or gave report to the receiving RN to ensure a safe transfer.

The hospital approved policy and procedure, "Patient Hand-Off Policy" (#8720-P-20 dated 12/22/09) was reviewed. The stated purpose included, "Smooth hand-offs include communication between caregivers at...in house patient transfers." The Description of the policy identified, "Hand-offs are interactive communications between caregivers that provide the most current information on the patient to optimize patient safety...including treatment and services, condition, and any recent or anticipated changes..."

Staff Job Descriptions were reviewed. The House Supervisor Job Description (revised 8/23/07) directed, "The House Supervisor maintains skills and knowledge necessary to function in the role of a clinical nurse and to provide assistance to staff with patient care." Under specific accountabilities, item 2 directed, "Functions as a clinically competent nurse as needed for backup care... " and item 8, "Participates in writing and reinforcing patient care standards and hospital policies and procedures."

Although the patient was transferred because of deterioration in his/her condition, staff failed to provide a safe transfer and give a comprehensive report prior to leaving the patient, failed to implement a heart monitor per special care unit protocol, and failed to provide needed care at the bedside until the patient transfer was safely completed.

Interview with administrative staff on 6/22 and 23/2010 (6 months following the event) revealed that there had been no internal investigation done to determine the cause of the failed transfer. Statements from staff involved in the care and transfer of the patient had been collected due to a directive by the Washington State Nursing Board. No other analysis of possible factors contributing to the incident had been done (such as staffing levels, qualifications and competencies of staff, historical staff performance, disciplinary issues and so forth).

The hospital approved policy and procedure "Incident Reporting" (#8610-I-3 dated 11/2006) was reviewed.
Under Procedure-Investigation, item 3 directed, "Appropriate investigation includes but is not limited to: Review of communication and handoffs; review of educational needs of parties involved; review of process to determine stability of processes involved and review of personnel issues such as staffing, behavioral issues and competency."
Under Definitions, Incident reporting was defined as, "An objective, factual description of an...adverse outcome...or any other event not considered a routine daily occurrence..." Under Procedure, item 7 directed, "The responsible party completes the report and responds with an action plan if appropriate within 72 hours."

Per interview with administrative staff members on 6/22-23/2010, no action plan had been formulated, implemented or evaluated to prevent possible recurrence. There was no evidence that follow-up staff training or procedural review had been done following the event to ensure that staff were routinely implementing safe transfer practices and to ensure that no similar incident would occur.

Six months after the incident, the hospital had not acted regarding staff failure to provide Patient #1 with immediate bedside care. The hospital failed to determine the causes of the failure and to prevent recurrence of a similar incident, thereby potentially placing all patients ' health and safety at risk.