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Based on medical record review, document review and interview, in one (1) of 10 medical records reviewed, nursing staff failed to assess and monitor a patient with significant changes in his medical condition and implement the facility's protocol for activation of the Rapid Response Team. (Patient #1).

Findings include:

Review of medical record for Patient #1 revealed that on 05/19/2019, the patient was admitted with a diagnosis of a stroke. The patient's previous medical history was significant for Saddle Embolism.

On 05/20/2019, at 5:20 pm, a nurse documented that the patient reported a sudden onset of dizziness. "Patient felt like he was going to pass out, observed to put hand over his chest briefly, not sure if he had pain. Saw 'spots' in front of his eyes... Event was reported to Staff A, a Physician Assistant (PA) who ordered an EKG and Troponin levels."

On 5/20/2019 at 6:13 pm, a nurse noted that the patient complained of shortness of breath and his oxygen saturation fluctuated between 85-90 (normal range 96% - 100%). The patient's oxygen saturation increased to 94% on three (3) Liters of oxygen per minute. The patient's routine vital signs were temperature 97.9 F, heart rate 102 beats per minute (normal range 60-100), respiration 22 (normal range 14-20) and blood pressure (BP) 137/88 (normal range 90/50-120/80). The patient was evaluated by Staff A and a stat Chest CT Angiography was ordered at 6:26 PM

The nursing assessment at 7:59 PM revealed the patient was tachycardic, had pursed lips, short of breath and had difficulty breathing with activity.

At 8:35 PM, nurse noted the patient returned to the unit from the Cat Scan and he was observed to be short of breath and diaphoretic on the stretcher.

At 8:48 PM, the patient's eyes rolled back, and he became unresponsive. A 'Code Blue' was called, and he was successfully resuscitated and transferred to the Intensive Care Unit. The patient was coded two more times and he was pronounced dead on 5/20/19 at 11:26 PM.

There was no documented evidence that this patient who was short of breath and tachycardic was continuously monitored; the patient's respiratory rates, oxygen saturation and heart rates were not reassessed.

There was no documented evidence that the patient's condition was closely monitored by a nurse when he was off the inpatient unit to the Radiology Department for a Cat Scan. The patient's vital signs were not reassessed from 6:14 PM until more than two (2) hours later at 8:55 PM, seven (7) minutes after the code was called at 8:48 PM.

During an interview conducted on 12/11/19 at 9:30 AM, Staff Bb, a RN stated that she could not recall these events but based on her review of the medical record she confirmed the above findings.

Review of the "Rapid Response Team" (Approved 04/12/19) policy revealed that the purpose of the policy is "to provide immediate medical assistance to patient experiencing a deterioration or acute change in medical condition, and to decrease the number of CODE Blue's that occur outside of the ICU and lower mortality ... Rapid Response Team shall be called when there is an acute change in blood oxygen saturation (SPO2) less than 90 percent despite of oxygen."

There was no documented evidence that nursing staff activated the rapid response team when there was an acute change in the patient's medical condition.

Based on medical record review and interview, in one (1) of five (5) medical records reviewed, it was determined the radiology department failed to perform a stat radiological test on a patient whose condition was deteriorating. (Patient#1).

Findings include:

Review of medical record for Patient #1 identified the following: this 53 year old patient presented to the facility on 5/19/19 with a complaint of weakness, slurred speech and numbness to the right side of his body and he was admitted with a diagnosis of a stroke. The patient had a previous medical history of Saddle Embolism. The patient developed shortness of breath, increased respiratory rate, low oxygen saturation (85%-90%) and a rapid heart rate at 6:14 PM on 5/20/19.

On 5/20/19 at 6:26 pm, Staff A, a Physician Assistant, ordered a stat chest CTA. At 7:08 PM, the order was reviewed by a nurse. On 05/20/2019 at 8:30 pm the chest CTA was completed and at 8:39 pm the results of the test were reported to the provider.

The Computed Tomography Report indicated there was "large filling defects spanning the main, right and left pulmonary arteries consistent with saddle pulmonary embolus. The thrombus extends into multiple lobar and subsegmental branches of the right pulmonary artery, as well as into the left upper and lower lobar and subsegmental pulmonary artery branches. The right ventricle is larger than the left, compatible with right heart strain."

The patient's breathing deteriorated and he was resuscitated three (3) times before he was pronounced dead at 11:26 PM.

The stat CTA was not completed and reported to a provider in a timely manner.

On 11/22/2019, at approximately 3:00 pm, during an interview with Staff F, the Director of Medical Imaging stated, "We do not have a defined timeframe for STAT CT-Scans."

During an interview conducted on 11/22/2019 at 2:30 PM, these findings were brought to the attention of the facility's administrative personnel.