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Based on observation, interview and record review, it was determined the facility failed to ensure the Condition of Participation for Nursing Services was met by failing to ensure:

1. Supervision and evaluation of nursing care provided for patients were supervised by the Registered Nurse (RN) (Refer to A0395);

2. The nursing care plan for the patient which reflected the patient's goal and addressed the patient's needs were developed (Refer to A0396);

3. The Certified Nursing Assistants (CNAs) assigned to each patient were competent and had a clear understanding of their role when a patient needed life-saving intervention for a medical emergency situation (Refer to A0397);

4. All nursing personnel must adhere to the facility's policies and procedures when providing nursing care for each patient (Refer to A0398); and

5. Medications would be administered to each patient in accordance with the physician's order (Refer to A0405).

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver statutorily mandated compliance with the Federal regulations for the Condition of Participation: Nursing Services.

Based on observation, interview, and record review, the facility failed to ensure for six sampled patients (Patients 1, 4, 6, 19, 21 and 23), assessments and reassessments of the patients' care needs, heath status and patients' response to nursing interventions were conducted when:

1a. Patient 1 had no documented evidence the patient's "RED ALARMS" (life threatening heart rhythm) from the telemetry monitor (an electronic monitoring of the patient's heart rhythm) was acknowledged by the Monitor Technician (MT, a person who was trained to recognized heart rhythm, monitoring the patients on telemetry) and was addressed and evaluated by the Registered Nurse (RN);

b. Patient 1 had no documented evidence the patient was assessed during bedside hand-off reporting (a process where the RN gives report to another RN at the end of shift to hand-off the care of the patient); and

c. Patient 1 had no documented evidence an assessment was conducted when Patient 1 had a change of condition and was given Zyprexa (antipsychotic medication).

In addition, there was no documented evidence Patient 1 was assessed and monitored when the patient had signs and symptoms of confusion after Zyprexa was administered.

These failures resulted in a delay in care and treatment of Patient 1. In addition, these failures resulted in Patient 1 experiencing an unidentified deadly heart rhythm, a delay in beginning lifesaving treatment (cardiopulmonary resuscitation-CPR), and may have contributed to Patient 1's death.

2. Patients 4, 6, 19, 21, and 23, had no documented evidence pain assessment and reassessment were conducted in accordance with the facility's policy and procedure (P&P).

In addition, there was no documented evidence Patients 4 and 21's continued severe pain, after an intervention was provided, was addressed by the RN.

These failures resulted for the patients' pain not managed and may lead to delayed in recovery and deterioration of the patients' health condition.

Findings:

1. During a concurrent interview and record review, on July 13, 2021, at 2:03 p.m., with Nursing Director (ND) 1, Patient 1's record was reviewed. The "Admission H&P (History and Physical)," dated June 14, 2021, indicated Patient 1 presented to the Emergency Department for worsening shortness of breath. Further review of the record indicated the plan for Patient 1 was to place the patient on telemetry.

Patient 1's "Nursing Narrative," dated June 18, 2021, at 12:28 a.m., authored by RN 1, indicated, "...pt (Patient climbing OOB [out of bed] and pulling off tele (telemetry) several times at the beginning of shift. (Patient 1's Responsible Party [RP]) called and (Patient 1's RP) arrived. Pt takes ativan at home. MD (physician) called and ativan ordered times one. Med (medication) given per MD orders. Pt resting/sleeping eyes closed. No s/s (signs and symptoms) distress. Will continue to monitor. (Patient 1's RP) went home..."

Patient 1's "Vital Signs (VS - temperature, blood pressure (BP), heart rate (HR), respiratory rate (RR) " flowsheet record indicated the patient's last VS recorded was at 4 a.m.

Patient 1's "Nursing Narrative," dated June 18, 2021, authored by RN 2, indicated, "...At 0750 (7:50 a.m.)...Upon entering the room CNA (Certified Nursing Assistant) informed me she was unable to obtain BP x (times) 2. I assessed pt and noticed no chest rise. I checked pulse and could not find one...I immediately called a code blue (hospital code for medical emergency) and code was initiated...Decision was made after second code blue to call time of death by (name of the physician) at 8:41 a.m..."

a. The "Telemetry Alarm Record," dated June 18, 2021, indicated the following:

- From 5:46 a.m. to 5:52 a.m., (a total of six minutes) Patient 1's telemetry monitor generated RED ALARMS (indicated Asystole [no electricity or movement of the heart] and Bradycardia [low heart rate] of less than 50 beats per min [bpm]) and were silenced in between alarms;

- From 6:12 a.m. to 6:14 a.m., (a total of three minutes) Patient 1's telemetry monitor generated RED ALARMS (indicated Premature Ventricular Contractions [PVCs extra heartbeats that may disrupt a regular heart rhythm] and Ventricular Tachycardia [V Tach - a condition in which the lower chamber of the heart beats very fast]) and were silenced in between alarms; and

- From 7:16 a.m. to 7:49 a.m., ( a total of 33 minutes) Patient 1's telemetry monitor generated RED ALARMS (indicated Asystole) and were silenced in between alarms.

There was no documented evidence the MT informed the RN of Patient 1's RED ALARMS from the telemetry monitor.

There was no documented evidence the RN assessed and evaluated Patient 1 to address the RED ALARMS from the patient's telemetry monitor.

Further review of the "Telemetry Alarm Record" indicated the following:

- At 6:15 a.m., "ECG (electrocardiogram) Leads Off Generated";

- At 6:26 a.m., "Transmitter Off Generated...Equipment Offline" (a total of 11 minutes after the ECG Leads Off was generated); and,

- At 7:16 a.m., "Equipment Online...ECG/Arrhythmia (a type of heart rhythm) Alarms On" (a total of one hour and one minute after the ECG Leads Off was generated).

ND 1 stated in (name of the telemetry unit) the patient in the room was attached to a telemetry monitoring box, and the monitoring box transmits the heart rhythm to the central monitor located in the nurses' station, where a MT was assigned 24 hours / seven days to monitor patients on telemetry.

ND 1 stated when an alarm was generated from the telemetry monitor, it would only be heard from the central monitor in the nurses' station. ND 1 stated all alarms generated from the telemetry monitor should be acknowledged by the MT.

ND 1 stated for all telemetry alarms involving changes or concerns in the patient's heart rhythm, the MT should call and report to the RN.

ND 1 stated when a patient's telemetry monitor generated RED ALARMS, the MT was not allowed to silence the alarm.

ND 1 stated the MT should report the RED ALARMS to the RN assigned to the patient and if the MT could not reach the RN, the MT should report the patient's RED ALARM to the Charge Nurse (CN) or the Nurse Manager. ND 1 stated MT should document the time and the name of the RN or CN the RED ALARM was reported to.

ND 1 stated the RN should assess and evaluate the patient to addressed the patient's telemetry RED ALARM and the RN should have documented what was done to address the RED ALARMS.

ND 1 stated Patient 1's "ECG leads off" alarm meant multiple leads (a conductive pad that is attached to the patient skin and enables recording of electrical currents) were not attached to Patient 1.

ND 1 stated Patient 1's "transmitter off generated" and "equipment off line" alarm could meant the telemetry monitoring for Patient 1 was turned off.

ND 1 stated Patient 1's telemetry alarm record indicated the patient was put back on the telemetry monitor at 7:16 a.m. ND 1 stated when Patient 1's telemetry monitor was turned back on, RED ALARMS indicating asystole was generated.

ND 1 stated there was no documentation MT 1 and MT 2 reported Patient 1's RED ALARMS generated from the telemetry monitor to the RN.

ND 1 stated there was no documentation RN 1 and RN 2 addressed Patient 1's RED ALARMS from the telemetry monitor.

ND 1 stated MT 1 and MT 2 should not have silenced Patient 1's RED ALARMS from the telemetry monitor and should have reported it to the RN.

During an interview on July 7, 2021, at 10:52 a.m., with ND 2, ND 2 stated she was involved in the investigation of the case and interviewed the involved staff. ND 2 stated when she interviewed RN 1 and RN 2, both RNs stated they gave the hand-off reporting for Patient 1 at the bedside.

ND 2 stated RN 1 and RN 2 both told her during the bedside report, they decided to put the ECG leads back on Patient 1. ND 2 stated both RN 1 and RN 2 told her they thought Patient 1 was just asleep.

ND 2 stated when the patient's leads were off and then subsequently placed back on the patient, the RN should call the MT and inform the MT that the patient's ECG leads were reattached to the patient. ND 2 stated the RN and the MT should both verify the patient's heart rhythm on the telemetry monitor after the ECG leads were put back on Patient 1.

ND 2 stated there was no documentation RN 2 informed MT 2 of Patient 1's ECG leads were reattached to the patient.

ND 2 stated there was no documentation RN 2 and MT 2 verified Patient 1's heart rhythm on the telemetry monitor after the patient's leads were placed back on the patient.

ND 2 stated when she interviewed MT 2, MT 2 told her when she started her shift (7 a.m. to 7 p.m.) MT 1 reported to her that Patient 1 was off the telemetry monitor because the patient was refusing and removing her leads.

ND 2 stated MT 2 told her when Patient 1's telemetry monitor was generating RED ALARMS, MT 2 ignored and did not report to the RN because MT 2 thought Patient 1 was still off the telemetry monitor.

ND 2 stated Patient 1's RED ALARMS generated from the telemetry monitor started at 7:16 a.m., indicated asystole and did not indicate ECG leads were off. ND 2 stated MT 2 should have addressed the RED ALARMS and reported it to the RN.

During an interview on July 14, 2021, at 8:39 a.m., with Clinical Nurse Manager (CNM) 1, CNM 1 stated there was no issue or concern reported to him regarding Patient 1's telemetry monitoring until around 6 a.m. to 6:30 a.m.

CNM 1 stated RN 1 came into the nurses station and told MT 1 she was turning off Patient 1's telemetry monitor because the patient kept taking off the leads. CNM 1 stated he told RN 1 she cannot turn off Patient 1's telemetry monitor without a physician's order. CNM 1 stated he told RN 1 to call and inform the physician regarding Patient 1's condition. CNM 1 stated RN 1 told him "okay" and left the nurses station.

CNM 1 stated there was no documentation the physician ordered Patient 1's telemetry monitor discontinued. CNM 1 stated when he asked RN 1 if she called and informed the physician of Patient 1's trying to remove ECG leads, RN 1 told him she did not informed the physician.

During a review of the facility's document titled, "(Brand name of the telemetry monitor) Instruction for Use," printed February 2012, First Edition, the document indicated, "...ECG LEADS OFF...Condition: Multiple leads are off...What to do: Re-attach ECG leads to patient...

TRANSMITTER OFF...Condition...Auto shut off after 10 minutes of all leads off...What to do: Reattached ECG leads to patient..."

During a review of the facility's P&P titled, "Dysrhythmia Monitoring," approved on March 30, 2020, the P&P indicated, "...After the patient has been connected to the telemetry box, the nurse will call the monitor technician to confirm placement of telemetry on the correct patient, identify the cardiac rhythm and document such in the electronic medical record (EMR)...

PATIENT MONITORING...Monitor Technicians/Registered Nurses will monitor and document ECG rhythms...Verify that Life Threatening (RED ALARMS) are on. THESE ARE NEVER TO BE TURNED OFF...The Monitor Technician will notify the patient's nurse for reportable rhythm changes...The nurse will be responsible for patient assessment upon notification of ECG rhythm changes...The nurse caring for the patient is to notify the patient's physician for significant dysrhythmia or rhythm changes as indicated, using appropriate nursing judgement...

ALARM/Arrhythmia NOTIFICATION...If a monitor alarm occurs, the patient must be checked immediately...The bedside and charge nurse must be alerted to high urgency alarms...Only a nurse may silence an emergency alarm after evaluation of the rhythm and patient condition...The nurse documents the intervention in the EMR (electronic medical record)..."

During a review of the facility's P&P titled, "Telemetry Units Criteria," approved on November 22, 2016, the P&P indicated, "...DISCONTINUATION OF MONITORING...A physician order will be required to discontinue telemetry monitoring..."

b. During a concurrent interview and record review on July 13, 2021, at 2:03 p.m., with Nursing Director (ND) 1, Patient 1's flowsheet record indicated the bedside handoff report was completed by RN 1 and RN 2 on June 18, 2021, at 7:31 a.m.

The "Telemetry Alarm Record," dated June 18, 2021, indicated the following:

- At 6:15 a.m., "ECG (electrocardiogram) Leads Off Generated";

- At 6:26 a.m., "Transmitter Off Generated...Equipment Offline" (a total of 11 minutes after the ECG Leads Off was generated); and,

- At 7:16 a.m., "Equipment Online...ECG/Arrhythmia (a type of heart rhythm) Alarms On" (a total of one hour and one minute after the ECG Leads Off was generated).

Further review of the "Telemetry Alarm Record" indicated the following:

- From 7:16 a.m. to 7:49 a.m., ( a total of 33 minutes) Patient 1's telemetry monitor generated RED ALARMS (indicated Asystole) and were silenced in between alarms.

There was no documented evidence MT 2 informed RN 2 or the Clinical Nurse Manager (CNM) of Patient 1's RED ALARMS from the telemetry monitor.

There was no documented evidence RN 2 assessed and evaluated Patient 1 to address the RED ALARMS from the patient's telemetry monitor.

ND 1 stated Patient 1's "ECG leads off" alarm meant multiple leads (a conductive pad that is attached to the patient skin and enables recording of electrical currents) were not attached to Patient 1.

ND 1 stated Patient 1's "transmitter off generated" and "equipment off line" alarm could meant the telemetry monitoring for Patient 1was turned off.

ND 1 stated Patient 1's telemetry alarm record indicated the patient was put back on the telemetry monitor at 7:16 a.m. ND 1 stated when Patient 1's telemetry monitor was turned back on, RED ALARMS indicating asystole was generated.

ND 1 stated there was no documentation MT 1 and MT 2 reported Patient 1's RED ALARMS generated from the telemetry monitor to the RN.

ND 1 stated there was no documentation RN 1 and RN 2 addressed Patient 1's RED ALARMS from the telemetry monitor.

ND 1 stated MT 1 and MT 2 should not have silenced Patient 1's RED ALARMS from the telemetry monitor and should have reported it to the RN.

ND 1 stated there was no documentation of Patient 1 assessment after the VS at 4 a.m. ND 1 stated the next documentation of Patient 1's assessment was when Certified Nursing Assistant (CNA) 1 came to check the patient's VS at the start of her shift (7 a.m. to 7 p.m.) and needed to call the RN to check on Patient 1.

During an interview on July 7, 2021, at 10:52 a.m., with ND 2, ND 2 stated she was involved in the investigation of the case and interviewed the involved staff. ND 2 stated when she interviewed RN 1 and RN 2, both RNs stated they gave the hand-off reporting for Patient 1 at the bedside.

ND 2 stated RN 1 and RN 2 both told her during the bedside report, they decided to put the ECG leads back on Patient 1. ND 2 stated both RN 1 and RN 2 told her they thought Patient 1 was just asleep.

ND 2 stated when the patient's leads were off and then subsequently placed back on the patient, the RN should call the MT and inform the MT that the patient's ECG leads were reattached to the patient. ND 2 stated the RN and the MT should both verify the patient's heart rhythm on the telemetry monitor after the ECG leads were put back on Paitent 1.

ND 2 stated there was no documentation RN 2 informed MT 2 of Patient 1's ECG leads were reattached to the patient.

ND 2 stated there was no documentation RN 2 and MT 2 verified Patient 1's heart rhythm on the telemetry monitor after the patient's leads were placed back on the patient.

During an interview on July 14, 2021, at 9:45 a.m., with Clinical Nurse Manager (CNM) 5, CNM 5 stated at the start of her shift (7 a.m. to 7 p.m.) CNM 1 reported to her that Patient 1 had episode of confusion and had been removing her ECG leads off. CNM 5 stated CNM 1 told her RN 1 was told to call the Physician to inform Patient 1's condition.

CNM 5 stated after receiving report for Patient 1, she stopped RN 2 in the hallway and asked RN 2 if she had been to Patient 1's room and checked on the patient. CNM 5 stated RN 2 told her, she had received Patient 1's report from RN 1 at the bedside. CNM 5 stated RN 2 told her Patient 1 "is okay" and "she put the patient back on telemetry monitoring."

CNM 5 stated a few minutes after she talked to RN 2, Certified Nursing Assistant (CNA) 1 came to her and informed her Patient 1 was not breathing and RN 2 had initiated a Code Blue.

During an interview on July 14, 2021, at 9:25 a.m., with CNA 1, CNA 1 stated she was the CNA assigned to Patient 1 on June 18, 2021. CNA 1 stated part of her morning routine was to go to each patient assigned to her and checked their VS.

CNA 1 stated when she entered Patient 1's room, the lights were off and the room was dark. CNA 1 stated Patient 1 was covered with a blanket up to her chin and appeared to be sleeping. CNA 1 stated she introduced herself and told Patient 1 she would be taking her BP. CNA 1 stated she then uncover Patient 1's left arm and repositioned it to take the BP. CNA 1 stated she felt something was wrong because the patient's arm was cold when she touched it and it was stiff. CNA 1 then took Patient 1's BP but the machine would not register the patient's BP.

CNA 1 stated she was about to press the call light button to have RN 2 come to the room and check on Patient 1. CNA 1 stated she then saw RN 2 standing outside the hallway close to Patient 1's room so she called RN 2 instead. CNA 1 stated she told RN 2 she could not get Patient 1's BP.

CNA 1 stated with RN 2 in the room, she took another BP and the machine would not register Patient 1's BP. CNA 1 stated she then turned on the light in the patient's room, and removed Patient 1's blanket. CNA 1 stated Patient 1 appeared to be pale white and was not breathing. CNA 1 stated RN 2 checked on the patient and called a Code Blue (hospital code for medical emergency).

During a review of the facility's document titled, "(Name of the Telemetry Monitor) Instruction for Use," printed in February 2012, First Edition, the document indicated, "...ECG LEADS OFF...Condition: Multiple leads are off...What to do: Re-attach ECG leads to patient...

TRANSMITTER OFF...Condition...Auto shut off after 10 minutes of all leads off...What to do: Reattached ECG leads to patient..."

During a review of the facility's P&P titled, "Dysrhytmia Monitoring," approved on March 30, 2020, the P&P indicated, "...After the patient has been connected to the telemetry box, the nurse will call the monitor technician to confirm placement of telemetry on the correct patient, identify the cardiac rhythm and document such in the electronic medical record (EMR)...

PATIENT MONITORING...Monitor Technicians/Registered Nurses will monitor and document ECG rhythms...Verify that Life Threatening (RED ALARMS) are on. THESE ARE NEVER TO BE TURNED OFF...The Monitor Technician will notify the patient's nurse for reportable rhythm changes...The nurse will be responsible for patient assessment upon notification of ECG rhythm changes...The nurse caring for the patient is to notify the patient's physician for significant dysrhytmia or rhythm changes as indicated, using appropriate nursing judgement...

ASSESSMENT ON INPATIENT UNITS...The nurse will verify lead placement at the beginning of each shift; and verify that the monitor/transmitter is functioning properly...The Monitor Technician/Nurse will obtain, evaluate, and post a rhythm strip in the patient record...At the beginning of every shift...With any dysrhytmia that is new, symptomatic or reflective of a change from a previous rhythm, or that requires immediate interventions...

ALARM/Arrhythmia NOTIFICATION...If a monitor alarm occurs, the patient must be checked immediately...The bedside and charge nurse must be alerted to high urgency alarms...Only a nurse may silence an emergency alarm after evaluation of the rhythm and patient condition...The nurse documents the intervention in the EMR (electronic medical record)..."

During a review of the facility's P&P titled, "Hand Off Communication," approved on December 17, 2020, the P&P indicated, "...A standardize approach to hand-off communication will occur for circumstances including but not limited to...shift change in nursing units...The SBAR communication format will be used with every hand-off event...the process for using SBAR communication will include the following steps...

Situation...briefly state what the problem is, when it happened or started, and how severe it is...

Background - Convey pertinent information that is relevant to the issue at hand and relevant to the receiver...

Assessment - What is the assessment of the situation...Consider reporting changes in the patient's status from prior assessments...

Recommendation...state what you think would help resolve a situation or what your desire response should be...

Whenever a caregiver has received a hand-off communication event...that caregiver will document in the electronic medical record that hand-off occurred, inclusive of the following elements...The caregiver receiving the patient has received adequate information to safely accept and care for his/her patient..."

c. During a concurrent interview and record review, on July 14, 2021, at 10:30 a.m., with RN 3, the telephone order received by RN 3 on June 17, 2021, at 5:16 p.m., indicated for Patient 1 to receive Zyprexa five milligram (mg - unit of measurement) intramuscular (IM) injection (injection of the medication into the muscle) one time dose only. There was no documented evidence of indication for the use for Zyprexa.

Patient 1's "Medication Administration" record indicated RN 3 administered Zyprexa five mg IM to the patient's left arm on June 17, 2021, at 5:35 p.m.

RN 3 stated she was the RN assigned to Patient 1 on June 17, 2021. RN 3 stated she took care of Patient 1 a couple days and she was familiar with the care of the patient. RN 3 stated Patient 1 was alert and oriented, the patient had shortness of breath (SOB) and needed to use the Oxygen (O2).

RN 3 stated on June 17, 2021, Patient 1 had increase SOB when the patient needed to use the bedside commode, when she would transfer from the bed to the commode. RN 3 stated Patient 1 became more anxious because of her increasing SOB.

RN 3 stated when Patient 1's RP came to visit, the patient's RP asked her if the physician could give the patient medication to calm her down. RN 3 stated Patient 1's RP told her the patient had used Ativan (medication used to treat anxiety) before and if the patient could have the same medication.

RN 3 stated she called the physician and relayed the patient RP's request. RN 3 stated the physician did not want to give Patient 1 Ativan and ordered Zyprexa instead for one dose only. RN 3 stated the Zyprexa was ordered by the physician for Patient 1's anxiety.

RN 3 stated she did not document Patient 1's change of condition and the reason for medicating the patient with Zyprexa. RN 3 stated she should have documented Patient 1's assessment when the patient became anxious and the intervention provided for Patient 1's anxiety.

RN 3 stated 30 minutes after she administered the Zyprexa to Patient 1, the patient's RP called her because Patient 1 was confused. RN 3 stated when she assessed Patient 1, the patient knew her name but the patient thought she was at her house with her gardener. RN 3 stated she reoriented the patient continued to be confused.

RN 3 stated she did not call the physician because she said Patient 1's confusion could be from the Zyprexa. RN 3 stated she was aware it was the first time Patient 1 had Zyprexa and having the signs and symptoms of confusion after the administration of the medication was a concern. RN 3 stated she felt it was not concerning enough for her to notify the physician.

RN 3 stated towards the end of the shift, Patient 1's confusion had lessened and the patient was more oriented to person, place, and time. RN 3 stated she did not document Patient 1's change of condition, her reassessment, and the intervention provided to the patient. RN 3 stated she should have documented on the patient's record.

During an interview on July 14, 2021, at 11:25 a.m., with ND 1, ND 1 stated when a patient received a new medication the RN should be aware of the patient's reaction after the medication was administered. When the patient had shown s/s of reaction to the new medication, the RN should assess and monitor the patient and the RN should inform the physician.

During a review of the facility's P&P titled, "Adult Admission, Assessment And Interdisciplinary Screening Documentation, Adult Shift Assessment and Reassessment," approved on April 23, 2018, the P&P indicated, "...Throughout the patient's stay, the Registered Nurse will perform assessments based on the individualized and prioritized needs to determine the response to treatment, therapy or educational sessions and determine the effectiveness of the interventions that have been instituted...

The Registered Nurse will also perform reassessments when there is a change in the patient's diagnosis or condition, or which necessitates changes in the plan of care or as ordered by a physician..."

During a review of the facility's P&P titled, "Safe Order Writing and Clarification of Unsafe Medication Orders," approved on December 4, 2019, the P&P indicated, "...Whenever applicable all prescription orders should include the reason for prescribing...This information may be written with the medication order or be available in the electronic medical record...

Behavior agents...should specify the specific behavior being modified and target parameters for use of the medication..."

2a. During a concurrent interview and record review, with Nursing Director (ND) 1, the "Admission H&P (History and Physical)," dated July 12, 2021, indicated Patient 4 was admitted to the facility with a chief complaint of chest pain and shortness of breath.

The "Physician's Order," dated July 12, 2021, indicated the following:

- At 4:54 a.m., administer to Patient 4 Ketorolac (pain medication) 15 milligram (mg - unit of measurement) intravenous (IV - through the vein) push every six hours as needed (PRN) for moderate pain (pain score of 4 to 6 [based on the scale of 1 to 10, 10 being the highest pain score]); and

- At 4:47 a.m., administer to Patient 4 Tramadol (pain medication) 25 mg, 1/2 tablet by mouth (po) every four hours for a total of four doses per day PRN for severe pain (pain score of 7 to 10).

The "Medication Details" indicated Ketorolac 15 mg IV push was administered to Patient 4 on the following dates:

- On July 12, 2021, at 8:33 a.m., for moderate pain.

There was no documented evidence Patient 4's pain was assessed after the patient was medicated for pain;

- On July 12, 2021, at 2:10 p.m., for moderate pain.

There was no documented evidence Patient 4's pain was assessed after the patient was medicated for pain; and

- On July 13, 2021, at 2:44 a.m., for moderate pain.

There was no documented evidence Patient 4's pain was assessed after the patient was medicated for pain.

The "Medication Details" indicated Tramadol 25 mg po was administered to Patient 4 on the following dates:

- On July 12, 2021, at 4:12 p.m., for severe pain.

There was no documented evidence Patient 4's pain was assessed after the patient was medicated for pain;

- On July 13, 2021, at 4:38 a.m., for severe pain.

There was no documented evidence Patient 4's pain was assessed after the patient was medicated for pain; and

- On July 13, 2021, at 8:30 a.m., for severe pain (pain score of 9).

At 9:30 a.m., Patient 4's pain was still severe (pain score of 9).

There was no documented evidence Patient 4's severe pain after pain medication was addressed.

ND 1 stated when a patient was medicated for pain, a pain reassessment should be conducted to know if the intervention provided was effective.

ND 1 stated when a patient's pain was not resolved after medication was administered, the RN should notify the physician to address the patient's continued pain.

ND 1 stated Patient 4's pain should have been reassessed after each pain medication to know if the patient's pain was managed.

ND 1 stated the RN should have notified the physician when Patient 4's pain was still severe after pain medication was given.

b. During a concurrent observation and interview on July 15, 2021, at 9:40 a.m., with Clinical Nurse Manager (CNM) 2, Patient 6 was observed lying in bed, awake, alert, and oriented. Patient 6 stated she was in the hospital because of abdominal pain and she received dialysis (a procedure to remove waste products and excess fluids from the blood when the kidneys stop working properly).

During a concurrent interview and record review on July 15, 2021, at 11:20 a.m., with Nursing Director (ND) 3, the "Admission H&P (History and Physical)," dated July 12, 2021, indicated Patient 6 was presented to the Emergency Department with a chief complaint of abdominal pain.

The "Physician's Order," dated July 12, 2021, at 6:02 a.m., indicated to administer Patient 6 Dilaudid (pain medication) 0.5 milligram (mg - unit of measurement) intravenous (IV - through the vein) push every four hours as needed (PRN) for severe pain (pain score of 6 to 10 [based on the scale of 1 to 10, 10 being the highest pain score]).

The "Medication Details" indicated Dilaudid 0.5 mg IV push was administered to Patient 6 on the following:

- On July 14, 2021, at 9:02 p.m., for severe pain.

There was no documented evidence Patient 6's pain was assessed after the patient was medicated for pain; and

- On July 15, 2021, at 12:49 a.m., for severe pain.

There was no documented evidence Patient 6's pain was assessed after the patient was medicated for pain.

The "Pain Assessment" flowsheet record indicated the following:

- On July 12, 2021, at 12:52 p.m., Patient 6's pain was assessed.

The patient was next assessed at 8 p.m. (seven hours later) and then on July 13, 2021, at 4:12 a.m. (eight hours later); and

- On July 13, 2021, at 7:05 a.m., Patient 6's pain was assessed.

The patient was next assessed on July 14, 2021, at 8 a.m. (25 hours later).

ND 3 stated in her unit, patients' pain should be assess every four hours.

ND 3 stated Patient 6's pain assessment had gaps. ND 3 stated Patient 6's pain should have been assessed every four hours.

ND 3 stated when a patient was medicated for pain, a pain reassessment should be conducted to know if the intervention provided was effective.

ND 3 stated Patient 6's pain should have been reassessed after each pain medication was administered to know if the patient's pain was managed.




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c. A review of Patient 19's record was conducted. Patient 19 was admitted to the facility on July 6, 2021, with a diagnosis of an abscess to her right neck which required surgical intervention.

The record reflected on July 6, 2021, Patient 19 had an order for Morphine 4 milligrams (a narcotic used for pain management) intravenous push (via a vein), every four hours for severe pain.

On July 8, 2021, at 4:50 p.m., Patient 19 indicated she had a pain level of 8 (based on a pain scale of 1-10, with 10 reflecting the most severe level of pain) and received the Morphine.

A reassessment of the patient's pain level was not documented after Patient 19 received the Morphine.

On July 10, 2021, Patient 19 had a physician's order to receive Norco 325 milligram/10 milligram, one tablet for severe pain every four hours as needed (a narcotic used for pain management).

On July 10, 2021, at 10:42 a.m., Patient 19 complained of a pain level of 8 and received the Norco.

A reassessment of the patient's pain was not documented after Patient 19 received the Norco.

An interview was conducted with Clinical Nurse Manager (CNM) 3 on July 13, 2021, at 3 p.m. CNM 3 stated when medication is given for pain a reassessment must be done in one hour in order to reflect the medications effectiveness for oral medication and a reassessment should be done in 15 minutes after administration of an intravenous medication .

d. A review of Patient 21's record was conducted. Patient 21 was admitted to the facility on July 1, 2021, due to abdominal pain secondary to a history of multiple gun shot wounds to the abdomen.

The record reflected on July 6, 2021, Patient 21 had a physician's order to receive Tramadol 50 milligrams (a narcotic used for pain management), one tablet orally every six hours as needed for severe pain.

On July 9, 2021, at 2:35 p.m., Patient 21 complained

Based on observation, interview, and record review, the facility failed to ensure for one patient (Patient 6), an individualized care plan was developed based on the patient's needs.

This failure had the potential for the staff not to be provided the communication to promote continuity of care and to reinforced implementation of nursing interventions to meet patient's individualized goals.

Findings:

During an observation on July 15, 2021, at 9:40 a.m., with Clinical Nurse Manager (CNM) 2, Patient 6's room door had a sign posted indicating the patient was hard of hearing and legally blind. Patient 6 was observed lying in bed, awake, alert, and oriented. Patient 6 was not able to track and was observed staring. When Patient 6 was asked a question, the question needed to be repeated in a louder voice and needed to speak closer to the patient's ears. The patient stated, "I can't hear." Patient 6 stated she was in the hospital because of abdominal pain and she had dialysis (a procedure to remove waste products and excess fluids from the blood when the kidneys stop working properly).

During a concurrent interview and record review on July 15, 2021, at 10:56 a.m., with the Director of Regulatory Compliance (DRC), the "Admission H&P (History and Physical)," dated July 12, 2021, indicated Patient 6 was presented to the Emergency Department with a chief complaint of abdominal pain. Patient 6 had a medical history of End Stage Renal Disease (ESRD - kidney failure) on HD (hemodialysis - a type of dialysis).

Patient 6's assessment on July 14, 2021, indicated the patient had hearing impairments on both ears.

Patient 6's assessment on July 14, 2021, indicated the patient had vision impairment.

There was no documented evidence a care plan was developed to address Patient 6's needs for pain management, dialysis, hearing and vision impairments.

The DRC stated an individualized care plan should have been developed to address Patient 6's needs for pain management, dialysis, hearing and vision impairment.

During a review of the facility's policy and procedure (P&P) titled, "Adult Admission, Assessment and Interdisciplinary Screening Documentation, Adult Shift Assessment and Reassessment," approved on April 23 2018, the P&P indicated, "...A patient specific plan of care is to be initiated that identified focus problems, expected outcomes and their target dates..."

Based on interview and record review, the facility failed to ensure for five Certified Nursing Assistants (CNAs) interviewed, the CNAs were aware of their role in the event a patient had a medical emergency and needed life-saving (cardiopulmonary resuscitation - CPR) intervention.

This failure had the potential to result in delayed treatment and death of the patient.

Findings:

1. During an interview on July 14, 2021, at 9:25 a.m., with CNA 1, CNA 1 stated she was the CNA assigned to Patient 1 on June 18, 2021. CNA 1 stated part of her morning routine was to go to each patient assigned to her and checked their vital signs (VS - temperature, blood pressure [BP], heart rate, and respiratory rate).

CNA 1 stated when she entered Patient 1's room, the lights were off and the room was dark. CNA 1 stated Patient 1 was covered with a blanket up to her chin and appeared to be sleeping. CNA 1 stated she introduced herself and told Patient 1 she would be taking her BP. CNA 1 stated she then uncover Patient 1's left arm and repositioned it to take the BP. CNA 1 stated she felt something was wrong because the patient's arm was cold when she touched it and it was stiff. CNA 1 then took Patient 1's BP but the machine would not register the patient's BP.

CNA 1 stated she was about to press the call light button to have RN 2 come to the room and check on Patient 1. CNA 1 stated she then saw RN 2 standing outside the hallway close to Patient 1's room so she called RN 2 instead. CNA 1 stated she told RN 2 she could not get Patient 1's BP.

CNA 1 stated with RN 2 in the room, she took another BP and the machine would not register Patient 1's BP. CNA 1 stated she then turned on the light in the patient's room, and removed Patient 1's blanket. CNA 1 stated Patient 1 appeared to be pale white and was not breathing. CNA 1 stated RN 2 checked on the patient and called a Code Blue (hospital code for medical emergency).

CNA 1 stated she did not call a Code Blue for Patient 1 even though she knew something was wrong with the patient and the patient would need medical emergency assistance. CNA 1 stated she had always been taught to always call the RN.

CNA 1 stated she did not know how to initiate a Code Blue. CNA 1 stated there was no Code Blue button inside Patient 1's room and she did not know the number to call on the telephone to initiate a Code Blue.



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2. An interview was conducted with CNA 2 on July 14, 2021, at 10:10 a.m.

CNA 2 stated during education and training taken at the facility regarding cardio pulmonary resuscitation (CPR), she was not instructed whether the CNAs could press the Code Blue button in a patients room to initiate CPR, but she would call the RN and take the patient's vital signs (pulse, respirations and blood pressure).

3. An interview was conducted with CNA 3 on July 14, 2021, at 10:20 a.m. CNA 3 stated if she found a patient that was not breathing, she would call the nurse and take the patient's vital signs, (pulse, respirations and blood pressure). CNA 3 stated she would have to wait for the nurse to initiate cardiopulmonary resuscitation.

4. An interview was conducted with CNA 4 on July 14, 2021, at 10:30 a.m.

CNA 4 stated if a patient was not breathing she would call the nurse, stay with the patient and have the nurse respond to the situation.

5. An interview was conducted with CNA 5 on July 14, 2021, at 10:40 a.m.

CNA 5 stated if a patient was not breathing she would call the nurse, but stated she did not know if she should call a Code Blue, or press the Code Blue button. CNA 5 stated she felt the training from the facility had to be clearer on the subject of how she would respond.

During an interview on July 14, 2021, at 9:45 a.m., with Clinical Nurse Manager (CNM) 5, CNM 5 stated every staff were expected to initiate a Code Blue if needed. CNM 5 further stated all staff were informed on how to call a Code Blue on the telephone.

During an interview on July 14, 2021, at 2:17 p.m., with the Chief Nursing Officer (CNO), the CNO stated the facility expectation was all staff should initiate a Code Blue by pressing the Code Blue button or calling #44 on the telephone. The CNO stated for emergency medical situation, Code Blue should be initiated and not to call the RN first.

Based on interview and record review, the facility failed to ensure for one patient (Patient 1), the patient care needs were met in accordance with the facility's policy and procedure when:

1a. Patient 1 had no documented evidence the patient's "RED ALARMS" (life threatening heart rhythm) from the telemetry monitor (an electronic monitoring of the patient's heart rhythm) was acknowledged by the Monitor Technician (MT, a person who was trained to recognized heart rhythm, monitoring the patients on telemetry) and was addressed and evaluated by the Registered Nurse (RN);

b. Patient 1 had no documented evidence the patient was assessed during bedside hand-off reporting (a process where the RN gives report to another RN at the end of shift to hand-off the care of the patient); and

c. Patient 1 had no documented evidence an assessment was conducted when Patient 1 had a change of condition and was given Zyprexa (antipsychotic medication).

In addition, there was no documented evidence Patient 1 was assessed and monitored when the patient had signs and symptoms of confusion after Zyprexa was administered.

These failures resulted in a delay in care and treatment of Patient 1. In addition, these failures resulted in Patient 1 experiencing an unidentified deadly heart rhythm, a delay in beginning lifesaving treatment (cardiopulmonary resuscitation-CPR), and may have contributed to Patient 1's death.

Findings:

1. During a concurrent interview and record review, on July 13, 2021, at 2:03 p.m., with Nursing Director (ND) 1, Patient 1's record was reviewed. The "Admission H&P (History and Physical)," dated June 14, 2021, indicated Patient 1 presented to the Emergency Department for worsening shortness of breath. Further review of the record indicated the plan for Patient 1 was to place the patient on telemetry.

Patient 1's "Nursing Narrative," dated June 18, 2021, at 12:28 a.m., authored by RN 1, indicated, "...pt (Patient climbing OOB (out of bed) and pulling off tele (telemetry) several times at the beginning of shift. (Patient 1's Responsible Party [RP]) called and (Patient 1's RP) arrived. Pt takes ativan at home. MD (physician) called and ativan ordered times one. Med (medication) given per MD orders. Pt resting/sleeping eyes closed. No s/s (signs and symptoms) distress. Will continue to monitor. (Patient 1's RP) went home..."

Patient 1's "Vital Signs (VS - temperature, blood pressure (BP), heart rate (HR), respiratory rate (RR) " flowsheet record indicated the patient's last VS recorded was at 4 a.m.

Patient 1's "Nursing Narrative," dated June 18, 2021, authored by RN 2, indicated, "...At 0750 (7:50 a.m.)...Upon entering the room CNA (Certified Nursing Assistant) informed me she was unable to obtain BP x (times) 2. I assessed pt and noticed no chest rise. I checked pulse and could not find one...I immediately called a code blue (hospital code for medical emergency) and code was initiated...Decision was made after second code blue to call time of death by (name of the physician) at 8:41 a.m..."

a. The "Telemetry Alarm Record," dated June 18, 2021, indicated the following:

- From 5:46 a.m. to 5:52 a.m., (a total of six minutes) Patient 1's telemetry monitor generated RED ALARMS (indicated Asystole [no electricity or movement of the heart] and Bradycardia [low heart rate] of less than 50 beats per min [bpm]) and were silenced in between alarms;

- From 6:12 a.m. to 6:14 a.m., (a total of three minutes) Patient 1's telemetry monitor generated RED ALARMS (indicated Premature Ventricular Contractions [PVCs extra heartbeats that may disrupt a regular heart rhythm] and Ventricular Tachycardia [V Tach - a condition in which the lower chamber of the heart beats very fast]) and were silenced in between alarms; and

- From 7:16 a.m. to 7:49 a.m., ( a total of 33 minutes) Patient 1's telemetry monitor generated RED ALARMS (indicated Asystole) and were silenced in between alarms.

There was no documented evidence the MT informed the RN of Patient 1's RED ALARMS from the telemetry monitor.

There was no documented evidence the RN assessed and evaluated Patient 1 to address the RED ALARMS from the patient's telemetry monitor.

Further review of the "Telemetry Alarm Record" indicated the following:

- At 6:15 a.m., "ECG (electrocardiogram) Leads Off Generated";

- At 6:26 a.m., "Transmitter Off Generated...Equipment Offline" (a total of 11 minutes after the ECG Leads Off was generated); and,

- At 7:16 a.m., "Equipment Online...ECG/Arrhythmia (a type of heart rhythm) Alarms On" (a total of one hour and one minute after the ECG Leads Off was generated).

ND 1 stated in (name of telemetry unit) the patient in the room was attached to a telemetry monitoring box, and the monitoring box transmits the heart rhythm to the central monitor located in the nurses' station, where a MT was assigned 24 hours / seven days to monitor patients on telemetry.

ND 1 stated when an alarm was generated from the telemetry monitor, it would only be heard from the central monitor in the nurses' station. ND 1 stated all alarms generated from the telemetry monitor should be acknowledged by the MT.

ND 1 stated for all telemetry alarms involving changes or concerns in the patient's heart rhythm, the MT should call and report to the RN.

ND 1 stated when a patient's telemetry monitor generated RED ALARMS, the MT was not allowed to silence the alarm.

ND 1 stated the MT should report the RED ALARMS to the RN assigned to the patient and if the MT could not reach the RN, the MT should report the patient's RED ALARM to the Charge Nurse (CN) or the Nurse Manager. ND 1 stated MT should document the time and the name of the RN or CN the RED ALARM was reported to.

ND 1 stated the RN should assess and evaluate the patient to addressed the patient's telemetry RED ALARM and the RN should have documented what was done to address the RED ALARMS.

ND 1 stated Patient 1's "ECG leads off" alarm meant multiple leads (a conductive pad that is attached to the patient skin and enables recording of electrical currents) were not attached to Patient 1.

ND 1 stated Patient 1's "transmitter off generated" and "equipment off line" alarm could meant the telemetry monitoring for Patient 1 was turned off.

ND 1 stated Patient 1's telemetry alarm record indicated the patient was put back on the telemetry monitor at 7:16 a.m. ND 1 stated when Patient 1's telemetry monitor was turned back on, RED ALARMS indicating asystole was generated.

ND 1 stated there was no documentation MT 1 and MT 2 reported Patient 1's RED ALARMS generated from the telemetry monitor to the RN.

ND 1 stated there was no documentation RN 1 and RN 2 addressed Patient 1's RED ALARMS from the telemetry monitor.

ND 1 stated MT 1 and MT 2 should not have silenced Patient 1's RED ALARMS from the telemetry monitor and should have reported it to the RN.

During an interview on July 7, 2021, at 10:52 a.m., with ND 2, ND 2 stated she was involved in the investigation of the case and interviewed the involved staff. ND 2 stated when she interviewed RN 1 and RN 2, both RNs stated they gave the hand-off reporting for Patient 1 at the bedside.

ND 2 stated RN 1 and RN 2 both told her during the bedside report, they decided to put the ECG leads back on Patient 1. ND 2 stated both RN 1 and RN 2 told her they thought Patient 1 was just asleep.

ND 2 stated when the patient's leads were off and then subsequently placed back on the patient, the RN should call the MT and inform the MT that the patient's ECG leads were reattached to the patient. ND 2 stated the RN and the MT should both verify the patient's heart rhythm on the telemetry monitor after the ECG leads were put back on Patient 1.

ND 2 stated there was no documentation RN 2 informed MT 2 of Patient 1's ECG leads were reattached to the patient.

ND 2 stated there was no documentation RN 2 and MT 2 verified Patient 1's heart rhythm on the telemetry monitor after the patient's leads were placed back on the patient.

ND 2 stated when she interviewed MT 2, MT 2 told her when she started her shift (7 a.m. to 7 p.m.) MT 1 reported to her that Patient 1 was off the telemetry monitor because the patient was refusing and removing her leads.

ND 2 stated MT 2 told her when Patient 1's telemetry monitor was generating RED ALARMS, MT 2 ignored and did not report to the RN because MT 2 thought Patient 1 was still off the telemetry monitor.

ND 2 stated Patient 1's RED ALARMS generated from the telemetry monitor started at 7:16 a.m., indicated asystole and did not indicate ECG leads were off. ND 2 stated MT 2 should have addressed the RED ALARMS and reported it to the RN.

During an interview on July 14, 2021, at 8:39 a.m., with Clinical Nurse Manager (CNM) 1, CNM 1 stated there was no issue or concern reported to him regarding Patient 1's telemetry monitoring until around 6 a.m. to 6:30 a.m.

CNM 1 stated RN 1 came into the nurses station and told MT 1 she was turning off Patient 1's telemetry monitor because the patient kept taking off the leads. CNM 1 stated he told RN 1 she cannot turn off Patient 1's telemetry monitor without a physician's order. CNM 1 stated he told RN 1 to call and inform the physician regarding Patient 1's condition. CNM 1 stated RN 1 told him "okay" and left the nurses station.

CNM 1 stated there was no documentation the physician ordered Patient 1's telemetry monitor discontinued. CNM 1 stated when he asked RN 1 if she called and informed the physician of Patient 1's trying to remove ECG leads, RN 1 told him she did not informed the physician.

During a review of the facility's document titled, "(Brand name of the telemetry monitor) Instruction for Use," printed February 2012, First Edition, the document indicated, "...ECG LEADS OFF...Condition: Multiple leads are off...What to do: Re-attach ECG leads to patient...

TRANSMITTER OFF...Condition...Auto shut off after 10 minutes of all leads off...What to do: Reattached ECG leads to patient..."

During a review of the facility's P&P titled, "Dysrhythmia Monitoring," approved on March 30, 2020, the P&P indicated, "...After the patient has been connected to the telemetry box, the nurse will call the monitor technician to confirm placement of telemetry on the correct patient, identify the cardiac rhythm and document such in the electronic medical record (EMR)...

PATIENT MONITORING...Monitor Technicians/Registered Nurses will monitor and document ECG rhythms...Verify that Life Threatening (RED ALARMS) are on. THESE ARE NEVER TO BE TURNED OFF...The Monitor Technician will notify the patient's nurse for reportable rhythm changes...The nurse will be responsible for patient assessment upon notification of ECG rhythm changes...The nurse caring for the patient is to notify the patient's physician for significant dysrhythmia or rhythm changes as indicated, using appropriate nursing judgement...

ALARM/Arrhythmia NOTIFICATION...If a monitor alarm occurs, the patient must be checked immediately...The bedside and charge nurse must be alerted to high urgency alarms...Only a nurse may silence an emergency alarm after evaluation of the rhythm and patient condition...The nurse documents the intervention in the EMR (electronic medical record)..."

During a review of the facility's P&P titled, "Telemetry Units Criteria," approved on November 22, 2016, the P&P indicated, "...DISCONTINUATION OF MONITORING...A physician order will be required to discontinue telemetry monitoring..."

b. During a concurrent interview and record review on July 13, 2021, at 2:03 p.m., with Nursing Director (ND) 1, Patient 1's flowsheet record indicated the bedside handoff report was completed by RN 1 and RN 2 on June 18, 2021, at 7:31 a.m.

The "Telemetry Alarm Record," dated June 18, 2021, indicated the following:

- At 6:15 a.m., "ECG (electrocardiogram) Leads Off Generated";

- At 6:26 a.m., "Transmitter Off Generated...Equipment Offline" (a total of 11 minutes after the ECG Leads Off was generated); and,

- At 7:16 a.m., "Equipment Online...ECG/Arrhythmia (a type of heart rhythm) Alarms On" (a total of one hour and one minute after the ECG Leads Off was generated).

Further review of the "Telemetry Alarm Record" indicated the following:

- From 7:16 a.m. to 7:49 a.m., ( a total of 33 minutes) Patient 1's telemetry monitor generated RED ALARMS (indicated Asystole) and were silenced in between alarms.

There was no documented evidence MT 2 informed RN 2 or the Clinical Nurse Manager (CNM) of Patient 1's RED ALARMS from the telemetry monitor.

There was no documented evidence RN 2 assessed and evaluated Patient 1 to address the RED ALARMS from the patient's telemetry monitor.

ND 1 stated Patient 1's "ECG leads off" alarm meant multiple leads (a conductive pad that is attached to the patient skin and enables recording of electrical currents) were not attached to Patient 1.

ND 1 stated Patient 1's "transmitter off generated" and "equipment off line" alarm could meant the telemetry monitoring for Patient 1was turned off.

ND 1 stated Patient 1's telemetry alarm record indicated the patient was put back on the telemetry monitor at 7:16 a.m. ND 1 stated when Patient 1's telemetry monitor was turned back on, RED ALARMS indicating asystole was generated.

ND 1 stated there was no documentation MT 1 and MT 2 reported Patient 1's RED ALARMS generated from the telemetry monitor to the RN.

ND 1 stated there was no documentation RN 1 and RN 2 addressed Patient 1's RED ALARMS from the telemetry monitor.

ND 1 stated MT 1 and MT 2 should not have silenced Patient 1's RED ALARMS from the telemetry monitor and should have reported it to the RN.

ND 1 stated there was no documentation of Patient 1 assessment after the VS at 4 a.m. ND 1 stated the next documentation of Patient 1's assessment was when Certified Nursing Assistant (CNA) 1 came to check the patient's VS at the start of her shift (7 a.m. to 7 p.m.) and needed to call the RN to check on Patient 1.

During an interview on July 7, 2021, at 10:52 a.m., with ND 2, ND 2 stated she was involved in the investigation of the case and interviewed the involved staff. ND 2 stated when she interviewed RN 1 and RN 2, both RNs stated they gave the hand-off reporting for Patient 1 at the bedside.

ND 2 stated RN 1 and RN 2 both told her during the bedside report, they decided to put the ECG leads back on Patient 1. ND 2 stated both RN 1 and RN 2 told her they thought Patient 1 was just asleep.

ND 2 stated when the patient's leads were off and then subsequently placed back on the patient, the RN should call the MT and inform the MT that the patient's ECG leads were reattached to the patient. ND 2 stated the RN and the MT should both verify the patient's heart rhythm on the telemetry monitor after the ECG leads were put back on Paitent 1.

ND 2 stated there was no documentation RN 2 informed MT 2 of Patient 1's ECG leads were reattached to the patient.

ND 2 stated there was no documentation RN 2 and MT 2 verified Patient 1's heart rhythm on the telemetry monitor after the patient's leads were placed back on the patient.

During an interview on July 14, 2021, at 9:45 a.m., with Clinical Nurse Manager (CNM) 5, CNM 5 stated at the start of her shift (7 a.m. to 7 p.m.) CNM 1 reported to her that Patient 1 had episode of confusion and had been removing her ECG leads off. CNM 5 stated CNM 1 told her RN 1 was told to call the Physician to inform Patient 1's condition.

CNM 5 stated after receiving report for Patient 1, she stopped RN 2 in the hallway and asked RN 2 if she had been to Patient 1's room and checked on the patient. CNM 5 stated RN 2 told her, she had received Patient 1's report from RN 1 at the bedside. CNM 5 stated RN 2 told her Patient 1 "is okay" and "she put the patient back on telemetry monitoring."

CNM 5 stated a few minutes after she talked to RN 2, Certified Nursing Assistant (CNA) 1 came to her and informed her Patient 1 was not breathing and RN 2 had initiated a Code Blue.

During an interview on July 14, 2021, at 9:25 a.m., with CNA 1, CNA 1 stated she was the CNA assigned to Patient 1 on June 18, 2021. CNA 1 stated part of her morning routine was to go to each patient assigned to her and checked their VS.

CNA 1 stated when she entered Patient 1's room, the lights were off and the room was dark. CNA 1 stated Patient 1 was covered with a blanket up to her chin and appeared to be sleeping. CNA 1 stated she introduced herself and told Patient 1 she would be taking her BP. CNA 1 stated she then uncover Patient 1's left arm and repositioned it to take the BP. CNA 1 stated she felt something was wrong because the patient's arm was cold when she touched it and it was stiff. CNA 1 then took Patient 1's BP but the machine would not register the patient's BP.

CNA 1 stated she was about to press the call light button to have RN 2 come to the room and check on Patient 1. CNA 1 stated she then saw RN 2 standing outside the hallway close to Patient 1's room so she called RN 2 instead. CNA 1 stated she told RN 2 she could not get Patient 1's BP.

CNA 1 stated with RN 2 in the room, she took another BP and the machine would not register Patient 1's BP. CNA 1 stated she then turned on the light in the patient's room, and removed Patient 1's blanket. CNA 1 stated Patient 1 appeared to be pale white and was not breathing. CNA 1 stated RN 2 checked on the patient and called a Code Blue (hospital code for medical emergency).

During a review of the facility's document titled, "(Name of the Telemetry Monitor) Instruction for Use," printed in February 2012, First Edition, the document indicated, "...ECG LEADS OFF...Condition: Multiple leads are off...What to do: Re-attach ECG leads to patient...

TRANSMITTER OFF...Condition...Auto shut off after 10 minutes of all leads off...What to do: Reattached ECG leads to patient..."

During a review of the facility's P&P titled, "Dysrhytmia Monitoring," approved on March 30, 2020, the P&P indicated, "...After the patient has been connected to the telemetry box, the nurse will call the monitor technician to confirm placement of telemetry on the correct patient, identify the cardiac rhythm and document such in the electronic medical record (EMR)...

PATIENT MONITORING...Monitor Technicians/Registered Nurses will monitor and document ECG rhythms...Verify that Life Threatening (RED ALARMS) are on. THESE ARE NEVER TO BE TURNED OFF...The Monitor Technician will notify the patient's nurse for reportable rhythm changes...The nurse will be responsible for patient assessment upon notification of ECG rhythm changes...The nurse caring for the patient is to notify the patient's physician for significant dysrhytmia or rhythm changes as indicated, using appropriate nursing judgement...

ASSESSMENT ON INPATIENT UNITS...The nurse will verify lead placement at the beginning of each shift; and verify that the monitor/transmitter is functioning properly...The Monitor Technician/Nurse will obtain, evaluate, and post a rhythm strip in the patient record...At the beginning of every shift...With any dysrhytmia that is new, symptomatic or reflective of a change from a previous rhythm, or that requires immediate interventions...

ALARM/Arrhythmia NOTIFICATION...If a monitor alarm occurs, the patient must be checked immediately...The bedside and charge nurse must be alerted to high urgency alarms...Only a nurse may silence an emergency alarm after evaluation of the rhythm and patient condition...The nurse documents the intervention in the EMR (electronic medical record)..."

During a review of the facility's P&P titled, "Hand Off Communication," approved on December 17, 2020, the P&P indicated, "...A standardize approach to hand-off communication will occur for circumstances including but not limited to...shift change in nursing units...The SBAR communication format will be used with every hand-off event...the process for using SBAR communication will include the following steps...

Situation...briefly state what the problem is, when it happened or started, and how severe it is...

Background - Convey pertinent information that is relevant to the issue at hand and relevant to the receiver...

Assessment - What is the assessment of the situation...Consider reporting changes in the patient's status from prior assessments...

Recommendation...state what you think would help resolve a situation or what your desire response should be...

Whenever a caregiver has received a hand-off communication event...that caregiver will document in the electronic medical record that hand-off occurred, inclusive of the following elements...The caregiver receiving the patient has received adequate information to safely accept and care for his/her patient..."

c. During a concurrent interview and record review, on July 14, 2021, at 10:30 a.m., with RN 3, the telephone order received by RN 3 on June 17, 2021, at 5:16 p.m., indicated for Patient 1 to receive Zyprexa five milligram (mg - unit of measurement) intramuscular (IM) injection (injection of the medication into the muscle) one time dose only. There was no documented evidence of indication for the use for Zyprexa.

Patient 1's "Medication Administration" record indicated RN 3 administered Zyprexa five mg IM to the patient's left arm on June 17, 2021, at 5:35 p.m.

RN 3 stated she was the RN assigned to Patient 1 on June 17, 2021. RN 3 stated she took care of Patient 1 a couple days and she was familiar with the care of the patient. RN 3 stated Patient 1 was alert and oriented, the patient had shortness of breath (SOB) and needed to use the Oxygen (O2).

RN 3 stated on June 17, 2021, Patient 1 had increase SOB when the patient needed to use the bedside commode, when she would transfer from the bed to the commode. RN 3 stated Patient 1 became more anxious because of her increasing SOB.

RN 3 stated when Patient 1's RP came to visit, the patient's RP asked her if the physician could give the patient medication to calm her down. RN 3 stated Patient 1's RP told her the patient had used Ativan (medication used to treat anxiety) before and if the patient could have the same medication.

RN 3 stated she called the physician and relayed the patient RP's request. RN 3 stated the physician did not want to give Patient 1 Ativan and ordered Zyprexa instead for one dose only. RN 3 stated the Zyprexa was ordered by the physician for Patient 1's anxiety.

RN 3 stated she did not document Patient 1's change of condition and the reason for medicating the patient with Zyprexa. RN 3 stated she should have documented Patient 1's assessment when the patient became anxious and the intervention provided for Patient 1's anxiety.

RN 3 stated 30 minutes after she administered the Zyprexa to Patient 1, the patient's RP called her because Patient 1 was confused. RN 3 stated when she assessed Patient 1, the patient knew her name but the patient thought she was at her house with her gardener. RN 3 stated she reoriented the patient continued to be confused.

RN 3 stated she did not call the physician because she said Patient 1's confusion could be from the Zyprexa. RN 3 stated she was aware it was the first time Patient 1 had Zyprexa and having the signs and symptoms of confusion after the administration of the medication was a concern. RN 3 stated she felt it was not concerning enough for her to notify the physician.

RN 3 stated towards the end of the shift, Patient 1's confusion had lessened and the patient was more oriented to person, place, and time. RN 3 stated she did not document Patient 1's change of condition, her reassessment, and the intervention provided to the patient. RN 3 stated she should have documented on the patient's record.

During an interview on July 14, 2021, at 11:25 a.m., with ND 1, ND 1 stated when a patient received a new medication the RN should be aware of the patient's reaction after the medication was administered. When the patient had shown s/s of reaction to the new medication, the RN should assess and monitor the patient and the RN should inform the physician.

During a review of the facility's P&P titled, "Adult Admission, Assessment And Interdisciplinary Screening Documentation, Adult Shift Assessment and Reassessment," approved on April 23, 2018, the P&P indicated, "...Throughout the patient's stay, the Registered Nurse will perform assessments based on the individualized and prioritized needs to determine the response to treatment, therapy or educational sessions and determine the effectiveness of the interventions that have been instituted...

The Registered Nurse will also perform reassessments when there is a change in the patient's diagnosis or condition, or which necessitates changes in the plan of care or as ordered by a physician..."

During a review of the facility's P&P titled, "Safe Order Writing and Clarification of Unsafe Medication Orders," approved on December 4, 2019, the P&P indicated, "...Whenever applicable all prescription orders should include the reason for prescribing...This information may be written with the medication order or be available in the electronic medical record...

Behavior agents...should specify the specific behavior being modified and target parameters for use of the medication..."

Based on observation, interview, and record review, the facility failed to ensure for two patients (Patients 6 and 7), the medications administered were in accordance with the physician's order.

This failure resulted in delayed treatment and may lead to a delay in recovery and deterioration of the patients' health condition.

Findings:

1. During a concurrent observation and interview on July 15, 2021, at 9:40 a.m., with Clinical Nurse Manager (CNM) 2, Patient 6 was observed lying in bed, awake, alert, and oriented. Patient 6 stated she was in the hospital because of abdominal pain and she received dialysis (a procedure to remove waste products and excess fluids from the blood when the kidneys stop working properly). Patient 6 stated she felt she was given too much pain medication because it made her nauseous.

During a concurrent interview and record review, on July 15, 2021, at 11:20 a.m., with Nursing Director (ND) 3, the "Admission H&P (History and Physical)," dated July 12, 2021, indicated Patient 6 presented to the Emergency Department with a chief complaint of abdominal pain.

The "Physician's Order," dated July 12, 2021, at 6:02 a.m., indicated the following:

- Administer Patient 6 Tylenol (pain medication) 650 milligram (mg - unit of measurement) by mouth every four hours as needed (PRN) for mild pain (pain score of 1 to 3 [based on the of scale of 1 to 10, 10 being the highest pain score]; and

- Administer Patient 6 Dilaudid (pain medication) 0.5 mg intravenous (IV - through the vein) push every four hours PRN for severe pain (pain score of 7 to 10).

There was no physician's order for moderate pain (pain score of 4-6 [from scale of 1-10]).

The "Medication Details" indicated Dilaudid 0.5 mg IV push was administered to Patient 6 on July 12, 2021, at 12:22 p.m. Patient 6's pain score was 6 (moderate pain).

ND 3 stated Pain 6's pain was moderate and the Dilaudid should not have been given because it was ordered for severe pain.

ND 3 stated if Patient 6 had no pain medication for moderate pain, the RN should have called the physician to get an order to manage Patient 6's pain appropriately.

2. During a concurrent interview and record review, on July 15, 2021, at 12:11 p.m., with the Director of Compliance and Regulation (DRC), the "ED (Emergency Department) Note," dated July 5, 2021, indicated Patient 7 was brought in by ambulance and presented to the ED with a gunshot wound.

The "Physician's Order," dated July 13, 2021, at 2:23 a.m., indicated to administer Patient 7 Labetalol (medication used to treat high blood pressure [BP]) 10 milligram (mg - unit of measurement) in two milliliters (ml) intravenous (IV - through the vein) push every two hours as needed, to give for systolic (first number in the BP, a phase in the heart beat when the heart muscle contracts and pumps blood into the arteries) BP above 160.

Patient 6's "Vital Signs Flowsheet" record indicated the following:

For July 13, 2021:

- At 10 a.m., BP reading was 166/76 mmHg (millimeters of mercury - unit of measurement);

- At 11 a.m., BP reading was 165/60 mmHg;

- At 12 p.m., BP reading was 166/71 mmHg; and

- At 11 p.m., BP reading was 163/72 mmHg.

For July 14, 2021:

- At 12 a.m., BP reading was 161/70 mmHg; and

- At 6:15 p.m., BP reading was 168/91 mmHg;

For July 15, 2021:

- At 4:15 a.m., BP reading was 162/70 mmHg; and

- At 10:15 a.m., BP reading was 166/71 mmHg.

There was no documented evidence Patient 7 received Labetalol for systolic BP of above 160.

The DRC stated Labetalol should have been administered to Patient 7 when needed for his systolic BP of above 160. The DRC stated if there was a reason for not administering the Labetalol as ordered by the physician, it should have been documented on the patient's record.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," approved on December 20, 2019, the P&P indicated, "...All medications, IV solutions and irrigating solutions will be administered in a safe manner following "Five Rights". Prior to administration the licensed personnel will do the following:

Prior to obtaining medications for administration, validate orders entered into the patient's electronic medical record (EMR) by comparing against written or electronic order, and documenting accordingly...

The licensed personnel will assure that the drug is delivered at the appropriate time. The reason for why a drug is not administered at the scheduled time will be indicated in the nursing comments in eMAR...

The correct dosage of the drug will be verified. The licensed personnel are responsible to know the correct dosage of each medication prior to administration..."