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Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure one (1) of ten (10) patients (Patient #1) received nursing supervision and evaluation in accordance with the patient's need.

The findings include:

Review of the facility's policy, titled, "Nursing Standards of Patient / Resident Care", revised 12/2015, revealed the patient can expect to receive nursing care based on an identification of his/her needs by nursing personnel and other members of the interdisciplinary health team. The identification of needs is based on initial assessment and reassessment, data obtained from the patient, and the patient's preferences. Initial assessments and reassessments are completed in accordance with professional and regulatory standards and applicable policies. The patient can expect to receive nursing care from staff members who function in a collaborative manner with other members of the healthcare team to achieve improved patient health outcomes.

Review of the facility's policy, titled, "Assessment of Patients/Residents Needs", revised 07/22/15, revealed assessment culminates in an interdisciplinary plan of care. This plan of care notes the need for reassessment and plans the reassessment interventions. Reassessments are done as patient needs/condition/diagnosis change. The Registered Nurse (RN) responsible for the patient's care acts as the facilitator to ascertain that the interdisciplinary plan of care is prioritized and implemented.

Record review revealed Patient #1 presented to the Emergency Department (ED) and registered on 08/21/17 at 3:06 PM. Record review revealed the patient presented with a chief complaint of fever and chills which started about three (3) days prior. The patient also reported shortness of breath and a productive cough with yellow, green sputum. The patient was seen by the ED Physician and diagnosed with pneumonia, right lower lobe. Laboratory studies and a chest radiograph were completed and reviewed by the Physician. The physical assessment by the Physician revealed blood pressure 161/77 mm/hg, heart rate 88 bpm, respirations 20, oxygen (O2) saturation of 90 per cent (%), and his/her temperature was 98.4 degrees Fahrenheit (F). The Physician's examination revealed the patient was alert and in no acute distress with moderate bilateral rhonchi present. Laboratory studies were completed and the White Blood Count (WBC) was listed at 10.4, within normal limits. The Physician discussed the case with the Hospitalist on 08/21/17 at 4:16 PM and agreed the patient would be admitted and admission orders were provided to the nurse. The Health Care Provider would see the patient in the hospital. The admission diagnoses was Pneumonia and Renal Insufficiency. The ED nurse triaged the patient at 3:09 PM and noted the patient was alert, in no acute distress. Home medications were noted as well as an allergy for Morphine. Review of past medical history included Cerebrovascular Accident (CVA), Kidney Failure, Prostate Enlarged, Arthritis, Macular Degeneration, Peripheral Vascular Disease (PVD), Hypertension (HTN), Hypercholesterolemia and Diabetes Mellitus. On 08/21/17 at 3:50 PM, a saline lock was inserted into the left forearm with a twenty (20) gauge angiocath. Blood was drawn and labeled at that time. A Duo Nebulizer was given to the patient by the Respiratory Therapist at 4:18 PM. On 08/21/17 an intravenous piggyback (IVPB) with one (1) gram of Rocephin was initiated via infusion pump after a sputum culture was obtained. On 08/21/17 at 5:00 PM, Zithromax 250 mg IVPB was initiated. At 4:53 PM, the ED nurse phoned report to the accepting nurse on the floor. On 08/21/17 at 5:00 PM, blood pressure was 171/74 mm/hg, heart rate 94 bpm, and respirations 20. O2 saturation was 92% on O2 at three (3) liters per minute (lpm) via nasal cannula. The patient was transported via stretcher by a technician with an IV catheter in place to the medical floor. The patient received an initial assessment on the floor by RN #1 at 5:44 PM. Vital signs were checked at 6:00 PM and documented as temperature of 98.1 degrees F, pulse 94, respirations 24, blood pressure 175/82 mm/hg, O2 saturation 86% on O2 at six (6) lpm per nasal cannula. RN #1 notified the admitting Physician at 6:50 PM that the patient was more short of breath. A telephone order was received for Albuterol Nebulizer treatments every four (4) hours as needed (prn). A nebulizer treatment was administered by the Respiratory Therapist at that time. The 8:00 PM nursing assessment was documented as completed at 11:12 PM. During that assessment, it was documented the patient's breathing was non-labored, with symmetrical chest expansion, and anterior and posterior inspiratory and expiratory lung sounds. Review of the documentation revealed the patient was on O2 at 5 lpm via nasal cannula. The Nurse Aide (NA) made a routine round at 8:21 PM and again at 9:04 PM. At 9:05 PM, the patient requested RN #2 to get him/her something to help with sleep. The RN notified the Hospitalist on-call and received an order for Sonata (a non-benzodiazepine hypnotic for the treatment of insomnia) five (5) milligrams (mg) by mouth (po) at bedtime prn sleep. Vital signs were documented as completed at 9:04 PM by the NA, temperature 97.5 degrees F, pulse 97, respirations 20, blood pressure 170/78 mm/hg, and O2 saturation 93% on a non-rebreather mask. At 9:15 PM, a nebulizer was administered by the Respiratory Therapist. The NA rounded on the patient at 10:46 PM. At 11:00 PM, a note by the Respiratory Therapist indicated an assessment was completed and documented as O2 saturation of 93% on a non-rebreather mask at 15 lpm. His/her pulse was 83 bpm, respirations 20, and described as non-labored. Review of a nurse's note entry by RN #2 revealed he assessed the effects of the Sonata at 11:30 PM - 11:45 PM and reported O2 was flowing via a venturi mask, and the patient was reportedly sleeping well with no labored breathing. The final NA documentation round was noted at 12:55 AM. Late documentation found in the chart revealed State Registered Nurse Aide (SRNA) #1 entered Patient #1's room at 4:45 AM to assess morning vital signs and found the patient to be non-responsive and cold to touch. She then stepped to the doorway and called for assistance. The Charge Nurse and the House Supervisor were sitting at the desk and responded.

Review of nurse's notes, dated 08/22/17 at 4:45 AM, by the Charge Nurse, revealed when SRNA #1 entered Patient #1's room to do morning vital signs, the patient was found to be non-responsive and cold to touch. At 5:00 AM, the patient's daughter was notified the patient had passed away. Further review of nurse's notes, dated 08/22/17 at 5:15 AM, revealed the Nursing House Supervisor notified the on-call Physician to obtain permission to pronounce the time of death at 4:45 AM, with an order received.

Interview with the Complainant, on 07/18/18 at 9:09 AM, revealed the patient probably had pneumonia and was in a room alone. The Complainant reported requesting a regular push button call light, but was never received. The nurse's light was mounted on the bed. The Complainant reported the patient had a mild case of Chronic Obstructive Pulmonary Disease (COPD) and would occasionally use an inhaler at home. It was further reported by the Complainant there was no Physician notification regarding changes. The Complainant stated the "head of nurses said they just didn't know he/she was as sick as he/she was". The Complainant was told the Unit Manager called the patient's admitting Physician. The Complainant felt like the patient's assessment was not adequate. The patient was a Do Not Resuscitate (DNR).

Interview with the Unit Manager, on 07/18/18 at 9:09 AM, revealed Patient #1 was moved closer to the nurse's station after admitted from the ED with O2 and a diagnosis of pneumonia. The on-call Physician was notified. The facility used computerized documentation. He stated he expected the respiratory protocol to be followed. Sonata was given as ordered by the Physician. Vital signs were checked by the technician. They do not use continuous O2 saturation checks on the unit. O2 was set up in the wall panel, they did not use portable tanks routinely. He stated it was reported to him the patient was found around 4:30 AM - 4:40 AM and was a DNR. He also reported when the patient came to the floor, it was reported to him the patient was restless and short of breath. and the staff called the on-call Physician at that time. He revealed a new respiratory protocol had gone into effect since this incident, which gave the Respiratory Therapist more authority to make changes/orders without having to go through the nurse. The facility charted by exception and wrote a note only if there was something unusual. Nursing staff were to check patients every eight (8) hours or as needed. A full system assessment was to be done every twelve (12) hours. A focused assessment was completed every eight (8) hours or as needed. There was no History and Physical (H&P) done on this patient, as he/she was not there for twenty-four (24) hours. He added the unit was now doing hourly rounds by nurses and aides. Under the old policy the nurse was responsible to monitor if a nebulizer was needed, respiratory staff were not responsible. He revealed it was his expectation now, for staff to do hourly rounding. The staff now do bedside reporting and someone sees the patient every hour. For Patient #1, they did not follow policy and should have checked on the patient every four (4) hours.

Interview with RN #1, on 07/18/18 at 1:55 PM, revealed she was the admitting nurse for Patient #1. The ED called report to her. She remembered the patient was "worse off than they had described". The O2 saturation was low and the O2 was bumped up almost immediately. Respiratory was called when the saturation level was reading low. She then called the patient's Physician and received an order for Albuterol nebulizers every four (4) hours as needed. The Physician stated he did not "know" the patient and wouldn't give other orders beside the breathing treatments. She received the order at 6:50 PM. Respiratory was at the bedside and administered the nebulizer. She reported the nurse would be responsible to reassess the patient's condition. She recalled the patient "perked up" after the nebulizer. She stated she was surprised to find out the patient had passed away when she returned the next day. She stated if a patient was having problems she would go back and check on them. NAs should check on patients every one-two (1-2) hours. She stated she gave report to RN #2 at shift change. She stated, at that time, they did not do bedside reporting as they do now. She recalled the patient was on a non-rebreather when she left her shift.

Interview with RN #2, on 07/19/18 at 8:05 AM, revealed he was assigned to care of Patient #1 by the Charge Nurse. He received report from RN #1. He stated he didn't remember much about the report. He does recall he was told the patient had breathing issues with pneumonia. He revealed, that on 08/21/17 at 8:00 PM, the patient requested to get something to help with sleep. The Physician on-call was notified and an order for Sonata five (5) mg po at bedtime prn for sleep was received. RN #2 administered the Sonata as ordered on 08/21/17 at 9:50 PM. RN #2 reassessed the effects of the sleeping medication at 11:30 PM and reported the patient was sleeping well with non-labored breathing wearing the O2 via mask. The RN stated the patient was not struggling with breathing or in any respiratory distress and if he/she had been, he would not have administered the Sonata. He reported it was the nurse's responsibility to reassess for the need of an "as needed" nebulizer after four (4) hours. He reported the next time he saw the patient was after he/she had passed away. He added, that in his nursing note, he had reported the patient was on a Venturi mask, but it was indeed a non-rebreather mask. He stated it was the responsibility of the nurses and the aides to alternate rounding on the patients every hour.

Interview with SRNA #1, on 07/19/18 at 5:04 PM, revealed she had been assigned to care for Patient #1. She stated they should round on patients every hour. She went to Patient #1's room on 08/22/17 at 4:40 AM to do vital signs. She noted the patient's O2 mask was lying beside his/her body and he/she was cold to touch. She called for help. The Charge Nurse and the Nursing Supervisor arrived. Cardiopulmonary Resuscitation (CPR) was not initiated as the nurses determined the patient was too far gone to do CPR. She stated she did not round hourly on the patient but she should have, and documented the round.

Interview with the RN House Supervisor, on 07/18/18 at 4:54 PM, revealed she was on the floor on 08/22/17 around 4:30 AM making rounds. While she was there SRNA #1 came to the door and stated, "I need help in here". The Charge Nurse and the House Supervisor proceeded to Patient #1's room. When they entered she said she could tell that the patient was deceased. He/she was cold to touch and not breathing. She stated according to the Charge Nurse, the patient was a full code. She revealed the nursing staff and aides were responsible for documenting hourly rounds.

Interview with the Charge Nurse, on 07/18/18 at 6:15 PM, revealed she had assigned the care of Patient #1 to RN #2. The day shift Charge Nurse told her the patient was a new admission and was on a non-rebreather mask at 15 lpm. The Respiratory Therapist was at the bedside before 8:00 PM. The patient called out to staff he/she wanted the temperature in the room adjusted. The patient was lying in the bed with the head of the bed elevated and was alert and oriented times three (A&O x3). The patient was able to make needs known, and at that time the patient was not in respiratory distress. The next time she saw the patient was when the patient was found deceased. She reported she was not aware the patient was not being rounded on. The last time she saw the patient, the patient was stable. She stated she expected respiratory and or the nurse to notify her of any changes in the patient's condition. If they were unable to stabilize, they would call the Physician and the daughter. The Charge Nurse revealed she didn't check behind staff to make sure they documented the care they provided. Vital signs were typically done every shift or every four (4) hours. The vital signs were done on the patient at 8:00 PM and should have been done again at midnight and again at 4:00 AM. The facility charted by exception. If there was no documentation, she didn't know whether it had been done or not. There was normally good communication between the NAs and Respiratory.

Interview with the Unit Director, on 07/19/18 at 1:20 PM, revealed the patient arrived to the ED on 08/21/17 at 3:09 PM, an IV catheter was inserted at 3:50 PM with blood drawn at that time. At 4:22 PM, the patient received a DuoNeb (bronchodilater) via nebulizer. At 4:40 PM IV Rocephin (antibiotic) was administered, at 5:00 PM the patient received Zithromax (antibiotic) 250 milligrams (mg). The patient was admitted to four (4) South at 5:24 PM via stretcher by a technician. The chest radiograph done in the ED revealed Cardiomegaly, probable mild Right Lower Lobe Pneumonia and the Radiologist could not exclude Mild Failure. Lab studies revealed a WBC count was within normal limits, blood cultures obtained were negative, and sputum culture was positive.

Interview with the current Risk Manager, on 07/18/18 at 1:50 PM, revealed Patient #1 was not seen by the admitting Physician due to the short time the patient was at the hospital and there was no discharge summary available.

Interview with the Registered Respiratory Therapist (RRT), on 07/18/18 at 6:39 PM, revealed he vaguely recalled the patient. He did recall the patient had progressed to a non-rebreather and the Physician was contacted regarding the patient's shortness of breath. An order was received for Albuterol (Bronchodilator) nebulizer every four (4) hours prn. He recalled there were only two (2) therapists to cover the entire hospital on the night shift. He reported he expected the nurse to call him for a nebulizer prn. The patient stated to the RRT that he/she didn't feel short of breath and requested the room door be shut. The patient did not have a scheduled treatment ordered.

Interview with the Respiratory Therapy Director, on 07/19/18 at 8:30 AM, revealed a therapist should evaluate patients once every eight (8) hours unless otherwise ordered. If an additional nebulizer was needed, the nurse was responsible to contact the Respiratory Therapist. She felt like the therapist followed hospital policy when caring for Patient #1. She revealed it was the policy when Patient #1 was hospitalized that Arterial Blood Gases (ABG's) had to be ordered by a Physician and the policy has since been revised to allow the therapist to use his/her discretion based on the clinical condition of the patient, then notify the Physician. She further revealed it was her expectation that staff follow facility policy.

Interview with the Certified Respiratory Therapist, on 07/19/18 at 9:02 AM, revealed she did not recall the specifics about Patient #1. She did recall giving the patient a nebulizer treatment in the ED. The patient was on O2 at two (2) lpm via nasal cannula with O2 saturation in the low 90's and was "a little short of breath", but reported the nebulizer had helped.

Phone interview with the former Risk Manager, on 07/22/18 at 1:30 PM, revealed she was not sure about Patient #1, and would have to review her notes. She reported she was on and off work during that time with health issues, then retired shortly thereafter. She reported generally there would be an incident report and computerized documentation.

Phone interview with the on-call Physician, on 07/19/18 at 5:00 PM, revealed she had left the area and did not recall the incident.

Four (4) unsuccessful attempts were made to contact the admitting Physician, on 07/18/18 at 3:38 PM, 07/18/18 at 4:06 PM, 07/19/18 at 8:48 AM, and 07/19/18 at 5:14 PM. A voicemail message requesting a return call was left each time.

Phone interview with the ED Physician, on 07/21/18 at 11:37 AM, revealed he spoke with the Hospitalist to admit Patient #1 on 08/21/17. The ED Physician stated the admitting Physician would have rounded on the patient the next morning. When the patient left the ED, his/her vital signs were stable as was the patient's condition.

Phone interview with the Chief Nursing Officer (CNO), on 07/23/18 at 9:17 AM, revealed he did not believe a grievance process form was done. The CNO and the Administrator both spoke with Patient #1's daughter by telephone, and would fax documentation of those conversations.