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Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23, NURSING SERVICES was out of compliance.

A-0395 - Standard: A registered nurse must supervise and evaluate the nursing care for each patient. The facility failed to provide nursing care based on standards of nursing practice and facility policy. In addition, the facility failed to ensure appropriate staff were notified of abnormal assessment findings in 1 of 10 medical records reviewed (Patient #2). The failure prevented timely reassessment and alerting of staff about changes in condition for patients. Patient #2 expired approximately 4 hours after his/her oxygen needs suddenly increased.

A-0405 - Standard: (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care as specified under §482.12(c), and accepted standards of practice.(i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations.(2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. The facility failed to ensure nursing staff followed hand hygiene guidelines to reduce the risk of infection associated with medication administration in 2 of 2 observations. This failure created the potential for negative patient outcomes related to unsafe medication administration.

Based on interviews and document review, the facility failed to provide nursing care based on standards of nursing practice and facility policy. In addition, the facility failed to ensure appropriate staff were notified of abnormal assessment findings in 1 of 10 medical records reviewed (Patient #2).

The failure prevented timely reassessment and alerting of staff about changes in condition for patients. Patient #2 expired approximately 4 hours after his/her oxygen needs suddenly increased.

FINDINGS:

POLICY

According to the policy, Assessment & Reassessment-Registered Nurse (RN), reassessment is a component of the patient plan of care and is conducted at key determinate events as well as throughout the care continuum. Reassessment is the evaluation of the patient response to treatment and care in order to evaluate the appropriateness and effectiveness of the care rendered. The goal of the assessment and reassessment process is to provide the patient with the best and most appropriate individualized care and treatment. Medical Surgical Nursing reassessment determines the patient response to care and treatment. Patients will be reassessed more frequently as indicated by changes in their condition, and/or with abnormal findings. Reassessment will be documented in the medical record under Nursing Intervention or in Narrative notes. The reassessment is based upon but not limited to the following: patient treatment, patient response to treatment, significant change in patient condition, significant change in the patient's diagnosis, and discharge planning.

According to the policy, Vital Signs-Routine, the nurse will be responsible for reporting abnormal trends in vital signs to the physician.

According to the policy, Rapid Response Team, nursing staff criteria for calling a Rapid Response Team (RRT) include, but are not limited to: staff member is concerned about the patient, acute change in vital signs, acute change in oxygen saturation despite maximal oxygen therapy, acute change in level of consciousness.

1. Nursing staff failed to reassess and evaluate Patient #2's response to treatment. Furthermore, nursing staff did not report the abnormal assessment to the physician assigned to Patient #2's care and did not call RRT per facility policy.

a) Medical record review showed Patient #2 was admitted to the facility on 06/17/16 for sepsis, an immune response to an infection, secondary to a urinary tract infection. According to the History and Physical, dated 06/17/16, the patient lived alone and had daytime caregivers. Patient #2 had a 2-day history of altered mental status with confusion, speech difficulties, loss of appetite and somnolence.

According to the Patient Progress Notes, dated 06/20/16, the Physician Assistant (PA) documented the patient was still extremely weak and lethargic and needed continued physical therapy and occupational therapy. Prior to admission, Patient #2 was on oxygen during the night at 2 liters/per minute, and was likely mild volume overloaded with an oxygen saturation level of 95% on 4 liters/per minute. The PA documented the sepsis resolved and ordered for a diuretic to be given. Additionally, the PA documented s/he met with the patient and his/her caregiver; the caregiver stated the patient's better, but not 100%.

Patient #2's cardiopulmonary resuscitation status was "Do Not Resuscitate" (DNR).

i) Review of Patient Notes, dated 06/20/16 through 06/21/16, revealed the following:

On 06/20/16, from 7:00 a.m. to 7:00 p.m., Patient #2 was able to ambulate in the room to the chair, respiratory was unlabored, and s/he was in the process of bladder training.

At 7:00 p.m., Registered Nurse #1 (RN) assumed care of Patient #2 from the day nurse. According to the vital sign flow sheet, at 7:54 p.m., Patient #2's oxygen saturation level was 90% on 4 liters/per minute of oxygen. The admitting physician ordered on 06/17/16, the patient's oxygen saturation level was to be maintained greater than 92%. RN #1 documented his/her shift assessment was done at 8:10 p.m. There was no evidence in his/her notes showing the physician was notified about the patient's low oxygen saturation level.

At 8:10 p.m., RN #1 documented the patient was joking around with staff, had no shortness of breath or chest pain. S/he documented the patient did have a slight headache and was given Tylenol for the pain. The patient had no other complaints.

At 8:45 p.m., RN #1 documented Patient #2 was agitated, climbing out of bed, and attempted to remove his/her oxygen. RN #1 administered IV Ativan, a sedative, which was ordered to be given as needed for agitation.

At 10:05 p.m., 1 hour and 20 minutes after the sedative was given, RN #1 documented Patient #2 was unable to maintain his/her oxygen saturations. Patient #2's oxygen saturation level was 82%. Respiratory Therapy (RT) was called to the bedside and the patient was suctioned. Patient #2 was then placed on 10 liters/per minute of oxygen. His/her saturation level was 91%. RN #1 did not notify the physician about the patient's change of condition.

On 06/21/16 at 1:00 a.m. (approximately 3 hours later), RN #1 documented Patient #2's oxygen saturations on 10 liters was 89 to 87%. Respiratory Therapy was notified. According to the RN notes, the therapist said "[s/he] is ok as long as [s/he] doesn't go lower".

At 1:50 a.m., Patient #2's oxygen saturations decreased to 83%. The RN documented s/he moved the pulse oximeter to several different places on the patient and the patient's saturation level was in the 70% range. RN #1 did not notify the physician about the patient's abnormal vital signs.

At 2:10 a.m., both RN #1 and RT #2 were at Patient #2's bedside. The patient's oxygen saturations were in the 50 to 60% range. RN #1 documented the patient was non responsive, placed on a non-rebreather, and had agonal (gasping) breaths. Additionally, the RN documented the patient had a faint pulse.

At 2:15 a.m., the House Supervisor was at the patient's bedside and s/he listened to the patient's heart rate.

At 2:20 a.m., the on call physician was notified about Patient #2's change in condition. The RN received new orders which included a respiratory nebulizer treatment and an IV diuretic. Both of the medications were to be given immediately. RN #1 documented when s/he returned to the patient's room, both the RT and House Supervisor stated the patient had a faint and diminished heart rate, and not much respiratory effort.

At 2:28 a.m., the patient expired while the RN was on the phone with the physician.

The facility was unable to provide evidence which showed RN #1 followed patient care policies. There was no evidence showing RN #1 reassessed Patient #2's response to treatment after an IV sedative was administered to the patient for agitation. There was no evidence in Patient #2's medical record showing in a 4 hour period, from 10:05 p.m. to 2:10 a.m., RN #1 performed a physical reassessment and obtained the patient's vitals signs including heart rate, blood pressure, and respiratory rate when the patient's condition changed. RN #1 documented the patient's level of consciousness only once which was 4 hours after the patient's respiratory status began to decline.

Additionally, in a 2 hour time period, from 7:54 p.m. to 10:05 p.m., Patient #2's oxygen needs increased from 4 liters/per minute to 10 liters/per minute. RN #1 did not call a RRT; although, Patient #2 met the criteria to call at 10:05 p.m. RN #1 did not notify the physician until approximately 4 hours after the patient's condition began to change and 8 minutes prior to the patient's death.

An attempt was made to interview RN #1; however, s/he was unavailable for an interview when the survey was conducted.

b) On 10/05/16 at 9:00 a.m., an interview was conducted with RN #6 who worked in the Emergency Department and participated in RRT calls. RN #6 stated the purpose of a RRT was early detection of patient issues and to provide interventions before a patient situation worsened. RN #6 stated the RRT provided support and could request physician presence if needed.

c) On 10/05/16 at 4:02 p.m., an interview was conducted with RT #2 who worked the night Patient #2 expired. RT #2 stated s/he remembered Patient #2. After review of the nurse's notes, dated 06/20/16 through 06/21/16, RT #2 stated the physician should have been notified about Patient #2's increased oxygen needs when the patient went from 4 liters to 10 liters/per minute. S/he stated this process allowed physicians to assess the cause of the increased oxygen needs. RT #2 confirmed neither the patient's RN, nor him/herself notified the physician when s/he was called to the bedside around 10:00 p.m.

d) On 10/06/16 at 9:46 a.m., an interview was conducted with Physician #3 who was one of the physicians involved with Patient #2's medical care. After review of Patient #2's discharge summary which the physician had written and the nursing notes dated 06/20/16 through 06/21/16, Physician #3 stated the patient was a DNR; however, a DNR did not mean do not treat. S/he stated the patient was frail, who was delirious and his/her level of consciousness fluctuated. Physician #3 stated s/he was unsure why the patient deteriorated so quickly. Physician #3 stated the RN should have notified the physician when the patient's oxygen needs significantly changed or called a RRT for an evaluation. S/he stated the fact the patient was given Ativan and became less responsive, should have triggered this process.

Physician #3 stated although s/he did not know if the interventions would have changed the patient's outcome; additional interventions could have been ordered.

e) On 10/06/16 at 10:43 a.m., an interview was conducted with RN #4 who was the House Supervisor on the night Patient #2 expired. RN #4 stated the purpose for the RRT was to provide additional resources at the bedside when unforeseen decline in a patient's status occurred. S/he further stated staff were encouraged to call the RRT early and not wait until it was too late. RN #4 stated s/he was not sure why a RRT was not called for Patient #2. RN #4 stated, although Patient #4 was a DNR, the DNR status did not mean do no treat. RN #4 stated by the time s/he was requested at Patient #2's bedside, there was a question whether the patient was breathing and s/he could barely obtain the patient's pulse. After review of the nursing notes documented by RN #1 on 06/20/16 through 06/21/16; RN #4 stated the physician should have been notified around 10:05 p.m. This was the first time RN #1 documented Patient #2's oxygen needs were increasing. Furthermore, RN #4 stated Patient #2's change in condition met the RRT criteria and required a physician to be notified.

f) On 10/06/16 at 3:54 p.m., an interview was conducted with the Chief Nursing Officer (CNO #5) who stated prior to the survey s/he was unaware Patient #2's physician was not notified by the RN about his/her change of condition prior to the patient's death. After s/he reviewed the patient's medical record, CNO #5 stated s/he was concerned RN #1 did not call the physician or a RRT when the patient's condition began to change. Additionally, s/he had concerns that there was no evidence in the medical record the nurse reassessed Patient #2 after the patient received IV Ativan for agitation and there were no vital signs documented during the 4 hour period when the patient's oxygen needs increased.

CNO #5 stated vital signs and a physical reassessment were an important process in assessing a patient's medical status and response to treatment. CNO #5 stated if a physician was called according to policy, the physician would have had a chance to provide guidance and order additional interventions to meet the patient's needs. S/he stated Patient #2 met the RRT criteria and physician notification criteria.

CNO #5 stated if staff followed policy, the patient's treatment may have been different.

Based on observations and interviews, the facility failed to ensure nursing staff followed hand hygiene guidelines to reduce the risk of infection associated with medication administration in 2 of 2 observations.

This failure created the potential for negative patient outcomes related to unsafe medication administration.

FINDINGS:

POLICY

According to the policy, Hand Hygiene, the purpose of hand hygiene is to remove dirt and transient flora, and to prevent or minimize the spread of infection. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands before having direct contact with patients, after contact with patients, after contact with inanimate objects (including medical equipment) in the vicinity of the patient, and after removing gloves.

1. Nursing staff did not perform hand hygiene during patient medication administration.

a) On 10/04/16 at 9:00 a.m., a medication administration observation was conducted on the Intensive Care Unit. Registered Nurse (RN #8) entered Patient #4's room, verified the patient's name and date of birth, then proceeded to don gloves. RN #8 continued to connect the ordered intravenous (IV) fluids with the IV tubing. At the same time, RN #8 grabbed a nearby trash container with his/her gloved hand, then continued to prime the IV tubing with the fluids. With the same gloved hand, RN #8 inserted the tubing into the IV pump, then began to disinfect the patient's IV catheter administration port. RN #8 connected the IV tubing to the patient's IV catheter. After the IV fluids were started, RN #8 removed his/her gloves, then left the patient's room. RN #8 did not perform hand hygiene prior to entering Patient #4's room, after handling the trash container, prior to medication administration, and before exiting the patient's room. This was in contrast to policy.

b) On 10/04/16 at 9:30 a.m., a medication observation was conducted on the 4th floor Medical/Surgical unit. RN #9 entered Patient #6's room, without performing hand hygiene. S/he then verified the IV Potassium with another RN present in room and proceeded to connect the IV medication to the IV tubing and initiated the administration through the patient's IV access line. Immediately after the observation, RN #9 was interviewed. S/he stated nurses were expected to perform hand hygiene when entering and exiting a patient's room. RN #9 stated this was the policy.

c) On 10/06/16 at 2:40 PM, an interview was conducted with the Infection Preventionist (IP #10). S/he stated staff were expected to perform hand hygiene when entering and exiting patients' rooms, before touching a patient, and prior to medication administration. IP #10 stated staff were trained annually on infection control and were expected to follow policy to prevent the spread of infection and transmission. S/he stated the facility followed the CDC recommended guidelines.