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Based on staff interview and review of medical records and medical staff bylaws, it was determined the CAH failed to ensure the physician provided medical care to 1 of 5 patients (#4) whose records were reviewed for care following a procedure. This resulted in a delay in providing medical treatment. Findings include:

1. Patient #4's medical record documented a 61 year old female who had upper gastrointestinal endoscopy with biopsy and colonoscopy with biopsy performed on 7/31/12. She suffered cardiopulmonary arrest at 4:10 AM on 8/01/12 and was transferred to an acute care hospital.

An H&P, dated 6/19/12, did not include any cardiac or pulmonary diagnoses. The H&P stated Patient #4 experienced some wheezing and coughing at times. No other cardiopulmonary symptoms were mentioned. The "PRE-ANESTHESIA EVALUATION", dated 7/31/12 at 9:50 AM, did not document pulmonary symptoms or difficulty walking.

The procedures ended on 7/31/12 at 12:36 PM and Patient #4 was taken to the recovery area. Recovery Room notes at 12:37 PM documented she complained of pain and nausea. At 12:45 PM on 7/31/12, the recovery nurse documented she attempted to assist Patient #4 to the bathroom but the patient could not move her legs to walk. At 2:10 PM on 7/31/12, the recovery nurse documented Patient #4 required oxygen at 10 liters per minute and said her abdominal discomfort made it difficult to breathe. A telephone order was obtained at 2:25 PM on 7/31/12 to admit Patient #4 to the medical floor for observation. A note by the day shift RN, at 3:00 PM on 7/31/12, stated Patient #4 rated her abdominal pain at 10 of 10, her abdomen was firm to touch, and she had no bowel sounds. Patient #4 was medicated with IV narcotic at 3:15 PM. A note by the day shift RN, at 3:15 PM on 7/31/12, stated Patient #4 took sips of water and vomited." A note by the day shift LPN, on 7/31/12 at 4:31 PM, documented Patient #4 did not have energy to ambulate. A note by the day shift RN, at 5:22 PM on 7/31/12, stated Patient #4 was medicated with Ativan 1 mg IV for abdominal pain rated 10 of 10. The final note by the day shift was an RN note at 7:45 PM on 7/31/12. It stated Patient #4's abdomen remained firm and it hurt for her to take a deep breath. A note by the LPN, on 7/31/12 at 8:15 PM, stated Patient #4 was assisted to stand but became dizzy and had to sit down. The note stated she was not able to ambulate to the bathroom and required a bedside commode. At 8:58 PM on 7/31/12, the LPN documented Patient #4 required assistance to ambulate.

A note by the LPN, on 7/31/12 at 8:35 PM, stated Patient #4 removed her oxygen. Her oxygen saturation level at the time was 94% without the oxygen. (The American Lung Association's "A QUICK GLANCE GUIDE TO OXYGEN THERAPY," not dated, stated "The goal of oxygen therapy is to provide oxygen saturation of at least 90 % at all activity levels.") A note by the LPN, on 7/31/12 at 10:12 PM, stated Patient #4's oxygen saturation level dropped to 79%. Oxygen was restarted at 3 liters per minute. At 10:17 PM on 7/31/12, Patient #4 was medicated by the RN with IV Demerol for pain rated at 10 of 10. A note by the LPN, on 7/31/12 at 10:40 PM, stated Patient #4 "...states still having pain. Did not rate at this time. Complains mainly about upper abdomen area." A note by the LPN, on 8/01/12 at 12:10 AM, stated Patient #4 "...has emesis bag in hand, spitting into it. States still feels nauseated." A note by the LPN, on 8/01/12 at 12:30 AM, stated Patient #4's abdominal girth appeared larger. The note stated the ED RN was called to start another IV. The note stated Patient #4 was on oxygen at 1.5 liters per minute.

A note by the LPN, on 8/01/12 at 12:58 AM, stated "Call from [surgeon]. Informed of pt's current condition. Orders received for fluid bolus then increased rate. Clindamycin, radiology, and labs in morning. Pt is now NPO except for sips and ice chips. Page [surgeon] if change in fever or tachycardia." No parameters regarding when to notify the physician were included in the order, such as if Patient #6's pulse exceeded a certain rate or her blood pressure was too high or low.

Patient #4's condition continued to decline. A note by the night RN, on 8/01/12 at 4:10 AM, stated patient #4 "...went into respiratory arrest and became pulseless. CPR initiated." Patient #4's heart rate was restored and she was transferred to an acute care hospital.

The medical record from the receiving hospital documented Patient #4 arrived at approximately 6:00 AM on 8/01/12. She was taken to surgery that morning to repair a perforated bowel. A nuclear medicine report, dated 8/01/12, stated a perfusion scan was performed at 1:44 PM. The report confirmed "brain death." The record stated Patient #4 was removed from life support on 8/03/12 and died.

A "Progress Note" by the physician, dated 8/01/12 but not timed, stated Patient #4 was admitted to the CAH post procedure for persistent distention, nausea, and failure to progress. The note stated the physician discussed the patient with the LPN at 1:00 AM (on 8/01/12). The note stated "The update at the time she was having persistent abdominal pain. The patient was able to walk on one occasion and pass a little but of gas, however, was still distended. The patient was also having nausea and had an episode of emesis. She was also having intermittent tachycardia, however maintaining her blood pressure. At that morning I ordered morning laboratories, x-rays, started Clindamycin and ordered a fluid bolus." The note further stated that, at approximately 4:00 AM, Patient #4 required resuscitation.

The physician was interviewed on 8/28/12 beginning at 1:55 PM. He stated he performed the scoping procedures on Patient #4 and then left the CAH. He confirmed giving orders to admit Patient #4 to the CAH. He stated he did not return to the CAH to examine Patient #4. He stated Patient #4 was brain dead when she arrived at the receiving hospital.

The physician did not provide medical care services to Patient #4. He did not examine her when she was admitted to the CAH when she failed to recover from the scoping procedures. He did not examine Patient #4 after he talked to the LPN at 12:58 AM, on 8/01/12, and was informed she was experiencing significant complications.

2. Medical Staff Bylaws, amended 2/28/12, stated at 18.1.1(f), "Each Practitioner must assume timely adequate professional care for his patients in the Hospital by being available, or having available an alternative Practitioner with whom prior arrangements have been made. Each member of the medical staff who does not reside in the immediate vicinity shall name a member of the Medical Staff who is a resident in the area and who may to attend the staff member's patients in an emergency or until the staff member arrives."

The physician chairman of the Medical Staff Quality Committee was interviewed on 8/29/12 beginning at 10:00 AM. She stated Patient #4's physician lived in another town (approximately 20 miles from the CAH). She stated the attending physician did not return to the CAH to examine the patient or turn the care over to a physician who resided near the CAH. She stated she had recommended to the medical staff if a non-local physician admits a patient to the CAH that their care be followed by a local physician.

Patient #4's physician did not follow medical staff bylaws by not naming a local member of the Medical Staff to attend to Patient #4's care.

Based on review of medical records and staff interview, it was determined the CAH failed to ensure services were provided to 2 of 9 patients whose records were reviewed. This failure resulted in a lack of safe and effective nursing care provided to patients. Findings include:

1. Refer to C-294 as it relates to the failure of the CAH to ensure nursing services met the needs patients.

2. Refer to C-295 as it relates the failure of the CAH to ensure an RN provided nursing care to patients.

3. Refer to C-298 as it relates to the failure of the CAH to ensure a nursing care plan was developed for in-patients.

The cumulative effect of these negative systemic practices resulted in the inability of the CAH to provide basic nursing care services.

Based on staff interview and review of medical records, it was determined the CAH failed to ensure nursing services met the needs of 1 of 5 patients (#4) whose records were reviewed for care following a procedure. This resulted in a lack of monitoring of an unstable patient. Findings include:

1. Patient #4's medical record documented a 61 year old female who had upper gastrointestinal endoscopy with biopsy and colonoscopy with biopsy performed on 7/31/12. The procedures ended at 12:36 PM and she was taken to the recovery area. Patient #4 did not recover sufficiently to be discharged. A telephone order was obtained at 2:25 PM on 7/31/12 to admit Patient #4 to the medical floor for observation. Orders included an IV, water as requested, Demerol IV for pain, Ativan IV for anxiety, and Zofran IV for nausea. Orders for oxygen were not present.

Patient #4's Clinical Documentation Report, dated 7/31/12 at 2:30 PM, stated she was transferred to the medical floor. Nursing notes on 7/31/12, between 2:30 PM and 8:15 PM, did not document Patient #4 received oxygen. At 8:35 PM on 7/31/12, the LPN documented Patient #4 removed her oxygen because it was "bothering me" and the oxygen was discontinued. At 10:12 PM on 7/31/12, the LPN documented Patient #4's oxygen saturation level dropped to 79%. Patient #4 was placed on oxygen at 3 liters per minute. At 12:30 AM on 7/31/12, the LPN documented Patient #4 was receiving oxygen at 1.5 liters per minute. At 12:58 AM on 7/31/12, the LPN documented speaking to Patient #4's physician. Orders were obtained for an antibiotic and morning laboratory and X-ray tests. No orders for oxygen were obtained. At 1:38 AM on 7/31/12, the LPN documented Patient #4's oxygen saturation level was 87% on 3 liters of oxygen. The note stated Patient #4's oxygen was increased to 4 liters per minute. A nursing note by the LPN, on 8/01/12 at 2:30 AM, stated Patient #4's oxygen was increased to 4 liters per minute via nasal cannula. At 4:10 AM on 8/01/12, nursing notes stated Patient #4 suffered cardiopulmonary arrest.

The Director of Quality reviewed Patient #4's medical record with the surveyors on 8/29/12 beginning at 2:05 PM. She confirmed orders for oxygen were not present in the medical record.

Nursing staff applied and adjusted Patient #4's oxygen without a physician order.

2. As noted above, Patient #4's medical record documented she was transferred to the medical floor at 2:30 PM on 7/31/12. Nursing notes documented Patient #4 complained of pain rated 10 of 10 on 7/31/12 at 3:00 PM, 3:15 PM, 5:22 PM, and 10:17 PM. Nursing notes on 7/31/12 documented Patient #4 vomited at 3:45 PM, was dry heaving at 4:00 PM, and complained of nausea at 8:15 PM. Nursing notes on 8/01/12 documented Patient #4 was spitting into an emesis bag and complaining of nausea at 12:10 AM.

Nursing notes, on 7/31/12 at 4:31 PM, documented Patient #4 did not have energy to ambulate. At 8:15 PM on 7/31/12, the LPN documented Patient #4 was assisted to stand but became dizzy and had to sit down. The note stated she was not able to ambulate to the bathroom and required a bedside commode. At 8:58 PM on 7/31/12, the LPN documented Patient #4 required assistance to ambulate.

No documentation was present stating the physician was notified of Patient #4's continuing nausea or her difficulty ambulating. At 12:58 AM on 8/01/12, the LPN documented the physician called the hospital. The note stated the physician was "Informed of pt's current condition" and orders were obtained. The note did not state specifically what symptoms the physician was informed of.

At 2:30 AM on 8/01/12, the LPN documented Patient #4's oxygen saturation levels dropped to the low 80s. Again, the physician was not informed of Patient #4's change in condition.

The LPN who care for Patient #4 was interviewed on 8/28/12 beginning at 2:40 PM. She stated Patient #4's physician called the hospital at 12:58 AM on 8/01/12. She stated she was attempting to call the physician at the time. However, she stated a nurse did not contact the physician from 7:00 PM on 7/31/12 until 4:10 AM on 8/01/12 when Patient #4 arrested. She stated she did not request the physician to come and examine Patient #4.

Patient #4's physician was interviewed on 8/28/12 beginning at 1:55 PM. He stated the LPN did not inform him of Patient #4's low oxygen saturation levels when he spoke to her by phone at 12:58 AM on 8/01/12. He stated the LPN sounded like Patient #4 was doing better.

Nurses failed to notify the physician of Patient #4's deteriorating condition.

3. Patient #4's "Clinical Documentation Report," dated 7/31/12 from 2:30 PM through 8/01/12 at 12:30 AM, documented her abdomen was firm and/or distended 5 different times. No documentation was present that nursing staff measured her abdomen in order to determine whether it was increasing in size.

The Director of Quality was interviewed on 8/30/12 beginning at 10:30 AM. She confirmed Patient #4's abdominal girth was not measured.

Nurses failed to measure Patient #4's abdominal girth.

Based on staff interview and review of medical records, it was determined the CAH failed to ensure an RN provided nursing care for 1 of 5 patients (#4) whose records were reviewed for care following a procedure. This resulted in a lack of assessment and oversight of patient care. Findings include:

1. Patient #4's medical record documented a 61 year old female who had upper gastrointestinal endoscopy with biopsy and colonoscopy with biopsy performed on 7/31/12. The procedures ended at 12:36 PM and she was taken to the recovery area. Patient #4 did not recover sufficiently to be discharged from same day surgery. A telephone order was obtained at 2:25 PM on 7/31/12 to admit Patient #4 to the medical floor for observation. Orders included an IV, water as requested, Demerol IV for pain, Ativan IV for anxiety, and Zofran IV for nausea.

Patient #4's Clinical Documentation Report noted the day shift RN cared for Patient #4 during that shift. The final progress note by the day shift RN was documented at 7:45 PM on 7/31/12.

Between 7:45 PM on 7/31/12 and 4:10 AM on 8/01/12, when Patient #4 suffered cardiopulmonary arrest, the RN documented 2 progress notes. The first note was dated 7/31/12 at 8:58 AM. It documented diminished lung sounds bilaterally and noted bowel tones in all 4 quadrants. The note stated Patient #4 required assistance to ambulate. The other progress note by the RN was dated 7/31/12 at 10:17 PM. It documented medicating Patient #4 with Demerol for pain which was rated at 10 of 10. No assessment of Patient #4's condition was documented at this time. No further assessment of Patient #4's condition by the RN was documented until 4:10 AM on 8/01/12.

At 10:12 PM on 7/31/12, the LPN documented Patient #4's oxygen saturation level dropped from 94% at 8:35 PM to 79%. Even though the RN medicated the patient 5 minutes later, no assessment of her condition by the RN was documented. The LPN documented speaking with the physician at 12:58 AM on 8/01/12. No documentation was present that the RN spoke to the physician or informed him of her opinion regarding Patient #4's condition. The LPN documented Patient #4's oxygen saturation level was 87% on 3 liters of oxygen at 1:38 AM and the level was in the low 80s at 2:30 AM on 8/01/12. No documentation of an assessment of Patient #4's condition or notification of the physician by the RN was present at these times.

The night shift RN was interviewed on 8/28/12 beginning at 3:20 PM. She confirmed the lack of RN documentation and stated she did not speak with the physician prior to Patient #4's cardiopulmonary arrest.

The RN failed to evaluate Patient #4 and to notify the physician of her condition.

Based on staff interview and review of medical records, it was determined the CAH failed to ensure a nursing care plan was developed for 1 of 5 in-patients (#9) whose records were reviewed. This resulted in a lack of direction to nursing staff caring for patients. Findings include:

Patient #9's medical record documented a 36 year old female who was admitted to the facility on 7/31/12 at 5:57 PM. The "HISTORY AND PHYSICAL,"dated 7/31/12, documented Patient #9 was admitted for an emergent Caesarean section (surgical procedure used to deliver a baby) secondary to severe pre-eclampsia (high blood pressure and excess protein in the urine after 20 weeks of pregnancy in a woman who previously had a normal blood pressure) and fetal distress. The "OPERATIVE CARE RECORD" documented Patient #9 underwent surgery on 7/31/12, from 6:03 PM to 7:26 PM, when Patient #9 was transferred to the post-anesthesia care unit. The infant was transferred to a neonatal intensive care unit in a nearby town. From the post-anesthesia care unit, Patient #9 was transferred to the medical/surgical floor at approximately 9:11 PM, where she remained until she was discharged on 8/03/12 at 11:54 AM. There was no nursing plan of care found in Patient #9's medical record to provide direction for nursing staff who cared for Patient #9 during her 3 day post-operative hospital stay.

The Director of Quality reviewed Patient #4's medical record with the surveyors on 8/30/12 beginning at 10:30 AM. She confirmed a nursing plan of care had not been developed for Patient #9.

Nursing staff did not develop a plan of care for Patient #9.