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The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program.

This CONDITION is not met as evidenced by: An Immediate Jeopardy (IJ) was identified beginning on 02/04/2023.

Based on review of medical records, review of hospital policy and procedures, and staff interviews, it was determined the facility failed to ensure an established facility committee that analyzed patient mortality, identified a potential cause or delay in care and failed to implement immediate corrective actions for the care and treatment of Patient #3. (See A0286)

The cumulative effect of these systemic problems resulted in the facility's inability to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program as required by the CFR 482.21, QAPI.

On 03/22/2023 the hospital submitted an acceptable removal plan for the Immediate Jeopardy deficiencies and an on-site survey was conducted on 03/22/2023 to evaluate the implementation of the removal plan. The hospital alleged Immediate Jeopardy removal on 03/22/2023 for the Condition of Participation (CoP) for QAPI. The facility immediacy removal plan for the Immediate Jeopardy was found removed at the conclusion of the survey on 03/22/2023 at 6:00 PM, per the dates the hospital alleged. The hospital provided evidence of removal of immediacy which included educating all staff, data summary of analysis, actions and analytics to be presented to Quality and Performance Improvement (QAPI) committees to ensure process improvements. The QAPI staff were reeducated while on site. Interviews conducted post implementation revealed QAPI staff were able to speak of the new education, confirming completion of removal actions and understanding of future actions of the QAPI to be implemented when similar situations occur in the future.
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Based on review of medical records, review of hospital policy and procedures, and staff interviews, it was determined the facility failed to ensure an established facility committee that analyzed patient mortality, identified a potential cause or delay in care and failed to implement an immediate corrective action related to Patient #3 (P#3).

The findings include:

1. Medical record review for Patient #3 revealed the patient presented to the Emergency Department (ED) via ambulance on 02/04/23 at 5:12 AM for a trauma alert related to a fall at home. On 02/04/23 a Computerized Tomography (CT) of the hip/lumbar was completed while in the ED which revealed no acute osseous (tissue that gives strength and structure to bones) abnormality. Patient #3 was seen in the ED two days prior to this visit related to broken ribs. Patient #3 had vital signs checked while in the ED on 02/04/23. He became tachycardic and oxygen saturation (SpO2) dropped below 92% prior to transfer. Oxygen saturation levels were documented on 02/04/23 at 11:40 AM at 91%; 1:00 PM at 92%; and 5:30 PM at 88% The ED Registered Nurse (RN) (Employee A) failed to notify the physician of the change in condition. On 02/04/23 at 7:14 PM a physician order was placed to notify physician of SpO2 less than 92%. Patient #3 was transferred out of the ED and admitted to Orthopedic Unit 4 South on 02/04/23 at 7:15 PM.

Upon arrival to 4 South, P#3 was tachycardic and had an SpO2 level of 85%. Additional oxygen saturation levels were documented at 7:30 PM, 90%; 9:44 PM, 85%; and 11:22 PM at 82%. A physician was not notified of the change in condition. On 02/05/23 at 12:30 AM, P#3's family member notified the primary RN (Employee B) that the patient vomited what looked like coffee grounds. Per documentation, the physician was not notified of this change in condition. On 02/05/23 at 2:38 AM Employee B entered P#3's room and discovered him unresponsive. She called a code blue and initiated Cardiopulmonary Resuscitation (CPR). The code efforts were unsuccessful. Patient #3 expired on 02/05/23 at 2:54 AM. Review of documentation revealed the abnormal vital signs were not reassessed and a physician was not notified. An adverse event was submitted to the Agency for Health Care Administration on 02/21/23. The facility failed to develop an immediate plan of correction related to the incident.

2. On 03/21/23 at 3:00 PM an interview was conducted with the Director of Risk Management, RN. She confirmed that there was not any immediate action put into place after the incident. She stated that she had 45 days to implement a plan of correction.

3. On 03/22/23 at 9:45 AM an interview was conducted with the Director of Quality. He confirmed that a Performance Improvement Specialist was not assigned to the event until 03/10/23. He confirmed no immediate action was put into place after the incident.
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The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse.

This CONDITION is not met as evidenced by: An Immediate Jeopardy (IJ) was identified beginning on 02/04/2023.

Based on review of medical records, review of hospital policy and procedures, and staff interviews, it was determined the facility failed to evaluate patients on an ongoing basis in accordance with accepted standards of nursing practice, and ensure physician notification of abnormal vital signs, including oxygen saturation, for 3 (P#3, P#4, P#5) out of 6 sampled patients. (see A0395)

The cumulative effect of these systemic problems resulted in the facility's inability to provide care in accordance with accepted standards of nursing practice as required by the CFR 482.23, Nursing Services.

On 03/22/2023 the hospital submitted an acceptable removal plan for the Immediate Jeopardy deficiencies and an on-site survey was conducted on 03/22/2023 to evaluate the implementation of the removal plan. The hospital alleged Immediate Jeopardy removal on 03/22/2023 for the Condition of Participation (CoP) for Nursing Services. The facility immediacy removal plan for the Immediate Jeopardy was found removed at the conclusion of the survey on 03/22/2023 at 6:00 PM, per the dates the hospital alleged. The hospital provided evidence of removal of immediacy which included educating all nursing staff to report abnormal vital signs within 30 minutes. The nursing staff reeducation was initiated while on site. A review of the sign-in sheets revealed 71 nursing staff signatures completed while on site. Interviews conducted post implementation revealed nursing staff were able to speak of the new education, confirming completion of removal actions and understanding of future actions of the nursing staff will be implemented when similar situations occur in the future.

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Based on review of medical records, review of hospital policy and procedures, and staff interviews, it was determined the facility failed to evaluate patients on an ongoing basis in accordance with accepted standards of nursing practice, and ensure physician notification of abnormal vital signs, including oxygen saturation, for 3 (P#3, P#4, P#5) out of 6 sampled patients.

The findings include:

1. Medical record review for Patient #3 revealed the patient presented to the Emergency Department (ED) via ambulance on 02/04/23 at 5:12 AM for a trauma alert related to a fall at home. On 02/04/23 a Computerized Tomography (CT) of the hip/lumbar was completed while in the ED which revealed no acute osseous (tissue that gives strength and structure to bones) abnormality. Patient #3 was seen in the ED two days prior to this visit related to broken ribs. Patient #3 had vital signs checked while in the ED on 02/04/23. He became tachycardic and oxygen saturation (SpO2) dropped below 92% prior to transfer. Oxygen saturation levels were documented on 02/04/23 at 11:40 AM at 91%; 1:00 PM at 92%; and 5:30 PM at 88% The ED Registered Nurse (RN) (Employee A) failed to notify the physician of the change in condition. On 02/04/23 at 7:14 PM a physician order was placed to notify physician of SpO2 less than 92%. Patient #3 was transferred out of the ED and admitted to Orthopedic Unit 4 South on 02/04/23 at 7:15 PM.

Upon arrival to 4 South, P#3 was tachycardic and had an SpO2 level of 85%. Additional oxygen saturation levels were documented at 7:30 PM, 90%; 9:44 PM, 85%; and 11:22 PM at 82%. A physician was not notified of the change in condition. On 02/05/23 at 12:30 AM, P#3's family member notified the primary RN (Employee B) that the patient vomited what looked like coffee grounds. Per documentation, the physician was not notified of this change in condition. On 02/05/23 at 2:38 AM Employee B entered P#3's room and discovered him unresponsive. She called a code blue and initiated Cardiopulmonary Resuscitation (CPR). The code efforts were unsuccessful. Patient #3 expired on 02/05/23 at 2:54 AM. Review of documentation revealed the abnormal vital signs were not reassessed and a physician was not notified. An adverse event was submitted to the Agency for Health Care Administration on 02/21/23.

2. Medical record review for Patient #4 revealed the patient presented to the Emergency Department via personal vehicle on 12/31/22 at 4:03 PM due to bilateral leg swelling, and hypertension (High Blood Pressure). He was admitted to the Medical Intensive Care Unit with an admitting diagnosis of Acute Renal Failure (ARF) on 12/31/22 at 6:53 PM. On 03/21/23 the patient was on 4 South as a current patient. Review of vital sign documentation revealed six abnormal vital signs, in red with an exclamation mark. Although Patient #4 had no medical decline, there was no documentation to indicate a physician was notified or that the patient was reassessed by the RN.

3. Medical record review for Patient #5 revealed the patient presented to the Emergency Department via personal vehicle on 03/13/23 at 1:15 PM due to a cough and dizziness. She was admitted to 4 South on 03/13/23 at 5:54 PM, with an admitted diagnosis of stage IV Lymphoma. On 03/21/23 the patient was a current patient on 4 South. Review of vital sign documentation revealed five abnormal vital signs, in red with an exclamation mark. Although Patient #5 had no medical decline, there was no documentation to indicate a physician was notified or that the patient was reassessed by the RN.

On 03/21/23 at 11:00 AM an interview was conducted with the Director of Risk Management, RN. She confirmed non-compliance with reporting of abnormal vital signs to a physician, and no nursing reassessment was present for Patient #3.

On 03/21/23 at 4:00 PM an interview was conducted with the Risk Specialist, RN. She confirmed Patient #4 and Patient #5 had abnormal vital signs that were not documented as being reported to a physician and no indication that a reassessment was conducted.

On 03/21/23 at 4:45 PM an interview was conducted with Employee A, Registered Nurse, Emergency Department. He was familiar with P#3. He stated he was unable to recall any information related to the care provided. He confirmed that vital signs are monitored on all patients that go into the ED. The vital signs include oxygen saturation levels. He confirmed that abnormal vital signs are required to be reported to a physician and the vital signs need to be reassessed as well.

On 03/22/23 at 9:10 AM an interview was conducted with Employee B, Registered Nurse, Orthopedics. She was familiar with Patient #3. She was assigned P#3 on 02/04/23. She works the night shift from 7:00 PM to 7:00 AM. She confirmed that P#3 had abnormal vital signs including hypertension and low oxygen saturation of 85%. She stated that abnormal vital signs are required to be reported to the physician and that a reassessment was also required. She confirmed that she did not notify the physician or reassess P#3. She stated that she was conducting morning rounds on 02/05/23 and discovered P#3 was unresponsive and she called a code blue at 2:38 AM. She stated the code blue was unsuccessful and the patient expired.

On 03/22/23 at 10:15 AM an interview was conducted with the Trauma Medical Director. He was very familiar with Patient #3. He stated that he was on call in the hospital the night of 02/04/23. He confirmed that he was never notified by the ED RN or the 4 South RN regarding abnormal vital signs. It is his expectation and hospital policy that physicians are notified of abnormal vital signs. He stated the trauma team conducted a review of the case and their findings included the lack of reporting change in condition to the physician, abnormal vital signs, and nursing failure to recognize/rescue. He stated that if he was made aware of the change in vital signed prior to the patient leaving the ED, he would have admitted the patient to a higher level of care.

On 03/21/23 at 11:15 AM a request for a policy related to abnormal vital signs was made with the Director of Risk Management. She stated the facility did not have a policy regarding abnormal vital signs. She stated that nursing is required to report vital signs outside of normal range, or per physician orders, to a physician and that a nursing reassessment was required.

A review of the facility's Policy and Procedure titled "Patient Assessment/Reassessment" with a last update of 03/2023 was conducted. On page three, F, stated all patients will be reassessed a minimum of every shift, whenever there are changes in a patient condition and/or diagnosis, and to determine the patient's response to intervention. Nursing reassessment will be documented in the Electronic Medical Record (EMR).
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