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Based on record review and interview, the hospital failed to ensure accountability of the medical staff for the quality of care provided to patients. The deficient practice is evidenced by failure of the admitting physician to order care based on the admitting diagnosis in 1 (#1) of 3 (#1-#3) reviewed medical records.
Findings:

Review of the medical record for Patient #1 revealed the patient presented to the emergency department on 08/11/2024 after falling twice due to dizziness. The patient reported a productive cough for 2 weeks and was positive for COVID-19. Computed tomography of the chest revealed "nonspecific patchy ground glass opacity in the right lung apex." Further review of the medical record revealed the patient was a smoker with a history of chronic obstructive pulmonary disease and obstructive sleep apnea. The patient had been prescribed home oxygen therapy, but was noncompliant secondary to financial constraints. Supplemental oxygen at 4 liters/ minute was required in the emergency department to maintain oxygen saturation above 90%. The patient was admitted to the hospital with a diagnosis of hypoxia.

Review of the history and physical documented by S9MD revealed in the physician's plan included: "1. Hypoxia: admit to tele, oxygen, cardiac monitor, symptomatic management. 2. COPD exacerbation: bronchodilator, steroid, breathing treatment, prophylactic antibiotic use. 3. Covid 19 positive: steroid and supportive care, consult pulmonary for further evaluation and management. . . ."

Review of the admission orders for Patient #1 failed to reveal an order for supplemental oxygen, bronchodilators, breathing treatments, antibiotics or antivirals, pulse oximetry, telemetry or other cardiac monitoring. Further review also revealed S9MD failed to set parameters for notification if the oxygen saturation could not be maintained at an acceptable level.

Review of the medical record revealed Patient #1 was transferred out of the emergency department and into a room on 08/12/2024 at 1:52 a.m. Review of the medical record failed to reveal documentation the patient received supplemental oxygen between 2:00 a.m. and 9:00 a.m. Oxygen saturation was documented only once at 4:00 a.m. in red as 84%. There were no documented interventions and no documentation the physician was notified.

Review of the nursing notes for Patient #1 revealed on 08/12/2024 at 9:01 a.m, S8RN documented "'S10DO' notified that pt was sating 87% on 4L O2. MD stated to pump pt up to 5L with a goal to keep pt above 90%." On 08/12/2024 at 9:08 a.m. S8RN documented, "'S10DO' notified that pt's O2 only came up to 88-89%. RN requested breathing treatments for pt. MD ordered breathing treatments and respiratory called to give patient PRN treatment."

Review of the orders for Patient #1 revealed on 08/12/2024 at 9:22 a.m. continuous pulse oximetry was ordered.

Further review of the record revealed Patient #1 was noted to decompensate throughout the morning of 08/12/2024. An arterial blood gas was collected on 08/12/2024 at 2:48 p.m. and revealed the arterial pH was 7.31, arterial pCO2 was 70, arterial O2 was 69, arterial HCO3 was 35, base excess was 6.6, and arterial O2Hb was 91.2. Patient #1 was transferred to a higher level of care for telemetry monitoring and placed on bilevel positive airway pressure (BiPAP) that evening.

In interview on 08/21/2024 between 10:21 a.m. and 10:27 a.m., S8RN verified she was the nurse for the day shift on 08/12/2024. S8RN verified the patient was on supplemental oxygen at 4 liters/ minute when she arrived for her shift but was not sure when it was initiated and did not know if the patient was on supplemental oxygen at 4:00 a.m. when the oxygen saturation was documented as 84%.

During the record review on 08/20/2024 between 12:35 p.m. and 2:25 p.m., S4RN verified the admission orders did not contain orders for supplemental oxygen or breathing treatments. S4RN also verified there were no orders for continuous pulse oximetry and there were no orders to call the physician if the oxygen saturations fell below an acceptable level.

In interview on 08/20/2024 at 2:02 p.m., S2SDQ and S3DQ verified there were no set parameters for nursing staff to contact the physician for abnormal vital signs on the unit where the patient was placed.

Based on record review and interview, the hospital failed to comply with the documented directives of the patient and patient's family. The deficient practice is evidenced by the initiation of resuscitative interventions in 1 (#2) of 1 reviewed medical record of a patient with a documented do not resuscitate/ do not intubate (DNR/ DNI) order.
Findings:

Review of Policy 15993403, "UHS Code Blue," last revised 07/2024, revealed in part, "Policy: I.B.1. Code Blue will not be called for patients who have "Do Not Resuscitate" orders or other physician orders restricting lifesaving steps pursuant to a patient's Advanced Directive. Resuscitation is not initiated in these situations."

Review of the medical record for Patient #2 revealed admission on 07/14/2024 with a diagnosis of acute on chronic respiratory failure.

Review of the physician's orders revealed DNR/DNI orders were initiated on 07/15/2024 at 11:16 a.m.

Review of an incident report submitted on 07/16/2024 at 4:05 a.m. revealed on 07/16/2024 at 2:16 a.m. the patient was found down, supine on the hallway floor. Code Blue was called at 2:14 a.m.

Review of the medical record revealed on 07/16/2024 at 2:16 a.m. S11RN documented the patient was nonresponsive with no pulse and no respirations and compressions were initiated. At 2:19 a.m. an intraosseous line was placed in the left proximal tibia and compressions were paused for a pulse check and then resumed. At 2:20 a.m., epinephrine 1 milligram was given via the intraosseous line. Compressions continued and 2:22 a.m. the patient was intubated. The code ended at 2:23 a.m. when the medical staff realized the patient had a DNR/DNI order.

In interview on 08/21/2024 at 9:10 a.m., S5RN verified the hospital staff initiated resuscitative efforts including intubation despite the patient/ patient's family's documented refusal of the interventions.

Based on record review and interview, nursing staff failed to initiate restraints according to hospital policy. The deficient practice is evidenced by failure of the nursing staff to notify the family of the need for the use of non-violent restraints in 1 (#1) of 1 reviewed records where restraints were used.
Findings:

Review of Policy #14929767, "LCMC Restraints and Seclusion,: last revised 01/2024, revealed in part, " Section III: Criteria for Restraint or Seclusion Use . . . B. Restraints are implemented in the least restrictive manner possible and are ended at the earliest possible time. When practical, restraint use is discussed with the patient and, when appropriate, with the patient's family around the time of restraint application." And "Section XI: Application of Restrained and/or Seclusion . . . C. Trained and competent staff members do the following: . . . 6. Explain the following to the patient and/or his or her family, as appropriate: i. Procedure to be used; ii. Reason for procedure; iii. Behavioral criteria for release. 7. Allow the patient and/or family to participate in the patient's care as appropriate."

Review of the medical record for Patient #1 revealed admission on 08/12/2024 with a diagnosis of hypoxia. The patient had fallen twice at home and the family tried to transport her to the hospital, but was unable to get her into the car because of ankle pain. Emergency medical services was called to the home for lift assistance and then transported the patient to the emergency department. Documentation revealed the daughter of Patient #1 was present in the emergency department and provided staff with information about her mother's medical history.

Further review of the medical record revealed the oxygen requirements for Patient #1 increased and the patient became less responsive after hospitalization. The patient was transferred to a higher level of care and BiPAP was required to maintain her oxygen saturation above 90%.

Review of the orders revealed on 08/14/2024 at 11:45 p.m., soft restraints were initiated to prevent the patient from pulling lines and removing her oxygen. Further review of the record failed to reveal any attempts to notify the family and explain the events that lead to the use of restraints. The restraints were removed on 08/15/2024 at 10:08 a.m.

In interview on 08/20/2024 at 2:19 p.m., S3DQ verified there was no documentation of attempts to notify the family.

Based on record review and interview, the Registered Nurse failed to ensure care was provided as ordered by the physician. The deficient practice is evidenced by 1) failure of nursing staff to document vital signs as ordered in 2 (#1, #2) of 3 (#1-#3) reviewed medical records; and 2) failure of nursing staff to document accurate intake and output every shift as ordered in 1 (#1) of 1 reviewed medical record of a patient with orders for intake and output.
Findings:

1) Failure of nursing staff to document vital signs as ordered.

Patient #1
Review of the medical record for Patient #1 revealed admission on 08/12/2024 with a diagnosis of hypoxia.

Review of the orders for Patient #1 revealed vital signs were to be documented every 4 hours.

Review of the medical record revealed the following:
4:07 a.m.- Temperature 98.7 degrees Fahrenheit; Pulse- 88; Respirations-18; Blood Pressure- 138/71; Oxygen saturation 84%.
9:13 a.m.- Temperature- 98.4 degrees Fahrenheit; Pulse- 74; Respirations- 18; Blood Pressure 117/67; Oxygen saturation- 89% on 5 liter/ minute via nasal cannula.

In interview on 08/20/2024, 2:11 p.m., S3DQ verified the vital signs were not documented every 4 hours.

Patient #2
Review of the medical record for Patient #2 revealed admission on 07/14/2024 with a diagnosis of acute on chronic respiratory failure.

Review of the admission orders revealed vital signs were to be documented every 4 hours.

Review of the medical record for the 7 a.m. to 7 p.m. shift for 07/15/2024 revealed the last documentation of complete vital signs at 5:25 p.m. Review of the 7 p.m. - 7a.m. shift for 07/15/2024 revealed the nursing staff documented the following:
8:00 p.m. - Pulse-102, Respirations-24; Cardiac Rhythm - normal sinus rhythm; oxygen saturation- 93%.
8:32 p.m. - Pulse-84; Cardiac Rhythm- normal sinus rhythm.
11:08 p.m. - Pulse -83; Respirations- 20; Blood Pressure 123/76; mean arterial pressure- 91; oxygen saturation - 95%.

In interview on 08/20/2024 at 2:49 p.m., S3DQ verified the nurse failed to document the blood pressure every 4 hours as ordered.

2) Failure of nursing staff to document accurate intake and output every shift as ordered.

Review of the medical record for Patient #1 revealed admission on 08/12/2024 with a diagnosis of hypoxia.

Review of the admission orders from 08/12/2024 at 12:57 a.m. for Patient #1 revealed intake and output were to be documented every shift.

Review of the flow sheet for Patient #1 revealed on 08/12/2024 intake was first recorded as 0 from 8:01 a.m. through 9:00 a.m. On 08/12/2024 between 10:01 a.m. and 1:00 p.m. intake was recorded as 120 milliliters and output was recorded as 700 milliliters.

In interview on 08/21/2024 at 9:26 a.m., S4RN verified intake and output were not recorded by nursing staff for 8 hours during the first shift after the order was placed.

Based on record review and interview, the nursing staff failed to ensure the nursing care plan reflected the patient's goals and nursing care to be provided. The deficient practice is evidenced by failure of the nursing staff to include significant acute and chronic conditions in the plan of care.
Findings:

Patient #1
Review of the medical record for Patient #1 revealed admission on 08/12/2024 with a diagnosis of hypoxia. At the time of admission the patient had a positive test for COVID-19 and a history of chronic obstructive pulmonary disease and obstructive sleep apnea.

Review of the nursing care plan failed to reveal any care related to her respiratory conditions.

In interview on 08/20/2024 at 2:09 p.m., S3DQ verified the care plan did not include care related to her respiratory illnesses or infection control care related to the positive COVID test.

Patient #2
Review of the medical record for Patient #2 revealed admission on 07/14/2024 with a diagnosis of acute on chronic respiratory failure. Review of the medical history revealed the patient had a history of deep vein thrombosis and was on anticoagulants at the time of admission.

Review of the nursing care plan failed to reveal care related to her history of thrombosis and use of anticoagulants.

In interview on 08/20/2024 at 2:54 p.m., S3DQ verified there was nothing in the care plan related to her history of deep vein thrombosis or anticoagulation.

Based on record review and interview, the Director of Nursing failed to ensure contract staff adhered to hospital policies. The deficient practice is evidenced by failure of an agency nurse to follow hospital policies in 1 (#2) of 3(#1-#3) reviewed medical records.
Findings:

Review of Policy 15993403, "UHS Code Blue," last revised 07/2024, revealed in part, "Policy: I.B.1. Code Blue will not be called for patients who have "Do Not Resuscitate" orders or other physician orders restricting lifesaving steps pursuant to a patient's Advanced Directive. Resuscitation is not initiated in these situations."

Review of Policy Fund-13, "Post Mortem Process- Adult," revised 10/27/2021, revealed in part, "8. Documentation reflects pertinent facts including time and pronouncement of death including physician name, post mortem care, and time to morgue."

Review of the medical record for Patient #2 revealed admission on 07/14/2024 with a diagnosis of acute on chronic respiratory failure.

Review of the physician's orders revealed DNR/DNI orders were initiated on 07/15/2024 at 11:16 a.m.

Review of an incident report submitted on 07/16/2024 at 4:05 a.m. revealed on 07/16/2024 at 2:16 a.m. the patient was found down, supine on the hallway floor. Code Blue was called at 2:14 a.m.

Review of the medical record failed to reveal any description of the incident other than "found down, supine on the hallway floor" the Code Blue documentation.

Review of the Code Blue documentation revealed on 07/16/2024 at 2:16 a.m. S11RN documented the patient was nonresponsive with no pulse and no respirations and compressions were initiated. At 2:19 a.m. an intraosseous line was placed in the left proximal tibia and compressions were paused for a pulse check and then resumed. At 2:20 a.m., epinephrine 1 milligram was given via the intraosseous line. Compressions continued and 2:22 a.m. the patient was intubated. The code ended at 2:23 a.m. when the medical staff realized the patient had a DNR/DNI order.

Further review of the medical record failed to reveal documentation of the post mortem care that was provided.

In interview on 08/21/2024 at 9:03 a.m., S2SDQ verified S11RN was assigned to care for Patient #2 on the shift that she expired. S2SDQ verified S11RN was an agency nurse.

In interview on 08/21/2024 at 9:10 a.m., S5RN verified the hospital staff initiated resuscitative efforts including intubation despite the patient/ patient's family's documented refusal of the interventions.

In interview on 08/21/2024 at 9:44 a.m., S7RN verified the nurse did not document the specifics surrounding the patient having been found down and did not document the post mortem care provided. S7RN verified she spoke with S11RN at the end of the shift and asked her to complete the record, but S11RN did not.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered as ordered by the physician. The deficient practice is evidenced by failure of the nursing staff to provide additional interventions for pain relief after initial administration of the prescribed pain medication failed to relieve the patient of pain in 1 (#3) of 3(#1-#3) reviewed medical records.
Findings:

Review of the medical record for Patient #3 revealed the patient had a surgical procedure on 07/15/2024 and was admitted for overnight observation.

Review of the orders for Patient #3 revealed an order initiated on 07/15/2024 at 4:00 p.m. for oxycodone-acetaminophen 5-325 mg; Ordered Dose: 1 tablet; Route: Oral; Frequency: Every 4 hours PRN for Pain Score 4-7, Pain Score 8-10.

Review of the medical record revealed on 07/15/2024 at 4:08 p.m., Patient #3 reported 10/10 pain and was administered one oxycodone-acetaminophen tablet. Follow up pain assessment at 5:08 p.m. revealed patient reported the pain as 5/10. The patient's stated pain goal was 3/10. Further review of the medical record revealed the nurse did not document any further interventions and did not contact the physician for additional orders.

In interview on 08/21/2024 at 10:55 a.m., S4RN verified the nurse did not document any additional interventions to relieve Patient #3 of his pain and did not contact the physician for additional orders.

Based on record review and interview, the hospital failed to ensure verbal orders were documented according to hospital policy. The deficient practice is evidenced by verbal orders missing required documentation in 1 (#1) of 3 (#1-#3) reviewed medical records.
Findings:

Review of Policy #15690283, "UHS Physician/Provider Order Sources (Written, Verbal, Telephone, and Electronic)," last revised 06/2024 revealed in part, "Policy . . . IV.C. Verbal and telephone orders should first be electronically entered and the verified by reading back the information to the prescriber."

Review of Policy #14357448, "Oxygen Administration," last approved 11/2021, revealed in part, "oxygen orders should contain: * Modality *FIO2 and/or liter flow (whichever is applicable) *If order states "oxygen" or "oxygen protocol" and the patient is in an eligible area and meets criteria, oxygen will be managed per oxygen protocol from start."

Review of the medical record for Patient #1 revealed on 08/12/2024 at 9:01 a.m. S8RN documented "S11DO notified that pt was sating 87% on 4LO2. S11DO stated to pump pt up to 5L with a goal to keep pt above 90%."

Review of the orders for Patient #1 revealed on 08/12/2024 at 9:28 a.m. S8RN documented the following nursing communication: "Comments: Keep pt's O2 > 90%." There was no order for the oxygen.

In interview on 08/21/2024 between 10:21 a.m. and 10:27 a.m., S8RN verified the documented communication in the orders at 9:28 a.m. was for the verbal order for oxygen at 5 liters/minute that she had documented in her note at 9:01 a.m.