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Based on review of medical records, review of facility policy, and staff interview it was determined the facility failed to ensure a registered nurse evaluated the patient's needs for one (#2) of four patients sampled.

Findings included:

Review of the facility policy, "Care Coordination and Discharge Planning", states (15)(b) significant changes or significant deterioration in the patient's condition will initiate the facility's Rapid Response Process; (e) the nurse will document change of condition, notification and interventions in the medical record.

Review of the medical record for patient #2 revealed the patient was admitted to the facility on 5/19/2018. Review of the physician orders, dated 6/6/2018 at 5:37 a.m., revealed a telephone order was obtained for a stat ABG (Arterial Blood Gas) and at 5:42 a.m., an order was obtained for Lasix 20 mg IV (Intravenous) stat. Review of the ABG results revealed critical laboratory values. Nursing documentation revealed the physician was called and provided with the ABG results at 5:45 a.m., and orders were provided to change the ventilation settings and repeat the ABG in the morning. Review of the nursing documentation revealed no evidence of the nurse's assessment of the patient or the patient's response.

Documentation revealed at 6:06 a.m., a call was placed to the physician to inform him the patient could not tolerate the change to the ventilator settings previously ordered, and new orders were obtained for the ventilator settings and to obtain an ABG in 1 hour. Documentation revealed the patient's vital signs were obtained at 6:05 a.m., and revealed blood pressure 92/54, pulse 120 bpm (beats per minute), and oxygen saturation 92%. Review of the Medication Administration Record (MAR) revealed Lasix 20 mg IV was administered at 6:15 am. Review of the medical record revealed a telemetry strip, dated 6/6/2018 at 7:00 a.m., which revealed the patient's blood pressure was 85/43, pulse 102 bpm, and oxygen saturation was 88%.

Review of the nursing documentation, dated 6/6/2018 at 7:36 a.m.,, stated the patient was hypertensive (low blood pressure) with systolic pressure in the 60's and a stat telephone call was placed to the physician.

Review of the medical record revealed telemetry strips were placed in the chart. At 7:36 a.m., the strip revealed the patient's blood pressure was 62/24, heart rate 47, respirations 24, and oxygen saturation 90%. At 7:39 a.m., the telemetry strip revealed the patient's blood pressure was 62/24, heart rate 44 and 4 seconds of apnea. At 7:40 am the telemetry strip revealed the patient's blood pressure was 62/24, heart rate 42, 4 seconds of apnea and respiratory rate 9. At 7:43 a.m., the telemetry strip revealed the patient's blood pressure was 62/24, heart rate 35, 28 seconds of apnea and respiratory rate 0. At 7:45 a.m., the telemetry strip revealed the patient's blood pressure was 62/24, heart rate 24, 6 seconds of apnea and respiratory rate 30. At 7:47 a.m., the telemetry strip revealed the patient's blood pressure was 62/32, heart rate 0, 6 seconds of apnea and respiratory rate 36.

Review of the code blue flowsheet, dated 6/6/2018, revealed at 7:49 a.m., the nurse initiated a code blue and ACLS (Advanced Cardiac Life Support) was performed until 8:05 a.m., when the code was ended and the patient expired.

Review of the medical record and interview with the Director of Education on 7/20/2018 at 10:45 a.m., confirmed nursing failed to document interventions and assessment of the patient with a change in condition on 6/6/2018 beginning at 5:37 a.m.