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Based on review of documents, review of the medical record for patient #1 and staff interviews it was revealed the facility failed to ensure nursing services was provided as per hospital policy and procedures. This failure has the potential for all patient's with a change of condition to not receive medical care. (see Tag 398).

A. Based on document review, review of the medical record for patient #1 and staff interviews it was revealed nursing failed to provide care according to nursing policies and procedures. Nursing failed to immediately notify the physician of a decline in a patient's condition and failed to notify the Nursing Supervisor of a significant change in the patient's condition. This failure was identified in one (1) of thirty (30) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed she was admitted to the hospital on 1/6/21 for shortness of breath and acute hypoxic respiratory failure. Patient #1 was admitted to the Medical Surgical unit on 1/6/21. She was alert and oriented to person, place and time. On 1/10/21 at 5:30 a.m. Personal Care Assistant #1 documented patient's vital signs, blood pressure 103/54, temp 96.2, pulse 64, respirations 17, O2 saturation of 90% and the patient was on thirteen (13) liters of oxygen (O2). There was no documentation by RN #2 that the physician was notified of the need to increase the O2 level for patient #1. No order for an increase in O2 was noted. Patient #1 was noted as on 4 liters of O2 at 9:20 p.m. on 1/9/21 and thirteen (13) liters of O2 on 1/10/21.

2. A telephone interview was conducted with RN #2 on 2/2/21 at 1:27 p.m. When asked about patient #1, she stated she took care of her after the fall. Her shift was 7:00 p.m. to 7:00 a.m. She stated she checked patient #1 right before 5:30 a.m. and she was mouth breathing. She stated she checked her O2 saturation and it was 80 %. She stated she had to take the patient's O2 level to thirteen (13) liters to get the O2 saturation to 90%. When asked if she called the physician she said, "No." She stated, "When I had seen the O2 SATs were low I checked her vital signs and increased the O2 until the O2 SATs came up."

3. A review of the policy titled "Notification of Nursing Supervisor," effective date 02/2019, stated in part: Notify the Nursing Supervisor with any unusual occurrence that happen, etc... Significant change in patient's condition."

4. A review of the policy titled "Nursing Guidelines for Notification of Physician," dated 04/2019, stated in part: THE FOLLOWING SITUATIONS WILL BE USED AS GUIDELINES FOR IMMEDIATE NOTIFICATION OF THE ATTENDING OR ON-CALL PHYSICIAN: Cyanosis or any respiratory distress or difficulty, etc...any deterioration of neuro status, sudden unresponsiveness."

3. A telephone interview was conducted with the Director of 4 South on 2/2/21 at 1:02 p.m. He concurred RN #2 did not call the physician immediately when the patient had a decline in condition and did not obtain a physician's order to increase the patient's O2 level.

B. Based on a review of the medical record for patient #1 and staff interviews it was revealed nursing failed to provide care according to nursing procedures and expectations of the facility due to nursing failed to provide care as per the physician's orders. This failure was identified in one (1) of thirty (30) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed she was admitted to the hospital on 1/6/21 for shortness of breath and acute hypoxic respiratory failure. Patient #1 was admitted to the Medical Surgical unit on 1/6/21. She was alert and oriented to person, place and time. On 1/10/21 at 5:30 a.m. Personal Care Assistant #1 documented the patient's vital signs, blood pressure 103/54, temp 96.2, pulse 64, respirations 17, O2 saturation of 90% and the patient was on thirteen (13) liters of oxygen (O2). There was no documentation by RN #2 that the physician was notified of the need to increase the O2 level for patient #1. No order for an increase in O2 was noted. Patient #1 was noted as on 4 liters of O2 at 9:20 p.m. on 1/9/21 and thirteen (13) liters of O2 on 1/10/21. On 1/17/21 an order for a computed tomography (CT) scan was ordered by the physician. It stated, "CT BRAIN WO CONTRAST, order source: TORV/RB." The order was signed by the physician on 1/17/21 at 1:37 p.m. The order was never completed. The order was canceled on 1/19/21 at 5:51 a.m. Patient #1 died on 1/19/21 at 2:23 a.m.

An order for a chest x-ray on 1/18/21 stated, "RAD PORTABLE CHEST AP/PA ONLY, order source: EPOM." The order was signed by the physician on 1/18/21 at 7:53 a.m. The order was never completed. The order was canceled on 1/19/21 at 5:47 a.m. after the death of patient #1.

2. A telephone interview was conducted with RN #1 on 2/2/21 at 10:54 a.m. When asked why patient #1 never got her CT scan that was ordered on 1/17/21, she stated they have to wait on respiratory to come to the unit and assist taking a patient on a ventilator to have a CT scan. She stated she never heard from respiratory. She stated she left at 8:00 p.m. that day and respiratory left at 6:00 p.m. She stated she put in the order for the CT scan and notified respiratory.

3. A telephone interview was conducted with the Director of Risk and Quality Management on 2/2/21 at 11:10 a.m. When asked if respiratory gets the order when nursing contacts them for assistance with a patient to a CT scan he stated, "No." He noted if the nursing staff needed assistance and respiratory did not respond then it is the nurse's responsibility to ensure all physician's orders are carried out. He stated nursing should have called respiratory again.

4. A telephone interview was conducted with RN #3 on 2/2/21 at 11:16 a.m. The Director of the Critical Care Unit (CCU) was also on the interview. She stated she was taking care of the patient the morning of January 18th. She stated she did not take her down to the CT scan due to the patient being so unstable. Her BP was unstable. She stated the physician was at her bedside and they were discussing her BP. She stated, " I did not say to the physician I wasn't taking her down to the CT scan, but the physician knew."

5. A telephone interview was conducted with the CCU physician on 2/2/21 at 11:30 a.m. When asked about patient #1, he stated he took over her care when she was transferred to the CCU. When asked why the CT scan was never completed, he stated he did not know.

6. A telephone interview was conducted with RN #2 on 2/2/21 at 1:27 p.m. When asked about patient #1, she stated she took care of her after the fall. Her shift was 7:00 p.m. to 7:00 a.m. She stated she checked patient #1 right before 5:30 a.m. and she was mouth breathing. She stated she checked her O2 saturation and it was 80 %. She stated she had to take the patient's O2 level to thirteen (13) liters to get the O2 saturation to 90%. When asked if she called the physician she said, "No." She stated, "When I had seen the O2 SATs were low I checked her vital signs and increased the O2 until the O2 SATs came up."

7. A telephone interview was conducted with the Director of 4 South on 2/2/21 at 11:02 p.m. When asked about the O2 level being increased by the nurse, he stated the patient was put on five (5) liters of O2 in the emergency department. He stated they have an O2 protocol that the physician's ordered allow respiratory to adjust the O2 when needed. He stated the O2 protocol was not ordered for the patient. When asked what his expectation for the nursing staff when a patient needs to have an increase in O2, he stated all nurses are to call the physicians and respiratory therapy should have the O2 protocol so increases to O2 is as needed. He concurred there is no documentation the nurse called the physician when she increased the O2 level for the patient.

8. A telephone interview was conducted with the Chief Nursing Officer (CNO) and the Director of Risk and Quality on 2/3/21 at approximately 12:40 p.m. The CNO stated there is no specific policy for nursing to follow physician's orders, it is the expectation of the facility and it is basic nursing care. They concurred the nursing staff did not follow the expectations of the facility.