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Based on interview and record review, the Governing Body allowed the hospital to have no physician available immediately in the inpatient area. One of one postoperative day 1 inpatient (Patient #1) was progressively getting worst on 03/26/20 and did not receive a physician evaluation. There was no physician available immediately when inpatients were in distress, unless there were surgical procedures taking place in the Surgery Department. This had been going on since 10/18/18.
Cross Refer to Tag 0044

Based on interview and record review, the hospital's physician did not evaluate one of one patient (Patient #1) who voiced out multiple complaints during patient's postoperative day 1 on 03/26/20. Patient #1 was not seen by a physician to check on his progress. Patient #1's condition progressively worsened and subsequently expired on postoperative day 1 at 23:03 PM.

Findings included:

On 03/25/20 at 12:10 PM Patient #1 underwent "Thoracic Lumbar Laminectomy Post Fusion T10 - L4." The surgical procedure ended on 03/26/20 at 01:28 AM, after 13 hours and 18 minutes. The surgeon was performed by Physician #3. Patient #1 was admitted to the inpatient unit on 03/26/20 at 03:00 AM. History and Physical dated 03/25/20 indicated the patient had diabetes mellitus type 2, hypertension, and previous lumbar fusion.

On 03/26/20, the last surgical procedure ended at 1407. There was no physician physically present after the last surgical procedure. The hospital had a physician on call list. Physician #4 was on call on 03/26/20.

On 03/26/20 the following events happened:
03:00 AM - LVN (licensed vocational nurse) noted "the patient verbalized "tingling in left toes." Vital signs were as follows: temperature 98.1, pulse 115, respirations 18, blood pressure 108/70, oxygen saturation 95% on oxygen at 4 liters/minute via nasal cannula.

03:00 AM - RN (registered nurse) noted "tachy vital signs stable will continue to monitor."

0400 AM - Vital signs were as follows: temperature 98.7, pulse 112, respirations 18, blood pressure 97/53, oxygen saturation 96% on oxygen at 4 liters/minute via nasal cannula. Output from Foley was 200 ml.

04:38 AM - LVN noted "Patient vomited x 1..." Zofran 4 mg IV (intravenous) was administered at 04:55 AM.

05:00 AM - RT (respiratory therapist) noted "the patient vomited earlier" received anti-nausea medication.

06:30 AM - RN noted "heart rate (HR) 107."

07:30 AM - RN noted "Noted facial and periorbital edema, pt denies visual changes...Pt (patient) reports some tingling to left arm and hand, noted slight swelling...Pain back to 6/10 at present time..."

08:50 AM Vital signs were as follows: temperature 98.2, pulse 112, respirations 18, blood pressure 97/59, oxygen saturation 99% on oxygen at 2 liters/minute via nasal cannula. Output 200 ml.

09:30 AM - RN noted "Spoke with Physician #3, updated on pt.'s status...New orders given and noted..." New orders via telephone call were as follows "Change IVF (intravenous fluid) to NS (normal saline) at 125 ml/hr. Urine output increase, then reduce rate to 60 ml/hr. Increase Zofran to 8 mg IV every 6 hrs. as needed for nausea/vomiting (N/V). May give additional dose now."

09:40 AM - RN noted "talked with Physician #4, updating on pt's status...New orders given..." New orders via telephone call were as follows "Discontinue Morphine. Dilaudid 1 mg IV every 2 hrs. as needed for BTP (breakthrough pain). Give NS 1-liter bolus now...Repeat BMP (basic metabolic panel) at 1700 today. Hold PO (per oral) meds until N/V have subsided..."

12:12 PM Vital signs were as follows: temperature 96.5, pulse 102, respirations 20, blood pressure 96/67, oxygen saturation 99% on oxygen at 2 liters/minute via nasal cannula. Output from Foley 150 ml.

12:41 PM - LVN noted "Patient unable to stand, feeling week...Attempt to stand later today."

13:00 PM - LVN noted "Patient has N/V vomiting after attempting clear chicken broth. 400 ml. of clear yellow tinted emesis. Patient stated once he vomited nausea subsided."

14:00 PM - Physician #4 ordered via telephone call the following "Give NS 1 liter now. Medication clarification: Protonix 40 mg IV every 24 hours. Add CBC (complete blood count) to 1700 labs. Call with results."

15:00 PM - RN noted "Phoned Physician #4. Updated on pt.'s current status. Order given and written."

15:30 PM - RN noted "Notified Physician #3 of pt.'s current status, informed of pt. continue complaint of numbness to left hand/arm and report of sensitivity to touch to bottom of left foot. Physical Therapist in room assisting pt. to stand and sit in recliner chair..."

18:00 PM - Physician #4 ordered via telephone call "Give NS 1-liter bolus now IV."

18:20 PM - Outgoing RN noted "Notified Physician #4 of urine output and BP- 88/56. Informed that pt. remains asymptomatic...transfer from chair to bed with 2 person assist. New orders given...#3 bolus started..."

18:20 PM - Incoming RN noted "...Patient has some facial edema noted at +1...Patient was receiving 3rd bag of NS bolus via left forearm 18g PIV for decrease in urine output..."

19:05 PM - LVN noted "...4-liters fluid per Physician #4, BP 99/63 holding all BP meds, readjusted Foley catheter and retrieved 30-40 ml urine, BS active, had bouts of nausea and vomiting, holding down chicken noodle soup and crackers so far. HR still elevated 100-120, on 02/NC, Zofran ODT will be given shortly."

19:25 PM - RN noted "Received patient's lab result from CBC, BMP. Notified Physician #4 and informed him that patient's creatinine: 2.4, BUN: 30. New orders to infuse another 1 liter of NS bolus IV for a total of 4 liters..."

20:36 PM - RN noted "Dilaudid 1mg was admin via left arm via for complaints of lumbar pain 6/10..."

21:00 PM -Vital signs were as follows: temperature 98.3, pulse 112, respirations 18, blood pressure 99/63, oxygen saturation 99% on oxygen at 2 liters/minute via nasal cannula.

21:24 PM - RN noted "Robaxin 1gm IV admin for complaint of back spasms..."

22:03 PM - LVN noted "Pt pushed call light stating feeling hot, pt diaphoretic, gave cool forehead towel, checked BS (blood sugar) 161, gave cranberry juice. Pt. c/o (complained) indigestion and belched. Pt. stated that belching didn't help and stated feeling winded. Informed charge nurse of pt stating SOB. Charge nurse in room and on phone with hospitalist."

22:16 PM - RN noted "Physician #4 notified of patient complaining of SOB and being diaphoretic. Informed of BS- 161 with BP (blood pressure) - 86/71, R (respiration) - 24, p (pulse) -72, sats. 98% on 2L/NC [oxygen]. Labs were ordered with a stat EKG and 20 mg Lasix IVP. EKG was read to Physician #4 by this nurse and patient became unresponsive. CPR (cardiopulmonary resuscitation) immediately started. Crash cart brought to room and all life sustaining measures began per doctor's order. AED (automated external defibrillator) placed while CPR continued, no shock indicated x 2, patient with no pulse or respiration noted. After continuous attempts at CPR with no pulse, 911 was called by a facility staff member while life sustaining measures continued to be performed."

22:24 PM - LVN noted "Hospitalist ordered labs and EKG, placed electrodes and started EKG, patient became unresponsive. RN placed CPR board and this nurse started chest compression, RN replaced and this nurse retrieved crash cart. Charge Nurse placed AED pads as CPR continued, Cleared and AED stated No charge indicated. Continued with CPR, called 911 as Charge nurse [RN] continued with chest compression. Attempted AED once more and No shock indicated. No pulse found, continue CPR."

22:38 PM - LVN noted "Chief Clinical Officer notified and stated she would inform Physician #3."

22:39 PM - LVN noted "CPR continued and Hurst paramedics came in and took over CPR with automated chest compression and intubated pt. Charge nurse and this nurse stayed by bedside for paramedics' questions."

22:42 PM - RN noted "Physician #3 contacted the facility to get update on patient. Informed that patient had become unresponsive and CPR performed by facility staff. Also informed that paramedics had just arrived and were intubating patient. Physician #3 informed this nurse that he was on his way, this nurse also informed Physician #3 that Physician #4 was on his way also."

23:03 PM LVN noted "Paramedics continued CPR, Physician #4 called time of death 2303. CPR ceased. Physician #3 called family."

The Fire Department record reflected on 03/26/20 at 22:36 PM the hospital call was received. A crew of 2 arrived at 22:40 PM. The nurses reported to the crew that they had performed CPR approximately 15 minutes. Patient #1's initial assessment was completed at 22:46 PM. Patient #1 was noted to have no palpable pulses. The crew took over Patient #1's care and manual CPR was continued. Patient #1 was unresponsive, pulse 0, respiration 0. Patient #1 was intubated. Small amount of vomit was suctioned from the airway. Resuscitation continued. Patient was bagged (bag valve mask) with flow rate at 15 LPM. ACLS medications were given per protocol. "Patient response: unchanged." "Physician #4 arrive on scene, gave verbal report with interventions performed, medications administered, and lack of any changes in patient's condition. Fire Department crew was "advised to terminate resuscitations." Resuscitations were discontinued at 2303 PM on 03/26/20.

In summary: Patient #1 was admitted to the inpatient unit on 03/26/20 at 0300. Patient #1's inpatient stay complained of nausea, vomiting and pain. The patient's BUN and Creatinine laboratory results were also abnormal, urine output and blood pressure were low and heart rate had been consistently high. On 03/26/20 at 22:16 PM Physician #4 was notified of the patient's condition. 911 was called. Fire Department received the call at 22:36 PM. Dispatch notified the crew at 22:36 PM and the Fire Department crew was enroute to the hospital at 22:37 PM. A crew of 2 arrived in the hospital at 22:40 PM, received verbal report from the nurse, and assessed Patient #1. Life sustaining measures were performed. Physician on call arrived and received verbal report from the Fire Department crew. Physician #4 instructed the Fire Department crew to terminate resuscitation. Resuscitation was discontinued at 2303 on 03/26/20. From the time Physician #4 was notified of Patient #1's emergent condition, it took Physician #4 over 30 minutes to arrive at the hospital.

During an interview with Personnel #1 on 08/30/21 at 10:15 AM she was asked why there was no physician present when the hospital had inpatients. She replied the hospital received a "waiver" on 10/18/18 that allowed the hospital to not have physicians physically present 24/7. The facility only had monthly physician on call list. If a nurse needed something from a physician, she would call the physician on call. Personnel #1 provided a copy of the waiver for the surveyor to review (please see below). Review of the waiver indicated this was applicable only to the licensure regulation for Emergency Department Services and not for the inpatient unit. This waiver was not applicable to Centers for Medicare and Medicaid Services (CMS)/ federal regulations for general hospitals. Personnel #1 also provided the surveyor the root-cause analysis that was conducted on 03/27/20 (please see below).

During an interview with Physician #3 on 08/30/21 at 10:49 AM via phone call he stated the patient's surgery went well and lasted longer than 10 hours. He said Patient #1 was stable during the surgery. He stated he did frequent follow up via phone regarding the patient's condition with the nurses. Physician #3 said that on post-op day #1 the patient was ambulating, his legs felt great, had nausea and vomiting related to pain medication. Physician #3 stated that he was happy and amazed with Patient #1's recovery. Patient #1 was able to move out of bed and walking. When asked about his reaction when he knew the patient had coded, Physician #3 replied "I was shocked, upset and sad, praying that the patient would not die." Physician #3 said he came to the hospital immediately after he was notified of the emergency. When he arrived, CPR had already stopped. Physician #3 was asked about what his thought process regarding the sudden demise of the patient. Physician #3 replied that most likely it was due to pulmonary embolism. Physician #3 was asked if there was anything he could have done to prevent the incident. Physician #3 replied "Nothing I could have done." He stated the patient was already on TED (thrombo-embolus deterrent) stockings and SCD (sequential compression device) as preventive measures. He stated that Lovenox and Heparin were not indicated for spinal surgery since these medications might cause severe post-op bleeding.

During an interview with Personnel #14 on 08/30/20 at 11:33 AM he stated he received a call from the security guard notifying him of Patient #1's incident. He said he knew there were two nurses doing the CPR prior to the arrival of 911. When asked if emergency medications were administered during the code, Personnel #14 replied there was no documentation of medication in the code sheet. Personnel #14 stated when he came the paramedics were already finishing up and the patient was pronounced. According to Personnel #14, upon his arrival he saw Physician #3 and Physician #4 talking to the family at the hallway. Personnel #14 told the surveyor that the RN on duty that night was no longer a hospital employee. He stated the other nurse (Personnel #12) was still an active employee.

During an interview with Physician #4 on 08/30/20 at 13:03 PM via phone call he stated after he received the call, he threw his scrubs and immediately raced to the hospital and arrived in less than 30 minutes. Upon his arrival he said that EMS was currently resuscitating the patient. He stated he noticed the patient was on asystole for a while. Patient #1 was not looking good to him. Physician #4 stated the EMS intubated the patient and did the bulk of the work. When asked what was going on his mind at that moment, Physician #4 replied "seemed sudden and cannot be prevented." He stated that everything was done, the patient was on SCDs and had been out of bed. To him treatments were appropriate. Physician #4 said that it was an awful experience just talking to the family for 3 hours. When asked if a physician was physically present in the hospital during the incident. Physician #4 replied there was none. The physician on call covered inpatient services.

During an interview with Personnel #12 on 08/30/21 at 14:10 PM via phone call she described Patient #1 was a "big man." The patient had diabetes. The patient complained of pain and was diaphoretic. The patient told her "I don't feel right." Personnel #12 checked the patient's blood sugar. The patient became unresponsive and she started compressions. The RN (registered nurse) on duty was not immediately available. The RN had a smoke break. There was no physician physically present in the hospital either. Personnel #12 texted the RN to come immediately to the floor. The RN came and Personnel #12 stated the RN did not know what to do. The RN did compressions and Personnel #12 got the crash cart. They placed the patient on a backboard. Personnel #12 stated she called 911. Then Personnel #12 did compressions, the RN got the AED (automated external defibrillator). Personnel #12 stated the RN could not figure out how to use the AED even if she was ACLS certified. They switched places, the RN was doing the compressions and Personnel #12 used the AED on the patient. The AED indicated no shock was required. Personnel #12 stated she continued the compressions. The EMS (emergency medical services) personnel came. The EMS asked "why did you take 30 minutes to call?" Personnel #12 replied "I don't know." The EMS personnel took over the patient's care. Personnel #12 stated the EMS did chest compressions. Personnel #12 stated "I was very upset." I heard the RN screaming on the phone. The RN was talking to Personnel #1, Physician #4, and Physician #3. Personnel #12 was asked if this was the only death in the hospital. She replied yes. Personnel #12 stated Personnel #1 came in that night and wrote down what happened.

During an interview with Physician #5 on 09/27/21 at 10:25 AM via phone call he stated physicians were available only from Monday through Friday up to the last procedure in the Surgery Department. There were no physicians on Saturday and Sunday due there were no patients undergoing surgeries on these days. Physician #5 was asked if he attended the RCA meeting conducted on 03/27/20. Physician #5 replied he did not know about the RCA. He stated he probably was busy on that day. Physician #5 stated he discussed Patient #1's incident briefly with Physician #4. Physician #5 was asked if he received a complaint from Patient #1's family. He replied no he did not. Physician #5 was asked if the RN (Personnel #15) on duty on the night of 03/26/20 was capable of taking care of Patient #1's emergent situation. He replied "I can't speak for that. I believe she could see potential issues and that she is not at all clueless."

"Medical Staff Regulations" dated 05/25/2016 on page 26 reflected "8.6 Responsibilities of Practitioners Who Performed Invasive Procedures for Seeing Patients Everyday. A physician involved in the care of a hospitalized patient will make daily rounds until the patient is discharged or transferred..."

Hospital's Waiver obtained from Health and Human Services Commission, Austin TX dated 10/18/2018 reflected the hospital requested a waiver of the following hospital licensing standards "Not requiring physicians to be in the underutilized emergency treatment area 24 hours a day, 7 days a week..."

Root Cause Analysis (RCA) was written in different template and not in their own accrediting body. The hospital was accredited by Center for Improvement in Healthcare Quality (CIHQ) with expiration date: 06/10/2022. The RCA had Patient #1's timeline from admission on 03/26/20 at 03:00 AM to 03/27/20 at 02:20 AM when Patient #1 was released to a Funeral Home. Per timeline, Physician #4 (on-call physician) arrived at the hospital at 23:00 PM on 03/26/20. The RCA's "Root Cause Analysis Findings" was filled out. There was no "Root Cause." There was no "Plan of action."

Policy Number: 109.02: Code Blue and Crash Carts, Revised: May 30, 2020.
IV.C. 2. The Code Blue team will consist of the following personnel. Their duties will include but are not limited to the following ...G.4. Each unit will be responsible ...3. Code Blue Record. Revised 08/2016. Purpose: To analyze the care provided in an arrest situation for adherence to established guidelines; to identify opportunities to improve performance; and to improve outcomes. The Code Blue record identified the following: 1. Physician did not respond in 5 minutes. 2. Airway was not established. 3. Patient was not placed in telemetry. And, 4. Suction was not available and/or set-up.

Code Blue and Crash Cart 109.02 revised 03/30/20 Addendum -***If situation exceeds capabilities call 911 and prepare for possible transfer."

Based on interview and record review, the hospital failed to have an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program, in that the Root Cause Analysis and Peer Review did not meet expectation. There were no action plans designed to reduce potential or future risk.

Cross Refer to Tag 0273

Based on interview and record review, the hospital failed to identify problems and create action plans after the demise of 1 of patient (Patient #1) on 03/26/20.

Findings included:

Patient #1 was admitted to the hospital on 03/26/20 at 03:00 AM after a "Thoracic Lumbar Laminectomy Post Fusion T10 - L4." Patient #1 voiced out multiple problems to the primary care nurse throughout the day and night. Subsequently, Patient #1 was pronounced deceased on 03/26/20 at 23:03.

A root-cause-analysis (RCA) was conducted on 03/27/20. A RCA is typically a finding related to a process or system that has a potential for redesign to reduce risk. After the review of the hospital's RCA which contained a total of 24 questions, the analysis did not meet expectation. There were no action plans designed to reduce potential or future risk.

The hospital's medical director did not attend the RCA discussion.

On 03/26/20 at 22:16 PM, the patient became unresponsive. There was no physician and respiratory therapist physically present to attend during code blue activation. The patient needed airway and 911 was not called immediately. There was a 26-minute delay in calling 911. The on-call physician came 30 minutes after the patient was unresponsive.

The peer review was conducted on 03/23/21 signed by Physician #5. There was a delay due to pandemic. The findings were:
Level I Review:

"Are there physician issues that need to be addressed. No." The physician did not make daily rounds to check on the patient's progress.

"Are there non-physician issues that need to be addressed. No."

"Are there process changes which would prevent this from happening again? No." The physician should be readily available during the Code Blue process.

-Quality Rating: Q1-Outcome acceptable or not unexpected; management appropriate; or not routine, but not unacceptable.

- Utilization Rating: U1-Utilization acceptable or not unexpected.

- Behavioral Ratings: B1-Behavior/conduct is acceptable or not unexpected.


During an interview on 10/06/21 at 11:29 AM, Personnel #1 confirmed that the hospital provided appropriate care to Patient #1. The RCA did not need action plans. Personnel #1 confirmed the peer review was dated on 03/23/21 due to pandemic.

Policy "Quality Improvement Plan" reviewed 03/20/21 page 1 & 3 "I. PURPOSE: This Quality Improvement Plan describes the systematic organization-wide approach to quality that is used to plan, design, measure, assess and improve organizational performance...E. Quality Improvement Committee The Quality Improvement Committee has the responsibility to assure that the principles of quality improvement are utilized throughout the organization..."

"Medical Staff Regulations" dated 05/25/2016 on page 26 reflected "8.6 Responsibilities of Practitioners Who Performed Invasive Procedures for Seeing Patients Everyday. A physician involved in the care of a hospitalized patient will make daily rounds until the patient is discharged or transferred..."

Based on interview and record review, the 1 of 1 registered nurse failed to:

1. Supervise and evaluate Patient #1;

2. Activate 911 when the patient was unresponsive; and

3. Use her competency at the time of this event.


Findings included:

Patient #1 was admitted to the hospital on 03/26/20 at 03:00 AM, after a "Thoracic Lumbar Laminectomy Post Fusion T10 - L4." Patient #1 voiced out multiple problems to the primary care nurse throughout the day and night. Subsequently, Patient #1 was pronounced deceased on 03/26/20 at 23:03 AM.

On 03/26/20 at 22:16 PM, Patient #1 became unresponsive. The primary care nurse (Personnel #12) was not immediately available to run the code since she was off the floor. The on-going cardiopulmonary resuscitation (CPR) was conducted without calling 911.

During an interview with Personnel #12 on 08/30/21 at 14:10 PM, via phone call, she described Patient #1 was a "big man." The patient had diabetes. The patient complained of pain and was diaphoretic. The patient told her "I don't feel right." Personnel #12 checked the patient's blood sugar. The patient became unresponsive and she started compressions. The RN (registered nurse) on duty was not immediately available. The RN had a smoke break. There was no physician physically present in the hospital either.

Personnel #12 texted the RN to come immediately to the floor. The RN came and Personnel #12 stated, the RN did not know what to do. The RN did compressions and Personnel #12 got the crash cart. They placed the patient on a backboard. Personnel #12 stated, she called 911. Then Personnel #12 did compressions, the RN got the AED (automated external defibrillator).

Personnel #12 stated, the RN could not figure out how to use the AED even if she was ACLS certified. They switched places, the RN was doing the compressions and Personnel #12 used the AED on the patient. The AED indicated no shock was required. Personnel #12 stated she continued the compressions. The EMS (emergency medical services) personnel came.

The EMS asked "why did you take 30 minutes to call?" Personnel #12 replied "I don't know." The EMS personnel took over the patient's care. Personnel #12 stated, the EMS did chest compressions. Personnel #12 stated, "I was very upset." I heard the RN screaming on the phone. The RN was talking to Personnel #1, Physician #4, and Physician #3. Personnel #12 was asked if this was the only death in the hospital. She replied yes. Personnel #12 stated Personnel #1 came in that night and wrote down what happened.