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Based on medical record review and interview, in one (1) of 10 medical records reviewed, it was determined the medical staff failed to request a pulmonary consultation in a timely manner for the treatment and management of a patient who was in respiratory distress. This was evident for Patient #1.

Findings include:

Review of Medical Record (MR) #1 identified the following: Patient #1 was admitted to the facility on 11/27/17 with complaints of shortness of breath for three (3) days. The patient's medical comorbidities included Chronic Obstructive Pulmonary Disease, obstructive sleep apnea, severe tracheomalacia, for which he was being followed by a pulmonary specialist in the outpatient setting. Throughout the course of the patient's hospitalization from 11/27/17 to 12/17/17 the nursing and medical staff documented the following regarding the patient's respiratory status:

On 11/28/17 a nurse documented the patient was tachypneic (rapid breathing) and short of breath.

On 11/29/17 a nurse documented the patient was short of breath, and that he had labored breathing with activity.

On 12/2/17 the nursing staff documented the patient had difficulty breathing with activity.

On 12/3/17 there was documentation of a change in the patient's respiratory status as evidenced by a chest x-ray which showed congestive changes with bilateral effusions and lower lobe congestions.

On 12/7/17 the patient became acidotic (Increase in the acidity of blood and body tissue) with a carbon dioxide (CO2) level of 32 (23-30).

On 12/7/17 at 7:58 AM the patient had labored breathing.

On 12/9/17 a renal specialist documented the patient "appears short of breath on minimal exertion."

On 12/11/17 at 11:16 AM, a cardiologist documented the patient had increased dyspnea (Difficult breathing), he feels no improvement with dyspnea. At 4:31 PM the patient had mild-moderate shortness of breath with oxygen saturation at 93%. At 7:00 PM, the patient had expiratory wheeze with diminished breath sounds. At 11:20 PM the renal specialist wrote the patient had progressive renal failure now with shortness of breath and fluid overload despite multiple medications and treatment.

There was no documented evidence that pulmonary consultation was obtained for the treatment and management of the patient's worsening respiratory condition.

On 12/14/17 at 12:09 PM, a nurse practitioner documented that the patient became unresponsive and hypoxic with oxygen saturation in the 80's and a rapid response was called. Another rapid response at 7:14 PM on the same day indicated that the patient had worsening pneumonia.

A pulmonary consultation was requested on 12/15/17 at 12:24 PM. On 12/15/17 at 1:50 PM, the pulmonary consultant noted the consultation was "cancelled because the patient was now on hospice care."

On 12/15/17, a nurse documented at 8:53 PM that the patient stated "I can't breathe." The patient died on 12/17/17 at 9:49 AM.

This finding was shared with Staff A, the Corporate Assistant Vice President of Quality on 11/27/18 at 3:00 PM.

Based on document review and interview, it was determined that the facility failed to investigate and respond to patient grievances. This was evident in seven (7) of nine (9) grievance files reviewed. Patients # 3, 4, 5, 6, 7, 8, & 10.

Findings include:

The hospital's policy and procedure titled, "Patient Complaint - Grievance Resolution," which was last reviewed on 08/09/18 states; patients will receive an initial response to their grievance within seven (7) business days and a resolution letter within 30 days. The written response will address each of the patients grievances and must contain steps taken to investigate the grievance, the result of the investigation and the completion dates.

Review of the hospital Grievance Log from 09/30/2017 to 9/30/18 showed:

Patient #3, wrote a letter to the hospital on 2/22/18 complaining about the care she received during her admittance from 2/5/18 to 2/16/18. The grievance file showed no documented evidence that the hospital responded to her letter or conducted investigations of the allegations that she made about her care.

Patient #4, wrote a letter to the hospital on 5/28/18 complaining about her "harrowing experiences" at the hospital during the last two (2) admissions. There was no documented evidence that the hospital acknowledged receipt of her letter or investigated her allegations.

Patient #5 wrote a letter to the hospital on 6/1/18 complaining about the care he received during his admission. The file showed no documented evidence that the hospital acknowledged receipt of this letter or conducted an investigation of the allegations that were made.

Similar findings of written complaints which did not have documented evidence of facility acknowledgement or investigations were noted for Patient #6, 7, 8, 9 and 10.

During interview on 11/27/18 at 11:00 AM, Staff B, Corporate Director of Regulatory Compliance acknowledged the findings.

Based on medical record review, document review, and interview, the facility failed to ensure that incidents involving patient safety were thoroughly investigated and corrective actions implemented. (Patient #2).

Findings include:

Review of medical record for Patient #2 identified a patient who was on a mechanical ventilator for respiratory failure. On 9/12/18, a physician order noted: "Start Patient on Weaning Protocol". The weaning protocol was initiated by respiratory therapist on 9/12/18.

On 9/15/18 at 6:25 PM, the nurse noted that the patient's heart rate dropped to 25 beats per minute (bpm) (normal heart rate 60-100), he was unresponsive and gray, and his blue corrugated oxygen tubing was disconnected and lying on the floor. The nurse initiated a code blue (emergency response).

Review of the Facility Root Cause Analysis (RCA) revealed that the pulse oximeter
(pulse ox) alarmed when the patient's oxygen tube dislodged but the alarm was not audible because of the sound from the air conditioner.

The RCA did not identify the reason for the detachment of the oxygen tubing from the patient's tracheostomy.

The RCA documented the following plan of correction for monitoring of patients that have been placed on weaning protocol:
a) Video Monitoring System
b) Investigate a blue tooth device for centralized oximetry monitoring
c) New Power plan includes: precheck of pulse ox, telemetry, capnography (Capnography is the monitoring of the concentration or partial pressure of carbon dioxide in the respiratory gases).
d) Multidisciplinary board round on weaning patients
e) Audit for up to 30 patients a month until greater than 90% is archived for 3 consecutive months.
f) Enhanced documentation of respiratory therapist monitoring of patients on t-piece and tracheostomy collar
e) Rounding at least every 2 hours.

There was no documented evidence that any of the corrective measures had been implemented.

During interview on 11/27/18 at 1:40 PM, Staff A, Corporate Assistant Vice President of Quality, acknowledged findings.

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Based on medical record review and interview, in two (2) of 10 medical records reviewed, it was determined the nursing staff failed to (a) identify in a timely manner a change in a patient's skin condition to prevent further break down and (b) respond in a timely manner to a pulse oximetry alarm of a patient who was oxygen dependent to ensure the patient was adequately oxygenated. This was evident for Patients #1 and #2.

Findings include:

Review of medical record #1 identified the following: Patient #1 was admitted to the facility on 11/27/17 with bilateral leg ulcers. The nursing skin assessment upon admission indicated the patient was "at risk" for decubiti formation. The nursing staff documented implementation of the "Skin Care" policy which includes skin inspection/assessment at least once daily, paying attention to the bony prominences.

Nursing documentation on 12/10/17 revealed the patient had developed an ulcer on the coccyx. The next day, on 12/11/17, the ulcer was assessed as a Stage 2 and measured 3 centimeter (cm) in length by 1 cm in width.

There was no documented evidence that the pressure ulcer was timely recognized and treated.

This finding was shared with Staff A, the Corporate Assistant Vice President of Quality, on 11/27/18 at 3:00 PM.

Review of the medical record for Patient #2 identified the following: On 8/2/18, Patient #2 was admitted to the Respiratory Care Unit for treatment of respiratory failure; he was on a mechanical ventilator and required continuous oxygenation. On 9/12/18, a physician order was noted to start the patient on weaning protocol, which was implemented and monitored by Respiratory Therapists.

On 9/15/18 at 6:25 PM, nursing note indicated that the patient's telemetry reading showed a heart rate of 25 beats per minutes (bpm). On arrival at the patient's bedside, he was unresponsive and gray. Nurse noted that the blue corrugated oxygen tubing attached to the patient's trach was lying on the floor. The nurse initiated a code blue (emergency response). At 6:29 PM, the nurse noted that the patient had been resuscitated and was immediately transferred to the Intensive care unit (ICU).

On 9/21/18 at 2:22 PM, the patient was pronounced dead after an unsuccessful resuscitation attempt.

There was no evidence that nursing staff responded immediately to the patient's pulse oximetry alarm when his oxygen delivery tube became disconnected.


During interview on 11/21/18 at 10:05 AM with Staff D, Respiratory Therapist, he confirmed that the patient was on weaning protocol and was on oxygen via trach collar. He was maintained on cardiac and pulse oximetry monitoring. The patient's pulse oximeter was set to alarm if his oxygen saturation dropped to 85%. The patient did not tolerate room air, his oxygen level would drop to 85% after 15 minutes of trial with room air.

During interview with Staff C, Respiratory Care Unit Nurse on 11/21/18 at 11:30 AM, she reported that the patient's pulse oximeter alarm was at the highest volume but was not heard by nursing staff due to the sound of the air conditioning unit at the nurses' station.

This finding was shared with Staff A, Corporate Assistant Vice President of Quality, on 11/27/18 at 3:00 PM.