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Based on staff interview, medical record review and policy and procedure review the facility failed to ensure staff followed facility policy and procedures for nursing service and patient transport for one (1) out of six (6) records reviewed: Patient #1.

Findings Include:

During an interview on 04/06/2022 at 1:58 p.m., the Risk Manager revealed the facility has a "Transportation Form" entitled "Ticket to Ride" to document the efficient and safe communication between clinical departments and transportation staff when a patient is being transported. The Risk Manager confirmed there was no documentation on Patient #1's transportation form, "Ticket to Ride," for the ordered oxygen setting, the oxygen in use, or liters of oxygen in tank from the nurse sending the patient to dialysis, the dialysis nurse sending patient to room, the transporter, or the nurse receiving patient in room.

The Risk Manger confirmed Registered Nurse (RN) #1 received Patient #1 in his room from dialysis, and signed the transportation form "Ticket to Ride," but failed to document on patient's oxygen status.

The Risk Manager confirmed her investigation revealed RN #1 received Patient #1 in his room, then left to get the patient something to drink when she was stopped and sent to receive another patient. The Risk Manager also confirmed Respiratory Therapist (RT) #1 went to Patient #1's room for a breathing treatment and noticed the patient did not have color and called a code.

Risk Manager was asked for a copy of the facilities investigation, Quality Assurance Performance Improvement (QAPI) documentation and any other documentation of the incident. No documentation was presented. The Risk Manager stated the information was in the "Patient Safety Organization (PSO)" data bank and she could not access the information.

During an interview on 04/07/2022 at 2:30 p.m., RN #1 revealed on 01/08/2022, Patient #1 arrived back to the floor in his hospital bed accompanied by a transporter but does not recall the time. RN #1 revealed the patient was verbal, alert, and oriented and did not appear in any distress and requested water and something to eat. RN #1 stated, "He was connected to an oxygen tank that was attached to his bed when I left the room." RN #1 stated, "I had eight (8) patients that day and I was called to another room because I had to discharge another patient, whose discharge was urgent due an existing outpatient dialysis appointment." RN #1 confirmed a respiratory therapist found Patient #1 unresponsive and called a code."

During an interview on 04/08/2022 at 2:53 p.m., RT#1 confirmed he went into Patient #1's room on 01/08/2022 at approximately 4:00 p.m. for a scheduled respiratory breathing treatment. RT #1 stated, "initially I thought he was resting. Then he started gasping for air but was unresponsive. I noticed the oxygen tubing was not attached to the wall outlet but to an empty tank. I hooked the oxygen to the wall meter and pressed the code button."

During an interview on 04/08/2022 at 11:15 a.m., the Risk Manager stated, "the problem with Transportation Form #11-100-49 (Ticket to Ride) is that no one completely fills them out." The Risk Manager revealed she could show me 100 of them and most would not be filled out.

Medical record review for Patient #1 revealed the "Progress Note", dated 01/07/2022 at 12:48 p.m. by the Internal Medicine physician, documents Patient #1, " ...oxygen requirement suddenly increased to 10 liters yesterday (01/06/2022). Did not improve after dialysis. Chest X-Ray ordered this morning (01/07/2022). Has complete whiteout of left lung field. Maintaining saturations on 10 liters/minute ...Concern for mucous plug versus large pleural effusion. Have consulted pulmonology. May require chest tube or bronchoscopy...".

Medical record review for Patient #1 revealed the "Pulmonologist consult note", dated 01/08/2022 at 12:04 p.m., with Patient #1 while in dialysis treatment, revealed " ...patient said he was breathing was worse yesterday but today seems a little better. Requiring eight (8) liters oxygen ...He denies any distress. He appears to be comfortable with oxygen saturation 100%." Patient has a "history of mucous plugging ...X-ray 01/07/2021 shows complete opacification of left chest, new as of 01/07/2022; may need bronchoscope. No need for emergency bronchoscopy today as patient is respiratory wise stable ... Will monitor him closely over the weekend. If he has any worsening or respiratory status, then will need to transfer to ICU for Bronchoscopy... ".

Medical record review for Patient #1 confirms there is no documented orders to change the oxygen rate from two (2) liters per minute to eight (8) or ten (10) liters per minute. However, there is documented evidence on the progress notes from the internal medicine physician and the pulmonologist.

Review of medical record for Patient #1's "dialysis notes" dated 01/08/2022 at 2:30 p.m. revealed Pulse 61, Respirations 14, Blood Pressure 145/65, and Oxygen Saturation 97%. There was no documented evidence of the patient's oxygen rate. Patient #1's exit time from floor was recorded as 3:04 p.m. and that the patient tolerated the procedure well. No other vitals were recorded between 2:30 p.m. and the time of the code at 4:04 PM.

Review of medical record for Patient #1, form "Transportation Safety Handoff," dated 01/08/2022, revealed no documented evidence of Oxygen rate, oxygen tank level, patient identifiers, or of a nurse accompanying the transport recorded on the form. The form documents patient was back in his room at 3:08 PM.

Medical record review of Patient #1's "Code Sign-Off" by the physician on 01/08/2022 at 4:38 p.m. revealed the beginning of the code was recorded at 4:04 p.m. and Type of Event "unknown ...no pulse presentation," and code ended at 4:30 p.m. Patient was taken to ICU with intubation.

Review of facility's policy "Transportation Safety Hand-off", policy # VIII-19 (review/revision 11/2021), revealed, " ... Purpose: provides a central place in the medical record for the documentation of efficient and safety communication between clinical departments and transportation staff ... 1. The form (11-100.49) is ordered and kept in the unit's forms ... 4. The Transportation Safety Hand-off is completed for any patient transportation utilizing a Transporter or non-licensed staff ... 7. Transporter notifies patients nurse on return to room ...For transportation from department to other department ...Nurse and Sending Department staff member documents ...3. 2 Patient Identifiers Confirmed ... 4. O2: Check box if patient on oxygen and indicate setting for liters per minute. a. O2 Tubing Connection Verified: Check box to determine verification of oxygen tubing connected to a portable tank. b. O2Liters Verified: Check box to indicate verification of Oxygen liters documented on form matches liters on tank ... Transporter and non-licensed staff documents: 1. Check box to indicate verification of tank level is at 1,000 PSI or above... Receiving department checks box to indicate call light is in reach ...IV plugged in if available ...Receiving Department verifies/documents: 3. Receiving department prints name, department, contact number, and time of patient arrival to department, indicating information safety hand off verified and reviewed."

Based on staff interview, medical record review and policy and procedure review the facility failed to ensure staff followed facility policy and procedures for patient transport for one (1) out of six (6) records reviewed, Patient #1.

Finding Include:

Cross Refer to A-0385 for facilities failure to follow nursing service and patient transportation policies.