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Based on review of facility policy, observations and employee interviews it was determined the facility staff failed to ensure the safety of a ventilator patient by placing in an area in ICU (Intensive Care Unit) where the patient could be viewed by the staff and the ventilator alarms could be heard.

This affected Patient Identifier (PI) # 1 and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Patient Service Department, Intensive Care Unit Policy
Assessment/Reassessment
Document Number: None
Review Date: 12/2017

Ventilators:

ICU/NBN (New Born Nursery)

RT (Respiratory Therapy) is to...check the settings routinely every four hours and each time there is a change...

Nursing is to monitor the function of the equipment and notify RT of "alarm" conditions.

1. PI # 1 was admitted to the facility on 8/23/19 with a diagnosis of Acute/Subacute Encephalopathy, Multifactorial and transferred to ICU to room # 18 on 8/26/19 at 11:30 AM and was placed on a ventilator that day.

Review of the MR revealed the patient was stable but confused and disoriented on admission to ICU on 8/26/19.

Further review revealed the patient was intubated with a 7.5 endotracheal tube on 8/26/19 and placed on the ventilator after arriving to ICU.

Review of the MR revealed on 8/27/19 during both the 7 AM and 7 PM shifts the patient was more alert and taking a few breaths on his/her own.

Review of the MR revealed on 8/28/19 at approximately 7:30 AM the patient was placed on spontaneous respiration settings on the ventilator in an attempt to wean the patient off the ventilator.

A tour was conducted on 12/3/19 at 10:35 AM of the ICU, which was found to be in the shape of a U.

ICU # 18, where PI # 1 was located, was unable to be seen from the nurses station and was located at the end of one side of the ICU hall. ICU # 18 had double doors due to being a negative pressure room.

During the tour of ICU an observation was conducted at 10:50 AM on 12/3/19 in ICU # 13, to observe EI # 8, Respiratory Therapist (RT) complete a ventilator check.

During the tour EI # 8 was asked how to check the alarm on the ventilator. EI # 8 demonstrated how the alarms were checked and stated "the ventilator alarm can not be turned off but it can be turned down to the lowest level."

EI # 8 then went into the computer system to document the alarm check by placing a number in each section that was required for either high or low pressures. EI # 8 was asked if there was a place in the system to document the alarms were checked. EI # 8 stated "no there is nothing in the system .

On 12/5/19 at 9:25 AM an interview was conducted with EI # 4, Director of Respiratory Service.

EI # 4 was asked about PI # 1 and if he/she remembered the patient. EI # 4 stated yes and the patient was at the end of the hall in ICU # 18 and the alarm on the ventilator had been turned to its lowest level.

An interview was conducted on 12/5/19 at 1:20 PM with EI # 5, ICU Manager.

During the interview with EI # 5 was asked if he/she remembered PI #1.EI # 5 responded that he/she remembers when the patient was transferred to ICU on 8/26/19. EI # 5 stated on the morning of 8/28/19 at approximately 9:00 AM, after arriving to ICU for work, EI # 5 stated he/she remembered the O2 (Oxygen) sat (saturation) monitor went off at the nurses station and he/she went to check on PI # 1. EI # 5 stated when he/she arrived in the room the vent alarm was also going off. EI # 5 then continued by stating when he/she looked at the ventilator tubing he/she could see a mucous plug in the tubing and PI # 1's O2 sat was at 86%. EI # 5 attempted to suction PI # 1 and his/her O2 sat dropped to 85%.

EI # 5 stated at approximately 9:05 AM on 8/28/19 the monitor room technician called ICU and stated PI # 1 was asystole (no heart beat) on the monitor. EI # 5 stated a code blue was initiated and chest compressions were started and the code continued until 9:15 AM when a heart rate and respirations resumed.

During the interview EI # 5 was asked if a vent alarm is ever turned down. EI # 5 responded by stating " no and if it was I would notify EI # 4, Director of Respiratory Services and continued by saying"but this vent alarm was turned down and I could not hear it from the desk but the alarms on the monitors across from the nurses station were loud and when I got into the room the vent alarm was going off but was not loud."

Review of PI # 1 MR dated 8/28/19 revealed no documentation of the mucous plug, the low oxygen saturations, the oxygen saturation monitor at the nurses station alarming nor was there documentation the ventilator alarm was set at the lowest level.

An interview was conducted on 12/5/19 at 3:45 PM with EI # 1, Director of Risk Management, and EI # 2, Assistant Vice President of Patient Services, who confirmed the ventilator alarms should never be turned down and EI # 1 confirmed the new tab in the computer system was added for the alarm check.

Based on review of medical records (MR), facility policy and interviews with the staff it was determined the facility failed to ensure the nursing staff followed the facility policy for nursing assessments and patient change documentation in the medical record. This affected Patient Identifier (PI) # 1 and had the potential to negatively affect all patients admitted to the facility.

Findings include:

Policy: Patient Services Department
Intensive Care Unity Policy
Assessment/Reassessment
Policy Number: None
Date Reviewed: 12/2017

Purpose:

To establish guidelines for the initial assessment and reassessments of the patient...

Policy:

4. Reassessments will be determined by the diagnosis of the patient, the patient's response to care and at least every 4 hours

Policy: Nursing Assessment
Policy Number: None
Review Date: August 2018

Purpose:

To provide a record of the patient's daily activities, the assessment/reassessment of the patient and the response to interventions that are made by nursing staff.

2. Documentation of each 8/12 hour shift should reflect the patient's status or if the patient's status has changed...

4. The patient's condition determines the focus and frequency of subsequent assessments...

1. PI # 1 was admitted to the facility on 8/23/19 with a diagnosis of Acute/Subacute Encephalopathy, Multifactorial and transferred to ICU (Intensive Care Unit) on 8/26/19 at 11:30 AM and was placed on a ventilator.

Review of the Respiratory Therapy (RT) assessment notes revealed at 11:30 AM the patient was disoriented and confuse on arrival and an endotracheal tube (ET) was placed and the patient was put on a ventilator.

Further review of the RT notes revealed the intitial set up of the ventilator and all seting were documented along with the RT assessment.

On 8/28/19 the patient was still incubated but the ventilator was changed to spontaneous respirations and not ventilator settings and they were going to wean the patient off the ventilator.

An interview was conducted on 12/5/19 at 1:20 PM with Employee Identifier (EI) # 5, ICU (Intensive Care Unit) Manager. During the interview EI # 5 described what took place on 8/28/19 at 9:05 AM with PI # 1.

On 8/28/19 at 9:05 AM PI # 1's alarm for the oxygen saturation monitor and the cardiac monitor at the nurses station alarmed. Employee Identifier (EI) # 5 entered PI # 1's room to find the ventilator alarm was also alarming and the volume was on low and could not be heard at the nurses station.

EI # 5 stated the patient's Oxygen saturation was at 85% and realized the patient had a mucous plug in the ventilator tubing. EI # 5 stated she tried to suction the patient but was unsuccessful the first time. The patient's heart rate began to drop and the oxygen saturation continued to drop. EI # 5 stated the monitor tech in the monitor room called the ICU to inform the staff the patient was asystole (no heart beat). CPR (Cardiopulmonary Recessitation) was started at 9:10 AM and the patient was suctioned again with success of removing the mucous plug.

Review of the MR revealed the code sheets when the code was initiated for the patient and all medication listed during the code.

The surveyor requested the call log from the monitor room on 12/4/19 and all related cardiac strips for the code.

Resuscitation continued for 5 minutes and the patient's heart rate returned along with respirations at 9:15 AM.

After the patient's heart rate and respirations returned the patient was again placed on the ventilator to assist with breathing.

EI # 5 was asked in the interview where the documentation was concerning the mucous plug and EI # 5 completed the suctioning and initiated the code status. EI # 5 responded by stating " I did not document it in the MR. I am a manager and do not document in the MR." EI # 5 stated the patient's nurse should be documenting that I did the suctioning and initiated CPR."

Review of the MR revealed no documentation of the above incident in the MR.

An interview was conducted on 12/5/19 at 3:00 PM with EI # 1, Director of Risk Management and EI # 2, Assistant Vice President of Patient Services. who confirmed the above mentioned findings.

Based on review of medical records (MR), facility policies, and interview, it was determined the respiratory staff failed to:

1. Assess/ document breath sounds within 1 hour of ventilator initiation. This affected Patient Identifier (PI) # 2.

2. Obtain a physician order before providing treatment. This affected PI # 2.

3. Assess/ document pre and post breath sounds after providing breathing treatments. This affected PI # 2, PI # 3, PI # 5.

4. Document ventilator checks every four (4) hours. This affected PI # 3, PI # 5 and PI # 1.

5. Document assessments at the time the respiratory treatments were documented as given. This affected PI # 3, PI # 5.

This affected Patient Identifier (PI) # 2, PI # 3, PI # 5 and PI # 1 which was 4 of 5 admitted to the ICU (Intensive Care Unit) on a ventilator and had the potential to negatively affect all patient admitted to the facility with respiratory therapy services.

Findings include:

Intensive Care Unit Policy
Assessment/ Reassessment
No document number
Reviewed: 12/2017

Purpose:

To establish guidelines for the initial assessment and reassessments of the patient requiring admission to the Intensive Care Unit...

4. Reassessments will be determined by the diagnosis of the patient, the patient's response to care and at least every 4 hours...


Facility Policy Title: Adult Ventilator Management and Weaning Goals
Document Number: RESP-275
Effective Date: 7/12/19

B. Initial assessment should be performed within one hour of initiation. Subsequent assessments should be performed at regularly scheduled intervals...

a. Assessment includes, but is not limited to:...

iii. Breath sounds...

v. Ventilator settings...

Facility Policy: Responsibility for Patients Respiratory Therapy Needs
No document number
Reviewed Date: December 2018

Ventilators: ICU/ NBN (New Born Nursery)

Respiratory Therapy (RT) is to supply all equipment, set it up, check the setting routinely every four hours and each time there is a change...

1. PI # 2 was admitted to the facility in the ICU on 7/28/19 with Acute Respiratory Failure status/post (s/p) Cardiac Arrest.

Review of the 7/28/19 Respiratory Progress Note revealed documentation at 3:31 AM of Ventilator (Vent) Procedure: Initial Start. The patient location was in the Emergency Department (ED) and no breath sounds were documented by RT.

Review of the 7/28/19 RT Assess and Treat note at 5:48 AM revealed documentation the patient location as ICU breath sounds diminished and/ or crackles. No treatment needed.

The RT staff failed to assess/ document an Initial Assessment with in one (1) hour of placing PI # 2 on the ventilator.

Review of the 7/29/19 Respiratory Progress Note revealed documentation of Duoneb Nebulizer treatments completed at 7:10 AM, 10:45 AM, and 2:55 PM and no pre and post assessment of breath sounds was documented.

Review of the MR revealed no physician order for the Duoneb Nebulizer treatments performed on 7/29/19.

The staff failed to obtain a physician order prior to providing care and assess/ document pre and post breath sounds with each treatment.

In an interview conducted on 12/4/19 at 9:40 AM, Employee Identifier (EI) # 3, Director of Quality Assurance, confirmed the above findings.

2. PI # 3 was admitted to the facility in the ICU on 9/22/19 with Shortness of Breath.

Review of the Medication Administration History Report revealed a physician order for the breathing treatment 9/22/19 twice a day (BID) 7:00 AM and 7:00 PM for Budesonide 2 milliliter (ml) 0.5 milligram (mg)/2 ml (Pulmicort).

Review of the RT Progress note for 9/22/19 revealed a vent check assessment was performed and the patient was suctioned at 8:12 PM and no documentation patient breath sounds were assessed.

The next vent check assessment was on 9/23/19 at 3:56 AM and no documentation lung sounds were assessed, which was 7 hours and 44 minutes later.

The RT failed to assess the ventilator patient in ICU every 4 hours.

Review of the RT Progress note for 9/24/19 revealed a vent check was performed at 2:23 PM and again on 9/25/19 at 12:28 AM, which was 10 hours and 3 minutes later.

The RT failed to complete a ventilator check every 4 hours.

In an interview conducted on 12/4/19 at 3:50 PM, EI # 3 confirmed the RT staff failed to follow facility policy for assessments and documentation.

3. PI # 5 was admitted to the facility in the ICU on 11/11/19 with the diagnosis of Shortness of Breath.

Review of the 11/11/19 RT Progress notes revealed vent checks were documented at 2:26 PM and the next vent check at 8:00 PM, which was 5 hours 34 minutes later.

Review of the 11/12/19 RT Progress notes revealed vent checks were documented at 3:10 AM and the next vent check at 9:08 AM, which was 5 hours and 58 minutes later.

Further review of the 11/12/19 RT Progress notes revealed documentation of a vent check at 6:48 PM. The next on 11/13/19 at 7:49 AM, which was 13 hours later.

The RT staff failed to complete ventilator checks every 4 hours.

An an interview conducted on 12/4/19 at 4:30 PM, EI # 3 confirmed the above findings.



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4. PI # 1 was admitted to the facility on 8/23/19 with a diagnosis of Acute/Subacute Encephalopathy, Multifactorial and transferred to ICU (Intensive Care Unit) on 8/28/19 and was placed on a ventilator that day.

Review of the RT Progress notes in the MR revealed documentation for 8/27/19 a vent check was performed at 2:16 PM and no other documentation until 8:50 PM which was 6 hours and 34 minutes later.

Review of the RT Progress notes revealed on 8/28/19 at 7:15 AM a vent check was complete. Further review revealed no documentation again until 7:46 PM which was 12 hours and 31 minutes later.

Review of the RT Progress notes revealed on 8/29/19 at 10:35 AM a vent check was complete. Further review revealed no documentation again until 8:40 PM which was 10 hours and 5 minutes later.

Review of the RT Progress notes revealed on 9/4/19 at 10:53 AM a vent check was complete. Further review revealed no documentation again until 6:42 PM which was 7 hours and 45 minutes later.

Review of the RT Progress notes revealed on 9/5/19 at 1:03 PM a vent check was complete. Further review revealed no documentation again until 7:17 PM which was 6 hours and 14 minutes later.

Review of the RT Progress notes revealed on 9/9/19 at 7:41 PM a vent check was complete. Further review revealed no documentation again until 3:24 AM which was 7 hours and 39 minutes later.

Review of the RT Progress notes revealed on 9/10/19 at 6:54 PM a vent check was complete. Further review revealed no documentation again until 9/11/19 at 12:12 AM which was 5 hours and 18 minutes later.

Review of the RT Progress notes revealed on 9/13/19 at 6:18 AM a vent check was complete. Further review revealed no documentation again until 2:16 PM which was 7 hours and 44 minutes later.

Further review of the RT Progress notes revealed on 9/13/19 at 10:33 PM a vent check was complete. Further review revealed no documentation again until 9/14/19 at 3:48 AM which was 5 hours and 15 minutes later.

The RT failed to complete ventilator checks every 4 hours per facility policy.

An interview was conducted on 12/4/19 at 10:15 AM with EI # 7, Registered Nurse Clinical Analyst Supervisor, who confirmed the above mentioned findings.