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Based on review of hospital policies and procedures, medical records, hospital documents, personnel files, physician and staff interviews and direct observations, it was determined the hospital failed to comply with the provisions of Nursing Services by failing to identity, prioritize, evaluate and execute corrective actions related to deficient practice by:

TAG A-0395- requiring an RN assess, evaluate, and intervene for 1 of 1 patient (patient # 10) who had condition changes prior to a code arrest at 0541 on 11/20/13,
as evidenced by:

1. RN staff failed to perform nursing assessments as per policy every 4 hours;

2. RN staff failed to notify the Physician of patient # 10's gasping and labored breathing respiratory status;

3. RN staff and /or monitor tech staff failed to intervene when patient # 10 was off the monitor for 45 minutes and document the patient's cardiac rhythm on the monitor strip;

4. RN staff, employee #36, failed to respond to the needs of patient # 10 and place the patient back on a cardiac monitor and oxygen; and initiate a Code (institute ACLS protocol ) without delay;

5. RN staff failed to oversee and monitor the practice of the monitor tech in his/her response to cardiac rhythms and alarms; alert nursing staff when the leads became disconnected for patient # 10; and failing to recognize the patient did not display a cardiac rhythm on the screen for greater than a 45 minute period of time; and

The cumulative effect of these practices and findings under the condition of Nursing Services resulted in the failure of the hospital to be in compliance with 42 CFR Part 482 Subparts A, B, C and D, requirements for a hospital.

Based on review of hospital policies and procedures, medical record, hospital documents, staff and physician interviews, and observations, it was determined the hospital failed to require an RN assess, evaluate, and intervene for 1 of 1 patient (patient # 10) who had condition changes prior to a code arrest at 0541 on 11/20/13,
as evidenced by:

1. RN staff failed to perform nursing assessments as per policy every 4 hours;

2. RN staff failed to notify the Physician of patient # 10's gasping and labored breathing respiratory status;

3. RN staff and /or monitor tech staff failed to intervene when patient # 10 was off the monitor for 45 minutes and document the patient's cardiac rhythm on the monitor strip;

4. RN staff, employee #36, failed to respond to the needs of patient # 10 and place the patient back on a cardiac monitor, oxygen and initiate a Code (institute ACLS protocol) without delay; and

5. RN staff failed to oversee and monitor the practice of the monitor tech in his/her response to cardiac rhythms and alarms, alert nursing staff when the leads became disconnected for patient # 10 and failing to recognize the patient did not display a cardiac rhythm on the screen for greater than a 45 minute period of time);

Findings include:

1. Review of hospital policy number DS.ICU.113, approved 5/30/14, "Nursing Care Scope of Practice" revealed: "...Standard Patient Care...assessments are performed every 4 hours...and documented on the electronic medical record by a qualified nurse...more frequent or partial assessments and vital signs are performed as the patient's condition warrants...."

Medical record review identified that Patient # 10 was admitted on 11/10/13, with chest pain, and numbness and tingling on the right side. Past medical history included intracoronary stent placement, diabetes, trans-ischemic attacks/cerebral vascular accident, obstructive sleep apnea, myocardial infarction, chronic obstructive pulmonary disease, congestive heart failure, hypertension, and arthritis. The patient was in lawful detention requiring two guards at the bedside 24/7. On 11/16/2013, the patient underwent open heart surgery for coronary artery bypass graft and aortic valve replacement and was admitted to ICU intensive care unit, room 112. Post operatively, on 11/19/2013, the patient developed moderate shortness or breath, stridor, and wheezing requiring different breathing treatments including: racemic epinephrine, indicated when stridor is present after removal of an endotracheal tube (extubation), albuterol to prevent or treat bronchospasm, Duo neb (combination of albuterol and atrovent) indicated for the treatment of bronchospasm associated with COPD (chronic obstructive airway disease) in patients requiring more than one bronchodilator, acetylcysteine, an adjunct therapy used in respiratory inhalation treatments for thickened mucous secretions and pulmonary complications of thoracic surgery, and Xopenex indicated to prevent or treat bronchospasm. On 11/19/2013 at 0100 hours a physician order was given for Bipap(bilevel positive airway pressure) to keep oxygen sats > 92%. On 11/20/2013, the patient required cardiopulmonary resuscitation, intubation,mechanical ventilation, and ACLS drugs. The patient remained unresponsive after the code, was diagnosed with anoxic encephalopathy (pathological deficiency of oxygen to the brain) and seizures. The patient expired on 12/3/2013, after all care was withdrawn.

Review of medical record revealed RN #44 documented an assessment at 1200 noon on 11/19/13. No other nursing assessments were documented until 2000 hours on 11/19/13. The RN failed to conduct a nursing assessment in four (4) hour intervals per policy and procedure.

2. Review of hospital policy number DS.ICU.113, approved 5/30/14, "Nursing Care Scope of Practice" revealed: "...the critical care nurse's practice is based on but not limited to ...critical care nursing standards of practice, policies and procedures...critical thinking,technical skills...knowledge of the inter-relatedness of body systems as the dynamic nature of the life process...collaboration with multi-disciplinary members of the health care team...direction from and collaboration with Medical staff...."

Review of medical record revealed RN # 33 documented the following: "...11/19/2013, at 2000 hours...Respiratory...Breath Sound Post (posterior) upper lobes wheezes expiratory, lower lobes diminished coarse...resp pattern...labored deep...sound/breathing...gasping...rhythm continuous sinus arryth (arrythmia) PAC (premature atrial contraction)...moaning inc (include) restlessness...11/20/2013...0015 hours...Respiratory...Breath Sound Post upper lobes wheezes expiratory, lower lobes diminished coarse...resp pattern...labored deep...sound/breathing...gasping...rhythm continuous atrial fib (fibrillation)...moaning inc restlessness... 0315 hours...patient's breathing is labored on the nasal cannula but he has been placed on Bipap several times tonight and has pulled the Bipap mask off each time along with his monitor leads...0415 hours...Respiratory...Breath Sound Post upper lobes wheezes expiratory, lower lobes diminished coarse...esp pattern...labored deep...sound/breathing...gasping....rhythm continuous atria fib...pt exhibits pain...moaning restlessness...0542 hours...was in another patient's room...heard the code alarm for room 112 (patient's room)...upon entering room...charge RN was at bedside starting CPR (cardiopulmonary resuscitation)...resuscitation concluded at 0552 hours...."

Review of physician progress notes, physician orders and nursing flowsheets in the medical record identified that no physicians were called with any of the signs and symptoms identified above from 11/19/13 1900 hours until the patient coded on 11/20/13 at 0541 hours.

Review of hospital document job code NUR1316 revealed: "...reports to the Director of ICU, BLS/ACLS required...formulates and revises plan of care as indicated by patient's response to treatment and evaluate overall plan...demonstrates the use of critical thinking skills and problem solving abilities in coordinating and supervising patient care...provides direct patient care to assigned patients...."

RN #33 confirmed during a telephone interview conducted on 12/5/2013 at 1530 hours, the patient had breathing issues, removed and refused Bipap through the night, was struggling to breath.

Physician #10 identified during an interview on 12/6/2013 at 1200 noon, that the patient may have been hypoxic as long as 12 hours. Physician # 10 also identified while making patient rounds, he assisted during the patient's code and resuscitation and remembers the patient to be unresponsive, with no blood pressure and required cardiac defibrillation.

3. Review of hospital policy number DS.ICU.113, approved 5/30/14, "Nursing Care Scope of Practice" revealed: Continuous cardiac monitoring...on each patient...interpretation of the ECG strips includes PR, QRS, ST segments and QT intervals; rate, rhythm, lead(s); and the nurse's signature...."

On 11/19/2013 at 2007 hours, the medical record revealed: "...cardiac monitoring strip...(no signature or interpretation)...11/20/2013 at 0209, cardiac monitor strip... (no signature or interpretation)...." At 04:57:50 the rhythm was not recorded and stops at 04:58:05 with a flat line. The rhythm resumes at 05:48:35.

Review of hospital document job code NUR1200 Unit Secretary/Monitor Technician-ICU revealed : "...interprets and documents patient's cardiac rhythms...maintains accuracy of electronic medical record in regards to rhythms to ensure complete and accurate patient care...."

4. Review of current ACLS (advanced cardiac life support) protocol includes: "...start analyzing the patient's heart rhythm...quickly search for possible causes of cardiac arrest...."

Guard # 43 confirmed during a telephone interview on 12/10/2013 at 1030, the patient # 10, had trouble breathing and kept taking off the monitor leads and oxygen "multiple times" during the early morning of 11/20/13. He explained the patient said the mask was uncomfortable. He reported each time the alarms sounded, the nurse responded to the alarms. This time the alarms sounded for a short period then stopped..."maybe they turn it off at the desk, I don't know. It was after the alarm stopped and the nurse didn't come in that they notified someone...the patient's nurse was in another patient's room at the time...."

RN # 36 was asked by the guard to check on patient # 10.

RN # 36 confirmed during an interview conducted on 12/6/2013 at 1030, the guard approached her and asked her to check the patient in room 112. RN # 36 noticed the patient was off all monitoring equipment, and the oxygen cannula was laying across the pillow. The patient was unresponsive and the radial pulse was weak. RN # 36 did not initiate a code, did not place the patient back on the monitor, or attempt respiratory resuscitation, but sought another RN for confirmation of the patient's condition. RN # 36, left the patient and sought assistance from RN # 37, the Charge Nurse, who was in room 116, with another patient emergency. RN # 36 was directed to RN #41, who was in an office of the nurses' station. RN # 41 assessed the patient, initiated CPR and called a code for assistance.

The hospital document titled cardiopulmonary resuscitation flowsheet for patient # 10, revealed: "...0541...11/20/13...pt. found non responsive in bed, pulseless & no respirations. Code called/CPR initiated....defibrillated twice...received 3 doses of 1:10,000 epinephrine and two doses of atropine 1 gram (sic)...time terminated 0552...patient successfully resuscitated...."

Review of personnel file for RN # 36 revealed date of hire May, 2013, current AZ RN, current ACLS, completed a 12 week orientation 7/7/2013 and graduated from nursing school 10/2012. No verification of cardiac rhythm competency was provided.

RN # 36 delayed calling a code for patient # 10, while she consulted with RN's in the ICU.

5. The medical record identifed Patient # 10 was off the cardiac monitor for greater than a 45 minute period of time with no documented notification to the nursing staff on the unit.

The patient was on a video camera, however; the monitor tech did not observe the patient's leads off and oxygen disconnected from the patient.

RN #33 confirmed during a telephone interview conducted on 12/5/2013 at 1530 hours, the guards were expected to to keep staff informed of something unusual or if patient removed monitoring equipment. RN # 33 confirmed monitors can be watched from another room, but this practice was not utilized the twelve (12) hours before the patient coded, and nobody caught the leads off for close to 25 to 30 minutes. The patient would desat quickly without oxygen, and the behavior of pulling of the monitor leads was probably due to hypoxia. The monitor tech has many jobs, and the monitoring alarms are not adequate to signify when monitors are off.

Monitor Tech # 34 confirmed during an interview conducted on 12/5/2013 at 1610, the monitor tech monitors the cardiac rhythms, the video, makes phone calls, and processes orders as necessary. The monitor alarms have yellow and red alarms with different tones. The monitor alarms can be turned off at the desk for brief periods of time. The red alarms are higher pitched than the yellow alarms. When the monitor alarms, a nurse is notified immediately. The monitor tech does not leave the desk to replace leads. All ICU patients are also continuously monitored by video at the desk. During a code, the monitor tech does secretarial duties as there are "back up eyes"(other nursing staff) watching the patients.

Guard # 43 confirmed during a telephone interview on 12/10/2013 at 1030, the patient had trouble breathing and kept taking off the monitor leads and oxygen "multiple times." The patient said the mask was uncomfortable. Each time the alarms sounded, the nurse responded to the alarms. This time the alarms sound for a short period then stopped..."maybe they turn it off at the desk, I don't know. It was after the alarm stopped and the nurse didn't come in is when they notified someone...the patient's nurse was in another patient's room at the time...." This officer was off-going when the code occurred, so did not witness the code.

Refer to # 4 above for confirmation of RN# 36

Physician #9 confirmed during an interview on 12/6/2013 at 1100, the patient had been improving and not expected to code with a respiratory arrest. The patient likely had anoxic brain injury with seizures after the code and resuscitation.

The CNO (Chief Nursing Officer), Quality Management, and ICU confirmed the nursing assessments were not performed every 4 hours per hospital policy, the RN failed to notify the Physician for changes in condition leading up to the code arrest, the cardiac rhythm strip was not verified and signed on the rhythm strip per hospital policy, RN # 36 failed to initiate ACLS or replace the monitor leads and oxygen to the patient, and the RN staff and monitor tech did not recognize the cardiac rhythm display was absent for greater than 45 minutes.

Based on review of policy and procedure, medical record, personnel files and physician and staff interviews, it was determined the hospital failed to require Respiratory services follow guidelines for delivering services and assessing for 1 of 1 patient # 10 in accordance with medical staff directives as demonstrated by failing to:

TAG 482.57(b)(4)-require respiratory therapy intervened for 1 of 1 patient # 10, who had gasping/labored respirations and failed to administer prn SVN treatments as ordered.

The cumulative effects of this practice and findings under the condition of Respiratory Services result in the failure of the hospital to be in compliance with 42 CFR 482 Subparts A, B, C and D, requirements for a hospital.

Based on review of hospital policies and procedures, medical records, job descriptions, and staff interviews, it was determined the hospital failed to require respiratory therapy intervened for 1 of 1 patient # 10, who had gasping/labored respirations and failed to administer prn SVN treatments as ordered.

Findings include:

Review of hospital policy DS.RESP.51 Respiratory Therapy Assessment and Reassessment revealed: "...each patient will have a basic assessment, which includes but may not be limited to assessment of breath sounds...cough production...Respiratory personnel will provide the respiratory care services and monitor the outcome of that care...Reassessment of the patient will be performed each time respiratory therapy is completed....or changes in condition are reported to the physcian and documented in the medical record...."

Review of patient # 10's medical record revealed the following documentation by nursing staff:

11/20/13:
0015 hours "...Respiratory...Breath Sound Post upper lobes wheezes expiratory, lower lobes diminished coarse...resp pattern...labored...deep...sound/breathing...gasping... moaning inc. (including) restlessness...."

0315 hours "...patient's breathing is labored on the nasal cannula but he has been placed on Bipap several times tonight and has pulled the Bipap mask off each time along with his monitor leads...."

0415 hours "...Respiratory...Breath Sound Post upper lobes wheezes expiratory, lower lobes diminished coarse...esp pattern...labored deep...sound/breathing...gasping....rhythm continuous atria fib...pt exhibits pain...moaning restlessness...."

0542 hours "...was in another patient's room...heard the code alarm for room 112 (patient's room)...upon entering room...charge RN was at bedside starting CPR (cardiopulmonary resuscitation)...resuscitation concluded at 0552 hours...."

Review of physician orders for patient # 10 revealed the patient had the following PRN medications for shortness of breath:

11/18/13:
1320 hours: " Xopenex 1.25mg neb TID PRN (as needed) sob (shortness of breath)...."

1912 hours: "Duoneb SVN q4h (every 4 hours) PRN...mucomyst (acetylcysteine) 2cc 10% + Albuterol 2.5mg SVN TID (three times a day)...."

Review of respiratory therapy staff documentation for 11/20/13 demonstrated the patient did not receive any PRN SVN breathing treatments on 11/20/13, prior to his code arrest.

The CNO, Quality Manager, and ICU Manager confirmed during an interview conducted on 12/06/13, patient # 10 had PRN SVN treatments ordered and none were given on 11/20/13, prior to the code arrest.

There was no respiratory assessment or reassessment for patient # 10, and no PRN SVN was given to the patient on 11/20/13.