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Based on interviews and document review, the facility failed to provide ongoing nursing care based on standards of nursing practice and facility policy. In addition, the facility failed to ensure appropriate staff and a physician were notified of changes in the patient's condition in 1 of 10 records reviewed (Patient #4).

This failure created the potential for patients' physical needs not being addressed or monitored.

FINDINGS

POLICY:

According to the Rapid Response/Code Blue (Cardiopulmonary Resuscitation) Response, a patient that has an adverse change in condition and the caregiver feels there is a need for assistance in the treatment or diagnosis of the changing condition, a Rapid Response may be activated.

According to Plan for Patient Care Services, each patient's assessment includes physical, functional, psychological and social status. A plan for patient's care/treatment needs is developed based on analysis of data collected. A Registered Nurse assesses the patient's need for care in all settings where nursing care is provided. Nursing reassessment continues throughout the patient's stay.

According to Chain of Command/ Communication, Patient Care, for clinical issues, the staff member needs to determine the urgency of the issue and move rapidly to the appropriate level or resource person in order to ensure patient safety and an optimal outcome. If unable to reach a physician to address a patient care concern, any of the medical staff leaders have the authority and responsibility to enlist a substitute provider to resolve the immediate problem.

According to Critical Alarms and Patient Safety Guidelines, full assessments in the Progressive Care Unit are expected to be completed every 12 hours, focused system reassessment PRN as condition warrants.

According to Centralized Telemetry Monitoring, telemetry monitoring will not be interrupted unless otherwise ordered by a physician, NP or PA. RN will answer phone calls from the centralized telemetry monitoring station immediately. If the RN does not answer immediately, the Telemetry Technician (TT) will escalate the phone call to next in chain of command (ex: CNC, Manager, Director, Hospital Supervisor, OR TT will call Rapid Response).

RN or nursing designee will respond immediately to the patients' room to assess patient based on information shared by TT on phone call.

Yellow Alarms include non-sustained Ventricular Tachycardia (VTach) greater than 10 beats, leads becoming detached or loss of tracing for any reason. In the event of a Yellow Alarm, the TT will call the RN, then the Charge RN. If no response within 2 minutes, Call Manager or Director of the unit patient is located. If no answer, immediately call Hospital Supervisor to come immediately to the unit and assess the situation. If the patient has not been placed back on telemetry within 6 minutes, call for Rapid Response.

Green Alarms involve changes that require nurse and physician notification, such as non-sustained VTach less than 10 beats.

1. The facility failed to ensure appropriate staff and medical personnel were notified of abnormal assessment patient findings.

a) A review of Patient #4's Discharge Summary, dated 10/27/16 at 11:06 p.m., revealed the patient was admitted on 10/07/16 for a presumed Non ST Elevation Myocardial Infarction (Non STEMI). Patient #4 underwent a cardiac catheterization and a balloon angioplasty on 10/07/16.

On 10/17/16 at 8:10 a.m., and at 10:20 p.m. Shift Assessment documentation reported Patient #4 had frequent liquid stools, a tender abdomen at palpation and hypoactive bowel sounds.

Review of Nurse Notes showed the following documentation:

On 10/19/16 at 9:00 a.m., Patient #4 had difficulty swallowing pills and that a physician was paged in order to place a speech therapy order.

At 10:28 a.m. the note stated there was no call back from the physician but that an order for speech therapy had been placed.

At 11:15 a.m. a note entry stated the Registered Nurse (RN) was called by the Certified Nursing Assistant (CNA) and was informed the patient had abdominal discomfort and an increased respiration rate of 24-26 breaths per minute. The physician was paged again at that time.

At 12:00 p.m. a Nurse Notes entry stated there was no call back from the physician about the abdominal distention and that s/he was paged again.

There was no further documentation regarding notification to the Charge Nurse or other medical staff leaders after the physician did not respond to being paged 3 times within a 3 hour period. This was in contrast to facility policy which stated if unable to reach a physician to address a patient care concern any of the medical staff leaders had the authority and responsibility to enlist a substitute provider to resolve the immediate problem.

On 10/19/16 at 1:00 p.m., a Nurse Notes entry stated the RN received call from a physician (a different than the physician previously paged) stating the patient had passed away. The RN went to the room and the patient was unresponsive, cyanotic and no pulses were found. No heart beat was auscultated apically.

b) On 11/02/16 at 9:49 a.m., an interview with RN #4 was conducted who stated s/he recalled caring for Patient #4 on 10/19/16. RN #4 stated the patient was not in pain at first but reported abdominal discomfort to the CNA at around 11:00 a.m. RN #4 stated s/he went into Patient #4's room about 15 minutes later and the patient looked uncomfortable. RN #4 stated s/he thought s/he paged Patient #4's physician between 3 to 4 times that morning with no results.

RN #4 then stated s/he had heard a lot of overhead pages for the same physician that day and that s/he had received a call from pharmacy staff who stated they were also trying to page the physician regarding an unrelated issue. RN #4 further stated s/he did not page anyone else regarding Patient #4's abdominal discomfort.

c) On 11/02/16 at 1:04 p.m., an interview with the Manager of the Progressive Care Unit (Manager #9) was conducted. When asked how long staff were expected to wait for a physician to respond to a page from staff regarding a patient concern, Manager #9 stated it would depend on the severity of the page but generally around 15 minutes would be acceptable. If there was no response, Manager #9 stated staff were expected to repage the physician and notify the charge nurse.

d) On 11/02/16 at 2:32 p.m., an interview with the Chief Nursing Officer (CNO #3) was conducted. CNO #3 stated s/he was not aware of a policy offering guidance on how long staff were expected to wait for a physician to respond to a page before notifying their manager. CNO #3 further stated s/he would expect staff to escalate patient concerns to their manager after paging the physician once or twice and not receiving a response in 15 minutes.

2. The facility did not ensure when policy defined alarms were identified for patients on telemetry monitors that the incidents were being documented by Telemetry Technicians (TT) per facility expectation.

a) Review of the History and Physical (H&P) for Patient #2 revealed the patient was admitted on 10/30/16 with a chief complaint of progressive generalized swelling and shortness of breath. The H&P reported Patient #2 was markedly hypertensive upon presentation to the Emergency Room (ER) with a blood pressure of 223/127 millimeters of mercury (mmHg). Patient #2 was admitted for concern of possible nephrotic syndrome.

Review of Patient #2's Nurse Notes dated 10/31/16 revealed Patient #2 experienced 16 beats of Ventricular Tachycardia (VTach - a very fast heart rate which can lead to negative outcomes for patients) at 7:21 p.m. and 7 beats of VTach at 11:10 p.m.

b) Review of the Daily Worksheet Log used by TTs to document telemetry alarms and communication with staff regarding those alarms revealed no evidence of documentation of the 2 episodes of VTach experienced by Patient #2 on 10/31/16.

c) On 11/02/16 at 10:26 a.m., an interview was conducted with TT #5, who stated s/he worked as a technician in the centralized telemetry unit. TT #5 stated his/her job responsibilities included notifying staff of any telemetry alarms initiated for each patient being monitored and to document the notification on the Log.

TT #5 then stated s/he was recently made aware of a new version of the log but s/he did not receive any education on the expectations for completing the new log.

d) On 11/2/16 at 1:04 p.m., an interview was conducted with the Manager of the Telemetry Technicians (Manager #9). Manager #9 stated a change in the documentation process for the TTs was recently implemented after an event occurred where a patient's heart rhythm was not being displayed on the telemetry monitor for more than 40 minutes due to the battery needing to be changed. During the lapse of monitoring, the patient had died.

After this event occurred, Manager #9 stated a new form was implemented and TTs were expected to document every phone call made to staff notifying them of a telemetry alarm. Manager #9 then reviewed the 2 incidents of VTach that occurred with Patient #2 and verified that the phone calls to notify staff of the irregular heart rhythm were not documented on the form but should have been.

Based on observations and interviews, the facility failed to ensure patient care supplies were stored in a manner to avoid diversion or tampering with from unauthorized personnel.

This failure created the potential for unauthorized staff, patients, and visitors to divert or tamper with supplies intended for patient use.

FINDINGS:

1. The facility did not ensure medications and supplies used for the administration of medications were secured in a manner to avoid diversion or tampering.

a) On 10/31/16 at 2:05 p.m., a tour of patient rooms in the Intensive Care Unit (ICU) was conducted and revealed the following unsecured patient medications and supplies:

ICU Room 5 revealed a mobile supplies cart with no ability to be locked. Two sets of Intravenous (IV) tubing were observed on top of the cart. The first drawer of the cart revealed several blunt tipped needles, 5 prefilled syringes of normal saline, IV caps, and alcohol cleansing wipes. The second drawer of the cart revealed several syringes of various sizes. The third drawer of the cart revealed patient gowns and linens.

ICU Room 40 revealed a mobile supplies cart with no ability to be locked. The first drawer of the cart revealed several alcohol cleansing wipes, IV caps and electrocardiogram (EKG) electrodes. The second drawer of the cart revealed several syringes of various sizes. The third drawer of the cart revealed patient gowns and linens.

b) On 10/31/16 at 2:30 p.m. a tour of the Emergency Department (ED) was conducted. During the tour, an unlocked mobile supplies cart was located in a hallway outside of the triage room. Inspection of the drawers of the cart revealed blunt IV needles, angio catheters, band aids, 5 IV starter kits and dressings, 7 1000 milliliter (ml) IV bags of normal saline, and 17 prefilled syringes of normal saline.

c) On 11/01/16 at 9:28 a.m., an interview was conducted with a Registered Nurse (RN #1), who stated s/he worked in the ICU. RN #1 stated the facility was in the process of working on obtaining supplies carts for each patient room that could be locked. RN #1 then stated there was no way to ensure supplies stored in the current supplies cart were free from being diverted or tampered with.

d) On 11/02/16 at 1:57 p.m., an interview was conducted with RN #2 who stated s/he worked as a charge nurse in the ED. RN #2 stated the supplies cart located outside of the triage room was expected to be locked at all times. RN #2 then stated s/he was unaware of why the cart had been observed unlocked but that staff knew it was supposed to be locked.

e) On 11/02/16 at 2:32 p.m., an interview with the Chief Nursing Officer (CNO #3) was conducted. CNO #3 stated it had been common practice to have unlocked supplies carts located in each ICU patient room. CNO #3 then stated the expectation was to empty and discard all supplies in the carts after patients were discharged; however, there did not seem to be a consistent practice for ensuring this was done.

Based on interviews and document review, the facility failed to provide ongoing nursing care based on standards of nursing practice and facility policy. In addition, the facility failed to ensure appropriate staff and a physician were notified of changes in the patient's condition in 1 of 10 records reviewed (Patient #4).

This failure created the potential for patients' physical needs not being addressed or monitored.

FINDINGS

POLICY:

According to the Rapid Response/Code Blue (Cardiopulmonary Resuscitation) Response, a patient that has an adverse change in condition and the caregiver feels there is a need for assistance in the treatment or diagnosis of the changing condition, a Rapid Response may be activated.

According to Plan for Patient Care Services, each patient's assessment includes physical, functional, psychological and social status. A plan for patient's care/treatment needs is developed based on analysis of data collected. A Registered Nurse assesses the patient's need for care in all settings where nursing care is provided. Nursing reassessment continues throughout the patient's stay.

According to Chain of Command/ Communication, Patient Care, for clinical issues, the staff member needs to determine the urgency of the issue and move rapidly to the appropriate level or resource person in order to ensure patient safety and an optimal outcome. If unable to reach a physician to address a patient care concern, any of the medical staff leaders have the authority and responsibility to enlist a substitute provider to resolve the immediate problem.

According to Critical Alarms and Patient Safety Guidelines, full assessments in the Progressive Care Unit are expected to be completed every 12 hours, focused system reassessment PRN as condition warrants.

According to Centralized Telemetry Monitoring, telemetry monitoring will not be interrupted unless otherwise ordered by a physician, NP or PA. RN will answer phone calls from the centralized telemetry monitoring station immediately. If the RN does not answer immediately, the Telemetry Technician (TT) will escalate the phone call to next in chain of command (ex: CNC, Manager, Director, Hospital Supervisor, OR TT will call Rapid Response).

RN or nursing designee will respond immediately to the patients' room to assess patient based on information shared by TT on phone call.

Yellow Alarms include non-sustained Ventricular Tachycardia (VTach) greater than 10 beats, leads becoming detached or loss of tracing for any reason. In the event of a Yellow Alarm, the TT will call the RN, then the Charge RN. If no response within 2 minutes, Call Manager or Director of the unit patient is located. If no answer, immediately call Hospital Supervisor to come immediately to the unit and assess the situation. If the patient has not been placed back on telemetry within 6 minutes, call for Rapid Response.

Green Alarms involve changes that require nurse and physician notification, such as non-sustained VTach less than 10 beats.

1. The facility failed to ensure appropriate staff and medical personnel were notified of abnormal assessment patient findings.

a) A review of Patient #4's Discharge Summary, dated 10/27/16 at 11:06 p.m., revealed the patient was admitted on 10/07/16 for a presumed Non ST Elevation Myocardial Infarction (Non STEMI). Patient #4 underwent a cardiac catheterization and a balloon angioplasty on 10/07/16.

On 10/17/16 at 8:10 a.m., and at 10:20 p.m. Shift Assessment documentation reported Patient #4 had frequent liquid stools, a tender abdomen at palpation and hypoactive bowel sounds.

Review of Nurse Notes showed the following documentation:

On 10/19/16 at 9:00 a.m., Patient #4 had difficulty swallowing pills and that a physician was paged in order to place a speech therapy order.

At 10:28 a.m. the note stated there was no call back from the physician but that an order for speech therapy had been placed.

At 11:15 a.m. a note entry stated the Registered Nurse (RN) was called by the Certified Nursing Assistant (CNA) and was informed the patient had abdominal discomfort and an increased respiration rate of 24-26 breaths per minute. The physician was paged again at that time.

At 12:00 p.m. a Nurse Notes entry stated there was no call back from the physician about the abdominal distention and that s/he was paged again.

There was no further documentation regarding notification to the Charge Nurse or other medical staff leaders after the physician did not respond to being paged 3 times within a 3 hour period. This was in contrast to facility policy which stated if unable to reach a physician to address a patient care concern any of the medical staff leaders had the authority and responsibility to enlist a substitute provider to resolve the immediate problem.

On 10/19/16 at 1:00 p.m., a Nurse Notes entry stated the RN received call from a physician (a different than the physician previously paged) stating the patient had passed away. The RN went to the room and the patient was unresponsive, cyanotic and no pulses were found. No heart beat was auscultated apically.

b) On 11/02/16 at 9:49 a.m., an interview with RN #4 was conducted who stated s/he recalled caring for Patient #4 on 10/19/16. RN #4 stated the patient was not in pain at first but reported abdominal discomfort to the CNA at around 11:00 a.m. RN #4 stated s/he went into Patient #4's room about 15 minutes later and the patient looked uncomfortable. RN #4 stated s/he thought s/he paged Patient #4's physician between 3 to 4 times that morning with no results.

RN #4 then stated s/he had heard a lot of overhead pages for the same physician that day and that s/he had received a call from pharmacy staff who stated they were also trying to page the physician regarding an unrelated issue. RN #4 further stated s/he did not page anyone else regarding Patient #4's abdominal discomfort.

c) On 11/02/16 at 1:04 p.m., an interview with the Manager of the Progressive Care Unit (Manager #9) was conducted. When asked how long staff were expected to wait for a physician to respond to a page from staff regarding a patient concern, Manager #9 stated it would depend on the severity of the page but generally around 15 minutes would be acceptable. If there was no response, Manager #9 stated staff were expected to repage the physician and notify the charge nurse.

d) On 11/02/16 at 2:32 p.m., an interview with the Chief Nursing Officer (CNO #3) was conducted. CNO #3 stated s/he was not aware of a policy offering guidance on how long staff were expected to wait for a physician to respond to a page before notifying their manager. CNO #3 further stated s/he would expect staff to escalate patient concerns to their manager after paging the physician once or twice and not receiving a response in 15 minutes.

2. The facility did not ensure when policy defined alarms were identified for patients on telemetry monitors that the incidents were being documented by Telemetry Technicians (TT) per facility expectation.

a) Review of the History and Physical (H&P) for Patient #2 revealed the patient was admitted on 10/30/16 with a chief complaint of progressive generalized swelling and shortness of breath. The H&P reported Patient #2 was markedly hypertensive upon presentation to the Emergency Room (ER) with a blood pressure of 223/127 millimeters of mercury (mmHg). Patient #2 was admitted for concern of possible nephrotic syndrome.

Review of Patient #2's Nurse Notes dated 10/31/16 revealed Patient #2 experienced 16 beats of Ventricular Tachycardia (VTach - a very fast heart rate which can lead to negative outcomes for patients) at 7:21 p.m. and 7 beats of VTach at 11:10 p.m.

b) Review of the Daily Worksheet Log used by TTs to document telemetry alarms and communication with staff regarding those alarms revealed no evidence of documentation of the 2 episodes of VTach experienced by Patient #2 on 10/31/16.

c) On 11/02/16 at 10:26 a.m., an interview was conducted with TT #5, who stated s/he worked as a technician in the centralized telemetry unit. TT #5 stated his/her job responsibilities included notifying staff of any telemetry alarms initiated for each patient being monitored and to document the notification on the Log.

TT #5 then stated s/he was recently made aware of a new version of the log but s/he did not receive any education on the expectations for completing the new log.

d) On 11/2/16 at 1:04 p.m., an interview was conducted with the Manager of the Telemetry Technicians (Manager #9). Manager #9 stated a change in the documentation process for the TTs was recently implemented after an event occurred where a patient's heart rhythm was not being displayed on the telemetry monitor for more than 40 minutes due to the battery needing to be changed. During the lapse of monitoring, the patient had died.

After this event occurred, Manager #9 stated a new form was implemented and TTs were expected to document every phone call made to staff notifying them of a telemetry alarm. Manager #9 then reviewed the 2 incidents of VTach that occurred with Patient #2 and verified that the phone calls to notify staff of the irregular heart rhythm were not documented on the form but should have been.

Based on observations and interviews, the facility failed to ensure patient care supplies were stored in a manner to avoid diversion or tampering with from unauthorized personnel.

This failure created the potential for unauthorized staff, patients, and visitors to divert or tamper with supplies intended for patient use.

FINDINGS:

1. The facility did not ensure medications and supplies used for the administration of medications were secured in a manner to avoid diversion or tampering.

a) On 10/31/16 at 2:05 p.m., a tour of patient rooms in the Intensive Care Unit (ICU) was conducted and revealed the following unsecured patient medications and supplies:

ICU Room 5 revealed a mobile supplies cart with no ability to be locked. Two sets of Intravenous (IV) tubing were observed on top of the cart. The first drawer of the cart revealed several blunt tipped needles, 5 prefilled syringes of normal saline, IV caps, and alcohol cleansing wipes. The second drawer of the cart revealed several syringes of various sizes. The third drawer of the cart revealed patient gowns and linens.

ICU Room 40 revealed a mobile supplies cart with no ability to be locked. The first drawer of the cart revealed several alcohol cleansing wipes, IV caps and electrocardiogram (EKG) electrodes. The second drawer of the cart revealed several syringes of various sizes. The third drawer of the cart revealed patient gowns and linens.

b) On 10/31/16 at 2:30 p.m. a tour of the Emergency Department (ED) was conducted. During the tour, an unlocked mobile supplies cart was located in a hallway outside of the triage room. Inspection of the drawers of the cart revealed blunt IV needles, angio catheters, band aids, 5 IV starter kits and dressings, 7 1000 milliliter (ml) IV bags of normal saline, and 17 prefilled syringes of normal saline.

c) On 11/01/16 at 9:28 a.m., an interview was conducted with a Registered Nurse (RN #1), who stated s/he worked in the ICU. RN #1 stated the facility was in the process of working on obtaining supplies carts for each patient room that could be locked. RN #1 then stated there was no way to ensure supplies stored in the current supplies cart were free from being diverted or tampered with.

d) On 11/02/16 at 1:57 p.m., an interview was conducted with RN #2 who stated s/he worked as a charge nurse in the ED. RN #2 stated the supplies cart located outside of the triage room was expected to be locked at all times. RN #2 then stated s/he was unaware of why the cart had been observed unlocked but that staff knew it was supposed to be locked.

e) On 11/02/16 at 2:32 p.m., an interview with the Chief Nursing Officer (CNO #3) was conducted. CNO #3 stated it had been common practice to have unlocked supplies carts located in each ICU patient room. CNO #3 then stated the expectation was to empty and discard all supplies in the carts after patients were discharged; however, there did not seem to be a consistent practice for ensuring this was done.