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Based on record review and interview, the facility failed to identify opportunities for improvement and changes that related to an adverse incident that would lead to improvement for one (Patient #2) out of 5 sampled patients.

The finding include:

Record review revealed Patient #2 was admitted on 12/18/2021 with a diagnosis of COVID-19 and Acute Respiratory Distress. Patient #2 was admitted to the dedicated COVID-19 unit which was considered the facility's Progressive Care Unit (PCU.) He coded on 01/02/2022 due to pulmonary complications. Patient #2 had a documented critical respiratory rate (RR) of less than 10 breaths per minute (BPM) on 01/01/2022 and there wasn't any documented evidence that the nurse assigned to the patient reassessed the patient, initiate the Rapid Response Team (RRT) or inform the MD. A Root Cause Analysis (RCA) was conducted by the risk management department. The RCA looked at the shift in which the patient coded, but failed to thoroughly identify the critical RR that started 12 hours prior to the patient coding. The plan of correction for the adverse event did not include items to correct the deficiency in the failure to report the critical results to an MD and to initiate the Rapid Response Team.

Interview with Employee A, Risk Manager, on 04/13/22 at 1:00 PM confirmed that the RCA should have included the prior shift and that the RCA failed to recognize the critical respiratory rate that started on 01/01/2022, twelve hours prior to the patient coding.

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Based on record review and interview, the facility failed to ensure that patient needs were met by ongoing assessments of patients' needs for 1 (Patient #2) of 5 sampled patients.

The findings include:

Record review revealed Patient #2 was admitted on 12/18/2021 with a diagnosis of COVID-19 and Acute Respiratory Distress. Patient #2 was admitted to the dedicated COVID-19 unit which was considered the facility's Progressive Care Unit (PCU.) He remained in the facility and coded on 01/02/2022 due to pulmonary complications. Patient #2 had a documented critical respiratory rate of less than 10 breaths per minute (BPM) on 12/31/21 and there was not any documented evidence that the nurse assigned to the patient reassessed the patient or inform the MD.

Record review revealed the following Documented Reparatory Rates (RR):
01/01/22 at 4:00 PM RR 8
01/01/22 at 4:30 PM RR 9
01/01/22 at 5:00 PM RR 10
01/01/22 at 5:30 PM RR 10
01/01/22 at 5:44 PM RR 10
01/01/22 at 6:10 PM RR 9
01/01/22 at 7:00 PM RR 10
01/01/22 at 8:00 PM RR 9
01/01/22 at 8:30 PM RR 10
01/01/22 at 10:00 PM RR 9
01/01/22 at 11:00 PM RR 9
01/02/22 at 2:56 AM RR not documented

On 01/02/22 at 4:58 AM, Patient #2 went into a respiratory code blue and expired on 01/02/22 at 7:04 PM.

Review of facility policy titled "Rapid Response Policy - Florida" stated on page one that Rapid Response Team (RRT) will be activated with an acute and persistent change in RR of 10 or less BPM.

Review of the facility policy titled "Critical Results Policy" stated on page one that critical results (RR 10 or less) are directly communicated to the ordering provider within one hour of critical value. Page two stated that critical results are a variance from normal or expected values considered to be life-threatening unless immediate action is taken.

Interview with Employee A, Risk Manager, on 04/11/2022 at 11:00 AM confirmed that the nursing staff should have called the MD and Rapid Response Team due to the critical RR value and documentation of critical results communication should have been in the patient's chart.

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Based on record review and interviews, the facility failed to ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs for 2 (Patient #1, Patient #2) out of 5 patients sampled.

The finding include:

1. Record review revealed Patient #1 was admitted on 07/25/2020 with a diagnosis of severe Chronic Obstructive Pulmonary Disease (COPD) requiring a bilateral lung transplant. The transplant was completed during his stay at the facility on 07/26/2020. He was transferred to the Intensive Care Unit (ICU) post-transplant. He remained in the facility post-transplant, and he coded on 10/28/2020 due to cardio-pulmonary complications. Patient #1 did not have a have a respiratory care plan initiated upon admission.

2. Record review revealed Patient #2 was admitted on 12/18/2021 with a diagnosis of COVID-19 and Acute Respiratory Distress. Patient #2 was admitted to the dedicated COVID-19 unit which was considered the facility's Progressive Care Unit (PCU.) He remained in the facility and coded on 01/02/2022 due to pulmonary complications. Patient #2 did not have a respiratory care plan initiated upon admission.

Review of the facility policy titled "Care Plan Preparation" revealed on page one that a care plan directs a patient's nursing care from admission to discharge. The care plan consists of three parts: goals or expected outcomes, which describe behaviors or results to be achieved within a specified time; appropriate nursing actions or interventions needed to achieve these goals; and evaluations of the established goals.

Review of the facility policy titled "Multidisciplinary Assessment and Plan of Care" (03/2022) stated on page one that plans of care must be developed and documented in the patient's medical record. Nursing will conduct an initial assessment to determine the care, treatment, and services that will meet the patient initial and continuing needs.

Interview with Employee A, Risk Manager, on 04/13/2022 at 10:00 AM confirmed that a respiratory care plan should have been initiated on Patient #1 and Patient #2 upon admission.


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