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Based on record review, policy review and staff interview it was determined the registered nurse failed to ensure patients were reassessed and failed to provide nursing care and services to meet the needs for one (#9) of 10 sampled patients for changes in condition.

Findings include:

Patient #9's physician orders dated 12/26/14 at 5:21 p.m. included instructions for the nurse to take the patient's vital signs on 12/26/14 at 6:30 p.m., 7:30 p.m., 9:30 p.m., 11:30 p.m., (12/27/14) 3:30 a.m., 7:30 a.m., 11:30 a.m., 3:30 p.m. and then once every shift. The order included instructions to notify the physician or nurse practitioner if changes.

The Vitals Flow Sheet dated 12/26/14 at 9:59 p.m., approximately four hours following her return to the nursing unit after surgery, indicated Patient #9's oxygen saturation was 92% on room air, blood pressure was 129/67, respirations were 18 per minute and the pulse was 89 per minute.

The vital signs were next documented at 11:34 p.m., approximately one and one half hours later. Patient #9's blood pressure was 92/45, respirations were 18 per minute and the pulse was 118 per minute. There was no evidence the patient's oxygen saturation was measured at 11:34 p.m.

There was no evidence of additional nursing reassessment of Patient #9 until 12/27/14 at 1:00 a.m. when the RN documented the patient was found pulseless and unresponsive.

The facility policy entitled Vital Signs, policy #TX-26, last revised 9/2012 was reviewed on 10/8/14. Page 1, Definitions indicated vital signs were defined as temperature, blood pressure, pulse, oxygen saturation and respirations.

The facility policy entitled Reassessment, policy #PE-5, last revised 6/2006 was reviewed on 10/18/14. Page 1, C indicated the reassessment process is documented on flow sheets, nurses notes, education records and/or plan of care.

An interview was conducted with RN #1 on 10/8/2014 at approximately 2:00 p.m. RN #1 was presented with a hypothetical clinical scenario of a post-operative surgical patient with Patient #9's vital sign information. She was asked what actions, if any, would she take. RN #1 indicated she would assess the patient for any additional symptoms: cold, clammy skin, pain, swelling at the operative site or indications of bleeding. She would arouse the patient if sleeping and ask how the patient was feeling and assess the patient's response. She indicated she would recheck the patient's vital signs to confirm the accuracy of the low blood pressure and high pulse. She would check the oxygen saturation level to evaluate whether it had increased or decreased from the previous reading. She indicated depending on the information she obtained she would possibly monitor the patient, rechecking her in 15 minutes or 30 minutes or notify the physician of the patient's change in condition immediately.

An interview and record review was conducted with the Risk Manager on 10/8/14 at approximately 4:00 p.m. She confirmed the findings Patient #9 had a significant change in condition between 9:59 p.m. and 11:34 p.m. on 12/26/14. She confirmed the finding the RN failed to ensure Patient #9's vital signs were taken in accordance with the physician order and facility policy. She confirmed the finding the RN assigned to the care of Patient #9 failed to appropriately reassess the patient and failed to take appropriate nursing action.