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Based on observation, staff interviews and facility and clinical record reviews, the facility failed to ensure that staffing is effective and sufficient to provide and ensure the provision of quality nursing care to 2 of 3 sampled patients (#1, #3).

Findings include:

An interview was conducted on 3/07/11 at approximately 8:50 AM, with the Nursing Manager who was asked to describe the facility ' s staffing policy The Manager stated the ratio of Nurses to Patients on the 2nd and 3rd floor is 1 nurse to 6 patients, and 1 Certified Nursing Assistant (C.N.A. ) to 10 patients. In the Intensive Care Unit on the fourth floor the ratio is one Nurse to every 2 or 3 patients. There is a Monitor Technician (MT) who reports to Nursing and is stationed on the 3rd floor. The MT continuously monitors all patients on Telemetry including those on Ventilators. The facility has a Unit Secretary who is either positioned in the ICU or 3rd floor, who covers for the MT when he goes on breaks.

A review of the facility staffing for February 2011 through March 06, 2011
disclosed on 2/20/11, the staffing was 2 Nurses and 1 C.N.A. on the 2nd floor scheduled to provide care for 12 patients of whom 8 were on Telemetry and 5 were on Ventilators.

The Nurse Manager was asked to describe how the facility ensures staff respond to patient call bells and alarms in a timely manner. She stated, we started giving each Nurse a phone since February 2011. Everyone is responsible to answer call bells whether it is their patient or not. The screen used by the Monitor Technician also has call lights on it, so he can notify the nurse as well. If a Ventilator alarm sounds it is a green light, and if it is a call bell, it is a yellow light. When staff respond and turn off the alarm, the screen light viewed by the technician turns off. We started using the phones because of the patient and physician complaints about call bell response times. We were doing audits, but the staff wasn ' t turning off the call lights and it was skewing the data, so we tried the phones instead.

A review of the Job Description for the Monitor Technician reveal the position reports to the Clinical Nurse Manager of the Nursing Department. Review of the Job Summary reveals the following Job descriptions: Monitors rhythm pattern of patients to detect abnormal pattern variances, using telemetry equipment; Reviews patient information to determine normal heart rhythm pattern, current pattern and prior variances. Observes screen of cardiac monitor, and listens for alarm to identify abnormal variation in heart rhythm. The job specific responsibilities and duties include the following:
? Monitors telemetry of patients by observing telemetry monitors for changes in cardiac rhythms.
? Maintains accurate records of telemetry patients.
? Immediately notifies R.N. or Supervisors of rhythm changes.
? Answers the telephone and intercom and takes messages and communicates information to the appropriate person.

A review of the facility ' s policy and procedure for resuscitation disclosed the following:
? The facility will maintain sufficient numbers of qualified staff to implement resuscitative services as appropriate.
? Evaluate the effectiveness of the plan ' s implementation through on-going performance improvement activities, such as Code Blue Critiques and aggregate data analysis regarding findings and patient outcomes.

A review of the Grievance Log dated January 2010 through 03/06/11 revealed multiple complaints regarding the lack of timely response to call bells and/or alarms. A grievance filed by a family member of Patient #1 dated 2/21/11 specifies the patient was off the Ventilator for 8 minutes on 2/20/11. The family member wanted to know why no one heard the alarm and responded, and requested to be informed what is the Hospital ' s plan to prevent this in the future. The Risk Manager documented on the Patient and Family Grievance Report Form, dated 2/21/11, interviews were conducted with the Nursing Supervisor and nursing staff involved; Attached Nurse Notes dated 2/20/11 at 1835 reveal the following entry, " Told by C.N.A. on duty that patient was disconnected from the Ventilator. I went into the patient's room and saw the patient off the Ventilator, turning blue, heart rate 44, unable to read Oxygen saturation level, unresponsive. Immediately I ambu ' d (perform mechanical / manual ventilation) the patient, and rapid response was called. Patient came back to his baseline with Oxygen. Apical pulse 44 /minute. Oxygen saturation95 %, blood pressure 158/92, heart rate 67.

A review of the Supervisors Report dated 2/20/11 revealed that Patient #1 experienced a Code Blue/ Change of Condition at 6:36PM. The Supervisor met with a family member of Patient #1 at 9:16PM as the patient had been off the ventilator for 8 minutes. The Supervisor reassured the patient that he was in the most appropriate place and that she would check / monitor him frequently.

A review of the Rapid Response Team Records dated 2/20/11 revealed the following documentation, " Time 1835, telemetry SB, RR 44, Action taken: Pt bagged by RT and placed back on vent. Oxygen saturation less than 85 % sustained despite Oxygen therapy.

At 11:28 AM, on 03/07/11 the Surveyor conducted an interview with the Nurse Practitioner who stated, she saw Patient #1 the day after he became disconnected from the ventilator. She stated, " I was told that they heard the vent alarm go off in the room. He was unconscious and they hooked him back up and he had no other issues". He is on very high settings, so if he comes off he will desaturate pretty well. I am sure if he came off the vent, it took no time for him to de saturate and he is very anxious. "

An interview was conducted at the bedside of Patient #1 who consented to an interview with his faimily member at 11:57 AM. The family member stated, she wasn ' t at the facility, but received a call at home notifying her that the respirator dislodged but the patient was fine. When she got to the Hospital, he stated, " It dislodged. I couldn ' t ring the bell and nobody came. I panicked and the next thing I knew I was passed out. I woke up and there were 7 people over me bagging me. I was petrified. I don ' t know what was happening to me. " We talked to the staff and they told us the facility is understaffed. Our experience is that you can ' t get anyone to answer the phone at night. Nobody is ever at the desk. I know it was the aide who noticed it. She just happened to come by and heard it. I know that his nurse was down the hall taking care of another patient. "

An interview was conducted with the Nurse #1 who was assigned to care for Patient #1 on 2/20/11 at approximately 12:30 PM on 03/07/2011. Nurse #1 was asked to describe the events of 2/20/11. The nurse stated, " I was coming out of another patient ' s room all the way at the end of the hall. I approached the Patient (#1) ' s room and saw the alarm going off. I saw the C.N.A. and asked what was going on. She stated that the patient was off the vent. I asked her if she had told anyone, and she said she had told the other nurse to go check on the patient. I went to the room and the other nurse was already checking all the wires to reconnect the patient, but hadn ' t yet placed him back on the vent. We started to ambu the patient right away and called respiratory immediately to check on him. He regained consciousness after respiratory arrived. " When the nurse was asked if she was aware of how long Patient #1 had been disconnected from the vent, she replied. " I was in room 202, I don't know. " The Surveyor asked the nurse if she had been called and/or notified by the Monitor Technician (MT) that Patient #1 ' s ventilator was disconnected. The Nurse stated she was not notified by the MT and was unaware of how long the patient was disconnected.

During an interview conducted with employee #2 (C.N.A.) at 12:53 PM, the employee was asked to describe the events of 2/20/11. She stated, " I was in room #222 with Nurse # 2 caring for a patient. We walked out of the room at the same time and we saw and heard the green light. The Nurse went into the patient's room and I went to the Nurses station which is directly opposite the Patient's (#1) room. The Nurse came to the door and told me to call respiratory which I did. She then came back to the door and said to call a " Rapid Response". I went to " gown up " to go into the room and everyone (the rapid response team) arrived at that time. I didn ' t stop to tell the other nurse (#1), as she was on the other hall. I saw her after the fact. As soon as we came out of room # 222, we heard and saw the green light. Unless you are in the hall, you don ' t know when another alarm sounds. You can only hear the alarms inside the room. "

A subsequent interview was conducted with employee #3, a Nurse, at 1:06 PM. She stated, " It was around 6:30 PM. I was in another patient ' s room with the C.N.A. And when we came out of the room we saw and heard the green light. I went in as soon as I saw it and the Patient (#1) was disconnected from the vent. He was desaturating, so I told the C.N.A. to call Respiratory. I was going to reconnect the vent, but it had come apart in a couple of places, so I yelled for the C.N.A. to call " Rapid Response " . I had started to hook up the ambu bag and the wall Oxygen when the other Nurse (Employee #1) came in. She was in a room with another patient and did not see or hear the light. The team showed up and took over bagging the patient. He came back up, but he wasn ' t awake. I think there should be more staff when we have so many patients on vents. With one nurse at one end of the hall and one on the other, there is nobody in the hall or desk to hear the alarms. You can ' t hear when you are in a room what is happening outside in the hall. The Monitor Tech did not call me on my phone. "

An interview was conducted at 2:30 PM with the Respiratory Therapist (Employee #4) who stated that he was in ICU when he heard a " Rapid Response code called " . " I went to the room and the patient was off the vent and the nurse was bagging him. His color was off and he looked bad. I did this for a minute or two and his color returned. He started to wake up and he was oxygenating. When I asked if he was ok, he shook his head no. I put him back on the vent and he told me, you needed to come sooner. " Review of the Respiratory Therapy Notes dated 2/20/11 did not reveal any documentation regarding the disconnection of Patient #1 ' s ventilator. Review of the Pulmonary Physician's Progress Note dated 2/21/11 reveal the following entry, " The patient did pull himself off mechanical ventilation, which did put him in some distress. "

The Director of Quality / Risk Management was interviewed on 03/07/11 at approximately 2:00PM.

She confirmed that an interview was not conducted with the Monitoring Technician. When asked if the MT should have notified the nurse as soon as the ventilator alarm sounded, she confirmed that this should have happened, but could not explain why the MT did not place a call to either nurse or the Nursing Supervisor. Facility staff was unable to determine at what time the alarm sounded; the MT did not respond to the Ventilator alarm by notifiying either of the Nurses or the Supervisor as listed in the job description. The Director confirmed they do not have any reports or logs that would reveal at what time the initial ventilator alarm sounded.

The Director of Quality/ Risk Management, Nursing Manager and Chief Clinical Officer confirmed at 3:35PM on 03/07/11 the following:

? Facility staff was unaware that Patient #1 had been disconnected from the ventilator until they exited another patient ' s room into the hallway.
? The Monitoring Technician failed to notify Nursing staff and/or Supervisor when the ventilator alarm sounded and those interviewed confirmed that this did not occur. It is unknown why the MT failed to notify staff when the event occurred.
? The facility confirms that there remains pervasive concerns from patients and staff regarding the availability of sufficient staff to provide timely care in accordance with patient requests for assistance and/or alarms.


Review of the Grievance Form dated 3/6/11 reveals the following notation, " Patient #3 states he called for the nurse with call bell and it took someone 30 minutes to respond. During that time he could hear people walking by and not coming in. He is frustrated with the staff not answering his call bell in a timely manner. " Department Manager ' s findings , " on the night shift of 03/04/11 and 03/05/11 there was only 1 C.N.A. for the 3rd floor". Immediate action taken: Apologized and spoke to day shift staff about answering call bell in a timely manner. Will speak to supervisor tonight to round more frequently on this patient".

Based on clinical record reviews and staff interviews, the facility failed to effectively activate the QAPI system to investigate and resolve a lack of timely response to patient alarms. This failure affected for one of 3 sampled patients (#1).

Findings include:
1) Clinical Record review revealed on 02/20/11 Patient #1 became disconnected from the ventilator for an unknown amount of time before staff responded to the Ventilator alarm. The Director of Quality / Risk Management was asked on 03/08/11 at approximately 3:00 PM, if an investigation had been conducted in to the events of 2/20/11 when Patient #1 ' s Ventilator became disconnected. She stated, because a family member filed a grievance, we did an investigation. She confirmed that she spoke to the nurse assigned to Patient #1, the second nurse on the unit, and the C.N.A. as well as the Nursing Supervisor.

She stated that an interview was not conducted with the Monitoring Technician as part of their investigation. When asked if it is the responsibility of the MT to have notified the nurse as soon as the ventilator alarm sounded, she stated yes, this should have happened, but could not explain why the MT did not place a call to either nurse or the Nursing Supervisor. She stated the facility is unable to determine at what time the alarm sounded because the MT did not respond by calling either of the Nurses or the Supervisor as listed in the job description. The Director stated, upon inquiry, there are no reports or logs kept by the MT that would reveal at what time the initial ventilator alarm sounded. On 03/07/11 a request was made by the surveyor to place a phone call to the MT who was on duty on 2/20/11 for an interview, however he did not respond the during abbreviated survey.

Further review of the Hospital's Investigation reveal the following:
? Event date and time: 2/20/11 6:30 PM
? Type of event: Patient was disconnected from the ventilator
? Supervisor notified at 6:35 PM
? Potential contributing factors / causes: Inadequate documentation, monitoring, distraction, rushing, inadequate patient supervision/monitoring.
? Narrative: C.N.A. reported to nurse that the patient had disconnected from the vent. Nurse entered room; patient appeared blue with heart rate of 44, unable to obtain O2 saturation level, patient unresponsive. Rapid Response called, nurse began to ambu the patient. Oxygen saturation returned to 96 %. Family notified. As of 2/23/11 patient remains stable, no further events.
The Director of Quality/ Risk Management, Nursing Manager and Chief Clinical Officer confirmed at 3:35PM the following:
? Facility staff was unaware that Patient #1 had been disconnected from the ventilator until they exited another patient's room an entered into the hallway.
? The Monitoring Technician failed to notify the Nursing staff and/or Supervisor when the ventilator alarm sounded and those interviewed confirmed that this did not occur. It is unknown why the MT failed to notify staff when the event occurred and/or if he was on duty at that time.
? Their investigation into the event did not include: an interview with the Monitoring Technician as to why he did not inform the staff of the disconnection; identification of the onset of the event, and the duration.
? The management staff confirms that there remains pervasive concerns from patients and staff regarding the availability of sufficient staff to provide timely care in accordance with patient requests for assistance and/or alarms.