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Based on interview and record review the facility failed to ensure nursing staff monitored, assessed and implemented an individualized plan of care for non-compliance with respiratory airway management for 1 (#1) of 6 patients reviewed for Critical Care Services out of a total of 14 sampled patients, resulting in critical blood pressure readings not addressed, patient status (respiratory, heart rate and oxygen percentage saturation not documented), alarms not addressed in a timely manner and the increased potential for reoccurrence for all patients on the Critical Care Unit (CCU). Findings Include:

See specific tags:
A-395: Failure to assess, monitor, and provide supervision for a non-compliant patient with her airway management.
A-0396: Failure to develop a nursing care plan based on patient's non compliance for airway management.
A-0397: Failure to ensure and document nursing supervision for orientee Staff F and cardiac competence of nursing Staff F.

This citation pertains to Intake MI00090417

Based on interview and record review, the facility failed to provide supervision for a patient known to remove her tracheostomy inner cannula and disconnect herself from needed respiratory support (BIPAP machine), failed to assess and monitor respiratory parameters as ordered (SPO2, pulse and respiration), and failed respond to a life threatening cardiac arrhythmia and cardiac arrest in a timely manner for one (Patient #1) of six patients reviewed for assessment and monitoring in the CCU, out of a total sample of 14, resulting in less than optimal outcomes. Findings include

On 10/2/17 at approximately 1430, Patient #1's clinical record was reviewed with Staff V, the Critical Care Step-down Unit clinical manager, and the following information was revealed:

Patient #1 was a 56 year old female with a tracheostomy (a surgical opening in the neck and windpipe for breathing) who was admitted to the facility on 9/11/17 with an admission diagnosis of "Chronic Respiratory Failure". Patient #1 expired in the facility Critical Care Unit (CCU) on 9/20/17, after she was found unresponsive and without a pulse.

Review of Patient #1's clinical record revealed documentation that Patient #1 was alert and oriented, with impulsive behavior, and had signed all her own consents for admission and treatment. Review of flowsheet information for Patient #1 before her transfer to the Cardiac Critical Care unit (CCU) on 9/20/17 at 08:31, revealed Patient #1 occasionally walked.

An admission Physician's History and Physical, dated 9/12/17 at 13:34 documented that Patient #1 had a tracheostomy, and was on a "ventilator" connected to BIPAP.

Review of Physician's orders that were active until discharge for Patient #1, revealed the following orders,
1."notify the physician for systolic blood (upper number) pressure greater than 140, or diastolic blood pressure (lower number) less than 60"
2. "Continuous pulse oximetry (monitoring SpO2 - oxygen saturation)"
3. "resuscitate in event of arrest (full code)."
4. "Cardiac monitoring"

Documentation revealed that Patient #1 removed her tracheostomy inner cannula and disconnected herself from the BIPAP machine against medical advice on multiple occasions. Nursing documented "impulsive behavior" on the assessment records. There was no documentation of any nursing interventions, or nursing a care plan to address Patient #1's noncompliance with needed respiratory devices. There was no documentation of increased monitoring of Patient #1 to prevent her from removing her tracheostomy inner cannula or disconnecting herself from the BIPAP machine.

A Physician progress note, dated 9/14/17 at 14:22 PM documented that Patient #1 was "BIPAP dependent", "refuses trach collar".

A Respiratory Therapy (RT) flowsheet entitled, "ventilator documentation" for Patient #1 contained an entry dated 9/13/17 at 10:35 noting, "Patient using BIPAP. Takes inner cannula out during usage".

A Nursing Note dated 9/10/17 at 19:10 documented, "Pt (patient) keeps taking trach collar off. Writer told pt (patient) numerous times not to take trach collar off. Pt refused to leave it on."

A Nursing Note dated 9/14/17 at 09:57 documented, "trach (tracheostomy) with no inner cannula. Patient stated it makes it harder to breathe, trach with BIPAP."

A Nursing assessment flowsheet dated 9/19/17 at 1700 documented, "Overestimates, forgets limitations."

A Nursing Note dated 9/20/17 at 04:08 documented, "Pt removing inner cannula of trach, despite instructions from RN (registered Nurse) and RT (respiratory technician) keep in place. Pt also removed oxygen collar despite instructions to keep in place. Green tie on one side of collar detached." A Rapid Response Team (RRT) note, dated 9/20/17 at 07:42 (three hours later) noted, "RRT called in for hypoxia (low oxygen levels), hypotension (low blood pressure) and diaphoresis (sweating)." "Intervention performed: oxygen device: BIPAP."

A Nursing Progress note dated 9/20/17 at 08:20 documented, "RRT (Rapid Response Team) called for persistent low sats (SPO2 - Blood oxygen saturation). BP started trending down. BP improved and SPO2 improved with BiPap and inline suction. Patient being transported to CCU (Cardiac Critical Care Unit).

Patient #1 was transferred to the CCU at approximately 0820 on 09/20/17 from the medical floor.
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A Physician's Progress Note dated 9/20/17 at 11:34 (in CCU) noted, "Patient got transferred to CCU this morning. Patient happened to have persistent low (oxygen) saturation this morning. Rapid Response Team was called. Arterial Blood Gas (ABG) was showing respiratory acidosis (a medical emergency due to breathing problems causing a build-up of carbon dioxide in the blood, which makes the blood too acidic). When I went in to see the patient in CCU, she is complaining about the BIPAP tubes are too heavy, she wanted to be discontinued, but I explained to her the importance of need keeping the BIPAP. Chest x-ray showing interval worsening aeration of the lungs bilaterally with a moderate vascular congestion and airspace opacities. Patient is being monitored in CCU management per critical care unit. Hypertension (high blood pressure) is controlled on current medications. In today because of respiratory acidosis and hypoxemia (low blood oxygen levels). Acute Kidney Injury: Resolved."

On 10/03/17 at 10:10, the CCU clinical Manager, Staff G was interviewed regarding Patient #1's documented self-removal of the tracheostomy inner cannula and self-disconnection from BIPAP on multiple occasions. Staff G stated, "She didn't want to be intubated. Her daughter and her boyfriend were the ones who wanted it. She did voice that she didn't want the intubation (breathing tube). I heard that she was pulling it out upstairs (on the other unit). Somebody said there was a note in the chart that she had de-cannulated herself. It wasn't accidental." When asked whether Patient #1 should have been monitored for, or have interventions implemented to try to prevent self-de-cannulation, Staff G said, "She was in the room closest to the nursing station. Everybody on the unit is responsible for monitoring."

Review of CCU Nursing Progress notes and monitoring flowsheets revealed the patient's oxygen status, vital signs, monitoring devices and tracheostomy were not documented as assessed per CCU protocol.

There was no documentation of increased monitoring and supervision, or of patient education to explain the risks and possible consequences of removing the trach inner cannula and disconnecting from the BIPAP machine. There was no documented attempt to assess why Patient #1 removed her inner cannula and disconnected herself from the BIPAP machine.

Review of CCU Flowsheet information for Patient #1 revealed no documentation of tracheostomy cannula changing or replacement after her transfer to CCU on 9/20/17.

A Flow sheet documentation dated 9/20/17 at 0749, verified by the RT (Respiratory Therapy) at 0749, (prior to transfer to CCU), documented "no inner cannula."

The CCU Nursing Admission Assessment Flowsheet, dated 9/20/17 at 0903 was verified (validated, signed to indicate it was reviewed) by Staff F (Patient #1's assigned CCU RN) at 1100. The assessment documented that the patient's surgical airway was secured, with "no inner cannula". There was no documentation to indicate that the inner cannula was replaced or that the patient was counseled, educated, or the reason for removal assessed. The patient's cognition was documented as "oriented x 4" (alert and oriented) and "impulsive." There was no documentation of an assessment for the need for increased supervision. There were no "comments" documented by the nurse at that time. "Psychosocial" was documented as "within normal limits (WNL)."

Review of CCU monitoring flow sheets for Patient #1 from 9/20/17 at 0903 (after she was transferred into the CCU) to 9/20/17 at 1309 (time documented as the start of cardiopulmonary resuscitation (CPR)) revealed the following monitoring was documented during her four and one half hours in CCU:

0931 - A cardiac monitor recording of Patient #1's electrocardiogram ( EKG) documented sinus rhythm. There were no additional EKG recordings between 09:31:07 and 13:03:39 on 9/20/17.

"Hourly Rounding", for Patient #1 was documented at 0900, 1000, 1100, and 1200. The "patient sleeping" box was marked "Y" (yes) at 0900, 1000 and 1200. There were no comments noted.

Hourly monitoring of vital signs on the monitoring flowsheets, was validated (signed as reviewed) by Staff F after the monitoring time frames on most times.

0903 - was validated by Staff F at 1100. Documentation noted, "no inner cannula". Patient #1 was in sinus rhythm (normal heart rhythm), with BIPAP, an SpO2 (oxygen saturation) of 96%, a blood pressure of 151/39 and continuous pulse and SpO2 monitoring from a device on her finger. It was documented that the patient had bathroom privileges with staff (stand by) assistance.

0951 Pain assessment was documented as verified by Staff F.

1003 - Verified as noted by Staff F at 1048, the cardiac rhythm was blank (not documented), blood pressure was abnormal with an elevated systolic (top number) and low diastolic (low number) at 164/40. Respiratory rate was high at 27 per minute, with a notation that the monitor sounded (alarmed) and SPO2 was low at 89%, with a notation to indicate that the alarm sounded. There was no nursing documentation to indicate that the physician was notified, but Physician Progress notes dated 9/20/17 at 1134 and 1141 reflected that the patient was seen by physicians.

1009 - Documentation of Critical Care Physician Assessment, "Tracheostomy with acute decompensation, now transferred back to CCU for full mechanical ventilator support. Assessment: Endotracheal tube (ETT) emerging from the mouth 23 centimeters (CM) at the tip. Assessment: 1. Acute on Chronic Respiratory Failure mixed Hypoxemic (low blood oxygen)/Hypercapneic (high blood carbon dioxide, usually due to inadequate breathing). 2. Acute Exacerbation (worsening) of COPD. 3. Debility. Recommendations: Continue with close monitoring of hemodynamic and Respiratory status in CCU. Full Mechanical ventilator support." It was unclear why a patient with a tracheostomy would have an endotracheal tube coming out of her mouth.

1036 - Chest X-ray was done, the report noted, "Tracheostomy tube positioning is not well evaluated on this exam. Significantly worsened aeration of the chest bilaterally."

1036 - RT documentation provided, only noted that the patient's arm band (identification) was checked.

1103 - Verified by Staff F at 11:22. Blood pressure (BP) = 172/42. The cardiac rhythm was not documented (blank, not recorded).There was no documentation to indicate the nurse had notified the physician of the systolic BP greater than 140 and the diastolic BP less than 60. There was no documentation to indicate that the nurse had gone into the room to assess the patient.

1134 - Documentation of Physician Assessment.

1141 - Documentation of Nephrology assessment - A Nephrology (kidney) Physician's Progress note, dated 9/20/17 at 11:41 documented the following, "Problem List: Acute Renal Failure, Chronic Respiratory Failure, Bleeding Around the Tracheostomy, Chronic Obstructive Pulmonary Disease (COPD) exacerbation, Respiratory Acidosis." The note documented, Seen and evaluated patient. Transferred to ICU for worsening respiratory failure. Renal function is worse, likely from low blood pressure (BP). Hold (don't give) Intravenous (IV) fluids for now."

At 1203 - validated by Staff F at 1204: no pulse recorded (blank), no respirations recorded (blank), no SpO2 recorded (blank), BP was abnormal at 184/56. There was no documentation to indicate that the nurse had gone into the room to assess the patient, or to check whether monitoring devices had been disconnected, or to ensure the patient had not disconnected her respiratory support devices. The recording contained an alert to indicate that the blood pressure reading had triggered the monitor alarm to sound. There was no nursing documentation to indicate this was addressed.

1224 - Documentation of Patient #1's temperature, verified by staff H.

1236 - Medication Records for Patient #1 revealed a "one time" dose of furosemide (a diuretic) was given.
There was no other written documentation of monitoring or assessment by nursing staff in between these times. There were no additional vital signs or patient assessments documented until the patient was found pulseless and unresponsive at 1309.

Review of a facility CPR (cardiopulmonary resuscitation) Data Sheet, dated 9/20/17 documented the facility code (resuscitation attempt)(CPR) for Patient #1 on that date. The Data Sheet documented that the event onset time was 9/20/17 at 13:09. The CPR data sheet documented that Patient #1 had no pulse, and was asystolic (no heart beat) at 13:09, and "time chest compressions (CPR) were started: 13:09." "Comments" noted, "patient de-cannulated self (pulled her tracheostomy cannula out), found unresponsive, in asystole." The Data sheet noted Patient #1's pre arrest status as "stable".

The time frame continued as followed: On 9/20/17 at:

13:03:39 - Patient #1's monitor recordings (EKG) at 13:03:39, approximately six minutes before the documented CPR event time, revealed the patient's monitor had printed a "red alert" (critical) alarm recording at 13:03:39 (six minutes before the documented start of CPR). The recording documented that the monitor alarms had sounded (alarmed) due to abnormal heart rhythm, defined on the monitor recording (strip) as ventricular tachycardia (rapid contraction of the lower chambers of the heart which prevents them from filling adequately, so the heart cannot pump blood normally.)

The monitor EKG recording at 13:03:39 documented that the device monitoring Patient #1's blood oxygen saturation (SpO2) and pulse was not recorded, "sensor off". The facility was not able to provide any documentation to verify that Patient #1's SPO2 was monitored since the physician assessment at 11:41, or documentation that Nursing had assessed the Patient's respirations, pulse and SPO2 since 11:22. There was no documentation to indicate that staff had checked the SPO2, pulse and respiration monitoring sensors to see why there was no data recorded since 11:03. There was no documentation to indicate that Patient #1's inner cannula was replaced since Staff F had noted it was missing at 11:00.

13:04:48 - A heart monitor recording for Patient #1 at 13:04:48 (one minute later, five minutes before the documented start of CPR)) documented that Patient #1 was in asystole (no heart beat) with a heart rate of zero. The SPO2 monitoring device was documented as "sensor off". The last documented SPO2 reading was at 11:03.

13:05:00 - A heart monitor recording strip at 13:05:00 (approximately four minutes before the documented start of CPR) documented that Patient #1 was in asystole. There were no movement artifacts on any of the recordings or any kind of documentation on the clinical record to indicate that CPR chest compressions were in progress. There was no documentation on the CPR data sheet to indicate that the defibrillator was hooked up to the patient, or that an attempt was made to defibrillate (electric shock) the patient.

13:09 - A facility telephone/pager log provided per request revealed documentation that a page was called on 9/20/17 at 13:09 for "Stat Intubation" in Patient #1's room. There was no other documentation of emergency paging for Patient #1 on 10/20/17 after transfer to the CCU.

13:09 - A Nursing Progress note dated 9/20/09 at 13:09 for a "date of service", documented as 9/20/17 at 13:09 noted, "Patient monitored alarmed. RN responded immediately to alarm. Upon entering room, RN found patient unresponsive with trach cannula removed and no pulse found. CPR started per ACLS protocol (advanced cardiac life support - " emergency procedures in which basic life support efforts of CPR are augmented by establishment of an IV fluid line, possible defibrillation, drug administration ...", Advanced cardiac life support. (n.d.) Mosby's Medical Dictionary, 8th edition. (2009), reviewed on October 16 2017 from https://medical-dictionary.thefreedictionary.com/advanced+cardiac+life+support), anesthesia called and at bedside to replace trach. CPR continued for approximately 35 minutes."

13:51 - A Physician's progress note dated 9/20/17 at 13:51 documented, "I was called to the bedside to evaluate the patient for cardiac arrest. The patient had reportedly been posturing all morning to have the tracheostomy removed. She eventually ripped it away and became unresponsive. Code Blue was called at 13:09. The patient was in cardiopulmonary arrest. ACLS protocol was started. Time of Death was called at 13:44."

On 10/02/17 at approximately 1600 Staff F, Patient #1's assigned nurse in CCU was interviewed in the presence of the CCU Clinical Manager, Staff G. Staff F reported, "I picked her up from the other floor around 0830. I also had a vented patient in bed 7. She de-desaturated once in the morning while I was tending to my other patient, so a couple of other nurses checked on her. About the time I was pulling a narc (narcotic) for bed 7, the alarm went off. I believe her alarms were going off because she was bradying down. There was documentation that she de-cannulated herself on the floor (prior nursing unit), but I wasn't told about that. She wasn't happy about it (BIPAP)."

On 10/02/17 at approximately 1615, Staff G was interviewed and reported that Patient #1's assigned nurse, Staff F was new to CCU, and was still on orientation. Staff G stated that Staff's preceptor (provided training and oversight), was Staff J. When queried, Staff G stated, "I was tending to another patient. I heard the alarms go off. (Staff S) and another nurse (unavailable for interview) found her (Patient #1). We had her (Patient #1) on her previous admission. She pulled her trach out multiple times. She didn't want the trach, but her significant other and her daughter pressured her into it, thinking she'd get better."

On 10/03/17 at 0945, Staff H, the nursing assistant who had taken Patient #1's temperature on 9/20/17 at 1224 (40 minutes before Patient #1's cardiac arrest) was interviewed. Staff H reported, "I am only able to record patient temperatures and blood sugars. I had 10 patients to check, on my rounds before lunchtime, checking their blood sugars and temperatures before lunch. When I did her (Patient #1's) temperature and blood sugar, I saw breathing tube not in good position when she turn her head. I feel she didn't want situation what happened, she didn't like what she had, was intubated with tracheostomy. She wants to be let go. I feel in my soul. She wants to end it. Something not right with way tracheostomy looked. Monitor also said something different than normal. I called RN (Registered Nurse). I was three or four rooms later when I heard the code (CPR)." When queried, Staff H was not able to identify the Nursing staff who responded to her call. All unit staff interviewed, plus CCU clinical manager, Staff G were asked to identify which staff checked on Patient #1 after Staff H's temperature check. All CCU Nursing staff interviewed during the survey were questioned regarding this, and were not able to identify the nurse in question or provide any additional information.

On 10/03/17 at approximately 1000, the Director of Nursing, Staff D and the CCU Clinical Manager, Staff G, who were present during Staff H's interview, were unable to provide any documentation that staff responded to Staff H's alleged call for a nurse, and were unable to identify the nurse who would have responded. Staff G reported that Staff F, Patient #1's assigned RN, and her preceptor, Staff J were busy with another patient during that time frame.

Review of Patient #1's clinical record at this time revealed no documentation that anyone assessed Patient #1's state of mind or respiratory connections after Staff H took Patient #1's temperature and blood sugar at 1224.

A Medication Administration record for Patient #1 documented that her assigned nurse, Staff F administered an "as needed (PRN)" dose of alprazolam, an anti-anxiety medication, at 1236, but there was no notation to explain the reason why, and no documentation that Patient #1's mood, or risk for suicide was assessed at this time. There was no notation that Patient #1's tracheostomy, BIPAP machine connection, or pulse and oxygen saturation monitor (SPO2) connections were checked between 1224 and her cardiac arrest at 1304.

On 10/03/17 at approximately 1010 CCU Clinical Manager, Staff G, was interviewed regarding Patient #1. Staff G stated, "She (Patient #1) was suicidal. She did voice that she did not want the intubation. I heard that she was pulling it out upstairs (on the prior unit). Somebody said that there was a note in the chart that she had de-cannulated herself. It wasn't accidental."

On 10/03/17 at approximately 1040, Staff J, Staff F's CCU preceptor was interviewed by telephone regarding patient #1. Staff J stated, "She wasn't happy about the move to CCU. She came to us around 08:30, and the code happened around 1300. At one point when we walked out of the room, her BIPAP got disconnected. I put it back on. We spent so much time in her room. (Staff F) and I were in the next door room when the code happened."

On 10/03/17 at approximately 1230, Staff G was interviewed again and stated, "Staff S and Staff RN (not available for interview) were the first nurses in the room (for Patient #1's code). I was at the desk. I noticed she was starting to brady down (develop bradycardia - a heart rate below normal). The person normally at the front desk had gone to lunch, so I was relieving her at the monitor. They said that they needed the crash cart, her trach was out, they were calling a code. They just yelled from the room. When I came in the room with Staff L and Staff M, Staff S was doing chest compressions. Staff L had the code cart." When asked whether she had heard the BIPAP machine alarming, Staff G stated, "Not that I can remember."

On 10/03/17 at approximately 1240, Staff S, the nurse who found Patient #1 unresponsive was interviewed. Staff S stated, "I saw the screen (monitor) because it was beeping and asystole. The patient was laying in bed. At first I went to her and did a sternal rub. (RN, not available for interview) dropped the bed and that's when we saw the cannula. We called the code within a minute of doing the sternal rub. We time the code off the life packs on the code cart." Staff S was unable to state if the BIPAP machine was alarming. It was unclear why Staff S and the other nurse would be unaware that the Patient's inner cannula was not in her trach (which would prevent adequate connection to the BIPAP machine) if the BIPAP machine was alarming as required.

On 10/03/17 at approximately 1430 Staff L and Staff M, two RN's who were working in the CCU at the time of Patient #1's cardiac arrest were interviewed. Staff M was documented as the recording nurse on Patient #1's CPR Data Sheet (code documentation). Staff M stated, "We started chest compressions. The Nurse Practitioner tried to put the trach back in. CPR wasn't started right away per the Nurse Practitioner, who wanted to re-intubate and was having trouble getting the trach back in." When queried about how vital signs were documented in the CCU, Staff M reported that the monitor automatically made an entry at the programmed monitoring intervals, but the result would not save unless the nurse validated it. Staff M reported that the system would save the result for a day or so, so a nurse could always go back and validate vital signs she missed. When asked why Patient #1 had no SPO2, pulse or respirations documented since 1103, Staff M stated, "If the rest of the vital signs were documented, it meant that the leads were probably off." When asked what a nurse should do if when disconnected leads were reconnected, Staff M stated, "verify a new reading (vital sign result). It would record the monitoring time as the time the nurse entered it, but that would mean that there was still an hourly (vital sign) recorded for that hour." When asked if the nurse could go back at the end of the shift and verify a vital sign entry for the time the leads were reconnected if she had forgotten to do so earlier, Staff M said, "Yes. The system continuously records and saves."

On 10/4/17 at 1235, Staff P, the Nurse Practitioner who was in charge at the beginning of Patient #1's code, was interviewed. When questioned, Staff P stated, "I happened to be in CCU that day. I was at the desk charting when I heard the nurses call for assistance. I went in the room. They were either doing CPR or rolling the patient over on the board when I came in. I didn't notice any alarms or the vent alarm going off. From what I understood, her leads were not on. When I looked at the monitor, it was asystole at that point. The crash cart was pushed into the room. I saw the trach cannula on the bed. Anesthesia was called. I took call until the Intensivist (Critical Care Physician) arrived. I called the Intensivist on my cell." Record review of Staff P's cell phone call log at this time with Staff P revealed the Intensivist was called at 1312. When asked whether CPR was delayed during an attempt to recannulate the patient, Staff P stated, "No. Nursing staff were bagging (giving rescue breaths) through the mouth."

On 10/04/17 at 1330, the facility Biomedical Maintenance Director, Staff Q was interviewed and reported that monitor readings were available for 96 hours after they were recorded, and could be verified by the RN and entered into the monitoring flow sheet at any time during that 96 hours. When queried, Staff Q reported that there had been no reported monitoring device malfunctions in the CCU in September 2017. When asked if BIPAP machines alarms turned off automatically after a certain length of time due to "alarm fatigue", Staff Q said, "Alarm fatigue, now that's the big question. I'm not talking about the machines." The clocks on the two defibrillators (on the crash carts) in the CCU were checked at this time with Staff Q, Staff D and Staff G, and were found to have the same times, to the minute, as the clocks on the monitor at the nursing station.

On 10/04/17 at 1215, Staff J, Staff F's preceptor was interviewed regarding Patient #1's cardiac arrest and subsequent code, and stated, "I was with (Staff F) in room 7. We were trying to switch sedation in bed 7 when I heard them shouting for the code. I was in a few seconds after that. They were already doing the code sheet, it takes only a few seconds."

On 10/04/17 at 1315 Review of Respiratory therapy assessments revealed only two documentation's of Respiratory Therapy (RT) monitoring of Patient #1 in the CCU on 9/20/1, at 0841 and at 1036. The RT documentation at 0841 documented BIPAP machine settings and "alarms on", but there was no documentation of tracheostomy care, or inner cannula assessment/replacement. and the box for blood oxygen saturation (SPO2) was left blank (not completed). The 1046 RT documentation only contained documentation that the patient's arm band (identification) was checked.

On 10/04/17 at 1330, the Respiratory Therapy (RT) Clinical Coordinator, Staff T was interviewed regarding Patient #1's RT documentation, and was requested to provide any additional documentation of RT assessments, cannula replacement/assessment or RT care for Patient #1 while in the ICU (from approximately 08:30 to 13:09 (code) on 9/20/17. Staff T was unable to provide any additional documentation by survey exit. Staff T stated, "I did an investigation and interviewed Staff Q, the RT who was assigned to the unit that day. She immediately came to us afterward to let us know. That day was exceptionally busy. RT had a couple of Stat (urgent) intubations, and a couple of Rapid Response Team (interventions). The RT (Staff Q) was busy in another room across the unit when the code was called. When The RT got to the room, the BIPAP alarm was sounding. The RT heard the nurse say that the patient was in asystole. The trach was still in, the inner cannula was out. The BIPAP alarms are loud. Everyone is supposed to respond to those alarms, not just the RT. It's inherent that it's immediate to respond to alarms. (Patient #1) required a lot of attention. She didn't like the BIPPAP machine tubing or the inner cannula, and removed them. Her alarms went off quite a bit. That was the problem. I don't think that she was suicidal. I just think she found the BIPAP and tracheostomy uncomfortable."

Review of a facility log of adverse events for the month of September 2017 revealed documentation that Patient #1 had a documented "Airway Management Event", dated 9/20/17. Review of the facility "Airway Management Event" file for Patient #1 dated 9/20/17 revealed documentation that staff had responded to alarms from Patient#1's monitor (device that recorded the patient's heart rhythm, i.e. the electrocardiogram, as well as other vital signs), and had found Patient #1 unresponsive. The Airway Management Event Summary noted that Patient #1 had removed her tracheostomy cannula (tube inserted into the tracheostomy to allow air flow) herself. The summary noted that a "Code" was called (cardiovascular resuscitation), CPR initiated (cardiopulmonary resuscitation started), anesthesia (provider) at bedside and replaced trach (cannula), coded for approximately 35 minutes, in which Critical Care Doctor called time of death."

The Airway Management Event "Follow Up Actions", for Patient #1, dated 9/20/17, signed by the Respiratory Therapy Manager, Staff T, noted that Patient #1 was noncompliant (did not comply with needed treatment) and did not want the BIPAP machine (a ventilation machine connected to the tracheostomy cannula to deliver air under pressure to expand the airway), "taking self on and off the BIPAP machine to the trach (tracheostomy). However her oxygen saturations (blood oxygen) would decrease to unsafe levels without it." Staff T also documented, "Could question whether high flow oxygen delivery device may have been an option she would have been more compliant with? Question how long she was alarming before someone picked up that she was asystolic (no heartbeat)."

Review of Patient #1's 9/20/17 Airway Management Event "Follow Up Actions" for her unplanned extubation and death on 9/20/17 revealed the event was referred to Safety Manager Staff W for review on 9/21/17 and on 9/25/17. There was no documentation of an investigation or response by Staff W. "Resolutions and Outcomes" of the event and "Outcome Actions Taken" were blank (no entry).

On 10/3/17 at 1442 the Director of Patient Safety, Staff M was interviewed and was asked whether the facility had identified any deficient practice or concerns during the investigation of Patient #1's airway management event, or her death. Staff M stated that mortality reviews were done weekly by the Patient Safety department, and that Adverse Events were forwarded for review. Staff M stated that the facility investigation regarding Patient #1's Airway management event was not done yet, and was unable to provide any preliminary notes or documentation of staff interviews to indicate that an investigation was in progress. Review of a facility log of patients discharged during September 2017 and their disposition (where they went after discharge) revealed a summary documenting that there were three patient deaths in the facility during the month of September. Patient #1 was not listed as one of the three expired patients, and her disposition at discharge was blank (not documented).

On 10/04/17 at 1320, the Respiratory Therapy Director, Staff T was interviewed regarding Patient #1 and stated, "She had a history of pulling herself off BIPAP and then putting herself back on, and then desaturating (lowered blood oxygen levels). The BIPAP machine would alarm, and that was the problem. The staff spent a lot of time with this patient because she wouldn't follow her treatment plan. The BIPAP machine has a loud alarm when it disconnects. We assign one RT to the CCU every day. It was pretty busy that day (9/20/17). We should have done a better job of documenting staff attempts to reeducate her. Maybe we should have looked into ways to make it less uncomfortable for her."

Per interviews on 10/02/17 at 1130 with the CCU Clinical Care Coordinator, Staff G, and on 10/02/17 at approximately 1135 with the Director of Nursing,

Based on interview and record review, the facility failed to develop and/or update a comprehensive nursing care plan that addressed the patient's non-compliance with her respiratory care needs for 1 patient (#1) out of a total of 14 sampled patients resulting in the increased potential for unrecognized needs and less than optimal outcomes for all patients served by the facility. Findings include:

On 10/3/17 at 0900 a review of patient #1's medical record was conducted and revealed patient (#1) was admitted to the facility on 9/11/17 with diagnoses that included acute respiratory failure and tracheostomy (surgical opening created through the neck to allow direct access to the breathing tube).
A review of progress notes dated 9/13/17 at 1035 per respiratory care documented, "patient using BiPap, takes inner cannula out during usage."
On 9/14/17 per nursing progress notes documented "...patient takes inner cannula out."
On 9/20/17 at 1134 per internal medicine, "...patient complains about BiPap being too heavy. She wanted to be discontinued. I explained the importance of the need for keeping the BiPap."

Further review of the medical record revealed a a care plan for "Respiratory status R/T ventilation support or respiratory failure or COPD or asthma or pneumonia or sepsis or other", dated 9/14/2017 that documented the patient was to have adequate oxygenation within the limits of her disease process. However, there were no updates or revisions to the patient's respiratory care plan that guided or directed the nursing care staff regarding the patients non-compliance with her respiratory care needs.

During an interview with Clinical Manager Staff G on 10/4/17 at approximately 1400 she explained she recalled when the patient was on her unit when she first got the trach. She Staff G said the patient did not want the tracheostomy (trach). When asked if she was aware that the patient was non-compliant with pulling her inner cannula out and disconnecting to the BiPap, Staff G said that the patient had only been on her unit on 9/20/17 for less than a few hours this time before she coded. When asked to explain why there was no care plan in the medical record that addressed the patient's non-compliance with her airway management, Staff G said there should have been.

A review of the facility's "Corporate Clinical Nursing Medical/Surgical Policy and Procedure Section: 400 Policy Number 401 dated 2/2017 documented the following:
"...B. Initial Assessments:...4. A care plan is initiated for all admitted patients. a. A general care plan is automatically generated by the EHR system based upon key assessment findings or orders. b. A specific care plan is manually added via the 'apply template' option. c. Interventions may be omitted or added based upon the patient situation. e. A flag may be added to the 'FYI' activity to alert other healthcare team member to special situations such as: difficult airway, difficult draw, vision/hearing impairments, legal guardian, extremity restriction, etc."

Based on interview and record review, the facility failed to ensure 1 (Staff F) of 3 Registered Nurses (RN) were supervised during orientation and failed to ensure RN competencies were performed for 1 (Staff F) of 4 RNs reviewed for competencies, resulting in the potential for less than optimal patient outcomes.
Findings include:

On 10/2/17 at approximately 1600 during an interview, Staff F explained she had worked at the facility for the past 2 years. She said transferred to the Cardiac Critical Care unit (CCU) from the Cardiac Step Down unit in August 2017. Staff F said she was still in orientation for the CCU.

When queried regarding patient #1, Staff F said she recalled the patient. She said she took report from the nurse who was transferring the patient from the Medical-Surgical unit to the CCU. When further queried regarding the patient, Staff F said the patient was alert, oriented and did not want to be on the BiPap. When asked to explain if she had been informed that the patient was not compliant with keeping her inner cannula in, Staff F stated, "No. I wasn't."

Staff F explained that on 9/20/17 she was "pulling a controlled substance for another patient". She said she and her preceptor were busy with another patient when patient #1's alarm sounded. She said she was not the first responder to the alarm. Staff F said she observed other staff members performing cardiopulmonary resuscitation (CPR) on the patient on her arrival to the patient's (#1's) room.

During a review of the patient's medical record with Staff F at that time, when asked to explain her response to the patient blood pressure readings of 178/42 at 1103 on 9/20/17 and 184/56 at 1203 on 9/20/17 and lack of heart rates, respiration rates, or pulse oximetry recordings for the aforementioned dates and times, and why there was no evidence in medical record that documented the patient was assessed or vitals signs retaken to address the critical values, Staff F offered no explanation. When asked to explain if her preceptor was aware of the aforementioned concerns she said no that she did not think so. When asked to explain if she had called the physician with the critical blood pressure readings she said no. When asked to explain if the patient's inner cannula was in place during her hourly assessments Staff F explained she could not recall.

On 10/3/17 at 1110 preceptor Staff J was interviewed via phone. When queried regarding her role for preceptor and supervision for Staff F on 9/20/17 she said she took report for the patient. She said she recalled when she and Staff F went to the Medical Floor to transfer the patient to the CCU the patient #1 said the patient had expressed that she was not happy being moved. Staff J said she spent 2-3 hours with the patient assisting her to the bedside commode. She said the patient's trach had gotten disconnected while they (Staff F and Staff J) were in the patients room. When asked to explain if she was aware of the patient's blood pressure readings and lack of documentation for the patient's heart rate, pulse oximetry and respiratory rate for 2 hours prior to the patient coding. Staff J stated, "We were in another room at the time of the code. That patient needed a lot of attention." When asked to explain if she reviewed Staff F's assessments/documentation during her orientation Staff J said not always.

On 10/4/17 at 1045 Critical Care Nurse Educator Staff N was interviewed regarding orientation and competencies for Staff F. Staff N said our training for the Step Down Cardiac Unit is the same for the CCU. She said it's usually 90 days depending on the individual needs of staff. Staff N was asked to provide evidence of Staff F's training and competency for the CCU.

On 10/4/17 at 1400 a review Staff F competencies were conducted with the Accreditation Coordinator Staff A. There were no competencies documented for 2016. A review of the CCU Orientation Competency Checklist for Staff F dated 8/16/17 through current revealed Staff F had not demonstrated Cardiovascular or Pulmonary competencies. Staff F had not documented a self evaluation of the competencies. The preceptor had not documented the "learner" had completed or demonstrated those competencies.

On 10/4/17 at approximately 1700 an interview was conducted with the Chief Nursing Officer who offered no further explanation regarding the aforementioned concerns. At that time a review of the facility's "Critical Care Registered Nurse Orientation Competency checklist" dated 10/2016, documented the competencies were mandatory competencies and were required to have been completed during orientation.