HospitalInspections.org

The Hospital is out of compliance with the Condition of Participation for Quality Assessment and Performance Improvement (QAPI).

Findings included:

The Hospital failed, for three (Patients #1, #2 & #11) of eleven sampled patients, to ensure that Hospital Quality Assessment & Performance Improvement (QAPI) Program activities provided effective corrective actions and implemented corrective actions after Patient #2's unexpected decline in condition and fetal death and Patient #11's unexpected decline in condition and death.

Refer To TAG: A-0286.

Based on record review and interviews, the Hospital failed, for three (Patients #2 & #11) of eleven sampled patients, to appropriately analyze adverse patient events and ensure that effective corrective actions were implemented.

1. Based on record review and interviews, the Hospital failed to investigate and analyze an adverse patient event and implement appropriate preventive actions where a patient (Patient #2) experienced an unexpected decline in condition and fetal death.

The Surveyors interviewed the Chief Nursing Officer (CNO) on 1/23/19, at 7:45 A.M. The CNO said that Patient #2 was admitted on 10/12/18 for a vaginal birth for a full term pregnancy. The CNO said Patient #2 arrived after having a Biophysical Profile (BPP) (a prenatal ultrasound evaluation of fetal well-being involving a scoring system-a score of four or less is abnormal and the fetus may not be receiving enough oxygen) appointment outside the Hospital and scored a 4/8, the Labor and Delivery Department was very busy and there was a delay in the nurse placing Patient #2 in a room and placing him/her on a monitor. The CNO said at some point there was difficulty obtaining a Fetal Heart Rate (FHR), Patient #2's Family Practitioner and a Hospital Obstetrician were in the room with Patient #2 and were unable to obtain a FHR with an ultrasound and Patient #2 had an emergent Caesarean section. The CNO said that the baby was delivered with 0 score on APGARs (A scoring system doctors and nurses use to assess newborns one minute and five minutes after they're born. At one minute a score of 0 to 3 is concerning. At five minutes a score of 0 indicates the baby didn't respond to interventions). A code was called and after attempting resuscitation the newborn was pronounced dead.

The Surveyors interviewed the Family Practitioner on 1/24/19, at 8:05 A.M. The Family Practitioner said that Patient #2 was scheduled for a Caesarean Section on 10/12/18 but on 10/11/18, the Family Practitioner met with Patient #2 and Patient #2 asked if he/she could have a vaginal birth. The Family Practitioner said that he agreed but scheduled a BPP for 10/12/18. The Family Practitioner said that the next morning Patient #2 arrived at the Hospital having contractions. The Family Practitioner said that Patient #2 was examined and was found not to be very far into his/her labor and told Patient #2 to keep his/her appointment for the BPP. The Family Practitioner said that he received a call regarding the BPP and Patient #2's BPP score was 4/8, which was "terrible" or words to that effect. The Family Practitioner said he called the Hospital and told Nurse #5 that he was sending Patient #2 in to the Labor and Delivery Unit and that her BPP was 4/8. The Family Practitioner said that his expectations were that Patient #2 would immediately be brought to a room, placed on a monitor, and provided 1:1 nursing coverage. The Family Practitioner said that when he arrived on the Labor and Delivery Unit it was very busy with multiple patients in labor. The Family Practitioner said that there was a delay in placing Patient #2 on the monitor by Nurse #6; however, once placed the FHR was normal and he felt relieved by this. The Family Practitioner said during review of the FHR strip there was a deceleration of the FHR (around time Patient #2 arrived on the unit) that he was unaware of and also felt that Nurse #6 was unaware of. The Family Practitioner said that he then went into the Physician's lounge where he could continue to monitor Patient #1 via a monitor. The Family Practitioner said that when he went into the Physician's Lounge the monitor was not working and shortly after that he was called by Nurse #6 to come back to Patient #2's room and when he arrived Nurse # 6 told him that there was a second deceleration of the FHR and she was having trouble getting a fetal pulse. The Family Practitioner said that he tried to place a lead on the baby's scalp to monitor the FHR and was having trouble with the lead placement. The Family Practitioner said that he asked the Obstetrician to assist and place a lead on the baby's scalp and could still not get a FHR. The Family Practitioner said that he left the room to get an ultrasound machine and brought it back to Patient #2's room. The Family Practitioner said that he measured a FHR of 90, which he later discovered was most likely Patient #2's heart rate and not a FHR. The Family Practitioner said that after trying to get a FHR several times unsuccessfully, they brought Patient #2 to the Operating Room (OR) for an emergent C-Section. The Family Practitioner said that the baby was delivered via C-Section but was not breathing and resuscitation was started. The Family Practitioner said that they were unsuccessful and the baby died.

The Surveyors interviewed Nurse #5 on 1/24/19, at 10:10 A.M. Nurse #5 said that on 10/12/18, Patient #2 was being sent into the Hospital by the Family Practitioner for a labor-check at 8:30 A.M. Nurse #5 said the Unit was very busy and that Patient #2 arrived at the same time as another patient who was in active labor and about to deliver. Nurse #5 said that she went and helped the patient in labor. Nurse #5 said that the Family Practitioner had seen Patient #2 and examined her and then sent him/her for his/her BPP. Nurse #5 said later that morning she received a call from the Family Practitioner who said that he received a call from the BPP staff and reported that Patient #2 scored a 4/8 and was returning to the Labor and Delivery Unit. Nurse #5 said a score of 4/8 is concerning but she was not sure how much weight should be given to the score because points can be taken off for low tone or breathing and that the test is just a "snapshot" or words to that effect. Nurse #5 said that when Patient #2 arrived she was not immediately placed on the monitor and placed in a room because there was no staff available to assign to Patient #2. Nurse #5 said that Nurse #6 then offered to place Patient #2 on a monitor and get her started. Nurse #5 said that she recalled the FHR was fine when she first saw her monitor from the hall. Nurse #5 said shortly after that she noticed Patient #2 was having trouble with the FHR on the monitor. Nurse #5 said she went to Patient #2's room and there were two physicians in the room with Nurse #6. Nurse #5 said that she heard someone say "there is no heart beat" and then I thought "let's get moving" or words to that effect, but everyone seemed to be moving slowly. Nurse #5 said that the team brought Patient #2 to the OR for an emergent C-Section. Nurse #5 said that the baby was not breathing at the time of delivery and an unsuccessful code followed.

The Surveyors interviewed Nurse #6 on 1/23/19, at 1:20 P.M. Nurse #6 said that 10/12/18 was a very busy day in the Labor and Delivery Unit. Nurse #6 said she received a call from the Family Practitioner about Patient #2, saying he/she was in labor and was enroute to the Hospital for an assessment. Nurse #6 said Patient #2 arrived and was placed on a monitor and assessed by the Family Practitioner and then sent to her BPP appointment. Nurse #6 said that later that day, Patient #2 returned and was waiting for a bed assignment. Nurse #6 said that she told Nurse #5 that she would take Patient #2 to a room and place her on the FHR monitor, place an intravenous line, and get her started. Nurse #6 said that after Patient #2 was placed on the monitor the FHR was good. Nurse #6 said that she was unaware that Patient #2 had a BPP score of 4/8 and did not know that she had been waiting for 30 minutes to be placed on the monitor. Nurse #6 said that shortly after that the Family Practitioner came in the room and examined Patient #2 and then left to go into the Physician's Lounge.

Nurse #6 said that Patient #2 was experiencing pain and the monitor was not reading. Nurse #6 said that when she repositioned the monitor she noticed a FHR deceleration and was then having trouble monitoring the FHR. Nurse #6 said that she notified the Family Practitioner to come to Patient #2's room. Nurse #6 said that the Family Practitioner came into the room and placed a lead on the baby's scalp and could not get a FHR and asked for another cable. Nurse #6 said I went to get a cable and when I returned the Obstetrician was in the room with the Family Practitioner. Nurse #6 said that three cables were attempted without getting a FHR. Nurse #6 said that she then left to get an ultrasound machine and brought it to Patient #2's room, and we still couldn't get a pulse. Nurse #6 said that the Family Practitioner then decided to have Patient #2 brought to the OR for an emergent C-section. Nurse #6 said that one hour had passed since she first lost the FHR on the monitor.

The Surveyors interviewed the Chief of Obstetrics on 1/23/19 at 11:35 A.M. The Chief of Obstetrics said that the 4/8 score was not addressed and Patient #2 should have been closely monitored at arrival, the first deceleration was missed. The Chief of Obstetrics said Patient #2 should have received closer monitoring and the Physicians waited too long to get a pulse and should have brought Patient #2 to the OR much earlier. The Chief of Obstetrics said that you try to get a pulse for 2-3 minutes maximum before getting an ultrasound, or words to that effect. The Chief of Obstetrics said that staffing was an issue and nurses should have escalated the issue to senior nursing and senior leadership for assistance and that over all there was an issue with communication.

The Surveyors interviewed the Director of Quality Improvement on 1/8/19, at 9:20 A.M. The Director of Quality Improvement said that a multidisciplinary Root Cause Analysis (RCA) was performed on 10/18/18. The Director of Quality Improvement said the RCA's plan of correction included: the development of an escalation plan for a notification of a surge in patient census, perform a Failure Mode and Effects Analysis (FMEA) of the surge plan, implemented emergency huddles and the use of new phones to communicate to staff, and utilize the phones to develop immediate plan of action for staffing for patients with concerning issues.

Review of the RCA indicated that the Hospital failed to identify the individual nurse's responsibility to react to Patient #2's BPP score and failure to immediately provide care. The RCA failed to identify the lack of communication between each nurse when receiving and caring for a patient with critical test results.

The Director of Quality Improvement acknowledged that the Hospital did not address these issues.

2. Review of Patient #11's medical record indicated that Patient #11 underwent a scheduled bedside liver biopsy on 1/28/19, at 11:30 A.M. At 11:42 A.M. the procedure ended. At 11:48 A.M. Patient #11 complained of severe pain at the biopsy site and blood pressure was measured at 119/76. At 12:01 P.M. Patient #11's blood pressure was 67/52. The Intensivist was notified and came to Patient #11's room to place a central line due to suspected bleeding. At 12:32 P.M. Patient #11 experienced a Cardiac Arrest and a Code 99 was called. At 12:59 P.M. there was a return of a spontaneous pulse. Patient #11 remained critically ill and required emergent transfer by LifeFlight to a tertiary hospital for further medical management. Patient #11 died shortly after arriving at the tertiary hospital.

The Surveyors interviewed Nurse #7 on 2/7/18 at 11:30 P.M. Nurse # 7 said that she was providing sedation for Patient #11 during the biopsy. Nurse # 7 said that immediately after the procedure Patient #11 was experiencing pain at the biopsy site that Nurse #7 would rate as 10/10. Nurse # 7 said that Patient #11's blood pressure dropped quickly after the procedure and she was concerned for internal bleeding. Nurse # 7 said that, at 12:32 P.M., Patient #11 went into Pulseless Electrical Activity (PEA) while the Intensivist was placing the central line. A Code 99 was then called and spontaneous circulation returned at approximately 12:59 P.M. Nurse # 7 said that immediately after the code the Intensivist left the Hospital to go to his office to see outpatients and left Nurse Practitioner #1 in charge of Patient #11's care. Nurse # 7 said that Patient #11 was very unstable at that time. Before the Intensivist left Nurse # 7 said that the Nurse Practitioner asked "What else can we do?" or words to that effect. The Intensivist said to keep giving blood and fluid and then he left the hospital. Nurse # 7 said that Patient #11's blood pressure kept dropping almost immediately after each unit of blood was administered. Nurse # 7 said about an hour after the Code ended the Nurse Practitioner was calling area hospitals to have the Patient #11 transferred. Nurse # 7 said that an area hospital had a bed available at 7:00 P.M. and that LifeFlight would be available for a 6:30 P.M. transport.

Nurse # 7 said that while preparing Patient #11 for transport at 4:30 P.M. she noticed when she changed the central line dressing that the central line migrated out of Patient# 11 a significant amount. The securement device was noted to be sutured to Patient #11's skin however the central line itself was not attached to it and was not secure. Nurse # 7 said she notified Nurse Practitioner #1 who then notified the Intensivist. Nurse # 7 said that she had to move Patient #11's IV which were infusing vasopressors (vasopressors are a group of medicines that tighten blood vessels and raise blood pressure) to a #22 gauge distal peripheral intravenous line (IV) which is contraindicated. Nurse # 7 said that vasopressors are best administered through central lines because vasopressors cause IV infiltration (when I.V. fluid or medications leak into the surrounding tissue) when administered through smaller gauge IVs. Nurse # 7 said that Patient #11's blood pressure started to drop shortly at this time. Nurse # 7 said that she thought Patient #11's blood pressure was dropping because he/she was not receiving the vasopressors through the central line and was still bleeding internally. Nurse # 7 said that she called the Intensivist to see when he would be coming to place the central line and the Intensivist said that he had one more patient to see in the office and did not provide an estimated time of arrival. Nurse # 7 said that the LifeFlight was canceled and needed to be rescheduled due to the delay in placing a central line. Nurse # 7 said that the Intensivist arrived at 6:15 P.M. (75 minutes after being notified) to place a new central line. Nurse # 7 said Patient #11 was unstable throughout the day and up until transport.

Review of the report titled "Surgery/Procedure Event 21816" dated 2/7/19, indicated that, on 1/28/19, at 5:00 P.M., the Intensivist was notified that Patient #11 needed a new central line and was being transported via LifeFlight within the next 30 minutes. The Intensivist was not in the Hospital and was at his office seeing outpatients. The Intensivist said that he had one more patient to see in the office. LifeFlight was canceled and required rescheduling due to a new central line having to be placed. At 6:15 P.M. (75 minutes after being notified) the Intensivist arrived to place a new central line. Patient #11 left the Hospital via LifeFlight at 7:20 P.M.

Nurse # 7 said that due to this critically ill and unstable condition, Patient #11 was being transferred for emergent surgical intervention. Nurse #7 said that between 5:30 P.M. and 6:15 P.M. she was responsible for overseeing Patient #11's care. There was no physician presence in the ICU and the Nurse Practitioner had gone home.

The Surveyors interviewed Nurse Practitioner #1 on 2/8/19, at 8:07 A.M. Nurse Practitioner #1 said that she was notified by Nurse #7 immediately after the liver biopsy about Patient #11's increasing pain and discomfort. Nurse Practitioner #1 said that Patient #11's blood pressure began to decrease and that she ordered a Computed Tomography (CT) Scan. Nurse Practitioner #1 said that she then notified the Intensivist that Patient #11 would need a central line. Nurse Practitioner #1 said that she suspected that Patient #11 was internally bleeding and would require fluids and blood, and the only IV access Patient #11 had was a small #22 gauge IV. Nurse Practitioner #1 said that the Intensivist arrived and placed the central line. During the central line placement Patient #11 developed a PEA and a Code 99 was called. Nurse Practitioner #1 said Patient #11's was recently diagnosed with heart failure and she was concerned with Patient 11's stability. Nurse Practitioner #1 said there was a repeat ultrasound at the end of the code and she did not receive the results. Nurse Practitioner #1 said that after the Code 99 the Intensivist left the Hospital to see patients in his office. Nurse Practitioner #1 said that she asked the Intensivist what the next step was and was told by the Intensivist to continue to give blood. Nurse Practitioner #1 said that she was never told the results of the ultrasound or the conversation between the Intensivist and the Radiologist.

Nurse Practitioner #1 said that Patient #11 continued to be very unstable and blood pressure continued to decrease between administrations of each unit of blood. Nurse Practitioner #1 said that at 2:30 P.M. (90 minutes after the Code 99) she texted the Intensivist and he then agreed to transfer Patient #11 to another hospital for an emergent intervention due to instability from internal bleeding. Nurse Practitioner #1 said that just before 5:00 P.M. Patient #11 was accepted at a tertiary hospital. Nurse Practitioner #1 said that Nurse #7 went to prepare Patient #11 for transfer and noticed the central line was not in place. Nurse Practitioner #1 said she notified the Intensivist that Patient #11 would need a new central line at 5:00 P.M. Nurse Practitioner #1 said that she completed the transfer paperwork and left the Hospital at 5:30 P.M. Nurse Practitioner #1 said that the Intensivist had not arrived and that there was no hand-off or report to the Intensivist before she left.

The Surveyors interviewed the Intensivist on 2/8/19, at 9:30 A.M. The Intensivist said that Patient #11 was admitted for sepsis due to pneumonia. The Intensivist said that, on 1/28/19, Patient #11 had a liver biopsy and experienced some internal bleeding after the procedure. The Intensivist said he had just completed placing a second central line when Patient #11 coded. The Intensivist said that Patient #11 was intubated and received CPR. The Intensivist said that Patient #11's pulse returned and was stabilized. The Intensivist said he then left the Hospital to see patients in his office. The Intensivist said that he knew that Patient #11 needed to be transported immediately after the code and that the Radiologist and Nurse Practitioner were trying to find placement. The Intensivist said that he was available by phone and could come back to the Hospital within five minutes if needed. The Intensivist said he returned to the Hospital to re-place a line between 5:45 P.M. and 6:00 P.M. The Intensivist said that, while he was in his office and not in the Hospital, Patient #11 was stable. The Intensivist said that vasopressors could not be given in a peripheral line smaller than an 18 gauge and that a central line was needed to run vasopressors. The Intensivist did not explain why he placed the central line 75 minutes after a central line was requested.

Review of the RCA performed on 2/1/19 in response to this incident failed to identify issues with communication/hand off between the Intensivist and the Nurse Practitioner, coverage of medical staff when a patient is critically ill, unstable and awaiting emergent transport, appropriate use of a central line device and product review/malfunction vs. operator error.

The Hospital was out of compliance with the Condition of Participation for Medical Staff.

Findings included:

The Medical Staff failed to provide appropriate physician coverage of their Intensive Care Unit and Emergency Department as stated in accordance with Medical Staff Bylaws, rules and regulations.

Refer to TAG: A-0341.

Based on record review and interviews the Hospital Medical Staff failed to provide appropriate and safe physician coverage for their Intensive Care Unit.

1. Review of Patient #1's Code 99 Document dated 10/12/17 at 1:00 A.M. indicated that the Emergency Room Physician attempted to place an endotracheal tube (ETT-a tube used to establish and maintain a patent airway and to ensure an adequate exchange of oxygen and carbon dioxide) at 1:12 A.M. and was unsuccessful (12 minutes after the Code started). From 1:14 A.M. to 1:17 A.M. there were four more attempts at establishing an airway/placing an endotracheal tube that were unsuccessful (Documentation failed to identify who was attempting to place the tubes). At 1:18 A.M. Cardiopulmonary Resuscitation (CPR) was started. At 1:24 A.M., there was another unsuccessful attempt at placing an ETT (Documentation failed to identify who made the attempt). At 1:27 A.M. (27 minutes after the code was started) an ETT was placed (documentation failed to identify who placed the tube). At 1:48 A.M. the code was stopped by the Hospitalist and the Patient was pronounced dead.

The Surveyors interviewed Nurse #2 on 1/9/19, at 7:57 A.M. and Nurse #4 on 1/10/19, at 7:48 A.M. Nurse #2 said that the Hospitalist was in the room when the Code 99 was called and soon after the Emergency Room Physician responded and that the physicians were having difficulty placing an ETT and there were 4-5 attempts. Nurse #4 said that Patient #1 was very anxious after being extubated and was complaining of shortness of breath and expressing a fear of dying. Nurse #4 said that she becomes a little nervous when patients are extubated late in the afternoon and early evening because there is less physician coverage later in the evening and overnight. Nurse #4 said that it is not uncommon for the Emergency Room Physician to respond to a Code 99 at night.

The Surveyors interviewed Hospitalist #1 on 1/09/19, at 1:45 P.M. The Hospitalist said that Patient #1 was cleared for extubation earlier in the day on 10/11/17, and shortly after extubation developed increased secretions, swelling and became very anxious and decompensated quickly. The Hospitalist said that when Patient #1 desaturated he maintained the airway by manually bagging Patient #1 with a bag valve mask. The Hospitalist said a Code 99 was called and the Emergency Department Physician responded. The Hospitalist said that he didn't attempt to intubate Patient #1 at that time because he was not privileged by the Hospital to intubate. The Hospitalist said he used a bag valve mask to administer oxygen while waiting for the Emergency Department Physician. The Hospitalist said that the Emergency Department Physician arrived and attempted 4-5 times to place a tube but was unsuccessful. The Hospitalist said that a long time had passed without establishing an airway/placing the tube so he attempted to place an ETT and was successful. The Hospitalist said that too much time had passed at that point and Patient #1 was without oxygen for too long and died.

Review of Hospitalist #1's credentialing file indicated that Hospitalist #1 was not privileged in endotracheal intubation, mechanical ventilation, or thoracentesis.

The Surveyors interviewed the Associate Chief Quality Officer/Chief of Emergency Medicine on 1/10/19 at 9:50 A.M. The Associate Chief Quality Officer/Chief of Emergency Medicine said that Patient #1 was an unexpected death, there was an unexpected delay placing/securing an airway (27 minutes), and was unaware what coverage the Emergency Department had when the Emergency Physician left the Emergency Department to respond to the Code 99. The Associate Chief Quality Officer/Chief of Emergency Medicine said he was unaware that the Hospitalist placed the ETT. The Associate Chief Quality Officer/Chief of Emergency Medicine said that if the Hospitalist was uncomfortable intubating patients they would not privilege the physician to intubate and it is not required. The Associate Chief Quality Officer/Chief of Emergency Medicine said that during the overnight Hospitalists are required to cover all admissions and inpatients (including the ICU).

The Associate Chief Quality Officer/Chief of Emergency Medicine said that from 2:00 A.M. to 5:00 A.M. there is one Emergency Physician covering the Emergency Department and one Hospitalist covering the rest of the Hospital including the ICU. The Associate Chief Quality Officer/Chief of Emergency Medicine said that the Emergency Physician is not required to respond to a Code 99s even though the Hospitalist is not privileged to intubate. The Associate Chief Quality Officer/Chief of Emergency Medicine acknowledged that would leave no physician presence in the Emergency Department. The Associate Chief Quality Officer/Chief of Emergency Medicine said that when a patient needs to be intubated the Hospitalist can call a Respiratory Therapist to intubate a patient.

Review of the Respiratory Therapy schedule indicates that not every Respiratory Therapist is approved to intubate and that overnight coverage can consist of only one Respiratory Therapist who is responsible for all patients on mechanical ventilators and patients receiving breathing treatments in the Hospital.

The Associate Chief Quality Officer/Chief of Emergency Medicine said that physician coverage is assessed by gathering feedback from the Hospitalist, staff, and reviewing incidents to determine if staffing is adequate. The Associate Chief Quality Officer/Chief of Emergency Medicine said that there have been no issues that he is aware of that indicate staffing is not adequate.

Review of the Hospital's ICU Staff Meeting minutes indicates that, in February of 2018 and again in June of 2018, ICU staffing and 7:00 P.M.-7:00 A.M. coverage was identified as needing additional physician or nurse practitioner coverage.

Review of the Hospitalist schedule indicates that both Hospitalist #1 and Hospitalist #2 were scheduled to cover the Hospital and ICU during overnights.

2. Review of Patient #11's medical record indicated that, on 1/19/19, Patient #11 was diagnosed with pneumonia and sepsis and was admitted to the Hospital's Intensive Care Unit (ICU). On 1/24/19, Patient #11 underwent an echocardiogram (a test that uses ultrasound to take pictures of your heart for diagnosis). Patient #11's echocardiogram showed that his/her left ventricular ejection fraction (LVEF) was 30 % (normal LVEF ranges from 55% to 70%). Patient #11's Discharge Summary dated 1/28/19 indicated that Patient #11 was found to have new systolic heart failure.

Patient #11 underwent a scheduled bedside liver biopsy on 1/28/19, at 11:30 A.M. At 11:42 A.M. the procedure ended. At 11:48 A.M. Patient #11 complained of severe pain at the biopsy site and blood pressure was measured at 119/76. At 12:01 P.M. Patient #11's blood pressure was 67/52. The Intensivist was notified and went to Patient #11's room to place a central line due to suspected bleeding. At 12:32 P.M. Patient #11 experienced a cardiac arrest and a Code 99 was called. At 12:59 P.M. there was a return of spontaneous pulse. Patient #11 remained critically ill and required emergent transfer by LifeFlight to a tertiary hospital for further medical management. Patient #11 died shortly after arriving at the tertiary hospital.

Review of the document titled "Bylaws of the Medical Staff", dated 11/2017, indicated that physicians who accept clinical privileges must accept the responsibility set forth in the Hospital Bylaws including provision of adequate back-up coverage for all patients admitted to the Hospital.

Review of the report titled Surgery/Procedure Event 21816 dated 2/7/19, indicated that on 1/28/19, at 4:30 P.M. Patient 11's central line dressing was changed. Upon removal of the dressing the central line migrated out a significant amount. The securement device was noted to be sutured to Patient #11's skin however the central line was not attached to it. The central line was placed emergently earlier in the day. At 5:00 P.M. the Intensivist was notified that Patient #11 needed a new central line and was being transported via LifeFlight within the next 30 minutes. The Intensivist was not in the Hospital and was at his office seeing outpatients. The Intensivist said that he had one more patient to see in the office. LifeFlight was canceled and required rescheduling due to the central line placement. At 6:15 P.M. (75 minutes after being notified) the Intensivist arrived to place a new central line. Patient #11 left the Hospital via LifeFlight at 7:20 P.M.

Nurse # 7 said that immediately after the procedure Patient #11 experienced pain at the biopsy site. Nurse # 7 said that Patient #11's blood pressure dropped quickly after the procedure and she was concerned for internal bleeding. Nurse # 7 said that, at 12:32 P.M., Patient #11 went into Pulseless Electrical Activity (PEA) while the Intensivist was placing a central line. A Code 99 (medical emergency) was then called and spontaneous circulation returned at approximately 12:59 P.M. Nurse # 7 said that immediately after the Code 99 the Intensivist left the Hospital to go to his office to see outpatients and left Nurse Practitioner #1 in charge of Patient #11's care. Nurse # 7 said that Patient #11 was very unstable at that time. Nurse # 7 said that the Nurse Practitioner asked "What else can we do?" or words to that effect. The Intensivist said to keep giving blood and fluids and then left. Nurse # 7 said that Patient #11's blood pressure kept dropping almost immediately between each unit of blood. Nurse # 7 said about an hour after the Code ended the Nurse Practitioner was calling area hospitals to have the Patient #11 transferred. Nurse # 7 said that an area hospital had a bed available at 7:00 P.M. and that LifeFlight would be available for a 6:30 P.M. transport.

Nurse # 7 said that she began to prepare Patient #11 for transport and at 4:30 P.M. she noticed that Patient #11's central line was not secured and migrated out of position. Nurse # 7 said she notified Nurse Practitioner #1 who then notified the Intensivist. Nurse # 7 said that she had to move Patient #11's vasopressors (vasopressors are a group of medicines that aid in raising blood pressure) to a #22 gauge distal peripheral intravenous line (IV) which is contraindicated. Nurse # 7 said that vasopressors are best administered through a central line because vasopressors can infiltrate (when I.V. fluid or medications leak into the surrounding tissue) when administered through smaller gauge IVs. Nurse # 7 said that Patient #11's blood pressure started to drop shortly after this time. Nurse # 7 said that she thought Patient #11's blood pressure was dropping because he/she was not receiving the vasopressors through the central line and was still bleeding internally. Nurse # 7 said that she called the Intensivist to see when he would be coming to place the central line. Nurse # 7 said that the Intensivist said that he had one more patient to see in the office and did not provide an estimated time of arrival. Nurse # 7 said that the LifeFlight was canceled and needed to be rescheduled due to the delay in placing a central line. Nurse # 7 said that the Intensivist arrived at 6:15 P.M. (75 minutes after being notified) to place a new central line. Nurse # 7 said Patient #11 was unstable throughout the day and at no time was stable.

Nurse # 7 said that due to this critically ill and unstable condition, Patient #11 was being transferred for emergent surgical intervention. Nurse #7 said that between 5:30 P.M. and 6:15 P.M. she was responsible for overseeing Patient #11's care. There was no physician presence in the ICU and the Nurse Practitioner had gone home.

The Surveyors interviewed Nurse Practitioner #1 on 2/8/19, at 8:07 A.M. Nurse Practitioner #1 said that she was notified by Nurse #7 immediately after the liver biopsy about Patient #11's increasing pain and discomfort. Nurse Practitioner #1 said that Patient #11's blood pressure began to decrease and that she ordered a Computed Tomography Scan. Nurse Practitioner #1 said that she then notified the Intensivist that Patient #11 would need a central line. Nurse Practitioner #1 said that she suspected that Patient #11 was bleeding internally and would require fluids and blood and the only IV access Patient #11 had was a small #22 gauge IV. Nurse Practitioner #1 said that the Intensivist arrived and placed the central line. Nurse Practitioner #1 said that during the central line placement Patient #11 developed pulseless electrical activity (PEA) and a Code 99 was called. Nurse Practitioner #1 said she did not see whether the Intensivist secured the central line. Nurse Practitioner #1 said that considering Patient #11's newly diagnosed heart failure, she was concerned with Patient #11's stability. Nurse Practitioner #1 said there was a repeat ultrasound at the end of the code and she did not receive the results. Nurse Practitioner #1 said that after the Code 99 the Intensivist left the Hospital to see patients in his office. Nurse Practitioner #1 said that she asked the Intensivist what the next step was. Nurse Practitioner #1 said that the Intensivist said to continue to give blood. Nurse Practitioner #1 said that she was never told about the results of the ultrasound or the conversation between the Intensivist and the Radiologist.

Nurse Practitioner #1 said that Patient #11 continued to be very unstable and blood pressure continued to decrease after each unit of blood was finished. Nurse Practitioner #1 said that at 2:30 P.M. (90 minutes after the Code 99) she texted the Intensivist and he agreed to transfer Patient #11 to another hospital due to instability and an emergent need for surgical intervention. Nurse Practitioner #1 said that just before 5:00 P.M. Patient #11 was accepted at a tertiary hospital. Nurse Practitioner #1 said that Nurse #7 went to prepare Patient #11 for transfer and noticed the central line was not in place. Nurse Practitioner #1 said she notified the Intensivist that Patient #11 would need a new central line at 5:00 P.M. Nurse Practitioner #1 said that she completed the transfer paperwork and left the Hospital at 5:30 P.M. Nurse Practitioner #1 said that the Intensivist had not arrived and that there was no hand-off or report to the Intensivist before she left. Nurse Practitioner #1 said she left because her shift had ended.

The Surveyors interviewed the Intensivist on 2/8/19, at 9:30 A.M. The Intensivist said that Patient #11 was admitted for sepsis due to pneumonia. The Intensivist said that, on 1/28/19, Patient #11 had a liver biopsy and experienced some internal bleeding after the procedure. The Intensivist said that he placed a central line and Patient #11 coded during the line placement. The Intensivist said that Patient #11 was intubated and received cardiopulmonary resuscitation (CPR). The Intensivist said that after the Code 99 Patient #11 was stabilized and he left the Hospital to see his office patients. The Intensivist said that he knew that Patient #11 needed to be transported immediately after the code and that the Radiologist and Nurse Practitioner were trying to find placement. The Intensivist said that he was available to come back to the Hospital within 5 minutes. The Intensivist said he returned to the Hospital to re-place a line between 5:45 P.M. and 6:00 P.M. The Intensivist said that, while he was in his office and not in the Hospital, Patient #11 was stable. The Intensivist said that vasopressors could not be given in a peripheral line smaller than an 18 gauge and that a central was needed to run vasopressors. The Intensivist did not explain why he placed the central line 75 minutes after a central line was requested.

Surveyors interviewed the Chief Medical Officer (CMO) on 2/8/19, at 12:00 P.M. The CMO acknowledged that due to Patient #11's acute critical condition and instability he would expect that the attending physician stay and oversee the emergent transport of Patient #11. The CMO acknowledged that the Intensivist not being on site delayed Patient #11's care and transport.

The Surveyors interviewed the Chief Nursing Officer (CNO) on 2/8/19, at 10:10 A.M. The CNO said he did not realize that Nurse Practitioner #1 had left the ICU without the Intensivist being present. The CNO said he would expect Nurse Practitioner #1 to stay to oversee Patient 11's care until the Intensivist arrived due to the critical condition of Patient #11, who was unstable, still experiencing blood loss, and was being emergently transferred by LifeFlight to another facility.