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Based on interview and record review, the hospital failed to ensure that 1 of 10 sampled patients (Patient 1) Patient 1's request to be a full code (resuscitation of heart and lungs) was carried out and Patient 1 received care in a safe setting when Patient 1 had a cardiopulmonary arrest (is a sudden stop in effective blood circulation due to the failure of the heart to contract effectively or not at all) was not resuscitated resulting in Patient 1's death. (A-144)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of care in a safe environment.

Based on staff interview and record review, the hospital failed to ensure that 1of 10 sampled patients (Patient1) Patient 1's right to be fully resuscitated, (Full Code) was carried out. Patient 1did not receive care in a safe environment when Licensed Staff G did not initiate cardio/pulmonary resuscitation, (CPR) for Patient 1 when he had a cardio/pulmonary arrest, resulting in Patient 1's death.

Findings:

Patient 1, was admitted to the hospital's cardiac telemetry, (portable heart monitor) unit on 3/10/16, with diagnoses including shortness of breath, acute influenza pneumonia, and sepsis.

Physician P's progress note dated 3/1/16, indicated that Patient 1 was a full code, (requested to be fully resuscitated during a cardio/pulmonary arrest).

During an interview on 3/25/16 at 10 a.m., Licensed Staff G stated Patient 1 was one of three patients assigned to her on the day shift 3/19/16. Licensed Staff G stated according to the shift report from Licensed Staff H at 7 a.m. on 3/19/16, Patient 1 had been stable during the night. Licensed G stated at 9 a.m. when she and a Patient Care technician repositioned Patient 1, Patient 1 was awake, alert, non-verbal with unlabored respirations. She stated one of her other patients was having respiratory distress, so she was unable to assess Patient 1 until an hour later at 10 a.m. It was at that time she found Patient 1 unresponsive, not breathing, with a slow heart rate of 30 beats/minute, (normal heart rate is 70 -80 beats/minute). Licensed Staff G stated she did not call a code blue, ( an emergency situation announced in a hospital in which a patient is in cardio/pulmonary arrest) and did not institute CPR for Patient 1. She thought Patient 1 was a DNR, (Do Not Resuscitate). She stated when Physician G arrived at the bedside he noted that Patient 1 was a full code and disclosed that to her. Licensed Staff G stated she guessed she had written it down wrong.

Physician P's progress notes for Patient 1, dated 3/17/16, indicated that Patient 's "code status is full." Physician P's Discharge Summary, dated 3/21/16, indicated Patient 1 "had
acute respiratory failure and expired 10:16 a.m. on 3/19/16."

The hospital's Patient Rights Publication, dated 2/2013, Attachment A, #7. indicated the patient has the right to participate in and the organization will address patient wishes regarding end of life care decisions. The ethical questions that arise including withholding resuscitative services will be addressed. Page 3, #20 indicated the patient will receive care in a safe setting.

Based on staff interview, and facility record review, the hospital failed to ensure that: Patient 1's request for full resuscitation was implemented. 2. a medication was administered to Patient 2 with a written physician order as evidenced by:

1. The nursing staff did not provide cardio/pulmonary resuscitation for Patient 1 who was a full code, when Patient 1 had a cardio/pulmonary arrest, resulting in the Patient 1's death. (Refer A- 395).

2. The nursing staff administered a medication, Propofol, to Patient 2, without a written physician order. (Refer A-405)

The cumulative effects of these systemic problems resulted in the hospital's inability to provide quality care in a safe and effective manner.

Based on staff interviews, hospital record review and facility policy review, the hospital failed to ensure that nursing staff met Patient 1's care needs when Patient 1, who was a full code, had a cardio/pulmonary arrest and full resuscitation was not provided. This failure resulted in Patient 1's death.

Findings:

Patient 1, was admitted to the hospital's cardiac/telemetry unit, (telemetry portable heart monitor) on 3/10/16, with diagnoses including shortness of breath, acute influenza bilateral pneumonia, and sepsis.

Physician P's progress notes dated 3/17/16, indicated that Patient 1 was a full code.

During interview on 3/25/16 at 10 a.m., Licensed Staff G stated she worked the day shift on 3/19/16 and her assignment included Patient 1 and two other patients. Licensed Staff G stated according to shift report from Licensed Staff H at 7 a.m., Patient 1 was stable during the night. At 9 a.m., when Licensed Staff G and a CNA repositioned Patient 1, Patient 1 was awake, alert, non-verbal and respirations were unlabored. Licensed Staff G stated one of her other patients was having respiratory distress, so she was unable to assess Patient 1 until an hour later at 10 a.m. It was at that time she found Patient 1 unresponsive, not breathing, with a heart rate of 30 - 40 beats/minute. She stated she did not call a code blue
(an emergency situation announced in a hospital or institution in which a patient
is in cardiopulmonary arrest) since she thought Patient 1 was Do Not Resuscitate, (DNR). Licensed Staff G stated during shift report she had written down that all three of her patients were DNR. She stated she guessed she heard wrong.

Physician P's Discharge summary Addendum for Patient 1, dated 3/21/16, for 3/19/16, indicated "the patient expired as mentioned in the initial discharge summary. However the patient was noted to be a full code and a code blue was not called by nursing. Upon arrival to bedside, I noted and disclosed the patient was a full code candidate. Nursing at bedside was unaware of this even though it was documented in my note and in the patient's medical record. At that time, I arrived at bedside, the patient had clearly expired. I disclosed this information to the patient's son that his father was a full code and no code blue or an attempt to resuscitate him when he was found to be in cardio/pulmonary arrest was attempted."

Based on interview and document review the hospital failed to follow the facility's policy and procedure for safe medication administration when a licensed nurse gave a medication, Propfol, (a medication used to calm or sedate a patient who is on a ventilator, (mechanical breathing machine), to Patient 2 without a written physician's order.

Findings:

Patient 2's physician progress note written by Physician O and dated 5/13/16 at 10:22 p.m., reflected Physician O received a telephone call from an un-named ICU RN regarding Patient 2's condition. In this note, Physician O wrote based on the patient's condition, "...we will reinstitute low-dose propofol." (Propofol is a medication used to calm or sedate a patient who is on a ventilator or breathing machine and it may cause temporary paralysis.)

During an interview on 5/18/16 at 8:10 a.m., Licensed Staff J stated a telephone discussion took place between Staff J and Physician O "around 10:00 p.m." on 5/13/16 regarding Patient 2's condition and the possibility of administering propofol to this patient. Shortly after the call, Staff J administered propofol to Patient 2.

The "CareFusion" records (an automated medication dispensing system) reflected Staff J removed a 100-milliliter bottle of propofol (10 mg/ml) from the storage system at 10:18 p.m. on 5/13/16 and signed it out to Patient 2.

Physician O did not write an order for propofol for Patient 2 on 5/13/16. The facility's "All Device Events Report" revealed Staff J obtained the medication from the medication dispensing system by "override."

During an interview on 5/18/16 at 8:55 a.m., Administrative Staff F explained an "override" would occur if a medication were removed from the medication dispensing system without an active order written for that medication. Staff J did not have a written order for the propofol administered to Patient 2, nor did staff J write a telephone order from Physician O for this medication. (A telephone order is one given verbally over the telephone, when the physician is not present at the facility. The order is verified and countersigned later, based upon facility policy.)

Physician N documented a progress note in Patient 2's medical record, dated 5/14/16 at 6:11 a.m. It stated, "Request by RN to write order for propofol that was been given (sic)."

Patient 2's Medication Administration History Report indicated Physician N wrote an order for propofol at 6:46 a.m. on 5/14/16, eight hours after Staff J administered the propofol.

Patient 2's electronic medication administration record showed no documented evidence of propofol administration to Patient 2 during Staff J's shift.

During the 5/18/16 8:10 a.m. interview, Staff J stated he did not document the propofol administration in Patient 2's medical record.

Patient 2's electronic medical record showed no documentation of a change in the patient's condition or the reporting of this condition change to the patient's physician. Staff J stated he would normally document a patient's change of condition in the medical record, but did not do so for Patient 2 during the night shift worked 5/13 to 5/14/16.

Professional nursing practice standards and the facility's policy, titled "Housewide Clinical Manual - Medication Administration" (dated 3/12), indicated in section IV. Assessment A., "Verify physician order and time order was written." and section IV. Medication Administration A.1., "Before giving any new medication, the medication order must be verified on the eMAR (electronic medication administration record) by comparing it to the written order from the MD."

The facility's medication administration policy, "Housewide Clinical Manual - Medication Administration" (dated 3/12), indicated in section I.D., "...it will be the responsibility of the Clinical Staff to assure all meds are given and documented in the eMAR for their shift prior to leaving" and section III.B.5., "Document information concerning medications accurately, completely and on the appropriate sections of the eMAR. Documentation includes route of administration, time given and caregiver's electronic signature."

Professional nursing practice standards and the facility's own policy, titled "Verbal and Telephone Orders from a Physician or a Physician Extender" (dated 6/13), indicated in section I, "All orders for ...medications, and intravenous solutions shall be written legibly and signed by the ordering physician or physician extender. In the event that a physician or physician extender is not present, all dictated verbal or telephone orders shall be received by a licensed health care provider, read back to the prescriber ...then promptly and legibly recorded in the patient's medical record. Once this is completed, the order(s) will be carried out."