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Based on interview, and record review, the hospital failed to ensure nursing services were provided in accordance with national standards of practice, and in accordance with regulations when the hospital failed to:

1. Ensure basic life support was initiated for Patient 1 according to American Heart Association Basic Life Support guidelines. (Refer to A 395)

2. Ensure Obstetric (OB) triage nurses completed required OB triage competencies according to policy and procedure, prior to caring for OB triage patients. (Refer to A 397)

3. Develop and implement a person centered nursing care plan addressing Patient 9's agitation and confusion. (Refer to A 396)

4. Develop and implement a person centered nursing care plan addressing Patient 9's smoking safety precautions and strategies. (Refer to A 396)

5. Develop a person centered nursing care plan addressing potential for infection for Patient 9 and Patient 30. (Refer to A 396)

6. Ensure medications were administered according to physician's order and policy and procedure for six of 12 sampled patients (Patient 1, Patient 16, Patient 23, Patient 24, Patient 25, Patient 17). (Refer to A 405).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure nursing services were provided in a safe manner, patient care need were being met, and had the potential to contribute to Patient 1, Patient 9, and Patient 16's deaths.


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Based on interview and record review, the hospital failed to ensure the obstetric (OB) triage nurses followed the American Heart Association (AHA) Basic Life Support (BLS) guidelines for one of 30 sampled patients (Patient 1). This failure resulted in Patient 1's respiratory status not being assessed and rescue breathing not being initiated according to the AHA BLS guidelines which may have contributed to Patient 1's death.

Findings:

During an interview and record review, on 1/17/20, at 10:35 AM, with Registered Nurse (RN) 10, RN 10 stated she and RN 11 responded to Patient 1's room in the Obstetrical (OB) triage (OB triage - an area in the hospital where pregnant patients receive care before being admission) unit when Patient 1's significant other called out for help. RN 10 stated Patient 1 was on the floor on her knees, "not making sense and then lost consciousness, and appeared gray" in color. RN 10 stated she did not recall Patient 1's respiratory status because she was "focused on getting the baby on the monitor." RN 10 stated RN 11 called RRT (Rapid Response Team- An Intensive Care Unit [ICU] Nurse and a Respiratory Therapist [RT] who respond to hospitalized patients with early signs of deterioration on non-intensive care units to prevent respiratory or cardiac arrest).

During review of the "Results Details", dated 1/10/20, at 1:24 AM, indicated "RN (10) called to bedside by FOB [father of baby], pt [patient] unresponsive in bathroom, sternal rub [firmly rubbing the knuckles of closed fist to the center chest of a patient who is not alert and does not respond to verbal commands] done, no response, pulse present, RRT called."

During an interview on 1/17/20, at 2:43 PM, with RN 11, RN 11 stated she responded to Patient 1's room on 1/10/20, at 1:24 AM, Patient 1 was on her right side and "not responsive." RN 11 stated she left Patient 1's room to call for RRT. RN 11 stated Patient 1's breathing was "maybe agonal [struggling to breath or gasping]" and she did not attempt to provide rescue breathing. RN 11 stated she left the room for the second time to call for RRT.

During an interview on 1/17/20, at 4:08 PM, with RN 12, RN 12 stated she heard the RRT call overhead on 1/10/20. She went to Patient 1's room in the OB triage unit. RN 12 stated Patient 1 was on the floor, partially in the bathroom. RN 12 stated Patient 1 had "gargly [shortness]breathing." RN 12 stated she applied pulse oximeter and it read 60% (Normal finding are 96% to 100%, critical findings that would prompt intervention for most patients would likely be in the mid to high 80% range) but did not document it. RN 12 stated she found Patient 1 without a pulse, she started chest compressions.

During an interview on 1/21/20, at 7:04 PM, with RN 8, RN 8 stated she was the charge nurse for the Labor and Delivery/Triage unit, on 1/9/20, and she responded to RRT call in the OB triage room. RN 8 stated Patient 1 had "snoring respirations," was unresponsive, and jaw was clenched. RN 8 stated she performed a sternal rub.

During an interview on 1/16/20, at 4:39 PM, with Medical Doctor (MD) 2, MD 2 stated on 1/10/20, she responded to a Code Blue in the OB triage unit. MD 2 stated Patient 1 had a noisy breathing that may have been due to a possible obstruction. MD 2 stated later she performed a "perimortem [taking place around the time of death]" cesarean section (surgical operation for delivering a child by cutting through the wall of the mother's abdomen).

During an interview on 1/17/20, at 6:01 PM, with RT 2, RT 2 stated he responded to a RRT call to the OB triage room. RT 2 stated Patient 1 was on floor with breathing similar to snoring and was unresponsive. RT 2 stated he attempted to open Patient 1's airway but the jaw was clenched and her tongue was between her teeth. RT 2 stated the oxygen tubing from the wall outlet could not reach the patient. He stated he was not part of the RRT.

During an interview on 1/17/20, at 5:33 PM, with RT 1, RT 1 stated she responded to an RRT call to the OB triage room. RT 1 stated Patient 1 appeared "discolored" and no oxygen was being given. RT 1 stated Patient 1's jaw was clenched and her tongue was clamped between her teeth. RT 1 stated Code Blue Team members [responds to medical emergencies] began arriving into Patient 1's room, but were unable to get through the locked L&D (Labor and Delivery) triage door because they did not know the door access code.

During an interview on 1/17/20, at 6:48 PM, with RN 6, RN 6 stated she was the ICU nurse on the RRT and Code team on 1/10/20. RN 6 stated she responded to RRT call in the OB triage room but she did not have the door access code to get into the OB triage unit. RN 6 stated once she gained access to Patient 1's room she gave the Automated External Defibrillator (AED) pads (connects to an electronic device that automatically diagnoses the life-threatening heart rhythms) on the crash cart to a nurse to apply to the patient. RN 6 stated Pulseless Electrical Activity (PEA- a cardiac arrest with a heart rhythm that should produce a pulse, but does not) was noted and a Code Blue was called.

During a review of the "Rapid Response Team RN Documentation Form", dated 1/10/20, at 1:29 AM, indicated, "Pt found on floor (collapsed) in the bathroom. Unresponsive/apneic [not breathing]. Hard to bagged [sic] [using a mask and squeezable device to provide artificial respirations]. Rescue breathing being done. Pt lost pulse [heart not beating]. Code blue [announcement of an emergency situation in a hospital when a patient is not breathing adequately or their heart is not beating effectively, requiring a team of providers to rush to the patient and begin immediate resuscitative efforts] called."

During a review of the hospital's policy and procedure (P&P) titled, "Emergency Medical Response for Adults and Pediatrics", dated 7/16, the P&P indicated, "1. First person to scene will perform the following procedure, and will remain with the patient until excused by the physician or code blue team directing the code. a. Check for responsiveness. If unresponsive, call for help using the active emergency response system. 1) Dial "77" from room phone and inform operator. . . 4) Push Code button, if available. 5. Call for help. Initiate BLS [Basic Life Support]. Request resuscitation cart. . . b. Initiate American Heart Association: BLS, ACLS [Advanced Cardiac Life Support]/PALS [Pediatric Advanced Life Support] algorithms until the physician arrives and follow physician direction afterwards."

During review of the "American Heart Association Basic Life Support" manual, dated 2016, indicated, "Look for no breathing or only gasping . . . provide rescue breathing."

Based on interview, and record review, the hospital failed to ensure person centered nursing care plans were initiated for Patient 9 and Patient 30 when:

1. A care plan addressing Patient 9's specific care needs related to agitation and confusion was not initiated. This failure placed Patient 9's safety at risk.

2. Care plans addressing safety precautions and strategies regarding Patient 9's smoking was not initiated. This failure contributed to patient 9 catching herself on fire and compromised patient, staff and visitor's safety.

3. A care plan addressing Patient 9's potential for infection related to her burns was not initiated. This failure had to potential for patient to develop a burn wound infection.

4. A care plan addressing Patient 30's potential for infection related to her cesarean section wound was not initiated. This failure had to potential for patient to develop an incision infection.

Findings:

1. During a review of Patient 9's "Nursing Notes" (NN), dated 12/28/19, at midnight, (note entered on 12/28/19, at 3:32 AM) entered by Registered Nurse (RN) 15, the "NN" indicated, "Came out of another patient's room and her pt [Patient 9] calling for help. Upon entering the room was filled with smoke. The patient [patient 9] was covered with water and sheets and gown had burn marks. Assessed pt and pt had burn marks to left hand, upper arm, and left adm. [abdomen]."

During a review of Patient 9's "NN", dated 12/28/19, at 12:20 AM, (note entered on 12/28/19, at 4:18 AM) entered by RN 15, the "NN" indicated, the patient (patient 9) was "extremely agitated."

During a review of Patient 9's "NN", dated 12/28/19, at 23:35 AM, (note entered at 12/28/19, at 4:18 AM) entered by RN 15, the nursing note indicated, patient (Patient 9) was agitated and repeating "the devil did this."

During a review of Patient 9's "NN", dated 12/28/19, at 12:30 AM, (note entered at 12/28/19, at 4:18 AM) entered by RN 15, the "NN" indicated, "Pt agitated not allowing staff to remove burnt linen."

During a review of Patient 9's "NN", dated 12/28/19, at 6:00 AM, (note entered at 12/28/19, at 6:20 AM) entered by RN 15, the "NN" indicated, "Pt agitated in room. . . Pt agitated and confused @ (at) this time."

During an interview on 1/22/20, at 3:39 PM, with RN 15, RN 15 stated, she did not initiate a nursing care plan (POC) addressing Patient 9's behaviors after the fire which included agitation and confusion. RN 15 also stated she did not initiate a potential for infection POC following Patient 9's burn wound on 12/28/19. RN 15 stated she did not know who should have initiated the care plans.

During review of Patient 9's Consultation Report (CR), dated 12/28/19, at 4:08 PM, the "CR" indicated, "HISTORY OF PRESENT ILLNESS: The patient (Patient 9) is a 79 year-old individual with a history of dementia . . . and a history of recent burns."

2. During review of Patient 9's "Emergency Department Physician Notes" (EDPN), dated 12/26/19, at 5:51 PM, the "EDPN" indicated, Patient 9 was seen by the ED physician on 12/26/19, at 4:31 PM. Patient 9 complained of chest pain and difficulty breathing. The "EDPN" indicated Patient 9 smoked four or less cigarettes per day (less than 1/4 pack per day in the last 30 days). Patient 9's final diagnosis included Pneumonia (infection of the lungs). Ceftriaxone (antibiotic), intravenously (given through the vein) was ordered for Patient 9.

During a review of Patient 9's "History and Physical" (H&P) dated 12/26/19, at 8:42 PM, the "H&P" indicated, nicotine patch (to decrease the urge to smoke) every day was ordered, indication smoking cessation, for patient using less than 1/2 pack (cigarettes) per day. Start date 12/27/19 at 9 AM.

During a review of Patient 9's "Adult Admission History" (AAH), on 12/27/19, at 12:54 AM by RN 15, the "AAH" indicated, Patient 9 had a social history of Tobacco usage one-four cigarettes daily and a physician's order for nicotine trans patch (to decrease the urge to smoke) everyday, Azithromycin (antibiotic) intravenously every 24 hours and Ceftriaxone intravenously every 24 hours.

During an interview on 1/22/20, at 3:39 PM, with RN 15, RN 15 stated she admitted Patient 9 on 12/27/19 and completed Patient 9's Adult Admission History.

During a concurrent interview and record review, on 1/23/20, at 8:30 AM, with Nurse Manager (NM) 4, Patient 9's "H&P" dated 12/26/19, at 8:42 PM, indicated Patient 9 smoked and had a diagnosis of pneumonia. NM 4 was unable to provide a nursing care plan addressing smoking or smoking safety. NM 4 was unable to provide a nursing care plan initiated timely addressing the burn wound potential for infection.

3. During a review of Patient 30's "Discharge Summary" (DS), dated 1/18/20, the "DS" indicated, Patient 30 was admitted on 1/16/19 and had a repeat caesarean section.

During a concurrent interview and record review, on 1/24/20, at 8:17 AM, with NM 3, Patient 30's "Operative Report" (OR), dated 1/16/20 was reviewed. The "OR" indicated Patient 30 had a repeat caesarean section on 1/16/20. NM 3 was unable to find a nursing care plan for Patient 30 addressing the cesarean section wound. NM 3 stated she would expect a cesarean section patient to have a potential for infection plan of care.

During a review of the hospital's policy and procedure (P&P) titled, "Multidisciplinary Patient Care Plan - Acute Care", dated 4/24/18, the P&P indicated, "Multidisciplinary Patient Care Plan (MPCP) is a guideline for the healthcare team to assess and reassess the progress of the patient. This plan of care will list the active clinically relevant patient problems, goals/outcomes and interventions individualized for the patient through out the stay from admission to discharge."

Based on interview and record review, the hospital failed to ensure OB (obstetric - pregnant) triage (Medical Screening Examination (MSE) and nursing care for OB patients (Patient 1) was provided by nurses who completed required OB triage competencies according to policy and procedure prior to taking care of OB triage patients. These failures resulted in Patient 1 not receiving nursing care and a MSE from an OB triage nurse with a valid competency. Patient 1 had a respiratory and cardiac arrest, perimortum cesarean section (baby delivered by incision into uterus during maternal cardiac arrest) and died in the OB triag unit.

Findings:

During an interview on 1/15/20, at 3:30 PM, with Registered Nurse Educator (RNE) 1, RNE 1 stated RN's are trained for OB triage by being precepted (learning from an OB triage nurse) for 2 shifts. RNE 1 verified RN 11 was assigned to OB triage. RNE 1 was unable to provide documentation RN 11 was precepted 2 shifts prior to being assigned to OB triage. RNE 1 was unable to provide documentation of OB triage orientation for RN's assigned to OB triage. RNE stated " I don't keep a record." RNE 1 was unable to provide documentation of RN 11's OB triage competency.

During an interview on 1/15/20, at 3:40 PM, with Director of Obstetrics (DOB), DOB stated there should be a record of when RN's have oriented on the OB triage unit and there should be a competency check list completed before they are assigned to the OB triage unit.


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During an interview on 1/17/20, at 10:35 AM, with RN 10, RN 10 stated her training for OB triage was three days of orientation with an OB triage nurse, but did not remember completing an OB triage competency check list.

During an interview on 1/17/20, at 2:43 PM, with RN 11, RN 11 stated her training for OB triage nurse was shadowing an OB triage nurse for 3 days, but did not recall completing a competency test.

During a concurrent interview and record review, on 1/17/20, at 4:21 PM, with Nurse Manager (NM) 1, NM 1 was unable to provide documentation of OB triage nursing competencies and S.T.A.B.L.E. (Sugar, Temperature, Airway, Blood pressure, Lab work and Emotional support - course for newborn stabilization) certification.

During an interview on 1/21/20, at 4:33 PM, with RNE 1, RNE 1 stated there was no written OB triage competency test. RNE 1 stated OB triage nurses were not signed off for OB triage competency by an OB doctor as per hospital policy.

During an interview on 1/27/20, at 11:45 AM, with Chief Nursing Officer (CNO), CNO confirmed no chart audits were done, per policy, to ensure OB triage nurses maintained competency to perform MSE for pregnant patients 37 weeks or greater. CNO also confirmed the OB triage nurses did not have current AWHONN (Association of Women's Health, Obstetric, Neonatal Nurses - a membership organization that promotes the health of women & newborns) Intermediate Fetal monitoring certification.

During a review of the hospital's policy and procedure (P&P), titled "Standardized Procedure for Medical Screening Exam for Labor Evaluation for Patients Greater than or Equal to 37 Weeks [pregnant]", dated 2/24/19, the P&P indicated, "Initial Competency Validation: 1. Upon completion of the didactic [classroom training] and practicum [clinical training] portions, RNs shall complete a post-test with a passing score of 90% or better. . . Practicum: 1. RNs must successfully complete orientation requirement for Labor & Delivery, including demonstration of MSE [Medical Screening Exams] to an assigned orientation preceptor, charge nurse, manager, or educator. 2. Continuing evaluation of competency will be accomplished though annual completion of a written test with a passing score of 90% or better, annual completion of an EMTALA [Emergency Medical Treatment and Labor Act] competency/written test, and ongoing retrospective chart audits by Perinatal Safety specialist/manager to ascertain compliance with above listed policies. Documentation of Validated Performers 1. Documentation of initial and continuing competency validation is maintained in each staff member's personnel file."

During a review of the hospital's policy and procedure (P&P), titled "Perinatal [relating to before and after birth] Services Medical Screening Examination and Care of Obstetrical Patients with a Potential Emergency Condition", dated 6/16, the P&P indicated "Those qualified to perform medical screening examination shall be set forth in the Medical Staff Bylaws and/or the Medical Staff Rules and Regulations as necessary. . . Standardized Procedure for Medical Screening for Labor Evaluation for Patient Greater Than or Equal to 37 Weeks. Designated qualified persons in this Department include: A Registered Nurse who has been certified by the Chair of the OB/GYN [Obstetrics and Gynocology - care for women] Section or Department for competency to perform such MSE using standardized protocols in consultation with a credentialed and privileged medical staff member."

During a review of the hospital job description for an OB triage nurse, dated 8/6/19, indicated "The OB Triage Unit RN must have more than 1 year experience in Labor & Delivery and successful completion of ESI [Emergency Severity Index - a method for categorizing and prioritizing patient needs]. Or more than 1 year experience as an Emergency Room Triage Nurse with current certifications in NRP (Neonatal Resuscitation Program), ACLS(Advanced Cardiac life Support), AWHONN (Association of Women Health, Obstetrics and Neonatal Nurses) intermediate fetal monitoring certificate and S.T.A.B.L.E."

Based on observation, interview, and record review, the hospital failed to administer medication according to physician's order and policy and procedure for six of 12 sampled patients (Patient 1, Patient 16, Patient 23, Patient 24, Patient 25, Patient 17).

1. For Patient 16, Fentanyl (A powerful drug used in the treatment of severe pain. Fentanyl overdose can cause respiratory distress and death) was administered over the prescribed dosage. This failure resulted in significant medication error which may have contributed to Patient 16's death.

2. For Patient 23, Patient 24, Patient 25, and Patient 17, there was no pain assessment utilizing Critical Care Pain Observation tool (CPOT- pain assessment scale for patients who are unable to report it, total scale ranging from 0 to 8. CPOT score of 2 or less: there is likely minimal to no pain present CPOT score of greater than 2: there is an unacceptable level of pain) and independent double check (IDC-a procedure in which two clinicians check each component of prescribing, dispensing, and verifying the high-alert medication before administering it to the patient) by two licensed staff prior to administering the initial dose of Fentanyl and prior to each dose increase. These failures had the potential to result in overdosage of Fentanyl and adverse event (incident that results in harm to the patient) and death.

3. For Patient 1, Ativan (sedative used to treat seizures) was not administered as per MD 1's verbal order, for a possible eclamptic seizure (seizures that occur during a woman's pregnancy or shortly after giving birth) during an Code Blue (emergency situation in a hospital when a patient is not breathing adequately or their heart is not beating effectively, requiring a team of providers to rush to the patient and begin immediate resuscitative efforts). This failure had the potential to contribute to Patient 1's medical condition and death.

Findings:

1. During a review the hospital's "Adverse Event Reporting Form" (AER), dated 1/19/20, indicated, "Type of occurrence: Death associated with medication error."

During a concurrent interview and record review, on 1/21/20, at 4:58 PM, with Emergency Department (ED) Manager (EDM), Patient 16's ED record dated 1/17/20 was reviewed. EDM verified Patient 16 received an over the prescribed dosage of Fentanyl intravenously (IV-through or within a vein). EDM stated, the standard mix of Fentanyl was 1000 micrograms (mics-unit of measure) in 100 milliliters (mls-unit of measure) of Normal Saline (NS-Normal saline-salt solution is nearly the same as that of human blood). EDM also stated Fentanyl was set on an IV pump (IVP) at 999 mls per hour instead of the prescribed dose of 5 ml per hour.

During a concurrent observation and interview on 1/22/20, at 9:45 AM, with Registered Nurse (RN) 1 and RN 2 in the ED, RN 1 and RN 2 demonstrated setting up an IV infusion on an IVP. RN 1 stated only hospital critical care areas (Areas of the hospital where seriously ill patients receive specialized care such as intensive monitoring and advanced life support) staff have access to the IVP's library of high risk IV medications such as Fentanyl. RN 2 stated there should always be two RNs to visually check (independent double check) the medication selected in the IVP medication library matches the physician's order and IV bag label. RN 2 also stated the 7 rights of medication administration (right patient, right medication, right dose, right time, right route, right to refuse, right to education) are verified. RN 1 stated documentation of the independent double check of high risk medication on Electronic Medication Administration Record (eMAR- electronic report that serves as a legal record of the drugs administered to a patient at a hospital by a health care professional) is a mandatory (required) screen.

During an interview on 1/22/20, at 11:55 AM, with Biomedical Engineering Manager (BEM), BEM verified the IVP used for Patient 16's Fentanyl over dosage infusion on 1/17/20 was removed from use and was checked. BEM stated, "Everything was fine in this [IVP machine]."

During an interview on 1/22/20, at 2:50 PM, with Patient Safety Officer/Director of Risk Management (PSO), PSO verified Patient 16 received an over the prescribed dosage of Fentanyl on 1/17/20 in ED. When the error was discovered, the Fentanyl was set on the IVP as a basic infusion at 999 ml/hour and NOT set as Fentanyl on IVP. PSO stated, "I think it's a human error. Fentanyl was set as a basic infusion. Fentanyl was not selected on the [IVP] so it [IVP] let them [ED nurses] run at 999 ml per hour."

During a concurrent observation and interview, on 1/22/20, at 4:48 PM, with Director of Pharmacy (DP), DP showed the bag of Fentanyl 1000 mics in 100 ml of NS infused to Patient 16, on 1/17/20, at 3:38 PM. DP stated 75 mls (equivalent to 750 mics) of Fentanyl was infused to Patient 16 and 25 mls was left in the bag.

During a concurrent interview and record review, on 1/23/20, at 3:43 PM, with BEM, the printed IVP machine report, dated 1/17/20 was reviewed. The IVPR indicated, on 1/17/20, at 3:38 PM, Fentanyl 1000 mics in 100 mls of NS at 999 ml an hour as basic infusion was started and was stopped at 3:44 PM (total of six minutes with 750 mics infused).

During a concurrent interview and record review on 1/21/20, at 4:58 PM, with Emergency Department (ED) Manager (EDM), Patient 16's ED record dated 1/17/20 was reviewed. EDM verified a physician's order for Fentanyl 1000 mics in 100 ml of normal saline at 5 ml (50 mics) an hour but was administered at 999 ml an hour.


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2. During a concurrent interview and record review, on 1/23/20, at 4 PM, with Registered Nurse Educator (RNE) 2 and Director of Pharmacy (DP), Patient 23's
clinical record was reviewed and noted the following:

Physician's orders (PO) dated 1/21/20, indicated Fentanyl 1000 mics in 100 ml NS at 5 ml (50 mics) an hour, titrate by 25 mics as often as every 15 minutes to achieve a CPOT less score of 3.

eMAR indicated there were no IDCs and CPOTs documented prior to starting and changing the Fentanyl dose on IVP. RNE 2 and DP were unable to find documentation of IDC and CPOT pain assessment prior to initiating and increasing Patient 23's dose of Fentanyl on the following dates and times:

On 1/21/20, at 8:23 PM, Fentanyl 5 ml (50 mics) was started.

On 1/21/20, at 8:38 PM, Fentanyl dose was increased to 7.5 ml (75 mics)

On 1/21/20, at 8:55 PM, Fentanyl dose was increased to 10 ml (100 mics)

On 1/22/20, at 12:30 AM, Fentanyl dose was increased to 15 ml (150 mics)

RNE 2 and DP confirmed, the staff should have assessed Patient 23's pain by completing CPOT scale and should have performed IDC prior to initiating the Fentanyl and prior to each dose increase.

3. During a concurrent interview and record review, on 1/23/20, at 5:40 PM, with RNE 2 and DP, Patient 24's clinical record was reviewed and noted the following:

PO dated 12/19/19, indicated Fentanyl 1000 mics in 100 ml NS at 5 ml (50 mics) an hour, titrate by 25 mics as often as every 15 minutes to achieve a CPOT- less score of 3.

eMAR indicated there were no IDCs and CPOTs documented prior to starting and changing the Fentanyl dose on IVP. RNE 2 and DP were unable to find documentation of IDC and CPOT pain assessment prior to initiating and increasing Patient 24's dose of Fentanyl on the following dates and times:

On 12/19/19, at 1:20 PM, Fentanyl at 5 ml (50 mics) was started.

On 12/19/19, at 2 PM, Fentanyl dose was increased to 10 ml (100 mics)

On 12/19/19, at 2:15 PM, Fentanyl dose was increased to 15 ml (150 mics)

RNE and DP confirmed, the staff should have assessed Patient 24's pain by completing CPOT scale and should have performed IDC prior to initiating the Fentanyl and prior to each dose increase.

4. During a concurrent interview and record review, on 1/23/20, at 6:10 PM, with RNE 2 and DP, Patient 25's clinical record was reviewed and noted the following:

PO dated 12/23/19, indicated Fentanyl 1000 mics in 100 ml NS at 5 ml (50 mics) an hour, titrate by 25 mics as often as every 15 minutes to achieve a CPOT less score of 3.

eMAR indicated there were no IDCs and CPOTs documented prior to starting and changing the Fentanyl dose on IVP. RNE 2 and DP were unable to find documentation of IDC and CPOT pain assessment prior to initiating and increasing Patient 25's dose of Fentanyl on the following dates and times:

On 12/23/19, at 10:23 AM, Fentanyl at 5 ml (50 mics) was started.

On 12/23/19, at 3 PM, Fentanyl dose was increased to 15 ml (150 mics)

On 12/23/19, at 3:40 PM, Fentanyl dose was increased to 17.5 ml (175 mics)

RNE 2 and DP confirmed, the staff should have assessed Patient 25's pain by completing CPOT scale and should have performed IDC prior to initiating and prior to each dose increase of Fentanyl.



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5. During a concurrent interview and record review on 1/23/2020, at 4:50 PM, with Pharmacy Manager (PM) 1, Patient 17's PO dated 12/27/19, at 9 AM indicated Fentanyl 1000 mics in 100 ml NS initial starting dose of 5 ml (50 mics) per hour, titrated by an increment of 2.5 ml (25 mics) per hour as often as every 15 minutes to achieve CPOT less than 3 up to a maximum Fentanyl dose limit of 30 ml (300 mics) per hour.

During a concurrent interview and record review on 1/23/20, at 5:12 PM, with RN 3 and PM 1, Patient 17's eMAR was reviewed. The eMAR on 12/17/19 at 8:32 AM indicated Fentanyl at 5 ml (50 mics) per hour was initiated. eMAR dated 12/17/19 at 8:45 AM, indicated the Fentanyl dose was increased to 10 ml (100 mics) per hour. On 12/17/19 at 3:09 PM, Fentanyl dose was increased to 20 ml (200 mics) per hour.
PM 1 and RNE 3 verified the two increases in Fentanyl dose were not titrated according to PO and not verified by a second licensed nurse.

eMAR dated 12/17/20 indicated there were no IDCs and CPOTs documented for Patient 17 prior to starting and changing the Fentanyl dose on the following dates and times:

On 12/17/19 at 8:32 AM, Fentanyl at 5 ml (50 mics) per hour was initiated.

On 12/17/19 at 8:45 AM, Fentanyl dose was increased to 10 ml (100 mics) per hour.


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3. During an interview on 1/21/20, at 7:04 PM, with RN 8, RN 8 stated she administered the medications during Patient 1's Code Blue. RN 8 stated she heard MD 1 give a verbal order for Ativan. RN 8 stated she did not give the medication. RN 8 stated Ativan was not in the crash cart and she was unsure of who was responsible to go and get the Ativan.

During an interview on 1/22/20, at 3 PM, with MD 1, MD 1 stated when she arrived to Patient 1's room, she observed her jaw to be clenched. MD 1 stated RT was unable to intubate due to Patient 1's clenched jaw. MD 1 gave a verbal order during the Code Blue for Ativan and Magnesium Sulfate (a naturally occurring mineral used to prevent seizures) for possible "eclamptic seizure [seizures that occur during a woman's pregnancy or shortly after giving birth]." MD 1 stated she was not aware Ativan was not given as ordered.

During a review of the hospital's policy and procedure (P&P) titled "Medication Administration" dated 10/23/19, the P&P indicated, "Medications are to be administered as ordered..."

During a review of the hospital's policy and procedure (P&P) titled "Medication Administration" dated 10/23/19, the P&P indicated, "7. The "seven rights" must be observed when giving medications: a. Right Patient b. Right Medication c. Right Dosage d. Right Time e. Right Route...18. High Risk Medications... require and independent double check by a second licensed person prior to administration. Documentation of the double check will be done on the MAR [Medication Administration Record] ...a15). When high risk meds [medications] are administered via a pump, the settings, concentration, and parameters must be independently double-checked by two licensed persons and shall be done anytime a new infusion is started, anytime the rate of any fluid is changed, or anytime a new syringe or bag is hung."

During a review of the hospital policy and procedure (P&P) titled "pain management" dated 10/24/18, the P&P indicated "4. Assess and document severity on the MAR for inpatients and in EDM for outpatients prior to and after the administration of scheduled or PRN pain relieving medications." And on page 18 of the same P&P under the directions for use of CPOT, it indicated " 3. The patient should be evaluated before and at the peak effect of analgesic agent to assess if the treatment was effective in relieving pain."

Based on interview and record review, the facility failed to ensure nursing staff accurately and completely documented nursing care provided to Patient 1, in the medical record. This failure resulted in an incomplete medical record.

During an concurrent interview and record review on 1/17/20, at 10:35 AM, with RN 10, Patient 1's IView/I&O/Graphs, dated 10/10/20, at 1:24 AM was reviewed. Patient 1's IView/I&O/Graphs indicated "RN called to bedside by FOB (father of baby). pt unresponsive in bathroom. sternal rub done. no response. pulse present. RRT (Rapid Response Team- An Intensive Care Unit [ICU] Nurse and a Respiratory Therapist [RT] who respond to hospitalized patients with early signs of deterioration on non-intensive care units to prevent respiratory or cardiac arrest).called. RN 10 stated she and RN 11 responded to Patient 1's room in the Obstetrical (OB) triage (OB triage - an area in the hospital where pregnant patients receive care before being admission) unit when Patient 1's significant other called out for help. RN 10 stated Patient 1 was on the floor on her knees, "not making sense and then lost consciousness." Patient 1 "appeared gray" in color. RN 10 stated she did not recall Patient 1's respiratory status because she stated she was "focused on getting the baby on the monitor." RN 10 stated RN 11 called RRT." RN 10 was unable to provide documentation of all emergency interventions she provided to Patient 1 on 1/10/20.

During an interview on 1/17/20, at 2:43 PM, with RN 11, RN 11 stated she responded to Patient 1's room on 1/10/20, at 1:24 AM, Patient 1 was on her right side and "not responsive." RN 11 stated she left Patient 1's room to call for RRT. RN 11 stated Patient 1's breathing was "maybe agonal [struggling to breath or gasping]" and she did not attempt to provide rescue breathing. RN 11 stated she left room a second time to call for RRT. RN 11 was unable to provide documentation of all emergency interventions she provided to Patient 1 on 1/10/20.

During an interview on 1/17/20, at 4:08 PM, with RN 12, RN 12 stated she heard the RRT call overhead on 1/10/20. She went to Patient 1's room in the OB triage unit. RN 12 stated Patient 1 was on the floor, partially in the bathroom. RN 12 stated Patient 1 had "gargly breathing." RN 12 stated she applied pulse oximeter and it read 60% (Normal finding are 96% to 100%, critical findings that would prompt intervention for most patients would likely be in the mid to high 80% range) but did not document it. RN 12 stated she found Patient 1 without a pulse, she started chest compressions. RN 12 stated she did not document her interventions because "a lot going on" in her head. RN 12 verified she should have documented her interventions.

During an interview on 1/17/20, at 4:21 PM, with Nurse Manager (NM) 1, NM 1 stated it was her expectation for "everyday normal charting" to be documented, but during a Rapid Response or Code Blue, the documentation would be on the RRT or Code Blue forms. NM 1 did not respond when asked what her documentation expectations would be for nursing interventions and tasks completed by the OB nursing staff, from the time Patient 1 was found unresponsive to when the RRT team arrived five minutes later.

During an interview on 1/27/19, at 3:18 PM, with CNO, CNO stated, "I've already acknowledged we have a problem with documentation."

During a review of the facility's policy and procedure (P & P) titled, Documentation by Nursing Personnel, dated 12/1/17, The P & P indicated "Documentation must be completed by the end of a person's shift, prior to leaving the hospital. . . a. Registered Nurses . . . will document care, treatments, patient education, emotional support, and interventions will be documented in the electronic medical record (EHR)."

Based on interview and record review, the hospital failed to ensure the safety of patients in accordance with the policy and procedures and with the regulations as evidenced by:

1. The staff failed to follow the hospital's Code Red-Fire Plan, when a fire erupted in one of 30 sampled patient's (Patient 9) room. This failure had the potential to endanger patients, staff, and visitors. (Refer to A 714)

2. The hospital failed to ensure fire drills were conducted per the hospital's Code Red-Fire plan. This failure had the potential to place all hospital occupants at risk in the event of a fire. (Refer to A 714)

3 The hospital failed to provide the Rapid Response Team (RRT - an Intensive Care Unit [ICU] Nurse and a Respiratory Therapist [RT] respond to patients with early signs of deterioration on non-intensive care units to prevent respiratory or cardiac arrest) access to the locked OB (Obstetrics) area during a life threatening situation for one sampled patient (Patient 1). This failure caused a delay in Patient 1's resuscitation efforts. Patient 1 died after an emergency Cesarean (a surgical operation for delivering a child by cutting through the wall of the mother's abdomen) section. (Refer to A 724).

The cumulative effect of these systemic problems had the potential to negatively impact the safety of patients, staff, and visitors in the hospital.

Based on interview and record review, the hospital failed to ensure:

1. The staff followed the hospital's Code Red-Fire Plan, when a fire erupted in one of 30 sampled patient's (Patient 9) room. This failure had the potential to endanger patients, staff, and visitors.

2. Fire drills were conducted per the hospital's Code Red-Fire plan. This failure had the potential to place all hospital occupants at risk in the event of a fire.

Findings:

1. During an interview on 1/24/20, at 8:52 AM, with Registered Nurse (RN) 16, RN 16 stated she was the Nurse Shift Manager during the fire on 12/28/19. RN 16 stated, "One of the nurses told me [Patient 9] caught on fire. I went to check." RN 16 stated the fire was out, but there was a little smoke in the room. RN 16 was asked if the fire alarm was activated and RN 16 stated "No." RN 16 also stated the fire extinguisher was not used and no Code Red was called. She was asked if she had participated in Code Red fire drills. RN 16 stated, "I don't remember being on duty for it (Code Red fire drill)."

During an interview on 1/24/20, at 9:09 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated "I went into Patient 9's room and saw flames. Patient 9 had a water pitcher and was pouring water [on the fire]. I grabbed the first thing I seen. I don't remember what it was. I was trying to get flames off her [referring to Patient 9]. Flames kept coming and getting big when she put water on it." CNA 1 stated she called for help and was trying to help the patient. CNA 1 stated staff arrived to help, but no Code Red was called.

During an interview on 1/24/20, at 9:19 AM, with RN 14, RN 14 stated he was the break nurse during the early morning of the fire on 12/28/19. RN 14 stated he heard the CNA yell. When he arrived to Patient 9's room, Patient 9 was observed to have burn marks to her abdomen and he noticed the oxygen tubing was burned. RN 14 also stated, "I didn't see fire, so I didn't call Code Red."

During an interview on 1/24/20, at 9:34 AM, with RN 13, RN 13 stated she was the House Supervisor during Patient 9's fire on 12/28/19. RN 13 stated, "I didn't hear a Code [Red] called. I was notified by a nurse." RN 13 was asked what do you in the event of a fire. RN 13 replied, "Call and follow RACE (Rescue, Alarm, Contain, Extinguish). Rescue patient, Evacuate, and Alarm call."

During an interview on 1/24/20, at 11:12 AM, with RN 17, RN 17 stated "At 2 AM I received a call from the House Supervisor that a patient received a burn. I went to see the patient [Patient 9] and she had burns to the left abdomen, left arm, and left palm of hand." RN 17 stated she did not hear a Code Red called, so she was unaware of the fire in Patient 19's room.

During an interview on 1/27/20, at 11:19 AM, with Security Officer (SO) 1, SO 1 stated, "I started rounding on the floor and the House Supervisor saw me and alerted me to a fire that occurred." SO 1 stated she did not hear a Code Red called. SO 1 stated the House Supervisor was calling the "Higher Ups", but no Code Red was called.

During an interview on 1/27/20, at 4:30 PM, with Director of Facilities/Emergency Management (DFEM), DFEM stated the facility plan and expectation is to follow RACE

During a review of the facility's written fire plan titled, "Code Red-Fire Plan", last revised date 8/16, indicated "It is the responsibility of every employee in the facility to be familiar with this policy and to be constantly on the alert to conditions that might cause a fire. If smoke odor or fire is detected in any area, locate the source and carry out the procedures in this plan. 1. Fire in Your Department . . . 2. Report the Fire by RACE: R- Rescue . . ., A - Alarm: Activate the nearest fire alarm pull box and call PBX. Identify yourself and furnish important information as to the location of the fire, what is burning and extent of the fire. . . AC - Contain: . . . E - Extinguish: Extinguish the fire by using fire extinguishers."

2. During an interview on 1/27/20, at 4:18 PM, with the Director of Facilities/Emergency Management (DFEM), DFEM stated Fire Drills are done "every quarter, every department, but I pick and choose." DFEM stated there are varied shifts in the hospital: Nursing has two 12 hour shifts; Housekeeping and Engineering has three eight hour shifts.

During a concurrent interview and record review, on 1/27/20, at 4:23 PM, with DFEM, the Completed Fire Drill Matrix, for the year 2019 was reviewed. The Completed Fire Drill Matrix indicated, "Definition of Shifts: 1st - 0700-1900 (7 AM to 7 PM), 2nd - 1900-0700 (7 PM to 7 AM), 3rd - 2300-0700 (11 PM to 7 AM)." The Completed Fire Drill Matrix indicated, during the first quarter of 2019 (January, February, and March) there were no fire drills during the third shift, during the second quarter of 2019 (April, May, and June) there were no fire drills during the third shift. DFEM verified the findings.

During a review of the Security Report for 12/28/19, the Security Report indicated, at 1:10 AM, Patient 9 on 4 NW (west) was on fire. RN 13, RN 14, RN 16, and CAN 1 all responded.

During a review of the "2019 Regional Fire Drill - Simulated" and "Attendance Record" from January 2019 to December 2019, RN 13, RN 14, RN 16, and CAN 1 did not participate in any of the fire drills.

During a review of the Completed Fire Drill Matrix, for the year 2019, the Completed Fire Drill Matrix did not have 4 NW listed for participation in a fire drill.

During a review of the facility's written fire plan titled, "Code Red - Fire Plan", dated 8/16, The purpose indicated the fire plan is designed to provide a guideline for staff to protect patients, staff, and visitors from the effects of fire. "8. Fire Drills a. There will be one fire drill per shift per quarter. The quarterly fire drill will exercise all primary elements of the fire plan. All staff in areas of where patients are housed or treated shall participate in drills to the extent called for in the facility's fire plan. All fire drills are critiqued to identify deficiencies and opportunities for improvement. B. Fire Drill will test staff knowledge of: Use and function of fire alarm system . . . Specific fire response duties."

Based on interview and record review, the hospital failed to provide the Rapid Response Team (RRT - an Intensive Care Unit [ICU] Nurse and a Respiratory Therapist [RT] respond to patients with early signs of deterioration on non-intensive care units to prevent respiratory or cardiac arrest) access to the locked OB (Obstetrics) area during a life threatening situation for one sampled patient (Patient 1). This failure caused a delay in Patient 1's resuscitation efforts. Patient 1 died after an emergency Cesarean (a surgical operation for delivering a child by cutting through the wall of the mother's abdomen) section.

Findings:

During an interview on 1/17/20, at 5:33 PM, with RT 1, RT 1 stated she responded to the overheard Rapid Response Team call for Patient 1 on 1/10/20. RT 1 stated the Rapid Response Team members were unable to get through the locked OB triage door (where Patient 1 was) because they did not know the access code to open the door.

During an interview on 1/17/20, at 6:39 PM, with Registered Nurse (RN) 6, RN 6 stated she was the ICU nurse who responded to the RRT call for Patient 1. RN 6 stated she was unable gain access to the triage unit and Patient 1 because she did not have the code to open the doors.

During an interview on 1/23/20, at 9:35 AM, with Director of Facilities/Emergency Management (DFEM), DFEM stated "I don't know how" key code changes are communicated to emergency responder staff.