HospitalInspections.org

The Condition of Participation for QAPI has not been met.

Based on review of hospital documentation and interview, the hospital failed to implement an effective QAPI program to prevent the reoccurrence of empty portable oxygen delivery systems during patient use.


Please see A286

Based on review of hospital documentation and interview, the hospital failed to implement an effective QAPI program to prevent the reoccurrence of empty portable oxygen delivery systems during patient use. The findings include:

a. Facility documentation identified on 9/23/21 at 8:30 PM Patient #7 was short of breath with an oxygen saturation of 65% and was noted to be attached to an empty oxygen tank. The nurse did not reconnect the patient to the wall source after a walk, and the nurses did not trace the tubing back to the source at change of shift. The corrective action plan dated 10/21/21 identified nursing and therapy staff were reeducated to hospital oxygen policies, including oxygen storage and management and patients with oxygen orders are now identified on the daily management board. Oxygen utilization and management audits to be monitored for 3 months.

b. Facility documentation identified on 9/27/21 Patient #4 was on 4 LPM nasal cannula in the Emergency Department (ED) waiting room for 6 hours. Patient #4 was transferred to an inpatient unit and upon arrival the portable oxygen tank was empty. The oxygen tank was not checked prior to transport from the ED. The hospital corrective action plan dated 10/21/21 identified a patient safety alert communication was circulated to quality and safety leaders throughout the hospital. The ED staff was reeducated on oxygen cylinder management. Oxygen cylinders will be randomly monitored in the ED for 3 months.

c. Facility documentation identified Patient #6 was transferred from a stepdown unit to a medical unit on 11/19/21 at 5:26 PM. At approximately 8:00 PM the nurse found the patient on a portable oxygen tank. The corrective action plan dated 12/21/21 the unit nursing staff will be educated to the revised handoff cards that reflect the need to validate oxygen tubing and audits of RN handoffs to be done ensure oxygen is validated.

d. Facility documentation identified on 11/23/21 Patient # 1 was placed on a portable oxygen tank to transfer from a front-end provider room to a room in the main ED and found in the room 20 minutes later by the RN with a low oxygen saturation and empty portable oxygen tank. The corrective action plan dated 1/6/22 identified that ED nursing staff was educated on the need to round and check patients who are on portable oxygen tanks and exploring the possibility of adding a visual reminder to the ED tracking board and audits will continue January-March 2022 to ensure a patient is attached to an oxygen source.

e. Facility documentation identified on 12/8/21 Patient #2 arrived in the ED on 4L LPM oxygen via nasal cannula and placed in a front-end provider room. Patient #2 was transferred to a room in the main ED and the PCA noted the portable tank was empty. The facility documentation identified it was unclear if the portable tank was checked for fullness upon arrival to the ED. The corrective action plan dated 1/11/22 identified the ED staff is continuing pursue a visual alert on the ED tracking board and the hospital is continuing to pursue an alternative oxygen tank and regulator system with an audible alarm for tanks with diminishing oxygen supply and revised the audit process for monitoring patients on portable oxygen tanks for waiting rooms and front-end provider rooms to continue January-March 2022.


f. Facility documentation identified on 1/15/22 Patient #3 arrived in a patient room from the waiting room with an empty oxygen tank. The corrective action plan dated 2/24/22 identified that staff was not able to determine the amount of oxygen that was present in the tank at the time the patient was transferred from the EMS stretcher to the emergency department stretcher. The event was reviewed at daily huddle and action plans were discussed at the clinical nurse leader meeting 1/13/22 and an educational email was distributed to staff on 1/27/22.

g. Facility documentation identified on 2/14/22 Patient #5 was transferred from the stepdown unit to a medical floor and while traveling the patient's oxygen saturation dropped and it was identified that the oxygen tank was empty. The corrective action plan dated 3/21/21 identified an RN did not/validate oxygen set at correct flow rate/or tank had enough O2 to last duration of transport. The corrective action plan was amended on 2/18/22 include additional education to be provided on oxygen tank usage, education to advanced practice providers regarding oxygen orders, and a new column was implanted on the track board to alert nurses that a patient is on oxygen.

Although the events were addressed in the hospital QAPIC meetings on 10/27/21, 11/18/21, 12/6/21 1/27/21 and 2/24/22 the hospital did not develop a plan that was effective to prevent the reoccurrence of seven (7) empty oxygen tanks in five (5) months.

Interview with APRN #1, the medicine co-director of quality, identified that although every event involved empty portable oxygen tanks, each occasion had a different component and the hospital adjusted the action plan to address the specifics of each occasion.

The Condition of Participation for Nursing Services has not been met.

Based on clinical record review, review of facility policy, and interviews, for 7 of 12 patients (Patients #1, #2, #3, #4, #5, #6, #7) reviewed for the delivery of oxygen, the hospital failed to ensure an RN supervised care to ensure that oxygen was administered per hospital policy, and for 1 of 4 patients (Patient #1) reviewed for triage assessments the hospital failed to ensure a patient was reassessed by an RN per hospital policy.

Please see A395

Based on review of clinical record, review of facility policy and interview for 7 of 12 patients (Patients #1, #2, #3, #4, #5, #6, #7) reviewed for the delivery of oxygen, the hospital failed to ensure an RN supervised care to ensure that oxygen was administered per hospital policy, and for 1 of 4 patients (Patient #1) reviewed for triage assessments the hospital failed to ensure a patient was reassessed by an RN per hospital policy. The findings include:

a. Patient #7 was admitted to the hospital on 9/10/21 with congestive heart failure.
The physician's order dated 9/10/21 directed to start oxygen at 0.5 liters per minute (LPM) via nasal cannula, increase by one (1) liter every five (5) minutes to maintain oxygen saturation of 90%, maximum rate 6 LPM.
Interview with Manager #4 and Director #3 on 3/17/22 at 2:53 PM identified RN #4 connected Patient #7 to the portable oxygen tank at approximately 5:00 PM to allow Patient #7 to walk around the unit with the patient's visitor. Upon return to the room RN #4 failed to connect Patient #7 to the wall oxygen supply. At approximately 7:00 PM RN #4 gave shift change report to RN #5 and they failed to trace the oxygen line back to the source. At 8:15 PM RN #5 assessed the patient and found the oxygen saturation was 65%.

Interview with RN #5 on 3/22/22 at 2:00 PM identified that she noted at approximately 7:30 PM that Patient #7 was sleeping in bed connected to a portable oxygen tank but did not reconnect the patient to the wall at that time because she was distracted and had to assist another patient.

RN #5 identified that she returned Patient #7's room soon after to assist patient with the bedpan and identified that the patient had a low oxygen saturation and thought it was related to the pulse oximeter not being able to get an accurate reading. RN #5 stated she increased the oxygen on the portable tank to 3 liters, sat the patient up, and adjusted the nasal cannula prongs. When the patient's oxygen saturation did not show significant improvement RN #5 identified she called in the charge nurse to assist and the charge nurse identified that the portable oxygen tank was empty and connected the patient to the wall oxygen and the patient's oxygen saturation improved to 92%.


b. Patient #4's present to the emergency department on 9/27/21 with shortness of breath and increased oxygen needs. The triage nurse assessment dated 9/27/21 at 5:38 PM identified Patient #4 had worsening pleural effusions and increased oxygen demands, oxygen saturation was 94% on 4 liters of oxygen via nasal cannula.

Review of the clinical record failed to identify Patient #4 had a physician's order for oxygen.

Interview with Nurse Educator #1 and Manager #1 on 3/10/22 at 1:00 PM identified that the hospital investigation identified that Patient #4 arrived at the emergency department on 9/27/21 on 4 liters of oxygen, was assessed by the triage nurse, and placed in the waiting room at approximately 6:00 PM with what was assumed to be a full tank of oxygen to wait for a bed on an inpatient unit. Nurse Educator #1 identified that the oxygen tank was not replaced or checked until the patient arrived on the inpatient unit at approximately 12:00 AM on 9/28/21.

Interview with Manager #3 on 3/17/22 at 3:00 PM identified that upon arrival to the unit on 9/28/21 at 12:00 AM from the ED Patient #4 was found with a dry 02 tank. The nurse identified the tank was dry upon arrival, and the patient's oxygen saturation was immediately determined to be within the patient's goal, and the patient was placed on wall oxygen.

c. Patient #6 was admitted on 11/14/21 with COVID-19 resulting in acute hypoxic respiratory failure.
The physician's order dated 11/17/21 directed to administer 0.5 LPM, may increase by 1 LPM every five minutes to maintain oxygen saturation of 88%, maximum 6 LPM.
Facility documentation dated 11/24/21 identified on 11/19/21 at 5:27 PM Patient #6 was transferred from the ICU to the step-down unit. At 8:00 PM the night shift nurse entered the room and found the Patient #6 connected to an empty portable oxygen tank. The patient's oxygen saturation was maintained at goal.

Interview with Manager #3 on 3/18/21 at 4:30 PM identified RN #7 connected Patient #6 to a portable oxygen tank and transferred Patient #6 to the Step down unit with the receiving nurse RN #8. Patient #6 was connected to the monitor by RN #7 and both nurses left the room. Manager #3 identified RN #7 and RN #8 failed to trace the oxygen line to ensure Patient #6 was connected to the wall prior to leaving the room. Manager #3 identified RN #9 entered the room at approximately 8:00 PM to assess the patient and when she traced the patient's oxygen tubing, she found Patient #6 connected to an empty portable oxygen tank. Manager #3 identified that Patient #6 did not drop below his/her oxygen goal.


d. Patient #1 presented to the ED on 11/22/21 with shortness of breath. The History and Physical dated 11/23/21 at 12:40 AM identified that Patient #1 arrived tachycardic and tachypneic, with oxygen saturation 97% on 4 liters of oxygen. The patient is typically on 3L of oxygen but now requires 4 LPM.

The clinical record lacked documentation of a physician's order for oxygen.

The nurse's note dated 11/23/21 at 6:50 AM identified Patient #1 desaturated to 47% and placed on nonrebreather at 15 L. The patient complains of pain with confused affect. The nurse's note dated 11/23/21 at 7:08 AM identified Patient #1's oxygen saturation improved to 95% on non-rebreather mask.

Interview with Nurse Educator #1 and Manager #1 on 3/10/21 at 11:30 AM identified that Patient #1 arrived in the evening on 11/22/21 and was placed in a front triage room and connected to the wall oxygen delivery system on 4 Liters of oxygen via nasal cannula while waiting for a room in the main ED. Nurse educator #1 identified early the next morning the triage nurse connected the patient to a portable oxygen tank and a Patient Care Associate (PCA)transported Patient #1 to the assigned room in the blue pod and left the patient in the room on portable oxygen for the nurse to transfer to the wall oxygen. Nurse Educator #1 identified RN #3 entered the room approximately 20 minutes later and found Patient #1 desaturating on an empty portable oxygen tank and immediately placed Patient #1 on the wall oxygen delivery system on a non-rebreather mask. Nurse Educator #1 identified that in the interview with the triage nurse she could not remember if she checked the oxygen tank prior to connecting Patient #1 for transport.
Interview with RN #3 on 3/17/21 at 12:00 PM identified that within five minutes of the patient arriving in the room she went in and noticed Patient #1 did not look well. RN #3 identified she noticed the patient was connected to an empty portable oxygen tank and hooked the patient up to the wall on a non-rebreather mask and the patient's oxygen saturation came up within a few minutes.


e. Patient #2 presented to the ED on 12/8/21 with chest pain and shortness of breath. The triage assessment dated 12/8/21 identified Patient #2 arrived from home via EMS with increased work of breathing and diffuse chest pain. The patient's oxygen saturation was 94% on 4 LPM.

The nurses note dated 12/9/21 at 12:10 AM identified the patient arrived in the room in respiratory distress from the waiting room, the PCA identified when the patient was placed in the room that the patient's oxygen tank was empty. The patient is now on 4 LPM on wall oxygen with SpO2 at 86%. Patient #2 was noted with accessory muscle use, the physician assessed the patient and rescue Bilevel Positive Airway Pressure (BiPap) was ordered.

The physician's note dated 12/9/21 at 12:13 AM identified on exam the patient has visible increased work of breathing but was not endorsing chest pain. Patient #2's oxygen is low and Bipap was ordered and initiated for presumed fluid overload. It was reported that Patient #2's oxygen ran out in the waiting room and that is likely why the patient became tachypneic.

Interview with Nurse Educator #1 and Manager #1 on 3/10/22 at 1:15 PM identified that the patient arrived by EMS at 9:45 PM and they transferred Patient #2 to the stretcher and hooked the patient to the oxygen tank on the stretcher and placed in hall waiting room. At 11:50 PM Patient #2 was brought into a patient room in the ED by the PCA who notified the nurse that the oxygen tank was empty. Nurse Educator #1 identified that following this event the ED purchased oxygen concentrators to use in place of portable oxygen tanks where appropriate and increased the waiting room rounding from every 3 hours to every 2 hours in addition to educations and audits.

f. Patient #3 diagnosis included acute renal failure and sepsis. Patient #3 presented to the ED on 1/15/22 at 4:12 PM from a long-term care facility to be assessed and treated for abnormal labs. The triage nurse assessment dated 2/15/21 at 4:12 PM identified Patient #3's oxygen saturation was 96% on 4 LPM via nasal cannula.

The clinical record lacked documentation that Patient #3 had a physician's order for oxygen.

The PA note dated 1/15/22 at 4:39 PM identified Patient #3 presenting from a long-term care facility with abnormal labs including potassium 5.8 and creatinine 0.9. The patient's mental status is alert and lethargic, breathing is non-labored.

The nurse's note dated 1/15/22 at 5:30 PM identified Patient #3 arrived in the room with an empty oxygen tank. The patient's oxygen saturation was 88% and the patient appeared lethargic and slow to respond. The patient was placed on 4 LPM oxygen via nasal cannula and the patient's oxygen saturation came up to 98% and the patient is responding to voice.

Interview with Nurse Educator #1 and Manager #1 on 3/10/22 at 11:00 AM identified Patient #3 was brought in on 1/15/22 and place on a stretcher and connected to a portable oxygen tank by EMS. Patient #3 was placed in the waiting area and when the patient was transported to a room at 5:30 PM it was noted that the oxygen tank was empty. The clinical nurse educator identified that the patient was not connected to an oxygen concentrator because it was initially thought that the patient would be placed directly in a room.

g. Patient # 5's diagnosis included lung cancer, COIVD-19, and respiratory failure. The physician's order dated 2/7/22 directed to administer 2 LPM of oxygen, adjust by 1 LPM every 5 minutes to maintain target oxygen saturation of 85%.

The nurse's note dated 2/15/22 at 5:42 PM identified that Patient #5 was not in acute distress, continues on 6 LPM oxygen via nasal cannula, desaturates with exertion. The nurse's note dated 2/16/22 at 7:45 AM identified vital signs stable, continue on high flow oxygen for shortness of breath and hypoxia into the 80's with ambulation.

Interview with Manager #2 on identified that the Patient #5 was transported from a stepdown unit to a medical unit by RN #10 at approximately 8:00 PM on 2/14/22. Patient #5 was noted to desaturate on the monitor and the oxygen tank was found empty. Review of the clinical record with Manager #2 at failed to identify documentation of the event. Manager #2 identified.

Interview with RN #10 on 3/22/22 at 2:30 PM identified that at approximately 7:30 PM on 2/15/22 she was asked to transport Patient #5 to a medical floor. Patient #5 was already connected to the portable monitor and oxygen tanks. RN #10 identified she checked the tank to ensure it was set to the correct liter flow but did not check the amount of oxygen remaining in the tank. RN #10 identified enroute to the destination Patient #5 desaturated to 87-88%, she traced the oxygen tubing back to the tank and found that the oxygen tank was empty. RN #10 identified that Patient #5 was stable so they briskly continued to the medical unit and immediately upon arrival connected Patient #5 to the wall oxygen delivery system and his oxygen saturation increased. RN #10 identified she did not document the event in the medical record because the patient was not symptomatic, and she reported it through the incident reporting process.

Following this event additional education was provided on oxygen tank usage to include tracing lines for patients on oxygen tanks, validating correct liter flow, and checking to ensure that the amount of oxygen in the tank will last for the duration of the transport.

The hospital policy for Oxygen Management dated 2/21/20 identified that any trained and licensed health care provider, certified ultrasound technician or nuclear medicine technician many perform oxygen related activities. Nursing responsibilities include verify oxygen order and titrate oxygen per order, document monitoring parameters, respiratory assessment and oxygen delivery in EMR. All oxygen delivery systems should be checked and documented each shift.


2. Patient #1 presented to the ED on 11/22/21 with shortness of breath. Review of the clinical record identified a triage assessment was completed on 11/22/21 at 7:59 PM identified Patient #1 presents from home with shortness of breath, progressively worsening per the patient. Mild work of breathing noted at time of arrival, with increased oxygen demands.

Further review of the clinical record failed to identify a reassessment was done until 6:50 AM on 11/23/21 when Patient #7 was transferred from the front-end triage room into a room in the main ED and noted to be in respiratory distress.

Interview with Nurse Educator #1 on 3/22/22 at 3:00 PM identified that the triage nurse should have reassessed Patient #7 every 3 hours per facility policy.

The Emergency Department Documentation Guidelines policy identified all patient in reception area for greater than 3 hours must be reassessed by the triage RN. Reassessment includes vital signs and status related to the patient's chief complaint.

Based on vaccine record reviews, review of facility policies and interviews the facility failed to ensure all staff were compliant with the vaccination mandate and failed to ensure all staff with vaccine exemptions adhered to the facility's policy of weekly testing. The findings include:

a. Review of the Facility's Vaccination records of employees and contracted staff with the Director and Nurse Coordinator of Colleague health on 3/11/22 at 8:20 AM identified four (4) active employees (RN #1, RN #2 Admin Associate #1, Admin Associate #2) were without documentation that the employees were fully vaccinated or had vaccine exemptions.

In an interview with the Director of Colleague Health on 3/11/22 at 10:30 AM the Director indicated that the 4 staff members that were not compliant with the Vaccine requirements were on the "Monitoring list" in which frequent phone calls were made to each staff to obtain vaccine records or request for exemptions. The Director indicated the hospital was unable to get in contact with the 4 noncompliant employees and identified it was the expectation that all staff were vaccinated for COVID 19 or had an approved exemption.

Review of the Hospital's Universal COVID 19 Prevention Program policy directed all HHC employed colleagues were required to receive their final dose of their primary vaccination series for COVID 19 by 5:00 PM August 27, 2021.

The Center for Medicare and Medicaid Services Center for Clinical standards and Quality safety and oversight Group document dated 12/28/21 indicated that within 60 days after the issuance of the memorandum if the facility demonstrated less than 100% of all staff that received at least one dose of a single dose vaccine, or all doses of a multidose vaccine series , or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC the facility is non-compliant under the rule.

b. Review of eight (8) facility staff and contracted employees with Exemptions to COVID-19 vaccine for the period 1/27/22 to 3/11/22 identified that 1 of 8 staff (RN #3) lacked documentation the staff consistently perform weekly COVID testing consistent with the facility's practice.

An interview with the Nurse Coordinator of Colleague Health on 3/11/22 at 9:45 AM identified that safety measures that the facility had in place for non-vaccinated staff/staff with exemptions included weekly COVID-19 testing and indicated it was the expectation that staff complied with weekly COVID-19 testing.

The Facility's Universal COVID -19 Prevention program Policy directed that colleagues with an approved exemption should receive a weekly COVID-19 PCR testing.

The facility failed to achieve 100% compliance with the COVID-19 Vaccine mandate.