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Based on a review of facility policy and procedure, medical records, observation, and patient and staff interview, the facility failed to monitor the oxygen status for one (1) patient (#5) by failing to maintain the patient's oxygen saturation. The facility also failed to ensure that one (1) patient's (#7) Sequential Compression Device was connected per physician orders.

Review of the Lippincott Procedures, 'Sequential Compression Therapy' literature, revised 07/10/15, revealed that compression devices are to be reapplied immediately after the patient returns to bed.

Review of the facility policy #HOSD.NUR.001, ' Lippincott Procedures,' effective date 07/24/2014, revealed that it is a practice of the facility to use Lippincott Procedures as a reference in performing nursing procedures throughout all of the clinical units at the facility.

Review of the patient #7's record revealed that on 06/21/16 at 9:59 a.m., the physician ordered continuous foot pumps for the patient.

During an observation of patient #7 on 06/27/16 at 1:47 p.m. in room 611, the patient was noted to be wearing bilateral (both sides) venous foot pumps (a device that alternates between applying pressure and no pressure on the sole of the foot to help prevent blood clots.) Upon further inspection, it was noted that the pumps were not hooked up to the power device. When the patient was asked how long the pumps had been off, the patient stated that the pumps were removed for physical therapy (PT). The patient thought it had been at least an hour since the physical therapist assisted him/her back to bed. The observation was confirmed by the Quality Risk Manager (Staff #9).

During an interview with the Registered Nurse (RN#2) on 06/27/16 at 1:55 p.m. in room 611, the RN revealed she thought the patient #7's foot pumps were hooked up. When asked what the facility protocol was for reconnecting the foot pumps or sequential compression therapy (SCD), a device that alternates between applying pressure and no pressure on the sole of the foot to help prevent blood clots), the RN stated that the foot pumps and SCDs are to be placed back on a patient immediately after returning to bed. When the RN was asked how often he/she rounds (assesses) on the patient the RN stated that it was every one (1) to two (2) hours. When asked why the patient's SCDs had not been reconnected after Physical Therapy, the RN stated that he/she did not know.

Review of the Physical Therapy Notes, dated 06/27/16, revealed the patient had completed his/her physical therapy treatment at 10:30 a.m.

During an interview with the Assistant Chief Nursing Officer (ACNO, Staff #8) on 06/29/16 at 11:10 a.m. in the Conference Room, the ACNO revealed that the nurses are to reconnect the patient's SCDs, as well as any other medical equipment prescribed for the patient, as soon as possible. The ACNO stated that the staff is normally given approximately half an hour to make sure the equipment is placed back on a patient. The ACNO explained that the half-hour is given in case the nurse is busy administering care to another patient. The ACNO conveyed that three (3) hours would have been an unacceptable length of time to reconnect the patient to the foot pumps.

During an interview with the Quality Risk Manager (QRM) on 07/01/16 at 9:20 a.m. in the Conference Room, the QRM revealed that the patient was reconnected to the foot pumps per the facility's policy. The QRM stated that the RN caring for the patient should have verified in a timelier manner that the SCDs were placed back on the patient per MD orders.

During an interview with the Nurse Manager of 6 Main (NM #1) on 06/28/16 at 12:03 p.m., the NM stated that he/she expects the nurses to recheck to make sure all medical equipment is reconnected to the patients during their hourly rounding. The NM indicated that all SCDs are to be reconnected as soon as possible after a patient has received treatment from any other department.

Review of the 'ICU standards of Care Contract' revealed that an ECG strip (a record of the heart's electrical action) was to be placed in every ICU (Intensive Care Unit) patient's chart every twelve (12) hours and PRN (as needed) with changes.

Review of patient #5's medical record revealed that the ECG strip, which provides a record of the patient's blood pressure, heart rate, cardiac rhythm, and oxygen saturation, was noted in the patient's chart from the day of admission to the ICU, 06/21/16 - 06/26/16, as well as for 06/28/16. The ECG strip for 06/27/16 was not noted in the patient ' s chart.

During an observation of patient #5 on 06/27/17 at 1:05 p.m. in an ICU (Intensive Care Unit) room, the patient's oxygen (O2) monitor (a medical device that monitors the oxygen saturation and displays the results on the screen at live time) was noted to be alarming upon entry into the patient's room. The patient was lying in bed with both eyes open, but the patient was observed to be unresponsive. A nasal cannula (a tube placed at the opening of both nostrils which delivers oxygen) was observed on the patient. Family members who were at the bedside were asked if the patient was alert and able to verbalize (talk), the family stated that the patient had just been talking earlier. The nursing staff was alerted and respiratory was called to the patient's bedside. The pulse oximetry (pulse ox, a monitor placed on the patient that reports a patient's level of oxygenation) was repositioned and the patient's O2 level was noted to be fifty-six (56) percent. Respiratory and nursing staff placed an O2 mask (a mask placed over the patient's nose and mouth to deliver a high rate of oxygen) on the patient and within fifteen (10) minutes, the patient's O2 saturation (the amount of oxygen in the blood to be carried to the organs and tissues) was noted to be ninety-seven (97) percent and the patient was observed to be alert and able to answer questions at that time. The Quality Risk Manager (QRM#9) confirmed the event.

During an interview with the ACNO on 06/29/16 at 11:10 a.m. in the Conference Room, the ACNO stated that each department follows their own protocols regarding the monitoring of patients. The ACNO the monitoring of patient's would be based on the physician's orders and the patient's condition. The ACNO stated that if a patient had a change in condition, the nurse would be expected to write a free text note regarding the event, and the ACNO would expect an ECG strip to be placed in the patient's chart, per that department's policy.

During an interview with the Quality Risk Manager (QRM) on 07/01/16 at 9:20 a.m. in the Conference Room, the QRM indicated that he/she would assist with patients when required. The QRM stated that it was the facility ' s expectation of staff to monitor all patients' vital signs as ordered and as needed. The QRM admitted that patient #5 should have been monitored more closely as the patient had only been extubated the morning of 06/27/16. The QRM confirmed that the patient was not responsive upon entering the room with this surveyor on 06/27/16 at 1:05 p.m. The QRM also acknowledged that the patient's O2 saturation was fifty-six (56) percent upon entering the room and that the patient became responsive once the patient's O2 saturation was returned to a normal range.

Based on facility policy and procedure, medical record review, and staff interview, the facility failed to initiate a care plan for nutrition for four (4) patients (#3, 4, 5, 7) per facility policy.

Review of the facility policy #MMC.FANS.032, 'Interdisciplinary Care Plan' effective date 08/26/2014, revealed that problems related to nutritional care of the patient will be communicated to other disciplines via the Interdisciplinary Care Plan. Further review revealed that a review/update was to be documented with each nutrition care follow-up.

Review of the patient #3's Nutritional Assessment dated 11/10/15 revealed that the patient was transferred to the Intensive Care Unit (ICU) due to respiratory distress (difficulty breathing.) The patient was placed on Bi-level Positive Airway Pressure (BiPAP, a means of delivering oxygen to a patient) and when removed, the patient desaturates (a decrease in oxygen concentration) immediately. The MD had ordered Glucerna three times a day, but the patient was unable to drink it due to the BiPAP. The Registered Dietician (RN) recommended a feeding tube be placed until the patient was able to come off the BiPAP without desaturating.

Review of the Physician's Orders dated 11/10/15 at 1:40 p.m. revealed an orogastric tube (OT, a flexible tube inserted through the mouth that passes to the stomach so that medications and nutritional supplements can be administered) was ordered and placed. An X-ray was done to verify placement of the tube into the stomach.

Review of the Nutritional Progress Note dated 11/12/15 revealed that the patient was being changed from Pivot 1.5 (a type of liquid nutrition used for patient ' s that require being fed through the OG tube due to a physical condition or illness) to Glucerna 1.2 (a type of liquid nutrition used for patient ' s that require being fed through the OG tube due to a physical condition or illness) at a rate of 50 (fifty) ml (milliliter) an hour as well as additional protein supplements and water flushes. Further review revealed that the patient had shown improvement in his/her electrolytes (chemical elements in the body vital to proper functioning) as a result of the tube feedings. The patient ' s magnesium (a mineral involved in many processes in the body) and phosphate (a salt mineral in the body that assists the body with energy and metabolism) levels indicated improvement.

Review of the patient #3's medical record revealed no care plan for nutrition had been completed for the patient.

Review of ten (10) other patient medical records revealed that three (3) patients (#4, 5, and 7) were being followed by the Registered Dietician. Patient #4 was noted to be losing weight and had a decreased appetite after admission for a right hip fracture.

Patient #5 had a history of cardiac arrest (a condition when the heart stops beating and medical interventions are usually required to try and help the heart start beating) during his/her admission and had skin excoriation (an abrasive or tearing injury to the surface of the skin) to his/her coccyx (the small tail-like bone at the bottom of the spine.)

Patient #7 was admitted for multiple fractures following a motor vehicle accident (MVA), and laboratory results revealed a low albumin (the main protein in the human blood.) Further review of the patient's records revealed a plan for nutrition was noted in the patient's records.

During an interview with the Assistant Chief Nursing Officer (ACNO) on 06/29/16 at 11:10 a.m. in the Conference Room, the ACNO revealed that it was his/her expectation of the nursing staff to evaluate each patient individually and to customize a care plan for each patient depending on each patient's needs. The ACNO added that the care plans are to be updated constantly based on the patient's change in condition. The ACNO acknowledged that a nutrition care plan was not initiated on for patients #3-4, and #7. The ACNO stated that a care plan should have been done on these patients due to their conditions and that the nutrition care plan should have been updated regularly to reflect any changes.