The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

COCHISE REGIONAL HOSPITAL 2174 WEST OAK AVENUE DOUGLAS, AZ March 26, 2015
VIOLATION: RESPONSIBILITIES OF DOCTOR Tag No: C0257
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review, and review of Medical Staff Bylaws and Rules and Regulations, it was determined for 1 of 13 inpatients (Patient #1), the governing authority failed to ensure the provision of quality care from the medical staff as evidenced by:

1. The patient's physician failed to write orders for the transport of the patient including mode of transportation. Patient #1 was removed from telemetry monitoring and left unattended for an extended period of time awaiting transportation to an outside dialysis provider. The patient became unresponsive and coded while being assisted into the transportation vehicle.

2. The Emergency Department physician's documentation did not include detailed events of the code or the patient's status during the two hour period he was in the ED prior to being airlifted nor did he document his communication with the physician at the receiving hospital.

This has a high potential for delays in patient care and management when communication is not direct nor documented.

Findings include:

Documentation in the Rules and Regulations of the Medical Staff included: "Every person seen in the Emergency Department have (sic) a detailed medical record kept by those providing care."

Patient #1 was admitted on [DATE]. The patient's admission diagnoses included: Cellulitis of lower leg; Diabetes mellitus type 2; Congestive heart failure; and Chronic renal failure syndrome. Physician documentation revealed the patient had been on dialysis for the past eight to nine years. The hospital's scope of services did not include the provision of hemodialysis within the hospital.

1. On 2/7/2015 at 1 p.m. the physician documented: "Initially declined HD today. d/w patient, RN and tech in the room during telemed encounter. Patient understands the need for compliance with HD, especially in the light of extra volume administered with the IVAbx (intravenous antibiotic) infusion...LLE (left lower extremity) exam significantly better comparing to yesterday."

Documentation in the record revealed the RN on duty on 2/7/2015 during the day shift made arrangements for the patient to receive a dialysis treatment at the local dialysis provider where he normally received his treatments. Transportation arrangements with a non-medical transport company were made through the patient's insurance company. There was no physician's order in the clinical record for the patient to be transported to a dialysis provider for treatment; no order for the patient to be removed from continuous telemetry monitoring (as ordered at the time of admission); and no order for mode of transportation the patient required for transport (i.e. accompanied by trained medical personnel).

The patient was removed from continuous telemetry monitoring by nursing staff and taken to the waiting room of the hospital's Emergency Department where he was left unattended awaiting pick up by non-medical transport. The transportation did not arrive for approximately 1.5 hours and the patient became unresponsive while being assisted into the transportation van and had to be brought back into the ED for resuscitation. The patient had to be intubated and placed on a ventilator. He was flown to a hospital in Tucson where he later died .

There was no documentation in the Rules and Regulations of the Medical Staff that defined medical staff responsibilities for the safe transport of a patient to an outside provider.

The Chief Medical Officer acknowledged during a telephone interview conducted on 2/24/2014, he was the patient's physician and had convinced the patient that he needed to be dialyzed. He acknowledged the hospital was not able to provide dialysis services within the hospital but it was his understanding that it was the hospital's practice to have patients in need of dialysis transported to the dialysis provider in town.

2. Nursing documentation dated 2/7/2015 at 1:50 p.m. revealed the patient became unresponsive while being transferred into the transportation van. The RN documented the patient was "limp" and had no carotid pulse at that time. At 1:55 p.m. the patient was taken into the ED, placed on a cardiac monitor, CPR and ACLS (Advanced Cardiac Life Support) were initiated and the ED physician was "preparing to intubate patient." At 2:10 p.m. the RN documented an oral airway was inserted and the patient was being manually ventilated with an ambu bag and an oxygen saturation level was "unobtainable" at that time. The patient was intubated by the ED physician at 2:12 p.m., 22 minutes after the patient was initially found unresponsive and without a pulse.

The ED physician's documentation dated 2/7/2015 at 2:35 p.m. of the patient's code arrest was the following: "Patient with collapsed (sic). The Onset is In the taxi as he was getting ready to go to dialysis center. Additional Symptoms or Pertinent History also involve HTN, ESRD T-TH-SAT...Patient has been in acute care for cellulitis of the left leg and was on his way to dialysis center. He was waiting for his taxi ride in te (sic) lobby and he was being helped to get in but was having difficult time that (name) went to help him practically lifted him to the back seat and as his legs were lifted in he was noted to collpapsed (sic) when his eye rolled back an was then taken to ER room where resuscitation was immediately started...Reviewed pertinent diagnostic tests, vital signs, and clinical notes." The ECG Report recorded 2/7/2015 at 2:52 p.m. "Interpretation (Unconfirmed)" was: "Ischemic ST-T changes in posterior leads...Prolonged QT interval."

Nursing documentation revealed arrangements were made for the patient to be air-lifted to an acute care hospital in Tucson, Arizona, however, the flight did not actually leave Cochise Regional Hospital until approximately 4 p.m. because of ICU bed availability at the receiving hospital in Tucson.

There was detailed nursing documentation of the resuscitation as well as the patient's unstable vitals signs during the two-hour period in the ED including interventions from the airflight crew.

There was no documentation by the ED physician that described the events of the code including the 22 minute delay in intubating the patient or the patient's status during the two hour period he was in the ED prior to being airlifted. There was no documentation of the ED physician's direct communication with the physician accepting the care of the patient at the receiving hospital.

The patient's clinical records from the receiving hospital were obtained and reviewed. The patient was a direct admission to the Intensive Care Unit. The physician's documentation in the History and Physical dated 2/7/ at 5:46 p.m. included: "Patient upon arrival non responsive no (sic) follow simple command, not on sedation. Right pupil dilated, left eye blind." A physician's progress note dated 2/8/2015 at 10:09 a.m. included: "Unfortunately on arrival here he has signs of severe cortical brain damage characterized by myoclonus and seizures. Hypothermia not done given evidence of severe neurologic injury. Head ct shows atrophy." The patient remained unresponsive while the hospital made efforts to locate next of kin. Physician documentation dated 2/14/2015 revealed a family member was located and was present at the patient's bedside. The physician documented the family decided on withdrawal of life support which was done that afternoon at which time the patient died .
VIOLATION: PROVISION OF SERVICES Tag No: C0270
Based on observations, staff interviews, and review of clinical records, policies and procedures, hospital logs and reports, it was determined the hospital failed to ensure that all services provided were in accordance with written policies and procedures for:

(C-271): Patient Care Policies.

Services were not provided in accordance with written policies and procedures when one (1) of one (1) patient transferred to an acute care hospital was not transferred according to the Hospital's policy (Patient # 21).

(C-294): Nursing Services.

1. The hospital failed to ensure a patient with physician orders for telemetry monitoring was supervised while awaiting transportation to a dialysis provider; failed to ensure physician orders were obtained to determine the status of telemetry monitoring while off the unit; and failed to obtain physician orders for the mode of transportation the patient required from the hospital to the dialysis provider. The patient was left unattended in the waiting room of the hospital's Emergency Department (ED) for approximately 1.5 hours. The patient became unresponsive while being assisted into the transportation van and had to be brought back into the ED for resuscitation. (Patient #1). Failure of the Nursing staff to recognize a patient ordered on telemetry and placed in the ED waiting room without monitoring or notification to another licensed person resulted in the patient not being assessed for >1 hour and the patient's condition changed resulting in resuscitation.

2. One (1) of one (1) ER patients with Chronic Obstructive Pulmonary Disease (COPD) presenting with Shortness of Breath (SOB), did not have oxygen initiated when the oxygen saturation was 83%. (Patient #3) Failure to initiate oxygen has the high potential risk of harm for a patient not being adequately oxygenated.

3. One (1) of one (1) acute care inpatients with COPD did not have oxygen administered by the RN, according to the physician's order. (Patient #3) Failure of the nursing staff to follow a physician order for oxygen administration has the high potential risk of the patient decompensating in Respiratory status.

4. The hospital failed to follow their policies and procedures to ensure new RN hires including new graduate RN's were deemed competent to follow nursing standards of care to meet the individual needs of the patients and competent to implement the facilities policies and procedures, prior to being scheduled to work independently as a staff nurse. (Staff #8, #11, and #16.) Failure to ensure staff competencies has the high potential risk of patients needs being met by qualified staff.

5. The hospital failed to ensure policies and procedures were developed and implemented including specialized training and competency validation for RN's administering intravenous Vecuronium (a skeletal muscle relaxant), and intravenous Etomidate. Two RN's administered Vecuronium (Patients #1 and #4) and one RN administered Etomidate (Patient #4) without documentation of specialized training and competency evaluation.

6. The hospital failed to ensure their policies and procedures that required specialized training and competency evaluation were followed for an RN to draw Arterial Blood Gasses (ABG's). Staff #18 drew an ABG on Patient #1 and attempted to draw an ABG on Patient #4 without documentation of the specialized training or competency evaluation.

(C-296): Nursing Services

1. A staff RN failed to obtain a physician order to remove telemetry monitoring for one (1) of one (1) patient, (Patient #21); who was transported by family members to a dialysis center as required by the Hospital's policy. Failure to ensure that the appropriate transportation mode to meet patient needs during transport lends a potential risk of harm for the patient.

2. One (1) of one (1) patients with an order to keep oxygen saturation levels >95% was transported without oxygen at a saturation level of 89%; and there was no order to discontinue the oxygen during transport (Patient #21). Transporting patients without oxygen, and at an acceptable saturation rate per MD order lends to a high potential risk to the patient.

The cumulative effect of these systemic problems resulted in the Critical Access Hospital's inability to ensure the provision of quality health care in a safe environment.
VIOLATION: PATIENT CARE POLICIES Tag No: C0271
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy and procedure review, document review, and interview, it was determined that the CAH's services were not provided in accordance with written policies and procedures, when one (1) of one (1) patient, (Patient #21) was transferred to an acute care hospital, not according to the Hospital's policy. The hospital staff failed to secure the patient's signature to ensure that the patient was informed of the risks and benefits of transfer by a physician.

Findings include:

The "Emergency Medical Treatment and Patient Transfer" policy revealed: "COCHISE REGIONAL HOSPITAL has approved this emergency medical treatment and patient transfer policy based on the state and federal laws relating to the emergency medical treatment and medically appropriate transfer of individuals between hospitals...A. II TRANSFER OF INDIVIDUALS...2. A licensed physician evaluates the individual and signs a certification, which includes a summary of the risks and benefits, that, based upon the information available at the time of the transfer, the medical benefits reasonably expected from the provision of the appropriate medical treatment at another medical facility outweigh the risks to the individual's medical condition from effecting the transfer...."

Patient #21 presented on [DATE] with diagnoses which included: Insulin Dependant Diabetes Mellitus, End Stage Renal Disease, Weakness, and Sepsis "of unclear source." On 09-26-14, the patient's family transported him to a local dialysis center for a dialysis treatment in the morning, and the patient had an order to "Transfer to (acute care hospital in another city). (Physician accepting)."

There was no "Transfer Consent and Record" on which the risks and benefits of transfer were documented, and no "Certifying Physician's Signature," as identified on a prototype form.

Medical record documentation from the hospital to which Patient #21 was transferred, revealed that he had been transferred there from Cochise Regional Hospital on 09-26-14.

The Director of Nursing acknowledged, during telephonic interview conducted on 02-18-15, that he was unable to find a record of the transfer form having been completed per the hospital's policy.
VIOLATION: PATIENT CARE POLICIES Tag No: C0275
Based on clinical record reviews, review of hospital policies and procedures, and staff interviews, it was determined for 2 of 2 inpatients who required hemodialysis (Patients #1 and #21) in the inpatient sample of 13, the hospital's administrator failed to ensure policies and procedures covering patient transport to and from the hospital were developed and implemented. Patient #1 was left unattended for an extended period of time, not assessed for greater than an hour while awaiting transport to the ESRD facility and coded while getting into the transport vehicle. Patient # 21 had the high potential risk of harm, when the patient was transported off monitor, unaccompanied by hospital staff and not assessed for greater than an hour.

Findings include:

-Patient #1 went to the hospital's ED on 2/6/2015 with a chief complaint of left leg pain and was admitted with diagnoses including cellulitis of lower leg, congestive heart failure, and chronic renal failure syndrome. The patient was admitted with physician orders including continuous Telemetry monitoring. Documentation in the clinical record revealed the patient had been on dialysis for the past eight to nine years and his current treatment schedule was three times a week. Cochise Regional Hospital does not have the capability of providing hemodialysis within the hospital.

Physician documentation dated 2/7/2015 revealed the patient's physician encouraged the patient to have a dialysis treatment at the dialysis provider in town and the patient agreed. The patient was removed from his telemetry monitoring at approximately 12:30 p.m. and taken by wheelchair to the waiting room of the ED to wait for transportation. The patient was left unattended and transportation did not arrive for approximately 1.5 hours. The patient became unresponsive while being assisted into the van and was brought back into the hospital's ED where he coded. The patient was intubated and placed on a ventilator and then airlifted to a hospital in Tucson, Arizona. The patient did not recover and died .

There was no documentation in the clinical record of physician orders for the transport, orders to discontinue the telemetry monitoring, or orders to determine the mode of transportation the patient would require. Refer to Tag C 294 for more specific details regarding Patients #1 and #21.

-Patient #21 went to the ED on 09-25-2014 with a chief complaint of weakness and generalized body aches. Other pertinent history included Insulin Dependent Diabetes Mellitus, Hypertension, and End Stage Renal Disease (ESRD). The patient was admitted as an inpatient with physician orders including continuous telemetry monitoring. A physician's order dated 09-26-14 included: "Family to take patient to Dialysis Center before...appointment and return to unit after."

The Chief Medical Officer, the Director of Operations, and the Director of Nursing acknowledged during interviews conducted on 2/14/2015, the hospital had no policies and procedures for the transport of patients from the hospital to an outside health provider.
VIOLATION: NURSING SERVICES Tag No: C0294
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of clinical records, hospital policies and procedures, Registered Nurse (RN) emergency room (ER) job descriptions, personnel files and interviews with staff, it was determined:

1. The hospital failed to ensure a patient with physician orders for telemetry monitoring was supervised while awaiting transportation to a dialysis provider; failed to ensure physician orders were obtained to determine the status of telemetry monitoring while off the unit; and failed to obtain physician orders for the mode of transportation the patient required from the hospital to the dialysis provider. The patient was left unattended in the waiting room of the hospital's Emergency Department (ED) for approximately 1.5 hours. The patient became unresponsive while being assisted into the transportation van and had to be brought back into the ED for resuscitation. (Patient #1). Failure of the Nursing staff to recognize a patient ordered on telemetry and placed in the ED waiting room without monitoring or notification to another licensed person resulted in the patient not being assessed for >1 hour and the patient's condition changed resulting in resuscitation.

2. One (1) of one (1) ER patients with Chronic Obstructive Pulmonary Disease (COPD) presenting with Shortness of Breath (SOB), did not have oxygen initiated when the oxygen saturation was 83%. (Patient #3) Failure to initiate oxygen has the high potential risk of harm for a patient not being adequately oxygenated.

3. One (1) of one (1) acute care inpatients with COPD did not have oxygen administered by the RN, according to the physician's order. (Patient #3) Failure of the nursing staff to follow a physician order for oxygen administration has the high potential risk of the patient decompensating in Respiratory status.

4. The hospital failed to follow their policies and procedures to ensure new RN hires including new graduate RN's were deemed competent to follow nursing standards of care to meet the individual needs of the patients and competent to implement the facilities policies and procedures, prior to being scheduled to work independently as a staff nurse. (Staff #8, #11, and #16.) Failure to ensure staff competencies has the high potential risk of patients needs being met by qualified staff;

5. The hospital failed to ensure policies and procedures were developed and implemented including specialized training and competency validation for RN's administering intravenous Vecuronium (a skeletal muscle relaxant), and intravenous Etomidate. Two RN's administered Vecuronium (Patients #1 and #4) and one RN administered Etomidate (Patient #4) without documentation of specialized training and competency evaluation.

6. The hospital failed to ensure their policies and procedures that required specialized training and competency evaluation were followed for an RN to draw Arterial Blood Gasses (ABG's). Staff #18 drew an ABG on Patient #1 and attempted to draw an ABG on Patient #4 without documentation of the specialized training or competency evaluation.

Findings include:

1. The hospital's policy and procedure on the subject of Telemetry Monitoring (Effective 06/2014) included: "1. Patients requiring cardiac monitoring will be placed on the telemetry system by the Primary Nurse once admitted to the AC (Acute Care) unit. Monitoring will be continued until order from provider to discontinue monitoring."

-Patient #1 went to the hospital's ED on 2/6/2015 with a chief complaint of left leg pain. The patient was evaluated by the ED physician who documented the patient had been on dialysis for the past eight to nine years. The patient's dialysis schedule was every Tuesday, Thursday and Saturday and that his most recent dialysis treatment was the day before the ED visit. At 11:55 a.m. the physician ordered: "Admit as Inpatient - Telemetry." The patient's admission diagnoses included: Cellulitis of lower leg; Diabetes mellitus type 2; Congestive heart failure; and Chronic renal failure syndrome.

The patient was evaluated by the admitting physician on 2/6/2015 at 1:33 p.m. utilizing the High Definition Camera. The physician documented the patient had an arteriovenous fistula (AVF) placement to his left groin in the past. The physician's documentation included: "Massive cellulitis most significantly from ankle to the knee, but extending all the way up to the left groin. Groin AVF does not seem to be affected. Surprisingly not septic, has tachycardia and borderline WBC. s/p (status post) Vanco (Vancomycin) x 1 in the ED. Will undergo HD (hemodialysis) tomorrow...per patient, good compliance with HD (T-Th-S schedule). Last HD yesterday, but +ve hypoxic resp failure. ECHO pending." On 2/7/2015 at 1 p.m. the physician documented: "Initially declined HD today. d/w patient, RN and tech in the room during telemed encounter. Patient understands the need for compliance with HD, especially in the light of extra volume administered with the IVAbx (intravenous antibiotic) infusion...LLE (left lower extremity) exam significantly better comparing to yesterday."

Nursing documentation in the clinical records revealed the following sequence of events:

-2/7/2015 at 8:24 a.m.: "Patient refuses to go to dialysis as per his regular schedule. Stressed importance of dialysis to patient yesterday, 02/06/2015. Patient stated that he 'wants to deal with one health problem at a time.' Dialysis center notified."

-2/7/2015 at 12:36 p.m.: "Patient to meet transportation in E.D. lobby to go to dialysis clinic. Patient taken to E.D. via wheelchair by (name), LPN. Patient transportation back to hospital arranged through insurance as well. Dialysis clinic is expecting patient."

-2/7/2015 at 1:50 p.m.: "Patient was transported via wheelchair to van for transportation to dialysis. Upon transferring patient to van, driver reported that patient seemed obtunded and lethargic. Driver from transportation entered ED and reported to (name), Tech patient's condition. (Name), Tech went to van to assess/assist with patient. Patient reported to (Name), Tech that he felt 'short of breath'. (Name) Tech contacted this RN to assess patient. This RN assessed patient and patient was unresponsive. Carotid pulse checked and none found. Patient was limp. Patient transported to Bed 1."

-2/7/2015 at 1:55 p.m.: Patient brought to Bed 1, placed on cardiac monitor. CPR and ACLS initiated."

Further documentation revealed the patient was intubated by the ED physician at 2:12 p.m. and placed on a ventilator. The patient was airlifted to a hospital in Tucson at approximately 3:52 p.m.

The Admitting Clerk who was on duty at the time of the incident, reported in an interview conducted on 2/14/2015 at 3 p.m., that she received a call from the Charge Nurse on the Acute Care Unit to let her know the patient was going to be in the waiting room of the ED until he was picked up by transportation. The Admitting Clerk is located in the reception area of the ED waiting room where he/she is able to visualize some but not all of the waiting area. The Admitting Clerk said the patient was brought to the waiting room by a nurse staff member from the acute care unit who then left. The patient was in a wheelchair and situated in front of the vending machine and she acknowledged she was able to see him from where she was sitting. She was not able to recall the amount of time the patient remained in the waiting room but said it was approximately one and one-half hours during which time no one from the unit called or came down to check on him. She reported that while he was there, the vending machine vendor came in to do something with the vending machine and she had to go out to the waiting room to move the patient. She said the patient was alert and responsive at that time. At that time she went to the House Supervisor who was in the ED and asked when the patient was going to be picked up as he had been waiting a long time. The House Supervisor she didn't know the patient was there and said she would contact the Acute Care Unit to see what was going on. Shortly after that the transportation driver arrived and asked the Admitting Clerk if he could take the wheelchair with the patient. A few minutes later the van driver came in and asked if there was someone available who could help him get the patient into the van and she asked the ED Technician.

The ED Technician acknowledged during an interview conducted on 2/14/2015 at 3:30 p.m., that he was requested by the Admitting Clerk to go outside and assist the transportation driver in getting the patient into the van. He stated that the patient was alert and responsive and told the ED Technician that he felt a "little weak" and "out of breath." The ED Technician told him to take his time and he would assist him when he was ready. He was able to "hoist" the patient up into the back seat. While trying to maneuver the patient into a better position the patient took a deep breath and his hand went limp. The ED Technician said the patient looked "winded" and told the driver to hold on to the patient because he was going to go back into the ED and get a gurney and take him back in to be assessed. The ED Technician did so and at the same time the Acute Care Unit RN was paged to go to the ED. The ED Technician and the RN were in the process of moving the patient from the van onto the gurney when the patient became unresponsive. He said resuscitation activities were initiated in the ED.

The RN Charge Nurse, who was on duty on the Acute Care Unit on 2/7/2015, reported during a telephone interview conducted on 2/14/2015 at 4:15 p.m., that she made arrangements for the patient's transportation to the dialysis facility; as directed by the patient's payer source. The transportation company contacted did not provide trained medical personnel during the transport. The transportation company told her they would pick the patient up at 12:30 p.m. and to have the patient waiting in the ED waiting room. The RN acknowledged she instructed another staff member to take the patient to the ED waiting room but did not instruct the staff member or any other staff member to stay with the patient until he was picked up. She said she called the Admitting Clerk in the ED and told her the patient would be in the waiting room awaiting transportation but did not notify the House Supervisor or any nursing staff in the ED that the patient would be in the waiting room there. She did not follow up to ensure the patient was picked up and and did not realize it until later when she was paged to go to the ED. The RN reported the patient's physician spoke with the patient and convinced him to go to dialysis, however, the physician did not provide orders for the patient to be transported to an outside dialysis provider. She acknowledged the patient was on continuous telemetry monitoring on the unit but did not obtain orders to discontinue telemetry or orders to specify the mode of transportation the patient required from the hospital to the dialysis facility.

The RN who was the House Supervisor on 2/7/2015, when the incident occurred, reported during a telephone interview, conducted on 2/14/2015 at 5 p.m., that she was not made aware of the patient being brought up and left in ED waiting room from the acute care unit until the Admitting Clerk asked her when his ride would be there. She said she called the unit and spoke with an RN who was at the nurses station but was not the patient's primary nurse. That RN said the patient was waiting for transportation to the dialysis facility. The RN House Supervisor stated she was on her way to the unit to talk to the patient's primary nurse when she was paged back to the ED. When she got back to the ED the patient had been brought back in from the van and was unresponsive at which time resuscitation efforts began.

The Licensed Practical Nurse (LPN), who was the staff member who took the patient from the acute care unit to the ED waiting room, stated during a telephone interview conducted on 2/14/2015 at 5:15 p.m., that she was functioning as a technician on the day of the incident. She said she got the patient ready for dialysis and that he was alert and "making jokes" at that time. She acknowledged that she took him to the ED waiting room and left him there. She said she was not instructed to stay with the patient and she then went to lunch.

The hospital's Chief Medical Officer, the Director of Operations, and the Director of Nursing, acknowledged during interviews conducted on 2/14/2015, it had been the hospital's practice in the past to admit patient's who required hemodialysis treatment even though the hospital was not able to provide that service. The practice was to send the patients to the dialysis facility in town for their treatment(s) and then have them come back. They acknowledged there was no policy and procedure for that practice.






2. The Registered Nurse (RN)-ER job description revealed: Job Summary: Under the general direction of the Chief Nursing Officer, the RN-ER coordinates total nursing care for patients according to the Nursing Process and participates in patient and family teaching and provides leadership...in maintaining standards for professional nursing practice in the clinical setting. DUTIES AND RESPONSIBILITIES: 1. Assesses the patient's condition and nursing needs; follows set standards for emergency room Nursing; understand triage and priority of care. 2. Reports pertinent observations and reactions regarding patients to the ER Physician and records those observations accurately and concisely...7. Assists team members in providing care to patients or administers direct care when professional nursing skills and judgment are needed...."

Patient #3 presented to the Hospital Emergency Department (ED), on 02-12-15 at 7:05 P.M., with a Chief Complaint of Shortness of Breath.

Nursing documentation revealed that Emergency Medical Systems (EMS) reported that the patient had an oxygen saturation (O2 sats) of 75% on room air (normal values are 97%-99%). At 7:30 P.M., a nursing assessment revealed: "Lung sounds-Bilaterally diminished in upper lobes and rhonchi auscultated in lower lobes bilaterally." Vital Sign documentation on 02-12-15 at 7:05 P.M., revealed that RN #1 documented O2 sats of 83% on room air.

Staff #3, an Emergency Department physician documented: "The Onset is Sudden. The symptoms are Severe, SOB (shortness of breath), Constant, 1 day.

RN #2 stated, during interview conducted on 02-14-15, that if the O2 sats are low, the Registered Nurse (RN) should initiate the administration of oxygen, then request an order from the physician. RN #2 acknowledged that there was no documentation that oxygen was initiated on Patient #3 until 8:05 P.M., when a Venturi mask (a Venturi masks is considered high-flow oxygen therapy device) was placed on the patient by physician order.

3. The RN-Acute Care job description revealed: "...DUTIES AND RESPONSIBILITIES: 1. Maintains the standards of nursing care and implements the policies and procedures of the Hospital and Acute Care department. 2. Assesses the patient's condition and nursing needs...8. Directs, supervises, initiates, and evaluates nursing care provided to patients based on nursing diagnosis, and applies knowledge of specific illness, injuries, diseases, human behavior, and appropriate standards of care...."

Patient #3 was admitted to the Hospital, and on 02-12-15 at 10:00 P.M., and an order was written for oxygen (O2) by nasal cannula to keep sats at 90-92%. Nursing documentation on 02-14-15 at 12:10 P.M., revealed: "O2 (sats) at 88% on R/A (room air). (O2) Back on at 2 L (liters)."

RN #2 stated, during telephonic interview conducted on 02-15-15 at 9:25 A.M., that the patient's sats had been up to 97%, so the patient was taken off oxygen at around 8:00 A.M. on 02-14-15. RN #2 acknowledged that the patient's O2 sats were not then reassessed until 12:10 P.M. RN #2 acknowledged that she should have checked sooner to assure that the patient remained in the O2 sat range of 90-92% as ordered by the physician.

4. The hospital's policy titled "Orientation of Staff" (Effective 06/2014) included: "POLICY...Patient Care Service staff is required to complete orientation and demonstrate competency as defined by professional licensure, required core and job-specific competencies including age-specific competencies...PROCEDURE...Acute Care nurses are to be oriented by working with another nurse who has more than six (6) months of nursing experience in our facility. Orientation may consist of a total of six (6) shifts for Acute Care depending on experience of RN...Orientation also includes review of Orientation packet and completion of Orientation modules. Emergency Department nurses orientation will take place in the Emergency Department, but will follow above-mentioned guidelines...Evaluation of the orientee's skills is to be made between the preceptor and nurse manager or Director of Nursing (DON)...If the new orientee is deemed competent, he/she will be scheduled to work as a staff nurse...The items listed below should be completed prior to a new employee working as a staff nurse:
-Review of competencies (to be completed during orientation process by preceptor)
-Orient to crash cart, medication room, med-dispense, Empower
-Review of policy and procedure manuals prior to and/or concurrently starting orientation to the unit."

The hospital had no policy that addressed the special needs of new graduate RN's.

A review of the hospital's Employee Status Report revealed a total of 20 RN's on staff. Eleven of the 20 were hired during the period from 5/20/2014 to 11/13/2014. Eight of the eleven were hired as new graduates.

-Staff #8 is a new graduate RN whose first date of licensure with the Arizona State Board of Nursing was 6/6/2014. Her date of hire at Cochise Regional Hospital was on 11/03/2014. There was no documentation in her personnel record of verification of competencies prior to being scheduled to work independently as a staff nurse. The RN was scheduled as the sole RN on the Acute Care inpatient unit on 2/15/2015. The RN confirmed during an interview that she was working independently on the inpatient unit.

-Staff #11 is an RN whose first date of licensure with the Arizona State Board of Nursing was 6/16/2014. Her date of hire at Cochise Regional Hospital was 6/25/2014. Her personnel record was reviewed on 2/15/2015 and there was no documentation of verification of her competencies. On 2/17/2015 the hospital provided copies of portions of the RN's personnel record that included a 12-page "180 day Competency Skills List." There were two columns for the employee's "Self Evaluation" of her ability to perform each task and another column for "Skill Evaluation Signed and Dated by Preceptor. The Preceptor signed and dated each page on 12/30/2014, approximately 180 days after hire date.

-Staff #16 was a new graduate whose first license with the Arizona State Board of Nursing was issued on 6/10/2014 and her hire date with Cochise Community Hospital was 10/31/2014. A review of her personnel record on 2/15/2015 revealed no documentation of competency verification prior to her being assigned to work independently as a staff nurse.

The Director of Nursing reported during an interview conducted on 2/15/2015, that nursing skills competencies are not completed until 180 days after their initial hire date. He stated he was not aware of a hospital policy and procedure for orientation of new graduates and verification of skills and competencies.

5. Vecuronium Bromide is classified as a nonpolarizing skeletal muscle relaxant used as an adjunct in general anesthesia as well as to aid in endotracheal intubation. The boxed warning on this intravenous injectable medication includes: "This drug should be administered by adequately trained individuals familiar with its actions, characteristics and hazards."

Etomidate is classified as an hypnotic medication used for the induction of general anesthesia. The boxed warning on this intravenous injectable medication includes: "Intravenous Etomidate should be administered only by persons trained in the administration of general anesthesia and in the management of complications encountered during the induction of general anesthesia."

The Arizona State Board of Nursing Advisory Opinion for ANESTHETIC AGENTS ADMINISTERED BY REGISTERED NURSES FOR LIMITED PURPOSES: AIRWAY MANAGEMENT OR PERIPHERAL NERVE BLOCK includes the following: "Registered nurses who do not meet the educational requirements of A.R.S. 32-1661, completion of a nationally accredited program in the science of anesthesia, may assist a licensed provider by administering anesthetic agents in situations where the licensed provider is present but unable to personally inject the anesthetic agent because the provider is performing these critical tasks for the patient: airway management or placement of a peripheral nerve block requiring the use of both hands...GENERAL REQUIREMENTS...1. A written policy and procedure is maintained by the employer...The registered nurse is required to have the same knowledge base for the anesthetic agents administered as for any other medication that the registered nurse administers...."

The hospital had no policies and procedures for the administration of Vecuronium Bromide or Etomidate by RN's.

-Documentation dated 2/7/2015 in Patient #1's clinical record revealed the patient was non responsive and resuscitative activities were initiated. Vecuronium Bromide 10 mg IV solution was administered at 2:24 p.m. and again at 4:22 p.m. by two different RN's (Staff #12 and Staff #18) in the ED following physician orders.

-Nursing documentation dated 01/07/15 in Patient #4's medical record revealed the following at 1735 (5:35 P.M.): "Due to 73% O2 (oxygen) sat (saturation) and what appeared to be a grand mal seizure, patient was manually ambubagged (ambu bag compressions to provide oxygenation) with 100% O2 at 15 L (Liters). Etomidate (drug used for induction of general anesthesia) administered per Dr. (doctor) order for RSI (Rapid Sequence Intubation)..." On 01-07-15 at 1748 (5:48 P.M.), documentation revealed: "Vecuronium 10 mg (milligrams) IVP (intravenous push)" was administered to Patient #4.

6. The hospital's policy and procedure titled Blood Gas Policies, Policy 2.C.1, revised 11/14 included:

"...Arterial Puncture and Patient Identification

Arterial blood is obtained via arterial line sample or by puncture of the radial or brachial artery in order to measure arterial blood gases and acid-base status of the patient. Only those individuals who have been certified in arterial blood gas collection by the Section's Medical Director may obtain arterial samples...

Certification Process
i. Registered Nurses may perform arterial punctures only after the following required activities:
ii. Attendance at a lecture of anatomy, technique and complications of arterial punctures.
iii. Supervised performance of a minimum of one successful arterial stick by a Physician or a Supervisor (depending upon previous experience).
iv. Successful completion of established written competencies (85% or greater).
v. Performance of arterial sticks will be continually evaluated and assessed through quality data provided by the Laboratory...."

-Patient #4, an elderly male, had presented on [DATE] with a history of sudden onset Shortness of Breath, Tachycardia, and Hypotension.

RN documentation dated 01-07-15 at 1:10 P.M. revealed: "Blood ABG (Arterial Blood Gasses) attempted at this time at the right radial pulse. Allen's test (A test to determine abnormal circulations) positive...."

The hospital's Director of Operations stated during a telephone interview on 2/23/2015 that the ABG draw was attempted by Staff #18, an RN.

-Patient #1 became unresponsive and resuscitation efforts initiated on 2/7/2015 in the ED. The ED physician ordered ABG's at 2:36 p.m. and the order was "executed" by Staff #18.

Staff #18 is an RN who was hired on 01/03/2010 and who primarily works in the hospital's ED.

Staff #18 reported during a telephone interview conducted on 2/24/2015 at 9:35 a.m., that she was trained 15 years ago at another hospital on performing ABG's; and that she "felt comfortable" with the procedure. She acknowledged that she would draw ABG's when ordered by the physician in the ED.

The hospital's Director of Operations acknowledged during a telephone interview on 2/24/2015 that there was no documentation in her personnel record of training and verification of competencies for performing ABG draws.

The Chief Medical Officer reported during a telephone interview on 02/28/2015 that only a physician could perform an ABG draw at Cochise Regional Hospital.
VIOLATION: NURSING SERVICES - SUPERVISION OF CARE Tag No: C0296
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, Registered Nurse (RN) job description review, policy and procedure review and interview, it was determined that the RN failed to supervise and evaluate the care of patients as evidenced by:

1. A staff RN failed to obtain a physician order to remove telemetry monitoring for one (1) of one (1) patient, (Patient #21); who was transported by family members to a dialysis center as required by the Hospital's policy. Failure to ensure that the appropriate transportation mode to meet patient needs during transport lends a potential risk of harm for the patient; and

2. One (1) of one (1) patients with an order to keep oxygen saturation levels >95% was transported without oxygen at a saturation level of 89%; and there was no order to discontinue the oxygen during transport (Patient #21). Transporting patients without oxygen, and at an acceptable saturation rate per MD order lends to a high potential risk to the patient.

Findings include:

1. The RN-Acute Care job description revealed: "...DUTIES AND RESPONSIBILITIES: 1. Maintains the standards of nursing care and implements the policies and procedures of the Hospital and Acute Care department. 2. Assesses the patient's condition and nursing needs...8. Directs, supervises, initiates, and evaluates nursing care provided to patients based on nursing diagnosis, and applies knowledge of specific illness, injuries, diseases, human behavior, and appropriate standards of care...."

The "Telemetry Monitoring" policy revealed: "...PROCEDURE: 1. ...Monitoring will be continued until order from provider to discontinue monitoring...."

Patient #21 presented on [DATE] at 9:56 A.M., with a Chief Complaint of Weakness and Generalized Body Ache. Other pertinent history included: Insulin Dependent Diabetes Mellitus, Hypertension, and End Stage Renal Disease (ESRD). A chest x-ray on 09-25-14 revealed a "correlation for early congestive heart failure (CHF) is advised...."

Staff #4, a physician, documented on 09-25-14 at 7:04 P.M.: "multifactoral weakness including anemia of chronic dz (acronym undetermined), ESRD, CHF, and impending sepsis (local or generalized invasion of the body by pathogenic microorganisms or their toxins) of unclear source at this time..." The medical orders at that time revealed: "Admit as an Inpatient-telemetry...."

On 09-26-14, Staff #5, a physician, documented: "...Patient transferring for hemodialysis the Am (sic)...."

On 09-26-14, Staff #7, a physician, wrote an order: "Family to take patient to Dialysis Center before (9:00 A.M.) appointment and return to unit after."

On 09-26-14 at 8:00 A.M., Staff #6, an RN documented: (Family Member) in room getting patient ready for transfer to Dialysis Center...Telemetry removed...."

There was no documented order that telemetry could be removed; there was no documentation that the RN caring for the patient had evaluated the risk of removing the patient from Telemetry for several hours while he was at dialysis.

The Medical Director acknowledged, during telephonic interview conducted on 02-18-15, that the Hospital has portable telemetry equipment, and the patient should have been placed on portable telemetry prior to being sent to dialysis.

2. Patient #21 had an order to keep the oxygen saturation levels at >95%. The "Vitals" documentation in the patient's medical record revealed that on 09-26-14 at 8:00 A.M., when the RN documented that she was getting the patient prepared to go to a dialysis center, the O2 sats were documented as "89%." There was no documentation that the RN took any measures to bring the levels to >95% as ordered, and no documentation that the patient was sent to dialysis with portable oxygen.

Nursing documentation revealed that Patient #21 returned from dialysis at 11:50 A.M. on 09-26-14. The Vitals form revealed that at 12:05 P.M. the pulse oxygenation was 88%. A "Comment" revealed: "placed on O2 (oxygen) at 2 L (liters) pulse ox increased to 91%."

There was no documentation by RN#6 what measures were then taken to get the pulse oxygenation up to the > than 95% ordered. There was no documentation that the RN evaluated what steps needed to be taken to assure that the oxygenation level was >95% as ordered.

The Director of Nursing acknowledged, during telephonic interview conducted on 02-18-15, that there is no written communication from the dialysis center RNs to the RN caring for the patient in the inpatient unit when they return from dialysis which would apprise the Hospital RN of the patient's oxygenation while at dialysis.