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.

INTERMOUNTAIN MEDICAL CENTER 5121 SOUTH COTTONWOOD STREET MURRAY, UT 84107 Feb. 26, 2019
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview and record review, it was determined the hospital failed to have an effective governing body that was responsible for the conduct of the hospital. Specifically, the governing body failed to ensure that nursing services were furnished in a way that adequately met the needs of the patients, failed to ensure the hospitals quality assurance and performance improvement program included all nursing units and areas of the hospital, and failed to ensure patient rights were upheld according to the conditions of participation.

Furthermore, the governing body failed to provide surveyors with requested information in a timely manner which delayed the investigation by several days. Specifically, surveyors were unable to complete their investigation in a timely manner due to the hospital not providing requested information promptly, limiting surveyors ability to review patient medical records in their entirety, and limiting access to their complaint documentation. The hospital delayed providing surveyors pertinent documentation regarding patient complaints by up to approximately 27 hours.

Findings include:

1. The hospital failed to inform each patient of the correct person to contact to report a grievance and failed to follow-up on patient grievances. Refer to tag A-0118

2. The hospital failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program that involved all hospital departments and services and failed to appropriately investigate and follow-up on patient incidents. Refer to tag A-0263

3. The hospital failed to furnish nursing services to adequately meet patient needs. Refer to tag A-0385

4. Several times during the survey from 2/19/19 through 2/26/19, surveyors had to depend on the hospital's compliance and risk management staff to participate in medical record review under their own log-ins to find pertinent documentation due to the limited view of the patient electronic medical record that had been provided to surveyors. The compliance and risk management staff stated they knew survey view was limited and had requested several times to allow surveyors full access to patient medical records, however, the administration considered surveyors as "auditors" and would only allow an auditing view to surveyors.





5. On 2/20/19, at approximately 10:00 AM, the hospital complaint log was reviewed and a complaint filed by the family of patient 7 was observed on the log. The survey team asked to see the investigation and resolution of the complaint. The survey team did not receive this documentation until approximately 1:00 PM on 2/21/19.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, it was determined that the hospital did not inform each patient of the correct person to contact to report a grievance. Furthermore the hospital did not follow-up on a grievance for 1 of 3 sampled patient grievances. (Patient identifier: 9)

Findings include:

1. Patient 9 was admitted on [DATE], with diagnoses which included foot infection, pain, diabetes mellitus and hypertension.

On 2/20/19 at 10:45 AM, an interview was conducted with patient 9. Patient 9 stated he came to the hospital on [DATE], for a foot infection and severe pain. He was admitted to the hospital for tests and eventually had surgery to amputate part of his foot on 2/16/19. Patient 9 stated that he had a history of chronic pain and was on a specific pain medication regimen at home and the pain regimen was not followed in the hospital. Patient 9 stated that his pain had been out of control and had not been addressed for approximately two and a half days. Patient 9 stated that he resorted to emailing and calling the hospital administrator on the morning of 2/17/19, to ask for help with getting someone to manage his pain appropriately. Patient 9 stated that no one from administration had contacted him about his concerns. Patient 9 stated that eventually, after approximately 2.5 days, the charge nurse contacted acute pain services who initiated a pain management program on the afternoon of 2/17/19.

2. On 2/20/19, at approximately 2:30 PM, an interview was conducted with the quality consultant (QC) for the office of patient experience. The QC was asked if administration had contacted the patient to address his concerns. The QC stated that she did not know. The QC stated that if the patient had called or left an email it probably would not have been received because the call was made on a weekend and the administrator did not work on the weekends and would not be responding to his emails or telephone calls. The QC also stated that Monday 2/18/19, was a holiday and the administrator did not work on holidays. The QC stated that she did not know what the process was for addressing patient concerns on the weekend.

3. On 2/21/19, the patient admission packet was reviewed. A review of the packet revealed information indicating that if a patient had concerns they could contact the hospital's administrator. The packet contained the contact information for the administrator, including a telephone number and email address of the prior administrator.

4. On 2/21/19, a follow up interview was conducted with the QC. The QC stated that the hospital had recently changed administrators. The admission packet had not been updated since the change. When asked if someone from administration should meet with the patient to discuss his concerns, the QC stated that she didn't think the office of patient experience knew about patient 9's concerns yet.

5. On 2/21/19, the QC provided a log of emails from administration noting patient 9's email to the prior administrator detailing his grievance. Patient 9's grievance was sent on 2/17/19 at 5:31 AM. The email contained patient 9's cell phone number as contact and requested to please assist him in getting his pain issues resolved immediately.

6. Further review of the email log revealed patient 9's email had been opened by the prior administrator on Monday 2/18/19 at 12:26 PM. The prior administrator forwarded the email to the the current administrator, the medical director and the director of nursing. The medical director responded on 2/18/19 at 1:30 PM, stating that the patient was in a better place now that his pain was under control and the medical director did not think the problem existed anymore.

7. An email from the the director of the office of patient experience, dated 2/21/19, at 12:29 PM, indicated that the patient was doing better when administration did go to see the patient. (Note: Administration responded to the patient after the surveyor brought it to the attention of administration that they had not contacted the patient to address his concerns.)
VIOLATION: QAPI Tag No: A0263
Based on interview and record review, it was determined the hospital failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program that involved all hospital departments and services. Furthermore, the hospital failed to appropriately investigate and follow-up on patient incidents.

Findings include:

1. The hospital failed to have an effective QAPI program that appropriately investigated and followed-up on patient incidents. Refer to tag A-0286

2. The QAPI program failed to include and involve all hospital departments.







On 2/27/19 at 3:00 PM, an interview was conducted with the clinical operations manager for quality (COMQ). The COMQ stated each hospital unit had "huddle boards" where they had their own goals, but that she was unsure if there was documentation of this information. The COMQ further stated, "going forward once a month they will input that data into a report and then we can see all 120 unit reports and see if they are hitting their goals and if they need assistance."

On 2/28/19 at 2:20 PM, a voicemail from the COMQ revealed the following information, "When I came here in November we looked at the reporting process of our metrics and we had a really great process for clinical programs and infection prevention, but noticed a gap where an individual floor would report in, which is something we started working on then." She further stated she met with the hospital nurse administrator, the hospital board, and discussed her concerns with the "gap" in the hospital's current QAPI process. The COMQ further stated there was going to be a new process in which each unit manager would put their individual unit metrics into a tool which would be sent to her and then reported to the hospital quality counsel. The COMQ further stated she could not provide documentation of current unit QAPI goals and data.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital did not appropriately analyze and investigate adverse patient events for 2 of 4 sampled patient events. (Patient identifiers: 7 and 11)

Findings include:

1. Patient 11 was admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]. Patient 11 continued to decline until her death on 12/2/18.

On 2/21/19, surveyors reviewed the hospital's adverse event logs. An event report involving patient 11 had been reported on 12/3/18, regarding an issue with oxygen therapy. A second event also involving patient 11 was reported on 12/3/18, regarding a possible medication error.

The oxygen therapy event was reported by the registered nurse (RN). The RN documented the patient had been on a continuous positive airway pressure (CPAP) device throughout the day on 12/2/18, and was requiring increasing amounts of oxygen. It was documented that the RN requested respiratory therapy (RT) to assess and treat the patient. The adverse event log detailed how the RN and RT debated who was responsible for the respiratory assessment of the patient. Further detail documented that the physician eventually ordered to intubate (put a breathing tube down the patients throat) at which time the patient's family chose to stop treatment. Patient 11 passed away shortly thereafter.

There was documented evidence the hospital had done an investigation into the CPAP/oxygen therapy event and had documented on 12/11/18, "...we are not able to find causation between the CPAP being a cause of the patient's death. In light of that, the event doesn't meet SERP (serious event review panel) criteria and is not considered an SSE (safety event). ZH (zero harm) completed, event closed."

The possible medication error event was reported by a night shift RN regarding a possible medication error around 11/19/18 to 11/23/18. The RN documented that on 11/24/18, after midnight she was replacing an empty bag of intravenous (IV) fluids and noticed the bag was labeled "D5 0.9% NS"; a rehydration fluid that contains both glucose (sugar) and sodium (salt). The RN documented that she questioned this fluid because the patient was having critically high levels of sodium in her blood. The RN documented that she reviewed the orders and discovered the order was written for the patient to receive fluids with only glucose (D5) and not sodium (0.9% NS). The RN documented that the patient had been receiving the incorrect fluid for 5 days. The medical record revealed that over those 5 days, the patients blood sodium levels rose to critically high levels. The RN documented that the physicians were notified and the patient was transferred to the ICU.

There was no documented evidence the hospital had investigated the second event involving a possible medication error.

On 2/25/19 at 3:25 PM, surveyors interviewed the system director of clinical risk management. When asked about the event involving the possible medication error, she stated that these 2 events had been "merged" in their system. She stated that when they received a review about the CPAP event, they had inadvertently closed the entire investigation. She stated the possible medication error event must have just been overlooked.








2. Patient 7 was admitted on [DATE], with diagnoses which included laceration of scalp and acute on chronic hypoxemia (below-normal level of oxygen in blood). Patient 7 passed away in the hospital on [DATE].

On 2/20/19 at approximately 10:00 AM, the hospital complaint log was reviewed and a complaint filed by the family of patient 7 was observed on the log. The survey team asked to see the investigation and resolution of the complaint.

On 2/21/19 at approximately 1:30 PM, the hospital's investigation into the complaint involving patient 7 was reviewed. It revealed the patient's CPAP had become dislodged and his oxygen saturation had declined. It revealed that a nurse and a nurses aide had been informed of the declining oxygen saturation by a telemetry technician who was monitoring the patient. It also revealed the patient did not have any staff intervention, after the notification from telemetry, for a period of approximately 22 minutes, from 7:31 PM to approximately 7:53 PM, on 11/28/18.

The hospital's investigation documentation revealed a focus on investigating the CPAP becoming dislodged and did not address the 22 minute delay in patient care. Refer to tag A-0392

On 2/25/19 at 2:38 PM, the survey team received additional information from the clinical risk manager (CRM) regarding the complaint. The CRM stated she had sent a letter to the family of patient 7 and had received the physician review regarding the incident. The CRM then provided the survey team with the letter and physician review.

The letter sent from a hospital patient advocate only addressed the use of patient 7's home CPAP machine "...We received the final autopsy report last week from the medical examiner's office, which notes the manner of death as 'Natural,' immediate cause of death as 'Chronic lung disease (emphysema and [DIAGNOSES REDACTED] fibrosis)' with other significant conditions including 'Chronic Kidney Disease, hypertensive cardiovascular disease.' Based on these findings, it has been determined that the cause of your husband's death was unrelated to CPAP equipment issues but was, instead, as a result of natural causes related to his clinical history of chronic lung disease..." The letter did not mention any delay in care received by patient 7.

The physician review given to the survey team by the CRM was reviewed. The review did not indicate when it was completed or by whom it was completed. The review contained conflicting information including differing timeframe's on when the patient was last seen by staff prior to the code being called. The review also did not address the lack of intervention when low oxygen saturation levels were reported.

On the first page of the review under the "Summary of Events" section the following was documented, "Essentially, what appears to have happened is that the patient was doing fine at 1800 (6:00 PM) and when they checked on him again at 2000 (8:00 PM) he was unresponsive...At 2000, patient was unresponsive, cyanotic and pulseless. They coded him, resuscitated him, brought him to the ICU (intensive care unit), put him on pressors, and a little while later the family decided to withdraw care."

On the second page of the review under "Was care appropriate? [(Please explain why or why not)]" the following was documented, "...The hospitalist identified acute on chronic hypoxemic respiratory failure with emphysema and [DIAGNOSES REDACTED] fibrosis, which was improving as a problem. He highlighted the importance of continuing oxygen therapy and noted that there was no overt evidence for a COPD (chronic obstructive pulmonary disease) exacerbation. Typically, patients are permitted to bring her (sic) CPAP machines from home which represents the usual care. These machines do not have continuous pulse oximetry monitoring. The patient was receiving oxygen at his baseline, without overt evidence of a COPD exacerbation, and continuous oxygen monitoring is burdensome to many patients [(hands tethered to another line)]. At night, it was reported that he used CPAP with 13 L (liters) oxygen bled in. This in fact was administered at the dose of CPAP, 12 L, leading to an oxygenation of 92%. Only 10 minutes later was the patient noted to upon follow-up be pulseless with saturations in the 70s, leading to the code..."

Note: Although the physician indicated continuous oxygen monitoring was burdensome and implying this was not being provided for this patient. The medical record and documentation, provided to the survey team by hospital staff, indicated at the time of the code the patient had been on continuous oxygen monitoring and staff had been alerted to low oxygen saturation levels. Additionally, no evidence could be located indicating that 10 minutes prior to patient 7 coding his oxygenation was 92%. The telemetry strips provided to the survey team indicate his oxygen saturations were 69% at 7:31 PM, and 62% at 7:41 PM, with a code being called at 8:02 PM. Per hospital documentation, patient 7's RN did enter his room at approximately 7:53 PM, however, the nursing staff could not get an oxygen saturation reading. Additionally, according to documentation, at 7:55 PM, per RT documentation, the patient was unresponsive, pulseless, and a code blue was called.

On 2/25/19 at 4:04 PM, a follow up interview was conducted with the CRM. The CRM stated she had again sent the case regarding patient 7 to the lead hospitalist on 2/22/19, after the survey team had discussed the case with her because the review had not been completed "due to restructuring".
VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, it was determined that the hospital failed to ensure that nursing services were furnished in a way that adequately met the needs of the patients.

Findings include:

1. The hospital failed to ensure the immediate availability of a registered nurse (RN) for bedside care of any patient. (Refer to tag A-0392)






2. Patient 9 was admitted on [DATE], with diagnoses which included foot infection, pain, diabetes mellitus and hypertension.

On 2/20/19 at 10:45 AM, an interview was conducted with patient 9. Patient 9 stated he came to the hospital on [DATE], for a foot infection and severe pain. He was admitted to the hospital for tests and eventually had surgery to amputate part of his foot on 2/16/19. Patient 9 stated that he had a history of chronic pain and was on a specific pain medication regimen at home and the pain regimen was not followed in the hospital. Patient 9 stated that his pain had been out of control and had not been addressed for approximately two and a half days. Patient 9 stated that he resorted to emailing and calling the hospital administrator on the morning of 2/17/19, to ask for help with getting someone to manage his pain appropriately. Patient 9 stated that no one from administration had contacted him about his concerns. Patient 9 stated that eventually, after approximately 2.5 days, the charge nurse contacted acute pain services who initiated a pain management program on the afternoon of 2/17/19.

On 2/25/19, patient 9's medical record was reviewed. A review of the pain scores from admission on 2/14/19 at 11:16 PM until 2/17/19 at 4:31 PM (when acute pain services ordered a pain pump), revealed scores averaging 8.1 on a scale of 1 through 10, with 10 being the worst pain possible. There was documented evidence that indicated patient 9's pain was at a 10 out 10 on multiple occasions during that timeframe. Patient 9's nursing care plans revealed patient 9 set his pain level goal as being "less than or equal to 4".

A review of the nursing to physician communication documentation revealed the nurse had not contacted the physician concerning patient 9's pain until 2/16/19 at 11:00 PM, which was 48 hours after the patient had been admitted .

The following nursing to physician communication documentation was found in patient 9's medical record:

a. On 2/16/19 at 11:00 PM, the nurse documented the patient was requesting a PCA (patient controlled analgesia) pump. At that time the physician discontinued his IV pain medication, and increased his oral pain medication dose.

b. On 2/16/19 at 11:30 PM, the nurse contacted the physician again, and requested the IV pain medication be reordered due to poor pain control.

c. On 2/17/19 at 3:03 AM, the nurse contacted the physician to clarify the pain medication orders.

d. On 2/17/19, at 4:18 AM, the nurse contacted the physician indicating that patient 9 was tearful with pain at a 10 out of 10, and the patient wanted to speak to the physician.

e. On 2/17/19 at 8:03 AM, the nurse contacted the physician requesting an increase in the pain medications because the current orders were not covering patient 9's pain. At 8:04 AM on 2/17/19, the physician ordered an acute pain service consultation for patient 9. The pain service consultation was completed at 3:05 PM. New medications orders were written and implemented at 4:31 PM on 2/17/19.

On 2/21/19, at approximately 4:00 PM, an interview was conducted with the office of patient experience (OPE) personnel. During the interview process, the OPE staff indicated that patient 9's pain issues should have been addressed more timely.






3. Patient 11 was admitted on [DATE], with a diagnosis of [DIAGNOSES REDACTED]. The patient was transferred between the ICU (intensive care unit) and regular medical floors of the hospital several times due to her severe illness.

On 2/21/19, surveyors reviewed the hospital's adverse event logs. An event report involving patient 11 had been reported on 12/3/18, regarding an issue with oxygen therapy. In the same event report there was a written report by a night shift registered nurse (RN) regarding a possible medication error for patient 11. The RN documented the patient had been receiving continuous intravenous (IV) fluids for several days. She documented that on 11/24/18, around midnight she was replacing an empty bag of IV fluids and noticed the bag was labeled "D5 0.9% NS"; a rehydration fluid that contains both glucose (sugar) and sodium (salt). The RN documented that she questioned this fluid because the patient was having critically high levels of sodium in her blood. The RN documented that she triple checked the fluid order then conferred with another nurse to verify the order. The RN documented the order was written for the patient to receive fluids with only glucose and not sodium. The RN documented that the patient had been receiving the incorrect fluid for 5 days. The RN also documented, "I documented all findings appropriately" and "I notified the previous nurse of what had happened as well as my supervisor."

(Note: Upon review of patient 11's medical record, surveyors could find no evidence of orders, administration, or documentation regarding the D5 0.9% NS fluid. There was also no evidence of the nursing documentation referring to the event.)

On 2/25/19, patient 11's medical record was reviewed. According to the RN's adverse event documentation, patient 11 began receiving the incorrect IV fluid on or around 11/19/18. According to documentation in the medical record, patient 11's blood sodium levels began to rise after 11/19/18. The results were as follows: (Note: The normal range for blood sodium levels is 137-146.)

11/18/18 at 4:33 AM = 138
11/19/18 at 5:28 AM = 137
11/20/18 at 5:57 AM = 141
11/21/18 at 5:04 AM = 147* high
11/21/18 at 1:37 PM = 150* high
11/22/18 at 12:49 AM = 153* high
11/22/18 at 4:06 PM = 163* critical high
11/22/18 at 9:40 PM = 160* critical high
11/23/18 at 2:26 AM = 161* critical high
11/23/18 at 5:59 AM = 160* critical high
11/23/18 at 10:55 AM = 160* critical high
11/23/18 at 9:06 PM = 160* critical high

The RN documented in the event report that earlier in the shift (evening/late night 11/23/18), patient 11's condition was changing which was reported to the physicians. The RN documented that the physicians did not change any treatment orders related to these findings; that they were "not worried" and "this is how she has been" and to "continue to monitor" the patient. The RN further documented that as soon as she found and verified that incorrect IV fluids were running (sometime between midnight and around 3:00 AM on 11/24/18), she immediately notified the physicians and began administering the correct IV fluid.

Further review of patient 11's medical record revealed that on 11/24/18 at 3:24 AM, a bag of glucose fluid was administered IV at the rate of 150 milliliters an hour. It also revealed new physician orders dated 11/24/18, to monitor patient 11's blood sodium level every 2 to 4 hours as well as new orders for the pharmacy to mix any IV medications in glucose water instead of sodium water. The medical record revealed patient 11 was transferred to the ICU the morning of 11/24/18.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, it was determined the hospital did not ensure the immediate availability of a registered nurse (RN) for bedside care of any patient. Specifically, when nursing staff were informed that a patient's blood oxygen saturation level dropped to unsafe levels they did not intervene timely. (Patient identifier: 7.)

Findings include:

Patient 7 was admitted on [DATE] with diagnoses which included laceration of scalp and acute on chronic hypoxemia (below-normal level of oxygen in blood). Patient 7 passed away in the hospital on [DATE].

On 2/20/19 at approximately 10:00 AM, the hospital complaint log was reviewed and a complaint filed by the family of patient 7 was observed on the log. The survey team asked to see the investigation and resolution of the complaint.

Once the surveyor reviewed the incident a concern regarding nursing services and the delay in their response to low blood oxygen saturation levels, was identified by the survey team. The following information was obtained from hospital documentation regarding the incident:

Patient 7's telemetry monitoring strips dated 11/28/18 revealed the following blood oxygen saturation levels, which were obtained via a pulse oximeter, and technician documentation:

a: At 7:31 PM, "69?" "Called (name of patient care technician), DESAT(low blood oxygen concentration), RT with PT (patient)"

b: At 7:41 PM, "62" "Called (name of RN), DESAT"

c. At 8:02 PM, "?" "CODE BLUE (cardiopulmonary arrest of patient) CALLED"

Note: Normal pulse oximeter readings usually range from 95 to 100 percent. Values under 90 percent are considered low.

The timeline provided by the respiratory therapist (RT) manager revealed the following:

a. At 6:38 PM, "RT increased O2(oxygen)...for CPAP to 12lpm (liters per minute) from 10lpm." "RT checked on patient saturations at 87% on pulse oximeter."

b. At 6:50 PM, "RT left room to give report to oncoming shift."

c. At 7:53 PM, "RN called night RT to say something wrong with Pt CPAP" "Commented it was disconnected--" "Unsure if RN reconnected it-"

d. At 7:55 PM, "RT arrived in room. Assessed patient-" "...Went to patient, tried to rouse him. Held jaw closed to see if CPAP working. RN and PCT trying to get pulse ox on patient. Patient not responsive to name/sternal rub when assessed by RT. She checked pulse- No pulse. RN double checked. Code blue called." "CPAP blowing through hose when in room."

The timeline provided by the NM revealed the following:

a. At 7:15 PM "RN bedside report" "Patient on CPAP 12L O2... Patient asleep but coughing and moving his head and upper body."

b. "Sometime between" 7:00 PM and 7:30 PM, "Patient calls to report IV beeping" "Dayshift RN states this was around 1930 (7:30 PM). She states she asked TT (telemetry technician) to call CN (charge nurse) as she was in report. TT states this was just after 1900 and reported day shift RN, who stated that she would be there shortly."

c. At 7:31 PM, "TT notices decreasing sats calls 'PCT (patient care technician)' but can't remember which PCT he called. States that PCT informed him that RT was in the room with patient addressing the low saturations."

d. At 7:41 PM, "TT concerned sats still low" "TT calls night RN who was in another patients room who was acutely bleeding. She reports leaving bleeding patient's room and going into (name of patient 7)'s room to find him with his mask off and tubing between mask and CPAP machine disconnected [(pulse ox was not reading a sat, patient was unresponsive, no pulse, code blue called).]

Note: The NM does not discuss or question the timeliness of the nurses response to patient 7's low oxygen saturation level reported at 7:41 PM. According to the timeline from the RT manager, the RN called the RT at 7:53 PM, to notify her that patient 7's CPAP was disconnected. This was 12 minutes after the TT notified the RN of patient 7's low oxygen saturation level. No evidence could be found in patient 7's medical record to indicate the RT had been in patient 7's room as documented in the NM timeline at 7:31 PM. Additionally, no evidence could be located in the complaint investigation, NM timeline, or patient 7's medical record indicating nursing staff responded to patient 7's low oxygen saturation level prior to 7:53 PM. This was approximately 22 minutes after the TT first informed nursing staff of patient 7's low oxygen saturation level.

On 2/21/19 at 3:15 PM and 3:36 PM, interviews were conducted with the nurse manager (NM) of the floor which patient 7 was on during his stay. The NM stated she had reached out to the RT manager to assist in looking into the concerns with the CPAP, and that she had conducted interviews with her staff to determine what had happened. When asked about the delay in staff addressing patient 7's low oxygen saturation the NM stated she could "see" how that was a concern. The NM stated when the RN was notified of patient 7's low oxygen saturations she should have either left the other patient's room she was in or contacted another nurse to go and address the concern. The NM kept stating the only delay was from 7:41 PM to approximately 7:53 PM. The surveyor informed her that per hospital documentation when the PCT was notified at 7:31 PM they stated an RT was in the room but that upon review of RT documentation and the RT managers investigation no RT was in the room at that time and were not notified of his low oxygen saturations, thus the delay in response began at 7:31 PM. The NM then confirmed patient 7's low oxygen saturation was not addressed from 7:31 PM to approximately 7:53 PM when the nurse called the RT. The NM stated she was unsure if staff were educated on timely intervention when informed of abnormal patient vital signs after this incident. The NM further stated it "could" have been discussed in the unit huddle which occurred prior to each shift with all nursing staff, but that she was again unsure and did not have any documentation of this occurring.

On 2/25/19 at approximately 9:00 AM, the quality consultant (QC) provided the survey team with two PowerPoint slides with information regarding staff communication and response to patient needs. The QC stated the NM of the floor which patient 7 was on during his stay provided the slides to the staff on her unit. The survey team requested documented evidence of who these slides were sent to and when. The hospital staff stated the NM was ill and they could not reach her.

On 2/26/19 at 4:17 PM, the QC called the NM and reported to the survey team the NM did not have documentation indicating who received the slides or when.

On 2/25/19 at 2:38 PM, an interview was conducted with the clinical risk manager (CRM) and the system director of clinical risk management (SDCRM). The CRM confirmed there was a concern with the response time of the nursing staff when patient 7 had decreased oxygen saturation levels. The SDCRM also confirmed a "gap" in the care provided to patient 7 on 11/28/18, and further stated it was "not normal" for staff to "take that amount of time" to respond to patient 7's decreased oxygen saturation. The SDCRM further stated the unit manger should have "immediately" provided education to unit staff, but that she was going to ensure the event would be reviewed, specifically the "monitoring piece", by the hospital director of nursing. The CRM then stated there were "opportunities for improvement" and that "we trust managers on the unit" are "taking immediate action".