HospitalInspections.org

Based on interview, and record review, the hospital failed to ensure for one of one sampled patient (Patient 5) with hypoglycemia the Condition of Participation (COP) for the Nursing Services was met when:

1. RN did not report the "Electrocardiogram [EKG- a heart functioning test] for one of 30 patients (Patient 5) to Doctor of Osteopathy (DO, doctor emphasizing a whole-person approach to medicine). Refer A395

2. RN did not follow facility hypoglycemia (low blood sugar) protocol to:
a) Immediately provide a source of glucose (sugar) during a hypoglycemic event for one of 30 patients (Patient 5) with low and critical low blood sugar level(s).
b) Monitor blood sugar levels every 15 to 30 minutes during a hypoglycemic event for one of 30 patients (Patient 5) with low and critical low blood sugar level(s).
c) Report a critical low blood glucose result for one of 30 patients (Patient 5) to DO. Refer A395

The cumulative effect of these systemic practices resulted in the failure of the hospital to ensure the provision of health care services to meet the needs on the patients.

The Governing Body failed to ensure the Medical Staff fulfilled their responsibility to ensure the quality of care provided to patients when the hypoglycemia protocol was not in alignment with Centers for Disease Control and Prevention (National Health Agency) and American Diabetes guidelines for one of 30 sampled patients (Patient 5) with a blood glucose (sugar) level of 50 (normal blood glucose level 70 - 100 milligrams/deciliter [mg/dl]). This failure resulted in an unplanned transfer of Patient 5 by to a higher level of care and ultimate death.

Findings:

During a record review on Patient 5's Finger Stick record (FS measures blood sugar), dated 10/19/2023, was reviewed. The FS indicated the following blood glucose levels:
3:49 p.m., Patient 5's glucose level was 50 (low) mg/dl.
4:11 p.m. Patient 5's glucose level was 54 (low) mg/dl.
4:52 p.m. Patient 5's glucose level was 47 (critical low) mg/dl.
5:06 p.m. Patient 5's glucose level was 49 (critical low) mg/dl.
5:43 p.m. Patient 5's glucose level was 49 (critical low) mg/dl.
6:16 p.m. Patient 5's glucose level was 51 (low) mg/dl.
7:13 p.m. Patient 5's glucose level was 60 (low) mg/dl.
7:28 p.m. Patient 5's glucose level was 57 (low) mg/dl.

During a review of the facility provided Hypoglycemia Protocol, (undated), the Protocol indicated, "For patients that can take food orally or have a feeding tube, perform the following steps: 1. If blood glucose is less than 70, administer 1 tube of glucose gel, 4 oz. juice (apple if renal patient), or 8 oz. milk. 2. Re-check in 15-30 minutes. 3. If the blood glucose is still less than 70, repeat Step #1 ....5. Re-check in 15-30 minutes. 6. If blood glucose is still less than 70, call MD for further orders ..." The P&P did not indicate a procedure for blood glucose less than 55 mg/dl.

During a review of the American Diabetes Association's peer-reviewed journal titled "Diabetes Care" volume 46, supplement 1, dated 1/23, the journal indicated "16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2023 ...The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted ...Among hospitalized patients, hyperglycemia, hypoglycemia, and glucose variability are associated with adverse outcomes, including increased morbidity and mortality (1). Careful management of people with diabetes during hospitalization has direct and immediate benefits ...Considerations on Admission High-quality hospital care for diabetes requires standards for care delivery, which are best implemented using structured order sets and quality improvement strategies for process improvement ...Where feasible, there should be structured order sets that provide computerized guidance for glycemic management ...Hypoglycemia in hospitalized patients is categorized by blood glucose concentration and clinical correlates [connections]. Level 1 hypoglycemia is defined as a glucose concentration of 54-[to]70 mg/dL (3.0-3.9 mmol/L). Level 2 hypoglycemia is defined as a blood glucose concentration <[less than]54 mg/dL (3.0 mmol/L), which is typically the threshold for neuroglycopenic symptoms [brain deprivation of oxygen resulting in confusion, sensation of warmth, weakness or fatigue, severe cognitive failure, seizure, coma]. Level 3 hypoglycemia is defined as a clinical event characterized by altered mental and/or physical functioning that requires assistance from another person for recovery. Levels 2 and 3 require immediate correction of low blood glucose. Prompt treatment of level 1 hypoglycemia can prevent progression to more significant level 2 and level 3 hypoglycemia ..."

During a review of the American Diabetes Association document titled "Treatment & Care Hypoglycemia (Low Blood Glucose)," undated, the document indicated "Low blood glucose is when your blood glucose levels have fallen low enough that you need to take action to bring them back to your target range. This is usually when your blood glucose is less than 70 mg/dL...The 15-15 rule-have 15 grams of carbohydrate to raise your blood glucose and check it after 15 minutes. If it's still below 70 mg/dL, have another serving.
Repeat these steps until your blood glucose is at least 70 mg/dL. Once your blood glucose is back to normal, eat a meal or snack to make sure it doesn't lower again.
This may be:
Glucose tablets (see instructions)
Gel tube (see instructions)
4 ounces (1/2 cup) of juice or regular soda (not diet)
1 tablespoon of sugar, honey, or corn syrup...
When low blood glucose isn't treated and you need someone to help you recover, it is considered a severe event..."

During a review of the Centers for Disease Control and Preventions (National Health Agency) document titled "How To Treat Low Blood Sugar (Hypoglycemia)" dated 12/30/ 2022, the document indicated "For low blood sugar between 55-69 mg/dL, raise it by following the 15-15 rule: have 15 grams of carbs and check your blood sugar after 15 minutes. If it's still below your target range, have another serving. Repeat these steps until it's in your target range. Once it's in range, eat a nutritious meal or snack to ensure it doesn't get too low again ...Treating Severely Low Blood Sugar Blood sugar below 55 mg/dL is considered severely low. You won't be able to treat it using the 15-15 rule...Injectable glucagon is the best way to treat severely low blood sugar."

During a review of the Medical Staff By-laws dated 3/8/2023, the Medical Staff Bylaws indicated "Article 2: Mission of the Medical Staff; Responsibilities of the Medical Staff; and Responsibilities of Members...2.3 Policies and Procedures. The Medical Staff shall recommend to the Governing Body any and all policies and procedures necessary to promote the quality, safety, and appropriateness of patient care at the Hospital, including, but not limited to...review of clinical practice guidelines ..."

Based on interview and record review, the facility failed to ensure one of six physical rehabilitation physicians (Doctor of Osteopathy, DO, doctor emphasizing a whole-person approach to medicine) was privileged to interpret or analyze an Electrocardiogram (EKG test to record activity from the heart every time it beats) on one of 30 sampled patients (Patient 5). This failure had the potential for an inaccurate EKG interpretation.

Findings:

During a concurrent interview and record review on 4/16/24 at 10:44 am, with Medical Staff Coordinator, (MSC) Doctor of Osteopathy (DO, doctor emphasizing a whole-person approach to medicine) DO's Core Privileges were reviewed. MSC stated, DO's core privileges did not include interpretation of EKGs. MSC stated, DO's file did not indicate the Medical Staff granted DO privileges to interpret EKGs.

During a review of Patient 5's "Discharge Summary" dated 10/20/23, by DO, the Discharge summary indicated "[Patient 5] Admit Date 10/18/2023 ...During medication reconciliation [process of comparing patient's medication orders to all medications patient has been taking] it was noted that patient [Patient 5] was on several QT [heart rhythm disorder] prolonging medications. In light of this an EKG was ordered for the following morning to determine corrected QT interval ...I spoke with the nurse in the morning asking for the EKG however a paper copy was not available. The only scanned in copy available was a tracing without any header or QT information. QTc [heart rate corrected interval] was calculated to be grossly normal by review."

During a review of Patient 5's EKG dated 10/19/23, at 7:17 a.m. the EKG indicated, "** ** ACUTE MI ** ** Abnormal ECG."

During a review of an article titled "ACC/AHA [American College of Cardiology/American Heart Association] Clinical Competence Statement on Electrocardiography and Ambulatory Electrocardiography" in Circulation (a peer reviewed journal) Volume 104, Number 25, dated 12/17/2001, the Article indicated Electrocardiograms are interpreted by physicians in many specialties, including cardiology, internal medicine, family practice, and emergency medicine. Interpretative skills vary among specialists. The Institute for Clinical Evaluation (ICE) is a foundation of the American Board of Internal Medicine (ABIM) that offers certifying examinations in clinical skills. A physician in any specialty whose interpretations of ECGs contribute to clinical decision-making should have a sufficient knowledge base to make accurate diagnoses. An adequate knowledge base should include the ability to define, recognize, and understand the basic pathophysiology of certain electrocardiographic abnormalities. A competent ECG reader should also be able to recognize potential clinical diagnoses on the basis of ECGs. Although these clinical syndromes do not always produce a diagnostic ECG pattern, ECG interpreters should recognize the characteristic patterns. "Granting clinical staff privileges to physicians to interpret AECGs is one of the mechanisms used by hospitals to ensure quality of care."

During a review of the Medical Staff By-laws dated 3/8/2023, the Medical Staff Bylaws indicated "Article 4 Clinical Privileges 4.1 Exercise of Clinical Privileges. Each Practitioner providing healthcare services at the Hospital shall exercise only those Clinical Privileges specifically granted by the Governing Body. Clinical Privileges granted by the Governing Body must be within the scope of the Practitioner's license to practice in the State. Regardless of the Clinical Privileges granted, each Practitioner must obtain consultation when necessary for the safety of his or her patients ..."


47095


During a concurrent interview and record review on 4/16/24 at 3:46 p.m. with Chief Executive Officer (CEO), the document titled, DO's "Delineation of Privileges," dated 6/1/23- 9/29/23, was reviewed. The DO's "Delineation of Privileges" indicated, "Approved CORE PRIVILEGES Admit, evaluate, diagnose, consult and provide nonsurgical therapeutic treatment and rehabilitation to adolescent and adult patients. . . Core Privileges Include: Comprehensive assessment and recommendation of a diagnostic plan and/or prescription for treatment that may include the use of physical agents. . . and/or other medical interventions; comprehensive evaluation, prescription, and supervision of medical rehabilitation treatment and establishment of goals. This includes ordering physical, occupational and speech/language therapies." CEO stated the facility staff are "absolutely" expected to follow professional standards of practice and adhere to the facility's P&P's.

Attempted to contact DO for interview on 4/17/24 at 9:28 a.m., on 4/17/24, at 2:43 p.m., and on 4/18/24 at 11:44 a.m. DO did not return call for interview.

During a review of the facility P&P titled, "Electrocardiograms," dated 6/15/23, indicated, "PURPOSE To insure[sic] no cardiac compromise that could inhibit participation in the rehab programs. POLICY. . . EKGs must be formally interpreted by a physician privileged to read EKGs as part of his/her hospital privileging."

During a review of the Medical Staff By-laws, dated 3/8/2023, the Medical Staff Bylaws indicated, "Article 2: Mission of the Medical Staff; Responsibilities of the Medical Staff; and Responsibilities of Members...2.2.9 Credentialing. Credentials shall be processed in a manner that matches verified qualifications, performance, and competence with Clinical Privileges for all Applicants, and that ensures these individuals are licensed and meet other applicable standards required by State law. 2.2.10 Recommendations to the Governing Body. The Medical Staff, acting through the Medical Executive Committee, shall make recommendations directly to the Governing Body with respect to Medical Staff appointments, reappointments, Medical Staff categories, Clinical Privileges..."

Based on interview and record review the facility failed to ensure a Registered Nurse (RN) evaluated the care of one of 30 sampled patients (Patient 5) with a change of condition when:

1. RN did not report the "Electrocardiogram [EKG- a heart functioning test] for one of 30 patients (Patient 5) to Doctor of Osteopathy (DO, doctor emphasizing a whole-person approach to medicine).

2. RN did not follow facility hypoglycemia (low blood sugar) protocol to:
a) Immediately provide a source of glucose (sugar) during a hypoglycemic event for one of 30 patients (Patient 5) with low and critical low blood sugar level(s).
b) Monitor blood sugar levels every 15 to 30 minutes during a hypoglycemic event for one of 30 patients (Patient 5) with low and critical low blood sugar level(s).
c) Report a critical low blood glucose result for one of 30 patients (Patient 5) to DO.

These failures resulted in a delay in care, the hospital transferring Patient 5 to a higher level of care and may have contributed to Patient 5's ultimate death.

Findings:

1. During an interview on 4/11/24 at 9:36 a.m. with RN 3, RN 3 stated the facility EKG patient care process was for respiratory therapists (RT) to perform the EKG, provide the patient's EKG result to the RN, and the RN notified the physician. RN 3 stated for abnormal EKG's, nurses notify the doctor and document in the patient's medical record (MR) the doctor was notified. RN 3 stated complete documentation includes the date, time, patient condition and doctor notification.

During a concurrent interview and record review on 4/11/24 at 2:09 p.m. with Chief Nursing Officer (CNO), Patient 5's EKG dated 10/19/23, at 7:17 a.m. was reviewed. The EKG indicated, "** ** ACUTE MI ** ** Abnormal ECG." CNO stated, it was her expectation for the RN to telephone the physician if there was an abnormal EKG result. CNO stated there was no documentation in Patient 5's medical record indicating the RN notified the DO of Patient 5's abnormal EKG result at this time.

During a concurrent interview and record review on 4/11/24 at 3:08 p.m. with RT 1, Patient 5's EKG dated 10/19/23 time 7:17 a.m. was reviewed. The EKG indicated, "** ** ACUTE MI ** ** Abnormal ECG." RT 1 stated the facility EKG patient care process was for RT to perform the EKG and provide the RN with the EKG result. RT 1 stated she was unable to find documentation the nurse notified DO of Patient 5's EKG.

Attempted to contact DO for an interview on 4/17/24 at 9:28 a.m., on 4/17/24 at 2:43 p.m., and on 4/18/24 at 11:44 a.m. with no return call from DO for interview.

During a review of the Agency for Healthcare Research and Quality Case Study titled "Electrocardiogram Results" dated 11/1/12, the Case study indicated "Take-Home Points ...All ECGs [EKGs] should be shown to the nurse responsible for the patient. Any disturbing statement in the computer reading of the ECG should be referred to the attending physician for any action required ..."

During a review of the facility Policy and Procedure (P&P) titled, "Electrocardiograms," dated 6/15/23, the P&P indicated, "Give original to MD for review ...original print will be given to the Unit Secretary to be scanned ...and be filed ..."

2a) During an interview on 4/11/24 at 9:38 a.m. with RN 3, RN 3 stated, nurses must call the doctor when a patient's blood sugar was 50 milligrams per deciliter (mg/dl, normal blood sugar levels 70 mg/dl to 120 mg/dl). RN 3 stated, it was expected to notify the doctor when the patient condition changes, because the changes could be fast and unpredictable.

During a concurrent interview and record review on 4/11/24 at 2:40 p.m. with CNO, Patient 5's Doctor's PN, dated 10/19/23, at 8:06 p.m. was reviewed. The PN indicated, "I [DO] was called at 6:16pm[sic] for a reported BG [blood glucose] of 47." CNO stated DO's documentation indicated RN notification for Patient 5's critical low blood sugar of 47 performed at 4:52 p.m. was at 6:16 p.m. 1 hour and 20 minutes after RN 1 obtained the result.

During a concurrent interview and record review on 4/15/24, at 1:51 p.m., with Risk Manager (RM), Patient 5's "Flowsheet Lab View," dated 10/18/23 to 10/19/23 was reviewed. The Flowsheet indicated the following Point of Care (at bedside) glucose results on 10/19/2023, at:
3:49 p.m., Patient 5's glucose level was 50 (low) mg/dl.
4:11 p.m. Patient 5's glucose level was 54 (low) mg/dl.
4:52 p.m. Patient 5's glucose level was 47 (critical low) mg/dl.
5:06 p.m. Patient 5's glucose level was 49 (critical low) mg/dl.
5:43 p.m. Patient 5's glucose level was 49 (critical low) mg/dl.
6:16 p.m. Patient 5's glucose level was 51 (low) mg/dl.
7:13 p.m. Patient 5's glucose level was 60 (low) mg/dl.
7:28 p.m. Patient 5's glucose level was 57 (low) mg/dl.
RM stated the nurse called DO at 5:19 p.m. (17:19, approximately one and a half hours after Patient 5's low value of 50) and received an order for glucose (sugar) gel.

During a review of the facility P&P) titled "Critical Test Results," dated 9/29/2023, the P&P indicated To ensure effective communication to the responsible caregiver of diagnostic procedures and test results that can be critical to patient outcomes and to enable provision of timely, appropriate treatment to the patient ...1. Upon receipt of a critical value, the nurse will contact the physician immediately and report the critical test results to the physician. Time of receipt of critical value will be documented in the medical record ... Report of the critical value must occur within one hour of receipt ...3. The nurse (or RT) will then document physician notification of the critical value and record the time the critical value was reported to the physician ...Glucose LOW: Less Than 50 mg/dl ..."

2b) During a concurrent interview and record review on 4/15/24, at 1:51 p.m., with Risk Manager (RM), Patient 5's "Flowsheet Lab View," dated 10/18/23 to 10/19/23 was reviewed. The Flowsheet indicated on 10/19/2023, at 3:49 p.m., Patient 5's glucose level was 50 (low) milligrams per deciliter (mg/dl). RM stated there was no documentation nursing provided any oral intake to Resident 5 at 3:49 pm.
The Flowsheet indicated on 10/19/2023, at 4:11 p.m., Patient 5's glucose level was 54 (low) mg/dl. RM stated there was no documentation nursing provided any oral intake to Resident 5 at 4:11 pm.
The Flowsheet indicated on 10/19/2023, at 4:52 p.m., Patient 5's glucose level was 47 (critical low) mg/dl. RM stated there was no documentation nursing provided any interventions.
The Flowsheet indicated on 10/19/2023, at 5:06 p.m., Patient 5's glucose level was 49 (critical low) mg/dl. RM stated the bedside nurse called rapid response team (RRT, provides early, rapid interventions in order to prevent adverse events) overhead at 5:07 p.m. and DO was called at 5:19 p.m.
The Flowsheet indicated on 10/19/2023, at 5:43 p.m., Patient 5's glucose level was 49 (critical low) mg/dl. RM stated there was no documentation nursing provided any interventions.

During a concurrent interview and record review on 4/16/24 at 2:17 p.m. with RN 1, Patient 5's "Flowsheet Lab View", dated 10/18/23 to 10/19/23 was reviewed. RN 1 stated on 10/19/23, at 3:49 p.m. Patient 5's blood glucose was low. RN 1 stated on 10/19/23 at 5:19 p.m. she made the first call to DO regarding Patient 5's low and critical low blood sugar levels. RN 1 stated she should have contacted DO earlier. RN 1 stated she should have followed the hypoglycemia protocol.

During a review of the facility document titled "Hypoglycemia Protocol" undated, the Protocol indicated "1. If blood glucose is less than70[sic], administer 1 tube of glucose gel, 4 oz. [ounce] juice (apple if renal patient), 8 oz. skim milk 2. Re-check in 15-30 minutes. 3. If the blood glucose is still less than 70, repeat Step #1 ...6. If blood glucose is still less than 70[sic], call MD [doctor] for further orders."

2c) During a concurrent interview and record review on 4/15/24, at 1:51 p.m., with Risk Manager (RM), Patient 5's "Flowsheet Lab View," dated 10/18/23 to 10/19/23 was reviewed. The Flowsheet indicated on 10/19/2023, at 4:11 p.m. Patient 5's glucose level was L (low) 54 mg/dl. The Flowsheet indicated on 10/19/2023, at 4:52 p.m., Patient 5's glucose level was C (critical) 47 (critical low) mg/dl. RM stated the C indicated a critical value. RM stated there were 41 minutes between the two glucose level checks. RM stated the facility was not short staffed on 10/19/2023.
The Flowsheet indicated on 10/19/2023, at 6:16 p.m., Patient 5's glucose level was 51 (low) mg/dl. The Flowsheet indicated on 10/19/2023, at 7:13 p.m., Patient 5's glucose level was 60 (low) mg/dl. RM stated there were 58 minutes between the two glucose level checks.

During a concurrent interview and record review on 4/16/24 at 2:17 p.m., with RN 1, Patient 5's "Flowsheet Lab View", dated 10/18/23 to 10/19/23 was reviewed. The flowsheet indicated on 10/19/23 at 3:49 p.m., Patient 5's glucose level was 50 mg/dl. RN 1 stated no nursing interventions were documented addressing Patient 5's low glucose level of 50 mg/dl. RN 1 stated that no documentation indicated "not done." The flowsheet indicated on 10/19/23, at 4:11 p.m., Patient 5's glucose level was 54 (low) mg/dl. RN 1 stated there was no oral intake provided to Patient 5 at 4:11 p.m. The flowsheet indicated on 10/19/23, at 4:52 p.m., Patient 5's glucose level was 47 (critical low) mg/dl. RN 1 stated there were no interventions done. The flowsheet indicated on 10/19/23, at 5:06 p.m., Patient 5's glucose level was 49 (critical low) mg/dl. RN 1 stated DO was contacted with a rapid response at 5:07 p.m. one hour and 18 minutes from Patient 5's intial low glucose level of 50 mg/dl at 3:49 p.m. RN 1 stated, "The rapid [response] should have been called sooner." The flowsheet indicated on 10/19/23, at 5:43 p.m., Patient 5's glucose level was 49 (critical low) mg/dl. RN 1 stated Patient 5's continued low blood glucose lab results were a priority and the "nurse [was] responsible to review and call with critical [values and] contact the doctor." RN 1 stated she should have followed the hypoglycemia protocol and called DO for Patient 5's continued low blood sugar results.

During a concurrent interview and record review on 4/16/23 at 3:34 p.m., with RN 1, Patient 5's "MAR Summary", dated 10/19/23 was reviewed. The MAR summary indicated, "glucagon [a medication that increases blood sugar levels] 1 mg[milligram] @1830[6:30 p.m.]. RN 1 stated Patient 5's blood sugar was consistently low and was emergently sent out to the hospital. RN 1 stated there was no documentation indicating Patient 5's low blood sugar level had been treated from 6:30 p.m. to the arrival of EMS and Patient 1's transfer to the emergency department (ED) from the facility at 7:45 p.m.

During an interview on 4/16/24 at 4 p.m., with RM, RM stated the facility does not have a diabetic management policy and the facility policies go through corperate.

During a review of the facility document titled "Hypoglycemia Protocol" undated, the Protocol indicated "1. If blood glucose is less than70[sic], administer 1 tube of glucose gel, 4 oz. [ounce] juice (apple if renal patient), 8 oz. skim milk 2. Re-check in 15-30 minutes ...5. Re-check in 15-30 minutes."

During a review of the Centers for Disease Control and Preventions (National Health Agency) document titled "How To Treat Low Blood Sugar (Hypoglycemia)" dated 12/30/ 2022, the document indicated "For low blood sugar between 55-69 mg/dL, raise it by following the 15-15 rule: have 15 grams of carbs and check your blood sugar after 15 minutes. If it's still below your target range, have another serving. Repeat these steps until it's in your target range. Once it's in range, eat a nutritious meal or snack to ensure it doesn't get too low again ...Treating Severely Low Blood Sugar Blood sugar below 55 mg/dL is considered severely low. You won't be able to treat it using the 15-15 rule...Injectable glucagon is the best way to treat severely low blood sugar."

During an interview on 4/16/24 at 3:51 p.m. with Chief Executive Officer (CEO), CEO stated the facility staff are "absolutely" expected to follow professional standards of practice and adhere to the facility's P&P's.

During a review of Resident 1's "ED [Emergency department] Physician Note (EDN)," dated 10/19/2023, from Hospital 1, the "EDN" indicated, Chief complaint: unresponsive. History of present illness: This 64-year-old female (Patient 1), with a history of high blood pressure, diabetes mellitus, high cholesterol. (Patient 1 was unresponsive and found to be pulseless with a blood sugar of 56 mg/dl. EMS administered dextrose [sugar] en route, bringing Patient 1's blood sugar up to 96 mg/dl. Upon arrival at the ED, Patient 1's blood sugar had come down to 54 mg/dl, D50 (dextrose) administered. Patient 1 did not have a heartbeat (asystole), EMS performed CPR (cardiopulmonary resuscitation-an emergency lifesaving procedure) during transport...ED Course, Data, and Interventions: Patient arrived at the ED with CPR being carried out by EMS. No agonal breathing (gasping for air) or cardiopulmonary/neurological (brain) activities were observed upon arrival. Patient 1 was emergently intubated (tube inserted into airway/windpipe to deliver oxygen] with CPR still in progress. Patient 1 was subsequently shocked [the use of electrical current to help the heart return to a normal rhythm] out of V-Tach (Ventricular tachycardia- a heart rhythm problem caused by irregular electrical signals) IV (intravenous- in the vein) Amiodarone (a medication to prevent and treat a fast or irregular heartbeat) was administered, with return of a wrist pulse, and subsequent return to asystole. Three Successive ultrasound [a test that uses sound waves to make pictures of organs, tissues, and other structures inside the body] showed no cardiac activity. Patient 1 was pronounced expired [deceased] at 8:37 p.m.

During a review of Resident 1's "CERTIFICATE OF DEATH (COD)," dated 4/17/24, the COD indicated "CAUSE OF DEATH (A) CARDIOPULMONARY ARREST (heart stops beating) (B) KIDNEY FAILURE (kidneys are bean shaped organs found on the right and left side of the body that are responsible for filtering and removing waste, and controlling the body's fluid balance) (C) DIABETES MELLITUS TYPE 2, (7) DATE OF DEATH 10/19/2023, (8) HOUR 2027 [8:27 p.m.].

During a review of the facility P&P titled, "Plan for the Provision of Patient Care", dated 3/8/23, indicated, "Nursing Department ...Nursing care is provided through a team-nursing approach in which the Registered Nurse (RN) bears primary responsibility and accountability for nursing practice based on specialized knowledge, judgment, and skills ...The needs of each patient are assessed every shift and as needed, to determine the level of patient acuity."

Based on observation, interview, and record review, the facility failed to ensure one of 30 sampled patients (Patient 5) had an accurate and complete medical record. This failure had the potential to negatively affect the care of Patient 5.

Findings:

1. During a concurrent interview and record review on 4/11/24 at 2:09 p.m. with Chief Nursing Officer (CNO), Patient 5's EKG, dated 10/19/23 at 7:17 a.m. was reviewed. Patient 5's electrocardiogram (EKG or ECG, test to record activity from the heart every time it beats) indicated "** ** ACUTE MI ** ** Abnormal ECG." Patient 5's nursing documentation was reviewed. CNO stated there was no documentation nursing notified Doctor of Osteopathy (DO, doctor emphasizing a whole-person approach to medicine) of Patient 5's abnormal EKG result.

During a concurrent interview and record review on 4/11/24 at 3:08 p.m. with Respiratory Therapist (RT) 1, Patient 5's EKG, handwritten dated 10/19/23 and at 7:17 a.m. was reviewed. Patient 5's EKG indicated, "** ** ACUTE MI ** ** Abnormal ECG." RT 1 stated the facility EKG patient care process was for the RT to perform the EKG, place the patient identification label, then the RT initials, dates the printed EKG result (does not input the date or time into the machine) and provide the patient's RN the EKG result. RT 1 stated she "cannot find" documentation that Patient 5's EKG was provided to the Registered Nurse (RN) 1 and or the DO.

2. During a concurrent interview and record review on 4/11/24 at 3:08 p.m. with RT 1, Patient 5's EKG, handwritten dated 10/19/23 and at 7:17 a.m. was reviewed. RT 1 stated, the date indicated at the bottom of Patient 5's EKG was inaccurately dated January 1, 2001.

During a concurrent interview and record review on 4/15/24 at 12:38 p.m. with RT Supervisor (RTS), the facility 300 wing EKG machine's "test sheet" was reviewed. The "test sheet" printed date indicated "01. Jan.2001 00:00:09." RTS stated, "That's why all the RT [Respiratory Therapists] write it down [current date and time] and initial it." RTS stated the facility process is to strike out the incorrect date "01. Jan.2001 00:00:09" because it's not accurate.

During an observation and interview on 4/15/2024, at 12:40 pm with RT Supervisor, on the East Wing, the facilities second EKG machine (MAC 1200) had a Service Due Sticker dated 2/2025. RT Supervisor performed a test print. RT Supervisor stated the EKG test printed a run date of January 1, 2001, that was why the RT wrote the date of the EKG test on the strip. RT Supervisor stated, the RT staff did not enter any patient data into the machine, but instead would affix a patient label to the EKG strip. RT Supervisor stated, the printed time would not match the time written by the RT on the EKG strip.

During an observation, interview and record review, on 4/16/24, at 11:30 a.m., with RT Supervisor, in the 300 wing, RT Supervisor stated her former supervisor trained her on the EKG machine. RT Supervisor stated the default date on the EKG machine was not correct. The Manufacturer's Instructions for Use were reviewed. RT Supervisor stated the Instructions were provided to set the date and time. RT Supervisor stated she trained the RTs to black out the incorrect printed date on the EKG strip. RT Supervisor stated the patient's medical record should be correct and incorrect information should be blacked out.

During a review of Patient 5's "Discharge Summary" dated 10/20/23, by DO, the Discharge summary indicated "[Patient 5] Admit Date 10/18/2023 ...During medication reconciliation [process of comparing patient's medication orders to all medications patient has been taking] it was noted that patient [Patient 5] was on several QT [heart rhythm disorder] prolonging medications. In light of this an EKG was ordered for the following morning to determine corrected QT interval ...I [DO] spoke with the nurse in the morning asking for the EKG however a paper copy was not available. The only scanned in copy available was a tracing without any header or QT information. QTc [heart rate corrected interval] was calculated to be grossly normal by review."

During a review of the facility's P&P titled, "Electrocardiograms", dated 6/15/23, indicated, "PURPOSE To insure[sic] no cardiac compromise that could inhibit participation in the rehab programs. POLICY The respiratory therapist, nurse, or other technician with training and competency (as allowed by state) may perform EKGs. EKGs must be formally interpreted by a physician privileged to read EKGs as part of his/her hospital privileging. . . 7. Give original to MD for review. If requested the EKG to be read, the original print out will be given to the Unit Secretary to fax to the contracted cardiologist. . . If MD suggests that that[sic] the original prin[sic] out does not need to be read the original print out will be given to the Unit Secrestary [sic] to be scanned. . . and be filed in the patient's soft chart."

3. During a concurrent interview and record review on 4/11/24 at 2:40 p.m. with CNO, DO's Progress Notes for Patient 5, dated 10/19/23, at 8:06 p.m. was reviewed. The PN indicated, "I [DO] was called at 6:16pm[sic] for a reported BG [blood glucose] of 47." CNO stated there was no documentation nursing notified DO of Patient 5's critical low blood glucose level result of 47 on 10/19/23, at 4:52 p.m., prior to 6:16 p.m.

During a concurrent interview and record review on 4/15/24, at 1:51 p.m., with Risk Manager (RM), Patient 5's "Flowsheet Lab View," dated 10/18/23 to 10/19/23 was reviewed. The Flowsheet indicated the following Point of Care (at bedside) glucose results on 10/19/2023, at:
3:49 p.m., Patient 5's glucose level was 50 (low) mg/dl.
4:11 p.m. Patient 5's glucose level was 54 (low) mg/dl.
4:52 p.m. Patient 5's glucose level was 47 (critical low) mg/dl.
5:06 p.m. Patient 5's glucose level was 49 (critical low) mg/dl.
5:43 p.m. Patient 5's glucose level was 49 (critical low) mg/dl.
6:16 p.m. Patient 5's glucose level was 51 (low) mg/dl.
7:13 p.m. Patient 5's glucose level was 60 (low) mg/dl.
7:28 p.m. Patient 5's glucose level was 57 (low) mg/dl.
RM stated the nurse called DO at 5:19 p.m. (approximately one and a half hours after Patient 5's low value of 50).

During a concurrent interview and record review on 4/16/24 at 2:17 p.m. with RN 1, Patient 5's Medication Administration Record (MAR) Summary, dated 10/19/23 was reviewed. The "MAR Summary" indicated "glucagon [medication to increase blood sugar] 1 mg [milligram] @1830 [6:30 p.m.]." RN 1 stated there was no documentation indicating Patient 5's low blood sugar had been treated from 6:30 p.m. to the arrival of EMS and Patient 1's transfer to the emergency department (ED) from the facility at 7:45 p.m. RN 2 stated, no documentation means "that's not done."

During a review of Patient 5's "DC [discharge] Info/Summary," dated 10/20/23 at 12:23 p.m. the DC Info/Summary indicated "Hospital Course: Please refer to rapid response note. Patient was admitted to our [Hospital] service on 10/18/2023 ...Later that evening I was called during a rapid response for a blood sugar of 47. EMS was called and patient transported to [Hospital 2] ..."

During a review of the facility document titled "Hypoglycemia Protocol" undated, the Protocol indicated "1. If blood glucose is less than70[sic], administer 1 tube of glucose gel, 4 oz. [ounce] juice (apple if renal patient), 8 oz. skim milk 2. Re-check in 15-30 minutes. 3. If the blood glucose is still less than 70, repeat Step #1 ...6. If blood glucose is still less than 70[sic], call MD [doctor] for further orders ..."

During a review of the facility P&P titled "Critical Test Results," dated 9/29/2023, the P&P indicated To ensure effective communication to the responsible caregiver of diagnostic procedures and test results that can be critical to patient outcomes and to enable provision of timely, appropriate treatment to the patient ...1. Upon receipt of a critical value, the nurse will contact the physician immediately and report the critical test results to the physician. Time of receipt of critical value will be documented in the medical record ... Report of the critical value must occur within one hour of receipt ...3. The nurse (or RT) will then document physician notification of the critical value and record the time the critical value was reported to the physician ...Glucose LOW: Less Than 50 mg/dl ..."

4. During a review of Patient 5's "Flowsheet Lab View," dated 10/18/23 to 10/19/23 the Flowsheet indicated the following Point of Care (at bedside) glucose results on 10/19/2023, at:
3:49 p.m., Patient 5's glucose level was 50 (low) mg/dl.
4:11 p.m. Patient 5's glucose level was 54 (low) mg/dl.
4:52 p.m. Patient 5's glucose level was 47 (critical low) mg/dl.
5:06 p.m. Patient 5's glucose level was 49 (critical low) mg/dl.
5:43 p.m. Patient 5's glucose level was 49 (critical low) mg/dl.
6:16 p.m. Patient 5's glucose level was 51 (low) mg/dl.
7:13 p.m. Patient 5's glucose level was 60 (low) mg/dl.
7:28 p.m. Patient 5's glucose level was 57 (low) mg/dl

During a concurrent interview and record review on 4/16/24, at 3:39 p.m. with RN 1, Patient 5's "Acute Care Transfer" note dated 10/19/23, at 9:22 p.m. was reviewed. The "Acute Care Transfer" note indicated "19:25 [7:25 p.m.] HR 116, 73 % 02, BP [Blood Pressure] 12/63[sic]. . . 19:39[7:39 p.m.] Blood sugar was 91. RN 1 stated the blood sugar checks completed at the facility should be in Patient 5's lab results section and automatically uploads into the patient's MR. RN 1 stated, "We dock the glucometer and automatic upload even when turn off it uploads." RN 1 stated, she was not sure of where the additional blood sugar at 7:39 p.m. came from. RN 1 stated the documentation "should be there" (in Patient 5's lab results section).

5. During a concurrent interview and record review on 4/11/24 at 2:50 p.m. with CNO, Patient 5's "Progress Note (PN)," dated 10/19/23 at 7:16 p.m. was reviewed. The "PN" indicated, " PT [Patient 5] FOUND SWEATY, COLD CLAMMY, AND UNRESPONSIVE WITH SLIGHT AGONAL BREATHING. . . 911 CALLED. . . BEGAN PROVIDING RESCUE BREATHS. . . PT MOAN TO. . . STERNAL RUB. . . EMS [emergency medical services] ARRIVED. . . EMS LEFT WITH PATIENT [5]." CNO stated Patient 5's discharge was unplanned. CNO stated Patient 5's condition was unresponsive, low blood sugars with rescue breathing. CNO stated Patient 5 required an emergent transfer on 10/19/23 at 7:45 p.m.

During a review of Patient 5's "DC [discharge] Info/Summary," dated 10/20/23 at 12:23 p.m. the DC Info/Summary indicated "Hospital Course: Please refer to rapid response note. Patient was admitted to our [Hospital] service on 10/18/2023 ...Physical Exam on Discharge: General: Bag breathing, Heart: Regular Rate, Lungs: Non-labored ...Neuro: non-responsive ...Disposition: Discharge to Living Setting ...Patient was prepared for discharge with the appropriate follow-ups, medications and continued rehabilitation as ordered ...Condition at Discharge: Stable and improved ...Discharge instructions reviewed with patient and/or caregiver ...[electronic signature] DO Electronically Authenticated on 10/20/2023 12:23 PM."

Attempted to contact DO for an interview on 4/17/24 at 9:28 a.m. and 2:43 p.m., on 4/18/24 at 11:44 a.m. with no return call from DO for interview.

During an interview on 4/16/24 at 3:51 p.m. with Chief Executive Officer (CEO), CEO stated the facility staff are "absolutely" expected to follow professional standards of practice and adhere to the facility's P&P's.

During a review of the facility's P&P titled, "Plan for the Provision of Patient Care", dated 3/8/23, indicated, "Nursing Department. . . Nursing care is provided through a team-nursing approach in which the Registered Nurse (RN) bears primary responsibility and accountability for nursing practice based on specialized knowledge, judgment, and skills. . . The needs of each patient are assessed every shift and as needed, to determine the level of patient acuity."