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Based on medical record review, staff interview and review of Root Cause Analysis (RCA) Corrective Action Plan, the facility failed to incorporate active monitoring/tracking for 1 (Plan related to Patient 3) of 2 action plans reviewed. The facility was unable to measure the effectiveness of the plan and make changes if needed. The total sample was 22. The facility census was 86. The findings include:

A. Record review on 12/5/12 of the closed medical record for Patient 3 revealed the patient on 6/21/12 was found unresponsive by nursing staff and resuscitation was unsuccessful. Review of the nursing assessments and vital signs recorded in the medical record on 6/21/12 found nursing staff failed to monitor the patient's vital signs. Record review of the Operative Report dated 6/21/12 noted the patient had a bronchial scope procedure done with needle aspiration of multiple fluid pockets in the right lung and biopsy of the bronchial lining. The patient tolerated the procedure well under intravenous sedation and was stable in the immediate recovery phase on the 4200 unit. The last vital signs recorded by the recovery staff were at 3:45 PM prior to transfer to 5500. Review of nursing assessments noted the Registered Nurse (RN) A assessed the patient on 5500 unit at 4:18 PM RN A's assessment did not include vital signs. Review of the medical record revealed vital signs were not done after transfer to the 5500 unit.

B. Staff interview with RN A on 12/5/12 at 2:45 PM revealed problems with handoff communication between the 5500 RN and the 4200 RN. RN A related report on the patient's condition was not provided by the 4200 RN after transfer to the 5500 nursing unit. RN A stated the nursing assessment was completed 15 minutes after arrival on 5500. RN A stated the Certified Nursing Assistant (CNA) assigned to the patient was to do the vital signs every 1 hour times 4. RN A did not recall informing the assigned CNA the patient had returned from the procedure. The patient was observed by RN A eating dinner and in no distress around 5:15 -5:30 PM. According to RN A at shift change around 6:30 PM the CNA for the evening shift went in to do the vital signs and found the patient unresponsive. A code blue (hospital code called for a medical emergency in an unresponsive patient) was called but resuscitative efforts failed and the patient died on 6/21/12.

C. Record review of the undated facility RCA titled "Corrective Action Plan 14-2012 Unanticipated Death" related to Patient 3 revealed a problem with "Inadequate handoff". Measurement strategies included to: A. "Set standard for handoff communication for post procedure patients and educate staff to same. Standard is that each transferring area calls report to the next area directly." Date of implementation states "Completed 9/30/12." B. "Educate staff on SBAR [a standardized reporting guideline for communication between health care staff with S for situation, B for background, A for assessment including vital signs, R for recommendation] expectations. Date of Implementation "Completed 9/30/12." The facility was unable to provide any record of data collection to ensure the action plan was effective.

D. Staff interview with the Operations Director of Quality Management Services on 12/6/12 at 9:08 AM revealed that when the hospital ownership changed on 9/1/12 the facility was told all action plans were to stop as they belonged to the previous owner. The Director confirmed that the facility did not bring forward the action plan related to Patient 3 to include quality measures to ensure the effectiveness of the plan. The Director further related that as of 12/5/12 the facility developed an audit tool to monitor handoff communications and time to first vital signs. The audits started on 12/5/12 at 11:30 PM.