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The hospital must have an organized nursing service that provides 24-hour nursing services.

LTACH nursing staff failed coordinate the patient's care with the dialysis unit staff, when the patient demonstrated sign/symptoms of intolerance to the tube feedings, failed to collaborate with one another and promptly report the patient's deterioration to respiratory therapy and the treating physician.

The cumulative effect of these systemic failures and deficient practices resulted in the LTACH's inability to ensure adequate communication between interdisciplinary team members to meet the patient's needs. Please refer to A-396.

LTACH nursing staff failed to follow their policy regarding NG (nasal gastric) tube placement on admission of a patient.

The cumulative effect of these system failures and deficient practices resulted in the patient receiving NG tube feedings without the LTACH nursing staff verifying correct placement of the patient's NG tube putting the patient at risk for complications and death. Please refer to A-398.

I. Based on document review and staff interview the Long Term Acute Care Hospital (LTACH) administrative staff failed to ensure nursing staff followed LTACH policy and notified a physician that a patient receiving tube feedings had an emesis (vomited) for 1 of 5 patients reviewed (Patient #1). Failure to follow policy and notify a physician of patient's emesis resulted in a delayed intervention for Patient #1, which could have contributed to their cardiac and respiratory arrest and subsequent death. The LTACH reported an average daily census of 20 patients.

Findings include:

1. Review of "Gastric/Duodenal Tube Guidelines...", last revised 10/1/22, revealed in part, "...If symptoms of nausea, vomiting, diarrhea, abdominal cramping or distention occur [while patient receiving a tube feeding], stop the feeding and notify physician."

2. Review of Patient #1's medical record revealed:

On 11/11/22 at 6:09 AM, RN F observed Patient #1 vomit a large amount of yellow stomach contents. Patient #1's tube feeding was temporarily stopped and Patient #1 was given Zofran (anti-nausea medicine). RN F talked to RN A (who was the House Supervisor that night) to inquire if the tube feeding could be resumed and RN A agreed. RN F notified RN A that Patient #1 had confusion and desated (O2 dropped below normal) and required increased O2 and then titrate back down.

On 11/11/22 at 5:59 AM, RN A documented that it had been reported by RN F that Patient #1 had an emesis while RN F was in the room. RN F was able to orally suction 60 milliliters of undigested tube feeding. RN F decompressed Patient #1's stomach and released copious amount
of gas. Tube feedings were placed on hold until 7:00 AM.

Medical record did not contain any evidence that a physician had been notified that Patient #1 had a large emesis and their oxygen level had dropped.

On 11/11/22 at 7:12 AM, RN F documented they moved Patient #1 to the Dialysis Unit. Patient #1 was alert and oriented.

On 11/11/22 at 9:00 AM, Dialysis RN G documented that Patient #1 had been coughing constantly for the last 30 minutes. Dialysis RN G called the LTACH and spoke to RN H and was told to pause Patient #1's tube feedings.

On 11/11/22 at 10:00 AM, RN H came to flush Patient #1's NG and Patient #1 coughed up the saline flush. Patient #1 was still coughing constantly. RN H said would re-assess Patient #1 when they returned to the LTACH.

On 11/11/22 at 10:11 AM, dialysis treatment was completed.

On 11/11/22 at 11:00 AM, RN H noted Patient #1 had a small emesis after they returned to their room after dialysis. Patient #1 was coughing, vital signs were stable, and they did not complain of any pain. Tube feedings were held, ARNP I was notified of the emesis and the coughing episode (approximately 5 hours after Patient #1 had a large emesis and their oxygen level had dropped).

On 11/11/22 at 12:00 PM, Director of Quality Management D documented Patient #1 had increased coughing and decreased oxygen saturation. Patient #1's family member was at the bedside and requested removal of the NG because they felt it was aggravating Patient #1's sore throat and causing them to cough.

On 11/11/22 at 12:45 PM, Director of Quality Management D, Respiratory Therapist (RT) J, and ARNP I was at Patient #1's bedside when Patient #1 stopped breathing and had no pulse. CPR was initiated.

On 11/11/22 at 12:46 PM, Pulmonologist K (physician who specializes in the respiratory system) intubated (inserted breathing tube into the lungs) Patient #1. Pulmonologist K noted the following complication: Large amount of secretions/gastric content were aspirated from the oropharynx (generally oral cavity) during the procedure. Patient #1 likely had aspiration of these gastric contents into their airways. Pulmonologist K then performed a bronchoscopy (procedure that allows visualization of lungs and air passages) due to aspiration of the gastric contents and need for airway clearance. Patient #1 was noted to have a small to moderate quantity of secretions/gastric contents in the left and right mainstem and left and right lower lobe bronchi (areas of the lung) which were removed with suction.

Patient #1 was transferred to Hospital B ICU and died on 11/11/22 at 4:06 PM.

3. During an interview on 12/08/22 at 4:00 PM, RN F recalled that Patient #1 had a large emesis early in the morning on 11/11/22. RN F stated that RN A had called the on call physician to get
an order for some Zofran (anti-nausea medication).

4. During an interview on 12/8/22 at 10:30 AM, RN A recalled that Patient #2 had had approximately 100 milliliters of emesis with a residual (what was still left in the stomach) of roughly 50 milliliters. RN A stated they had called the on call provider twice that night and was told to keep monitoring Patient #1 and give them some Zofran.

5. During an interview on 12/9/22 at approximately 11:00 AM, Director of Quality Management L confirmed that the medical record did not contain any documentation that RN A had made a call to the on-call provider.

6. During an interview on 1/5/22 at 12:51 PM, the CNO and Director of Quality Management D revealed they were unable to obtain the call log to identify who the on call provider was on the night of 11/11/22 when Patient #1 had a large emesis.

7. During an interview on 1/4/23 at 4:00 PM, RN H remembered Patient #1 was receiving dialysis on the morning of 11/11/22 when she received a call from Dialysis RN G who said Patient #1 had been coughing. RN H told Dialysis RN G to pause Patient #1's tube feedings, they then went to the Dialysis Unit to pause it themselves because they were unsure if the Dialysis RN G knew how to use the LTACH's feeding pumps. RN H did not recall the exact time, thought it was more toward the end of the dialysis session. RN H also recalled flushing the NG tube when they paused the tube feedings, at that time Patient #1 was sitting up in bed, was not coughing, was not having difficulty breathing, and denied any pain. RN H was always concerned about aspiration but did not think it was an immediate concern. RN H did not notify DO B or ARNP I.

After returning to the floor, RN H received a second call from Dialysis RN G and was told Patient #1 had vomited the fluid from the flush that RN H had recently placed in the NG. RN H relayed this information to Director of Quality Management D and then shortly after that the dialysis session was finished and Patient #1 returned to the LTACH. Upon return, Patient #1 had another emesis and RN H notified ARNP I.

8. During an interview on 12/8/22 at 11:00 AM, Director of Quality Management D recalled working as the charge nurse on 11/11/22, knew RN H had gone to the Dialysis Unit to stop NG tube feedings, had said to tell Dialysis RN to call their physician if patient required assistance. Patient #1 had returned from dialysis around 10:45 AM, at around 11:00 or 11:15 AM Director of Quality Management D was notified that Patient #1 was coughing, couldn't catch their breath, and their oxygen level was dropping. Respiratory Therapist (RT) J came and increased Patient # 1's oxygen, ARNP I was notified and had ordered an x-ray. Patient #1's NG was removed at the request of a family member but that did not help Patient #1's cough. Director of Quality Management D, RT J and ARNP I remained in Patient #1's room and around 12:15 PM Patient # 1 was coughing, their heart rate dropped, and then they had no pulse. They started CPR and called a code (an alert for a patient who has had a cardiac or respiratory arrest). Patient #1's pulse returned within a minute or so, Pulmonologist K was the physician who responded and intubated Patient #1.

9. During an interview on 1/4/23 at 11:30 AM, ARNP I had cared for Patient #1 and stated that things were going well based on ARNP I's assessments of Patient #1. ARNP I was notified that
Patient #1 was coughing when Patient #1 returned from dialysis, ARNP I gave an order to stop the tube feedings and get a chest x-ray. ARNP I did not know if the tube feedings were running at that time. On examination Patient #1 could follow commands, and their cough was better. NG had been removed per family request. ARNP I was probably in the room 10-15 minutes before Patient #1 arrested. CPR was immediately started, literally seconds before pulse returned and Pulmonologist K came to intubate Patient #1.

ARNP I confirmed that they were not made aware that Patient #1 had vomited earlier that morning on 11/11/22, explained that had they known that Patient #1 had vomited, they would have gotten an x-ray earlier that morning. ARNP I did not get the results until after Patient #1 had passed away but had ARNP I had those results they would have begun a workup for aspiration pneumonia.

10. During an interview on 1/4/23 at 12:30 PM, RT J recalled that Patient #1 had been on low oxygen and had not had a lot of respiratory therapy involvement in her care. On 11/11/22 after returning from Dialysis Unit had been gagging and coughing, oxygen was dropping, thought it was related to coughing. NG had been removed at the family's request. RT J did increase the oxygen to see if that would be helpful. Patient #1's oxygen bounced back quickly. Recalled they were still trying to deduce what was causing this when Patient #1 arrested.

Patient #1 did have a large volume of emesis during CPR which RT J suctioned out. RT J had seen emesis many times during an arrest, explained that chest compressions and ambu breaths (forced air into the lungs) can cause air in the belly and pretty common to have vomiting. Patient #1's pulse returned prior to the arrival of Pulmonologist K, RT J assisted with the intubation and bronchoscopy. Patient #1 was then transferred to Hospital B.

11. During an interview on 12/08/22 at 1:00 PM, Pulmonologist K responded to the code and on arrival Patient #1 had a pulse but had agonal breathing (gasping for air due to low oxygen). Pulmonologist K intubated Patient #1 and noted there were gastric (stomach) contents in their airway, Pulmonologist K then did a bronchoscopy to remove any sort of residual gastric contents out of the airways. Pulmonologist K confirmed that Patient #1 had aspirated into their lungs what looked like gastric contents and tube feedings. Pulmonologist K explained that during CPR some air is instilled into the airways and stomach, and the aspiration could have happened then. Could not reliably say whether or not the aspiration had preceded the arrest or happened during the CPR.

12. During an interview on 12/08/22 at 1:30 PM, DO B described Patient #1, said had been treated for aspiration pneumonia while at Hospital A prior to the coming to the LTACH. Patient #1 had a feeding tube in place and was on tube feedings at 25 milliliters per hour (most people get 100 milliliters an hour). DO B thought Patient #1 did have another single event of emesis (prior to 11/11/22), shared it not uncommon for patients as ill as Patient #1 to have an emesis, but DO B was not informed that Patient #1 had vomited the morning of the 11th prior to dialysis, and their oxygen saturation had dropped. In hindsight, DO B stated had they known they probably would have held the tube feedings until DO B had a chance to examine Patient #1.

DO B stated it was highly likely that Patient #1 had aspirated, but also noted that Patient #1 could have also aspirated during CPR chest compressions. DO B did not think there was anything done prior to Patient #1's cardiac arrest that would 100% prove that they aspirated. DO B knew ARNP I was aware after Patient #1 returned from dialysis and had stopped tube feedings and ordered a chest x-ray.




II. Based on documents review, and staff interviews the Long Term Acute Care Hospital (LTACH) failed to provide timely interventions to address persistent symptoms of a potential underlying problem for 1 of 1 patient (Patient #1) who underwent in-patient dialysis treatment on 11/11/22. The LTACH reported a weekly average of 10 dialysis treatments within the last 2 months.

Findings include:

1. On 1/12/23 at 2:30 PM, the Director of Quality Management (DQM) summarized the process for the care of patients undergoing dialysis treatments as follows, the facility's (floor unit) staff members will take the patients to the dialysis unit and give report to the receiving staff members. From there, the dialysis unit will assume care for the patients, and the floor unit's staff members should not be doing anything to the patients once they are handed over to the dialysis unit for dialysis treatments. The DQM stated that the floor unit's staff members can go and "visualize" the patients at the dialysis unit but not care for them.

The DQM said that on 11/11/22, the floor unit's night registered nurse (identified as RN F) noted Patient #1 to have had symptoms of vomiting and Oxygen desaturation in the early morning. The DQM said that the symptoms were reported to the provider, who gave an "OK" to proceed with dialysis. The DQM also said RN F took Patient #1 to the dialysis unit, and reported symptoms to the dialysis unit's staff member. The DQM said expectations for the dialysis unit's staff members to call the provider for concerns related to Patient #1's symptoms while in the dialysis unit.

2. On 1/12/23 at about 2:42 PM, the Chief Nursing Officer (CNO) provided documents that showed Patient #1's care transitions to and from the dialysis unit, and intradialytic assessments and interventions for Patient #1's signs and symptoms of discomfort, as follows:

The nurses' notes (RN F) dated 11/11/22 at 7:12 AM, indicating Patient #1 with Oxygen at 4 liters per minute, was transported to the dialysis unit via hospital bed, and that prior episode of desaturation was reported to the dialysis nurse.

Patient #1's dialysis treatment flow sheet titled, "FRESENIUS KIDNEY CARE FMS INPATIENT SERVICES DIALYSIS TREATMENT SUMMARY" dated 11/11/22, showed the
following:

-At 6:47 AM, pre-treatment handoff, where RN G (dialysis nurse) received report from RN F (floor nurse);

-At 6:57 AM, RN G documented, Patient #1's pre- treatment assessment noted, "moaning and not alert" and "obtunded" (diminished response) level of consciousness;

-At 7:07 AM, Patient #1's dialysis treatment started;


-At 9:00 AM, RN G noted that Patient #1 had "non-stop" coughing for the last 30 minutes (since 8:30 AM), and reported it to RN H (floor unit nurse). RN G also noted that the tube feeding was "paused" per advice from RN H;

-At 9:30 AM, RN G's note indicated that RN H went to the dialysis unit and flushed the tube feeding; RN G's note also indicated that the liquid flush was "coughed up" and Patient #1 continued to cough constantly; RN G further noted that RN H "will assess once pt [patient] returns to floor." and

-At 10:11 AM, the post-treatment assessment indicated that Patient #1's level of consciousness as "obtunded" and moaning and not alert.

-The post treatment handoff lacked information whether or not a report was given, time of report, and who gave the report.

The nurses' notes (RN H) also showed that on 11/11/22 at 11:00 AM, Patient #1 returned to the floor unit and "vomited a small amount of emesis upon returning to her room." The nurses' notes further showed that Patient # 1 demonstrated "some coughing" and the provider was then notified about the emesis and the coughing episode.

3. During an interview on 1/12/23 at 3:08 PM, the Program Manager Acute Dialysis (PMAD), stated that patients coming from the floor to the dialysis unit for treatments are sick, and expectedly symptomatic. The PMAD also stated that the dialysis unit staff members do not call the nephrologist for notification of a problem that was not dialysis-related. The PMAD further stated expectations that dialysis staff members report and collaborate with the floor staff members any assessments or problems that were not dialysis-related such as Patient #1's continuous coughing and issues with tube feeding while on dialysis.

When clarified if floor nurses can do care in the dialysis unit, the PMAD retorted, "Why not? They do that all the time." The PMAD added that the dialysis unit was only to provide dialysis services and the floor unit staff members to do the rest, including provider notifications if needed.

4. On 1/12/23 at about 3:18 PM, the DQM, who was also in the room during the interview with PMAD, stated that there was a lack in RN H's notes to show about going to the dialysis unit to flush Patient #1's feeding tube. The DQM said, "[RN H] did not document, so I don't know." The DQM further said that floor nurses were not supposed to be caring for patients in the dialysis unit.

5. On 1/12/23 at about 3:48 PM, the Interim DQM and the Chief Executive Officer (CEO), who were also in the room during the interviews, acknowledged the importance of clear guidelines regarding assignments, tasks, and roles of staff members between the two units (floor unit and the dialysis unit), in order to implement effective action plans to address patients' problems in a timely manner.

6. On 1/18/23 at 9:30 AM, RN G acknowledged caring for Patient #1 at the dialysis unit on 11/11/22. RN G verified documentation that Patient #1 had constant coughing during dialysis on 11/11/22. RN G said, "I called the floor nurse who said to turn off the feeding, so I did. The floor nurse came to flush the feeding tube, but [Patient #1] coughed up the flush. I called the floor nurse again, [who] said will assess when [Patient #1] is back because it was towards the end of treatment." When asked who to be notified regarding abnormal or unusual assessments for
patients on dialysis, RN G replied that it would be communicated to the "correct specialty" involved in the care of the patient. RN G said they would notify and take orders from the nephrologist, but that "on a dialysis standpoint, Patient #1 was stable." RN G said that Patient # 1's coughing was reported to the floor nurse to manage the feeding tube.

7. On 1/18/23 at 9:44 AM, the PMAD stated that although they work for the facility, they are not employees of the facility, and also stated the importance of clearly specified lines on what the staff members of each unit can and cannot do.

I. Based on document review and staff interview, the Long Term Acute Care Hospital (LTACH) administrative staff failed to ensure nursing staff followed LTACH policy to confirm appropriate placement of the nasogastric (NG -- tube that goes through the nose into the stomach) with an x- ray for 1 of 5 patients reviewed (Patient #1). Failure to follow policy and confirm appropriate placement of the nasogastric (NG) tube with an x-ray could have resulted in Patient #1 aspirating (inhaling) stomach contents into their lungs which could have contributed to their cardiac and respiratory arrest and subsequent death. The LTACH reported an average daily census of 20 patients.

Findings include:

1. Review of "Gastric/Duodenal Tube Guidelines...", last revised 10/1/22, revealed in part, "...Upon admission...before instilling anything or beginning any feeding through the nasogastric...feeding tubes...placement must be confirmed via a radiograph (such as chest and/or abdominal xray) that visualizes the entire course of the tube...Radiograph must be ordered by physician..."

"...Verify that radiograph placement has been confirmed for nasogastric...feeding tubes...Do not use auscultatory (air bolus) ...to determine tube location..."

2. Review of Patient #1's medical record revealed:

On 11/8/22 at 12:00 AM, Patient #1 was admitted to the LTACH from Hospital A where they had been treated for bacterial endocarditis (life-threatening inflammation of the inner lining of the heart's chambers and valve) atrial fibrillation (irregular, and often rapid, heart beat), stroke, acute kidney failure, Type II diabetes, hypertension (high blood pressure), debility and dysphagia (difficulty swallowing). Patient #1 had also received a 14 course of antibiotics for presumed aspiration pneumonia, had an NG tube in place and was receiving tube feedings to provide additional nutrition.

On 11/8/22 at 2:02 AM, RN A received a verbal order from DO (Doctor of Osteopthic) B that Patient #1 may have tube feedings at 25 milliliters an hour.

Medical record lacked evidence that the LTACH had completed an x-ray to confirm placement of the NG tube prior to continuation of the tube feedings.

3. During an interview on 12/8/22 at 10:30 AM, RN A verified Patient #1 was admitted with an NG tube, stated it was in place and "bridled" (clamp that is used on NG tube so it does not move or slide). Patient #1 was receiving tube feedings. RN A shared they would start tube feedings on a newly admitted patient, without checking to see if placement had been confirmed by x-ray, if they could hear air sounds in the belly after they put air in the NG tube. RN A was aware of the policy but could not recall what it said specific to confirming placement of the NG.

4. During an interview on 12/8/222 at 10:00 AM, RN C recalled that Patient #1 was admitted with an NG tube and had been receiving tube feedings. RN C did not know if the placement had been verified on arrival, was not aware that LTACH policy required x-ray verification.

5. During an interview on 12/8/22 at 12:30 PM, DO B explained that Patient #1 had an x-ray to confirm NG placement when they were at Hospital A prior to coming to LTACH. DO B does not typically get another one to confirm placement if a patient has had the NG for awhile.

6. On 1/9/23 at 9:45 AM, Director of Quality Management D acknowledged that Patient #1's NG placement was not verified on admission with an x-ray as required by policy. Director of Quality Management D confirmed the reason for the x-ray was to confirm the NG tube was not dislodged during transport of the patient to the LTACH.