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Based on Record Review, Interviews, and policy review, the facility failed to provide the patients right to receive care in a safe setting for two (Patient #1, Patient #9) out of three patients sampled.

Findings include:

1) Patient #1, a sixty-eight-year-old male was admitted on February 1, 2025, for fever and influenza-like symptoms, with a medical history of type two Diabetes Mellitus (DMII), mood disorder, and back pain. The patient was placed in the Progressive Care Unit (PCU), where vital signs on 2/10/25, showed an elevated Heart Rate (HR) of 105-109 Beats Per Minute (bpm) and Blood Pressure (BP) 143/88 with an oxygen saturation at 90-95% on high-flow oxygen therapy. Starting a few hours prior to the patient coding the patient's status demonstrated a decline with vital signs trending down. There was no documentation within the medical record to indicate that the provider was notified. There was no documentation related to nursing assessment or reassessment in conjunction with the status change in condition. There was no documentation within the medical record to indicate any interventions were being provided during the patients decline in status until the patient was discovered unresponsive. On 2/11/25 at 5:27 AM, nursing staff found the patient unresponsive in Pulseless Electrical Activity (PEA), and a code blue was initiated with ACLS algorithms followed appropriately and the patient was intubated and had ROSC at 5:46 AM. The patient was transferred to the intensive care unit, but a second arrest occurred at 6:25 AM, and life-saving efforts were stopped at the family's request. On 2/11/25 at 6:28AM the patient expired. The discharge summary indicated the patient diagnoses were acute respiratory distress syndrome, Influenza B pneumonia, and non-ST-elevation myocardial infarction.

2) Patient #9, a fifty-four-year-old woman was admitted on June 13, 2025, for Diabetic Ketoacidosis (DKA, sepsis, Pneumonia (PNA), and Urinary Tract Infection (UTI), with a medical history of type two diabetes mellitus (DMII), cerebrovascular accident (CVA), atrial fibrillation (A-Fib), hypertension (HTN), and substance abuse. She was intubated in the intensive care unit on June 14, 2025, and transferred to PCU on June 17, 2025. A STAT post-procedure chest x-ray was ordered at 11:00 AM but delayed until 13:16 PM due to a competing order. The x-ray, signed at 14:10 PM, revealed near complete opacification of the right hemithorax with mediastinal shift, indicative of tension hemothorax. There was no documentation that the radiologist notified the nursing staff or physician of this critical result. Vital signs post-procedure showed a steady decline leading to the patient coding. There was no documentation indicating the patients decline was notified to the physician. There wasn't any assessment/reassessment noted during the decline despite critical findings of vital signs with decrease in heart rate, increase in respiratory rate, decrease in oxygen saturation. The medical record had vital signs listing a respiratory rate of 101 breaths per minute with no intervention, or physician notification. On 6/19/2025 at 4:42 PM Rapid Response was called to assess the patient. Rapid Response arrived at the patient's bedside at 4:44 PM and immediately called a code blue. Advanced Cardiac Life Support (ACLS) algorithms were appropriately followed and the patient Return of Spontaneous Circulation (ROSC). Patient #9 was transferred to the Intensive Care Unit (ICU). Ultimately, the family placed the patient on hospice and was terminally weaned on 6/20/2025. The patient expired on 6/20/25 at 7:15 PM.

On 8/12/25 at 2:30 PM an interview was conducted with the Patient Safety Coordinator Risk Specialist. She confirmed the abnormal vital signs that were documented and no indication that the critical abnormal vital signs were escalated to the physician, no nursing assessment/reassessment related to the change in condition.

On 8/13/25 at 10:15 AM an interview was conducted with Employee A, Registered Nurse. She confirmed she was the primary nurse for P#9 on the shift P#9 coded. She stated that she called the doctor about an elevated heart rate at the beginning of her shift and received an order for Cardizem. She was unable to articulate why documentation did not reflect that in the medical record. She was unable to articulate why several critical vital signs over the course of hours prior to the patient coding with no assessments or interventions documented.

A review of the facility policy titled "Patient Rights and Responsibilities, RI.0003" with a last revised date of August 2024, was conducted. On page 2 number 5 stated "A patient has the right to receive care in a safe setting (e.g., environmental safety, physical safety, and emotional safety.)

Based on Record Reviews, Interviews, and policy reviews, the facility failed to track, trend, analyze medical errors, adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital for two (Patient #1, Patient #9) out of three patients sampled.

Findings include:

1. Patient #1, a sixty-eight-year-old male was admitted on February 1, 2025, for fever and influenza-like symptoms, with a medical history of type two Diabetes Mellitus (DMII), mood disorder, and back pain. The patient was placed in the Progressive Care Unit (PCU), where vital signs on 2/10/25, showed an elevated Heart Rate (HR) of 105-109 Beats Per Minute (bpm) and Blood Pressure (BP) 143/88 with an oxygen saturation at 90-95% on high-flow oxygen therapy. Starting a few hours prior to the patient coding the patient's status demonstrated a decline with vital signs trending down. There was no documentation within the medical record to indicate that the provider was notified. There was no documentation related to nursing assessment or reassessment in conjunction with the status change in condition. There was no documentation within the medical record to indicate any interventions were being provided during the patients decline in status until the patient was discovered unresponsive. On 2/11/25 at 5:27 AM, nursing staff found the patient unresponsive in Pulseless Electrical Activity (PEA), and a code blue was initiated with ACLS algorithms followed appropriately and the patient was intubated and had ROSC at 5:46 AM. The patient was transferred to the intensive care unit, but a second arrest occurred at 6:25 AM, and life-saving efforts were stopped at the family's request. On 2/11/25 at 6:28AM the patient expired. The discharge summary indicated the patient diagnoses were acute respiratory distress syndrome, Influenza B pneumonia, and non-ST-elevation myocardial infarction.

2. Patient #9, a fifty-four-year-old woman was admitted on June 13, 2025, for Diabetic Ketoacidosis (DKA, sepsis, Pneumonia (PNA), and Urinary Tract Infection (UTI), with a medical history of type two diabetes mellitus (DMII), cerebrovascular accident (CVA), atrial fibrillation (A-Fib), hypertension (HTN), and substance abuse. She was intubated in the intensive care unit on June 14, 2025, and transferred to PCU on June 17, 2025. A STAT post-procedure chest x-ray was ordered at 11:00 AM but delayed until 13:16 PM due to a competing order. The x-ray, signed at 14:10 PM, revealed near complete opacification of the right hemithorax with mediastinal shift, indicative of tension hemothorax. There was no documentation that the radiologist notified the nursing staff or physician of this critical result. Vital signs post-procedure showed a steady decline leading to the patient coding. There was no documentation indicating the patients decline was notified to the physician. There wasn't any assessment/reassessment noted during the decline despite critical findings of vital signs with decrease in heart rate, increase in respiratory rate, decrease in oxygen saturation. The medical record had vital signs listing a respiratory rate of 101 breaths per minute with no intervention, or physician notification. On 6/19/2025 at 4:42 PM Rapid Response was called to assess the patient. Rapid Response arrived at the patient's bedside at 4:44 PM and immediately called a code blue. Advanced Cardiac Life Support (ACLS) algorithms were appropriately followed and the patient Return of Spontaneous Circulation (ROSC). Patient #9 was transferred to the Intensive Care Unit (ICU). Ultimately, the family placed the patient on hospice and was terminally weaned on 6/20/2025. The patient expired on 6/20/25 at 7:15 PM.

On 8/13/25 at 3:00 PM an interview was conducted with Director of Patient Safety and Quality. She confirmed that the adverse event for P#1 was not investigated due to the adverse event was not placed. When asked about redundancy plan for capturing fall outs, she stated there was no other means to identify adverse events outside of the facility adverse event reports system. When asked about P#9 and not discovering the patient decline in status with no interventions or notification to the physician, she stated that the Root Cause Analysis (RCA) team were focused on the radiology portion and did not go further. She confirmed that a thorough and complete record review should have been conducted.

A review of the facility "2025 Organizational Quality & Performance Improvement Plan" was conducted. Throughout the document indicated several times that adverse events must be tracked, trended, analyzed, reviewed, initiate performance improvement activities, evaluate, monitor progress, and prevent further risks and safety concerns.

Based on Record Reviews, Interviews, and policy reviews, the facility failed to ensure all practitioner's orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient's condition for two (Patient #1, Patient #9) of three patients sampled.

Findings include:

1. Patient #1, a sixty-eight-year-old male was admitted on February 1, 2025, for fever and influenza-like symptoms, with a medical history of type two Diabetes Mellitus (DMII), mood disorder, and back pain. The patient was placed in the Progressive Care Unit (PCU), where vital signs on 2/10/25, showed an elevated Heart Rate (HR) of 105-109 Beats Per Minute (bpm) and Blood Pressure (BP) 143/88 with an oxygen saturation at 90-95% on high-flow oxygen therapy. Starting a few hours prior to the patient coding the patient's status demonstrated a decline with vital signs trending down. There was no documentation within the medical record to indicate that the provider was notified. There was no documentation related to nursing assessment or reassessment in conjunction with the status change in condition. There was no documentation within the medical record to indicate any interventions were being provided during the patients decline in status until the patient was discovered unresponsive. On 2/11/25 at 5:27 AM, nursing staff found the patient unresponsive in Pulseless Electrical Activity (PEA), and a code blue was initiated with ACLS algorithms followed appropriately and the patient was intubated and had ROSC at 5:46 AM. The patient was transferred to the intensive care unit, but a second arrest occurred at 6:25 AM, and life-saving efforts were stopped at the family's request. On 2/11/25 at 6:28AM the patient expired. The discharge summary indicated the patient diagnoses were acute respiratory distress syndrome, Influenza B pneumonia, and non-ST-elevation myocardial infarction.

2. Patient #9, a fifty-four-year-old woman was admitted on June 13, 2025, for Diabetic Ketoacidosis (DKA, sepsis, Pneumonia (PNA), and Urinary Tract Infection (UTI), with a medical history of type two diabetes mellitus (DMII), cerebrovascular accident (CVA), atrial fibrillation (A-Fib), hypertension (HTN), and substance abuse. She was intubated in the intensive care unit on June 14, 2025, and transferred to PCU on June 17, 2025. A STAT post-procedure chest x-ray was ordered at 11:00 AM but delayed until 13:16 PM due to a competing order. The x-ray, signed at 14:10 PM, revealed near complete opacification of the right hemithorax with mediastinal shift, indicative of tension hemothorax. There was no documentation that the radiologist notified the nursing staff or physician of this critical result. Vital signs post-procedure showed a steady decline leading to the patient coding. There was no documentation indicating the patients decline was notified to the physician. There wasn't any assessment/reassessment noted during the decline despite critical findings of vital signs with decrease in heart rate, increase in respiratory rate, decrease in oxygen saturation. The medical record had vital signs listing a respiratory rate of 101 breaths per minute with no intervention, or physician notification. On 6/19/2025 at 4:42 PM Rapid Response was called to assess the patient. Rapid Response arrived at the patient's bedside at 4:44 PM and immediately called a code blue. Advanced Cardiac Life Support (ACLS) algorithms were appropriately followed and the patient Return of Spontaneous Circulation (ROSC). Patient #9 was transferred to the Intensive Care Unit (ICU). Ultimately, the family placed the patient on hospice and was terminally weaned on 6/20/2025. The patient expired on 6/20/25 at 7:15 PM.

On 8/14/25 at 11:00 AM an interview was conducted with Director of Patient Safety and Quality. She confirmed the required elements of the medical records for P#1 and P#9 were not in the medical record.

A review of the facility policy titled "Clinical Documentation" with a last approved date of February 2025 was conducted. On pages 4-5 listed required nursing documentation and not elements were within the reviewed medical records of P#1 and P#9.