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Based on interview and record review, the facility failed to meet the condition of participation of Patient's Rights as evidenced by:

1. The facility failed to ensure that information about a proposed procedure was provided in a preferred language (Spanish) for one (1) of 51 sampled patients (Patient 36) when two (2) informed consents (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) were obtained without the use of language assistance services (mechanisms used to facilitate communication with individuals who do not speak English, those who have limited English proficiency, and those who are deaf or hard of hearing), in accordance with the facility's policy and procedure regarding the use of translation services and patient rights (a subset of human rights such as the right to be informed of the treatment plan).
This deficient practice violated Patient 36's right to receive effective communication in their preferred language (Spanish) to understand the information contained in the consent forms and make informed decisions about the proposed procedures. This deficient practice also had the potential to result in inappropriate treatments thus putting a patient's health at risk. (Refer to A-0129)

2.a. The facility failed to ensure staff recognized and respected the Patient Rights (the subset of human rights) for one (1) of 51 sampled patients (Patient 20), when Patient 20 was observed in bed without a blanket which exposed patient 20's private area, in accordance with the facility's policy and procedure regarding Patient Rights pertaining to considerate and respectful care and patient privacy. .

This deficient practice resulted in the violation of Patient 20's Patient Right to be treated with dignity and an acknowledgment Patient 20's value as an individual by staff providing care for Patient 20. (Refer to A-0143)

2.b. The facility failed to ensure one (1) of 51 sampled patients (Patient 24) was provided the physical privacy and respectful care due, in accordance with the facility's policy and procedure regarding Patient Rights pertaining to considerate and respectful care and Patient privacy, when Patient 24 was physically exposed to public view when Patient 24's privacy curtain was not drawn closed, and the room door was open during an administration of medication via Patient 24's gastrostomy tube (GT - A small tube inserted into the stomach through the abdomen).

This deficient practice had the potential to result in psychosocial harm to Patient 24, potentially affecting Patient 24's self-image and dignity, cause great embarrassment, and was a violation of Patient 24's personal privacy rights. (Refer to A-0143)

3. The facility failed to provide a safe setting and ensure call light (a button or cord placed next to patients' bed and in the bathroom allowing patients to alert hospital staff remotely of their need for help. When the button is pressed, a signal alerts staff at the nurse's station and staff can respond to such a call) was within patient reach and respond in a timely manner when call light was activated for five (5) of (51) sampled patients (Patients 3, 4, 12, 13, and 14), in accordance with the facility's policy and procedure regarding patient call devices, when:

3.a. Patient 3, who required a "Soft Touch (a pad specifically designed for patients with limited physical movement who are physically unable to operate a traditional call button system to summon aid)" call system due to all four extremities being amputated (surgical removal of a limb), did not have the call system within reach. This deficient practice compromised Patient 3's safety. Patient 3 was not able to summon help; Patient 3 may attempt to transfer or reposition herself and may lead to a fall (an unintentional event that results in the person coming to rest on the ground or another lower level) and sustaining injury. (Refer to A-0144)

3.b. Patient 4, who was connected to an intravenous pump (a medical device that delivers fluids, such as nutrients and medications, into the patient's vein), call device was not within Patient 4's reach and was found wedged between the side rail and the mattress. This deficient practice compromised Patient 4's safety, which may include experiencing discomfort or an adverse reaction to the IV (Intravenous, through the vein) medication but not being able to summon help. (Refer to A-0144)

3.c. Patient 12 had to wait for ten (10) minutes for nursing staff to go to his (Patient 12) room to check on him (Patient 12) after call light was activated. This deficient practice had resulted in Patient 12 suffering back pain, delay of care, and had the potential to put Patient 12 at risk for fall and a delay in responding to a medical emergency. (Refer to A-0144)

3.d. Patient 13's and Patient 14's call lights were found on the floor and on the wall, respectively. This deficient practice resulted in Patient 13 and Patient 14 not having the means to call for assistance. This deficient practice also had the potential to put both patients (Patients 13 and 14) at risk for fall and a delay in responding to a medical emergency. (Refer to A-0144)

4. The facility failed to provide a safe setting free of hazard to keep the continuous pulse oximetry machine (an electronic device connected to patient's finger to earlobe to monitor blood oxygen level and heart rate) away from oxygen source for one (1) of 51 sampled patients (Patient 11), when Patient 11's pulse oximetry machine was observed placed on top of the oxygen flow meter (oxygen source supplying oxygen for patients), in accordance with the standards of practice on patient safety pertaining to medical equipment. This deficient practice put Patient 11 in fire hazards danger and had the potential for Patient 11 to get hurt. (Refer to A-0144)

5. The facility failed ensure that patients are free from all forms of abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), when Registered Nurse (RN) 7 failed to report the alleged physical abuse of one (Patient 16) of 51 sampled patients, in accordance with the facility's abuse policy that consist of mechanisms/methods put into place for effective abuse protection which included reporting any incidents of abuse.

This deficient practice resulted in the facility not immediately taking the necessary steps to determine if the alleged physical abuse occurred and resulted in a delay in the investigation for the abuse allegation, which had the potential to put the patient (Patient 16) and other patients at risk for further abuse. (Refer to A-0145)

6. The facility failed to ensure one (1) of 51 sampled patients (Patient 25) remained free from inappropriate use of chemical restraints (a drug given to a person to control their behavior or restrict their movement) and maintained the right to remain unrestricted in the ability to function for daily activities, in accordance with the facility's policy and procedure regarding "Patient Rights and Responsibilities" as well as "Identification and Reporting of Chemical Restraints," when the facility (Facility 3) staff attempted to keep Patient 25 sedated and confined to her (Patient 25) bed by administering Ativan (medication given to make one feel calmer and has sedating effect [state of sleepiness]) 0.5 milligrams (mg, a unit of measurement) by mouth..

This deficient practice had the potential for Patient 25 to experience the reduced ability to function effectively, appropriately interact with others, and participate in her (Patient 25) own care due to being sedated (state of sleepiness). (Refer to A-0160)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe setting, potentially placing patients at risk for a delay in care and treatments, abuse, and/or death.

Based on interview and record review, the facility failed to meet the condition of participation of QAPI (Quality Assessment & Performance Improvement) as evidenced by:

1. The facility's Quality Assessment and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) committee failed to perform gathering and analyze the information on an unexpected and unusual death for one of 51 sampled patients (Patient 2) when Patient 2 passed away on 3/30/2024 at the facility (Facility 2) within 48 hours of admission, and to ensure there is documentation of an investigation of Patient 2's death for that Patient 2's condition change that was not addressed by staff and the physician was not notified, in accordance with the facility's policy and procedure regarding patient assessment and physician notification as well as the facility's QAPI plan regarding the facility's performance improvement and patient safety activities.

This deficient practice led to the reoccurrence of a second patient (Patient 32) change of condition that was not addressed by staff and the physician was not notified. (Refer to A-0286)

2. The facility's Quality Assessment and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) committee failed to implement an effective preventative measure to prevent the potential reoccurrence of physicians not being notified for patients' change of condition for one of 51 sampled patients (Patient 2), in accordance with the facility's policy and procedure regarding patient assessment and physician notification as well as the facility's QAPI plan regarding the facility's performance improvement and patient safety activities.

This deficient practice led to the reoccurrence of a second patient's (Patient 32) change in condition that was not reported to the physician resulting in Patient 32 being intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) and eventually passed away at Facility 1. (Refer to A-0286)

3. The facility's Quality Assessment and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) program committee failed to communicate to the Governing Body (responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) the event that led to Patient 2's death in which Patient 2's condition change was not recognized, and the physician was not notified, in accordance with the facility's QAPI plan regarding the facility's performance improvement and patient safety activities.

This deficient practice resulted in the lack of information dissemination and prevented all three facility campuses (Facility 1, 2, and 3 which are all part of the triad of facilities investigated) from analyzing data collected relating to Patient 2's death at Facility 2 to formulate a plan of correction to prevent another incident of a patient's condition change not being addressed. This resulted in a reoccurrence of a second incident when a second patient's (Patient 32) change in condition was not reported to the physician which led in Patient 32 being intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) and eventually passed away at Facility 1. (Refer to A-0308)

Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by:


1. The facility (Facility 2) failed to provide adequate number of licensed nursing staff (nurses who are registered nurses or licensed vocational nurses) for 34 patients in the Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit on 7/23/2024, in accordance with the facility's policy and procedure regarding provision of care and regulatory standards pertaining to staffing, when three of four sampled Registered Nurses (RN 15, 16, and 17) covered each other and cover the Licensed Vocational Nurses (LVN 3 and 4) for the thirty (30) minutes lunch break. Thus, leaving a RN with 8 or 9 patients to attend to while the other licensed staff was on lunch break.

This deficient practice had the potential to result in the Telemetry unit not having enough licensed nursing staff to respond to patients' care needs, cause delay of care and services and put patients' safety at risk. (Refer to A-0392)

2. The facility (Facility 1) failed to ensure adequate number of nursing staff, in accordance with regulatory standards regarding nurse-to-patient ratios (number of patients a licensed nurse can care for at one time) and safe patient care assignments, when three of five sampled Registered Nurses (RNs 23, 24, and 25) covered three (3) of three Licensed Vocational Nurses (LVNs 8, 9 and 10) for meal breaks (30 minutes lunch break) in two (2) of two sampled units (Medical Surgical unit [a hospital unit that provides care for long-term patients who are hospitalized for illness, surgery, testing, or observation] and Telemetry [a floor in a hospital where patients undergo continuous cardiac monitoring] unit), both units housing mixed medical surgical and telemetry patients. The nurse-to-patient ratio in both units was one RN and one LVN to nine (9) patients, one RN and one LVN to eight (8) patients, or one RN to four (4) patients. When covering meal breaks for LVNs, each RN assumed the care of all 9 or 8 patients, and/or additional 3or 4 patients aside from their own assigned 3, 4, or 5 patients.

This deficient practice had the potential to result in Medical Surgical and Telemetry areas not having enough licensed staff to respond to patients care needs, cause delay of care and services and put patients' safety at risk. (Refer to A-0392)

3. The facility failed to ensure one (1) of the 51 sampled patients (Patient 1), who had a nasal gastric tube (NGT, a tube that is inserted through the nose, down the throat, and into the stomach to provide nutrition), had a complete assessment, which included assessing the placement or position of the NGT, in accordance with the facility's policy and procedure regarding enteral feeding (use of a feeding tube to supply nutrients and fluids to the patient's body when the patient cannot safely chew or swallow). This deficient practice resulted in Patient 1 aspirating (when food, liquid, or other material enters a patient's airway and eventually the patient's lungs) a large number of feedings. This deficient practice also had the potential to result in serious health issues such as Pneumonia (lung infection). (Refer to A-0395)

4. The facility failed to ensure one (1) of 51 sampled patients (Patient 42) was monitored, evaluated, and cardiac [heart] activity changes was addressed, in accordance with the accepted standards of nursing practice and the facility's policy and procedure regarding Interdisciplinary Assessment and Reassessment. This deficient practice had the potential to result in delay of care and treatment for Patient 42, when Patient 42's increasing heart rate was not addressed in a timely manner, resulting in Patient 42 eventually being transferred to the intensive care unit (ICU, a unit in a hospital providing intensive care for critically ill or injured patients). (Refer to A-0395)

5. The facility failed to develop and implement a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for two (2) of 51 sampled patients (Patient 12 and 32), in accordance with the facility's policy and procedures regarding care plan development when:

5.a.There was no care plan developed to address Patient 12's back pain. This deficient practice resulted in ineffective pain management for patient 12 and Patient 12 suffering back pain. (Refer to A-0396)

5.b.There was no care plan for pneumonia (PNA, lung infection) developed for Patient 32. This deficient practice resulted in Patient 32's treatment and care goals not being met by not identifying the patient's needs and risks associated with PNA, such as hypoxemia (an abnormally low concentration of oxygen in the blood) and respiratory failure (a serious condition that makes it difficult to breathe on your own). (Refer to A-0396)

6. The facility failed to ensure nursing staff at facility 2 notified the physician (MD 2) regarding a change of condition for one (1) of 51 sampled patients (Patient 2), in accordance with the facility's policy and procedure regarding Reporting/Notification of a change of condition (a clinically important deviation from a patient's baseline health condition that without interventions may result in complications or death), when Registered Nurse (RN) 5 identified Patient 2 with urethra (duct [tube of the body] by which urine leave the body) and mouth bleeding on 3/29/2024 at 8 p.m. This deficient practice resulted in Patient 2's worsening bleed and Patient 2 was found unresponsive (unconscious, possibly dead or dying) with large amount of hemoptysis (coughing up blood) on 3/30/2024 at 3:02 p.m. (19 hours later). Patient 2 eventually passed away at 3:47 p.m. (within 48 hours of admission). (Refer to A-0398)

7. The facility failed to identify a change of condition (a clinically important deviation from a patient's baseline health condition that without interventions may result in complications or death) and notify the physician regarding a decline in vital signs (VS, measurements of the body's most basic functions, such as breathing rate, body temperature, pulse rate, and blood pressure) for one (1) of 51 sampled patients (Patient 32), in accordance with the facility's policy and procedure pertaining to Reporting/Notification of a change of condition . This deficient practice resulted in Patient 32's condition deterioration leading to emergency intubation (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their trachea [airway/windpipe]) to provide artificial ventilation (breathing). and may have possibly contributed to Patient 32's negative outcome (death). (Refer to A-0398)

8. The facility failed to perform and document a Venous Thromboembolism (VTE, a condition that occurs when a blood clot forms in a vein that carries blood back to the heart) Risk Assessment and need for therapy for one (1) of 51 sampled patients (Patient 32), in accordance with the facility's policy and procedure regarding Anticoagulation Management Program. This deficient practice had the potential to increase Patient 32's risk for VTE which can result in mortality (death) by not identifying Patient 32's need for anti-coagulation (treatment with anticoagulant [blood thinning] drugs to reduce the risk of the formation of blood clots) therapy. (Refer to A-0398)

9. The facility failed to obtain and document routine vital signs (VS, measurements of the body's basic functions, such as breathing, heart rate, and temperature) for one (1) of 51 sampled patients (Patient 32), as per physician's order and in accordance with the facility's policy and procedure regarding routine vital signs. This deficient practice had the potential for Patient 32's change of condition (a clinically important deviation from a patient's baseline health condition that without interventions may result in complications or death) to remain undetected and unmonitored, predisposing Patient 32 for negative outcomes such as clinical deterioration (physiological changes detected by monitoring vital signs) and or death. (Refer to A-0398)

10. The facility failed to label two (2) of two sampled glucose strips containing bottles (glucose [sugar] test strips are medical devices that come in protective, resealable bottles and are used to measure blood sugar levels) after opening to indicate the expiration date, as per manufacturer's instruction. This deficient practice had the potential to compromise the safety and wellbeing of the facility's patients if expired glucose test strips give inaccurate readings, which can be dangerous for patients such as those with diabetes (a disease that occurs when the blood sugar is too high) who use insulin [ (moves sugar from the bloodstream to the body's cells to produce energy) and adjust their dose of insulin based on their blood sugar level readings using the glucose test strips. (Refer to A-0398)

11. The facility failed to label a formula bag (a bag that contains a liquid nutritional formula that is fed directly into a patient's stomach or intestine through a feeding tube [medical device used to provide nourishment, fluids, and medications by bypassing oral intake]) hang date and time for one patient of 51 sampled patients (Patient 34), in accordance with the facility's policy and procedure regarding labeling enteral nutrition bags. This deficient practice had the potential to compromise Patient 34's wellbeing by being administered a contaminated formula if the formula exceeded recommended hang time of 24 hours. (Refer to A-0398)

12. The facility failed to ensure staff safely stored and secured a medication (Metoprolol tablet [medication to lower blood pressure]) for one of 51 sampled patients (Patient 24) prior to administration, in accordance with the facility's policy and procedure regarding Medication Management. The Medication (Metoprolol) was crushed and placed inside a pouch with no label and was left on top of a medication cart.
This deficient practice had the potential for the crushed medication in a pouch to be contaminated and administered to Patient 24 or taken by someone else for use, which may cause patient harm such as infection, etc. (A-0405)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on observation, interview, and record review, the facility failed to ensure that the Condition of Participation for Respiratory Services were followed as evidenced by failure to:

1. Ensure one (1) of 51 sampled patient's (Patient 1) oxygenation (the process of ensuring adequate levels of oxygen in the body) was reassessed following a critical result (test results that fall significantly outside the normal range and may represent life-threatening values even if from routine tests) of a prior arterial blood gas (ABG, a test to measure the balance of oxygen and carbon dioxide in the blood) and not following orders to collect a repeat arterial blood gas after placing Patient 1 on a higher level of oxygen therapy (BIPAP, Bilateral positive airway pressure oxygen therapy to aid in breathing), in accordance with the facility's (Facility 2) policy and procedure regarding Assessment and Reassessment of Respiratory Status (how well a patient is producing air exchange).

This deficient practice had the potential to delay treatment and compromise Patient 1's safety and putting Patient 1 at risk for unidentified hypoxemia (low oxygen levels) in which the new oxygen therapy was not working and the patient may continue to experience low oxygen levels despite being on increased oxygen therapy. (Refer to A-1160)

2. Ensure one (1) of 51 sampled patient's (Patient 7) pulse oximetry (device used to measure level of oxygen) alarm was set at a parameter (set limit) that follows the facility's (Facility 2) respiratory protocol or have a physician order for setting the oxygen level at which the pulse oximetry alarm will activate, in accordance with the facility's (Facility 2) policy and procedure regarding Oxygen Therapy Protocol.

This deficient practice poses a safety risk for Patient 7, including inadequate monitoring, unidentified low oxygen level, and may likely cause a delay in responses to critical changes in the patient's (Patient 7) respiratory condition. (Refer to A-1160)

3. Ensure one (1) of 51 sampled patient's (Patient 1) arterial blood gas (ABG, a test to measure the balance of oxygen and carbon dioxide in the blood) with a critical result (test results that fall significantly outside the normal range and may represent life-threatening values even if from routine tests) was run a second time to confirm result, in accordance with the facility's (Facility 2) policy and procedure regarding Documentation of Critical ABG (Arterial Blood Gas, a test to measure the balance of oxygen and carbon dioxide in the blood) Values.

This deficient practice placed Patient 1 at risk for unidentified deteriorating conditions, as the confirmation of the critical values that were not completed, may indicate life-threatening situations, and without confirmation of these results (ABG result), appropriate actions may not be taken, potentially leading to a life-threatening situation. (Refer to A-1162)

4. Ensure two (2) of the 42 sampled patients (Patients 6 and Patient 7) had written orders for the oxygen saturation (O2 Sats, a measure of the percentage of oxygen in a person's blood) parameter (set limits), in accordance with the facility's policy and procedure regarding Oxygen Therapy Protocol.

This deficient practice compromised Patient 6 and Patient 7's safety and quality of care; without established oxygen saturation parameters, staff may not monitor patients' oxygen levels effectively. Likewise, this absence of a written order regarding oxygen saturation parameter can lead to an insufficient assessment of the patient's respiratory status, potentially resulting in undetected respiratory deterioration for Patients 6 and 7. (Refer to A-1164)

The cumulative effect of these systemic practices resulted in the facility's inability to ensure the condition of participation for Respiratory Services was met.

Based on interview and record review, the facility's governing body (responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) failed to assume full legal responsibility for implementing and monitoring policies governing the facility's assessment and monitoring of patients by not ensuring nursing staff recognized when patients experienced a change of condition (a clinically important deviation from a patient's baseline health condition that without interventions may result in complications or death) and followed policy and procedure to notify the physician.

This deficient practice resulted in the reoccurrence of nursing staff failing to follow the facility's policy to ensure that when Patient 2 and Patient 32 had a change of condition, immediate intervention was implemented, and the physician was notified. This deficient practice also resulted in Patient 2 coding (cardiac arrest [absent or abnormal heart activity]) and eventually expired (died). Likewise, this deficient practice resulted in Patient 32 getting intubated (placement of a flexible plastic tube into the trachea to maintain an open airway).

Findings:

1. The first event occurred on 3/30/2024 with Patient 2. During a concurrent interview and record review on 7/23/2024 at 2:28 p.m. with the House Supervisor (HS) 2, Patient 2's "Nursing Assessment," dated from 3/28/2024 to 3/30/2024 was reviewed. The nursing assessment indicated on 3/28/2024, Patient 2 was admitted to the facility's (Facility 2's) telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit for pneumonia (lung infection).
On 3/29/2024 at 8 p.m., Registered Nurse (RN) 5 identified Patient 2 as having bleeding from urethra (duct by which urine leaves the body) and mouth. There was no notification to the physician for Patient 2's change of condition (a clinically important deviation from a patient's baseline health condition that without interventions may result in complications or death) regarding the bleeding.
On 3/30/2024 at 3:02 p.m., Patient 2 was found with an abrupt, large amount of hemoptysis (coughing up blood), ashen skin color (extremely pale color), and pupils already glazed, no blinking. The facility activated rapid response (a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration). House supervisor and resource nurse RN rushed with a crash cart (container carrying medicine and equipment for use in emergency resuscitations). On 3/30/2024 at 3:05 p.m., Code Blue (the hospital emergency code used to summon help when a patient is in need of resuscitation) was initiated, and cardio-pulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) started. Patient 2 passed away on 3/30/2024 at 3:47 p.m.

During an interview on 7/26/2024 at 11:05 a.m. with Director of Quality and Risk Management (DQM) 2, DQM 2 stated the following: Patient 2's death was unusual because Patient 2 was in the facility (Facility 2) for a short period of time (3/28/2024-3/30/2024). She (DQM 2) reviewed Patient 2's medical record but did not speak with the nursing staff who was involved. It was handled by the Director of Nursing at that time, and there was no record of the investigation available. There was concern with no documentation for physician notification of patient's (Patient 2) change of condition. The incident (involving Patient 2) was sent for peer review (medical peer review is a performance assessment to evaluate other physician's clinical performances), but the facility (Facility 2) did not perform a root cause analysis (RCA, the process of discovering the root causes of problems in order to identify an appropriate solution).

During an interview on 7/26/2024 at 12:15 p.m. with DQM 2, DQM 2 stated, "The patient's (Patient 2's) death was not brought up to the governing body (responsible for guiding the hospital's long-term goals and policies and assists with strategic planning and decision-making) because it was an isolated case." The DQM 2 further stated, "If it was found that one of the departments was at fault, it would be brought up to the governing body." DQM 2 confirmed that there was a reoccurrence of the incident where staff did not recognize a change in a patient condition with Patient 32 at Facility 1, and the DQM stated, "This is why we started the change in condition education."

During a concurrent interview and record review of the facility's Governing Body's Board Meeting minutes titled, "Governing Board Meeting," with the DQM 2, dated from March 2024 through 6/5/2024, the meeting minutes did not reflect documentation regarding the Governing Body's oversight to ensure that staff recognized when patients experienced a change in condition that staff follows policy and procedure to implement intervention and notify the physician. DMQ 2 stated, "Governing Body was not made aware of Patient 2's incident because it did not result in an unexpected death."

2. The second event occurred on 7/23/2024 with Patient 32. On 7/22/2024, at 8:15 p.m., Patient 32 was found tachypneic (a medical term that describes rapid, shallow breathing in adults) with audible crackles (sounds like bubbling, popping, or clicking noises, audible [heard] during inhalation [breathing in]) on room air. Patient 32's oxygen saturation level (a measure of the percentage of oxygen in a person's blood) was at 73% (normal oxygen saturation is 90 - 100 %) and Patient 32 was placed on supplemental oxygen delivered by a non-rebreather mask (NRM, a type of oxygen mask that gives a person a lot of oxygen, typically in an emergency).

During a concurrent interview and record review on 7/24/2024 at 10:20 a.m., with the Clinical Educator (CE), Patient 32's vitals flowsheet (record and track Patient's health vitals and other custom parameters), dated 7/22/2024 from 7:19 p.m. through 7/23/2024, 7:30 a.m., was reviewed. The flowsheet indicated there was no oxygen saturation rate and respiratory rate recorded. No documentation of the physician being notified of Patient 32's declining vital signs and continued increased respiratory rate was recorded in Patient 32's medical record. No additional records of assessment of Patient 32's oxygen saturation level was documented in the medical chart from 10:19 p.m. on 7/22/2024 through 7:30 a.m. on 7/23/2024. The CE reviewed and stated the physician should have been notified about Patient 32's oxygen saturation level that was at 73 %, and Patient 32 being tachypneic (a change in the patient's condition) as per facility's policy and procedures.

During a concurrent interview and record review on 7/23/2024 at 10:20 a.m., with the Clinical Educator (CE), Patient 32's medical record (MR) titled, "Change of Condition," dated 7/23/2024, at 7:30 a.m., was reviewed. The MR indicated on 7/23/2024, at 7:30 a.m., a respiratory therapist (RT) found Patient 32 on a nonrebreather mask, saturating 82%, with labored breathing (breathing that is difficult or impaired) and respirations of 30 BPM. A Rapid Response was called for Patient 32 at 7:53 a.m., followed by a transfer of Patient 32 to an intensive care unit (ICU, a unit in a hospital providing intensive care for critically ill or injured patients), where Patient 32 was intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) and eventually expired (died).

During an interview on 7/26/2024 at 12:15 p.m. with DQM 2, DQM 2 stated, "The patient's (Patient 2's) death was not brought up to the governing body (responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) because it was an isolated case." The DQM 2 further stated, "If it was found that one of the departments was at fault, it would be brought up to the governing body." DQM 2 confirmed that there was a reoccurrence of the incident where staff did not recognize a change in a patient condition with Patient 32 at Facility 1, and the DQM stated, "This is why we started the change in condition education."

During a concurrent interview and record review of the facility's Governing Body's Board Meeting minutes titled, "Governing Board Meeting," with the DQM 2, dated from March 2024 through 6/5/2024, the meeting minutes did not reflect documentation regarding the Governing Body's oversight to ensure that staff recognized when patients experienced a change in condition that staff follows policy and procedure to implement intervention and notify the physician. DMQ 2 stated, "Governing Body was not made aware of Patient 2's incident because it did not result in an unexpected death."

Based on interview and record review, the facility failed to ensure that information about a proposed procedure was provided in a preferred language (Spanish) for one (1) of 51 sampled patients (Patient 36) when two (2) informed consents (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) were obtained without the use of language assistance services (mechanisms used to facilitate communication with individuals who do not speak English, those who have limited English proficiency, and those who are deaf or hard of hearing), in accordance with the facility's policy and procedure regarding the use of translation services and patient rights (a subset of human rights such as the right to be informed of the treatment plan).

This deficient practice violated Patient 36's right to receive effective communication in their preferred language (Spanish) to understand the information contained in the consent forms and make informed decisions about the proposed procedures. This deficient practice also had the potential to result in inappropriate treatments thus putting a patient's health at risk.

Findings:

During a review of Patient 36's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 5/16/2024, the H&P indicated, Patient 36 was admitted to the facility (Facility 1) for continuation of care. The H&P further indicated, Patient 36 had past medical history (PMH, a record of information about a person's health) of chronic obstructive pulmonary disease (COPD, a common lung disease causing restricted airflow and breathing problems), congestive heart failure (CHF, a condition affecting the heart making it difficult for the heart to pump blood), atrial fibrillation,(Afib, a type of arrhythmia, or irregular heartbeat, that causes the heart to beat abnormally fast and irregularly), diabetes (a disease in which the body's ability to produce or respond to the hormone insulin [moves sugar from the bloodstream to the body's cells to produce energy] is impaired), chronic respiratory failure (a long-term condition that occurs when the lungs cannot exchange oxygen and carbon dioxide properly), and tracheostomy (a permanent opening in the neck that's surgically created to provide access to the trachea, or windpipe).

During a review of Patient 36's medical record (MR) titled, "Nursing Admission Assessment (a comprehensive evaluation of a patient's health when they are first admitted to a facility)," dated 5/16/2024, the MR indicated, Patient 36's preferred language was Spanish.

During a concurrent interview and record review on 7/25/2024, with the Patient Advocate/Employee Health Nurse (EHN 1), Patient 36's "Informed Consent for Dialysis," dated 5/16/2024, was reviewed. EHN 1 stated, the informed consent (permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits) for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) was obtained on 5/16/2024. EHN 1 reviewed the consent form and stated, the consent for Dialysis was provided in English form and contained no documentation of "Interpreter Certification (a section on the consent form, completed to indicate the consent information was presented to patient [Patient 36] in their primary language [Spanish])," filled out to indicate interpreter services were provided.

During an interview on 7/25/2024 at 11:21 a.m. with the EHN 1, the EHN1 stated, the facility shall provide translation services (mechanisms used to facilitate communication with individuals who do not speak English, those who have limited English proficiency, and those who are deaf or hard of hearing) to patients with limited English proficiency (individuals who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English). EHN 1 stated, the "Interpreter Certification" section on the consent form should contain the name and identification number (ID #) of the interpreter used.

During a concurrent interview and record review on 7/25/2024 at 11:21 a.m., with EHN 1, EHN 1 reviewed Patient 36's informed consent for a procedure called "Percutaneous Endoscopy-Gastrostomy (a procedure to surgically insert a feeding tube through the skin and into the stomach)," dated 6/13/2024. EHN 1 stated, the consent was obtained without documentation of using the interpreter services (mechanisms used to facilitate communication with individuals who do not speak English, those who have limited English proficiency, and those who are deaf or hard of hearing), and the section allocated for "Interpreter Certification" was left blank. EHN 1 stated, the facility provides interpretive and translation services by video and phone and the services should have been provided to Patient 36, when both consents (Informed Consent for Dialysis and Informed Consent for Percutaneous Endoscopy-Gastrostomy) were obtained from Patient 36.

During a review of the facility's policy and procedure (P&P) titled, "Translation Services," dated 6/2023, the P&P indicated, "The facility shall provide for communication with Limited English Proficient (LEP) persons, to provide them an equal opportunity to benefit from services and guarantee that information about services is communicated to LEP persons in languages they understand. The facility will provide interpretive service through Language Line service and not via individual facility's employees. When a translator is needed, they will contact the Language Line service by phone or video service, as appropriate."

During a review of the facility's policy and procedure (P&P) titled "Informed Consent," dated 6//2021, the P&P indicated, "Informed consent must be obtained at a time when the patient is fully capable of understanding the procedure so that he/she can make informed decision regarding consent. The patient should be given an opportunity to ask questions and to have them answered to the patient's satisfaction."

During a review of the facility's policy and procedure (P&P) titled "Patient Rights and Responsibilities," dated 6/2022, the P&P indicated, "The facility respects the rights of the patient, recognizes that each patient is an individual with unique health care needs ...Patients have the right to considerate and respectful care. Patients have the right to effective communication ... Patients have the right to make decisions regarding medical care and receive as much information about any proposed treatment or procedure as they may need to give informed consent or to refuse a course of treatment."

Based on observations interview and record review, the facility failed to:

1. Ensure staff recognized and respected the Patient Rights (the subset of human rights) for one (1) of 51 sampled patients (Patient 20), when Patient 20 was observed in bed without a blanket which exposed patient 20's private area, in accordance with the facility's policy and procedure regarding Patient Rights pertaining to considerate and respectful care and patient privacy.

This deficient practice resulted in the violation of Patient 20's Patient Right to be treated with dignity and an acknowledgment Patient 20's value as an individual by staff providing care for Patient 20.

2. Ensure one (1) of 51 sampled patients (Patient 24) was provided the physical privacy and respectful care due, in accordance with the facility's policy and procedure regarding Patient Rights pertaining to considerate and respectful care and Patient privacy, when Patient 24 was physically exposed to public view when Patient 24's privacy curtain was not drawn closed, and the room door was open during an administration of medication via Patient 24's gastrostomy tube (GT - A small tube inserted into the stomach through the abdomen).

This deficient practice had the potential to result in psychosocial harm to Patient 24, potentially affecting Patient 24's self-image and dignity, cause great embarrassment, and was a violation of Patient 24's personal privacy rights.

Findings:

1. During a review of Patient 20's "Face Sheet (FS, a document that gives a patient's information at a quick glance and includes the patient's name, date of birth, address, etc.)," dated 7/2024, the FS indicated Patient 20 was admitted to room 1, in the facility's (Facility 3) Intensive Care Unit (ICU, a unit in a hospital providing intensive care for critically ill or injured patients) on 6/25/2024 for Respiratory Failure (a serious condition that makes it difficult to breathe on your own).

During a review of Patient 20's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/2024, the H&P indicated the following: Patient 20 had a history of alcoholism (a severe form of alcohol abuse and involves the inability to manage drinking habits) and polysubstance abuse (when two or more drugs are taken together or within a short time period, either intentionally or unintentionally). Patient 20 was ventilator dependent (when a patient is unable to breathe independently and requires the use of a breathing device) and does not follow commands.

During a review of Patient 20's "Nurses Notes (NN)," dated 7/2024, the Nurses Notes indicated the following: Patient 20's Neurological Assessment (an evaluation of the brain and nervous system's [made up of the brain, spinal cord- a tube like structure that runs from the brain to the lower back, and the nerves] functioning) indicated Patient 20 needed orientation (awareness) to person, place, and time.

During a concurrent observation and interview on 7/23/2024 at 12:40 p.m. with Registered Nurse Educator (RNE) 1 in the Intensive Care Unit, room 1, Patient 20 was observed in bed without a blanket. Patient 20 was in bed with a small towel placed on Patient 20 but not covering his (Patient 20) private area. RNE1 stated the following: The small towel is not covering patient's (Patient 20) private area. I (RNE 1) will inform the assigned nurse to cover patient's (Patient 20) private area with blanket, patient needs to be provided with blanket to cover private area, part of patient's right (a subset of human rights) to have privacy.

During an observation on 7/23/2024 at 12:58 p.m., in the Intensive Care Unit (ICU), room 1, Registered Nurse Educator (RNE) 1 and Registered Nurse (RN) 9 were observed closing the curtain of ICU room 1 to cover Patient 20 with a blanket.

During an interview on 7/23/2024 at 1:13 p.m. with Registered Nurse (RN) 9, RN 9 stated the following: RN 9 confirmed Patient 20's private area was not fully cover with small towel. RN 9 and RN Educator (RNE 1) used blanket to cover patient's (Patient 20) private area instead. Patient 20 had the right to have privacy, should not expose patient's private area. Patient 20 was alert but not aware of situation, still need to cover patient's (Patient 20) private part and not expose it.

During an interview on 7/24/2024 at 9:14 a.m., with Registered Nurse Educator (RNE) 1, RNE 1 stated the following: "We have addressed to staff that privacy was not provided for Patient 20, not covered appropriately, the private area of Patient 20 should have been covered, staff were educated on patient rights." RNE 1 confirmed RN 9 did not follow policy of Patient Rights and Responsibilities.

During an interview on 7/24/2024 at 11:29 a.m. with the Director of Nursing (DON) 1, DON 1 stated the following: "Patient 20 had exposed private part in the Intensive Care Unit. Correct thing to do was to cover patient with blanket per patient's rights policy. We need to do education for the staff and immediate education was provided to ICU staff." DON 1 confirmed staff did not follow Patient Rights Policy.

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights & Responsibilities," dated 9/2022, the P&P indicated the following: " The hospital respects the rights of the patient, recognizes that each patient is an individual with unique health care needs, and because of the importance of respecting each patient's personal dignity, provides considerate, respectful care focused upon the patient's individual need. The hospital assists the patient in the exercise of his/her rights and informs the patient of any responsibility incumbent upon him/her in the exercise of those rights. This list shall include, but not be limited to, the following: You have the right to: Considerate and respectful care, and to be made comfortable."

2. During a review of Patient 24's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/22/2024, the "H&P" indicated, Patient 24 was admitted to the facility (Facility 3) on 7/22/2024 for tracheostomy (a tube placed into the neck to help a person breath) dislodge, and had medical diagnoses that included hypertension (elevated blood pressure), atrial fibrillation (A-fib - an irregular heart beat), heart failure (HF - when the heart is too weak or too stiff to pump blood), and subglottic/tracheal stenosis (narrowing of the airway).

During an observation on 7/23/2024 at 1:15 p.m. at the bedside in Patient 24's room, with the Wound Care Coordinator (WCC) standing at the doorway, Registered Nurse 8 (RN 8) entered Patient 24's room with prepared medication, pulled back Patient 24's privacy curtain and physically exposed Patient 24 to public view. As Patient 24's door remained in the open position, RN 8 proceeded to pull Patient 24's gown back to access Patient 24's GT (Gastrostomy tube, a small tube inserted into the stomach through the abdomen to give the prepared medication), as well as began to check Patient 24's GT placement.

During an interview on 7/23/2024 at 1:15 p.m. with RN 8, RN 8 stated he (RN 8) was expected to keep the curtain closed for the patient's privacy. RN 8 further said, it was not appropriate to open the curtain and violate Patient 24's privacy, because we (the facility staff) were supposed to protect the patient's (Patient 24) privacy.

During an interview on 7/23/2024 at 1:20 p.m. with the WCC, the WCC stated, during a procedure, the patient's curtain should be closed at all times for the patient's privacy.

During an interview on 7/24/2024 at 9:57 a.m. with the Director of Nursing Care Services (DNCS) 3, the DNCS 3 stated, to protect the patient's privacy during a procedure, it was expected for the nurse to pull the curtain closed, close the room door, inform the patient of any procedure about to be done, and check their identification (ID) band.

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," dated June 2022, the P&P indicated, " ... 11. patients have the right to personal privacy respected ... examination and treatment are confidential and should be conducted discreetly ... Privacy curtains will be used in semi-private rooms ..."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights & Responsibilities," dated 9/2022, the P&P indicated the following: " The hospital respects the rights of the patient, recognizes that each patient is an individual with unique health care needs, and because of the importance of respecting each patient's personal dignity, provides considerate, respectful care focused upon the patient's individual need. The hospital assists the patient in the exercise of his/her rights and informs the patient of any responsibility incumbent upon him/her in the exercise of those rights. This list shall include, but not be limited to, the following: You have the right to: Considerate and respectful care, and to be made comfortable."

Based on observation, interview and record review, the facility failed to:

1. Provide a safe setting and ensure call light (a button or cord placed next to patients' bed and in the bathroom allowing patients to alert hospital staff remotely of their need for help. When the button is pressed, a signal alerts staff at the nurse's station and staff can respond to such a call) was within reach and timely respond when call light was activated for five (5) of 51 sampled patients (Patients 3, 4, 12, 13, and 14), in accordance with the facility's policy and procedure regarding patient call devices, when:

1.a. Patient 3, who required a "Soft Touch (a pad specifically designed for patients with limited physical movement who are physically unable to operate a traditional call button system to summon aid)" call system due to all four extremities being amputated (surgical removal of a limb), did not have the call system within reach. This deficient practice compromised Patient 3's safety. Patient 3 was not able to summon help; Patient 3 may attempt to transfer or reposition herself and may lead to a fall (an unintentional event that results in the person coming to rest on the ground or another lower level) and sustaining injury.

1.b. Patient 4, who was connected to an intravenous pump (a medical device that delivers fluids, such as nutrients and medications, into the patient's vein), had a call device that was not within Patient 4's reach and call light was found wedged between the side rail and the mattress. This deficient practice compromised Patient 4's safety, which may include experiencing discomfort or an adverse reaction to the IV (Intravenous, through the vein) medication but not being able to summon help.


1.c. Patient 12 had to wait for ten (10) minutes for nursing staff to go to his (Patient 12) room to check on him (Patient 12) after call light was activated. This deficient practice had resulted in Patient 12 suffering back pain, delay of care, and had the potential to put Patient 12 at risk for fall and a delay in responding to a medical emergency.

1.d. Patient 13's and Patient 14's call lights were found on the floor and on the wall, respectively. This deficient practice resulted in Patient 13 and Patient 14 not having the means to call for assistance. This deficient practice also had the potential to put both patients (Patients 13 and 14) at risk for fall and a delay in responding to a medical emergency.

2. Provide a safe setting free of hazard to keep the continuous pulse oximetry machine (an electronic device connected to patient's finger to earlobe to monitor blood oxygen level and heart rate) away from oxygen source for one (1) of 51 sampled patients (Patient 11), when Patient 11's pulse oximetry machine was observed placed on top of the oxygen flow meter (oxygen source supplying oxygen for patients), in accordance with the standards of practice on patient safety pertaining to medical equipment. This deficient practice put Patient 11 in fire hazards danger and had the potential for Patient 11 to get hurt.

Findings:

1.a. During a review of Patient 3's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/23/2024, the H&P indicated Patient 3's medical history included bilateral hands and feet amputation secondary to gangrene (death of body tissue due to lack of blood flow or a serious infection) at another hospital and placed on IV (giving a drug or other substance through a needle or tube inserted into a vein) antibiotic (a medicine that inhibits the growth of or destroys microorganisms). The H&P further indicated Patient 3 was transferred to (Facility 2's name) for rehabilitation and wound care.

During a concurrent observation and interview on 7/23/2024 at 1:07 p.m. with the Director Nursing Care Services (DNCS) 2 in Patient 3' room, Patient 3 was observed as an amputee of all four limbs. Patient 3 did not have the "Soft Touch (a pad specifically designed for patients with limited physical movement who are physically unable to operate a traditional call button system to summon aid)," call system within reach. DNCS retrieved the soft touch call system behind Patient 3's bed board and laying on top of the IV pump. DNCS 2 stated, "It is important that the patient (Patient 3) have the soft touch pad at her reach as she is high risk for fall (an unintentional event that results in the person coming to rest on the ground or another lower level) and injuries. Nursing staff should clip the soft touch pad to the patient pillow or linen within the patient reach."

During an interview on 7/23/2024 at 1:35 p.m. with the Registered Nurse (RN) 3 outside of Patient 3's room, RN 3 stated, Patient 3 was assigned to the care of herself (RN 3) and her (RN 3) team, which included one licensed vocational nurse (LVN, an entry-level health care provider who is responsible for rendering basic nursing care), and one certified nursing assistant (CNA, a healthcare professional who provides basic care to patients under the supervision of a Registered Nurse). RN 3 said "The patient's (Patient 3's) call light (a button or cord placed next to patients' bed and in the bathroom allowing patients to alert hospital staff remotely of their need for help. When the button is pressed, a signal alerts staff at the nurse's station and staff can respond to such a call) should be within her reach as she is high fall risk." RN 3 further stated that during the huddle with her team of CNA and LVN, she (RN 3) will remind them to place the call light back after repositioning or cleaning the patient.

During a review of the facility's policy and procedure (P&P) titled, "CORE: Patient Call Devices," dated 6/2021, the P&P indicated, "Appropriate devices shall be available to help facilitate the communication for the patient's needs ...assure that there is a functional call light easily accessible by the patient ...secure the call light proximal to the patient and within easy reach ... when rounding/interacting with patient, staff shall verify that the patient's call device is easily accessible for use."

During a review of the facility's policy and procedure (P&P) titled, "CORE: Patient Rights and Responsibilities," dated 6/2023, the P&P indicated, "provide an environment that respects and protects the rights of patients and patients' families and conducts all activities related to care with primary concern for the values and dignity of patient ... The rights and responsibilities ... shall be protected and exercised for each patient and their family/ guardian at [the facility]."

1.b. During a review of Patient 4's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/23/2024, the H&P indicated Patient 4's past medical history included treatment at another facility for septic shock (a serious condition that occurs when a body-wide infection leads to dangerously low blood pressure). The H&P further indicated, "She (Patient 4) remains on IV (giving a drug or other substance through a needle or tube inserted into a vein) antibiotic (a medicine that inhibits the growth of or destroys microorganisms) ...transferred to (name of facility 2).

During a concurrent observation and interview on 7/23/2024 at 1:40 p.m. with the Director Nursing Care Services (DNCS) and Patient 4, observed Patient 4 had an IV catheter to the right arm which was connected to an IV pump. The call device (a button or cord placed next to patients' bed and in the bathroom allowing patients to alert hospital staff remotely of their need for help. When the button is pressed, a signal alerts staff at the nurse's station and staff can respond to such a call) was not found within Patient 4's reach. Patient 4 searched for the call device and stated, "I do not know where it is." DNCS searched for the call device and found the call device wedged in between the mattress and the bed's side rail. DNCS stated, "The patient call light should be within the patient reach for safety reason, and so the patient can call for assistance."

During a review of the facility's policy and procedure (P&P) titled, "CORE: Patient Call Devices," dated 6/2021, the P&P indicated, "Appropriate devices shall be available to help facilitate the communication for the patient's needs ...assure that there is a functional call light easily accessible by the patient ...secure the call light proximal to the patient and within easy reach ... when rounding/interacting with patient, staff shall verify that he patient's call device is easily accessible for use."

During a review of the facility's policy and procedure (P&P) titled, "CORE: Patient Rights and Responsibilities," dated 6/2023, the P&P indicated, "provide an environment that respects and protects the rights of patients and patients' families and conducts all activities related to care with primary concern for the values and dignity of patient ... The rights and responsibilities ...shall be protected and exercised for each patient and their family/ guardian at [the facility].

1.c. During a review of Patient 12's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/13/2024, the H&P indicated Patient 12 was admitted to the facility's (Facility 2's) Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit with diagnoses of sepsis (a body's overwhelming and life-threatening response to infection), pneumonia (lung infection), and end stage real disease (ESRD, a stage where the kidneys can no longer support the body's needs for waste removal and fluid balance). The H&P also indicated Patient 12 had back pain.

During a concurrent observation and interview on 7/23/2024 at 1:05 p.m. with the Infection Control (IP 2) in Patient 12's room, observed Patient 12 pressing call light (a button or cord placed next to patients' bed and in the bathroom allowing patients to alert hospital staff remotely of their need for help. When the button is pressed, a signal alerts staff at the nurse's station and staff can respond to such a call) for assistance for repositioning and back pain. Observed Patient 12 pressed call light again at 1:11 p.m. due to no staff coming into the room (Patient 12's room). Observed two (2) nursing staff came in to Patient 12's room at 1:15 p.m. IP 2 stated the goal was for staff to respond to call light as soon as possible. IP 2 stated Patient 12 waited for ten (10) minutes for staff to help him (Patient 12). IP 2 stated, "Ten (10) minutes was too long."

During an interview on 7/23/2024 at 1:35 p.m. with the Licensed Vocational Nurse (LVN) 3, LVN 3 stated the goal was for all staff including registered nurse (RN), licensed vocational nurse (LVN) and certified nursing assistant (CNA) to respond to call light within one to two minutes or as soon as possible. LVN 3 stated it was important to check on patients as soon as possible because it could be a medical emergency and patients could not talk and tell what happened sometimes.

During an interview on 7/23/2024 at 2:02 p.m. with the certified nursing assistant (CNA) 1, CNA 1 stated the goal was to be at the patient's room within five (5) minutes once a patient pressed the call light just in case there was an emergency. CNA 1 stated, "Ten (10) minutes was too long, anything could happen."

During an interview on 7/23/20024 at 2:36 p.m. with CNA 2, CNA 2 stated call light should be answered less than five (5) minutes because, "you never know what they (patients) need. It could be an emergency. Many patients here are on the ventilator (machines that move air in and out of the lungs for patients who cannot independently breathe) and cannot talk."

During an interview on 7/25/2024 at 11:59 a.m. with the House Supervisor (HS) 2, HS 2 stated all patients should have a call light so that they could call for assistance whenever they need. HS 2 stated the expectation was for staff to respond to call light as soon as possible. HS 2 stated ten minutes wait was too long because anything could happen to patients including putting patients at risk for falling (an unintentional event that results in the person coming to rest on the ground or another lower level) and putting patients' safety at risk for delay of response of a potential medical emergency.

During a review of the facility's policy and procedure (P&P) titled, "CORE: Patient Call Devices," dated 6/2021, the P&P indicated, "Appropriate devices shall be available to help facilitate the communication for the patient's needs ...assure that there is a functional call light easily accessible by the patient ...secure the call light proximal to the patient and within easy reach ... when rounding/interacting with patient, staff shall verify that he patient's call device is easily accessible for use."

During a review of the facility's policy and procedure (P&P) titled, "CORE: Patient Rights and Responsibilities," dated 6/2023, the P&P indicated, "provide an environment that respects and protects the rights of patients and patients' families and conducts all activities related to care with primary concern for the values and dignity of patient ... The rights and responsibilities ... shall be protected and exercised for each patient and their family/ guardian at [the facility]."

1.d. During a review of Patient 13's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/22/2024, the H&P indicated Patient 13 was admitted to the facility's (Facility 2's) Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) with diagnoses of pneumonia (lung infection), respiratory failure (condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (deficiency in the amount of oxygen reaching the tissues), ventilator (an appliance for artificial respiration) dependent with status post tracheostomy (an artificial opening through the neck usually for the relief of difficulty in breathing), and dysphagia (difficulty swallowing) status post gastrostomy (an artificial external opening into the stomach for nutritional and medication administration).

During a concurrent observation and interview on 7/23/2024 at 2:06 p.m. with the Registered Nurse (RN) 18 in Patient 13's room in the ICU, observed a call light (a button or cord placed next to patients' bed and in the bathroom allowing patients to alert hospital staff remotely of their need for help. When the button is pressed, a signal alerts staff at the nurse's station and staff can respond to such a call) on the floor next to Patient 13's bed. RN 18 stated the following: the call light should not be on the floor. The call light should be next to Patient 13. Without the call light, Patient 13 could not call for help.

During an interview on 7/23/20024 at 2:36 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated call light should be answered less than five (5) minutes because, "you never know what they (patients) need. It could be an emergency. Many patients here are on the ventilator and cannot talk."

During an interview on 7/25/2024 at 11:59 a.m. with the House Supervisor (HS) 2, HS 2 stated all patients should have a call light so that they could call for assistance whenever they need. HS 2 stated the expectation was for staff to respond to call light as soon as possible. HS 2 stated ten minutes wait was too long because anything could happen to patients including putting patients at risk for fall (an unintentional event that results in the person coming to rest on the ground or another lower level) and putting patients' safety at risk for delay of response of a potential medical emergency.

During a review of the facility's policy and procedure (P&P) titled, "CORE: Patient Call Devices," dated 6/2021, the P&P indicated, "Appropriate devices shall be available to help facilitate the communication for the patient's needs ...assure that there is a functional call light easily accessible by the patient ...secure the call light proximal to the patient and within easy reach ... when rounding/interacting with patient, staff shall verify that he patient's call device is easily accessible for use."

During a review of the facility's policy and procedure (P&P) titled, "CORE: Patient Rights and Responsibilities," dated 6/2023, the P&P indicated, "provide an environment that respects and protects the rights of patients and patients' families and conducts all activities related to care with primary concern for the values and dignity of patient ... The rights and responsibilities ... shall be protected and exercised for each patient and their family/ guardian at [the facility]."

1.e. During a review of Patient 14's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/9/2024, the H&P indicated Patient 14 was admitted to the facility's (Facility 2's) Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) with diagnoses of pneumonia (lung infection), respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) with ventilator (an appliance for artificial respiration) dependent and atrial fibrillation (an irregular, often rapid heart rate that can cause poor blood flow, leading to blood clots, stroke, or heart failure).

During a concurrent observation and interview on 7/23/2024 at 2:25 p.m. with Registered Nurse (RN) 14 in Patient 14's bed in ICU, observed Patient 14 with a family member at bedside and the call light (a button or cord placed next to patients' bed and in the bathroom allowing patients to alert hospital staff remotely of their need for help. When the button is pressed, a signal alerts staff at the nurse's station and staff can respond to such a call) was hanging on the wall. RN 14 stated the call light should be next to Patient 14 so family member could use it as well if they (Patient 14 and family member) needed help.

During an interview on 7/23/20024 at 2:36 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated call light should be answered less than five (5) minutes because, "you never know what they (patients) need. It could be an emergency. Many patients here are on the ventilator and cannot talk."

During an interview on 7/25/2024 at 11:59 a.m. with the House Supervisor (HS) 2, HS 2 stated all patients should have a call light so that they could call for assistance whenever they need. HS 2 said the expectation was for staff to respond to call light as soon as possible. HS 2 stated ten minutes wait was too long because anything could happen to patients including putting patients at risk for falling (an unintentional event that results in the person coming to rest on the ground or another lower level) and putting patients' safety at risk for delay in response to a potential medical emergency.

During a review of the facility's policy and procedure (P&P) titled, "CORE: Patient Call Devices," dated 6/2021, the P&P indicated, "Appropriate devices shall be available to help facilitate the communication for the patient's needs ...assure that there is a functional call light easily accessible by the patient ...secure the call light proximal to the patient and within easy reach ... when rounding/interacting with patient, staff shall verify that he patient's call device is easily accessible for use."

During a review of the facility's policy and procedure (P&P) titled, "CORE: Patient Rights and Responsibilities," dated 6/2023, the P&P indicated, "provide an environment that respects and protects the rights of patients and patients' families and conducts all activities related to care with primary concern for the values and dignity of patient ... The rights and responsibilities ... shall be protected and exercised for each patient and their family/ guardian at [the facility]."

2. During a review of Patient 11's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/12/2024, the H&P indicated Patient 11 was admitted to the facility's (Facility 2's) Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit with diagnoses of anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood, resulting in pallor and weariness), acute (new onset) hypoxic (deficiency in the amount of oxygen reaching the tissues) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), and status post (after) gastrostomy (an artificial external opening into the stomach for nutritional and medication administration).

During a concurrent observation and interview on 7/23/2024 at 12:56 p.m. with Registered Nurse (RN) 4 in Patient 11's room, a continuous pulse oximetry machine (pulse ox machine, an electronic device connected to patient's finger to earlobe to monitor blood oxygen level and heart rate) was sitting on top of the oxygen flow meter (oxygen source supplying oxygen for patients). RN 4 stated the continuous pulse oximetry machine was used to monitor Patient 11's oxygen level. RN 4 stated the pulse oximetry machine should be on a table and not on top of the oxygen flow meter, but there was no space.

During a concurrent observation and interview on 7/23/2024 at 1:18 p.m. with the Plant Operation Director (POD 2) in Patient 11's room, the pulse oximetry machine was sitting on top of the oxygen flow meter. POD 2 stated, "having an electronic device on an oxygen flow meter is a fire hazard." POD 2 stated he (POD 2) would remove the pulse oximetry machine immediately.

During an interview on 7/24/2024 at 10:59 a.m. with the Director of Respiratory Services (DRS), DRS stated a continuous pulse oximetry machine was provided for all ventilator patients. DRS stated the pulse oximetry machine should be placed on a bedside table and should not be hanging next to an oxygen flow meter. DRS stated, "it was dangerous because it was fire hazard."

During an interview on 7/26/2024 at 3:30 p.m. with the Director of Quality and Risk Management (DQM 2), DQM 2 stated the facility did not have policy and procedure in place relating to fire safety around oxygen source.

Based on interview and record review, the facility failed to ensure that patients are free from all forms of abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) when Registered Nurse (RN) 7 failed to report the alleged physical abuse of one (Patient 16) of 51 sampled patients, in accordance with the facility's abuse policy that consist of mechanisms/methods put into place for effective abuse protection which included reporting any incidents of abuse.

This deficient practice resulted in the facility not immediately taking the necessary steps to determine if the alleged physical abuse occurred and resulted in a delay in the investigation for the abuse allegation, which had the potential to put the patient (Patient 16) and other patients at risk for further abuse.

Findings:

During a review of Patient 16's face sheet (document that gives a patient's information at a quick glance), the face sheet indicated that Patient 16 was admitted to the facility on 1/13/2024 with the diagnosis of respiratory failure (serious condition that makes it difficult to breathe on your own), unspecified hypoxia (low levels of oxygen) or hypercapnia (buildup of carbon dioxide [waste product made by the body] in blood).

During a concurrent interview and record review on 7/24/2024 at 10:37 a.m. with the Director of Quality Management (DQM) 3, Patient 16's Nursing note dated 3/26/2024 and timed at 11:18 a.m., were reviewed. DQM 3 stated a chart review of Patient 16 was conducted on 4/12/2024 and that was when the abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) allegation, made by Patient 16's family on 3/26/2024, was discovered from the review of Nursing Note. The DQM 3 stated that after finding out about the alleged physical abuse through a record review, conducted on 4/12/2024, an investigation was conducted (17 days after the alleged abuse incident on 3/26/2024), the appropriate agency was notified, and local police department was contacted. The DQM 3 stated that they were unable to substantiate the alleged abuse (following the facility's [Facility 3] late investigation).

During an interview on 7/24/2024 at 10:57 a.m. with the Wound Care Nurse (WCN) 1, WCN 1 stated on 3/26/2024 a blister was found on the left upper thigh during wound care treatment of Patient 16. Patient 16's family members were present and began to accuse staff (RN 7) of burning Patient 16. WCN 1 said that Registered Nurse (RN) 7 and her (WCN 1) began to explain to the family members how the blister can form but the family was not listening and was insisting that staff burned Patient 16. WCN 1 stated it was a back-and-forth conversation until the family members understood.

During an interview on 7/24/2024 at 11:08 a.m. with RN 7, RN 7 stated that the alleged abuse, made by Patient 16's family on 3/26/2024, should have been reported to the supervisor. RN 7 said that he "was not thinking clearly" at the time (on 3/26/2024) and was concerned of Patient 16's family members. RN 7 stated that everyone (at the facility [Facility 3]) was a mandated reporter and should report any allegations of abuse.

During a concurrent interview and record review on 7/25/2024 at 2:03 p.m. with the Director of Nursing Care Services (DNCS) 3, the facility's policy and procedure (P&P) titled, "Abuse of Patient, Elder, Child by Staff Identification Response and Reporting," revised 6/2023, was reviewed. The P&P indicated the hospital maintains a strict policy to prevent or respond to allegations of abuse, neglect or mistreatment, including prompt reporting of any alleged abuse incident to hospital leaders and applicable state agencies. The DNCS 3 stated that the RN should have reported the alleged abuse to the supervisor. DCNS 3 also confirmed that the facility's policy regarding abuse reporting was not followed.

Based on interview and record review, the facility failed to ensure one (1) of 51 sampled patients (Patient 25) remained free from inappropriate use of chemical restraints (a drug given to a person to control their behavior or restrict their movement) and maintained the right to remain unrestricted in the ability to function for daily activities, in accordance with the facility's policy and procedure regarding "Patient Rights and Responsibilities" as well as "Identification and Reporting of Chemical Restraints," when the facility (Facility 3) staff attempted to keep Patient 25 sedated and confined to her (Patient 25) bed by administering Ativan (medication given to make one feel calmer and has sedating effect [state of sleepiness]).

This deficient practice had the potential for Patient 25 to experience the reduced ability to function effectively, appropriately interact with others, and participate in her (Patient 25) own care due to being sedated (state of sleepiness).

Findings:

During a review of Patient 25's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/8/2024, the "H&P" indicated, Patient 25 was admitted to the facility on 7/8/2024 for RLL (right lower leg) cellulitis (bacterial skin infection) and upper respiratory tract infection (a common viral infection of the nose, throat and airways), and had a medical history including Left eye retinal blastoma (eye cancer), atrial fibrillation (A-fib - an irregular heartbeat), Right cerebral vascular accident (CVA - also known as a stroke, where blood flow is disrupted in the brain), and Left AKA (Above the Knee Amputation). The "H&P" further indicated, Patient 25 was alert and oriented.

During an interview on 7/23/2024 at 1:24 p.m. with Registered Nurse 12 (RN 12), RN 12 stated, Ativan was given to Patient 25 for severe anxiety (to feel nervous, restless and/or fearful). RN 12 stated Ativan was given to Patient 25 when she (Patient 25) shouted a lot, was being needy, or was in pain. RN 12 further stated, Patient 25 was on the call light (a button or cord placed next to patients' bed and in the bathroom allowing patients to alert hospital staff remotely of their need for help. When the button is pressed, a signal alerts staff at the nurse's station and staff can respond to such a call) all the time and was calm when sleeping.

During an interview on 7/23/2024 at 3:33 p.m. with the Director of Care Services 3 (DNCS 3), the DNCS 3 stated, there was no facility protocol for giving Ativan to patients for screaming out, as there must be parameters to give Ativan and it's not the protocol to give Ativan when the patient was shouting or on the call light constantly. The DNCS 3 further stated, it would be known when the patient was screaming for pain or if the patient needed Ativan, as the history of the patient would be looked at.

During a concurrent interview and record review on 7/24/2024 at 9:59 a.m. with the DNCS 3, Patient 25's "Nurses Notes," dated 7/21/2024 was reviewed. The "Nurses Notes" indicated, on 7/21/2024 at 11:30 a.m., Ativan 0.5 mg (milligram, a unit of measurement) tablet by mouth was given to Patient 26 due to "the patient is screaming loud and repeating the same thing over." The DNCS 3 reviewed the record for Patient 26 and stated, no other actions were taken to calm down the patient (Patient 25) prior to the Ativan administration on 7/21/24 at 11:30 a.m.

During an interview on 7/24/2024 at 10:35 a.m. with the DNCS 3, the DNCS 3 stated, before offering patients medication intervention for anxiety, nurses were expected to assess what was causing anxiety for the patient, turn on the television, call the patient's family, offer the patient to hold something for comfort, and/or open the room curtain if patient felt claustrophobic (irrational fear of confined spaces).

During a review of Patient 25's "Medication Record," dated 7/21/24, the "Medication Record"
indicated, Ativan PO (by mouth) was given to Patient 25 on the following dates and times:
- On 7/21/2024 at 11:30 a.m. for "screaming loud and repeating the same thing over." At 12:30 p.m. "pt (Patient 25) awake but calm."

- On 7/22/2024 at 8:35 a.m. for "yelling she (Patient 25) states she's afraid of the dark." At 8:38 a.m. Patient 25 was "resting comfortably with eyes closed, no signs of restlessness or agitation."

- On 7/23/2024 at 2:13 a.m. for "pt (Patient 25) yelling in room." At 3:30 a.m. "Not effective..." and "pt still yelling."


During a review of Patient 25's "Doctors Orders," dated 7/20/2024, the "Doctors Orders" indicated, Ativan was ordered for Patient 25, for severe anxiety.

During a review of the facility's policy and procedure titled, Patient Rights and Responsibilities, dated 8/2022, indicated, "Patient has the right to be free from restraints and seclusion of any form used as a means of coercion, discipline, convenience or retaliation by staff."

During a review of the facility's policy and procedure (P&P) titled, "Identification and reporting of Chemical Restraints (a drug given to a person to control their behavior or restrict their movement)," dated 6/2022, the P&P indicated, "Chemical Restraints are used only after determining other alternatives."

Based on the interview and record review, the facility's Quality Assessment and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) committee failed to:

1. Perform gathering and analyze the information on an unexpected and unusual death for one of 51 sampled patients (Patient 2) when Patient 2 passed away on 3/30/2024 at the facility (Facility 2) within 48 hours of admission, and to ensure there is documentation of an investigation of Patient 2's death for that Patient 2's condition change that was not addressed by staff and the physician was not notified, in accordance with the facility's policy and procedure regarding patient assessment and physician notification as well as the facility's QAPI plan regarding the facility's performance improvement and patient safety activities.

This deficient practice led to the reoccurrence of a second patient (Patient 32) change of condition that was not addressed by staff and the physician was not notified.

2. Implement an effective preventative measure to prevent the potential reoccurrence of physicians not being notified for patients' change of condition for one of 51 sampled patients (Patient 2), in accordance with the facility's policy and procedure regarding patient assessment and physician notification as well as the facility's QAPI plan regarding the facility's performance improvement and patient safety activities.

This deficient practice led to the reoccurrence of a second patient's (Patient 32) change in condition that was not reported to the physician resulting in Patient 32 being intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) and eventually passed away at Facility 1.

Findings:

1. During a review of Patient 2's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/28/2024, the H&P indicated Patient 2 was admitted to the facility's (Facility 2's) Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit with diagnoses of acute (new onset) pneumonia (lung infection) associated with sepsis (a body's overwhelming and life-threatening response to infection) and acute hypoxic (deficiency in the amount of oxygen reaching the tissues) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood).

During a concurrent interview and record review on 7/24/2024 at 2:55 p.m. with House Supervisor (HS) 2, Patient 2's "Nursing Assessment," dated 3/29/2024 was reviewed. The nursing assessment indicated on 3/29/2024 at 8 p.m., "Patient (Patient 2) had bleeding from urethra (duct [tube of the body] by which urine leave the body) ... bleeding from oral cavity (mouth). HS 2 stated it was a change of condition (a clinically important deviation from a patient's baseline health condition that without interventions may result in complications or death) and Registered Nurse (RN) 5 did not report to the physician the location of bleeding and amount of bleeding for physician order and instruction.

During an interview on 7/24/2024 at 2:56 p.m. with HS 2, HS 2 stated RN 5 did not follow the process and did not contact the physician. HS 2 stated there would be potential risk for delay of care for not reporting change of condition, and Patient 2's bleeding could get worse.

During a review of Patient 2's "Change of Condition (COC)," dated 3/30/2024, the COC indicated, "Patient (Patient 2) suddenly experienced abrupt, large amount of hemoptysis (coughing up blood) ... arrived and observed immediately that patient (Patient 2) looked ashened (extremely pale looking) and pupils already glazed, no blinking ...3:05 p.m. Code Blue (hospital emergency code use to summon help when a patient is in need of resuscitation) was initiated and Cardio-pulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) started ...patient (Patient 2) expired (died) on 3/30/2024 at 3:47p.m."

During an interview on 7/26/2024 at 11:05 a.m. with the Director of Quality and Risk Management (DQM) 2, DQM 2 stated the following: Patient 2's death was unusual because Patient 2 was in the facility (Facility 2) for short period of time (3/28/2024 - 3/30/2024). She (DQM 2) reviewed Patient 2's medical record but did not speak with the nursing staff who was involved. It was handled by the Director of Nursing at that time and there was no record of investigation available. There was concern with no documentation for physician notification of patient's (Patient 2) change of condition. The incident (involving Patient 2 on 3/30/2024 was sent for peer review (medical peer review is a performance assessment to evaluate other physician's clinical performances), but the facility (Facility 2) did not gather more information and perform analysis of what led to the death of Patient 2.

During an interview on 7/26/2024 at 11:16 a.m. with DQM 2, DQM 2 stated QAPI did not audit nursing for physician notification of patient's (Patient 2) change of condition.

During a review of the facility's policy and procedure titled, "CORE: Interdisciplinary Assessment and Re-assessment," dated 6/2023, the P&P indicated, "Reporting/ Notification of change in condition ... an acute change in condition may occur abruptly or over several hours to several days, presenting as physical changes as changes in function, mood, cognition, or behavior ... because a change in condition depends in part on the patient's prior condition and because there are numerous physical and mental symptoms that may signal a patient's change in condition ... a significant change in condition may include, but are not limited to: heart rate less than 50 or above 140 beats per minutes sustained and/or symptomatic, systolic blood pressure less than 80 or above 180 sustained, respiratory distress (shortness of breath, labored and rapid breathing, cyanosis [bluish color of skin, lips, or nails due to lack of oxygen in the blood], coarse rales [small clicking, rattling, or bubbling sounds in the lungs], and rhonchi [low pitched or snoring sounds associated with large airway obstruction] heard over lung fields). Respiration less than 10 or above 40 sustained. Oxygen saturation less than 85% sustained despite oxygen therapy ... nurse concern of any situation in which the nurse feels uncomfortable with the patients' condition and/ or response to treatment ... The nurse assigned to the patient or supervising the care of the patient is responsible for notification of and communication to the patient's primary physician or designee using appropriate channels and chain of command for assuring that there is physician response. Significant changes of significant deterioration in the patient's condition will initiate the facility's Rapid Response (a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) Process ... document change of condition, notification and interventions in the medical record (Electronic medical record [EMR, digital version of paper chart]), facilities document under the 'Change of Condition' Pathway."

During a review of the facility's Quality Assurance Performance Improvement (QAPI) Plan, dated 2024, the QAPI Plan indicated, "The prioritization of performance improvement activities should focus on high-risk, high volume, or problem-prone areas and their effects on health outcomes, patient safety, and quality of care ... the single best indicator of the effectiveness of the QAPI is the ability of a hospital to self-identify quality issues ...concurrent self-assessment activities performed to evaluate compliance to regulatory and accreditation standards as well as key internal policies and procedures ... Mortality Review: review of patient deaths to evaluate clinical practice patterns and identify significant departure from established patterns of clinical practice."



2. During a concurrent interview and record review on 7/24/2024 at 10:20 a.m., with the Clinical Educator (CE), Patient 32's (Patient involved in the second incident in which the physician was not notified of patient's change of condition following the first incident with Patient 2) vitals flowsheet (record and track Patient's health vitals and other custom parameters) was reviewed. The flowsheet indicated there was no oxygen saturation rate and respiratory rate recorded. No documentation of the physician being notified of Patient 32's declining vital signs and continued increased respiratory rate was recorded in Patient 32's medical record. No additional records of assessment of Patient 32's oxygen saturation level was documented in the medical chart from 10:19 p.m. on 7/22/2024 through 7:30 a.m. on 7/23/2024. The CE reviewed and stated the physician should have been notified about the change of condition, as per facility's policy and procedures.

During a concurrent interview and record review on 7/23/2024 at 10:20 a.m., with the Clinical Educator (CE), Patient 32's medical record (MR) titled, "Change of Condition," dated 7/23/2024, at 7:30 a.m., was reviewed. The MR indicated on 7/23/2024, at 7:30 a.m., a respiratory therapist (RT) found Patient 32 on a nonrebreather mask, saturating 82%, with labored breathing (breathing that is difficult or impaired) and respirations of 30 BPM. A Rapid Response was called for Patient 32 at 7:53 a.m., followed by a transfer of Patient 32 to an intensive care unit (ICU, a unit in a hospital providing intensive care for critically ill or injured patients), where Patient 32 was intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) and eventually expired (died).

During a review of the facility's Quality Assurance Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) Plan, dated 2024, the QAPI Plan indicated, "The prioritization of performance improvement activities should focus on high-risk, high volume, or problem-prone areas and their effects on health outcomes, patient safety, and quality of care ... the single best indicator of the effectiveness of the QAPI is the ability of a hospital to self-identify quality issues ...concurrent self-assessment activities performed to evaluate compliance to regulatory and accreditation standards as well as key internal policies and procedures ... Mortality Review: review of patient deaths to evaluate clinical practice patterns and identify significant departure from established patterns of clinical practice."

During an interview on 7/26/2024 at 11:16 a.m. with the Director of Quality and Risk Management (DQM) 2, DQM 2 stated the QAPI (Quality Assurance and Performance Improvement, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) committee did not audit nursing for physician notification of patients' change of condition (a clinically important deviation from a patient's baseline health condition that without interventions may result in complications or death).

During an interview on 7/26/2024 at 12:15 p.m. with DQM 2, DQM 2 stated, "The patient's (Patient 2's) death was not brought up to the governing body (responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) because it was an isolated case." The DQM 2 further stated, "If it was found that one of the departments was at fault, it would be brought up to the governing body." DQM 2 confirmed that there was a reoccurrence of the incident where staff did not recognize a change in a patient condition with Patient 32 at Facility 1, and the DQM 2 stated, "This is why we started the change in condition education."

During a concurrent interview and record review on 7/24/24 at 10:20 a.m., with the Clinical Educator (CE), Patient 32's (Patient involved in the second incident in which the physician was not notified of patient's change of condition following the first incident with Patient 2) vitals flowsheet (record and track Patient's health vitals and other custom parameters) was reviewed. The flowsheet indicated there was no oxygen saturation rate and respiratory rate recorded. No documentation of the physician being notified of Patient 32's declining vital signs and continued increased respiratory rate was recorded in Patient 32's medical record. No additional records of assessment of Patient 32's oxygen saturation level was documented in the medical chart from 10:19 p.m. on 7/22/2024 through 7:30 a.m. on 7/23/2024. The CE reviewed and stated the physician should have been notified about the change of condition, as per facility's policy and procedures.

During a concurrent interview and record review on 7/23/2024 at 10:20 a.m., with the Clinical Educator (CE), Patient 32's medical record (MR) titled, "Change of Condition," dated 7/23/2024, at 7:30 a.m., was reviewed. The MR indicated on 7/23/2024, at 7:30 a.m., a respiratory therapist (RT) found Patient 32 on a nonrebreather mask, saturating 82%, with labored breathing (breathing that is difficult or impaired) and respirations of 30 BPM. A Rapid Response was called for Patient 32 at 7:53 a.m., followed by a transfer of Patient 32 to an intensive care unit (ICU, a unit in a hospital providing intensive care for critically ill or injured patients), where Patient 32 was intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) and eventually expired (died).

During a review of the facility's policy and procedure titled, "CORE: Interdisciplinary Assessment and Re-assessment," dated 6/2023, the P&P indicated, "Reporting/ Notification of change in condition ... an acute change in condition may occur abruptly or over several hours to several days, presenting as physical changes as changes in function, mood, cognition, or behavior ... because a change in condition depends in part on the patient's prior condition and because there are numerous physical and mental symptoms that may signal a patient's change in condition ... a significant change in condition may include, but are not limited to: heart rate less than 50 or above 140 beats per minutes sustained and/or symptomatic, systolic blood pressure less than 80 or above 180 sustained, respiratory distress (shortness of breath, labored and rapid breathing, cyanosis [bluish color of skin, lips, or nails due to lack of oxygen in the blood], coarse rales [small clicking, rattling, or bubbling sounds in the lungs], and rhonchi [low pitched or snoring sounds associated with large airway obstruction] heard over lung fields). Respiration less than 10 or above 40 sustained. Oxygen saturation less than 85% sustained despite oxygen therapy ... nurse concern of any situation in which the nurse feels uncomfortable with the patients' condition and/ or response to treatment ... The nurse assigned to the patient or supervising the care of the patient is responsible for notification of and communication to the patient's primary physician or designee using appropriate channels and chain of command for assuring that there is physician response. Significant changes of significant deterioration in the patient's condition will initiate the facility's Rapid Response (a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) Process ... document change of condition, notification and interventions in the medical record (Electronic medical record [EMR, digital version of paper chart]), facilities document under the 'Change of Condition' Pathway."

During a review of the facility's Quality Assurance Performance Improvement (QAPI) Plan, dated 2024, the QAPI Plan indicated, "The prioritization of performance improvement activities should focus on high-risk, high volume, or problem-prone areas and their effects on health outcomes, patient safety, and quality of care ... the single best indicator of the effectiveness of the QAPI is the ability of a hospital to self-identify quality issues ...concurrent self-assessment activities performed to evaluate compliance to regulatory and accreditation standards as well as key internal policies and procedures ... Mortality Review: review of patient deaths to evaluate clinical practice patterns and identify significant departure from established patterns of clinical practice."

Based on interview and record review, the facility's Quality Assessment and Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) program committee failed to communicate to the Governing Body (responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) the event that led to Patient 2's death in which Patient 2's condition change was not recognized, and the physician was not notified, in accordance with the facility's QAPI plan regarding the facility's performance improvement and patient safety activities.

This deficient practice resulted in the lack of information dissemination and prevented all three facility campuses (Facility 1, 2, and 3 which are all part of the triad of facilities investigated) from analyzing data collected relating to Patient 2's death at Facility 2 to formulate a plan of correction to prevent another incident of a patient's condition change not being addressed. This resulted in a reoccurrence of a second incident when a second patient's (Patient 32) change in condition was not reported to the physician which led in Patient 32 being intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) and eventually passed away at Facility 1.

Findings:

During a review of Patient 2's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/28/2024, the H&P indicated Patient 2 was admitted to the facility's (Facility 2's) Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit with diagnoses of acute (new onset) pneumonia (lung infection) associated with sepsis (a body's overwhelming and life-threatening response to infection) and acute hypoxic (deficiency in the amount of oxygen reaching the tissues) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood).

During a concurrent interview and record review on 7/24/2024 at 2:55 p.m. with House Supervisor (HS) 2, Patient 2's "Nursing Assessment," dated 3/29/2024 was reviewed. The nursing assessment indicated on 3/29/2024 at 8 p.m., "Patient (Patient 2) had bleeding from urethra (duct [a tube of the body] by which urine leave the body) ... bleeding from oral cavity (mouth). HS 2 stated it was a change of condition (a clinically important deviation from a patient's baseline health condition that without interventions may result in complications or death) and Registered Nurse (RN) 5 did not report to the physician the location of bleeding and amount of bleeding for physician order and instruction.

During an interview on 7/24/2024 at 2:56 p.m. with HS 2, HS 2 stated RN 5 did not follow the process and did not contact the physician. HS 2 stated there would be potential risk for delay of care for not reporting change of condition, and Patient 2's bleeding could get worse.

During a review of Patient 2's "Change of Condition (COC)," dated 3/30/2024, the COC indicated, "Patient (Patient 2) suddenly experienced abrupt, large amount of hemoptysis (coughing up blood) ... arrived and observed immediately that patient (Patient 2) looked ashened (extremely pale looking) and pupils already glazed, no blinking ...3:05 p.m. Code Blue (hospital emergency code use to summon help when a patient is in need of resuscitation) was initiated and Cardio-pulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) started ...patient (Patient 2) expired (died) on 3/30/2024 at 3:47p.m."

During an interview on 7/26/2024 at 11:05 a.m. with the Director of Quality and Risk Management (DQM) 2, DQM 2 stated the following: Quality and Risk Management was responsible to review all mortality (death) that happened at the facility. Patient 2's death was unusual because Patient 2 was in the facility (Facility 2) for short period of time (3/28/2024 - 3/30/2024). She (DQM 2) reviewed Patient 2's medical record but did not speak with the nursing staff who was involved. It was handled by the Director of Nursing at that time and there was no record of investigation available. There was concern with no documentation for physician notification of patient's (Patient 2) change of condition. The incident was sent for peer review (medical peer review is a performance assessment to evaluate other physician's clinical performances), but the facility (Facility 2) did not perform a root cause analysis (RCA, the process of discovering the root causes of problems in order to identify appropriate solution).

During a concurrent interview and record review on 7/26/2024 at 12:09 p.m. with DQM 2, the facility's "Medical Executive Committee/ Quality Council Minute Report January to March 2024 Data (MEC/QAPI minute)," dated 5/31/2024, was reviewed. The MEC/QAPI minute indicated, "Peer Review: 3/8/2024, 4/12/2024, and 5/10/2024 - the committee was presented with a summary of the Peer Review meetings ... Charts fallouts were reviewed and leveled. Some required letters to be sent." DQM 2 stated it was too general and did not specify which facility it was referring to. DQM 2 stated she (DQM 2) was unable to indicate Patient 2's death was mentioned per MEC/QAPI minute.

During an interview on 7/26/2024 at 12:15 p.m. with DQM 2, DQM 2 stated, "The patient's (Patient 2's) death was not brought up to the governing body (responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) because it was an isolated case." The DQM 2 further stated, "If it was found that one of the departments was at fault, it would be brought up to the governing body." DQM 2 confirmed that there was a reoccurrence of the incident where staff did not recognize a change in a patient condition with Patient 32 at Facility 1, and the DQM 2 stated, "This is why we started the change in condition education."

During a concurrent interview and record review on 7/24/24 at 10:20 a.m., with the Clinical Educator (CE), Patient 32's (Patient involved in the second incident in which the physician was not notified of patient's change of condition following the first incident with Patient 2) vitals flowsheet (record and track Patient's health vitals and other custom parameters) was reviewed. The flowsheet indicated there was no oxygen saturation rate and respiratory rate recorded. No documentation of the physician being notified of Patient 32's declining vital signs and continued increased respiratory rate was recorded in Patient 32's medical record. No additional records of assessment of Patient 32's oxygen saturation level was documented in the medical chart from 10:19 p.m. on 7/22/2024 through 7:30 a.m. on 7/23/2024. The CE reviewed and stated the physician should have been notified about the change of condition, as per facility's policy and procedures.

During a concurrent interview and record review on 7/23/2024 at 10:20 a.m., with the Clinical Educator (CE), Patient 32's medical record (MR) titled, "Change of Condition," dated 7/23/2024, at 7:30 a.m., was reviewed. The MR indicated on 7/23/2024, at 7:30 a.m., a respiratory therapist (RT) found Patient 32 on a nonrebreather mask, saturating 82%, with labored breathing (breathing that is difficult or impaired) and respirations of 30 BPM. A Rapid Response was called for Patient 32 at 7:53 a.m., followed by a transfer of Patient 32 to an intensive care unit (ICU, a unit in a hospital providing intensive care for critically ill or injured patients), where Patient 32 was intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) and eventually expired (died).

During a review of the facility's policy and procedure (P&P) titled, "CORE: Interdisciplinary Assessment and Re-assessment," dated 6/2023, the P&P indicated, "Reporting/ Notification of change in condition ... an acute change in condition may occur abruptly or over several hours to several days, presenting as physical changes as changes in function, mood, cognition, or behavior ... because a change in condition depends in part on the patient's prior condition and because there are numerous physical and mental symptoms that may signal a patient's change in condition ... a significant change in condition may include, but are not limited to: heart rate less than 50 or above 140 beats per minutes sustained and/or symptomatic, systolic blood pressure less than 80 or above 180 sustained, respiratory distress (shortness of breath, labored and rapid breathing, cyanosis [bluish color of skin, lips, or nails due to lack of oxygen in the blood], coarse rales [small clicking, rattling, or bubbling sounds in the lungs], and rhonchi [low pitched or snoring sounds associated with large airway obstruction] heard over lung fields). Respiration less than 10 or above 40 sustained. Oxygen saturation less than 85% sustained despite oxygen therapy ... nurse concern of any situation in which the nurse feels uncomfortable with the patients' condition and/ or response to treatment ... The nurse assigned to the patient or supervising the care of the patient is responsible for notification of and communication to the patient's primary physician or designee using appropriate channels and chain of command for assuring that there is physician response. Significant changes of significant deterioration in the patient's condition will initiate the facility's Rapid Response (a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) Process ... document change of condition, notification and interventions in the medical record (Electronic medical record [EMR, a digital version of paper chart]), facilities document under the 'Change of Condition' Pathway."

During a review of the facility's Quality Assurance Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) Plan, dated 2024, the QAPI Plan indicated, "The leadership team must align all improvement activities with the quality domains for the organization and identify gaps in activities and infrastructure that would be barriers to reaching goals ...The Quality Council coordinates the performance improvement process by ... ensuring that processes for identifying and managing serious and sentinel patient safety events (a patient safety event that results in death, permanent harm, or severe temporary harm) are defined and implemented ...The Quality Council is the coordinating body for all hospital-wide quality assurance and performance improvement activities and process. The Quality Council's Committee Structure supports implementation of the Quality Plan utilizing first level working quality committees ...report findings, analyses, recommendations, actions and follow up specific to the individuals' committee's functions... The ultimate responsibility for performance improvement rests with the Hospital Governing Board ..."

Based on interview and record review, the facility failed to:

1. Provide adequate number of licensed nursing staff (nurses who are registered nurses or licensed vocational nurses) for 34 patients in the Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit at the facility (Facility 2) on 7/23/2024, in accordance with the facility's policy and procedure regarding provision of care and regulatory standards pertaining to staffing, when three of four sampled Registered Nurses (RN 15, 16, and 17) covered each other and covered the Licensed Vocational Nurses (LVN 3 and 4) for the thirty (30) minutes lunch break. Thus, leaving a RN with 8 or 9 patients to attend to while the other licensed staff was on lunch break.

This deficient practice had the potential to result in the Telemetry unit not having enough licensed nursing staff to respond to patients' care needs, cause delay of care and services and put patients' safety at risk.

2. Ensure adequate number of nursing staff, in accordance with regulatory standards regarding nurse-to-patient ratios (number of patients a licensed nurse can care for at one time) and safe patient care assignments, when three of five sampled Registered Nurses (RNs 23, 24, and 25) covered three (3) of three Licensed Vocational Nurses (LVNs 8, 9 and 10) for meal breaks (30 minutes lunch break) in two (2) of two sampled units (Medical Surgical unit [a hospital unit that provides care for long-term patients who are hospitalized for illness, surgery, testing, or observation] and Telemetry [a floor in a hospital where patients undergo continuous cardiac monitoring] unit), both units housing mixed medical surgical and telemetry patients. The nurse-to-patient ratio in both units was one RN and one LVN to nine (9) patients, one RN and one LVN to eight (8) patients, or one RN to four (4) patients. When covering meal breaks for LVNs, each RN assumed the care of all 9 or 8 patients, and/or additional 3or 4 patients aside from their own assigned 3, 4, or 5 patients.

This deficient practice had the potential to result in Medical Surgical and Telemetry areas not having enough licensed staff to respond to patients care needs, cause delay of care and services and put patients' safety at risk.

Findings:

1. During a review of the facility's (Facility 2's) "Daily Nursing Staffing Sheet Final Assignment (nursing assignment, document indicates specific patients are assigned to licensed nursing staff) AM shift," dated 7/23/2024, the nursing assignment indicated Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) Unit was staffed with four (4) Registered Nurses (RN) 4, 15, 16, and 17, four (4) Licensed Vocational Nurses (LVN) 3, 4, 6 and 7 and one (1) RN (RN 14) as resource nurse for 34 patients in the following detail:
RN 4 and LVN 7 were assigned with nine (9) patients
RN 15 and LVN 4 were assigned with eight (8) patients
RN 17 and LVN 3 were assigned with eight (8) patients
RN 16 and LVN 6 were assigned with nine (9) patients

During an interview on 7/23/2024 at 1:30 p.m. with LVN 3 in the Telemetry unit, LVN 3 stated the following: she (LVN 3) worked with RN 17 today (7/23/2024) with eight (8) patients assigned for both RN 17 and LVN 3 to take care of together. When she (LVN 3) went on lunch break, RN 17 would cover all eight (8) patients (thus going over the 1:4 nurse to patient staffing ratio [1 licensed nurse assigned to four patients] on any given shift). When RN 17 went on lunch break, RN 17 would ask a resource RN or another RN in the unit to cover her (RN 17) so that there would always be a licensed RN covering all patients.

During an interview on 7/23/2024 at 1:57 p.m. with LVN 4 in Telemetry unit, LVN 4 stated the following: she (LVN 4) worked with RN 15 today (7/23/2024) with eight (8) patients assigned for both RN 15 and LVN 4 to take care of together. When she (LVN 4) went on lunch break, RN 15 would cover all eight (8) patients (thus going over the 1:4 nurse to patient staffing ratio). When RN 15 went on break, RN 15 would tell another RN in the unit or resource RN to cover her (RN 15).

During an interview on 7/23/2024 at 2:21 p.m. with the resource RN (RN 14), RN 14 stated that he (RN 14) was the resource RN today (7/23/2024) and his (RN 14) responsibility was to cover RNs in the ICU (Intensive Care Unit, a unit in a hospital providing intensive care for critically ill or injured patients.) for lunch break. RN 14 stated he (RN 14) did not cover RNs in Telemetry unit. RN 14 stated he (RN 14) was not sure who performed lunch break relief for nurses in the Telemetry unit.

During an interview on 7/23/2024 at 2:29 p.m. with LVN 6 in the Telemetry unit, LVN 6 stated the following: he (LVN 6) worked with RN 16 today (7/23/2024) with nine (9) patients assigned for both LVN 6 and RN 16 to take care of together. RN 16 just clocked out minutes ago for lunch break but did not inform him (LVN 6) who covered her (RN 16) while she (RN 16) was on lunch break. Since he (LVN 6) was the only one covering all nine (9) patients, there was possibility that patients needed to wait a longer time to receive pain medications if they needed one.

During an interview on 7/23/2024 at 2:40 p.m. with RN 15 in Telemetry unit, RN 15 stated the following: she (RN 15) worked with LVN 4 today (7/23/2024) with eight (8) patients assigned for both RN 15 and LVN 4 to take care of together. When LVN 4 went on lunch break, she (RN 15) would be overseeing all eight (8) patients (thus going over the 1:4 nurse to patient staffing ratio). Sometimes it could be difficult to cover all eight (8) patients by herself (RN 15) especially when the patients needed more attention and nursing care.

During an interview on 7/25/2024 at 4:11 p.m. with the House Supervisor (HS) 2, HS 2 stated the following: lunch break was thirty minutes long for each staff. When a LVN went on lunch break, the RN would be overseeing all the patients (8 or 9 patients assigned to each team of a RN and a LVN) for thirty (30) minutes.The facility followed state regulation for nurse staffing ratio (maximum number of patients can be assigned to one licensed nurse at one time) in which one licensed nurse (RN/LVN) should have no more than four (4) telemetry (patients with heart problems who need continuous cardiac monitoring) status patients and one licensed nurse (RN/LVN) should have no more than five (5) medical surgical (general patient population hospitalized for various causes such as illness and surgery) status patients. The facility utilized team nursing model in which a RN and a LVN teamed up together to take care of no more than nine (9) telemetry and/or medical surgical patients.

During a concurrent interview and record review on 7/25/2024 at 5:24 p.m. with the Chief Operating Officer (COO 2), the facility's (Facility 2's) "Break Log (record of nursing staff taking lunch break and which licensed nursing staff provided break coverage)," dated 7/23/2024 was reviewed. The "Break Log" indicated the following:

RN 16 covered RN 17's lunch break
RN 15 covered RN 16's lunch break
RN 15 covered LVN 4's lunch break
RN 17 covered LVN 3's lunch break
COO 2 stated RN 15, 16, and 17 should not be covering each other and should not be covering LVN 3 and 4 for lunch break because it would make them out of state mandated nurse staffing ratio (the maximum number of patients that maybe assigned to a RN during one shift) during that thirty-minute covering period as they needed to provide oversight on more patients than they were allowed to. COO 2 stated the resource RN or the house supervisor should be the one providing lunch break coverage for all licensed nursing staff. COO 2 stated there would be potential risk to compromise patient safety when licensed nursing staff went out of ratio.

During an interview on 7/26/2024 at 2:41 p.m. with HS 1, HS 1 stated the following: the facility followed the state regulation for mandated staffing ratio and adopted team nursing model in which a RN would team up with a LVN to take care of eight (8) to nine (9) patients. The RN had the ultimate responsibility to all eight (8) to nine (9) patients. The RN would be out of ratio when covering the LVN for lunch break because the RN would have eight (8) to nine (9) patients by himself or herself during that time. The purpose of staying within staffing ratio was for patient safety and to provide quality of care. If a nurse had too many patients, then he or she would not be able to provide quality care and patients could be at risk for harm.

During a review of the facility's "Organization Plan for the Delivery of Patient Care, Treatment and Services (provision of care)," dated 2023, the provision of care indicated, "The staffing plan shall be developed and implemented for each patient care unit and shall specify patient care requirements and the staffing levels for registered nurses and other licensed and unlicensed personnel. The plan will include the following ... D. [state] Staffing Ratios ... Staffing is accomplished according to the patient system and staffing guidelines as well as regulatory requirements. Lunch and breaks are accounted for in the core staffing."

2. During a review of the facility's daily nursing assignment (DNA, assignment refers to number of patients assigned to provide routine care, activities, and procedures assigned to registered nurses [RN] and/or licensed practical/vocational nurses [LPN/VN], or assistive personnel [example: certified nursing assistant, CNA]), dated 7/22/2024, night shift, the daily nursing assignment indicated, medical surgical (a hospital ward or other health care facility that provides care for patients who are hospitalized for illness, surgery, testing, or observation) and telemetry (a hospital floor where patients with chronic heart conditions receive continuous cardiac monitoring) units, with 34 patient census (complete count of patients), were staffed with three (3) LVNs, and 5 RNs assigned to patient care.

During further review of the facility's DNA, dated 7/22/2024, the DNA indicated, the assignment consisted of 4 Teams as follows:

Team A, consisted of 1 RN (RN 23) and 1 LVN (LVN 8) assigned to total of nine (9) mixed telemetry and medical-surgical patients (4 telemetry, 5 medical-surgical).
Team B, consisted of 1 RN (RN 24) and 1 LVN (LVN 9), assigned to total of eight (8) mixed telemetry and medical-surgical patients (6 telemetry, 2 medical-surgical).
Team C, consisted of 1 RN (RN 25) and 1 LVN (LVN 10), assigned to total of 9 mixed telemetry and medical-surgical patients (4 telemetry and 5 medical-surgical).
Team D consisted of 2 RNs (RN 26 and RN 27) assigned to 4 patients each (all telemetry patients).
The assignment, dated 7/22/2024 (night shift), did not indicate break time for each licensed nurse, and contained no information about how mealtime coverage was provided during breaks for each RN and each LVN assigned to patient care.

During an interview on 7/26/2024 at 2:42 p.m. with house supervisor (HS 1), the HS 1 stated, typically the facility always has two house supervisors on duty present during each shift. The HS 1 further stated, one supervisor usually covers intensive care unit nurses for breaks and provides break relief to monitor tech (a cardiovascular technologist, observes and analyzes the heart monitors attached to patients in a hospital), another supervisor covers telemetry and medical surgical areas' registered nurses. The HS 1 stated, all LVNs breaks are covered by their supervising registered nurses (this means that the RN will end up with eight or nine patients for 30 minutes while the LVN goes on a lunch break).

During an interview on 7/26/2024 at 2:42 p.m. with HS 1, the HS 1 stated, the facility follows regulatory standards for mandated staffing ratios (the maximum number of patients that may be assigned to an RN during one shift, such as 1 RN to 4 patients for telemetry and 1 RN to 4 to 5 patients for Med Surg depending on acuity [severity of patient illness or medical condition]). The HS 1 further said, the facility utilizes a team nursing model which typically consists of a RN, LVN, and a CNA (certified nursing assistant) in the medical-surgical and telemetry areas. The HS 1 stated, typically, the assignment is not divided into 4 or 5 patients per nurse (RN), and instead, all 8 to 9 patients are assigned to a supervising RN and a LVN, and the tasks involving patient care are shared responsibility between the two licensed nurses (RN and LVN comprising each team). The HS 1 further said, in the facility's team nursing model, the RN supervises the LVN and the CNA, and is ultimately responsible for all patients assigned, but the facility does not violate mandated staffing requirements, because a team is never assigned more than 8 telemetry patients a shift per two licensed nurses (1 RN and 1 LVN).

During further interview on 7/26/2024 at 3:10 p.m. with HS 1, the HS 1 reviewed the daily nursing assignment for Team A, Team B, and Team C, dated 7/22/2024. HS 1 stated, on 7/22/2024, during the night shift, RNs assigned to each team (Team A, Team B, and Team C) covered LVNs for their meal breaks. The HS 1 further stated, RNs covering 8 to 9 patients during LVNs meal breaks (covers the 15 minutes and the 30 minutes meal break) exceed regulatory standards regarding nurse-to-patient ratios (number of patients a licensed nurse can care for at one time). The HS 1 said, "Perhaps, when one RN has to cover 8 to 9 patients during mealtime, while covering for their LVN, it places the RN out of ratio," and further stated, the purpose of mandatory staffing ratios is to ensure safe and quality patient care. The HS 1 said, one RN overseeing 8 to 9 patients during meal breaks, while covering for their LVN who is on a lunch break, has been practiced in the facility for as long as HS 1 could remember.

During a review of the facility's "Organization Plan for the Delivery of Patient Care, Treatment and Services (Provision of Care)," dated 2024, the provision of care indicated, "The staffing plan shall be developed and implemented for each patient care unit and shall specify patient care requirements and the staffing levels for registered nurses and other licensed and unlicensed personnel. To determine staffing assignments within the established staffing allocation guidelines, the facility's staffing system shall include, but not limited to the following elements: A. individual patient care requirements B. the patient care delivery system C. generally accepted standards of nursing practice D. State staffing ratios. Staffing is accomplished according to the patient acuity system (a method for determining how much nursing care a patient need based on the severity of their illness and the intensity of care required) and staffing guidelines as well as regulatory requirements. Lunch and breaks are accounted for in the core staffing."

Based on interview and record review, the facility failed to:

1. Ensure one (1) of the 51 sampled patients (Patient 1), who had a nasal gastric tube (NGT, a tube that is inserted through the nose, down the throat, and into the stomach to provide nutrition), had a complete assessment, which included assessing the placement or position of the NGT, in accordance with the facility's policy and procedure regarding enteral feeding (use of a feeding tube to supply nutrients and fluids to the patient's body when the patient cannot safely chew or swallow).

This deficient practice resulted in Patient 1 aspirating (when food, liquid, or other material enters a patient's airway and eventually the patient's lungs) a large number of feedings. This deficient practice also had the potential to result in serious health issues such as Pneumonia (lung infection).

2. Ensure one (1) of 51 sampled patients (Patient 42) was monitored, evaluated, and cardiac [heart] activity changes were addressed, in accordance with the accepted standards of nursing practice and the facility's policy and procedure regarding Interdisciplinary Assessment and Reassessment.

This deficient practice had the potential to result in delay of care and treatment for Patient 42, when Patient 42's increasing heart rate was not addressed in a timely manner, resulting in Patient 42 eventually being transferred to the intensive care unit (ICU, a unit in a hospital providing intensive care for critically ill or injured patients).

Findings:

1. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 1/25/2024, the "H&P" indicated, Patient 1's medical history included HTN (hypertension, high blood pressure), uncontrolled DM (Diabetes, a disease that occurs when the blood sugar is too high), renal failure (one or both of your kidneys no longer function well on their own), with acute respiratory failure ( an inability to maintain adequate oxygenation) and with history of intubation (the insertion of a tube into a patient's windpipe to aid in ventilation). The H&P further indicated: Patient 1 was "Transferred to (facility name, Facility 2) for further management. Upon evaluation, Patient (Patient 1) in ICU (Intensive Care Unit, unit in a hospital providing intensive care for critically ill or injured patients) on Oxymizer (a device placed in the nostrils to deliver continuous high-flow oxygen) support. Patient is alert and oriented."

During a concurrent interview and record review on 7/24/2024 at 12:40 p.m. with Registered Nurse (RN) 3, Patient 1's "Change of Condition (a clinically important deviation from a patient's baseline health condition that without interventions may result in complications or death)," report dated 2/15/2024 at 9:30 p.m., was reviewed. The change of condition report indicated, "When taking report it was noted that NG tube was at 25 cm (centimeter, a unit of length measurement), clear bubbling was heard on aspiration, family noted that it has been going on since 12 p.m., RT (respiratory therapist) suctioned lungs and feeding in large amounts was withdrawn, NG tube (NGT, a tube that is inserted through the nose, down the throat, and into the stomach to provide nutrition) tried to reinsert without success, NG tube removed."

During a concurrent interview and record review on 7/24/2024 at 12:42 p.m. with Registered Nurse (RN) 3, Patient 1's "Nursing Notes," dated from 2/11/2024 through 2/15/2024, were reviewed. RN 3 stated that the assessment of the NGT site should include checking for any abdominal pain, distention, or firmness. RN 3 further added that the residual gastric residual volume (the amount aspirated from the stomach following the administration of enteral feed) must be checked, and checking for the placement of the NGT was important. RN 3 stated, "Centimeter marking at the patient's nares (opening of the nose) should be checked to verify placement." RN3 stated that if the cm marking was not where it should be for the patient, the patient was at risk for aspiration (when food, liquid, or other material enters a patient's airway and eventually the patient's lungs) of the tube feeding into the lungs. The nursing note indicated as follows:

On 2/15/2024, for the a.m. shift (from 7 a.m. to 7 p.m.), there was no documentation of NGT placement or position check.
On 2/14/2024 for the p.m. shift (from 7 p.m. to 7 a.m.), there was no residual check and no documentation of NGT placement or position check.
On 2/14/2024, for the a.m. shift, there was no NGT assessment completed.
On 2/13/2024 for the a.m. shift, there was no NGT assessment completed.
On 2/12/2024 p.m. shift, there was no NGT assessment completed.
On 2/12/2024 a.m. shift, there was no documentation of NGT placement check.
On 2/11/2024 a.m. shift, there was no documentation of NGT placement check.
On 2/11/2024 p.m. shift, there was no documentation of NGT placement check.

During a review of the facility's policy and procedure (P&P) titled, "Core: Administration of Enteral Nutrition (use of a feeding tube to supply nutrients and fluids to the patient's body when the patient cannot safely chew or swallow)," dated June 2023, the P&P indicated, "1. The principal indication for enteral nutrition is a functional gastrointestinal tract with sufficient length and absorptive capacity and the inability to take nutrients through the oral route either totally or in part such as inability to swallow without choking or aspiration, or lack of sufficient alertness for oral nutrition ...The patient is monitored to identify and address any actual or potential complications related to the enteral nutrition formula, enteral nutrition infusion, or the feeding tube and the physician is notified to help evaluate and manage these complications ...Monitor the patient routinely for appropriate positioning ...Assess for GI (Gastrointestinal, made up of the mouth, the stomach, the intestines, etc.) intolerance to enteral tube feedings by assessing for abdominal distention, monitoring for complaints of abdominal pain, and observing for passage of flatus (gas generated in the stomach or bowels) and stool every shift and PRN (as needed). Look for marking on nasal tube at or near the exit of the nares from initial radiographic confirmation of placement. If mark is not visible or movement of nasal tube cannot be confirmed, call physician for an X-RAY (a test that captures images of the structures inside the body) order to confirm tube placement."

During a review of the facility's adopted guideline by Lippincott titled "Lippincott Procedures: Nasogastric or Orogastric Tube (tube inserted through the mouth) Monitoring," dated 12/11/2023, the guideline indicated, "Providing effective NG or OG tube care requires meticulous monitoring of the patient and the equipment. Monitoring the patient involves assessing GI function, including the volume and appearance of NG or OG tube drainage (if applicable). Monitoring the equipment involves verifying correct tube placement and function."

2. During a review of Patient 42's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 5/23/2024, the H&P indicated, Patient 42 was admitted to the facility's telemetry area (a hospital unit where patients with chronic heart conditions receive continuous cardiac monitoring) for treatment of respiratory failure (a serious condition that makes it hard to breathe on your own) and acute renal failure (a sudden episode of kidney failure or kidney damage

The H&P indicated, Patient 42's past medical history included hemodialysis (HD, a mechanical way to treat advanced kidney failure by removing waste products and excess fluid from blood), prolonged intubation (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their trachea [airway/windpipe]) and tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow air to fill the lungs), with ventilator dependency (a patient is unable to breathe independently without the use of a ventilator [machines that move air in and out of the lungs for patients who cannot independently breathe]), and percutaneous gastrostomy (PEG tube, a feeding tube that is surgically inserted through the abdominal wall and into the stomach,) placement.

During a review of Patient 42's medical record (MR) titled, "Telemetry Assessment," dated 6/7/2024, the MR indicated the following:
On 6/7/2024, at 8:00 a.m., Patient 42's heart rate (HR) was documented 88 beats per minute (bpm)
On 6/7/2024, at 12:00 p.m., Patient 42's HR was 116 bpm (normal HR is 60 to 100 bpm),
On 6/7/2024, at 4:00 p.m., Patient 42's HR was 140 bpm.

During further review of Patient 42's MR titled, "Telemetry Strip (the heart's activity is translated into line tracings)," dated 6/7/2024, the MR indicated the following:
On 6/7/2024, at 2:22 p.m., Patient 42's HR was 134 bpm.
On 6/7/2024, at 2:39 p.m., Patient 42's HR was 139 bpm.
On 6/7/2024, at 2:52 p.m., Patient's 42's HR was 140 bpm.

During a concurrent interview and record review on 7/24/2024 at 12:16 p.m., with the Patient Advocate/Employee Health Nurse (EHN 1) and the Chief Operational Officer (COO 1), Patient 42's medical records titled, "Telemetry Assessment" and "Telemetry Strip," dated 6/7/2024, were reviewed. The COO 1 stated, the facility's registered nurses do not have cardiac monitors (visual monitors displaying patients' heart activity and rhythm) set up anywhere inside the facility and registered nurses rely on central monitoring (Centralized Cardiac Telemetry Monitoring, the use of telemetry [monitoring cardiac activity]), if a patient develops a heart arrhythmia, the Telemetry Technician alerts the nurse who responds quickly to address the issue. The COO 1 stated, monitor technicians (MT, monitor multiple patient's heart activity and interpret heart rhythms from a central monitoring center covering multiple acute care locations) should report any changes in patients' heart activity to the supervising registered nurses. The EHN 1 stated, MT, working on 6/7/2024, day shift, should have notified Patient 42's supervising registered nurse of Patient 42's change in heart rate, but the EHN 1 was unsure when exactly the notification to the registered nurse should have been done.

During an interview on 7/24/2024 at 12:16 p.m. with the COO 1, the COO 1 stated, the MTs keep a separate log called "Telemetry Call Log," where notifications to registered nurses regarding any changes in cardiac activities are documented each shift. The COO 1 was unable to provide the log for the date of 6/7/2024, day shift (7:00 a.m. to 7:00 p.m.) and stated, the log has been missing and there is no way to verify if and when the monitor tech, working on 6/7/2024, day shift, notified Patient 42's supervising registered nurse of Patient 42's increasing heart rate.

During an interview on 7/24/2024, at 12:18 p.m., with COO 1, the COO 1 stated, ultimately, the RN is accountable for the care of their assigned patients and cardiac monitoring.

During an interview on 7/26/2024, at 10:18 a.m., with the monitor technician (MT 1), the MT 1 stated, typically, monitor technicians shall notify registered nurses when the heart rate increases above 120 bpm or decreases to below 50 bpm or when the heart rhythm (abnormal heartbeat) changes. The MT 1 further stated, once the supervising registered nurse is notified of changes in the patient's heart rate or rhythm, the information should be recorded in the "Telemetry Call Log," indicating the time of notification, observed changes, and who was notified.

During an interview on 7/26/2024 at 9:58 a.m. with the House Supervisor (HS 1), the HS 1 stated, MTs should notify registered nurses if any changes in patients' heart rate or rhythm are detected. The HS 1 stated, facility's registered nurses rely on centralized monitoring. The HS 1 stated, there are no cardiac monitors set up to display patients' heart activity and rhythms anywhere in the facility for the nurses to have a visual on their patients' cardiac rhythm and rate, but registered nurses can call the monitor technician or go to the centralized monitoring location to check on their patients.

During a review of Patient 42's medical record (MR) titled, "Change of Condition," dated 6/7/2024 at 4:38 p.m., the MR indicated, the physician was only notified of Patient 42's heart rate of 138 bpm at 4:38 p.m. on 6/7/2024. There was no notification of the physician regarding Patient 42's previous elevated heart rate at other times prior to 4:38 p.m.

During further review of Patient 42's MR titled, "Change of Condition," dated 6/7/2024, at 5:53 p.m., Patient 42 was transferred to intensive care unit (ICU, a unit in a hospital providing intensive care for critically ill or injured patients) for further treatment.

During a review of the facility's policy and procedure (P&P) titled "Interdisciplinary Assessment and Reassessment," dated 6/2023, the P&P indicated, "An RN directs the nursing care of every patient through delegation and supervision to other nursing and non-nursing personnel. The RN is accountable for the care outcomes of his/her patients. As a clinical decision maker and care coordinator, the RN oversees the direct care activities of other nursing staff and health professionals."

Based on interview and record review, the facility failed to develop and implement a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for two (2) of 51 sampled patients (Patient 12 and 32), in accordance with the facility's policy and procedures regarding care plan development when:

1. There was no care plan developed to address Patient 12's back pain. This deficient practice resulted in ineffective pain management for Patient 12 and Patient 12 suffering back pain.

2. There was no care plan for pneumonia (PNA, lung infection) developed for Patient 32. This deficient practice resulted in Patient 32's treatment and care goals not being met by not identifying the patient's needs and risks associated with PNA, such as hypoxemia (an abnormally low concentration of oxygen in the blood) and respiratory failure (a serious condition that makes it difficult to breathe on your own).

Findings:

1. During a review of Patient 12's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/13/2024, the H&P indicated Patient 12 was admitted to the facility's (Facility 2's) Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit with diagnoses of sepsis (a body's overwhelming and life-threatening response to infection), pneumonia (lung infection), and end stage renal disease (ESRD, a stage where the kidneys can no longer support the body's needs for waste removal and fluid balance). The H&P also indicated Patient 12 had back pain.

During a concurrent observation and interview on 7/23/2024 at 1:05 p.m. with the Infection Control (IP 2) in Patient 12's room, observed Patient 12 pressing call light for assistance in repositioning and back pain problem.
During an interview on 7/23/2024 at 1:10 p.m. with Patient 12, Patient 12 stated he (Patient 12) did not know what pain medications was given but he (Patient 12) did not think the pain medication he (Patient 12) received, was effective. Patient 12 stated, "I still had pain."

During a concurrent interview and record review on 7/23/2024 at 1:52 p.m. with Licensed Vocational Nurse (LVN) 4, Patient 12's "Medication Administration Record (MAR, record of medications given to patients)," dated 7/23/2024, was reviewed. The MAR indicated Tylenol (medication to relief pain) 650 milligrams (mg, unit of measure) by mouth was given on 7/23/2024 at 10:30 a.m. for pain level of 6/10 from a numeric pain scale type (0-10, a pain scale used in rating the severity of pain with 0 being no pain, 1-3 for mild pain, 4-6 for moderate pain and 7-10 for severe pain). LVN 4 stated after the pain medication was given, she (LVN 4) should recheck Patient 12's pain level but she (LVN 4) was too busy and did not reassess Patient 12's pain level.

During an interview on 7/23/2024 at 2:44 p.m. with Registered Nurse (RN) 15, RN 15 stated pain re-assessment should be performed within an hour after the pain medication was given to a patient by mouth. RN 15 stated the purpose of pain reassessment was to check if pain medication was effective or not. RN 15 stated if the pain medication was not effective, then nurse may contact physician for further order in order to keep the patient comfortable.

During a concurrent interview and record review on 7/25/2024 at 11:45 a.m. with the House Supervisor (HS) 2, Patient 12's "care plan (care plan, provides a framework for evaluating and providing patient care needs related to the nursing process)," dated 7/13/2024, was reviewed. The care plan indicated, there was no care plan addressing Patient 12's pain. HS 2 stated there should be a care plan related to pain developed for Patient 12 to address his (Patient 12) back pain. HS 2 stated without the care plan, nursing staff would not know what and how to manage Patient 12's pain.

During a review of the facility's policy and procedure (P&P) titled, "CORE: Pain Management Plan," dated 6/2023, the P&P indicated, "The pain management plan delineates the necessary assessments, interventions, monitoring, and patient/family education to promote effective pain relief ...Nursing delivery of care ... Patient Plan of Care ...the registered nurse will develop a patient specific plan of care with identification of pain when conducting the patient's admission assessment and/or anytime during the patient's hospital stay. A licensed nurse involved in the care of the patient will update the patient specific plan of care as needed. The plan of care should consider realistic pain relief goals based on the individual patient's pain history and the patient's description of their own patient tolerance."

2. During a review of Patient 32's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 7/21/2024, the H&P indicated, Patient 32 was admitted to facility (Facility 1) telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit on 7/21/2024 to continue respiratory care (a field of treatment that helps people with respiratory conditions improve and maintain their breathing and lung function) and pulmonary toilet (a set of procedures and exercises that help clear mucus and other secretions from the airways) after a recent diagnosis with COVID pneumonia (a lung infection caused by SARS CoV-2, the virus that causes COVID-19).

During a concurrent interview and record review on 7/24/2024 at 12:01 p.m. with the Clinical Educator (CE 1), Patient 32's medical record (MR), from 7/21/2024 through 7/24/2024, was reviewed. The CE 1 stated, Patient 32 was admitted with COVID pneumonia. The CE 1 also said there was no nursing care plan on file to address potential problems associated with pneumonia for Patient 32 from 7/21/2024 through 7/24/2024.

During further interview on 7/24/2024 at 12:01 p.m. with the CE 1, the CE 1 stated registered nurses are responsible for developing and maintaining current nursing care plans for each patient. The CE 1 also said nursing care plans help registered nurses navigate goals and identify appropriate interventions to meet patients' care needs.

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Assessment and Reassessment," dated 6/2023, the P&P indicated, "The admission assessment data is a primary source for the registered nurse (RN) to determine and prioritize nursing care needs specific to the patient. A patient Plan of Care developed and recorded within 24 hours of admission by the RN based on identified problems that reflect the patient's goals and the nursing care to be provided to meet the patients' specific needs."

Based on observation, interview, and record review, the facility failed to:

1. Ensure nursing staff at Facility 2 notified the physician (MD 2) regarding a change of condition for one (1) of 51 sampled patients (Patient 2), in accordance with the facility's policy and procedure regarding Reporting/Notification of a change of condition (a clinically important deviation from a patient's baseline health condition that without interventions may result in complications or death), when Registered Nurse (RN) 5 identified Patient 2 with urethra (duct [tube of the body] by which urine leave the body) and mouth bleeding on 3/29/2024 at 8 p.m.

This deficient practice resulted in Patient 2's worsening bleed and Patient 2 was found unresponsive (unconscious, possibly dead or dying) with large amount of hemoptysis (coughing up blood) on 3/30/2024 at 3:02 p.m. (19 hours later). Patient 2 eventually passed away at 3:47 p.m. (within 48 hours of admission).


2. Identify a change of condition (a clinically important deviation from a patient's baseline health condition that without interventions may result in complications or death) and notify the physician regarding a decline in vital signs (VS, measurements of the body's most basic functions, such as breathing rate, body temperature, pulse rate, and blood pressure) for one (1) of 51 sampled patients (Patient 32), in accordance with the facility's policy and procedure pertaining to Reporting/Notification of a change of condition.

This deficient practice resulted in Patient 32's condition deterioration leading to emergency intubation (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their trachea [airway/windpipe]) to provide artificial ventilation (breathing). and may have possibly contributed to Patient 32's negative outcome (death).

3. Perform and document a Venous Thromboembolism (VTE, a condition that occurs when a blood clot forms in a vein that carries blood back to the heart) Risk Assessment and need for therapy for one (1) of 51 sampled patients (Patient 32), in accordance with the facility's policy and procedure regarding Anticoagulation Management Program. This deficient practice had the potential to increase Patient 32's risk for VTE which can result in mortality (death) by not identifying Patient 32's need for anti-coagulation (treatment with anticoagulant [blood thinning] drugs to reduce the risk of the formation of blood clots) therapy.

4. Obtain and document routine vital signs (VS, measurements of the body's basic functions, such as breathing, heart rate, and temperature) for one (1) of 51 sampled patients (Patient 32), as per physician's order and in accordance with the facility's policy and procedure regarding routine vital signs. This deficient practice had the potential for Patient 32's change of condition (a clinically important deviation from a patient's baseline health condition that without interventions may result in complications or death) to remain undetected and unmonitored, predisposing Patient 32 for negative outcomes such as clinical deterioration (physiological changes detected by monitoring vital signs) and or death.

5. Label two (2) of two sampled glucose strips containing bottles (glucose [sugar] test strips are medical devices that come in protective, resealable bottles and are used to measure blood sugar levels) after opening to indicate the expiration date, as per manufacturer's instruction. This deficient practice had the potential to compromise the safety and wellbeing of the facility's patients if expired glucose test strips give inaccurate readings, which can be dangerous for patients such as those with diabetes (a disease that occurs when the blood sugar is too high) who use insulin (moves sugar from the bloodstream to the body's cells to produce energy) and adjust their dose of insulin based on their blood sugar level readings using the glucose test strips.

6. Label a formula bag (a bag that contains a liquid nutritional formula that is fed directly into a patient's stomach or intestine through a feeding tube [medical device used to provide nourishment, fluids, and medications by bypassing oral intake]) hang date and time for one patient of 51 sampled patients (Patient 34), in accordance with the facility's policy and procedure regarding labeling enteral nutrition bags. This deficient practice had the potential to compromise Patient 34's wellbeing by being administered a contaminated formula if the formula exceeded recommended hang time of 24 hours.

IJ Statements:

1. On 7/24/2024 at 6:24 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements have caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Regional Chief Operation Officer (RCOO), the Chief Operation Officer/Chief Clinical Officer (COO 2), and the Director of Quality and Risk Management (DQM 2). The facility (Facility 2) failed to identify a change of condition requiring notification to the physician, as per facility's policy and procedure resulting in Patient 2 coding (cardiac arrest [absent or abnormal heart activity]) and eventually expired (died).

On 3/28/2024, Patient 2 was admitted to the facility's (Facility 2's) telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit for pneumonia (lung infection). On 3/29/2024 at 8 p.m., Registered Nurse (RN) 5 identified Patient 2 had bleeding from urethra (a tube of the body by which urine leave the body) and mouth. There was no notification to physician for Patient 2's change of condition regarding the bleeding. On 3/30/2024 at 3:02 p.m., Patient 2 was found with abrupt, large amount of hemoptysis (coughing up blood), ashen skin color (extremely pale color), and pupils already glazed, no blinking. The facility activated rapid response (a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration). House supervisor and resource nurse RN rushed with crash cart (container carrying medicine and equipment for use in emergency resuscitations). On 3/30/2024 at 3:05 p.m. Code Blue (hospital emergency code use to summon help when a patient is in need of resuscitation) was initiated and Cardio-pulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) started. Patient 2 passed away on 3/30/2024 at 3:47 p.m.

On 7/25/2024 at 6:27 p.m., the IJ was removed in the presence of the Senior Vice President Pacific Region (SVPPR), the Chief Operating Officer (COO 2), the Director of Quality & Risk Management (DQM 2), and the Director of Nursing Care Services (DNCS 2). The elements of the IJ Removal Plan (interventions to correct the deficient practice) were verified and confirmed through observations, interviews, and record reviews. The IJ Removal Plan indicated that for immediate action taken by the facility, on 7/24/2024, the primary nurses immediately reassessed all patients in house for any change of condition (COC, a clinically important deviation from a patient's baseline health condition that without interventions may result in complications or death), including but not limited to bleeding, change in respiratory status, cardiac status, and hemodynamic status (adequate blood flow to various organs [heart, lungs, kidney, etc.]in the body). This was completed on 07/24/2024 and continued with each shift.

Education began with nursing (RN, LVN [Licensed Vocational Nurse], CNA [Certified Nursing Assistant], Monitor Techs) and respiratory staff that were on duty on 7/24/2024. This re-education was also repeated before the shift started for the day shift on 7/25/2024 and will continue to be repeated on all shifts at the beginning of each shift until all nursing and respiratory staff have been re-educated. The nursing and respiratory staff were and will be re-educated on the following: An acute change of condition, identifying acute changes of conditions, changes in the condition of the patient are determined by assessments using clinical parameters, current and past documented medical condition, medical orders, and/or by patient safety factors, review examples of the types of condition changes, review of Interdisciplinary Assessment & Reassessment Policy, and review of ProTouch (system that allows the tracking of patients' change of condition) instructions, and the education also included upon discovery of condition change from baseline, the steps the first responder must take.

The IJ removal plan also included monitoring and auditing plans to ensure that nursing staff address patient change of condition. Audits were also done and will continue regarding notification and escalation of change of condition per facility policy.

2. On 7/24/2024 at 6:29 p.m., the survey team called a second Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Senior Vice President of Pacific Region (SVPPR), Chief Operating Officer (COO 1), Director of Clinical Services (DCS 1), and the Chief Executive Officer (CEO). On 7/22/2024, the facility failed to identify a change of condition (a clinically important deviation from a patient's baseline health condition that without interventions may result in complications or death) and decline in vital signs (VS, measurements of the body's most basic functions, such as breathing rate, body temperature, pulse rate, and blood pressure) in a patient (Patient 32) requiring notification to the physician, as per facility's policy and procedure, resulting in Patient 32's condition deterioration leading to intubation (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their trachea (airway/windpipe) to provide artificial ventilation [breathing]).

Patient 32 was admitted to facility (Facility 1) telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit on 7/21/2024 to continue respiratory care (a field of treatment that helps people with respiratory conditions improve and maintain their breathing and lung function) and pulmonary toilet (a set of procedures and exercises that help clear mucus and other secretions from the airways) after a recent diagnosis with COVID pneumonia (a lung infection caused by SARS CoV-2, the virus that causes COVID-19).

Patient 32's diagnoses included respiratory failure (a serious condition that makes it difficult to breathe on your own) secondary to COVID-19 pneumonia with superinfection (Infectious process in which a second infection develops additionally) of bacterial infection Klebsiella pneumoniae (bacteria associated with pneumonia), Parkinson's dementia (a brain condition that causes problems with movement, mental health, sleep, pain, and other health issues eventually leading to a loss of intellectual functioning), hypertension (a medical condition where the pressure in the blood vessels is too high), and hyperlipidemia (an abnormally high concentration of fats or lipids in the blood).

On 7/22/2024, at 8:15 p.m., Patient 32 was found tachypneic (a medical term that describes rapid, shallow breathing in adults) with audible crackles (sounds like bubbling, popping, or clicking noises, audible [heard] during inhalation [breathing in]) on room air. Patient 32's oxygen saturation level (O2Sats, a measure of the percentage of oxygen in a person's blood) was at 73% (normal is 90 - 100 %) and Patient 32 was placed on supplemental oxygen delivered by a non-rebreather mask (NRM, a type of oxygen mask that gives a person a lot of oxygen, typically in an emergency).

On 7/22/2024, at 8:43 p.m., Patient 32's oxygen saturation level was 85% (an oxygen saturation level of 85% could be a sign of hypoxemia, which means the body is not getting enough oxygen to function properly), and Patient 32 was receiving 100% oxygen. No interventions addressing the abnormal oxygen saturation level were documented. No additional vital signs (include temperature (T), blood pressure (BP), heart rate (HR), and respiratory rate [RR]) were recorded. No documentation of the physician being notified of Patient 32's abnormal oxygen saturation level was documented either.

On 7/23/2024, at 12:09 a.m., Patient 32's cardiac strip (records the electrical signals from a heart and captures them on a computer monitor) indicated, Patient 32's HR was 106 and RR was 33 breaths per minute [BPM] (respiratory rate of 33 BPM is considered abnormal for a resting adult). In addition, on at 12:25 a.m., Patient 32's vital signs indicated: T was 98.8 Fahrenheit (F, the Fahrenheit scale of temperature), BP was 104/64 mm Hg (millimeters of mercury, measuring unit), HR was 104 beats per minute (bpm). No oxygen saturation rate and respiratory rate recorded.

Later, at 3:57 a.m., Patient 32's cardiac strip indicated, Patient 32's RR was still 31 bpm and at 4:10 a.m., Patient 32's vital signs indicated: T was 96.0 F, BP was 95/62 mm Hg, and HR was 94 bpm. No oxygen saturation rate and respiratory rate recorded. No documentation of the physician being notified of Patient 32's declining vital signs and continued increased respiratory rate was recorded in Patient 32's medical record. No additional records of assessment of Patient 32's oxygen saturation level was also documented in the medical chart during 10:19 p.m. on 7/22/2024 through 7:30 a.m. on 7/23/2024. During an interview, clinical educator (CE) reviewed Patient 32's vital signs records and stated, the physician should have been notified about the change of condition, as per facility's policy and procedures.

On 7/23/2024, at 7:30 a.m., a respiratory therapist (RT) found Patient 32 on a nonrebreather mask, saturating 82%, with labored breathing (breathing that is difficult or impaired) and respirations of 30 BPM. A Rapid Response (a system implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration) was called for Patient 32 at 7:53 a.m., followed by a transfer of Patient 32 to an intensive care unit (ICU, a unit in a hospital providing intensive care for critically ill or injured patients), where Patient 32 was intubated (placement of a flexible plastic tube into the trachea to maintain an open airway).

On 7/26/2024 at 10:30 a.m., the 2nd IJ was removed in the presence of the Senior Vice President of Pacific Region (Sr. VP), Chief Operating Officer (COO 1), Director of Clinical Services (DCS 1), and the Chief Executive Officer (CEO) after the facility submitted an acceptable IJ Removal Plan (Interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record reviews. The IJ Removal Plan indicated that for immediate action taken by the facility (Facility 1) all facility's patients were assessed for current Change of Conditions (COC) including, but not limited to, bleeding, change in respiratory status, cardiac status and/or hemodynamic status (adequate blood flow to various organs [heart, lungs, kidney, etc.]in the body). This was completed on 7/24/2024 and will continue each shift.

Education and training began on 7/24/2024, with the night shift nursing (RN, LVN, and CNA's) and respiratory staff (RT) that were on duty. This re-education was also repeated before the shift started for the day shift on 07/25/2024 and continued to be repeated on all shifts at the beginning of each shift until all nursing and respiratory staff have been re-educated. The nursing and respiratory staff were and will be re-educated on the following: Frequency of obtaining routine Vital Signs, Change of Conditions, RN process of how to document "RN Oversight," identification and documentation of the change of condition, reassessment, and resolution of the change of condition utilizing the Change of Condition Pathway in the electronic medical record (EMR, a digital version of the paper chart).

In addition, the Plan included implementation of the change of condition protocol. This included identification of the change of condition by any discipline and relaying the information to primary RN. The facility mandates that the primary RN will initiate documentation via change of condition pathway in the EMR and will implement and document the following: signs and symptoms observations, vital signs, physician notification, family notification, treatment initiated and response to treatment, comments, and Care Plan ((provides a framework for evaluating and providing patient care needs related to the nursing process) as needed. Once implementation(s)/intervention(s) are completed, RN will reassess the patient to ensure patient's condition has returned to baseline condition and is stable, and document same. If the patient is not stable, change of condition protocol will continue to be followed. At the end of each shift the "RN Oversight" will be executed, at which point, RN has verified, if any, change of condition have occurred, the correct documentation and notification were completed.

The IJ removal plan also included monitoring measures to ensure that a patient's change of condition is addressed in a timely manner. The IJ removal included auditing regarding notification and escalation of change of condition per facility policy.

Findings:

1. During a review of Patient 2's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/28/2024, the H&P indicated Patient 2 was admitted to the facility's (Facility 2's) Telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit on 3/28/2024 with diagnoses of acute (new onset) pneumonia (lung infection) associated with sepsis (a body's overwhelming and life-threatening response to infection) and acute hypoxic (deficiency in the amount of oxygen reaching the tissues) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood).

During a concurrent interview and record review on 7/24/2024 at 2:37 a.m. with the House Supervisor (HS) 2, Patient 2's Medication Administration Record (MAR, record of medications given to patients) from 3/29/2024 to 3/30/2024 was reviewed. The MAR indicated the following:

3/29/2024 at 8:30 a.m. Aspirin (medication that can treat pain, fever and reduce risk of heart attack, also has increased risk for bleeding) 81milligrams (mg, unit of measure) by mouth daily given by Licensed Vocational Nurse (LVN) 5

3/29/2024 at 8:30 a.m. Heparin (blood thinner that stops the blood from forming blood clots) 5000 units subcutaneous (fatty tissue just under the skin) injection every 12 hours given by LVN 5

3/30/2024 at 12:34 a.m. Heparin 5000 units subcutaneous injection every 12 hours not given due to "Patient (Patient 2) has bleeding from urethra (duct [tube of the body] by which urine leave the body), mouth" by RN 5

3/30/2024 at 2:06 a.m. Heparin 5000 units subcutaneous injection every 12 hours not given due to "Patient (Patient 2) has bleeding" by RN 5

3/30/2024 at 9:26 a.m. Aspirin 81 mg not given due to "held for bloody secretions, RN aware" by LVN 5

3/30/2024 at 9:26 a.m. Heparin 5000 units subcutaneous injection every 12 hours not given due to "held for bloody secretions" by LVN 5

HS 2 stated RN 5 and LVN 5 should have reported the bleeding to the physician. HS 2 stated there was no document of "Change of Condition (COC, facility 2's nursing documentation for patient's change of condition)" by RN 5 and LVN 5 relating to Patient 2's bleeding.

During a concurrent interview and record review on 7/24/2024 at 2:55 p.m. with HS 2, Patient 2's "Nursing Assessment," dated 3/29/2024 was reviewed. The nursing assessment indicated on 3/29/2024 at 8 p.m., "Patient (Patient 2) had bleeding from urethra (duct by which urine leave the body) ... bleeding from oral cavity (mouth). HS 2 stated it (referring to the urethra and oral cavity bleeding) was a change of condition (a clinically important deviation from a patient's baseline health condition that without interventions may result in complications or death) and RN 5 did not report to the physician the location of bleeding and amount of bleeding for physician order and instruction.

During an interview on 7/24/2024 at 2:56 p.m. with HS 2, HS 2 stated RN 5 did not follow the process and did not contact the physician. HS 2 stated there would be a potential risk for delay of care for not reporting change of condition, and Patient 2's bleeding could get worse.

During an interview on 7/24/2024 at 3:01 p.m. with HS 2, HS 2 stated Patient 2 was on Aspirin and Heparin which were medications that placed Patient 2 at high risk for bleeding.

During a review of Patient 2's "care plan (provides a framework for evaluating and providing patient care needs related to the nursing process)," dated 3/28/2024, the care plan indicated, Patient 2's care problem with risk for bleeding with intervention including observing for signs and symptoms of bleeding.

During a review of Patient 2's "Change of Condition (COC, nursing documentation for patient's change of condition)," dated 3/30/2024, the COC indicated, "Patient (Patient 2) suddenly experienced abrupt, large amount of hemoptysis (coughing up blood) ... arrived and observed immediately that patient (Patient 2) looked ashened (extremely pale looking) and pupils already glazed, no blinking ...3:05 p.m. Code Blue (hospital emergency code use to summon help when a patient is in need of resuscitation) was initiated and Cardio-pulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) started ...patient (Patient 2) expired (died) on 3/30/2024 at 3:47 p.m."

During a review of the facility's policy and procedure (P&P) titled, "CORE: Interdisciplinary Assessment and Re-assessment," dated 6/2023, the P&P indicated, "Reporting/ Notification of a change of condition ... an acute (sudden and severe onset) change of condition is a clinically important change from a patient's established and documented baseline in physical, cognitive (related to thinking, learning, and understanding), behavioral, or functional domains (interpersonal activities, self-care, etc.). An acute change in condition may occur abruptly or over several hours to several days, presenting as physical changes or as changes in function, mood, cognition, or behavior ... because a change in condition depends in part on the patient's prior condition and because there are numerous physical and mental symptoms that may signal a patient's change in condition ... nurse concern of any situation in which the nurse feels uncomfortable with the patients' condition and/ or response to treatment ... Notification responsibilities when an assessment reveals a change or suspected change in condition ... The nurse assigned to the patient or supervising the care of the patient is responsible for notification of and communication to the patient's primary physician or designee using appropriate channels and chain of command for assuring that there is physician response ... document change of condition, notification and interventions in the medical record (Electronic medical record [EMR, digital version of the paper chart]), facilities document under the 'Change of Condition' Pathway."

2. During a review of Patient 32's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 7/21/2024, the H&P indicated, Patient 32 was admitted to facility (Facility 1) telemetry (a floor in the hospital where patients receive continuous cardiac [heart] monitoring) unit on 7/21/2024 to continue respiratory care (a field of treatment that helps people with respiratory conditions improve and maintain their breathing and lung function) and pulmonary toilet (a set of procedures and exercises that help clear mucus and other secretions from the airways) after a recent diagnosis with COVID pneumonia (a lung infection caused by SARS CoV-2, the virus that causes COVID-19).

During further review of Patient 32's H&P, dated 7/21/2024, the H&P indicated, Patient 32's past medical history (PMH, a record of information about a person's health) included respiratory failure (a serious condition that makes it difficult to breathe on your own) secondary to COVID-19 pneumonia with superinfection (infectious process in which a second infection develops additionally) of bacterial infection Klebsiella pneumoniae (bacteria associated with pneumonia), Parkinson's dementia (a brain condition that causes problems with movement, mental health, sleep, pain, and other health issues eventually leading to a loss of intellectual functioning), hypertension (a medical condition where the pressure in the blood vessels is too high), and hyperlipidemia (an abnormally high concentration of fats or lipids in the blood).

During a review of Patient 32's Medical Record (MR) titled, "Change of Condition (COC, facility 1's nursing documentation for patient's change of condition)," dated 7/22/2024 at 8:15 p.m., the MR indicated, Patient 32 was found tachypneic (a medical term that describes rapid, shallow breathing in adults) with audible crackles (sounds like bubbling, popping, or clicking noises, audible [heard] during inhalation [breathing in]) on room air. The MR indicated, Patient 32's oxygen saturation level (O2Sats, a measure of the percentage of oxygen in a person's blood) was at 73% (normal is 90 - 100 %) and Patient 32 was placed on supplemental oxygen delivered by a non-rebreather mask (NRM, a type of oxygen mask that gives a person a lot of oxygen, typically in an emergency).The MR further indicated, the physician was notified of Patient 32's change of condition, and new orders for Lasix (used to treat the symptoms of fluid retention), arterial blood gases (ABGs, a blood test that measures the levels of oxygen and carbon dioxide in the blood, as well as the blood's acidity) level, and a breathing treatment were placed and carried out. The MR indicated, Patient 32's oxygen saturation improved to 94% while on nonrebreather mask and after Lasix administration.

During a concurrent interview and record review on 7/24/2024 at 10:20 a.m. with the Clinical Educator (CE 1), Patient 32's medical record (MR) titled, "Change of Condition," dated 7/22/2024, at 8:43 p.m., was reviewed. The MR indicated, Patient 32 desaturated (the condition of a low blood oxygen concentration) to 85% and was receiving 100% oxygen. No notification to the physician was recorded in Patient 32's medical record regarding desaturation to 85% while receiving 100% oxygen. CS 1 stated, any change in a patient condition must be communicated to the physician, but the registered nurse (RN) did not document notification to the physician regarding Patient 32 desaturating to 85% while receiving 100% oxygen.

During a review of Patient 32's MR titled, "Respiratory Care," dated 7/23/2024 at 12:00 a.m., the MR indicated, Patient 32 received a breathing treatment, but no oxygen saturation rate was documented.
During a review of Patient 32's "Vital Signs (VS, measurements of the body's most basic functions. The four main vital signs routinely monitored by medical professionals include the following: body temperature (T) pulse rate (HR) respiration rate (RR, rate of breathing), and blood pressure [BP])" record , dated 7/23/2024, at 12:25 a.m., the record indicated, Patient 32's T was 98.8 Fahrenheit (F, the Fahrenheit scale of temperature), BP was 104/64 mm Hg (millimeters of mercury, measuring unit), HR was 104 beats per minute (bpm). No oxygen saturation rate was recorded.

During a review of Patient 32's MR titled, "Respiratory Care," dated 7/23/2024 at 3:30 a.m., Patient 32 received another breathing treatment, but no oxygen saturation rate was recorded.

During a review of Patient 32's "Vital Signs" record, dated 7/23/2024 at 4:10 a.m., the record indicated, Patient 32's temperature was 96.0 F [considered low for adults], Pulse was 94 bpm, and BP was 95/62 mm Hg [BP of 95/62 is considered low in adults], and breathing rate was 26 breaths per minute [increased respiratory rate], no oxygen saturation rate was recorded.

During an interview on 7/24/2024 at 10:20 a.m., with CE 1, the CE 1 stated, Patient 32's VS obtained on 7/23/2024 at 4:10 a.m. should have been reported to the physician as a change of patient (Patient 32) condition. CE 1 further stated, registered nurses provide oversight for their patients and are responsible for communicating any changes in patients' conditions to the physician.

During a record review of Patient 32's MR, dated 7/23/2024, the registered nurse, taking care of Patient 32 on 7/23/2024, night shift, did not document a change of Patient 32's condition and did not document notification to the physician regarding Patient 32's change in vital signs.

During a review of Patient 32's MR titled, "Change of Condition," dated 7/23/2024, at 7:30 a.m., the MR indicated, Patient 32 was found on nonrebreather mask, saturating 82%, with labored breathing (breathing that is difficult or impaired) and respirations of 30 breaths per minute. The MR further indicated, a Rapid Response (a process for working with a rapidly declining patient) was called for Patient 32 at 7:53 a.m., followed by a transfer of Patient 32 to an intensive care unit (ICU, a unit in a hospital providing intensive care for critically ill or injured patients), where Patient 32 was intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their trachea [airway/windpipe]).

During a review of Patient 32's MR titled, "Code Blue (hospital emergency code use to summon help when a patient is in need of resuscitation) Flowsheet (a chart used as a quick visual guide for responding to a medical emergency)," [ dated 7/25/2024, the MR indicated, on 7/25/2024 at 10:51 a.m., Patient 32 had a cardiopulmonary arrest (cessation of adequate heart function and respiration and results in death) and at 11:10 a.m. Patient 32 was pronounced dead.

During a review of the facility's policy and procedure (P&P) titled, "CORE: Interdisciplinary Assessment and Re-assessment," dated 6/2023, the P&P indicated, "Reporting/ Notification of a change of condition ... an acute (sudden and severe onset) change of condition is a clinically important change from a patient's established and documented baseline in physical, cognitive (related to thinking, learning, and understanding), behavioral, or functional domains (interpersonal activities, self-care, etc.). An acute change in condition may occur abruptly or over several hours to several days, presenting as physical changes or as changes in function, mood, cognition, or behavior ... because a change in condition depends in part on the patient's prior condition and because there are numerous physical and mental symptoms that may signal a patient's change in condition ... nurse concern of any situation in which the nurse feels uncomfortable with the patients' condition and/ or response to treatment ... Notification responsibilities when an assessment reveals a change or suspected change in condition ... The nurse assigned to the patient or supervising the care of the patient is responsible for notification of and communication to the patient's primary physician or designee using appropriate channels and chain of command for assuring that there is physician response ... document change of condition, notification and interventions in the medical record (Electronic medical record [EMR, digital version of the paper chart]), facilities document under the 'Change of Condition' Pathway."

During a review of the facility's policy and procedure (P&P) titled, "CORE: Interdisciplinary Assessment and Re-assessment," dated 6/2023, the P&P indicated, "14.c. Changes in the condition of the patient are determined by assessments using clinical parameters, current and past documented medical condition, medical orders, and by patient safety factors. 15.a. The nurse assigned to the patient is responsible for notification of and communication to the patient's primary physician for assuring that there is a physician response. Documentation of change of condition, notification and interventions shall be done in the medical record."
During further review of the facility's policy and procedure (P&P) titled, "Assessment and Re

Based on observation, interview, and record review, the facility failed to ensure staff safely stored and secured a medication (Metoprolol tablet [medication to lower blood pressure]) for one (1) of 51 sampled patients (Patient 24) prior to administration, in accordance with the facility's policy and procedure regarding Medication Management. The Medication (Metoprolol) was crushed and placed inside a pouch with no label and was left on top of a medication cart.

This deficient practice had the potential for the crushed medication in a pouch to be contaminated and administered to Patient 24 or taken by someone else for use, which may cause patient harm such as infection, etc.

Findings:

During a review of Patient 20's "Face Sheet (FS, a document that gives a patient's information at a quick glance and includes the patient's name, date of birth, address, etc.)," dated 7/2024, the FS indicated Patient 24 was admitted to room 6, in the facility's (Facility 3) Intensive Care Unit (ICU, a unit in a hospital providing intensive care for critically ill or injured patients) on 6/21/2024 for Respiratory Failure (condition in which not enough oxygen passes from the lungs into the blood).

During a review of Patient 24's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/2024, the H&P indicated the following: Patient 24 with a history of Hypertension (high blood pressure), Diabetes (elevated blood sugar level), and Seizures (a sudden, uncontrolled burst of electrical activity in the brain that cause changes in behavior, movements, etc.). Patient 24 was ventilator (machines that move air in and out of the lungs for patients who cannot independently breathe) dependent.

During a review of Patient 24's "Medication Administration Recorded (MAR)," dated 7/2024, the MAR indicated the following: Patient 24 had an order for Metoprolol (lowers blood pressure) Medication for blood pressure to be administered every 12 hours.

During a concurrent observation and interview on 7/23/2024 at 1:34 p.m. with Registered Nurse Educator (RNE 1) in the Intensive Care Unit Medication room, the medication cart labeled for Patient 24, was observed with 1 unlabeled medication pill crushed in a plastic pouch. RNE 1 stated the following: The medication in the plastic pouch should not be left unsecured and left in the med cart. If the medication was not used, it should be discarded or put in a secured cabinet. The staff nurse who left it there could mistakenly not know what medication was left there and also someone else can enter the medication room and take the medication since it was unsecured, will educate the staff on this situation. The medication left crushed in the pouch can be contaminated. If the patient takes the contaminated medication, it can cause complication (example: vomiting, infection, etc.) to the patient (Patient 24).

During an interview on 7/23/2024 at 1:42 p.m. with Registered Nurse (RN) 11, RN 11 stated the following: RN 11 Confirmed a medication was left unsecured and unlabeled on the medication cart belonging to Patient 24. RN 11 unable to identify medication left in the medication cart.

During an interview on 7/23/2024 at 1:42 p.m. with Registered Nurse Educator (RNE) 1, RNE 1 stated the following: Looked up the medication left in medication cart for Patient 24 and identified that the medication left unlabeled and unsecured was Metoprolol (a blood pressure medication). The staff should be discarding the medication if not using the medication or return the medication if not used. In this case since the medication was crushed already the staff should be discarding the medication if not used.

During an interview on 7/24/2024 at 9:24 a.m., with the Registered Nurse Educator (RNE) 1, RNE 1 stated the following: Confirmed RN 11 did not follow the policy of Medication Management for Patient 24. Prepared medication should not be left unsecured.

During an interview on 7/24/2024 at 11:43 a.m. with the Director of Nursing (DON) 1, DON 1 stated the following: Confirmed Patient 24's medication was left unsecured in the Intensive Care Unit Medication room and staff did not follow Medication Management policy. Education was provided to the staff regarding the Medication Management policy.

During a review of the facility's policy and procedure (P&P) titled, "Medication Management," dated 6/2022, the P&P indicated the following: "PURPOSE: This procedure establishes a system by which medications will be administered to patients safely, accurately, and efficiently by qualified personnel. POLICY: The policy of Kindred Hospital is to ensure the following: All medications must be properly stored/secured at all times prior to administration. Prepared medications must never be left unsecured."

Based on observation, interview, and record review, the facility failed to:

1. Ensure one (1) of 51 sampled patient's (Patient 1) oxygenation (the process of ensuring adequate levels of oxygen in the body) was reassessed following a critical result (test results that fall significantly outside the normal range and may represent life-threatening values even if from routine tests) of a prior arterial blood gas (ABG, a test to measure the balance of oxygen and carbon dioxide in the blood) and not following orders to collect a repeat arterial blood gas after placing Patient 1 on a higher level of oxygen therapy (BIPAP, Bilateral positive airway pressure oxygen therapy to aid in breathing), in accordance with the facility's (Facility 2) policy and procedure regarding Assessment and Reassessment of Respiratory Status (how well a patient is producing air exchange).

This deficient practice had the potential to delay treatment and compromise Patient 1's safety and putting Patient 1 at risk for unidentified hypoxemia (low oxygen levels) in which the new oxygen therapy was not working and the patient may continue to experience low oxygen levels despite being on increased oxygen therapy.

2. Ensure one (1) of 51 sampled patient's (Patient 7) pulse oximetry (device used to measure level of oxygen) alarm was set at a parameter (set limit) that follows the facility's respiratory protocol or have a physician order for setting the oxygen level at which the pulse oximetry alarm will activate, in accordance with the facility's (Facility 2) policy and procedure regarding Oxygen Therapy Protocol.

This deficient practice poses a safety risk for Patient 7, including inadequate monitoring, unidentified low oxygen level, and may likely cause a delay in responses to critical changes in the patient's (Patient 7) respiratory condition.

Findings:

1. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 1/25/2024, the "H&P" indicated, Patient 1's medical history included HTN (hypertension, high blood pressure), uncontrolled DM (Diabetes, a disease that occurs when the blood sugar is too high), renal failure (one or both of your kidneys no longer function well on their own), with acute respiratory failure (an inability to maintain adequate oxygenation) with history of intubation (the insertion of a tube into a patient's windpipe to aid in ventilation [breathing]). The H&P further indicated Patient 1 was "Transferred to (facility name [Facility 2]) for further management. Upon evaluation, Patient (Patient 1) in ICU (Intensive Care Unit, a unit in a hospital providing intensive care for critically ill or injured patients) on Oxymizer (a device placed in the nostrils to deliver continuous high-flow oxygen) support. Patient is alert and oriented."

During a concurrent interview and record review on 7/24/2024 at 10:42 p.m. with the Director of Respiratory Services (DRS), Patient 1' order report for ABG dated 2/17/2024 at 8:43 p.m., was reviewed. The order for ABG indicated, "Arterial blood gases, start today, 2/17/2024, time 1 (one), read back verification: Yes, order read back to provider." DRS stated, "A repeat ABG order should be completed as soon as time permits. Usually, an hour after the new treatment for most physicians." DRS also stated he (DRS) was unsure about the reason that the repeat ABG was not completed by the respiratory therapist. DRS stated, "It could be the respiratory therapist was busy tending to the patient (Patient 1)." However, DRS also stated, "If the respiratory therapist is unable to carry out task such as a repeat ABG, he must go to supervisor," to help collect the repeat ABG.

During a concurrent interview and record review on 7/24/2024 at 12:40 p.m. with Registered Nurse (RN) 4, Patient 1's Respiratory note dated 2/17/2024 at 8:38 p.m., was reviewed. The respiratory note indicated, "Patient (Patient 1) in distress (abnormal symptoms), ABG shows PH 7.17 (the acidity of the blood which may signify an abnormality in gas exchange) ... Inform (physician name) for BIPAP (Bilateral positive airway pressure oxygen therapy to aid in breathing) order and agree, ordered a follow up ABG order ..." RN 4 confirmed the ABG results was a critical result (test results that fall significantly outside the normal range and may represent life-threatening values even if from routine tests) indicating the patient (Patient 1) was acidotic (a condition in which acids build up in the body). RN 4 also confirmed that the order for repeat ABG dated 2/17/2024 at 8:43 p.m. was entered by the respiratory therapist (RT) 3 but the ABG was not collected.

During a concurrent interview and record review on 7/24/2024 at 12:55 p.m. with Registered Nurse (RN) 4, Patient 1's ABG results dated 2/17/2024 at 6:33 p.m. was reviewed. The ABG results indicated, "PH 7.17- Critical (the blood acid level is out of balance, and it can mean that the body is not able to get rid of carbon dioxide [gas removed from the body during exhalation] which happens because the lungs are not working well)."

During a concurrent interview and record review on 7/24/2024 at 1:05 p.m. with Registered Nurse (RN) 4, Patient 1's Code Blue (staff is summoned to the aid of a patient in cardiac arrest [absent or abnormal heart activity]) Flowsheet (tools developed to help clinicians document patient data in a grid-like format), dated 2/17/2024, was reviewed. The Code Blue flowsheet indicated Patient 1 coded on 2/17/2024 at 11:14 p.m. (2 hours and 31 minutes after a repeat ABG was ordered). The flowsheet indicated, "Summary of events preceding code/precipitating factors: desaturation (low in oxygen) ..."

During an interview on 7/25/2024 at 12:15 p.m. with the Director of Intensivist Services (MD 1), MD 1 stated after a critical ABG, the time frame to repeat an ABG was after a new intervention has started for one to two hours. MD 1 stated, the ABG should be rechecked after an hour to see if the intervention was working. MD 1 confirmed that if the ordering physician wants the ABG to be carried out later than an hour after treatment, he (the MD) would specify and it (time frame to collect ABG later than an hour) would be written in the orders. MD 1 confirmed that after BIPAP treatment, if the patient does not improve, the next step would be to intubate the patient.

During a review of the facility's policy and procedure (P&P) titled, "Arterial Blood Gas," dated 2020, the P&P indicated, "Arterial Blood Gases (ABGs) obtained through an arterial puncture, require a physician's order ... Indications: Protocol ABG orders may be performed when a patient demonstrates a change in condition as determined by: Increased W.O.B. (Work of Breathing), Increased RR (respiratory rate), Decreased Sp02 (measure of the percent of oxygen saturation in the blood), Change in mental status, Cardio-respiratory arrest ..."

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Re-Assessment," dated June 2023, the P&P indicated, "Patient receiving Respiratory Therapy services are reassessed each shift and when there is a significant change in respiratory status or condition: To determine response to treatment."

2. During a review of Patient 7's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/20/2024, the "H&P" indicated, Patient 7 was treated at another hospital for shortness of breath and generalized weakness for the past two (2) months. The H&P further indicated, "Patient was medically managed with BiPAP (Bilateral positive airway pressure oxygen therapy to aid in breathing) for chronic hypercapnic respiratory (breathing problems that makes it difficult to take in oxygen and breathe out carbon dioxide [gas removed from the body during exhalation]) ..."

During a concurrent observation and interview on 7/23/2024 at 12:40 p.m. with the Director Nursing Care Services (DNCS) in Patient 7's room, Patient 7's pulse oximetry (device used to measure the oxygen level) alarm parameter was observed to be set at 88%. DNCS confirmed the alarm setting was set at 88%.

During a concurrent interview and record review on 7/24/2024 at 1:40 p.m. with Registered Nurse (RN) 4, Patient 7's "List of Orders," dated from date of admission (7/20/2024) through 7/24/2024, was reviewed. The List of Orders indicated, there was no order for oxygen level parameter. RN 4 stated there was an order indicating to keep Patient 7 on a continuous pulse oximetry monitoring.

During a concurrent interview and record review on 7/25/2024 at 11:35 a.m. with the Director of Respiratory Services (DRS), the facility's policy and procedure (P&P) titled, "Oxygen Therapy Protocol," dated May 2023, was reviewed. The P&P indicated, "Oxygen Therapy is the administration and delivery of oxygen at concentrations greater than ambient air with the intent of treating or preventing the symptoms and manifestation of hypoxia (low levels of oxygen). Responsible Disciplines: Respiratory Therapist. Indications: To establish guidelines to safely monitor and the delivery of oxygen therapy ... Oxygen therapy protocol will be initiated after receiving a physician's order or per admission order set checked and signed by the physician. Specific physician orders indicating target saturation will take precedence over the oxygen protocol. If the saturation is < 92%, Oxygen therapy protocol will be initiated as ordered and a saturation performed within 30 minutes to confirm a saturation > 92%, if the saturation remains < 92%, the oxygen flow will be adjusted to achieve a saturation of > 92% and the physician will be notified ...Adjust supplemental oxygen to maintain a SpO2 of greater or equal to 92% to the MD target SpO2 ..." DRS stated the patient saturation should be set at 92 % because there is no order from the physician. DRS confirmed respiratory staff did not follow the facility policy and respiratory service protocol.

Based on observation, interview, and record review, the facility (Facility 2) failed to ensure one (1) of 51 sampled patient's (Patient 1) arterial blood gas (ABG, a test to measure the balance of oxygen and carbon dioxide in the blood) with a critical result (test results that fall significantly outside the normal range and may represent life-threatening values even if from routine tests) was run a second time to confirm result, in accordance with the facility's (Facility 2) policy and procedure regarding Documentation of Critical ABG (Arterial Blood Gas, a test to measure the balance of oxygen and carbon dioxide in the blood) Values.

This deficient practice placed Patient 1 at risk for unidentified deteriorating conditions, as the confirmation of the critical values that were not completed, may indicate life-threatening situations, and without confirmation of these results (ABG result), appropriate actions may not be taken, potentially leading to a life-threatening situation.

Findings:

During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 1/25/2024, the "H&P" indicated, Patient 1's medical history include HTN (hypertension), uncontrolled DM (Diabetes, a disease that occurs when the blood sugar is too high), renal failure (one or both of your kidneys no longer function well on their own), with acute respiratory failure (an inability to maintain adequate oxygenation) and with history of intubation (the insertion of a tube into a patient's windpipe to aid in ventilation). The H&P further indicated Patient 1 was "Transferred to (facility name [Facility 2]) for further management. Upon evaluation, Patient in ICU (Intensive Care Unit, a unit in the hospital providing intensive care for the critically ill) on Oxymizer (a device placed in the nostrils to deliver continuous high-flow oxygen) support. Patient is alert and oriented."

During a concurrent interview and record review on 7/24/2024 at 12:40 p.m. with Registered Nurse (RN) 3, Patient 1's Nursing notes titled "Change of Condition," dated 2/16/2024 at 8:25 p.m., was reviewed. The note indicated, "Patient was desaturating (the condition of a low blood oxygen concentration) of 88%. Immediately called the respiratory therapist ...ABG (Arterial Blood Gas, a test to measure the balance of oxygen and carbon dioxide [gas removed from the body during exhalation] in the blood) was done by RT (respiratory therapist [RT 3])."

During a concurrent interview and record review on 7/24/2024 at 9 a.m. with the Director of Respiratory Services (DRS), Patient 1's "ABG results report," dated 2/17/2024, was reviewed. The report indicated that on 2/17/2024 at 6:33 p.m., there was no second run of the ABG sampled after a critical laboratory value (test results that fall significantly outside the normal range and may represent life-threatening values even if from routine tests). The DRS stated the report indicated "insufficient samples." DRS further stated that when the ABG results in a critical value, the process was to confirm the results by running a second sample using the same blood sample. The record indicated only one sample was run. DRS also stated the respiratory therapist (RT) 3 should have run a second sample by drawing another sample if there was an insufficient sample from the first ABG test.

During a review of the facility's respiratory services protocol titled "Documentation of Critical ABG Values," undated, the protocol indicated, "Critical Results must be run a second time to verify results."

Based on observation, interview, and record review, the facility (Facility 2) failed to ensure two (2) of the 42 sampled patients (Patient 6 and Patient 7) had written orders for the oxygen saturation (O2 Sats, a measure of the percentage of oxygen in a person's blood) parameter (set limits), in accordance with the facility's policy and procedure regarding Oxygen Therapy Protocol.

This deficient practice compromised Patient 6 and Patient 7's safety and quality of care; without established oxygen saturation parameters, staff may not monitor patients' oxygen levels effectively. Likewise, this absence of a written order regarding oxygen saturation parameter can lead to an insufficient assessment of the patient's respiratory status, potentially resulting in undetected respiratory deterioration for Patients 6 and 7.

Findings:

1. During a review of Patient 6's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/13/2024, the "H&P" indicated, medical history included "dementia (loss of memory), who was admitted at (name of the hospital [Facility 2]) for chief complaint of shortness of breath (difficulty breathing). Patient (Patient 6) had shortness of breath and hypoxemia (an abnormally low concentration of oxygen in the blood) from a skilled nurse facility and patient was tachypneic (breathing is rapid, shallow breathing) to the point where she (Patient 6) was placed on BiPAP (Bilateral positive airway pressure oxygen therapy to aid in breathing). She (Patient 6) was subsequently intubated (the insertion of a tube into a patient's windpipe to aid in ventilation [breathing]) on June 27, 2024 due to pneumonia (lung inflammation caused by bacterial or viral infection) ...She (Patient 6) was extubated (removal of a breathing tube placed in the patient's windpipe) at 1 (one) point on July 3, 2024 but had to be reintubated due to worsening respiratory failure (an inability to maintain adequate oxygenation)." The H&P further indicated the plan was to admit Patient 6 to ICU (intensive care unit, a unit in the hospital providing intensive care for the critically ill) and consult (name of physician) pulmonology (a doctor who specializes in lung conditions).

During a concurrent observation and interview on 7/23/2024 at 3:00 p.m. with Registered Nurse (RN) 19 in the ICU (Intensive Care Unit, a unit in the hospital providing intensive care for the critically ill) nursing station, Patient 6's alarm setting for oxygen saturation was observed to be set at 88%. RN 19 stated the patient (Patient 6) should have a physician order for an oxygen saturation level setting.

During a concurrent interview and record review on 7/24/2024 at 2:40 p.m. with Registered Nurse (RN) 3, Patient 6' s "List of Orders," report dated from date of admission (7/20/2024) through 7/25/2024 was reviewed. The report indicated, there was no order for oxygen level parameter (set limit). RN 3 confirmed there was no oxygen saturation parameter order for Patient 6.

During a concurrent interview and record review on 7/25/2024 at 11:35 a.m. with the Director of Respiratory Services (DRS), the facility's policy and procedure (P&P) titled, "Oxygen Therapy Protocol," dated May 2023 was reviewed. The P&P indicated, "Oxygen Therapy is the administration and delivery of oxygen at concentrations greater than ambient air with the intent of treating or preventing the symptoms and manifestation of hypoxia. Responsible Disciplines: Respiratory Therapist. Indications: To establish guidelines to safely monitor and the delivery of oxygen therapy ... Oxygen therapy protocol will be initiated after receiving a physician's order or per admission order set checked and signed by the physician. Specific physician orders indicating target saturation will take precedence over the oxygen protocol. If the saturation is < 92%, Oxygen therapy protocol will be initiated as ordered and a saturation performed within 30 minutes to confirm a saturation > 92%, if the saturation remains < 92%, the oxygen flow will be adjusted to achieve a saturation of > 92% and the physician will be notified ...Adjust supplemental oxygen to maintain a SpO2 of greater or equal to 92% to the MD target SpO2 ..." DRS stated the patient saturation should be set at 92 % because there is no order from the physician. DRS confirmed respiratory staff did not follow the facility policy and respiratory service protocol.

2. During a review of Patient 7's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/20/2024, the "H&P" indicated, Patient 7 was treated at another hospital for shortness of breath (difficulty breathing) and generalized weakness for the past two (2) months. The H&P further indicated, "Patient (Patient 7) was medically managed with BiPAP (Bilateral positive airway pressure oxygen therapy to aid in breathing) for chronic hypercapnic respiratory (breathing problems that makes it difficult to take in oxygen and breathe out carbon dioxide [gas removed from the body during exhalation]) ..."

During a concurrent observation and interview on 7/23/2024 at 12:40 p.m. with the Director of Nursing Care Services (DNCS) in Patient 7's room, Patient 7's pulse oximetry (device used to measure the oxygen level) alarm parameter was observed to be set at 88%. DNCS confirmed the alarm setting was set at 88%.

During a concurrent interview and record review on 7/24/2024 at 1:40 p.m. with Registered Nurse (RN) 4, Patient 7's "List of Orders," dated from date of admission (7/20/2024) through 7/24/2024 was reviewed. The List of Orders indicated, there was no order for oxygen level parameter. RN 4 stated there was an order indicating to keep Patient 7 on a continuous pulse oximetry (device used to measure level of oxygen) monitoring.

During a concurrent interview and record review on 7/25/2024 at 11:35 a.m. with the Director of Respiratory Services (DRS), the facility's policy and procedure (P&P) titled, "Oxygen Therapy Protocol," dated May 2023 was reviewed. The P&P indicated, "Oxygen Therapy is the administration and delivery of oxygen at concentrations greater than ambient air with the intent of treating or preventing the symptoms and manifestation of hypoxia. Responsible Disciplines: Respiratory Therapist. Indications: To establish guidelines to safely monitor and the delivery of oxygen therapy ... Oxygen therapy protocol will be initiated after receiving a physician's order or per admission order set checked and signed by the physician. Specific physician orders indicating target saturation will take precedence over the oxygen protocol. If the saturation is < 92%, Oxygen therapy protocol will be initiated as ordered and a saturation performed within 30 minutes to confirm a saturation > 92%, if the saturation remains < 92%, the oxygen flow will be adjusted to achieve a saturation of > 92% and the physician will be notified ...Adjust supplemental oxygen to maintain a SpO2 of greater or equal to 92% to the MD target SpO2 ..." DRS stated the patient saturation should be set at 92 % because there was no order from the physician. DRS confirmed respiratory staff did not follow the facility policy and respiratory service protocol.