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Based on observations, interviews, policy review, and record review, the facility failed to:
-Ensure that two of two high risk patients, one current (#18) and one discharged (#19), were appropriately assessed and monitored, in which both patients expired after a cardiac arrest event.
-Perform appropriate interventions within a Code Blue (an emergency situation in which a person has stopped breathing or has no pulse) for two of two code blues observed for Patient #18.
-Protect one of one discharged patient (#19) who had a tracheostomy tube (trach, a surgically created hole made in the windpipe for passage of air with a tube placed through the opening to provide an airway and to remove secretions from the lungs) and was in a restraint, from altering her oxygen flow rate, which caused a desaturation (low blood oxygen concentration) and required emergency interventions.
-Ensure nursing staff provided 1:1 nursing care for two of two patients (#13 and #11) as indicated by facility risk assessment.
-Follow physician's orders for feeding tube (a tube inserted into the stomach to allow liquid nourishment) site care for one (#9) patient of one reviewed.

Please see A395

The cumulative effect of these systemic failures resulted in the facility's non-compliance with 42 CFR 482.23 Condition of Participation: Nursing Services. These failures had the potential to put all patients in the facility at risk for negative outcomes, up to and including death, also known as Immediate Jeopardy (IJ).

On 08/24/16, the survey team notified the facility of the IJ, and on 08/25/16, the facility responded with a plan to remove the IJ, which was unacceptable to prevent further potential harm to patients. The Administrator was notified on 08/25/16 at 3:00 PM that the Immediate Jeopardy was ongoing.

Based on interview, and policy review the facility failed to investigate and resolve, per their policy, two of three patient (#19 and #21) grievances reviewed. This had the potential to affect all patients who file a complaint or grievance regarding their care. The facility census was 27.

Findings included:

1. Record review of the facility's policy titled, "Patient Complaint/Grievance Process," released 06/2016, showed the following:
- When reasonably possible, the person receiving the complaint should address and resolve it.
- It is the supervisor's responsibility to handle unresolved complaints or grievances promptly.
- The Director of Quality Management (DQM) shall enter complaint information into a log, determine whether the issue is a complaint or grievance and assign the most appropriate investigator.
- It is the DQM's responsibility to make sure the process is followed and a response is provided within seven days.
- The CEO (Chief Executive Officer) oversees the complaint/grievance process.

2. Record review of the facility's complaint/grievance log from 05/01/16 through 08/19/16 showed 41 total complaints/grievances filed during that timeframe. Three complaint patients were randomly chosen from the log.

During an interview on 08/24/16 at 12:58 PM, Staff DD, Registered Nurse, Senior Director of Clinical Operations, stated that the three (#21, #19, and #20) complaints chosen should have been investigated, but were not.

During an interview on 08/25/16 at 8:35 AM, Staff U, Resource DQM (interim), stated that the facility lost their DQM approximately two weeks prior to her start date of August 1, 2016. Staff U stated that she had not gone back to investigate any of the complaints/grievances unresolved at the time of the regular DQM's date of unemployment (she was able to show one of the complaints (#20) chosen had been investigated).

Based on observations, interviews, policy review, and record review, the facility failed to:
- Ensure that two of two high risk patients, one current (#18) and one discharged (#19), were appropriately assessed and monitored, in which both patients expired after a cardiac arrest event.
-Perform appropriate interventions within a Code Blue (an emergency situation in which a person has stopped breathing or has no pulse) for two codes of two observed for Patient #18.
-Protect one discharged patient (#19) who had a tracheostomy tube (trach, a surgically created hole made in the windpipe for passage of air with a tube placed through the opening to provide an airway and to remove secretions from the lungs) and was in a restraint, from altering her oxygen flow rate, which caused a desaturation (low blood oxygen concentration) and required emergency interventions.
-Ensure nursing staff provided 1:1 nursing care for two of two patients (#13 and #11) as indicated by facility risk assessment.
- Follow physician's orders for feeding tube (a tube inserted into the stomach to allow liquid nourishment) site care for one (#9) patient of one reviewed.
These failures had the potential to put all patients in the facility at risk for negative outcomes, up to and including death. The facility census was 27.

Findings included:

1. Record review of the facility's policy titled, "Assessment/Re-Assessment-Interdisciplinary Patient," dated 06/2016, showed that:
-Rationale for the policy was to assure care provided to each patient was based on an assessment of the patient's relevant physical, psychological, and social needs.
- Patients were re-evaluated by a licensed nurse at a minimum of every 12 hours based on level of care and patient care needs.
- Patient reassessment was to evaluate patient response to care, treatment, and services.
- Patient reassessment was to respond to a significant change in status and/or diagnosis or condition.
- An acute change of condition was a clinically important change from a patient's established and documented baseline in physical, cognitive, behavioral, or functional domains.
- The nurse assigned to the patient or supervising care of the patient is responsible for notification and communication to the patient's primary physician.
- The Nursing Supervisor should be notified of patient change in conditions.

2. Record review of Patient #18's History and Physical (H&P) dated 07/21/16, showed:
- The patient was a 31 year old male, who was admitted on 07/20/16 with the chief complaint of tricuspid valve endocarditis (inflammation of the inner lining of the heart at the area of the tricuspid valve), cardiomyopathy (chronic disease of the heart muscle), and history of intravenous (IV, administered within, or by use of, a vein) substance abuse, ejection fraction (the measurement of the percentage of blood leaving your heart each time it contracts, a normal heart's ejection fraction may be between 50 and 70%) of 20-25% and drug abuse.
- The patient was admitted for IV antibiotic administration, prior to receiving surgery to complete a valve repair of his heart.
- The patient's medical history included Lemierre Syndrome (inflammation and infection in the internal jugular [neck] vein), multiple septic pulmonary embolizations ( clots that become infected and move to the lungs), bilateral pleural effusions (a buildup of fluid between the layers of the tissue that lines the lungs and chest cavity), sinus tachycardia (abnormally high heart rate), hyponatremia (low level of sodium in your blood), respiratory failure, tobacco use, pulmonary lesion (a growth in the lung), abscess (a swollen area within the body that contains pus and can be highly infectious), and sepsis (the presence in tissues in the body of harmful bacteria).

Record review of Patient #18's Change of Condition (area where nursing documents any clinically important change in the patient's condition) documentation showed:
- On 07/20/16 at 4:18 PM, the patient left the floor to get food and beverages unassisted. The patient was restricted to 180 milliliters (a unit of measurement that amounts to approximately 6 ounces) of fluids from 7:00 PM to 7:00 AM due to his medical condition. The patient was reminded of his fluid restriction.
- On 07/22/16 at 10:00 AM, the patient was noted to have no IV access and refused to get a new one placed. He only wanted a Peripherally Inserted Central Catheter (PICC line, a thin, soft, long catheter that is inserted in to a large vein that carries blood to the heart) placed.
- On 07/24/16 at 12:40 AM, and on 07/30/16 at 12:29 PM, the patient left the unit without permission or having notified staff. On one occasion, the patient had to be overhead paged to be located. The Nursing Supervisor was made aware of both occurrences.
- On 08/10/16, the patient received a visit from an unidentified male. The visit lasted less than a minute, and the nurse entered the room with the visitor. There was a brief verbal exchange and the male visitor exited the facility. Upon re-assessment the patient was up, very active, very verbal and anxious. His heart rate increased to 120-130's (normal heart rate is from 60-100), but no other apparent signs or symptoms of distress. The physician and Nursing Supervisor were notified.
- On 08/11/16 at 11:15 AM, the patient was up in his room cleaning, fixing his bed, pacing, and talking to himself. The physician and Nursing Supervisor were both made aware of the patients change in activity level.
- On 08/16/16 at 12:57 AM, the patient was moved to the High Acuity Area (HAU) for airborne isolation precautions, due to a concern for an airborne infectious process. The HAU has a negative pressure room (a room that contains the appropriate airflow to manage airborne isolation).
- On 08/24/16 at 9:03 AM, a Code Blue was called for Patient #18, then at 9:27 AM a second Code Blue was called.
- The patient was transferred to the Emergency Department of an acute care hospital at approximately 9:57 AM on 08/24/16.

During an interview on 08/24/16 at 3:40 PM, Staff KK, Nursing Supervisor, stated that:
- During the Code Blue for Patient #18, a syringe was found in his pocket and a cup with a pill that was dissolving in water. His Hickman catheter (a tube that is passed through a vein to end up in to vena cava [the large vein returning blood to the heart] or in the right atrium [a chamber of the heart] of the heart) also had a cap removed which gave access to the line. They assumed he had injected a dissolved Oxycodone (pain medication) in to his catheter.
- She had been aware of this patient prior to his Code Blue, and previously in his stay after she had observed the patient and his behavior she, "had an inkling that he was using drugs."
- A few weeks ago she had been approached by an RN who had cared for the patient for three day's who had concerns that he had been given drugs by a visitor. Staff KK went to corporate leadership to inquire about searching the patient's room. She stated they told her that they would look in to it, and then returned with a positive response that they could search the patient's room.
- She did not feel they should search the patient's room until after a visitor had been there to see him. No other interventions were put in place.
- She didn't think they could have done anything differently to prevent the patient from using drugs. She noted, "If there is a will there is a way."
- They could have placed a sitter with him all the time, but that it wasn't reasonable to do so because they had no proof and only assumptions.

During a telephone interview on 08/26/16 at 9:03 AM, Staff RR, RN, stated that:
- She cared for Patient #18 on multiple shifts and was very familiar with him.
-The patient had been quiet and would not talk to her for the first few days. He was also noted to be angry and would rarely get out of bed.
- On the third day she had the patient, he had a visitor who presented to the desk and asked to see the patient. She had concerns because the visitor didn't seem to be able to pronounce the patient's last name correctly, so she escorted him to the patient's room. She said she went in the room with the visitor who was there for a very short period of time. She did not visualize any inappropriate behavior, but had concerns that the patient had purchased drugs.
- She confronted the patient about her concerns, but he denied any drug use or that he had purchased drugs.
- She noted that later in the day the patient had a 360 degree change in personality. She stated he was up all night and cleaning his room, whereas previously he rarely left his bed.
- She talked to a Nursing Supervisor about her concerns, and was told to keep an eye on him.
- She felt like the concern about his behavior got lost in other patient issues on the unit and this situation was not a priority.
- After her observations and concerns, she took no further interventions except that she spoke to her Nursing Supervisor, and passed the information in report to the oncoming RN.

During an interview on 08/24/16 at 11:59 AM, Staff K, Interim Chief Clinical Officer (CCO), stated that immediately following the Code Blue, staff searched Patient #18's room, and found a spoon (commonly used to "cook" drugs), a lighter, and a plastic thermometer probe with a small hole made in it that was wrapped in a paper and plastic bed pad. The assumption was made by staff that the patient had utilized the thermometer probe to smoke drugs and utilized the bed pad to wrap around it to mask the smell.

During an interview on 08/24/16 at 3:00 PM, Staff I, RN, stated that she had cared for Patient #18 before, and that he had been edgy with her and that she had concerns because he was "toxic" about everything. She noted that he had his curtain closed the majority of the time. She never knew there were any previous concerns about drug use while in the hospital and had received no information in report.

3. Observation on 08/22/16 at 10:30 PM, and again on 08/23/116 at 10:50 AM showed that Patient #18's curtain was always closed and there was no ability to visualize the patient in the room.

During a concurrent interview on 08/25/16 at 9:30 AM with Staff M, Nursing Educator, and Staff PP, Nursing Manager reported only knowing about issues with Patient #18 leaving the floor. They stated that leadership had talked to him the previous week about that concern. They felt that by having him in the HAU he would have higher visibility, but they were not aware that he had kept his curtain closed consistently. Staff M stated, "We didn't underestimate him, we underestimated the possibility (obtaining and utilizing drugs while in the facility)."

4. Record review of Patient #18's medical record from his previous acute hospital admission prior to transfer to this facility showed:
- He was admitted on 07/11/16 with the primary diagnosis of Sepsis.
- H&P noted that the patient reported his last IV drug use was in March, but the previous week he had used "speed" (the street name for a drug used as a stimulant) by ingestion and used marijuana. - Urine drug screen completed on 07/12/16 showed that the patient was positive for Amphetamines (drugs such as speed that are stimulants), Opiates (drugs utilized for pain control), and Cannabinoids (drugs such as marijuana).
- Patient was transferred on 07/20/16 from the acute care hospital to the current facility.

The facility had received this information from the acute care facility prior to admitting him to this facility.

The facility failed to closely monitor the patient when they were aware of his past drug use and current changes in behavior (leaving the unit, hyperactivity), as well as his physical condition (rapid heart rate).

5. Record review of the facility's policy titled, "Resuscitative Services Plan," dated 01/2016, showed:
- The Resuscitative Services Plan identifies the critical elements and processes involved in ensuring that all patients have access to life-saving measures that are performed efficiently and effectively at all times.
- The American Heart Association's 2010 Advanced Cardiac Life Support (ACLS) protocol is used to identify criteria and patient symptom specific interventions in response.
- A Code Team is identified for each tour of duty and responds as required.
- ACLS providership is required for all Nursing Supervisors, HAU RN's, and contract physician coverage.

6. Observation on 08/24/16 at 9:03 AM of the Code Blue response for Patient #18, and retrospective review of the facility Code Blue Flowsheet showed:
- Staff called a Code Blue overhead at 9:03 AM.
- A crash cart (a cart in which all supplies needed for a resuscitation event are located) was outside of the room, and Cardiopulmonary Resuscitation (CPR) was in progress.
- Approximately five RN's were at the bedside, one Certified Nurse Assistant (CNA, non-licensed patient care staff) was present outside the door of the room, three Respiratory Therapist's (RT) were at the bedside, and a Pharmacist was present outside of the room near the crash cart which contained the defibrillator (a device that applies an electrical current to the heart.)
- There was initially no physician present.
- Staff were yelling out looking for a person to "write" (someone who records medication administration, procedures, and other occurrences during a Code Blue).
- Numerous staff members were asking for Narcan (a drug that blocks or reverses the effects of opioid medication). The information was called out that the patient was on pain medication, and upon the start of resuscitation staff found a syringe in the patient's pocket as well as a small cup filled with water and a semi-crushed pill that was identified as Oxycodone (a pain medication).
- Staff continued to discuss how much Narcan to give while CPR continued to be in progress.
- At approximately 9:07 AM, Narcan was administered, followed by Romazicon (used to reverse the effects of benzodiazepines, which are medications for anxiety, muscle relaxation, and sedation.)
- The code was called at approximately 9:03 AM, and staff did not pull the crash cart into the room and apply pads until approximately 9:08 AM.
- The patient was intubated (a tube placed down the throat to assist with breathing) at 9:09 AM.
- Staff were attempting to find a physician to respond to the Code Blue. A physician was asked to leave another patient's room and he responded to the code in progress at approximately 9:10 AM.
- At 9:10 AM, the first dose of Epinephrine (used to increase the heart rate, and is considered the first line of drugs that should be utilized for Advanced Cardiac Life Support, ACLS, as soon as possible) was administered.
- A pulse check was done at the same time the Epinephrine was administered and it lasted approximately 45 seconds (per American Heart Association, AHA, Guidelines, the healthcare provider should take no longer than 10 seconds to check for a pulse, and the interruption of compressions to complete a pulse check should be infrequent).
- Between 9:11 AM and 9:12 AM, multiple pulse checks occurred while staff attempted to find a pulse via ultrasound and CPR was paused during this time.
- Staff frequently asked for supplies and attempted to find items in the crash cart.
- A pulse was recovered at 9:14 AM.
- The code leader at the bedside was observed giving high fives (hand slaps) and fist bumps (the hand is made in to a fist and bumped up against another person's hand) and loudly congratulating staff at the bedside while the patient remained intubated and critically ill.

Observation on 08/24/16 at 9:28 AM of a second Code Blue response for Patient #18 showed:
- At approximately 9:28 AM, the patient was again pulseless, and CPR was restarted by an RN.
- Medications were administered per order and ACLS guidelines, and at approximately 9:35 AM, Levophed (a medication used to treat life-threatening low blood pressure), was verbally ordered by the physician. The pharmacist had difficulty finding supplies in the crash cart, and found some supplies missing, such as syringes which delayed medication administration.
- Staff was able to palpate Patient #18's pulse at 9:51 AM, and the staff transported the patient to the Emergency Room of an acute care facility.

7. Record review of Patient #18's medical record from the Emergency Department of the acute care facility showed that the patient expired at approximately 11:25 AM on 08/24/16.

8. Observation and assessment of the two Code Blue situations on 08/24/16 at 9:03 AM and 9:28 AM for Patient #18, showed:
- Staff was focused on the patient's history of drug abuse and did not immediately start ACLS guidelines by placing pads on the patient. Pads were placed over five minutes past the initial call of the code even though the crash cart had been available and outside of the room.
- Staff did not immediately begin ACLS guidelines and administer Epinephrine. The first drugs given were Narcan and Romazicon, and Epinephrine was not administered until seven minutes after the patient was without a pulse (per AHA guidelines, a patient found to be without a pulse should be treated as a cardiac arrest, and standard ACLS resuscitative measures should be followed and take priority over Narcan administration.)
- Staff was confused regarding where supplies were in the crash cart and what doses to administer for Narcan and Romazicon.
- Staff was unsure who was the recorder for the code.
- A physician present on the unit did not respond to the overhead page for a Code Blue and had to be pulled from another patient room by staff to respond.
- Staff did frequent and inappropriately long pulse checks throughout the first code.
- There was no backboard placed under the patient during the first code.
- Staff inappropriately cheered and gave high fives and fist bumps at the bedside immediately following the first code.
- Pharmacy had difficulty finding items in the crash cart, and found that items were missing and had not been replaced causing a delay in medications being mixed per physician order.
- One staff member was noted to be doing ineffective compressions by standing on her toes and looking visibly tired. She refused to switch when asked if she needed to be relieved.

During an interview on 08/25/16 at 8:45 AM, Staff K, CCO, stated that the confusion during Patient #18's first Code Blue was due to the way the leader went about the code process.

During an interview on 08/25/16 at 9:30 AM with Staff M, Nursing Educator, and Staff PP, Nursing Manager, stated that:
- They had been present at the Code Blue on 08/24/16.
- They felt that staff had followed ACLS protocol.
- They discussed after the code that at times one RN was overly loud, and that they could have better kept track of the excitement.
- They confirmed that there was an initial focus on the concern for a drug overdose and administering Narcan, and agreed that in following ACLS protocol, Epinephrine should have been a priority drug to administer.
- They agreed that the pulse checks were too frequent and lasted too long.
- They confirmed that the hand slapping and fist bumping at the bedside were inappropriate behaviors.
- A physician was in the facility from 7:00 PM to 7:00 AM, except on weekends when the coverage is from 1:00 PM to 7:00 AM.
- During the hours a physician was not scheduled to be at the facility, an attending physician was frequently available because of varied patient rounding times.
- If there is no physician on the unit and a Code Blue is called, the staff would run the Code and the patients physician is contacted via phone.

The assumption of a drug overdose was made at the time of Patient #18's cardiac arrest, but with the patient's significant cardiac history the facility could not have known with certainty the reason for the patient becoming unresponsive and pulseless. The facility failed to immediately begin ACLS standards of care for a patient in cardiac arrest.

9. Record review of Patient #19's H&P dated 06/10/16, showed:
- The 73 year old female was admitted on 06/09/16 with the chief complaint of respiratory failure (the respiratory system cannot keep oxygen and carbon dioxide, or both, at a normal level.)
- The patient's medical history included a tracheostomy, subarachnoid hemorrhage (a life threatening condition caused by bleeding in the space surrounding the brain), acute deep vein thrombosis (a blood clot forms in the deep veins of the body), end stage renal disease (chronic and irreversible kidney failure), hypertension (increased blood pressure), diabetes (a metabolic disease in which the body's inability to produce any or enough insulin causes elevated levels of glucose in the blood), anemia (a deficiency of red blood cells or hemoglobin in the blood), right ocular (eye) injury, facial bone fracture, and malnutrition.

Record review of Patient #19's Decannulation Risk Assessment (an assessment of the artificial airway and decannulation, or removal of the airway, risk factors) dated 08/09/16 showed that for all shifts Patient #19 was a high decannulation risk, and that she required 1:1 (one nurse to one patient) nursing care.

Record review of Patient #19's restraint documentation on 08/09/16 showed that the patient had mitten restraints (a soft covering of the entire hand to the wrist that can be tied to the bed) on both hands.

Record review of Patient #19's Change of Condition form (a flowsheet updated throughout the admission) showed the patient had significant decannulation episodes in June and July of 2016, including one that caused a Cardiac Arrest and the patient was resuscitated.
- The flowsheet showed staff documented on 08/09/16 at 1:52 PM, the patient removed the restraint from her right hand and was pulling at the trach. Oxygen saturations (the level of oxygen in the blood) did fall, but an RN was able to stop the patient from decannulating. RT was called to the bedside and the patient was bagged (considered an emergency maneuver, where a special bag is attached to the tracheostomy site and large amounts of air are pushed into the lungs to recover a patient) to increase saturations.

During an interview on 08/24/16 at 7:30 AM, Staff GG, RN, stated that:
- She was the nurse for Patient #19 on 08/09/16.
- Staff did not consider the patient on 1:1 observation, but only "line of sight" which meant "laying eyes" on the patient. (This conflicts with the Decannulation Risk Assessment, which showed the patient should have 1:1 care.)
- She was assigned one other patient as well as Patient #19, and they were located across the hall from one another.
- She could not have kept Patient #19 in line of sight the entire time as she had to care for her other patient.
- On 08/09/16 she had left Patient #19's room and walked across the hall to her other patient to administer a pain medication. She had not been gone greater than two minutes when she heard the commotion in Patient #19's room and she observed an RT bagging the patient.
- The patient had pulled the mitten off of her hand and manipulated her trach, it had not decannulated, but a desaturation had occurred.
- The patient's vital signs returned to normal limits.

Record review of Patient #19's Change of Condition flowsheet showed:
- Staff documented on 08/15/16 at 6:14 AM, the patient had a body temperature of 95.1 degrees Fahrenheit (a scale of temperature, the normal range is 97.8 to 99. An abnormally low body temperature could indicate a systemic infection, cold exposure, shock, or complications of diabetes). Oxygen saturations at the time were 93% (normal range is 95-100%) The staff warmed the patient with blankets. Based on nursing documentation, the physician was aware of this abnormal vital sign.
- On 08/16/16 at 2:00 AM, staff documented the patient had a temperature of 97.8, pulse was 68 beats per minute, and her respiratory rate was 26 breaths per minute.
- The RN documented at 2:00 AM that she was unable to detect an oxygen saturation on the monitor. RT staff was contacted, and the oxygen probe (an adhesive device that attaches to normally a finger or earlobe and detects the oxygen level in the blood) was changed.
- The RT documented at 2:03 AM that she attempted to get an oxygen saturation level from a warm left ring finger with a new oxygen probe. She noted the patient was unresponsive, not breathing, and pulseless. The RN also checked for a pulse and responsiveness. Cardiopulmonary Resuscitation (CPR) was initiated, and staff called a Code Blue.

Record review of the facility document titled, "Code Blue Flowsheet", dated 08/16/16 showed that a Code Blue was called at 2:07 AM, and a pulse was recovered at 2:19 AM. The patient had numerous subsequent losses of pulse and recovery. The patient expired on 08/16/16 at 5:18 AM.

During an interview on 08/24/16 at 12:10 PM, Staff II, RN, stated that:
- She was the primary nurse for Patient #19 on 08/16/16.
- She was providing 1:1 nursing care for the patient.
- She and the staff on the previous shift had all had problems picking up an oxygen saturation, and many different probes had been attempted.
- The previous shift had difficulty with a low body temperature, and had used a warming blanket.
- She went to lunch and was relieved by the CNA who monitored the patient in her absence. She notified the CNA that the patient's pulse oximetry (oxygen level) had been alarming all day.
- Upon returning from lunch, the RN noted that the alarm continued to go off for the oxygen level. The patient was awake but the RN noticed that she was using her abdominal muscles to breathe (a common sign of respiratory distress.)
- She contacted RT to assist her with picking up a pulse oximetry more clearly after she attempted twice on the patient's ears, and then other fingers.
- RT arrived and they determined the patient had become unresponsive and no longer had a pulse. CPR was initiated and a Code Blue was called.

During an interview on 08/24/16 at 2:45 PM, Staff CC, CNA, stated that:
- She worked the night of 08/16/16.
- She was the relief staff for the RN caring for Patient #19 for her lunch break or any other needs.
- She was the only person in the room while the RN was at lunch.
- While she was monitoring the patient her blood pressure fluctuated from the 90's to the 80's (the systolic level that describes the maximum arterial pressure during contraction of the left ventricle of the heart. Normal range is 90-120.)
- She alerted the RN when she returned that the blood pressure had been low, and the RN informed her that it had been doing that all day.
- She denied the patient had any breathing issues while she was in the room.
- In general, she often covered for the RN's that provide 1:1 care so that they can go to lunch, get medications, or pick up supplies.

There are no entries in the Change of Condition documentation for 08/16/16 that refer to any blood pressure fluctuations or abnormal readings of other vital signs. There is no documentation of any communication with the physician regarding fluctuations in the patient's blood pressure.

10. Record review of email communication dated 08/29/16, by Staff M, Nursing Educator, to the survey team showed:
- Based on the 08/04/16 plan of correction, licensed staff was required to complete three mock decannulation events before an airway/decannulation competency is completed.
- When competency had been verified and the attestation (a letter that shows that something defined in the document is true and agreed upon) signed by the staff member that they feel competent, the staff member may then be allowed to take more than one airway patient.
- Education and leadership continued to assess employees with post-test verification to determine if retraining was necessary.

Record review of a document titled, "Airway/Decannulation Education Progression," dated 08/29/16, showed that Staff GG completed her mock decannulations on 08/06/16, 08/08/16, and 08/09/16. Staff GG signed her competency attestation on 08/09/16. The document also showed that Staff II completed her mock decannulations on 07/31/16, 08/09/16, and 08/11/16. Staff II signed her competency attestation on 08/15/16.

Although education and competency was determined for Staff GG on 08/09/16, Patient #19 was still able to manipulate her airway enough to cause the need for an emergent respiratory intervention. Documentation for the patient on the date of the event also continued to report 1:1 nursing care, but the nurse was assigned two patients based on her competency.

On 08/16/16, Staff II determined that Patient #19 was a high risk decannulation patient who required 1:1 nursing care, but left the patient multiple times with an unlicensed staff member who was not educated or considered competent to monitor 1:1 high risk decannulation patients.

During an interview on 08/25/16 at 8:45 AM, Staff K, Interim Chief Nursing Officer, stated that the facility did not have a policy that directed facility staff when they sat with a patient or provided 1:1 nursing care for a patient.

11. Observation with concurrent interview on 08/23/16 at 1:45 PM showed Staff Q, RN, stood in the hall, outside Patient #13's room, with no other nurse at door and put on a Personal Protective Equipment (PPE) gown and gloves and stated that she needed to go back into Patient #13's room. Staff Q stated that she was the 1:1 nurse for Patient #13 and left to obtain medication while another nurse stood at the door and watched the patient. She stated that staff could not prevent decannulation if the 1:1 staff was outside the door.

During an interview on 08/23/16 2:00 PM, Staff S, RN, stated that he watched Patient #13 while the other nurse (Staff Q) went to get the patient's medication. He stood at the door for approximately five minutes and could only see the patient's hands and could not visualize the tracheostomy. He watched the patient to ensure the patient did not climb out of bed or pull out anything. He stated that he did not know what was expected of a 1:1 nurse. When the other nurse arrived at the door he left.

During an interview on 08/23/16 at 2:15 PM, Staff Q stated that a nurse in the hall could not prevent decannulation of the patient.

12. Observation on 08/23/16 at 3:00 PM showed Patient #11's 1:1 nurse, Staff T, RN, stood at the door with her back to the patient and visited with other staff members.

During an interview on 08/23/16 at 3:25 PM, Staff T, stated that when a staff was 1:1 with a patient they would need to be at the bedside to prevent decannulation. She stated that when she talked with staff at the door and her back was to the patient she could not prevent decannulation of the patient.

During an interview on 08/24/16 at 2:15 PM, Staff K, Interim CCO, stated that 1:1 was defined as a patient's acuity (an assessment of patient needs) that required a nurse that cared for only the one patient. This nurse would provide total patient care which included safety needs, such as patient's who pulled at tubes and medical needs. She expected a nurse that provided this care to have a line of sight of the patient. It would not be acceptable if nurses stood at the door, of the patient's room, with their back to the patient or stood outside the patient's room.

During an interview on 08/23/16 at 1:55 PM, Staff HH, RT, reported that if a patient was considered 1:1 she always saw staff in the room, but at times observed them sleeping, wearing earbuds (speakers that fit in the ear), or on their phone.

13. Record review of the facility's standard of care titled, "Enteral Feeding Tube Exit Site Care," published by Lippincott and revised in 2015, showed direction for staff to apply a sterile dressing or foam dressing around the site, if there is leakage at the exit site.

14. Record review of Patient #9's History and Physical (H&P) dated 06/29/16, showed the patient was admitted on 06/28/16 with a feeding tube.

15. Record review of physician's orders dated 08/10/16, showed an order for triple antibiotic ointment and a drain sponge to be applied to the tube site every 12 hours.

16. Observation on 08/23/16 at 11:15 AM in Patient #9's room showed the patient did not have a drain sponge around the tube site. Staff L, RN, cleansed the site with a wet wash cloth, failed to apply triple antibiotic ointment (a topical ointment that contains three antibiotics, used to treat/prevent infections) and failed to apply a drain sponge around the tube site.

During an interview on 08/23/16 at 3:10 PM, Staff L, Registered Nurse (RN) stated that she was unaware of the order for a drain sponge to the

Based on observation, interview, and policy review the facility failed to ensure one of one agency nurse (Staff G) completed, signed and dated risk assessments at the time of completion for one patient (#6) of seven patients with risk assessments reviewed. This failure had the potential to affect all patients who might receive inappropriate treatment due to incorrect assessments. The facility census was 27.

Findings included:

1. Record review of the facility's policy titled, "General Documentation Guidelines," dated 08/24/14, showed that all clinical entries in the patient's medical record shall be accurately dated, timed and authenticated (signed, dated, and timed) and their authors identified.

2. Record review of Staff G's, Licensed Practical Nurse (LPN), personnel file showed she was an agency (business that supplies facilities with nurses as requested) nurse. Review of the job description dated and signed by Staff G on 03/08/16, showed she would maintain records according to facility policies and procedures.

3. Observation with concurrent interview on 08/22/16 at 11:25 PM showed Staff G provided care for Patient #6 in his room. Staff G documented two Decannulation Risk Assessments (an assessment of the artificial airway and decannulation, or removal of the airway, risk factors), signed and dated them 08/23/16, but did not time the documents. She stated that she would review her pre-documented assessment at the delineated time for the assessment. If something she pre-documented changed she would cross out the documentation with a line and place her initials by the line.

During an interview on 08/22/16 at 11:45 PM Staff H, Registered Respiratory Therapist, RRT and Staff K, Interim Chief Clinical Officer (CCO) both verified the assessments were already completed with Staff G's name and a date. Staff H stated that this was not typical.

During interviews on 08/23/16 at 12:00 Noon and 08/24/16 at 2:15 PM, Staff K, stated that she came back to Patient #6's room later in the shift and the pre-assessment documentation was not found. She stated that she expected the nurses to document the assessment at the time it was completed.