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Based on record review and interviews with staff the hospital failed to meet the requirement for the condition of Participation for Nursing Services by failing to:
1) follow hospital policy for transferring a patient experiencing an emergency medical condition (low blood pressure, change in mental status) to an acute care hospital for 1 of 16 sampled patients (patient #5);
2) notify the physician responsible for the care of patient #5 of significant changes in the patient's status as evidenced by mental status changes and labile blood pressures over a 15 hour period to include a 15 minute period when no blood pressure could be obtained for 1 of 16 sampled patients (patient #5); 3) to increase assessments/reassessment of the patient, after mental status changes and labile blood pressures were identified for 1 of 16 sampled patients (patient #5) (See Findings at A0395)
4) to ensure the nursing plan of care was developed and updated/revised based on the patient care needs as evidenced by failing to update the care plan when mental status changes and labile blood pressures were identified for 1 of 16 sampled patients (patient #5) (See Findings at A0396)
Findings:

An Immediate Jeopardy situation was identified 7/28/2011 at 4:10 PM by the survey team and was reported to the Director of Nursing Service. It was determined that the hospital failed to:
1) adhere to the hospital policy regarding treatment of patient #5 having an medical emergency by failing to transfer a patient to an acute care hospital in the event of an emergency;
2) notify the physician responsible for the care of the patient (patient #5) of significant changes in patient's status as evidenced by mental status changes and labile blood pressures over a 15 hour period to include a 15 minute period when no blood pressure could be obtained;
3) increase assessment/re-assessment of the patient with mental status changes and labile blood pressures and make changes to the care plan of the patient (patient #5).
4) The hospital failed to have a system in place to ensure the physician on-call responds in a timely manner as evidenced by the failure of the physician to respond to a call from the hospital to provide physician oversight of a patient experiencing a medical emergency for 40 minutes. Patient #5 was transferred to an Emergency Room on 5/22/2011 at 9:00 AM and subsequently died on 5/23/2011 at 12:00 noon.

The hospital's plan of removal was submitted on 7/9/2011 at 2:45 PM by the DON to address the Immediate Jeopardy situation which revealed the hospital implemented the following:

1) The Medical Director approved a change in the Medical Staff General Rules and a Regulations Policies and Procedures regarding response time. A policy has been added to include that physicians must answer a call in a reasonable amount time. The appropriate response time would be 15 minutes for a nonemergency situation. If the on-call physician does not call back then the nursing staff will call the Medical Director and DON. The purpose of this policy is to ensure that the nursing staff will be able to reach a physician at all times. All credentialed physicians have been made aware of this policy change. The staff has been in-serviced on the appropriate response time of a physician.

2) The Medical Director, Administrator, and DON have approved the revision for the emergency protocol. The revision was made to allow the Rn to transfer a patient in an acute medical crisis to the Emergency Department without an order from the attending physician. The purpose of the revision is to ensure the safety of the patient in which a person's emergency needs may exceed the hospital's capabilities.

3) A critical assessment guide has been created to assist the nursing staff immediately when a patient's medical condition begins to decline. The patient will be assessed by the charge nurse. The level of consciousness and vital signs will be assessed every 3-5 minutes. The RN will stay with the patient and will delegate the LPN to call the attending physician. Critical changes in the patient's assessment will be explained to the attending physician. Orders will be obtained for initial treatment needed by the patient. If there is no improvement in the patient's medical status within 10 minutes, the physician will be notified again. If at any time the patient's medical condition or vital signs continue to decline the nurse will call 911 and transfer the patient to the nearest emergency department without a MD order. All actions performed will be documented. These guidelines will assist the nursing staff and ensure appropriate care needs to maintain the safety of the patients. It also allows the nursing staff to transfer a patient when their condition exceeds the capabilities of this hospital. It also allows the nursing staff to make a clinical judgement to transfer a patient in which their needs exceed the capabilities of this hospital without an order from the attending physician. The purpose of the critical assessment guide line is to ensure that individuals in a hospital without an emergency department will receive appropriate care. When an individual's needs exceed the capabilities of this hospital, the patient will be transferred immediately.

4)The nursing staff will update and revise care plans based on chronic, potential and immediate problems. The care plan outlines the nursing care provided to the patient. The purpose is to provide nursing care and assist in the evaluation of that care.

5) The Director of Nurses will began to in-service the RN's and LPN's on July 28, 2011 and will continue until all RN's and LPN's are in-serviced. The staff will sign and date the in-service sheet. The in-service will include verbal instructions to the RN's and LPN's on emergency care protocol policy, physician response time, critical care patient assessment, care plans and proper documentation. RN's and LPN's will not be allowed to work on the floor unless they have received this in-service. This verbal in-service will be given to all new RN's and LPN's before they will be able to work on the floor.

6) Dr. SF7, Medical Director was called in regards to physician response time. A letter regarding this conversation, the immediate jeopardy tag, in-service agenda and emergency care protocol procedure was faxed to (other MDs on staff and the PA). This information was sent by e-mail and certified mail on 7/29/2011.

As a result of the hospital's plan of removal the Immediate Jeopardy was removed on 7/29/2011 at 2:45 PM. This deficiency remains at a condition level. (See findings A0395)

Based on record review and interview the Governing Body failed to ensure the medical staff had a system in place to ensure the on-call physician (SF8) responds in a timely manner as evidenced by the failure of the physician to respond to a call from the hospital to provide physician oversight of a patient (patient #5) experiencing a medical emergency for 40 minutes. Patient #5 was transferred to an Emergency Room on 5/22/2011 at 9:00 AM and subsequently died on 5/23/2011 at 12:00 noon. Findings:

Review of the medical record from Community Rehabilitation Hospital revealed patient #5 was a 26 year-old who was transferred from Hospital A and admitted to Community Specialty Hospital on 5/17/2011 at 2:25 PM with chief complaint of "non-healing wounds, generalized and severe debilitation following prolonged hospitalization".

Review of the 5/21/2011 nurse progress notes revealed at 6:00 AM SF9 LPN documented that patient #5 was alert, confused, depressed and her temperature was 97.9 F heart rate 110 beats per minute and respirations 22 breaths per minute and blood pressure 98/67. Review of the 5/21/2011 progress notes revealed SF9 LPN documented that she "received report from (SF6 LPN) on status. Morphine IVP given per (SF16 RN) while receiving report (no documentation of how much Morphine was in the medical record). Informed pt (patient #5) constantly called all shift after receiving pain mgmt (management). Awake confused @times." Further review revealed on 5/21/2011 at 8:45 AM patient #5 complained of pain in abdomen at the "incision site/wound site" and rated the pain at a 10. Further documentation at that time revealed SF9 LPN administered Lortab 10 mg by mouth. Documentation at 12:00 noon on 5/21/2011 revealed the patient complained of nausea and pain (did not document the site of pain) rated at 9/10. Further documentation revealed that SF17 RN administered Zofran 4 mg and Morphine 4 mg IVP to patient #5. Further review of the 5/21/2011 nurse progress notes revealed at 4:20 PM patient #5 complained of nausea and pain at a rate of 9/10 and SF17 administered Zofran 4 mg and Morphine 4 mg IVP. According to documentation by SF9 LPN patient #5 was " resting quietly with eyes closed at 5:50 PM". Further documentation failed to reveal that the 6:00 AM to 6:00 PM nurse notified the physician or the PA regarding the patient's changed in level of consciousness, nausea and "constantly called all shift after receiving pain mgmt" reported by the 6:00 PM to 6:00 AM nurse. According to the nurse progress notes patient #5 received Morphine 3 times, Lortab 1 time and Zofran 2 times on the 6:00 AM to 6:00 PM shift on 5/21/2011 and this was not reported to the physician or PA.

Further review on the 5/21/2011 assessments revealed at 6:00 PM patient #5 was alert, lethargic, memory was poor and her temperature was 98.2 F, heart rate 120 beats per minute, respirations 20 breaths per minute and blood pressure 80/56. There was no documentation that the nurse reported this to the physician. Review of the 5/21/2011 nurses progress notes revealed at 7:10 PM patient #5 was "asleep but a little lethargic. Pt stated it was her pain meds (medications)". This was a continued changed in condition but according to the medical record the nurse failed to report the patient's decline in condition to the physician or PA. Further review on 5/21/2011 revealed at 9:45 PM the patient remained "lethargic. tried to take Bp (blood pressure) (with) machine & manually but no Bp could be heard. Continued to try for Bp. HR (heart rate)-120 RR (respirations) 14 t (temperature) 97.0. pt cold to touch. Strong pulse to dorsales pedis. Respiration equal & unlabored. (SF4 RN) assessed pt & could not get bp (blood pressure) also". Documentation revealed that SF10 LPN called Dr. SF8 at 10:00 PM (15 minutes after a blood pressure could not be obtained) and "got his answering service" and there was no "call back from Dr. SF8". Review of the 5/21/2011 nurse progress notes revealed at 10:00 PM a 70/40 blood pressure was obtained with a "machine" (15 minutes after the nurse documented a blood pressure could not be obtained). Further documentation revealed Dr. SF8 returned the call at 10:40 PM (40 minutes after SF10 LPN called him and 55 minutes after SF 10 LPN and SF4 RN could not obtain a blood pressure) with orders.

Review of the physician orders dated 5/21/2011 at 10:45 revealed a telephone order documented by SF4 RN to bolus patient #5 with 250 cc (cubic centimeters) of normal saline over 2 hours, to continue the normal saline at a rate of 80 cc per hour, to administer one dose of Narcan (use to reverse narcotics) 0.4 mg IVP and to "hold all narcotics till further notice". According to 5/21/2011 nurse progress notes the saline bolus and Narcan was administered at that time (10:45 PM). Further documentation at that time revealed the patient was still lethargic after the Narcan and saline was administered.

Documentation revealed on 5/21/2011 at 11:50 PM patient #5's blood pressure was 80/57 (one hour and fifty minutes after the last blood pressure was obtained) and at 12:15 AM on 5/22/2011 her blood pressure was 90/65. SF10 LPN documented at 5:30 AM on 5/22/2011 that the patient was sleep, was in no distress and her blood pressure was 109/82.
Review of the 5/22/2011 nursing assessments at 6:00 AM revealed patient #5 was lethargic, anxious and her speech was slurred. Review of the 5/22/2011 at 7:00 AM nursing progress notes revealed SF18 LPN documented that patient #5 was asleep when she rounded, easily aroused but lethargic. She further documented at that time that her eyes were glassy, pupils sluggish, blood pressure was 60/40, heart rate 120 beats per minute, respirations 16 breaths per minute and temperature 98.4 F. Further documentation revealed she reported this to the charge nurse at 8:50 AM and paged the doctor on call. SF18 documented and he ordered Levaquin. Review of the 5/22/2011 at 8:45 AM physician orders revealed Dr SF7 gave a telephone order for Levaquin (antibiotic) 500 mg to be administered by mouth "now" and that Dr. SF7 will evaluate patient #5 in the morning to see if she needed IV antibiotics. At 8:50 SF18 LPN documented that there was change in patient #5's condition and that she remained lethargic. Documentation at 9:00 AM on 5/22/2011 (10 minutes after she documented that there was a change in the patient's condition) revealed SF18 RN paged Dr. SF8 due to the patient vomiting "20 cc dark colored bile" and gave an order to transfer patient to hospital. Further documentation revealed at 9:30 AM on 5/22/2011 the ambulance had arrived to transport patient #5 to Hospital B. Review of the 5/22/2011 at 9:00 AM physician orders revealed a telephone order from Dr. SF 8 to "cancel previous orders for Levaquin" and to "transfer to Hospital B to evaluate & treat" and to "notify Dr. SF7 of patients arrival to ER". Review of the medical from Hospital B revealed patient #5 was pronounced deceased on 5/23/2011 at 12:00 noon.

Review of a hospital policy titled "Emergency Care Protocol", approved 06/24/11, last revised 07/28/11, reads in part: "Policy. Community Specialty Hospital does not provide physician services on site 24 hours a day and does not provide an Emergency Department. It is the policy of this hospital to conduct appraisals, render initial treatment and transfer the patient when the patient's clinical condition exceeds the capabilities of Community Specialty Hospital. Procedure. In a presenting emergency situation, the following is to be done concurrently in coordination with the staff as assigned by the RN. 9-1-1 is called to initiate the emergency response for transfer. The facility does have an AED (Automatic External Defibrillator). The RN is to assess the patient in all presenting emergency situations and the MD (on-site or on-call) is notified immediately to give orders for initial stabilizing treatment and to provide medical oversight ... "

On 7/27/2011 at 9:15 AM an interview was held with Dr. SF7 who stated he was the medical director at Community Rehabilitation center and that he was the only physician on staff and he has a PA that works with him. He stated that when he takes time off Dr. SF8 provides medical management for his patients. Dr. SF7 was asked by the survey team to review patient #5's medical record. After reviewing the record Dr. SF7 stated patient #5 came to this hospital with an open wound to the abdomen with fistulas.

A second interview was held on 7/28/2011 at 1:15 PM Dr. SF7 who stated he personally accepted patient #5 in transfer from Hospital " A " after conversation with SF3 Case Manager. (On 5/21/2011 and 5/22/2011 Dr. SF8 was on call for Dr. SF7) Dr. SF7 confirmed the nursing documentation for 5/20/2011 revealed patient #5 was awake and alert. Dr. SF7 reviewed the nursing documentation for 5/21/2011 at 6:00 AM which indicated patient #5 was alert, confused and depressed and the 6:00 PM documentation that patient #5 was alert and lethargic. Dr. SF7 reviewed the nursing documentation for 2145 (9:45 PM) which indicated nursing staff was " unable to obtain a blood pressure, HR (heart rate) was 120, (#5) was cold to touch " . Dr. SF7 (also Medical Director) stated patient #5 needed to go to the ER at this point. He confirmed the next documented blood pressure was 15 minutes later, at 10:00 PM and was documented to be 70/40. SF7 MD confirmed it took SF8 MD 40 minutes to call the hospital after his answering service was called at 10:00 PM by nursing. Dr. SF7 stated " we need a call back policy " . Dr. SF7 stated there " should have been increased monitoring of patient #5 " . Dr. SF7 reviewed the nursing documentation for patient #5 for 5/22/2011 at 7:00 AM that revealed patient #5 was " lethargic, eyes glassy, pupils sluggish, had a blood pressure of 60/40, and a heart rate of 120 " and this was reported to the charge nurse and Dr. SF8 at 8:50 AM. Dr. SF7 stated patient #5 needed to be sent to the ER. Dr. SF7 reviewed the telephone order from Dr. SF8 to give patient #5 " Levaquin 500 mg po X (times one) dose now & (and) Dr. SF7 to evaluate in AM " (which would not be until the next day). Dr. SF7 stated that this is " inadequate and not aggressive enough " . Dr. SF7 further stated the RN treatment of patient #5 was not aggressive enough.

Based on record review, Hospital policy and Procedures, and staff interview the hospital failed to ensure the registered supervised and evaluated 1 of 1 patient (patient #5) in a total of 16 sampled patient by failing to:
1) follow hospital policy for transferring a patient experiencing an emergency medical condition (low blood pressure, change in mental status) to acute care hospital for 1 of 16 sampled patients (patient #5,)
2) notify the physician responsible for the care of patient #5 of significant changes in the patient's status as evidenced by mental status and loabile blood pressures over a 15 hour period to include a 15 minute period when no blood pressure could be obtained for 1 of 16 sampled patients (patient #5) and
3) failing to increase assessments/re-assessment of a patient (patient #5).
Findings:


Review of the medical record from Community Rehabilitation Hospital revealed patient #5 was a 26 year-old who was transferred from Hospital A and admitted to Community Specialty Hospital on 5/17/2011 at 2:25 PM with chief complaint of " non-healing wounds, generalized and severe debilitation following prolonged hospitalization " . Review of the 5/18/2011 at 11:40 AM History and Physical (H and P) revealed the SF14 PA (physician assistant) documented patient #5 had a previous history of consuming one quart of " vodka per day having progressive mid-abdominal belt like pain that radiated to the back associated with nausea, vomiting, and abdominal distension " . There is stiffness to all of her joints and there is some muscle spasms, tremulousness and drop foot bilaterally. Overall, generalized motor weakness. Chronic pain associated with any movement of her limbs and diffuse at the surgical sites. She has a residual wound on her mid abdomen and multiple ostomies.

Continued review or the H&P revealed SF14 PA documented his examination for patient #5 as follows: vital signs were as follow: temperature 99.2 F, heart rate 134 beats per minute, respirations 20 breaths per minute and blood pressure was 98/61. Review of the 5/17/2011 at 7:00 PM initial assessments revealed patient #5 was cooperative, her speech was slurred and she was disoriented per minute and heart rate 120 beats per minute.

Review of the 5/18/2011 nursing assessments revealed at 6:00 AM and 6:00 PM patient #5 was alert, oriented, memory adequate, cooperative and quiet. Review of the 5/18/2011 nurses progress notes indicated that at 1:00 PM the nurse administered Morphine (narcotic and analgesic that depresses respirations) 4 mg IVP for abdominal pain rated on 9. The nurse failed to document what area of the abdomen the pain was experienced and also failed to obtain the patient respirations before administering Morphine.

Documentation revealed on 5/18/2011 patient #5 received Morphine 1 time for complaints of pain but the nurse failed to assess the patient's respirations before the medication was administered.

Review of the 5/19/2011 at 6:00 AM and 6:00 PM nursing assessments revealed patient #5 was alert, oriented, cooperative, quiet, had adequate memory and her speech was not slurred. Review of the nurse progress notes dated 5/19/2011 revealed patient #5 received 2 doses of Morphine but the nurse failed to assess her respirations before the drug was given.
Review of the 5/20/2011 nurses progress notes check off assessments revealed at 6:00 AM and 6:00 PM patient #5 was alert, oriented and cooperative. Further review revealed at 6:00 AM the temperature was 98.3 F (Fahrenheit), heart rate 102 beats per minute, respirations 22 breaths per minute and blood pressure 112/81. The 5/20/2011 progress notes at 6:00 PM revealed her temperature was 98.1 F, heart rate 129 beats per minute (27 beats per minute increase since 6:00 AM), respirations 12 breaths per minute (10 breaths per minute less since 6:00 AM) and blood pressure 92/64 (a decrease in systolic and diastolic since 6:00 AM).

Review of the 5/20/2011 nurses progress notes revealed patient #5 complained more frequently of pain. On 5/20/2011 at 6:40 AM SF15 LPN documented that the patient had no signs and symptoms of distress. Further review revealed at 10:20 PM patient #5 complained of pain and SF15 RN administered Morphine 4 mg IVP (intravenous push). Review of the MAR (Medication Administration Record) revealed on 5/20/2011 at 10:20 AM SF15 RN documented that patient #5 complained of generalized abdominal pain rated by the nurse as a 10. The 5/20/2011 at 3:30 PM nursing progress notes revealed patient #5 complained of pain and SF15 RN administered Morphine 4 mg IVP but there was no documented evidence that the nurse evaluated the patient's respirations. Review of the 5/20/2011 at 3:30 PM MAR revealed SF15 RN documented that patient #5 complained of generalized pain. Documentation failed to reveal SF15 RN rated the severity of the pain and also failed to assessed patient #5 to determine the area of her body that was in pain. The 5/20/2011 at 4:30 PM nurses revealed the patient received some relief. Further review on the same date revealed at 8:45 PM SF6 LPN documented that patient #5 complained of pain and rated it as a 10. She also documented at that time that SF16 RN administered Morphine 2 mg IV. Review of the MAR revealed SF16 RN administered the Morphine for generalized pain but there failed to be documentation as to which area/areas of the body the pain was experienced. There failed to documentation in the medical record that the nurse assessed patient #5 respirations before administering Morphine, since this drug has a tendency to depress respirations. There failed to be documented evidence that the nurse contacted the physician or PA to inform him that the patient had a change in pain status, that the intensity of her pain was rated more severely and she required a more potent pain medication (Morphine).

Review of the 5/21/2011 nurse progress notes revealed at 6:00 AM SF9 LPN documented that patient #5 was alert, confused, depressed and her temperature was 97.9 F heart rate 110 beats per minute and respirations 22 breaths per minute and blood pressure 98/67. Review of the 5/21/2011 progress notes revealed SF9 LPN documented that she " received report from (SF6 LPN) on status. Morphine IVP given per (SF16 RN) while receiving report (no documentation of how much Morphine was in the medical record). Informed pt (patient #5) constantly called all shift after receiving pain mgmt (management). Awake confused @times. " Further review revealed on 5/21/2011 at 8:45 AM patient #5 complained of pain in abdomen at the " incision site/wound site " and rated the pain at a 10. Further documentation at that time revealed SF9 LPN administered Lortab 10 mg by mouth. Documentation at 12:00 noon on 5/21/2011 revealed the patient complained of nausea and pain (did not document the site of pain) rated at 9/10. Further documentation revealed that SF17 RN administered Zofran 4 mg and Morphine 4 mg IVP to patient #5. Further review of the 5/21/2011 nurse progress notes revealed at 4:20 PM patient #5 complained of nausea and pain at a rate of 9/10 and SF17 administered Zofran 4 mg and Morphine 4 mg IVP. According to documentation by SF9 LPN patient #5 was " resting quietly with eyes closed at 5:50 PM " . Further documentation failed to reveal that the 6:00 AM to 6:00 PM nurse notified the physician or the PA regarding the patient ' s changed in level of consciousness, nausea and " constantly called all shift after receiving pain mgmt " reported by the 6:00 PM to 6:00 AM nurse. According to the nurse progress notes patient #5 received Morphine 3 times, Lortab 1 time and Zofran 2 times on the 6:00 AM to 6:00 PM shift on 5/21/2011 and this was not reported to the physician or PA.

Further review on the 5/21/2011 assessments revealed at 6:00 PM patient #5 was alert, lethargic, memory was poor and her temperature was 98.2 F, heart rate 120 beats per minute, respirations 20 breaths per minute and blood pressure 80/56. There was no documentation that the nurse reported these assessments to the physician. Review of the 5/21/2011 nurses progress notes revealed at 7:10 PM patient #5 was "asleep but a little lethargic. Pt stated it was her pain meds (medications)". This was a continued change in condition but according to the medical record the nurse failed to report the patient's decline in condition to the physician or PA. Further review on 5/21/2011 revealed at 9:45 PM the patient remained "lethargic. tried to take Bp (blood pressure) (with) machine & manually but no Bp could be heard. Continued to try for Bp. HR (heart rate)-120 RR (respirations) 14 t (temperature) 97.0. pt cold to touch. Strong pulse to dorsales pedis. Respiration equal & unlabored. (SF4 RN) assessed pt & could not get bp also". Documentation revealed SF10 LPN called Dr. SF8 at 10:00 PM (15 minutes after a blood pressure could not be obtained) and "got his answering service" and there was no "call back from Dr. SF8". Review of the 5/21/2011 nurse progress notes revealed at 10:00 PM a 70/40 blood pressure was obtained with a "machine" (15 minutes after the nurse documented a blood pressure could not be obtained) but she failed to assess the patient's respirations and heart rate. Further review at that time revealed the nurse would "continue to monitor pt". Further documentation revealed Dr. SF8 returned the call at 10:40 PM (40 minutes after SF10 LPN called him and 55 minutes after SF 10 LPN and SF4 RN could not obtain a blood pressure) with orders. The nurse failed to document whether or not the patient's respirations were faint, deep or shallow and also failed to document an apical pulse.

Review of the physician orders dated 5/21/2011 at 10:45 PM revealed a telephone order documented by SF4 RN to bolus patient #5 with 250 cc (cubic centimeters) of normal saline over 2 hours, to continue the normal saline at a rate of 80 cc per hour, to administer one dose of Narcan (use to reverse narcotics) 0.4 mg IVP and to "hold all narcotics till further notice ". According to 5/21/2011 nurse progress notes the saline bolus and Narcan was administered at that time (10:45 PM). Further documentation at that time revealed the patient was still lethargic after the Narcan and saline was administered. Continued review revealed no documented evidence that vital signs were obtained.

Documentation revealed on 5/21/2011 at 11:50 PM patient #5 ' s blood pressure was 80/57 (one hour and fifty minutes after the last blood pressure was obtained) and at 12:15 AM on 5/22/2011 her blood pressure was 90/65 but there was no documented evidence that the nurse assessed the patient ' s respirations and heart rate. Further documentation revealed at 1:00 AM the patient was asleep, her respirations were equal and unlabored but the nurse failed to document the rate of the respirations and also failed to document a heart rate. The 5/22/2011 nursing progress notes revealed SF10 LPN administered Ultram (analgesic) 50 mg for pain at 2:40 AM " to help with pain. SF10 LPN documented at 5:30 AM on 5/22/2011 that the patient was sleep, was in no distress and her blood pressure was 109/82. Further review revealed the nurse failed to assess the patient ' s respirations and heart rate. Documentation in the medical record failed to reveal a registered assessed and evaluated patient #5 on 5/21/2011 during the 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM shifts.

Review of the 5/22/2011 nursing assessments at 6:00 AM revealed patient #5 was lethargic, anxious and her speech was slurred. Review of the 5/22/2011 at 7:00 AM nursing progress notes revealed SF18 LPN documented that patient #5 was asleep when she rounded, easily aroused but lethargic. She further documented at that time that her eyes were glassy, pupils sluggish, blood pressure was 60/40, heart rate 120 beats per minute, respirations 16 breaths per minute and temperature 98.4 F. Continued review failed to reveal the nurse obtained more than one set of vital signs after patient #5's blood pressure was 60/40 and heart rate was 120 beats per minute. Further documentation revealed she reported this to the charge nurse at 8:50 AM and paged the doctor on call (1 hour and 50 minutes after the 7:00 assessments were made). SF18 documented that the Dr. SF8 gave a telephone order for Levaquin. Review of the 5/22/2011 at 8:45 AM physician orders revealed Dr SF7 gave a telephone order for Levaquin (antibiotic) 500 mg to be administered by mouth " now " and that Dr. SF7 will evaluate patient #5 in the morning to see if she needed IV antibiotics. At 8:50 SF18 LPN documented that there was change in patient #5's condition and that she remained lethargic. Documentation at 9:00 AM on 5/22/2011 (10 minutes after she documented that there was a change in the patient's condition) revealed SF18 RN paged Dr. SF8 due to the patient vomiting "20 cc dark colored bile" and gave an order to transfer patient to hospital. There failed to be documented evidence in the medical record that the registered nurse assessed and evaluated patient #5 on 5/22/2011.

An interview on 7/28/2011 at 9:25 AM with SF2 Don revealed, when the nurses could not obtain a blood pressure on patient #5 the nurse should have remained with the patient and the physician should have been informed immediately and the nurse should not have left the patient ' s bedside. SF2 said the nurse should have assessed the patient every minute and took vital signs every 5 minutes. He also said the physician should have been notified when the nurse first observed a change in her mental status. SF2 DON stated also that he would have expected the nurse to remain with the patient after the physician ordered fluids and Narcan on 5/21/2011 at 10:40 and obtained vital signs every 3 to 5 minutes. SF2 DON stated the physician should have been notified of the 05/22/11 at 7:00 AM vital signs of patient #5. SF2 DON stated the delay in physician notification is " not appropriate. " Additionally, SF2 stated the hospital does not have a policy on reporting a significant change in a patient ' s condition. He said the nurses should implement the changes in the patient ' s plan of care. SF2 confirmed that Morphine was a respiratory depressant and the the nurse should have measured the patient's respirations before administering that medication.

Review of a hospital policy titled "Charge Nurse Responsibilitie", approved 07/20/09, last revised 02/24/11, presented as current hospital policy reads in part: "Assess every patient daily (in a 24 hour period) and document ...Maintain communication with the staff and practitioner to address clinical changes in patient conditions that have the potential to warrant a change in care and services ...Conduct an assessment of the patient's condition and coordinate staff in a presenting emergency situation ..."

Based on record review, policy review and staff interview the hospital failed to ensure the nursing plan of care was developed and updated/revised based on the patient care needs as evidenced by failing to update the care plan when mental status changes and labile blood pressures were identified for 1 of 16 sampled patients (patient #5). Findings:

Review of the medical record revealed patient #5 was a 26 year-old who was transferred from Hospital A and admitted to Community Specialty Hospital on 5/17/2011 at 2:25 PM with chief complaint of "non-healing wounds, generalized and severe debilitation following prolonged hospitalization". Review of the 5/18/2011 at 11:40 AM History and Physical (H and P) revealed the SF14 PA (physician assistant) documented patient #5 had a previous history of consuming one quart of "vodka per day having progressive mid-abdominal belt like pain that radiated to the back associated with nausea, vomiting, and abdominal distension". There is stiffness to all of her joints and there is some muscle spasms, tremulousness and drop foot bilaterally. Overall, generalized motor weakness. Chronic pain associated with any movement of her limbs and diffuse at the surgical sites. She has a residual wound on her mid abdomen and multiple ostomies.

Review of the 5/17/2011 nursing progress notes revealed patient #5 was admitted to room 124 at 2:25 PM and the vital sign sheet revealed at 2:30 PM her temperature was 100.4 degrees Fahrenheit, blood pressure 110/78, respirations 22 breaths per minute and heart rate 130 beats per minute. Review of the 5/17/2011 at 2:25 PM assessments revealed that on admission patient #5 was alert, oriented and her memory was adequate. Review of the 5/17/2011 at 7:00 PM initial assessments performed by SF13 RN revealed patient #5 ' s temperature was 100.4, heart rate 130 beats per minute respirations 22 breaths per minute and blood pressure 109/78.

Review of the 5/18/2011 nursing assessments revealed at 6:00 AM and 6:00 PM patient #5 was alert, oriented, memory adequate, cooperative and quiet. Further documentation revealed at 6:00 AM her temperature was 99.8 F., hear rated 125 beats per minute, respirations 20 breaths per minute and blood pressure 106/77. Documentation at 6:00 PM revealed her temperature was 99.9 F., heart rate 127 beats per minute, respirations 24 breaths per minute and blood pressure 95/62.

Review of the 5/19/2011 at 6:00 AM and 6:00 PM nursing assessments revealed patient #5 was alert, oriented, cooperative, quiet, had adequate memory and her speech was not slurred. Continued review revealed at 6:00 AM her temperature was 98.8 degrees F., heart rate 79 beats per minute, respirations 20 breaths per minute and blood pressure 113/69. Further review revealed at 6:00 PM her temperature was 99.0 degrees F., heart rate 102 beats per minute, respirations 20 breaths per minute and blood pressure 100/68.

Review of the 5/20/2011 nurses progress notes check off assessments revealed at 6:00 AM and 6:00 PM patient #5 was alert, oriented and cooperative. Further review revealed at 6:00 AM the temperature was 98.3 F (Fahrenheit), heart rate 102 beats per minute, respirations 22 breaths per minute and blood pressure 112/81. The 5/20/2011 progress notes at 6:00 PM revealed her temperature was 98.1 F, heart rate 129 beats per minute (27 beats per minute increase since 6:00 AM), respirations 12 breaths per minute (10 breaths per minute less since 6:00 AM) and blood pressure 92/64 (a decrease in systolic and diastolic since 6:00 AM).

Review of the 5/21/2011 nurse progress notes revealed at 6:00 AM SF9 LPN documented that patient #5 was alert, confused, depressed and her temperature was 97.9 F heart rate 110 beats per minute and respirations 22 breaths per minute and blood pressure 98/67. Review of the 5/21/2011 progress notes revealed SF9 LPN documented that patient #5 and at 6:00 PM her temperature was 99.9 F., heart rate 127 beats per minute, respirations 24 breaths per minute and blood pressure 95/62 and at 6:00 PM her temperature was 99.9 F., heart rate 127 beats per minute, respirations 24 breaths per minute and blood pressure 95/62 and at 6:00 PM her temperature was 99.9 F., heart rate 127 beats per minute, respirations 24 breaths per minute and blood pressure 95/62 and at 6:00 PM her temperature was 99.9 F., heart rate 127 beats per minute, respirations 24 breaths per minute and blood pressure 95/62. Further documentation at that time revealed the patient was awake and confused at times.

Further review on the 5/21/2011 assessments revealed at 6:00 PM patient #5 was alert, lethargic, memory was poor and her temperature was 98.2 F, heart rate 120 beats per minute, respirations 20 breaths per minute and blood pressure 80/56. There was no documentation that the nurse reported this to the physician. Review of the 5/21/2011 nurses progress notes revealed at 7:10 PM patient #5 was "asleep but a little lethargic. Pt stated it was her pain meds (medications)". This was a continued changed in condition but according to the medical record the nurse failed to report the patient's decline in condition to the physician or PA. Further review on 5/21/2011 revealed at 9:45 PM the patient remained "lethargic. tried to take Bp (blood pressure) (with) machine & manually but no Bp could be heard. Continued to try for Bp. HR (heart rate)-120 RR (respirations) 14 t (temperature) 97.0. pt cold to touch. Strong pulse to dorsales pedis. Respiration equal & unlabored. (SF4 RN) assessed pt & could not get bp (blood pressure also". Documentation revealed that SF10 LPN called Dr. SF8 at 10:00 PM (15 minutes after a blood pressure could not be obtained) and "got his answering service" and there was no "call back from Dr. SF8". Review of the 5/21/2011 nurse progress notes revealed at 10:00 PM a 70/40 blood pressure was obtained with a "machine" (15 minutes after the nurse documented a blood pressure could not be obtained. The nurse failed to document whether or not the blood pressure was faint or loud.

Documentation revealed on 5/21/2011 at 11:50 PM patient #5's blood pressure was 80/57 (one hour and fifty minutes after the last blood pressure was obtained) and at 12:15 AM on 5/22/2011 her blood pressure was 90/65 but there was no documented evidence that the nurse assessed the patient's respirations and heart rate. SF10 LPN documented at 5:30 AM on 5/22/2011 that the patient was sleep, was in no distress and her blood pressure was 109/82.

Review of the 5/22/2011 nursing assessments at 6:00 AM revealed patient #5 was lethargic, anxious and her speech was slurred. Review of the 6:00 AM nurses' progress notes revealed the patient was resting and was not in distress. Review of the 5/22/2011 at 7:00 AM nursing progress notes revealed SF18 LPN documented that patient #5 was asleep when she rounded, easily aroused but lethargic. She further documented at that time that her eyes were glassy, pupils sluggish, blood pressure was 60/40, heart rate 120 beats per minute, respirations 16 breaths per minute and temperature 98.4 F. Continued review failed to reveal the nurse obtained more than one set of vital signs after patient #5's blood pressure was 60/40 and heart rate 120 beats per minute. At 8:50 SF18 LPN documented that there was change in patient #5's condition and that she remained lethargic.

Review of the nursing care plan for patient #5 revealed no documented evidence that the care plan was updated to include interventions for conducting neurological assessments after mental status changes were assessed and blood pressure assessments after labile blood pressures were assessed.

Review of a hospital policy titled "care Plan" , effective date 9/29/205, last reviewed and revised 7/28/2011, presented as current hospital policy reads in part: " Policy. It is the policy of this facility to develop care plans that will identify nursing diagnosis and patient care needs related to the diagnosis. Procedure ...4. Care plans based on written assessment of all chronic and potential as well as immediate problems. 5. The care plans will be revised and updated as needed. "

In an interview on 7/28/2011 at 9:25 AM SF2 DON (Director of Nursing Services) stated the nurses did not take the appropriate action when patient #5 mental and physical condition was declining. Further interview with SF2 Don revealed when the nurses could not obtain a blood pressure on patient #5 the nurse should have remained with the patient and the physician should have been informed immediately and the nurse should not have left the patient's bedside. SF2 said the nurse should have assessed the patient every minute and took vital signs every 5 minutes. He also said the physician should have been notified when the nurse first observed a change in her mental status. Additionally, SF2 stated the hospital does not have a policy on reporting a significant change in a patient's condition. He said the nurses should implement the changes in the patient's plan of care.