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Based on record review and interview, the facility failed to ensure the performance improvement activities would identify opportunities for improvement based on adverse patient events, in that, the quality review of Patient #4's 6/28/17 unexpected death did not analyze the quality and coordination of care to identify preventive actions and mechanisms that include feedback and learning throughout the hospital.

Findings included

The electronic record for Patient #4 reflected he was awake, alert, and signed his own consents. Patient #4 was on a 2000 ADA Diet. Patient #4's record reflected, "History and Physical...6/21/17...Lung collapse...acute respiratory failure...2/2 (secondary to) HCAP (healthcare-associated pneumonia), COPD (Chronic Obstructive Pulmonary Disease), CHF (Congestive Heart Failure)...A-fib (Atrial Fibrillation)...Coumadin...DM (diabetes)...HTN (hypertension), HLD (Hyperlipidemia), CKD (Chronic Kidney Disease)...was in AKI (acute Kidney Injury...Progress Note...6/22/17...non-ischemic cardiomyopathy, status post AICD (Automatic Implantable Cardioverter Defibrillator) placement..."

Patient #4 was seen by the attending daily. Pulmonology and Nephrology/Renal were consulted and seen Patient #4 as well.

Patient #4's 6/28/17 note by Personnel #11 reflected, "13:39 PM...now on BiPAP, in mild respiratory distress...Increased work of breathing..."

Patient #4's 6/28/17 Respiratory (RT) note reflected, "16:00 PM...The patient refused neb treatment at this time. Patient (pt) stated he wanted me out of his room." There was no physician notification documented.

Personnel #12 met with the patient on 6/28/17 at 17:12 PM after being called by the ex-wife in regards to Patient #4 wanting to leave against medical advice.

Patient #4's 6/28/17 respiratory note by for the code blue reflected, "21:05...Code Blue initiated at 1920-2000. House doctor called time of death 2000. 3 incubations attempt by house Dr., lab-Chem8I-strat (sp) done. No EKG or ABG (electrocardiogram/arterial blood gas) Done due to one RT in the building. PCT found pt unresponsive, called a nurse, Personnel #7 who was sitting at the station for help but she didn't even got (sp) up to help her. She went back to the room and Personnel #5 came in and initiated code blue." There was no order for ABG or EKG in the record.

Patient #4's 6/28/17 I-STAT (Bedside Lab test) Chem 8 (K = Potassium) completed at the time of the code reflected, "K 8.2."

Patient #4's 6/28/17 nurse note for the code blue reflected, "23:39...1925 Code Blue initiated by the house supervisor. Pt found unresponsive by the PCT (patient care tech/certified nurse assistant/CNA) who called for help. Present at the room were the primary nurse, PCT, RT, 2 RN and the house Physician. Code blue protocol initiated, ISTAT done. 3 attempt made to intubate pt, Code lasted for about 35 minutes. Time of death was pronounced at 2000 hours. By (Personnel #16)...23:48...Pt body taken to...Funeral home at 22:35, with the family member present."

There were 3 respiratory issues (6/24/17 at 9:10 AM & 20:18 PM, and 6/28/17 at 13:39 PM) documented for Patient #4's the 8-day stay. No family notifications were documented.

There was no Care Plan Meeting documented for Patient #4's 8-day stay.

Patient #4's 6/29/17 physician progress note reflected, "6:55 AM...patient is about the same...currently in bed...Verbally abusive..." by Personnel #14. The patient had been picked up by the funeral home the night before.

There was a Code Blue Critique at the end of the code by the staff involved. There were no explanations/notes to explain if opportunities found.

There was a Code Blue Chart Review on 7/05/17. There were no explanations/notes to explain if opportunities found.

There was a 7/05/17 Mortality Review completed for the "Unexpected Mortality" signed by Personnel #3 and #15. The outcome was documented as "Medical care which resulted in a life-threatening situation, permanent loss to the patient of a major physical function, or which resulted in the patient's death." There were no explanations/notes to explain if opportunities found.

There was no RCA completed for this unexpected death.

The "QAPI" and "Medical Executive" meeting minutes were reviewed. Numbers of deaths were reported. The processes completed to review the unexpected death did not analyze the quality and coordination of care to identify preventive actions and mechanisms that include feedback and learning throughout the hospital.

The "Governing Board" meeting minutes did not reflect number of or a review of deaths.

During an interview on 8/29/17 ending at 1:49 PM, Personnel #3 was asked about the mortality review process and reporting. Personnel #3 stated, "I do the review with (Personnel #15's name). We review Rapid responses, Code Blues, Mortality, and unplanned transfers. We report numbers to Quality and Med Exec."

During an interview on 8/30/17 ending at 12:40 PM, Personnel #12 and #13 were asked what is done with patients refusing medication, vital signs, treatment, and yelling at staff. Personnel #12 stated, "We meet weekly on all patients. Patients are told that we do them: family conferences and weekly IDT/Team Conferences and they can ask for them." Personnel #12 was asked if the care plan meeting included Patient #4. Personnel #12 stated, "No." Personnel #12 was asked about Patient #4's situation and if he had meet with the patient and/or family about his behavior with the staff and his refusals. Personnel #12 stated, "No." Personnel #12 added, "I got a call on 6/28/17 from (ex-wife's name) and she told me the friend was headed up to pick him up. I went to talk to him (patient) then."

In an email response to questioning on 8/31/17 at 4:13 PM, Personnel #3 was notified of the 6/29/17 physician note after the death of the patient. Personnel #3's response was, "Wrong date is noted/physician will be notified for correction." Personnel #3's was notified of the 6/28/17 Nurse Practitioner note that reflected respiratory distress at 13:39 PM and was asked if a RRT (Rapid Response Team/Code) was called or documented. Personnel #3's response was, "Upon further review it was noted she did not activate an RRT."

During an interview on 8/29/17 ending at 9:24 AM, Personnel #3 was informed there were no explanations/notes to explain opportunities found during the chart/code/mortality reviews completed for Patient #4. Personnel #3 stated, "I see what you are saying." Personnel #4 was asked if the reviews had identified the issues the survey found (diet, renal failure, high potassium, respiratory refusals, and general breakdown in coordination of care). Personnel #3 stated, "No."

During a telephone interview on 9/01/17 ending at 1:20 PM, Personnel #3 was asked if an RCA was completed for Patient #4's unexpected death/sentinel event. Personnel #3 stated, "No." Personnel #3 was asked if they realized it was a sentinel event. Personnel #3 stated, "No Ma'am."

In a 9/01/17 at 2:12 PM email response to 1:20 PM questioning, Personnel #3 stated, "PCT going into patient's room for vitals is the one who finds the patient and called for help; 1925 Code Blue initiated by house supervisor."

During a telephone interview on 9/01/17 ending at 2:21 PM, Personnel #4 was asked if the patient complained or was non-compliant. Personnel #4 stated, "No, not to (complain) me. I got report that he was non-compliant with medications, oxygen, diet, water and that he yells out a lot, but not for me."

In a 9/01/17 at 3:17 PM email response to 1:20 PM questioning, Personnel #3 stated, "(respiratory/RT) was in-serviced (for the progress note) by RT Director."

During a telephone interview on 9/01/17 ending at 4:18 PM, Personnel #16 was asked if he remembered Patient #4's code. Personnel #16 stated, "I arrived at the hospital and 5 minutes later was in the code with little history of the patient. I remember being told COPD, and refusing dialysis. When I got to the room, they (staff) were doing CPR (cardio-pulmonary resusitation) and bag /mask breaths. (Patient #4) had a pulse Oximeter and (Automated external Defibrillator) AED. ACLS (Advanced Cardiac Life Support) was followed. I attempted intubation 3 times, the last time after the Respiratory tech got the glide scope. His body habitus (Patient #4) of morbid obese, thick beard and copious secretions. He (Patient #4) looked like an ICU (Intensive Care Unit) patient. He had a lot of secretions. He (Patient #4) never got a pulse back. We had lots of hands on deck: house supervisor/male, 2 nurses, RT (respiratory) and 2 CNA's. After the code, they (staff) said he (Patient #4) wanted to AMA (leave against medical advice) that morning and had required an increased amount of oxygen throughout the day. We did a debriefing with house supervisor/RT/RN and discussed things. I said there was no delay, crash cart was there, would have been helpful to have the glide scope earlier. I said if the patient was refusing treatment and wanted AMA, they should have had DNR/DNI (Do not resuscitate/intubate) already. It was shift change so that makes it worse."

During a telephone interview on 9/05/17 ending at 12:01 PM, Personnel #6 was asked if she knew the patient. Personnel #6 stated, "Yes. I had taken care of him. He refused his breathing treatments and was wheezing a lot." Personnel #6 was asked about her documentation. Personnel #6 stated, "I thought I was supposed to document everything. The CNA and I spoke after the code. It is what she said. I don't know if it happened." Personnel #6 was asked about the code of Patient #4. Personnel #6 stated, "I got to the room and the CNA, the house supervisor, and the primary nurse were there. I started getting stuff out of the crash cart. The house doctor came in after me. He (doctor) tried blind intubation twice. I went over to ICU (on the other end of the hallway) for the glide scope. He (doctor) tried it but he couldn't get it either. He (Patient #4) had not pulse. The doctor said we all did a good job and worked well."

The July 2017, last reviewed "Risk Management Plan" required, "Continuous analysis occurs, in part, by the hospital's unusual occurrences reporting, response procedures, and strategies for prevention of such events...ensuring a culture of safety...record audits for mortalities or unusual events like rapid response team activation and code blue events...procedures for responding to system or process failures...conduct thorough and credible comprehensive systemic analysis (RCA/Root cause analysis) in response to sentinel events...disseminate lessons learned from comprehensive systemic analysis...to all staff that provide services for the specific situation...identifying the basic or causative factors that underlie variation in the performance...unanticipated death...positive impact in improving patient care treatment and services and preventing future similar occurrences...product of the investigation/root cause analysis is an action plan..."

the facility failed to ensure an RN supervised and evaluated the nursing care for each patient, in that, a 24 hour RN assessment (registered nurse) for 3 of 12 patients (Patient #4, #11, and #12) was not documented during their respective admissions.

Findings included

Patient #4's record did not document a 24 hour RN assessment on 6/25/17 (last documented 6/24/17 at 06:30 AM) and 8/28/17 prior to the death (last documented 6/27/17 06:35 AM) .

Patient #11's record did not document a 24 hour RN assessment on 8/26/17 and 8/27/17 consecutively (last documented 8/25/17 at 18:20 PM).

Patient #12's record did not document a 24 hour RN assessment on 8/23/17 (last documented 8/22/17 at 18:40 PM); 8/26/17 (last documented 8/25/17 at 18:52 PM); and 8/28/17 (last documented 8/27/17 at 10:07 AM).

During electronic record review and interview on 8/30/17 ending at 12:30 PM, Personnel #10 was asked to navigate the clinical records and confirm the findings above. Personnel #10 confirmed the findings.

The 2016 Admission Assessment" Policy required, "Reassessment will take place as the patient condition warrants. An RN will assess each patient at least daily and more often if needed."

Based on record review and interview, the facility failed to ensure the care plan process was completed for each patient which addresses the patient's needs, in that, Patient #4's care plan was initiated on 6/20/17, but was not updated with his issues and non-compliance and not discussed as a care team.

Findings included

Patient #4's record reflected the initiation of a nursing care plan on 6/20/17.

The care plan did not document a updated with his verbal/behavior issues and non-compliance and was not discussed as a care team in IDT.

There was no Care Plan Meeting documented for Patient #4's 8-day stay.

Patient #4's nurse notes reflected, "6/21/17 ...19:40 PM ...pt (patient) refuses all tx's (treatments) until his throat stops hurting ...6/22/17 ...08:30 AM ...Cardiologist seen the PT...informed him that he was refusing teli (sp/telemetry), He talked to him also ...11:00 AM ...Stuck him once unsuccessful ...Pt refused to do it again ...12:00 PM ...Cardiac Monitoring ...Pt refused ...23:30 PM ...refused phlebotomy for blood cultures...6/23/17 ...5:35 AM ...refused says will do bath later ..."

The 6/23/17 physician note reflected, "...progress note ...patient will adamantly not wear the telemetry monitor ...Flat effect ..."

The 6/25/17 physician note reflected, " ...Progress note ...Somewhat combative and verbally abusive affect ..."

The 6/28/17 physician note reflected, " ...Progress Note ...Somewhat verbally combative."

The 6/28/17 note by Personnel #11 reflected, "13:39 PM ...now on BiPAP, in mild respiratory distress ...Increased work of breathing ..."

The Personnel #12 met with the patient on 6/28/17 at 17:12 PM after being called by the ex-wife in regards to Patient #4's wanting to leave against medical advice.

Patient #4's 6/28/17 Respiratory note reflected, "16:00 PM ...The patient refused neb treatment at this time. Patient stated he wanted me out of his room."

During an interview on 8/30/17 ending at 12:40 PM, Personnel #13 and Personnel #12 were asked what is done with patients refusing medication, vital signs, treatment, and yelling at staff. Personnel #12 stated, "We meet weekly on all patients. During the assessment, we tell them about family conferences and weekly IDT Conferences. Patients are told that we do them and they can ask for them." Personnel #12 was asked if he had meet with Patient #4 about his behavior with the staff and his refusals. Personnel #12 stated, "No." Personnel #12 was asked if a patient/family meeting was done. Personnel #12 stated, "No." Personnel #12 was asked if the Interdisciplinary Team Care (IDT) Conference included Patient #4. Personnel #12 stated, "No."

The January 2017, last revised "Discharge Planning" Policy required, "...coordinating the activities of an interdisciplinary team, such as the Interdisciplinary Team Care Conference,. During this weekly conference , staff members discuss the patient's discharge needs and disposition options with the attending physician, nursing , and ancillary therapy staff...Patients and family members may occasionally attend the weekly conference, or a separate care conference...The Case Manager will complete weekly routine re-assessment and ongoing monitoring and evaluation..."