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Based on record review and interview the facility failed to identify and analyze an adverse patient event to possibly prevent a recurrence for (1)one of 10 patient's medical records reviewed. (Patient #1)

Findings Included:

Review of patient #1's history and physical dated 4/21/15 reflected a 60 year old male was admitted to the hospital after falling off a ladder. Patient #1 underwent surgery on 4/22/15 and was transferred to the medical surgical unit.

Review of Patient #1's medical surgical unit nursing notes dated 4/22/15 reflected two incidents, at 3:20 a.m. and at 6:15 a.m. in which respiratory therapy was called to assess patient #1 for increased difficulty breathing and abnormal lung sounds. Following a CT, (Computed tomography.) on 4/23/15 Patient #1 was transferred to the Intensive Care Unit/Intermediate Care Unit (ICU/IMC).

Review of Patient #1's Intensive Care/ Intensive Medical Care unit progress notes reflected:
- On 4/23/15 at 7:30 a.m., Respiratory therapist note reflected, Pt (patient) removing NRB. Oxygen saturation dropped to 79%. NRB replaced. Instructed patient on importance of coughing.

-On 4/23/15, Staff #4's nurse progress notes reflected:
-At 11:30 p.m. ...Current infusions include saline locked. Lungs noted to be coarse with crackles throughout on auscultation, sats (saturation, the amount of oxygen bound to the hemoglobin in the blood)>92% on 100% NRB (Non Rebreather mask, does not allow carbon dioxide to accumulate) plus 12L HFNC (high flow nasal cannula). Pt complaining of dryness to nose, asking to turn the nasal cannula down, sat 98%, turned to 6L(liter) on the HFNC, sats remained >92% , will continue to monitor. Patient seems irritated with many aspects of his care, questions answered, pt verbalized understanding. Reviewed plan of care and goals, patient verbalized understanding. Call light in reach. Will continue to monitor.
-On 4/24/15 at 12:15 a.m., recheck after pain medication. Pt asleep in bed, sats 92%, no distress noted.
-On 4/24/15 at 12:25 a.m., entered Pt room as monitor showing Pt off monitor, Pt found in chair, no pulse, no respirations, nasal cannula and NRB removed. Code Blue called and CPR (Cardiopulmonary Resuscitation) initiated.
-On 4/24/15 at 12:52 a.m., Pulses present, ROSC (Return of spontaneous circulation).

Review of the ICU/IMC nurse staffing for the 4/23/15, 11:00 p.m. to 4/24/15 7:00 a.m. shift revealed Staff #4, RN only had one patient, Patient #1.

During an interview on 11/4/15 in the Conference room, Staff #5, the ICU Director stated the unit admitted two patients that night. Staff #5 stated Staff #4 might have left the nurses station to assist with the admissions, but Staff #4 had been in the room at 12:15 a.m. and the patient was asleep. Staff #5 stated there were no other events on the ICU, that evening, to take the nurse away from caring for Patient #1.

During an interview on the morning of 11/3/15 in the conference room, Staff #2 (Director of Quality and Patient Safety) was asked if a Root Cause Analysis (RCA) had been completed for this event, Staff #2 stated the facility cannot be expected to conduct a RCA on all codes. When asked if the facility had completed an incident report in keeping with the facility's Sentinel Event policy, Staff #2 stated she started working at the facility in July of 2015 and was not aware of the event.

During an interview on the afternoon of 11/3/15 in the conference room, Staff #2 stated Staff #9, Staff #10, and Staff #11 had reviewed the incident for Patient #1 on 4/24/15, and did not submit the incident for a Root Cause Analysis. Staff #2 stated the individuals who reviewed the incident were no longer employed at the facility and she could not provide answers concerning their review process. Staff #2 stated since July she has been reviewing incidents and has sent several incidents to be reviewed for a Root Cause Analysis.

Review of facility documentation on 11/4/15 indicated that an Incident Report had been completed for Patient #1 on 4/24/15.

There was no evidence found or provided to indicate that there was a RCA for this incident as required by the facility Sentinel Event policy.

Facility provided Sentinel Event Policy #QUA.002.01 (last reviewed 12/2014) reflected:
Policy: Unexpected events or occurrences involving death or serious physical or psychological injury, or the risk thereof are to be reported to the Quality and Risk Management Department immediately upon identification.
Procedure:
I. Reporting
A. Any such event requires immediate action to examine, in-depth, the event to determine why the incident occurred and how to reduce the likelihood of recurrence.
II. All identified SE (sentinel event) or PAE's (preventable adverse event) will be investigated through the conduction of a Root Cause Analysis (RCA).
IV. The following is an established list of sentinel events related to this policy and procedure.
A. SENTINEL EVENT CRITERIA: 1. An event that has resulted in an unexpected death or major permanent loss of function, not related to the natural course of the patient's illness or underlying condition.

Based on observation, record review and interview, the facility failed to supervise contracted travel nurses as they did not check emergency crash carts on the Intensive Care Unit (ICU).

Findings Included:


Observation of the ICU on 11/3/15 in the morning revealed:
-The Crash Cart on the back hall was not checked on 11/1/15, 10/15, 10/4, 10/5, 10/11, 10/12, 10/28, 9/12, 9/20, and on 9/31. The sharps container (for used medical needles) was full, potentially preventing the safe disposal of used needles during a code.
-The Crash Cart on the front hall was not checked on 11/1, 10/9, 10/10, 10/12, 10/25, 10/27, 10/28, 9/19, 9/20, and on 9/3.

During an interview on the morning of 11/4/15 in the Conference room, Staff 5, the ICU Director stated the facility has been partially staffing with contracted travel nurses and they had missed checking the crash carts. Staff #1 stated the Emergency Crash carts are checked daily to ensure they are ready for use and have all the supplies and working equipment. Staff #5 stated she reviews the check off sheets and re-educates staff as needed.

During an interview on the afternoon of 11/3/15 in the ICU nursing station, Staff #5 confirmed she is responsible for the supervision nursing services on the ICU.

Based on observation, record review and interview, the facility failed to provide respiratory care services when one (1) of seven (7) patients reviewed with respiratory interventions did not receive an Incentive Spirometer, or instructions on its use, as ordered.

Patient #5 was not provided an Incentive Spirometer (IS - respiratory device) as ordered.

Findings Included:

During an interview on the morning of 11/3/15 in the ICU nursing station, Staff #5 (ICU Director) stated that respiratory related orders are completed by the respiratory staff.

Review of patient #5's physician's orders dated 11/2/15 reflected:
Incentive Spirometry, RT (Respiratory Therapy) every two hours while awake.
Continuous Positive Airway Pressure (CPAP), Instructions may use home machine on home setting.

Observation on 11/3/15 at 11:30 a.m. in ICU room 05, revealed Patient #5 sitting in a bedside chair, there was no Incentive Spirometer noted in the room.

During an interview on 11/3/15 at 11:30 a.m. in ICU room 05, Patient #5 stated she had not received an Incentive Spirometer and had not been given instructions on the use of the Incentive Spirometer.

During an interview on the morning of 11/3/15 in the ICU nursing station, Staff #7 (Respiratory Director) stated the IS can be provided by the respiratory department or by the nursing staff. When Staff #7 was asked for a policy for the implementation of the IS orders, Staff #7 stated there is no policy regarding who has the responsibility of ensuring the order is completed. When asked what instructions are provided for the patient in the use of the IS, Staff #7 stated there used to be a pamphlet that came with the devices but that the facility had changed suppliers and the new IS did not come with directions. Staff #7 stated the facility had not developed an instruction sheet for IS. Staff #7 confirmed the respiratory therapist had not instructed the patient on the use of the incentive spirometer.