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Based on review of facility documents, medical records (MR) and interview with staff (EMP), it was determined that the facility failed to respond timely and appropriately to a medical emergency for one patient (MR1), and failed to ensure that all staff were adequately trained in change in condition notification. Due to the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

On July 2, 2025, at 2:50 PM, Immediate Jeopardy (IJ) was identified, and the facility was notified, regarding its failure to fully assess and respond timely to a patient having a decline in condition and failed to ensure that all staff were adequately trained on change in condition notification. At ¿July 2, 2025, at 6:40 PM¿, IJ was removed after the State Survey Agency verified implementation of corrective actions to remove the immediate risk to patients.

Cross Reference:
482.23(b)(6) Nursing Services

Based on facility documents, review of medical records (MR), and interviews with staff (EMP), it was determined that the facility failed to identify, respond timely and appropriately to a medical emergency for one patient (MR1) and failed to ensure that all staff were adequately trained on physician notification protocols.

Findings include:

Review of facility policy "Change in Patient Condition" with a most recent review date of April 1, 2025, states, "... The following could describe a significant change in patient condition. This list is not meant to exclude other possibilities, but rather to describe the most common causes for significant changes in condition. Any single finding does describe a significant change in condition and requires Assessment, Documentation, and Notification ... Change in BP from baseline that is not intended by therapeutic intervention. Any BP < 90 systolic, > 180 systolic ... Assessment and Basic Recommendations: 1. A complete head to toe assessment will be performed along with consultation as appropriate among the clinical team. It is the responsibility of the charge nurse to ensure that the process to assess the patient occurs in a timely fashion, and to gather other relevant data. 2. Data to be obtained includes but is not limited to: A complete set of vital signs including accurate temp-rectal or tympanic membrane. If hypotensive with systolic BP<90, obtain IV access and administer 250 ml NS fluid bolus over 30 minutes. Send serum troponin level and obtain stat 12 lead EKG if suspected cardiac issue. Telemetry: Monitor patient on telemetry for the next 24 hours or per physician ' s order. A rhythm strip ...Pulse ox reading. If <88 stat ABG ' s or VBG ' s. Finger stick glucose ... Review and validation of current-recent labs, medications and IV fluids, tube feeding orders ... RAPID RESPONSE TEAM ACTIVATION SEQUENCE: 1. Recognition of a worrisome or acute change in condition by bedside caregiver, family member, or other. 2. Rapid assessment completed by primary caregiver. 3. Activation of Rapid Response Team (RRT). 4. RRT arrives at bedside, receives SBAR report from bedside caregiver and performs assessment including but not limited to: head to toe physical assessment, vital signs, EKG rhythm, pulse oximetry, medication and lab results review. 5. Appropriate RRT protocols initiated by team and orders placed on patient record/EMR. 6. Attending physician and/or appropriate consultants notified utilizing SBAR communication process. 7. Assessment, interventions, and physician communication documented on RRT form/EMR. NOTIFICATION: (use SBAR format to communicate all critical information) 1. It is the Charge Nurse ' s responsibility to ensure that the attending physician is notified expeditiously. If the attending physician cannot be notified in a timely way, the Medical Director should be notified as well as the Administrator-On-Call. DOCUMENTATION: 1. The complete assessment should appear on the nursing flow sheet/EMR. The change in condition and physician communication should be documented in the clinical notes or electronic medical record (EMR). 2. When a Rapid Response Team (RRT) is initiated, utilize the RRT Response Record/EMR to document assessment data, interventions, and physician communication ..."

Review of facility policy "Assessment and Reassessment of Patients" with a most recent review date of January 1, 2025, states, "... Reassessment is a documented description of the patient's response/status relative to medical and/or nursing interventions, effectiveness of interventions, resolution of patient problems/needs, and discharge preparation. All data collected on patients is reviewed and analyzed by the RN assigned to oversee care for the patient; interdisciplinary team goals are adjusted based upon the changing needs of the patient and/or his response to prescribed interventions. Reassessment is documented approximately every twelve (12) hours and when the patient's needs/condition warrants ..."

Review of facility policy "Communication SBAR [Situation, Background, Assessment, Recommendation]" with a most recent review date of April 1, 2025, states, "... Policy: 1. SBAR is a framework for communication that relays information that needs immediate attention and action. 2. The SBAR communication process will be utilized when communicating to physicians. 3. Prior to calling the physician, follow these steps: a. Assess the patient b. Discuss the situation with House Supervisor/Nursing Supervisor c. Review the chart for appropriate physician to call d. Know the admitting diagnosis and date of admission e. Read the most recent physician progress notes and notes from the previous shift f. Have available when speaking to the physician: i. Patient's chart ii. List of current medications, allergies, IV fluids, and labs iii. Most recent vital signs iv. Reporting lab results: provide the date and time test was done and results of previous tests for comparison ... 5. The clinician will use the SBAR communication process to ensure all critical elements of communication are completed: a. Situation: This includes patient identification information, code status, vital signs and the clinician concerns. b. Background: Pertinent information on medical history and diagnosis as well as treatment to date should be included. Information such as patient ' s mental status, pain level, skin condition and whether he or she is on oxygen should be noted. c. Assessment: All assessment findings that have changed from a previous assessment are communicated. The clinician will indicate what he or she believes to be the problem. d. Recommendation: The clinician should say what they think may be beneficial or what needs to be done. Any physician follow-up actions are suggested, including possible tests ... Documentation: The clinician will document in the medical record all pertinent information related to physician notification such as ... date, time, physician name, patient status, orders received, and actions/interventions completed ... "


On July 2, 2025, review of MR1 revealed nursing documentation dated June 14, 2025, that the patient's condition was declining. Review of nursing note on June 14, 2025, at 0348, "Patient returned to bed from cardiac chair as coloring appeared dusky. Immediately following the patients return to bed this RN took patients vitals. Blood Pressure (BP) 63/49, Heart Rate (H) 59, Respirations 28. Pulse ox was difficult to obtain. Respiratory in room to adjust. This RN asked RN in hall to make charge nurse aware and request presence in room. This RN requested assistance in obtaining BP, as this RN adjusted cuff on left upper extremity and re-cycled the passport [patient monitoring system to track vitals] to confirm that the BP was correct. Charge RN had this RN chart rapid response while in room. Patient was placed in Trendelenburg [laid on back with feet raised], repositioned and BP returned to normal. The rapid response outcome was documented and ended at that time. This RN requested that the charge make MD (medical doctor) aware in case additional intervention was needed. The charge RN declined to do so at that time." No documentation of notification to the Doctor on call was found for this event in MR1.

Nursing note on June 14, 2025, at 0450, "This RN in room as the passport was alarming that the patients BP was low. Passport BP 68/12. Manual BP obtained on left upper arm. 89/38. Charge RN made aware. This RN requested the MD be contacted for Levophed [medication used to treat severe low blood pressure] drip, or transfer to ICU as the patients repeated low BP. Charge RN said no. Charge RN told this RN to give patients midodrine dose via peg tube. Midodrine given. Charge RN in room at this time. BP recycled. Passport unable to effectively obtain BP. This RN again requested levophed drip, and for the MD on call to be made aware. Charge RN declined." No documentation of notification to the Doctor on call was found for this event in MR1.

Further review of MR1 revealed, a second rapid response was initiated on June 14, 2025, at 0450 for low BP of 89/38. Pulse was 80 and respirations 34. Nursing note on June 14, 2025, at 0505, stated "This RN continues in room with patient to monitor BP. Patient's BP continues to be difficult to obtain even with manual BP." Midodrine 10mg was given per tube. At 0515, an order was placed for Norepinephrine (Levophed) infusion. Documentation in MR1 shows the charge nurse did not contact the physician to report the change of condition for 25 minutes following the time the second rapid response episode was initiated.

MR1 revealed on June 14, 2025, at 0525, the patient was started on Levophed drip at 8 mcg/min. Patient's vital signs were as follows: Blood Pressure (BP) 71/46, pulse 80, respiratory rate 31, O2 sat (oxygen saturation) 95%.

Review of MR1 showed the following timeline for that day:

At 0530, BP 145/67, pulse 80, respiratory rate of 34, and pulse ox of 96% with a respiratory pattern of tachypneic.
At 0540, BP 72/40, pulse 80, and MAP 50.
At 0547, Levophed drip was increased to 10 mcg/min.
At 0552, BP 81/37 and a pulse of 80.
At 0558, BP 105/89, pulse 80, respirations 31, and respiratory pattern tachypneic.
At 0605, BP 136/70, pulse 80, respirations 36.
At 0610, BP 122/19.
At 0618, Levophed drip was increased to 12 mcg/min. BP was 97/13, pulse 80, respirations 33, O2 sat 100%.

MR1 nursing note on June 14, 2025, at 0618, "This RN continues in room with patient. Patient has intermittent decrease in responsiveness. This RN asked another RN on unit to attempt to place IV, as I was unable to even palpate/visualize any possible areas for access upon assessment. IV placement unsuccessful for this RN and 2nd RN. RN in room with ultrasound to assess for vascular access. Additional IV access unable to be obtained at this time ... BP cuff moved from left upper extremity to right thigh ... Charge RN in room to make this RN aware that patient's family is on their way. Requested patient be transferred to ICU. Charge RN replied no and walked out of room. Will continue to monitor in room until oncoming shift arrives." MR1 revealed notification to the Doctor for this event was not made until after 7:00 AM when the next shift arrived.

At 0623, BP was 112/66.
At 0635, Levophed drip was increased to 14 mcg/min.
At 0637, BP was 61/27 and orders were placed for a blood glucose, arterial blood gas, strict I&O, blood and urine cultures, CMP, chest x-ray, and lactic acid. (Automatic orders per protocol.)
At 0643, BP was 81/33 and pulse 80.
At 0644, Levophed drip was increased to 16 mcg/min. BP 75/39
At 0646, BP was 119/27.
At 0649, Levophed drip was increased to 18 mcg/min. BP was 75/39.
At 0654, Levophed drip was increased to 20 mcg/min. BP 82/36 and pulse 80.

Nursing note on June 14, 2025, at 0700, "As I approached room 558 to complete bedside report I witnessed patient Pale, lethargic, severely hypotensive, and respiratory at bedside changing vent settings. Patient appeared to be actively dying."

At 0701, BP was 74/39.
At 0702, Levophed drip was increased to 22 mcg/min.
At 0713, Levophed drip was increased to 24 mcg/min, order to insert a PICC line was placed. BP was 65/33.
At 0719, Levophed drip was increased to 26 mcg/min. BP 75/33
At 0724, Levophed drip was increased to 28 mcg/min. BP 77/34
At 0730, Levophed drip was increased to 30 mcg/min. BP 61/33, pulse 79
At 0730, Nursing Note "Levo maxed at 30mcgs, still receiving report from night shift nurse, day shift charge notified and calling MD currently to update them on patient's status."

MR1 revealed the patient's condition continued to worsen and the Physician on call was not notified again until around 0730 on June 14, 2025. At that time MR1 was transferred to another hospital with a higher level of care at 0801 and died that morning. Review of MR1 revealed no SBAR assessment documentation on June 14, 2025. .

Interview with EMP3 (RN) on July 2, 2025, at 1630 stated, "I mainly focused on the blood pressure." When asked if an SBAR was used to communicate all the information to the Provider (doctor) EMP3 explained that they did not do a full head to toe assessment, but they did do an assessment. When asked if the assessment was documented, EMP3 stated, "No, I just did a note ..." When asked if EMP3 assessed the patient after starting the Levophed drip, EMP3 stated that they came back around, and checked and blood pressure was stable. It wasn't until they were rounding with the day charge nurse that they learned the blood pressure was low.

Interview with EMP2 (Medical Doctor) on July 2, 2025, at 1430 stated that they received a call in the middle of the night that MR1 blood pressure was low and ordered the Levophed drip. The next call received was not until morning from the charge nurse. EMP2 confirmed they were not informed of any other changes with MR1.

Interview with EMP7 (RN) on July 8, 2025, at 1225 stated that they do not know where the doctor's phone numbers are located, and they were told during orientation that the charge nurse is the only one who should call the Doctor to notify of a change in patient condition. In addition, EMP7 stated that not all required personnel attended the rapid response incidents for this patient.

Interview with EMP6 on July 8, 2025, at 1400 explained that the Rapid Response team is the charge nurse, primary nurse and respiratory therapist. There is also a code team assigned at the start of every shift by the charge nurse. This delegates someone to chart, give medications, and assistance for airway and chest compressions in the event of a code. EMP6 confirmed a code team was not documented as being assigned for June 13 into June 14, 2025.