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Based on interview and record review, the facility failed to ensure patient rights were maintained when:

1. For Patient 9, the facility failed to ensure the grievance process was implemented (see A-0118).

2. For Patient 1, the facility failed to provide care in a safe setting when facility policy and procedures were not followed for an invasive bedside procedure (see A-0144).

The cumulative effects of these systemic failures had the potential to impact the health and treatment of the patients and may cause delays in the provision of patient care.

Based on observation, interviews, and record review, the facility failed to follow their policy and procedures when:

1. For Patient 25, a pacing detection error on their cardiac (heart) monitor was not reported to the physician (see A-0398).

2. For Patient 26, a new bundle branch block (a condition in which there's a delay or blockage along the pathway that electrical impulses travel to make the heartbeat) was not reported to the physician (see A-0398).

3. For Patient 1, the facility did not perform a time out prior to an invasive procedure, did not document the start and end of the procedure, and a post procedure assessment (see A-0398).

The cumulative effects of these systemic failures had the potential to impact the health and treatment of the patients and may cause delays in the provision of patient care.

Based on interview and record review, the facility failed to ensure the grievance process was implemented, for one of 31 sample patients (Patient 9), in accordance with the facility's policy and procedure (P&P).

This failure had the potential to cause harm and delay of care to the patient.

A review of Patient 9's record was conducted on November 19, 2024, at 10 a.m., with the Radiology Manager (RM).

A review of the facility document titled, "History and Physical," dated September 27, 2024, was reviewed. The document indicated Patient 9 was admitted to the facility on September 26, 2024, with a diagnoses of end-stage renal disease (End Stage Renal Disease-irreversible kidney failure) on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), obesity, peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (high blood pressure).

A review of the facility document titled, "Change of condition," dated October 3, 2024, indicated, "...family member also stated that Patient 9's roommate yells and makes it difficult for him to sleep at night while here at the hospital, so if possible could he move to another patient room? DNCS [Director of Nursing and Clinical Services] communicated that due to the hospital census and infection control practices, it is not possible at this time. But, DNCS let family member know that future efforts will be made to accommodate this request..."

An interview was conducted on November 20, 2024, at 10:40 a.m., with the Chief Operating Officer (COO). The COO indicated, all formal grievances are entered in the Event Reporting System (ERS) and a letter is sent out regarding the complaint. The COO was unable to show documentation of the complaint in the ERS system.

An interview was conducted on November 21, 2024, at 1:25 p.m., with the DNCS. The DNCS indicated she spoke to the family regarding the request for a room change and does not remember if she documented follow up in the ERS system. The DNCS indicated the facility typically resolves complaints within 3-5 business days without it being escalated to the quality department. The DNCS stated she was unaware if this issue was resolved.

A review of the facility's policy and procedure titled, "Procedure-Patient Complaint and Grievance Process," dated June 2022, indicated, "...Intake and Initial Handling of a Complaint/Grievance. When reasonably possible, the person who receives a complaint should address and resolve it...Initiate an investigation if it has not already been started, including interviews of individuals with information about the issue (patient, family, staff, etc.) Initiate the complaint and Grievance entry into the Event Reporting System...Every effort should be made to complete entries by end of the shift. Communicate the status of the investigation to the patient and/or individual who reported the issue..."

Based on interview and record review the facility failed to provide care in a safe setting for two of 30 sampled patients, (Patient 1, 26), when hospital policy and procedures were not followed for an invasive bedside procedure, and when Patient 26's hyperkalemia [medical condition where too much potassium is in the blood] was not treated properly.

These failures had the potential to result in an invasive procedure being performed on the wrong patient, wrong procedure and had the potential to cause harm or death to the patient.

Findings:

On November 18, 2024, at 8:30 a.m., an unannounced visit was conducted at the facility to investigate facility reported incidents and complaints.

1. On November 18, 2024, at 10:08 a.m., a review of Patient 1's record was conducted. The "History and Physical," dated September 30, 2024, at 4:59 p.m., indicated Patient 1 was admitted to the facility on September 26, 2024, with diagnoses of multi substance abuse, morbid obesity, diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN-high blood pressure).

Review of a facility document titled, "General Surgery Consult," dated October 2, 2024, at 7:54 a.m., was reviewed. The document indicated, "...PLEASE PUT QC [Quinton Catheter] HD [Hemodialysis -Life saving treatment for kidney failure] CATHETER IN...Timeframe: Urgent - 48 hrs..."

Review of a facility document titled, "PROCEDURE CHECKLIST...INVASIVE PROCEDURES WITHOUT SEDATION," was reviewed. There was no documented evidence the facility completed this form for Patient 1's procedure on October 4, 2024.

Review of a facility document for Patient 1 titled, "Operative/PROCEDURE Report," dated October 4, 2024, was reviewed. The document indicated, "...ANESTHESIA: Local...DESCRIPTION OF PROCEDURE: The patient was placed on the bed...A 13 cm [centimeter - unit of measurement] Quinton catheter was threaded over the guidewire...The catheter was anchored in place with two interrupted 2-0 nylon sutures...and a postprocedure [sic] chest x-ray was ordered. There was no documented evidence of the time out, start of procedure or end of procedure. There was no documented evidence care provided during the procedure was completed. There was no documented evidence patient's vital signs were assessed during the procedure. There was no documented evidence there was a handoff report to the unit nurse at the conclusion of the procedure. There was no documented evidence post-procedure assessment was completed.

Review of a facility document for Patient 1 titled, "Change of Condition," indicated, "...Other change of condition...HD catheter placement...at 10/04/2024 [October 4, 2024] 17:00 [5 p.m.] Comment: Pt transfer to OR for HD catheter placement. Vital sign [sic] are BP [blood pressure] 112/62, HR [heart rate] 82, Resp. [respirations] 20, Temp [temperature] 98.2..."

Review of a facility document for Patient 1 titled, "Change of Condition," indicated, "...Other change of condition...Oxygen Desaturation...at...17:40 [5:40 p.m.]..."

Review of a facility document for Patient 1 titled, "Change of Condition," indicated, "...Other change of condition...Patient had a rapid response 1742 [5:42 p.m.] led to code blue 1745 [5:45 p.m.]...comment...After HD placement, patient wheeled back to patient room where she was observed to be struggling to breath...Rapid response called and ambubagging started...code blue called...CPR initiated but no ROSC [Return of spontaneous circulation]...Patient pronounced by [Name of MD 4] at 1809 [6:09 p.m.]..."

Review of Patient 1's document titled, "Chest 1 View portable," indicated, "...DATE OF EXAM: 10/04/2024 [October 4, 2024] 17:52 [5:52 p.m.]...CLINICAL INDICATORS: verify tube/line placement, renal dialysis catheter...Signed Date: 10/04/2024 18:26 [6:26 p.m.].

Facility document titled, "Discharge Summary," for Patient 1 indicated, "...[Patient 1] is scheduled for the temporary hemodialysis catheter replacement...underwent the procedure on October 4th...postop chest x-ray reportedly okay with no pneumothorax...Please note...the chest x-ray was...for postop dialysis catheter placement but she developed a good [sic] blue it was done during the code...Soon after the procedure she went back to her room and she developed desaturation and eventually coded and expired...the cause of death at this point is probable pulmonary embolisms..."

Facility document titled, "RAPID RESPONSE TEAM AND CODE H RECORD," indicated, "...Reason for Call: HR less than 50...O2 sat [oxygen saturation]...43...Vital Signs [VS] on arrival: Time 1742 [5:42 p.m.]...HR 12, BP 63/33, SPO2 [Peripheral Oxygen Saturation] 40, Temp 98...Repeat VS: Time: 1745 [5:45 p.m.] HR 0, BP N/A...Outcome: Code Blue called..."

Facility document titled, "CODE BLUE FLOWSHEET," indicated, "...Time Code Called: 1745 [5:45 p.m.]...Xray done 1752 [5:52 p.m.] Pronounced by Physician (P) 2...Expired...Time Pronounced 18:09 [6:09 p.m.]..."

On November 19, 2024, at 8:55 a.m., an interview was conducted with the Registered Nurse (RN) 5. RN 5 stated she was dealing with another patient and was not aware of why Patient 1 was moved to the OR for a bedside procedure. RN 5 stated she took Patient 1's vitals prior to Patient 1 being moved. RN 5 stated the House Supervisor (HS) moved Patient 1 to the OR. RN 5 stated at the time of the procedure there was no OR staff available. She further stated when the procedure was a bedside procedure the RN or the HS will assist in the procedure. RN 5 stated she was not aware of when Patient 1 returned from the OR, and she did not assess the patient when they returned.

On November 19, 2024, at 9:26 a.m., an interview was conducted with the House Supervisor (HS). The HS stated Patient 1 was scheduled to have a bedside procedure for a hemodialysis catheter placement. The HS stated Physician (P) 1 requested to have the procedure in a larger room. The HS additionally stated staff should have documented the time Patient 1 was moved to the OR.

During continued interview, the HS stated she should have completed the "PROCEDURE CHECKLIST" throughout the procedure, and she did not, and that there was no documented evidence a "timeout" was completed prior to start of procedure as per the policy. The HS stated there was also no documentation of post procedure vitals being taken for Patient 1.

During further interview, the HS stated the on-call X-ray technician should have been called prior to the procedure to verify placement, and rule out perforation or bleeding, immediatly following th procedure. The HS stated that when the Licensed Vocational Nurse (LVN) 1, and CNA 1 were cleaning Patient 1 following the procedure, Patient 1 stated she was having difficulty breathing so, LVN 1 called a rapid response. The HS stated she came to assess Patient 1, and upon assessment, Patient 1 did not have a pulse so a Code Blue was called and CPR started at 5:45 p.m. The HS stated Physician 1 had already left the building and she (HS) called her to come back during the code. The HS stated she was on the phone with P 2, and P 2 requested for an X-ray to be completed during the code blue. The HS stated Patient 1 did not achieve ROSC (return of spontaneous circulation, resumption of a sustained heart rhythm after cardiac arrest) and Patient 1 was pronounced deceased at 1809 (6:09 p.m.).

On November 19, 2024, at 10:02 a.m., an interview was conducted with LVN 1. LVN 1 stated no one was documenting anything in the OR room. LVN 1 stated the on-call X-ray tech was called while patient was in the OR room, but the HS requested Patient 1 to be moved to her room before the X-ray tech arrived. LVN 1 stated Patient 1 had a bowel movement and needed to be cleaned. She stated after cleaning Patient 1, she started thrashing around and was having trouble breathing, oxygen on the monitor started to fall, and a code rapid was called. She stated the rapid response was then converted to a code blue.

On November 20, 2024, at 3 p.m., an interview was conducted with P 1. P 1 stated there is a form that is filled out prior to a bedside procedure but was not sure who filled it out. P 1 stated they could not recall who was in the OR during the procedure on Patient 1. P 1 stated she did not recall if there was a timeout for this procedure. P 1 stated they were not sure where the timeout would be documented.

On November 20, 2024, at 3:30 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated the HS asked her to stay in the OR to help P 1 with the procedure. CNA 1 stated she handed Tegaderm (transparent medical dressing) and 4x4 sponge pads to P 1. CNA 1 stated Patient 1 stated she had difficulty breathing during procedure in the OR room. CNA 1 stated P 1 left the facility prior to the X-ray. CNA 1 stated Patient 1 had a bowel movement and after being cleaned up, Patient 1 started thrashing around stating she was having difficulty breathing. CNA 1 stated a code rapid was called, and then shortly after a code blue was called. CNA 1 stated after the code blue was called, she exited the room and was asked to call P 1 so they could return to the facility. CNA 1 stated no staff was documenting anything while the procedure was being performed.

A review of the policy and procedure (P&P) titled, "Procedure-Documentation Requirements for Invasive Procedures with or Without Sedation," dated June 2022, was conducted. The P&P indicated, "...verification of the patient's identification and completion of all patient safety procedures including site marking and time out procedures must be performed prior to every inpatient and outpatient invasive procedures with or without sedation...Complete and accurate documentation as outlined here is required for all invasive procedures with our without sedation...Postoperative documentation records the patient's vital signs...any unusual events...Nursing and/or surgical personnel are to maintain a log of all bedside and non-bedside operative or invasive procedures...The following steps are required before any procedure may proceed:...Pre-procedure checklist...Time out completed...Note: No procedure may proceed if the above required steps are not followed. Any physician, nurse, licensed therapist involved in the procedure may halt the procedure until the required steps are completed...Perform all "Timeout" procedures as outlined on the forms. One designated team member ensures that a final verification of the correct patient, procedure, site, and as applicable...During the Procedure/Post Procedure...Document all care provided on the appropriate forms...At the conclusion of the procedure, the procedure nurse provides a complete "handoff" communication to the unit nurse. The hand off after a procedure should include at least the following: patient's vital signs prior to and after the conclusion of the procedure...Invasive Procedures without Sedation (Local Anesthesia only)...Invasive procedures without sedation - this includes both pre-procedure checklist and post-procedure assessment..."

A review of the P&P titled, "PATIENT'S RIGHTS AND RESPONSIBILITIES," undated, indicated, "...the expectation that understanding and observation of the rights will result in more effective patient care and in promotion of the confidence and trust which must exist between the patient, the physician...name of facility has responsibilities and duties of its own to the patient...The right to considerate and respectful care..."

2. On November 20, 2024, at 10:59 a.m., Patient 26's medical record was reviewed with CARN. The facility document titled "Inpatient Admission Face Sheet" undated, indicated, "...Admit date: 09/06/2024 [September 6, 2024]...Reason for visit: Respiratory Failure [a medical condition where the lungs are unable to adequately provide oxygen to the blood or remove carbon dioxide from it, leading to a lack of oxygen in the body's tissues and potentially dangerous levels of carbon dioxide in the bloodstream]..."

Review of a facility document titled, "History and Physical," indicated, "...Past medical History: atrial fibrillation [a type of arrhythmia, or irregular heartbeat, that occurs when the electrical signals in the heart's upper chambers fire rapidly and irregularly], and chronic kidney disease stage II..."

The facility's untitled document dated September 20, 2024, indicated, "...Basic metabolic panel partial result: potassium [an electrolyte and mineral found in the blood that helps the heartbeat regularly, muscles work properly, and cells, nerves and muscles function properly] 6.3 mmol/L [Unit of measurement -Millimoles per litre] CRITICAL [dangerous] HIGH...called comment Critical result[s] called to and read back by: k [potassium]= [Name of Registered Nurse ][Registered Nurse 1]..."

The facility's untitled document dated September 20, 2024, indicated, "...Change of condition...critical value [specify]: K [potassium]+ 6.3 at 09/20/2024 [September 20, 2024] 09:56:00 [9:56 a.m.]...Attending physician notified: [Name of Physician] [ Doctor of Medicine [MD] 1]...comment: left message with [Name of Physician] awaiting call back. Treatment initiated: Kayexalate [a medicine used to treat high levels of potassium in the blood] ordered with follow up K+ level at 1430..."

The facility untitled document dated September 20, 2024, indicated, "...physician orders...[telephone], 09/20, 2024 [September 20, 2024]10:30 [10:30 a.m.]...potassium, serum: start 09/20/2024 [September 20, 2024] 14:30 [2:30 p.m.] x 1, not renewable, ancil [ancillary-department that provides support] dept to draw...Read back verification: yes..."

The facility's untitled document dated September 20, 2024, indicated, "...Physician orders...[Name of RN 2] September 20, 2024 [telephone], 09/20/2024 [September 20, 2024] 10:44...sodium polystyrene sulfonate [a medicine used to treat high levels of potassium in the blood] : PO susp, 60 g [unit of measurement - grams]*** k+ 6.3**** start today [09/20/24] [September 20, 2024] , x1, not renewable Read back verification: yes..."

The facility's untitled document dated September 20, 2024, indicated, "...sodium polystyrene sulfonate: PO sus, 60 g...DOSE: Sodium Polystyrene sulfonate 60 GM-240 ml [milliliters-unit of measurement] September 20, 2024 10:52...administered by...[ Name of RN] [RN 2]..."

There was no documented evidence of any other ordered treatment regarding Patient 26's critical serum potassium level.

The facility's untitled document dated September 20, 2024, indicated, "...Monitor observations: 09/20/2024 [September 20, 2024] 20:00 [8 p.m.]...cardiac rhythm [heart rhythm]: normal sinus rhythm [normal heart rhythm], w/ [with] BBB [bundle branch block -a condition that occurs when the electrical signals that make the heartbeat are delayed or blocked]...QRS [the time it takes for an electrical signal to spread through the heart's ventricles] interval: 0.12 sec [seconds]..."

An interview was conducted on November 21, 2024, at 2:51 p.m., with the CARN. The CARN stated there was no change of condition nurses' notes referring the BBB to a doctor or doctors' orders for the BBB documented in Patient 26's medical records. CARN stated the nurse should have referred to the doctor regarding the BBB. She further stated, "they [doctors] can't treat patients if they don't have information regarding the patient's condition." The CARN further stated, the facility does not have a policy or procedure for treatment of hyperkalemia.

Review of a facility untitled document dated September 21, 2024, indicated, "... [ Name of RN 3] 09/21/24 [September 21, 2024] 01:59 [1:59 a.m.]...oxygen desaturation [a decrease in the level of oxygen saturation in the blood]: at 09/21/2024 [September 21, 2024] 1:50 [1:50 a.m.]... Comment: patient had O2 sat [oxygen saturation-the percentage of oxygen in the blood]. below 90% RT [respiratory therapist] change NC (nasal cannula-a medical device that provides supplemental oxygen to a patient through two prongs that fit into the nostrils) to venti mask (a medical device that delivers a specific concentration of oxygen to a patient) at 40% O2 (oxygen). It got up to 93%. RT did ABG (arterial blood gas-a medical test that measures the levels of oxygen and carbon dioxide in your blood) stat result available at RT labs. Called HS (House Supervisor) MD [Doctor of Medicine 2] [Name of Physician] saw ABG result ordered to do Hiflow [oxygen therapy that delivers oxygen, through nasal prongs, at higher-than-normal flow rates of traditional oxygen therapy] and chest X-ray in AM. Will continue to monitor...Comment: at 0540 (5:40 a.m.) Pt. patient[sic], cardiac rhythm change to bradycardia [slow heart rate], reassessed pt. He was still desating [a drop in oxygen levels in the blood] to 86%. Call rapid response [a program that aims to quickly identify and treat patients who are at risk of clinical deterioration]/ code blue [a patient is experiencing a life-threatening medical emergency, typically a cardiac arrest or respiratory failure]...Continue with code blue but patient was pronounced at 0635 (6:35 a.m.) hr [hour]..."

Review of a facility untitled document dated September 21, 2024, indicated, "...laboratory results...potassium, serum...8.2mmol/L...Called comment Critical result [s] K called to and read back by: [Name of RN 4]: 09/21/2024 [September 21, 2024], 07:29 (7:29 a.m.)...slightly hemolized..."

Review of a facility document titled, "Expiration Summary," dated September 21, 2024, indicated, "...Date of expiration: September 21, 2024...Causes of death...Acute cardiopulmonary arrest..."

An interview was conducted on November 21, 2024, at 2:16 p.m., with MD 1. MD 1 stated the process for treating patients with high serum potassium levels include Kayexalate and EKG [Electrocardiogram- test that measures the electrical activity of the heart]. EKG to identify any EKG changes. She further stated if serum potassium is higher than 6, treatment includes insulin, Dextrose 50 Water 50, calcium, kayexalate and sodium bicarbonate if patient has EKG change. MD 1 stated high serum potassium is not safe for patients because "it causes cardiac arrhythmias (an irregular heartbeat that can cause the heart to beat too fast, too slow, or with an irregular rhythm) and cardiac arrest (sudden, sometimes temporary, cessation [stopping] of function of the heart)."

Based on observation, interviews, and record review, the facility failed to follow their policy and procedures when:

1. For Patient 25, a pacing detection error on the cardiac (heart) monitor was not reported to the physician;

2. For Patient 26, a new bundle branch block (a condition in which there's a delay or blockage along the pathway that electrical impulses travel to make the heartbeat) was not reported to the physician; and

3. For Patient 1, the facility did not perform a time out (an immediate pause by the medical team to confirm the correct patient, procedure, and site) prior to an invasive procedure, did not document the start and end times of the procedure, and did not document a post procedure assessment.

These failures had the potential to place patients' medical condition at risk for injury or death, and for the potential for the wrong procedure to be conducted.

Findings:

1. On November 20, 2024, at 10:06 a.m., Patient 25's medical record was reviewed with the Clinical Analyst Registered Nurse (CARN). Review of the facility document titled "Inpatient Admission Face Sheet" undated, indicated, "...Admit date: 09/28/2024 [September 28, 2024]...Reason for visit: Acute and Chronic Respiratory Failure..."

Review of a facility document titled, "History and Physical," dated 10/03/2024 [October 3, 2024], indicated, "...History and Physical...patient has a history of pacemaker history of CVA [stroke, medical condition that occurs when blood flow to the brain is suddenly interrupted], diabetes mellitus [a chronic metabolic disease that occurs when the body can't control its blood sugar levels], congestive heart failure..."

On November 20, 2024, at 11:34 a.m., a tour of Patient 25's room was conducted with the Chief Operating Officer (COO). Patient 25's cardiac monitor was observed showing a silenced alarm. The COO stated the monitor showed alarm silenced because of the pacing (the process of delivering electrical impulses to the heart to stimulate a contraction) detection error on the cardiac monitor. During continued observation the alarm silenced image was observed to automatically show after the pacing detection error appeared when the COO unplugged and plugged the cable connected to the cardiac monitor.

On November 20, 2024, at 11:44 a.m., an observation and concurrent interview was conducted in Patient 25's room with the Intensive Care Unit Registered Nurse (ICU RN) 1. Patient 25 was observed unconscious and connected to the ventilator (a machine that helps patients breathe by mechanically pushing air into their lungs when they are unable to). Observation of the cardiac (heart) monitor on Patient 25 showed a pacing detection error. ICU RN 1 stated she could see the pacing detection error on Patient 25's monitor, and that she had checked the leads and patient, and everything was working fine. ICU RN 1 stated she did not call the physician to report the error message.

On November 20, 2024, at 1:47 p.m., an interview with ICU RN 2 was conducted. ICU RN 2 stated if she saw a pacing detection error on the monitor, she would check the patient and the monitor. She further stated there might be something wrong, "it may be the monitor, or it may be the pacemaker." She stated the pacemaker makes the patient's heartbeat. If the pacemaker is not functioning properly, it would affect the patient's heart.

On November 20, 2024, at 2:12 p.m., an interview with Biomed Technician (BT) was done. BT stated he contacted (Name of Company) tech support, and they evaluated the unit. He further stated the monitor is 100 % functional.

A review of facility policy titled, "CORE: Continuous Cardiac monitoring (Telemetry)," dated, June 2023, indicated, "...the nurse assigned to the patient responds immediately if any of the following occurs...any observed change in the patient's cardiac rhythm..."

A review of facility policy titled, "CORE: Interdisciplinary Assessment and Re-Assessment," dated, August, 2023, indicated, "...Patients are re-evaluated by a licensed nurse [RN, LPN/LVN-according to state specific practice acts] at a minimum every 12 hour shift-based on level of care...to respond to a significant change in status and/or diagnosis or condition...Reporting/Notification of a change in condition...changes in the condition of the patient are determined by assessments...the nurse assigned to the patient or supervising the care of the patient is responsible for notification of and communication to the patient's primary physician or designee using appropriate channels and chain of command for assuring that there is physician response..."

2. On November 20, 2024, at 10:59 a.m., Patient 26's medical record was reviewed with CARN. The facility document titled "Inpatient Admission Face Sheet" undated, indicated, "...Admit date: 09/06/2024 [September 6, 2024]...Reason for visit: Respiratory Failure..."

Review of a facility document titled, "History and Physical," indicated, "...Past medical History: atrial fibrillation [a type of arrhythmia, or irregular heartbeat, that occurs when the electrical signals in the heart's upper chambers fire rapidly and irregularly], and chronic kidney disease stage II..."

On November 20, 2024, at 9:43 a.m., an interview and concurrent record review of Patient 26's recorded rhythm strips (a test that records the electrical activity of the heart) dated September 20, 2024, was conducted with the House Supervisor (HS). The untitled document, dated September 20, 2024, indicated, "...September 20, 2024, 07:20 (7:20 a.m.)...SR (sinus rhythm) -67 c [with] BBB [Bundle Branch Block-a condition that occurs when the electrical signals that make the heart beat are delayed or blocked]..." HS stated the monitor technician watches the rhythms for patients in the telemetry unit and refers the reading to the nurses. She further stated, the nurse assigned to the patient verifies the strip and calls the doctor for any changes. She stated, "we want to be proactive and catch anything that may need treatment or to get some treatment to prevent a more serious condition."

On November 21, 2024, at 2:51 p.m., an interview and concurrent record review of Patient 26's recorded rhythm strip, dated September 20, 2024, was conducted with CARN. The document indicated, "...Monitor observations: 09/20/2024 [September 20, 2024] 20:00 (8 p.m.)...cardiac rhythm: normal sinus rhythm, w/ BBB...QRS [the time it takes for an electrical signal to spread through the heart's ventricles] interval: 0.12 sec [seconds]..." The CARN stated, "there are no change of condition nurse's notes or doctors' orders for the BBB" documented in Patient 26's medical records. The CARN further stated the nurse should have referred the BBB to the doctor and that "they (doctors) can't treat patients if they don't have information regarding the patient's condition."

A review of facility policy titled, "CORE: Continuous Cardiac monitoring (Telemetry)," dated, June 2023, indicated, "...the nurse assigned to the patient responds immediately if any of the following occurs...any observed change in the patient's cardiac rhythm..."

A review of facility policy titled, "CORE: Interdisciplinary Assessment and Re-Assessment," dated, August, 2023, indicated, "...Patients are re-evaluated by a licensed nurse [RN, LPN/LVN-according to state specific practice acts] at a minimum every 12 hour shift-based on level of care...to respond to a significant change in status and/or diagnosis or condition...Reporting/Notification of a change in condition...changes in the condition of the patient are determined by assessments...the nurse assigned to the patient or supervising the care of the patient is responsible for notification of and communication to the patient's primary physician or designee using appropriate channels and chain of command for assuring that there is physician response..."

3. On November 18, 2024, at 10:08 a.m., a review of Patient 1's record was conducted. The "History and Physical," dated September 30, 2024, at 4:59 p.m., indicated Patient 1 was admitted to the facility on September 26, 2024, with diagnoses of multi substance abuse, morbid obesity, diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN-high blood pressure).

Review of a facility document titled, "General Surgery Consult," dated October 2, 2024, at 7:54 a.m., was reviewed. The document indicated, "...PLEASE PUT QC [Quinton Catheter] HD [Hemodialysis -Life saving treatment for kidney failure] CATHETER IN...Timeframe: Urgent - 48 hrs..."

Review of a facility document titled, "PROCEDURE CHECKLIST...INVASIVE PROCEDURES WITHOUT SEDATION," was reviewed. There was no documented evidence the facility completed this form for Patient 1's procedure on October 4, 2024.

Review of a facility document for Patient 1 titled, "Operative/PROCEDURE Report," dated October 4, 2024, was reviewed. The document indicated, "...ANESTHESIA: Local...DESCRIPTION OF PROCEDURE: The patient was placed on the bed...A 13 cm [centimeter - unit of measurement] Quinton catheter was threaded over the guidewire...The catheter was anchored in place with two interrupted 2-0 nylon sutures...and a postprocedure [sic] chest x-ray was ordered. There was no documented evidence of the time out, start of procedure or end of procedure. There was no documented evidence care provided during the procedure was completed. There was no documented evidence patient's vital signs were assessed during the procedure. There was no documented evidence there was a handoff report to the unit nurse at the conclusion of the procedure. There was no documented evidence post-procedure assessment was completed.

Review of a facility document for Patient 1 titled, "Change of Condition," indicated, "...Other change of condition...HD catheter placement...at 10/04/2024 [October 4, 2024] 17:00 [5 p.m.] Comment: Pt transfer to OR for HD catheter placement. Vital sign [sic] are BP [blood pressure] 112/62, HR [heart rate] 82, Resp. [respirations] 20, Temp [temperature] 98.2..."

Review of a facility document for Patient 1 titled, "Change of Condition," indicated, "...Other change of condition...Oxygen Desaturation...at...17:40 [5:40 p.m.]..."

Review of a facility document for Patient 1 titled, "Change of Condition," indicated, "...Other change of condition...Patient had a rapid response 1742 [5:42 p.m.] led to code blue 1745 [5:45 p.m.]...comment...After HD placement, patient wheeled back to patient room where she was observed to be struggling to breath...Rapid response called and ambubagging started...code blue called...CPR initiated but no ROSC [Return of spontaneous circulation]...Patient pronounced by [Name of MD 4] at 1809 [6:09 p.m.]..."

Review of Patient 1's document titled, "Chest 1 View portable," indicated, "...DATE OF EXAM: 10/04/2024 [October 4, 2024] 17:52 [5:52 p.m.]...CLINICAL INDICATORS: verify tube/line placement, renal dialysis catheter...Signed Date: 10/04/2024 18:26 [6:26 p.m.].

Facility document titled, "Discharge Summary," for Patient 1 indicated, "...[Patient 1] is scheduled for the temporary hemodialysis catheter replacement...underwent the procedure on October 4th...postop chest x-ray reportedly okay with no pneumothorax...Please note...the chest x-ray was...for postop dialysis catheter placement but she developed a good [sic] blue it was done during the code...Soon after the procedure she went back to her room and she developed desaturation and eventually coded and expired...the cause of death at this point is probable pulmonary embolisms..."

Facility document titled, "RAPID RESPONSE TEAM AND CODE H RECORD," indicated, "...Reason for Call: HR less than 50...O2 sat [oxygen saturation]...43...Vital Signs [VS] on arrival: Time 1742 [5:42 p.m.]...HR 12, BP 63/33, SPO2 [Peripheral Oxygen Saturation] 40, Temp 98...Repeat VS: Time: 1745 [5:45 p.m.] HR 0, BP N/A...Outcome: Code Blue called..."

Facility document titled, "CODE BLUE FLOWSHEET," indicated, "...Time Code Called: 1745 [5:45 p.m.]...Xray done 1752 [5:52 p.m.] Pronounced by Physician (P) 2...Expired...Time Pronounced 18:09 [6:09 p.m.]..."

On November 19, 2024, at 8:55 a.m., an interview was conducted with the Registered Nurse (RN) 5. RN 5 stated she was dealing with another patient and was not aware of why Patient 1 was moved to the OR for a bedside procedure. RN 5 stated she took Patient 1's vitals prior to Patient 1 being moved. RN 5 stated the House Supervisor (HS) moved Patient 1 to the OR. RN 5 stated at the time of the procedure there was no OR staff available. She further stated when the procedure was a bedside procedure the RN or the HS will assist in the procedure. RN 5 stated she was not aware of when Patient 1 returned from the OR, and she did not assess the patient when they returned.

On November 19, 2024, at 9:26 a.m., an interview was conducted with the House Supervisor (HS). The HS stated Patient 1 was scheduled to have a bedside procedure for a hemodialysis catheter placement. The HS stated Physician (P) 1 requested to have the procedure in a larger room. The HS additionally stated staff should have documented the time Patient 1 was moved to the OR.

During continued interview, the HS stated she should have completed the "PROCEDURE CHECKLIST" throughout the procedure, and she did not, and that there was no documented evidence a "timeout" was completed prior to start of procedure as per the policy. The HS stated there was also no documentation of post procedure vitals being taken for Patient 1.

During further interview, the HS stated the on-call X-ray technician should have been called prior to the procedure to verify placement, and rule out perforation or bleeding, immediatly following th procedure. The HS stated that when the Licensed Vocational Nurse (LVN) 1, and CNA 1 were cleaning Patient 1 following the procedure, Patient 1 stated she was having difficulty breathing so, LVN 1 called a rapid response. The HS stated she came to assess Patient 1, and upon assessment, Patient 1 did not have a pulse so a Code Blue was called and CPR started at 5:45 p.m. The HS stated Physician 1 had already left the building and she (HS) called her to come back during the code. The HS stated she was on the phone with P 2, and P 2 requested for an X-ray to be completed during the code blue. The HS stated Patient 1 did not achieve ROSC (return of spontaneous circulation, resumption of a sustained heart rhythm after cardiac arrest) and Patient 1 was pronounced deceased at 1809 (6:09 p.m.).

On November 19, 2024, at 10:02 a.m., an interview was conducted with LVN 1. LVN 1 stated no one was documenting anything in the OR room. LVN 1 stated the on-call X-ray tech was called while patient was in the OR room, but the HS requested Patient 1 to be moved to her room before the X-ray tech arrived. LVN 1 stated Patient 1 had a bowel movement and needed to be cleaned. She stated after cleaning Patient 1, she started thrashing around and was having trouble breathing, oxygen on the monitor started to fall, and a code rapid was called. She stated the rapid response was then converted to a code blue.

On November 20, 2024, at 3 p.m., an interview was conducted with P 1. P 1 stated there is a form that is filled out prior to a bedside procedure but was not sure who filled it out. P 1 stated they could not recall who was in the OR during the procedure on Patient 1. P 1 stated she did not recall if there was a timeout for this procedure. P 1 stated they were not sure where the timeout would be documented.

On November 20, 2024, at 3:30 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated the HS asked her to stay in the OR to help P 1 with the procedure. CNA 1 stated she handed Tegaderm (transparent medical dressing) and 4x4 sponge pads to P 1. CNA 1 stated Patient 1 stated she had difficulty breathing during procedure in the OR room. CNA 1 stated P 1 left the facility prior to the X-ray. CNA 1 stated Patient 1 had a bowel movement and after being cleaned up, Patient 1 started thrashing around stating she was having difficulty breathing. CNA 1 stated a code rapid was called, and then shortly after a code blue was called. CNA 1 stated after the code blue was called, she exited the room and was asked to call P 1 so they could return to the facility. CNA 1 stated no staff was documenting anything while the procedure was being performed.

A review of the policy and procedure (P&P) titled, "Procedure-Documentation Requirements for Invasive Procedures with or Without Sedation," dated June 2022, was conducted. The P&P indicated, "...verification of the patient's identification and completion of all patient safety procedures including site marking and time out procedures must be performed prior to every inpatient and outpatient invasive procedures with or without sedation...Complete and accurate documentation as outlined here is required for all invasive procedures with our without sedation...Postoperative documentation records the patient's vital signs...any unusual events...Nursing and/or surgical personnel are to maintain a log of all bedside and non-bedside operative or invasive procedures...The following steps are required before any procedure may proceed:...Pre-procedure checklist...Time out completed...Note: No procedure may proceed if the above required steps are not followed. Any physician, nurse, licensed therapist involved in the procedure may halt the procedure until the required steps are completed...Perform all "Timeout" procedures as outlined on the forms. One designated team member ensures that a final verification of the correct patient, procedure, site, and as applicable...During the Procedure/Post Procedure...Document all care provided on the appropriate forms...At the conclusion of the procedure, the procedure nurse provides a complete "handoff" communication to the unit nurse. The hand off after a procedure should include at least the following: patient's vital signs prior to and after the conclusion of the procedure...Invasive Procedures without Sedation (Local Anesthesia only)...Invasive procedures without sedation - this includes both pre-procedure checklist and post-procedure assessment..."

A review of the P&P titled, "PATIENT'S RIGHTS AND RESPONSIBILITIES," undated, indicated, "...the expectation that understanding and observation of the rights will result in more effective patient care and in promotion of the confidence and trust which must exist between the patient, the physician...name of facility has responsibilities and duties of its own to the patient...The right to considerate and respectful care..."

Based on interview and record review, the facility failed to develop and implement a policy on the prevention of transmission of infections, within the hospital for one of 30 patient's (Patient 17), when Patient 17 developed a hospital acquired infection.

Based on interview and record review, the facility failed to prevent the transmission of infections within the hospital for one patient (Patient 17), when the patient developed a hospital acquired infection.

This failure led to Patient 17 developing Candida Auris (C. Auris; a type of yeast that can cause severe illness and spreads among patients in healthcare facilities) fungemia (a systemic infection that occurs when fungi or yeast are present in the blood) and had the potential to further impact the patient's health.

Findings:

On November 18, 2024, an unannounced complaint validation survey was conducted at the facility.

On November 19, 2024, at 10 a.m., a review of Patient 17's medical record was conducted with the Resource Chief Operating Officer (RCOO).

The facility document titled "History and Physical" dated July 24, 2024, indicated Patient 17 was admitted to the facility on July 24, 2024.

An untitled facility document indicated a blood culture was collected from Patient 17 on July 25, 2024, "...Preliminary result...blood culture...no growth after 24 hours..."

An untitled facility document indicated a Candida Auris screen was collected from Patient 17's axilla/groin on July 25, 2024, "...Final result...Candida Auris screen...detected..."

The facility document titled, "Operative/Procedure Report," dated August 7, 2024, indicated "...Removal of right internal jugular vein tunneled hemodialysis catheter..."

The facility document titled "Progress Note," dated August 8, 2024, indicated "Assessment: HD cath removal indicated; done yesterday; cath tip sent for cx...patient needs new HD cath ASAP [as soon as possible]...patient is C auris colonized; contact precautions are in place..."

The facility document titled, "Operative/Procedure Report," dated August 9, 2024, indicated "...Right internal jugular vein Quinton hemodialysis catheter placement under ultrasound guidance..."

An untitled facility document indicated a blood culture was collected on August 22, 2024, "...Final result...blood culture...Candida auris has been isolated..."

The facility document titled "Progress Note," dated August 28, 2024, indicated "Assessment: C auris fungemia...must schedule HD cath removal...cath to be left out for at least 48 hrs [hours] before replacement of new HD quinton cath..."

An untitled facility document indicated a catheter tip culture was collected on August 28, 2024, "...Final result...source: dialysis catheter...Candida auris has been isolated..."

The facility document titled "Progress Note," dated August 30, 2024, indicated "Subjective...C auris fungemia dx'd [diagnosed]...HD cath tip cx [culture] c/w [consistent with] this cath as the source of fungemia...WBC 14..."

The facility document titled "Progress Note," dated September 4, 2024, indicated "WBC 15.2...Assessment: Sepsis...W/ [work] up pos [positive] for fungemia...C auris isolated...HD cath [hemodialysis catheter] out on 8/28 [August 28, 2024]..."

The facility document titled "Discharge Summary," dated September 8, 2024, indicated "...WBC 23.9...Impression...acute hypoxic respiratory failure...sepsis with shock...severe abdominal distension...candida auris fungemia- line sepsis...multiple pressure wounds unstageable...partially dislodged G tube likely not in stomach...large ascites-most likely G tube feed...to be transferred to [name of facility] for surgical evaluation of abdomen..."

On November 21, 2024, at 11:15 a.m., an interview was conducted with the Infection Preventionist (IP). The IP stated all patients are tested for C. auris upon admission to the facility. The IP stated a patient is considered colonized with C. auris when there is a positive culture result of the axilla (Armpit) and or groin. The IP stated if C. auris is present in the blood, sputum, or wounds it would be considered a clinical positive versus colonized. The IP stated they would consult with the infectious disease doctor (ID) to determine if the patient required treatment or not. The IP further stated that a positive C. auris culture in the blood three days after the patient's admission would be considered hospital acquired.

A review of an untitled facility document was conducted on November 21, 2024, at 11:30 a.m., with the IP. The document indicated between August 1, 2024, and November 21, 2024, the facility had 19 patients with hospital acquired C. Auris infections cultured after three days of the patient's admission.

On November 21, 2024, at 2 p.m., during an interview with the IP she stated the facility does not have specific policies for infection control at this time. The IP stated infection control policies were changed to guidelines/procedures only.

Based on interview and record review the facility failed to implement their policy and procedure for one of 30 sampled patients, (Patient 1), for an invasive bedside procedure.

These failures had the potential to result in an invasive procedure being performed on the wrong patient, wrong procedure, and had the potential to cause harm or death to the patient.

Findings:

On November 18, 2024, at 10:08 a.m., a review of Patient 1's record was conducted. The "History and Physical," dated September 30, 2024, at 4:59 p.m., indicated Patient 1 was admitted to the facility on September 26, 2024, with diagnoses of multi substance abuse, morbid obesity, diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN-high blood pressure).

Review of a facility document titled, "General Surgery Consult," dated October 2, 2024, at 7:54 a.m., was reviewed. The document indicated, "...PLEASE PUT QC [Quinton Catheter] HD [Hemodialysis -Life saving treatment for kidney failure] CATHETER IN...Timeframe: Urgent - 48 hrs..."

Review of a facility document titled, "PROCEDURE CHECKLIST...INVASIVE PROCEDURES WITHOUT SEDATION," was reviewed. There was no documented evidence the facility completed this form for Patient 1's procedure on October 4, 2024.

Review of a facility document for Patient 1 titled, "Operative/PROCEDURE Report," dated October 4, 2024, was reviewed. The document indicated, "...ANESTHESIA: Local...DESCRIPTION OF PROCEDURE: The patient was placed on the bed...A 13 cm [centimeter - unit of measurement] Quinton catheter was threaded over the guidewire...The catheter was anchored in place with two interrupted 2-0 nylon sutures...and a postprocedure [sic] chest x-ray was ordered. There was no documented evidence of the time out, start of procedure or end of procedure. There was no documented evidence care provided during the procedure was completed. There was no documented evidence patient's vital signs were assessed during the procedure. There was no documented evidence there was a handoff report to the unit nurse at the conclusion of the procedure. There was no documented evidence post-procedure assessment was completed.

Review of a facility document for Patient 1 titled, "Change of Condition," indicated, "...Other change of condition...HD catheter placement...at 10/04/2024 [October 4, 2024] 17:00 [5 p.m.] Comment: Pt transfer to OR for HD catheter placement. Vital sign [sic] are BP [blood pressure] 112/62, HR [heart rate] 82, Resp. [respirations] 20, Temp [temperature] 98.2..."

Review of a facility document for Patient 1 titled, "Change of Condition," indicated, "...Other change of condition...Oxygen Desaturation...at...17:40 [5:40 p.m.]..."

Review of a facility document for Patient 1 titled, "Change of Condition," indicated, "...Other change of condition...Patient had a rapid response 1742 [5:42 p.m.] led to code blue 1745 [5:45 p.m.]...comment...After HD placement, patient wheeled back to patient room where she was observed to be struggling to breath...Rapid response called and ambubagging started...code blue called...CPR initiated but no ROSC [Return of spontaneous circulation]...Patient pronounced by [Name of MD 4] at 1809 [6:09 p.m.]..."

Review of Patient 1's document titled, "Chest 1 View portable," indicated, "...DATE OF EXAM: 10/04/2024 [October 4, 2024] 17:52 [5:52 p.m.]...CLINICAL INDICATORS: verify tube/line placement, renal dialysis catheter...Signed Date: 10/04/2024 18:26 [6:26 p.m.].

Facility document titled, "Discharge Summary," for Patient 1 indicated, "...[Patient 1] is scheduled for the temporary hemodialysis catheter replacement...underwent the procedure on October 4th...postop chest x-ray reportedly okay with no pneumothorax...Please note...the chest x-ray was...for postop dialysis catheter placement but she developed a good [sic] blue it was done during the code...Soon after the procedure she went back to her room and she developed desaturation and eventually coded and expired...the cause of death at this point is probable pulmonary embolisms..."

Facility document titled, "RAPID RESPONSE TEAM AND CODE H RECORD," indicated, "...Reason for Call: HR less than 50...O2 sat [oxygen saturation]...43...Vital Signs [VS] on arrival: Time 1742 [5:42 p.m.]...HR 12, BP 63/33, SPO2 [Peripheral Oxygen Saturation] 40, Temp 98...Repeat VS: Time: 1745 [5:45 p.m.] HR 0, BP N/A...Outcome: Code Blue called..."

Facility document titled, "CODE BLUE FLOWSHEET," indicated, "...Time Code Called: 1745 [5:45 p.m.]...Xray done 1752 [5:52 p.m.] Pronounced by Physician (P) 2...Expired...Time Pronounced 18:09 [6:09 p.m.]..."

On November 19, 2024, at 8:55 a.m., an interview was conducted with the Registered Nurse (RN) 5. RN 5 stated she was dealing with another patient and was not aware of why Patient 1 was moved to the OR for a bedside procedure. RN 5 stated she took Patient 1's vitals prior to Patient 1 being moved. RN 5 stated the House Supervisor (HS) moved Patient 1 to the OR. RN 5 stated at the time of the procedure there was no OR staff available. She further stated when the procedure was a bedside procedure the RN or the HS will assist in the procedure. RN 5 stated she was not aware of when Patient 1 returned from the OR, and she did not assess the patient when they returned.

On November 19, 2024, at 9:26 a.m., an interview was conducted with the House Supervisor (HS). The HS stated Patient 1 was scheduled to have a bedside procedure for a hemodialysis catheter placement. The HS stated Physician (P) 1 requested to have the procedure in a larger room. The HS additionally stated staff should have documented the time Patient 1 was moved to the OR.

During continued interview, the HS stated she should have completed the "PROCEDURE CHECKLIST" throughout the procedure, and she did not, and that there was no documented evidence a "timeout" was completed prior to start of procedure as per the policy. The HS stated there was also no documentation of post procedure vitals being taken for Patient 1.

During further interview, the HS stated the on-call X-ray technician should have been called prior to the procedure to verify placement, and rule out perforation or bleeding, immediately following th procedure. The HS stated that when the Licensed Vocational Nurse (LVN) 1, and CNA 1 were cleaning Patient 1 following the procedure, Patient 1 stated she was having difficulty breathing so, LVN 1 called a rapid response. The HS stated she came to assess Patient 1, and upon assessment, Patient 1 did not have a pulse so a Code Blue was called and CPR started at 5:45 p.m. The HS stated Physician 1 had already left the building and she (HS) called her to come back during the code. The HS stated she was on the phone with P 2, and P 2 requested for an X-ray to be completed during the code blue. The HS stated Patient 1 did not achieve ROSC (return of spontaneous circulation, resumption of a sustained heart rhythm after cardiac arrest) and Patient 1 was pronounced deceased at 1809 (6:09 p.m.).

On November 19, 2024, at 10:02 a.m., an interview was conducted with LVN 1. LVN 1 stated no one was documenting anything in the OR room. LVN 1 stated the on-call X-ray tech was called while patient was in the OR room, but the HS requested Patient 1 to be moved to her room before the X-ray tech arrived. LVN 1 stated Patient 1 had a bowel movement and needed to be cleaned. She stated after cleaning Patient 1, she started thrashing around and was having trouble breathing, oxygen on the monitor started to fall, and a code rapid was called. She stated the rapid response was then converted to a code blue.

On November 20, 2024, at 3 p.m., an interview was conducted with P 1. P 1 stated there is a form that is filled out prior to a bedside procedure but was not sure who filled it out. P 1 stated they could not recall who was in the OR during the procedure on Patient 1. P 1 stated she did not recall if there was a timeout for this procedure. P 1 stated they were not sure where the timeout would be documented.

On November 20, 2024, at 3:30 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated the HS asked her to stay in the OR to help P 1 with the procedure. CNA 1 stated she handed Tegaderm (transparent medical dressing) and 4x4 sponge pads to P 1. CNA 1 stated Patient 1 stated she had difficulty breathing during procedure in the OR room. CNA 1 stated P 1 left the facility prior to the X-ray. CNA 1 stated Patient 1 had a bowel movement and after being cleaned up, Patient 1 started thrashing around stating she was having difficulty breathing. CNA 1 stated a code rapid was called, and then shortly after a code blue was called. CNA 1 stated after the code blue was called, she exited the room and was asked to call P 1 so they could return to the facility. CNA 1 stated no staff was documenting anything while the procedure was being performed.

A review of the policy and procedure (P&P) titled, "Procedure-Documentation Requirements for Invasive Procedures with or Without Sedation," dated June 2022, was conducted. The P&P indicated, "...verification of the patient's identification and completion of all patient safety procedures including site marking and time out procedures must be performed prior to every inpatient and outpatient invasive procedures with or without sedation...Complete and accurate documentation as outlined here is required for all invasive procedures with our without sedation...Postoperative documentation records the patient's vital signs...any unusual events...Nursing and/or surgical personnel are to maintain a log of all bedside and non-bedside operative or invasive procedures...The following steps are required before any procedure may proceed:...Pre-procedure checklist...Time out completed...Note: No procedure may proceed if the above required steps are not followed. Any physician, nurse, licensed therapist involved in the procedure may halt the procedure until the required steps are completed...Perform all "Timeout" procedures as outlined on the forms. One designated team member ensures that a final verification of the correct patient, procedure, site, and as applicable...During the Procedure/Post Procedure...Document all care provided on the appropriate forms...At the conclusion of the procedure, the procedure nurse provides a complete "handoff" communication to the unit nurse. The hand off after a procedure should include at least the following: patient's vital signs prior to and after the conclusion of the procedure...Invasive Procedures without Sedation (Local Anesthesia only)...Invasive procedures without sedation - this includes both pre-procedure checklist and post-procedure assessment..."