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Based on interview, record review, and policy review, the facility failed to ensure nursing staff consistently and accurately assessed, supervised, evaluated, responded to and documented nursing care/interventions for continuous monitoring of telemetry for one discharged patient (#1) out of one discharged patient reviewed. These failures had the potential to affect all patients admitted to the facility (Refer to A-0395).

These failures created an unsafe environment and had the potential to place all patients admitted to the facility at risk for their safety. The facility census was 25.

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.23 Condition of Participation: Nursing Services that resulted in a condition of Immediate Jeopardy (IJ).

On 07/25/18, after the survey team informed the facility of the IJ, the Chief Nursing Officer completed rounds on all patients on telemetry and pulse oximetry to ensure that alarms were activated and working properly, staff created educational tools (Mock Rapid Response/Code Blue Scenarios) and began educating all staff and put into place interventions to protect patients.

As of 07/27/18, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- All current patients with orders for telemetry and/or pulse oximetry was assessed by leadership to ensure the alarms was activated and working properly. Rounding to continue every 4 hours.
- All in house staff including Registered Nurses (RN), Certified Nurse Aides, unit secretaries, telemetry technicians, respiratory therapists (RT), agency RNs, and agency RT staff was educated on the following policies/procedures:
- Change in condition (includes Rapid Response Teams);
- Telemetry, Alarms Prioritation (includes pulse oximetry); and
- Hand-off Communication.
- All other staff to be educated prior to next shift.
- All in house staff including Registered Nurses (RN), Certified Nurse Aides, unit secretaries, telemetry technicians, respiratory therapists (RT), agency RNs, and agency RT staff was educated on Rapid Response and Code Blue using mock scenarios with immediate debriefing.
- Physician will respond to mock code in appropriate time frame until 100% is achieved.





18018

Based on interview, record review and policy review, the facility failed to ensure Respiratory Therapy (RT) staff met the needs of patients that required RT care and/or treatment within acceptable standards of practice and expectations when RT staff failed to:
- Follow physician's orders to continuously monitor discharged Patient #1's pulse oximetry (medical equipment used to monitor the amount of oxygen carried in the blood throughout the body).
- Maintain discharged Patient #1's pulse oximetry monitor with alarms on for a 12 hour night shift on 06/24/18.
- Document in the medical record change in condition of discharged Patient #1 when he experienced desaturated (fall of oxygen levels in blood) oxygen levels throughout the 12 hour night shift on 06/24/18.
- Notify discharged Patient #1's physician that the patient experienced desaturation levels throughout the 12 hour night shift on 06/24/18.
- Ensure unauthorized personal pocket pulse oximetry monitor was not used on discharged Patient #1 during the 12 hour night shift on 06/24/18.
- Respond timely to an alarm on current Patient #4's pulse oximetry monitor when it went off on the afternoon of 07/20/18.
These failures had the potential to lead to negative patient outcomes including death and could affect all patients that required respiratory care and treatment. The facility census was 25.

The severity and cumulative effects of these failures resulted in the facility's being out of compliance with 42 CFR 482.57 Condition of Participation: Respiratory Services.

Refer to the 2567 for additional information.

Based on interview, record review, and policy review, the facility failed to ensure nursing staff provided ongoing nursing assessment, interventions, and oversight to meet patient needs and/or prevent complications for continuous telemetry (monitoring the electrical activity of the heart for an extended time) and pulse oximetry (medical equipment used to monitor the amount of oxygen carried in the blood throughout the body), monitoring for one discharged patient (#1) of one discharged patient reviewed when nursing staff failed to:
- Follow physician's orders for continuous telemetry and pulse oximetry monitoring;
- Respond timely to Patient #1's telemetry alarm notification by the Telemetry Monitor Technician (TLMT - person responsible to observe and interpret a patient's heart status while in the hospital);
- Assess patient #1 following notification of change in cardiac rhythm (the predominant electrical activity of the heart) by the TLMT;
- Notify the physician that patient #1 had experienced a change in condition; and
- Document in the medical record that patient #1 had experienced a change in condition.
These failures had the potential to negatively affect all patients admitted to the facility. The facility census was 25.

Findings included:

1. Review of the facility's policy titled, "Telemetry, Alarms, Prioritization," dated 10/2016, showed:
- Indications for Telemetry:
Absolute (Must be on telemetry or continuous EKG [a recording of the electrical activity of the heart] monitoring):
1. Physician's Order; and
2. Any patient who has developed a significant change in condition.
Recommended:
1. Initial ventilator (a machine designed to move breathable air into and out of the lungs) weaning trials;
2. At least 48 hours post decannulation (the process where a tracheostomy [trach - a surgically created hole in the windpipe used to assist a person with breathing] tube is removed once a patient no longer needs it); and
3. Patient liberated (discontinuation and removal from a mechanical ventilator machine) from mechanical ventilation (trach collar or endotracheal extubation) for at least 48 hours post wean.
- Monitor Techs/Telemetry Techs (TLMT): The TLMT will notify the Charge Nurse or Assigned Nurse of a telemetry alarm, a change in rhythm, or signal. If the TLMT is unable to notify the Charge Nurse or Assigned Nurse, the secondary notification system would audibly page overhead for assistance. The TLMT may not set alarms, silence alarms or change alarm parameters. Only the Charge Nurse may change the telemetry alarm parameters.
- Alarms, Analysis, Documentation and Notification
1. Alarms shall be validated and charted by the Assigned Nurse caring for the patient as part of the cardiac assessment (evaluation of the cardiovascular system).
2. The TLMT, or person who is watching telemetry, will notify the Charge Nurse or Assigned Nurse of a telemetry alarm and/or a change in rhythm. In the event that the Charge Nurse or Assigned Nurse is unavailable to be reached, an audible page overhead will be transmitted for assistance.

Review of the facility's policy titled, "Change in Patient Condition," dated 04/01/18, showed:
- Significant Change in Condition Described: Any single finding does describe a significant change in condition and requires Assessment, Documentation, and Notification.
- New onset arrhythmia (problem with the rate or rhythm of a heartbeat);
- Change in heart rate from baseline (starting point used for comparisons);
- Pulse oximetry < (less than) 90 (monitoring to measure the oxygen saturation of the blood; displayed on the electronic screen as a percentage of oxygen saturation in the blood) (results less than 90 require monitoring).
- Rapid Response Team (RRT-a medical emergency team of health care providers that responds to hospitalized patients with early signs of deterioration on non-intensive care units to prevent respiratory or cardiac arrest) will:
- Complete a rapid assessment (a quick evaluation of information to measure the damages and identify the basic needs that require immediate response);
- Follow appropriate RRT protocols (official procedure);
- Notify attending physician and/or appropriate consultants; and
- Document all changes in condition, assessment, interventions, and physician communication in the medical record.

Review of discharged Patient #1's record showed:
- Admission on 05/24/18, due to acute respiratory failure with hypoxia (lack of oxygen) post tracheostomy (construction of an artificial opening through the neck into the windpipe, usually for the relief of difficulty in breathing) on 05/22/18, patient on a ventilator;
- Sick Sinus Syndrome (a relatively uncommon heart rhythm disorder, a group of signs or symptoms that indicate the heart's natural pacemaker is not functioning properly) with pacemaker (an artificial device for stimulating the heart muscle and regulating its contractions) intact; and
- Two episodes of Pulseless Electrical Activity (PEA) cardiac arrest (cardiac arrest in which the electrocardiogram shows a heart rhythm that should produce a pulse, but does not) prior to admission.
- History and Physical (H&P) dated 05/25/18, showed the plan was to wean the patient off the ventilator per protocol and to have the patient on continuous telemetry and pulse oximetry monitoring.
- Admission Orders dated 05/24/18 showed:
-Code (resuscitation) status: Full;
-May implement Rapid Response Team Protocols;
- Continuous Pulse Oximetry; and
-Telemetry: Set high rate at 125 beats per minute (BPM) and low rate at 45 BPM.
- The 24-Hour Patient Record & Plan of Care dated from 7:00 AM on 06/24/18 to 6:00 AM on 06/25/18 showed that Staff F, Registered Nurse (RN - Patient #1's assigned nurse), and Staff I, Certified Nursing Assistant (CNA - Patient #1's assigned CNA), alternated hourly rounds on Patient #1 from 7:00 PM on 06/24/18 to 6:00 AM on 06/25/18.
- Staff documented the following items during their hourly rounds made on Patient #1:
- Direct observations every hour;
- Offer food/fluids every 2 hours and as needed;
- Offer urinal/bedpan every 2 hours and as needed;
- Provide comfort measures every 2 hours and as needed; and
- R=Reposition, E=Exercise, O=Out of bed and B=back to bed every 2 hours and as needed.
- Nurses Progress/Narrative Notes showed that on 06/24/18 at 8:10 PM, Staff F, RN, documented telemetry alarms were on and audible with high and low alarms set per physician's order (no further documentation regarding the pulse oximetry or telemetry was made after 8:10 PM).
- Activity, Alarm-Message Sent Telemetry Report dated 06/24/18 to 06/25/18 showed Staff M, TLMT, sent an alarm message to nine nursing staff members' assigned phones between 6:25 AM and 6:26 AM, indicating the telemetry leads were off/no signal. At 6:25 AM, Staff F, RN, (assigned nurse) and Staff I, CNA, (assigned CNA) was sent a message from Staff M, TLMT, indicating Patient #1's telemetry leads were off/no signal. At 6:26 AM, when neither staff member replied, a second message was automatically generated to two additional nursing staff members' assigned phones. At 6:26 AM, the second message was noted to be undelivered to both nursing staff members. At 6:26 AM, a third message was automatically generated and escalated to five additional nursing staff members. Staff F, RN and Staff I, CNA did not respond to these alarm messages.
- Mechanical Ventilator Flow Sheet dated 06/25/18 at 6:50 AM, showed Staff L, Day Shift RT, documented that she responded to a code (an emergency situation announced in a hospital in which a patient is in cardiopulmonary arrest, requiring staff to respond and begin resuscitative efforts) called by an unknown RN. The patient was on 40% TP, not breathing, and no pulse upon arrival. Ambu (a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) bag attached to 100% 02 (oxygen) and breaths are given every 5 to 6 seconds throughout the code. Upon entry to the room, pulse oximetry was turned off.

During a telephone interview on 07/31/18 at 10:30 AM, Staff L, RT, stated that:
- When she responded to the code for Patient #1, one to two nurses were present and cardiopulmonary resuscitation (CPR) was in progress with chest compressions.
- When she went to hook up the ambu bag into the wall oxygen, she noticed that the pulse oximetry monitor was not turned on.
- Patient #1's daughter was in the room when she arrived and the daughter reported that when she (daughter) arrived the patient was "gurgling (bubbling sound)" from his trach, the pulse oximetry monitor was black, not turned on and the telemetry monitor was alarming.

During an interview on 7/26/18 at 9:00 AM, Staff I, CNA, stated that:
- She was the primary CNA that cared for Patient #1 on 06/24/18 from 7:00 PM to 7:00 AM on 06/25/18;
- She and Staff F, RN, alternated making hourly rounds on Patient #1 during the 12 hour night shift;
- On 06/25/18 at approximately 5:30 AM, Patient #1 had a bowel movement, she cleaned him, turned him, asked if he was ok, and Patient #1 nodded his head yes. The patient did not sound like he was in respiratory distress, experiencing difficulty in breathing or had a lot of secretions. The patient's skin color was "yellowish" not pale or blue and neither his lips or nailbeds was blue in color;
- She changed the telemetry leads during that time, and after placement, verified the telemetry leads were functioning with Staff M, Telemetry Monitor Tech (TLMT);
- She did not see the patient again after she rounded on him at 5:30 AM on 06/25/18;
- On 06/25/18 sometime between approximately 6:00 AM and 6:20 AM, Staff M, TLMT, asked staff to check on Patient #1's telemetry leads and Staff I, CNA, responded that she directly observed Staff F, RN, go into the patient's room;
- After Staff F, RN, returned to the nurse's station, Staff I asked if everything was ok with Patient #1 and Staff F, RN, replied everything was fine;
- She observed Patient #1's daughter walk by the nurse's station and enter his room at approximately 6:30-6:40 AM and then she heard a RRT called to the room; and
- She did not know why Staff M, TLMT, reported that she (Staff I) stated the patient was pale/blue in color and did not report it to anyone because she (Staff I) never made those comments to Staff M.

During a telephone interview on 07/31/18 at 11:58 AM, Staff M, TLMT, stated:
- On 06/24/18, she did not notice a lot of changes in Patient #1's activity and that he was pretty stable on the monitor throughout the night;
- On 06/25/18, between approximately 6:00 AM and 6:15 AM she noticed Patient #1's telemetry leads were off and she spoke face-to-face with Staff I, CNA, and Staff O, CNA.
- Staff O, CNA, stated to Staff M, TLMT, that Patient #1 was fine and that Staff F, RN, was currently in the patient's room, and Staff I, CNA, confirmed;
- Staff I, CNA, came to her at approximately 6:30 AM to 6:40 AM, while staff were conducting the code on Patient #1, and stated that she (CNA I) had noticed toward the end of the shift that the patient was pale and a little bluish but she (CNA I) did not report it; and
- A staff huddle was facilitated by Staff B, CNO, a couple of weeks ago. Staff was instructed to be sure patient monitors were being monitored appropriately, not to turn any patient monitors off, and not to remove any monitors from patients.

Review of document provided by facility titled, "Staff M, TLMT, Written Statement," dated 06/25/18 showed Staff M, TLMT, stated that between approximately 6:00 AM and 6:15 AM, she had noticed the telemetry leads were off in Patient #1's room. She initiated an overhead page to alert all A-Hall staff. Staff M stated she turned to Staff O, CNA and asked about the telemetry leads being put on and Staff O, CNA, responded that the Tech and RN had been in the room attending to the patient. Staff M, stated she took the CNA's word and left the tele-monitor alarm suspended to let staff attend to the patient's needs. Time had passed and she (Staff M) noticed the leads still had not been put on. Once again, she (Staff M) initiated an overhead page to alert staff the telemetry leads were currently off. Staff M, stated she did not know the telemetry leads were off the entire time due to some activity on the tele-monitor that looked closely like artifact (the patient had a pacemaker in place that would show up as spikes/artifact).

Review of Patient #1's Code Blue Record dated 06/25/18 showed that:
- The code was called for the patient at 6:53 AM with CPR being started at 6:54 AM. There is no documentation of who called the code.
- The reason for calling the code was patient stopped breathing and had no pulse.
- The patient's skin was pale, his airway had some secretions and a trach collar was in place with high humidity at 40%.
- At 6:58 AM the first dose of epinephrine (Epi - medication that acts quickly to improve breathing, stimulate the heart, and raise a dropping blood pressure in emergency situations) was administered by Staff F, RN.
- At 7:00 AM pulse check done - asystole (indicated that the patient did not have a pulse or any heart activity).
- At 7:01 AM a second dose of Epi was administered and CPR continued.
- At 7:02 AM the first dose of Bicarbonate (medication used to correct metabolic acidosis buildup of acid waste during cardiac arrest).
-At 7:04 AM the second dose of Bicarbonate was administered and a third dose of Epi was administered.
-At 7:09 AM a fourth dose of Epi was administered.
- At 7:10 AM the first dose of calcium chloride (medication used to stabilize cardiac arrhythmia - abnormal heart rhythm) was administered and pulse checked.
- At 7:15 AM the code was ended and the patient expired.

Review of Progress Notes dated 06/25/18 at 7:30 AM, showed Staff P, Physician (responded to Patient #1's code blue), showed that:
- Procedure: Cardiopulmonary resuscitation;
- Indication: Cardiac arrest;
- Situation: Found unresponsive, asystole on monitor (pacer spikes only [patient had a pacemaker in place]), continuous CPR, bagged via tracheostomy, copious secretions suctioned from trach. Received Epinephrine 1 mg (milligram) times four, sodium bicarbonate 50 mEq (milliequivalents) times two and calcium chloride 1g (gram). Never regained rhythm or pulse. Code terminated after approximately 20 minutes. Daughter was at bedside throughout.

Review of the Death Summary addendum dated 07/02/18 at 2:57 PM showed the physician documented the final cause of death for Patient #1 on 06/25/18 at 7:15 AM was:
1. Cardiac arrhythmia;
2. Hypoxemia (abnormally low levels of oxygen in the blood);
3. Coronary artery disease (blood vessels cannot carry enough blood and oxygen to the heart); and
4. Hypoxemic respiratory failure (inability of the lungs to perform their basic task of gas exchange).

Staff F, RN, failed to provide ongoing nursing assessment, intervention, and oversight when he failed to ensure Patient #1's pulse oximetry monitor alarm was powered on and functioning during his 12-hour night shift from 7:00 PM on 06/24/18 to 7:00 AM on 06/25/18 (the patient's pulse oximetry monitor was not turned on with alarm when he was found unresponsive by the daughter at 6:50 AM on 06/25/18). Staff F, RN, failed to intervene timely when Staff M, TLMT, sent an electronic message indicating Patient #1's telemetry leads was off/no signal. Staff F, RN, failed to document Patient #1's respiratory response to vent weaning trials during his 12-hour night shift. Staff F, RN, failed to notify the physician of the patient's change in condition. Staff F, RN, failed to provide ongoing nursing assessment, intervention, and oversight for Patient #1 after 8:10 PM on 06/24/18.

During a telephone interview on 07/31/18 at 9:42 AM, Staff F, RN (Patient #1's assigned nurse), who has been terminated, stated that he would contact the facility to see if he could speak with surveyors and would return the call. Contact information was provided to Staff F, RN, and administrative staff could verify our recent survey at the facility, additional information provided included surveyor names and office telephone number. Staff F, RN, did not return call.

The facility failed to ensure that staff:
- Followed physician/pulmonology orders for continuous pulse oximetry monitoring for Patient #1 during vent weaning when his pulse oximetry monitor with alarm was turned off the morning of 06/25/18.
- Recognized changes in Patient #1's condition during rounding and after notification from TLMT of telemetry off/no signal.
- Intervened timely when notification sent indicating Patient #1's telemetry leads were off/no signal.
- Documented Patient #1's respiratory response to vent weaning trials during 12-hour night shift.
- Provided ongoing nursing assessment, intervention, and oversight for Patient #1 after 8:10 PM on 06/24/18.

These failed practices by the facility had the potential to place all patients that required nursing services at increased risk, including death.







18018

Based on interview, record review and policy review, the facility failed to ensure Respiratory Therapy (RT) staff met the needs of patients that required RT care and/or treatment within acceptable standards of practice and expectations when RT staff failed to:
- Follow physician's orders to continuously monitor discharged Patient #1's pulse oximetry (medical equipment used to monitor the amount of oxygen carried in the blood throughout the body) during vent weaning (process to remove the patient from a mechanical breathing machine so they can return to breathing on their own).
- Maintain discharged Patient #1's pulse oximetry monitor on with alarms during the night shift from 12:00 AM on to 6:00 AM on 06/25/18.
- Document in the medical record change in condition of discharged Patient #1 when he experienced desaturated (fall of oxygen levels in the blood) oxygen levels throughout the night shift from 12:00 AM to 6:00 AM on 06/25/18.
- Notify discharged Patient #1's physician/pulmonologist that the patient experienced desaturation levels throughout the 12 hour night shift from 5:30 PM on 06/24/18 to 6:00 AM on 06/25/18.
- Ensure unauthorized personal pocket oximetry monitor was not used on discharged Patient #1 during the 12 hour night shift from 5:30 PM on 06/24/18 to 6:00 AM on 06/25/18.
- Respond timely to an alarm on current Patient #4's pulse oximetry monitor when it went off on the afternoon of 07/20/18.
These failed practices had the potential to lead to negative patient outcomes including death and could affect all patients that required respiratory care and treatment. The facility census was 25.

Findings included:

1. Review of the facility's policy titled, "Pulse Oximetry Monitoring," dated 01/01/16 showed that:
- Pulse Oximetry Monitoring:
Spot Check (random checking)
- BID (twice daily) and PRN (as needed) - all patients on 22-44% oxygen.
Continuous
- All patients receiving 45% oxygen or greater.
- Patients requiring mechanical ventilation (a machine used to help people breathe when they are not able to breathe on their own).
- Anytime patient is wearing CPAP (Continuous Positive Air Pressure - a machine used to force air into nasal passages to prevent episodes of airway collapse that blocks the breathing in people)/BIPAP (Bilevel Positive Airway Pressure - a machine used to assist in opening up the lungs using positive air pressure).
- All patients with artificial airways until 24 hours post decannulation (the process where a tracheostomy [trach - a surgically created hole in the windpipe used to assist a person with breathing] tube is removed once a patient no longer needed it).

Record review of the facility's policy titled, "Change in Patient Condition: Early Recognition and Intervention," revised 04/01/18, showed that:
- Significant Change in Condition described:
- Pulse oximetry < (less than) 90%;
- Change in respiratory rate or increased work of breathing: especially those that require ventilator mode/rate changes. Any respiratory rate < 10 or > (greater than) 30.
-Assessment and Basic Recommendations:
- A complete head to toe assessment will be performed along with consultation as appropriate among the clinical team.
- Data to be obtained includes, but not limited to: Pulse ox (oximetry) reading. If < 85, stat (immediately) ABG's.
- Protocol 1 - Altered Respiratory Status: Non-ventilator patient:
- Position patient in semi-fowlers (head of bed elevated at approximately 30 to 45 degrees) if BP (blood pressure) adequate;
- Assess patency of airway (RT only - if patient has trach, remove inner cannula to assess for occlusion);
- Pulse Oximetry - titrate oxygen to maintain pulse ox > 94%;
- Place on telemetry;
- Patent (open, not obstructed) IV (intravenous - needle placed into a vein used to administer fluids, medications and/or nutrition) NS (normal saline) KO (keep vein open) rate;
- Stat ABG's;
- CBC (complete blood count), CMP (comprehensive metabolic panel) stat.
- Suction as indicated;
- Stat portable chest x-ray; and
- If trach, may place back on ventilator at previously tolerated settings.

Review of the facility's policy titled, "Assessment and Reassessment of Patient," revised 01/01/18, showed that:
- Assessment and reassessment data will be documented in the patient's medical record.
- Scope of Respiratory Therapy Assessment: Reassessment is the analysis of patient data to determine the appropriateness and effectiveness of therapy provided. Patients with artificial airways, mechanical ventilation (invasive and/or non-invasive), and/or requiring heated high flow oxygen are reassessed every 3 to 4 hours; patients requiring nocturnal (night) non-invasive ventilation will be assessed each shift while unit is "not in use", further assessed upon application and/or removal, and reassessed every 3 to 4 hours "while the device is in use". Reassessment may include, but is not limited to, HR (heart rate), RR (respiratory rate), BP, SpO2 (amount of oxygen in the blood), oxygen/vent settings, work of breathing, secretion clearance, airway patency, patient tolerance, adverse reactions, ect. Those patients requiring supplemental oxygen, less than 45%, will be reassessed once per shift; reassessment should include, but is not limited to, liter flow and SpO2. Reassessment also occurs at the time a patient need/request for treatment and/or medication.

Review of the facility's policy titled, "Ventilator Weaning Protocol," revised 06/01/18, showed that:
- Responsibility: Respiratory Therapist under the guidance of the Pulmonary Physician.
- The RT will work closely and communicate effectively with appropriate nursing and medical staff in the management and weaning of all ventilator patients.
- The RT will assure that airway care is optimized during mechanical ventilator support. In addition, the RT will manage oxygen administration to maintain SpO2 (blood oxygen saturation - the amount of oxygen in the blood) greater than or equal to 92% unless otherwise specified by the physician.
- The RT will acquire ABG (Arterial Blood Gas - measures the level of oxygen and carbon dioxide in the blood) samples per discretion as needed when feasible.
- Should there be an acute deterioration of the patient's pulmonary condition at any time during management or weaning of the ventilator, the therapist will immediately notify the pulmonary physician and take appropriate steps to treat the symptoms.
- Liberation (discontinuation and removal from a mechanical ventilator machine) of Mechanical Ventilation: A patient must remain on continuous pulse oximetry monitoring according to policy.

Review of discharged Patient #1's medical chart showed:
- He was admitted to the facility on 05/24/18 with complaints of acute respiratory failure with hypoxia (lack of oxygen).
- History and Physical (H&P) dated 05/25/18 showed the plan was to wean the patient off the ventilator per protocol.
- Admission orders dated 05/24/18 showed:
- Code Status: Full Code - all indicated methods of resuscitation are to be used;
- Respiratory: Continuous pulse oximetry, mechanical ventilation, and trach;
- Respiratory to evaluate and treat; and
- Specialty Consult: Pulmonology.
- Internal Medicine (the physician that cares for adults) Progress Note dated 06/24/18 showed that the patient had been liberated off the vent on 06/23/18. Status post-cardiac arrest times two prior to arrival (patient was admitted from a local acute care hospital) and on telemetry (cardiac telemetry - used to monitor the electrical activity of the heart to include heart rate).
- Pulmonary (physician that specializes in lung diseases/disorders) Consult Progress Note dated 06/24/18 showed that the patient was currently off the vent for 24 hours, vent support with AC (Assist Control - a patient is able to assist the ventilator by initiating some additional breaths, over and above the set rate), wean per protocol.
- Mechanical Ventilator Flow Sheet (document RT used) dated 06/24/18 at 9:50 PM, showed that Staff G, Night Shift Registered Respiratory Therapist (RT), documented that the patient was on a trach collar (TC - a medical device used to secure a trach tube in its position) with 0.40 (FI02 - fraction of inspired [breathed in] air) and SpO2 at 100%.
- Mechanical Ventilator Flow Sheet Comments dated 06/24/18 and untimed, showed that Staff G, RT, documented that the patient was on 40% TC, tolerated well.
- Mechanical Ventilator Flow Sheet dated 06/25/18 at 12:55 AM, showed that Staff G, RT, documented that the patient was on a TC with FI02 at 0.40 and SpO2 at 95% (Staff G did not document on the patient for six hours on 06/25/18 per the Mechanical Ventilator Flow Sheet. The only entry Staff G made on 06/25/18 was at 12:55 AM).
- Mechanical Ventilator Flow Sheet Comments dated 06/25/18 at 6:50 AM, showed that Staff L, Day Shift RT, documented that she responded to a code (an emergency situation announced in a hospital in which a patient is in cardiopulmonary arrest, requiring staff to respond and begin resuscitative efforts) called by Registered Nurse (RN) at this time. The patient was on 40% TC, not breathing, and no pulse upon arrival. Ambu (a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) bag attached to 100% oxygen and breaths given every 5 to 6 seconds throughout the code. Upon entry to the room, pulse oximetry was turned off.
- Room Activity, Alarm- Message Sent Pulse Oximetry Report showed that from 7:53 PM on 06/24/18 to 3:57 AM on 06/25/18 an alarm message from the patient's pulse oximetry monitor alarmed 33 times. The Room Activity Report did not show any pulse oximetry monitor alarms after 3:57 AM indicating that the alarm on the pulse oximetry monitor did not alarm from 3:57 AM to 6:50 AM including when staff found the patient unresponsive.
- Death Summary addendum dated 07/02/18 at 2:57 PM showed that the physician documented the final cause of death:
1. Cardiac arrhythmia;
2. Hypoxemia;
3. Coronary artery disease; and
4. Hypoxemic respiratory failure.

During an interview on 07/25/18 at 5:15 PM and a telephone interview on 07/31/18 at 11:10 AM, Staff G, RT, stated that:
- She was the RT assigned to Patient #1 for the 12 hour night shift from 5:30 PM on 06/24/18 to 6:00 AM on 06/25/18.
- She received training and education on the facility's equipment.
- Her responsibilities as an RT working at the facility included: management of patients' ventilators, trachs, and non-invasive CPAP/BIPAP and breathing treatments.
- RT rounds are to be made on patients every three to four hours.
- Expectations of RT with a patient on a pulse oximetry monitor were to check the monitor during airway checks and record how the patient was doing that included respirations and heart rate.
- Patient #1 was being weaned off the vent and had a high humidity trach collar in place with continuous pulse oximetry monitoring.
- Patient #1's pulse oximetry monitor alarmed a lot throughout the night and he did desaturate (low blood oxygenation) below 90% and needed the oximetry probe (medical device attached to a finger, ear or toe and information is transmitted from the probe to the monitor and provided a read out of the results of the saturated oxygen level) on the pulse oximetry monitor to be repositioned and/or moved approximately four to five times during her shift from ear to ear, she silenced the alarm (a silenced alarm would only last for approximately a minute or so), and used her own personal pocket pulse oximetry monitor to check his oxygen level.
- It would be up to her discretion when she would use her own personal pocket pulse oximetry monitor on a patient and she would use it when she did not think the facility's pulse oximetry monitor was correlating with the probe on either a patient's finger or ear.
- She did not document in Patient #1's medical record when she used her own pocket pulse oximetry monitor.
- She did not know if personal equipment had to be Ok'd with the facility prior to use on patients.
- She did not recall reporting to Staff L, RT, that she had turned off Patient #1's pulse oximetry monitor during her 12 hour night shift from 5:30 PM on 06/24/18 to 6:00 AM on 06/25/18.
- She forgot to document in Patient #1's medical record after 12:55 AM on 06/25/18.
- RT staff was expected to document on patients every two to three hours if the patient was on a trach collar.
- When a patient's pulse oximetry monitor alarms, the alarm would audibly sound in the patient's room and a message would be sent to RT and nursing staffs' assigned phone. If staff did not respond to the alarm, the message would go out to all assigned phones.
- She had not received any education/training after the incident with Patient #1 but was given verbal instruction not to silence or turn off pulse oximetry monitors or alarms.

Staff G, RT did not ensure and maintain Patient #1's pulse oximetry monitor was on with alarms and functioning during her 12 hour night shift from 5:30 PM on 06/24/18 to 6:00 AM on 06/25/18 (the patient's pulse oximetry monitor was not turned on with alarms when he was found unresponsive by staff at 6:50 AM on 06/25/18). Staff G did not document on the patient for six hours on 06/25/18 per the Mechanical Ventilator Flow Sheet. The only entry Staff G made on 06/25/18 was at 12:55 AM. Staff G did not document that she experienced difficulty with obtaining a continuous pulse oximetry (SpO2) reading on the patient throughout her 12 hour night shift. Staff G did not document that she notified the patient's physician/pulmonologist or assigned nurse of the difficulty she experienced in obtaining continuous pulse oximetry readings during weaning the patient off the vent during her 12 hour night shift. Staff G did not obtain ABG's to assess if the patient experienced signs of difficulty with being weaned off the vent.

During an interview on 07/25/18 at 12:04 PM, Staff H, RT Manager, stated that:
- RT staff was to maintain patients' pulse oximetry monitors, ventilator machines, and BIPAP, however; if an alarm goes off any staff (RN) should check the alarm.
- If non-RT staff checked an alarm and they are not able to resolve the alarm issue, staff would need to contact RT and RT would contact the pulmonary physician.
- When the pulse oximetry monitor alarm goes off, an audible alarm sounded in the patient's room and the alarm also goes to the facility's call bell system and if the alarm was not responded to by staff within 20 seconds the alarm goes out to all staffs' assigned phone. The alarm would also show up at the nurse's station where the Telemetry Monitor (responsible to observe and interpret a patient's heart status in the hospital) Technician (TLMT) was located.
- There was a recording of alarms when they went off.

During an interview on 07/26/18 at 9:01 AM, Staff I, Certified Nursing Assistant (CNA), stated that:
- She worked the night shift from 7:00 PM on 06/24/18 to 7:00 AM on 06/25/18 and was the primary CNA caring for Patient #1.
- She made rounds on Patient #1 at least every hour during her shift.
- At 5:30 AM when she went to turn Patient #1 she noticed that his pulse oximetry monitor was not turned on and she did not know what staff had turned it off, but he was connected to the blood pressure machine that displayed his blood pressure, heart rate, and respirations (the blood pressure machine did not include pulse oximetry monitoring).
- She asked Patient #1 if he was "ok", and he nodded that he was.
- Patient #1 did not sound like he was in respiratory distress, having difficulty breathing or had a lot of secretions.
- She stated that Patient #1's color was "yellowish" but denied that he was "sweaty" or "pale/blue" in color and that he did not have pale/blue lips or nailbeds.
- She did no tell Staff M, TLMT, that the patient appeared "bluish" in color during her shift or that she did not report it.
- She was responsible to report any changes in a patient's condition.
- She had not received any education/training by the facility related to Patient #1's event related to the pulse oximetry monitor and alarms being off until today, July 26, 2018.

During an interview on 07/26/18 at 9:49 AM, Staff J, RT, stated that:
- She came into work on the morning of 06/25/18 and worked from 5:30 AM to 6:00 PM.
- She heard Staff G, RT, give a report to Staff L, RT that she (Staff G) had turned off Patient #1's pulse oximetry monitor so he could sleep and that she (Staff G) made "spot checks" on him.
- Staff G reported to Staff L that the alarm disturbed Patient #1 and she (Staff G) wanted to let him sleep.
- Staff G reported to Staff L that she turned the pulse oximetry monitor back on but did not say what time she (Staff G) turned it back on.
- RT staff was to check on patients with advanced airways every three hours.
- RT staff would receive a notice per their assigned phone if there was a problem with a patient's pulse oximetry monitor or if an alarm sounded.
- It was not an acceptable practice of the facility for staff to silence alarms (unless staff was with the patient in the room), or to turn off alarms or the monitor.

During an interview on 07/27/18 at 9:00 AM, Staff H, RT Manager, stated that it was the expectation for RT staff to document at a minimum every three hours and if Staff G, RT, did not document every three hours during her 12 hour night shift, she did not meet expectations. Staff H stated that RT staff can draw ABG's and notify the patient's physician/pulmonologist any time they encountered issues during vent weaning.

During a telephone interview on 07/31/18 at 10:30 AM, Staff L, RT, stated that:
- When she arrived to work on the morning of 06/25/18, Staff G, RT, gave her report about Patient #1's activity during the night shift.
- Staff G, RT, reported that she turned off Patient #1's pulse oximetry monitor due to the monitor alarm caused him to become aggravated when it alarmed so she performed "spot checks".
- Staff G, RT, reported that she turned the pulse oximetry monitor back on but did not say what time she turned it back on.
- When she (Staff L) responded to the code for Patient #1, one to two nurses were present and cardiopulmonary resuscitation (CPR) was in progress with chest compressions.
- When she (Staff L) went to connect the ambu bag into the wall oxygen, she noticed that the pulse oximetry monitor was not turned on.
- Patient #1's daughter was in the room when she arrived and the daughter reported that when she (daughter) arrived the patient was "gurgling (bubbling sound)" from his trach, the pulse oximetry monitor was black, not turned on and the telemetry monitor was alarming.
- Both RT and nursing staff received a notice from their assigned phone if an alarm sounded from the pulse oximetry monitor and everyone was expected to respond.
- RT and nursing staff can silence the alarm if they are in the room working with the patient.
- RT can notify a patient's physician/pulmonologist when a patient was being weaned from the vent, when a rapid response was called, when blood gases are drawn, need for a chest x-ray, and when titrating oxygen to keep levels above 90%.
- RT staff was expected to document every three to four hours for patients with a trach or on a vent.
- One time documentation from 1:00 AM to 5:30 AM by RT staff would not be an acceptable practice and acceptable practice for RT documentation would be between four to five entries.
- If a patient's pulse oximetry monitor signal was not strong, it could indicate the monitor was not reading accurately.
- RT staff was trained to know when the pulse oximetry monitor reading was not accurate.
- RT staff was not to use their own personal pocket pulse oximetry monitors on patients and the facility provided portable pulse oximetry monitors for RT to use.
- RT staff cannot make the decision on their own to turn off a patient's pulse oximetry monitor.
- When the pulse oximetry monitor first alarms it sounded from the monitor in the patient's room, after several seconds, the alarm would go to both RT/RN assigned phones and display what patient room the alarm came from.
- If staff did not respond to the alarm, the alarm would keep alarming.

During a telephone interview on 07/31/18 at 12:00 PM, Staff M, TLMT stated that:
- She worked the night shift on 06/24/18.
- She monitored Patient #1's telemetry monitor (a medical device that monitors the patient's heart activity) for the 12 hour night shift on 06/24/18.
- She did not notice too much difference with the patient, no activity during the night from the monitor and the patient appeared stable.
- On 06/25/18 at between approximately 6:00 AM and 6:15 AM, she noticed Patient #1's monitor leads were not functioning, she informed Staff I, CNA, and Staff I stated that the patient was "OK" and Staff F, RN, ( Patient #1's assigned nurse) was in the room with the patient.
- If a patient's pulse oximetry monitor was silenced or turned off it would not alert if a patient experienced desaturation and would not send an alert to staff.
- Between 6:30 AM and 6:40 AM, during the time that staff found Patient #1 unresponsive and called a code, Staff I, CNA, came up to the desk and stated that Patient #1 was "pale" and a little "bluish" but that she (CNA I) had not reported it.
- As a TMLT, she was responsible to send a page over the phone and call into the patient's room to notify staff of alarms (pulse oximetry monitor alarms and Telemetry alarms).

During a telephone interview on 08/01/18 at 10:38 AM, Staff N, RT Director, stated that:
- He was aware of the lack of documentation by Staff G, RT, for Patient #1 for her 12 hour night shift on 06/24/18.
- The expectation for RT documentation was RT were required to document on patients every three to four hours and during any interaction with a patient, for example, when a patient was suctioned or breathing treatments administered.
- RT was not allowed to use their own equipment including personal pocket pulse oximetry monitors on patients and all RT staff was aware they are not to use non-facility equipment on patients.
- The RT department supplied staff with needed equipment, for example, stethoscopes (a medical device used to listen to a person's heart, lungs, and abdomen) and pocket pulse oximetry monitors.
- Patient #1 had a physician order for continuous pulse oximetry monitoring.
- No staff was to turn off pulse oximetry monitors without consulting with the physician/pulmonologist first.
- RT staff had other means available to them to obtain pulse oximetry monitor readings, the RT department had different probes RT staff can use when they experienced difficulty with readings.
- When RT staff had trouble with pulse oximetry monitor readings they need to trouble shoot and change out the probe but they are never to turn off the pulse oximetry monitor.
- If a patient experienced desaturation, RT staff was responsible to:
- Assess the amount of oxygen a patient was on;
- Notify the physician/pulmonologist for orders to increase oxygen and initiate titration based on the oxygen demands of the patient; and
- According to physician/pulmonology orders, titrate the patient's oxygen according to need.
- He expected RT staff to document in the medical record RT assessments and any notification/communication with the physician/pulmonologist.
- For a patient being weaned off the vent, the patient would have continuous pulse oximetry monitoring and staff would need a physician/pulmonology order to only "spot check" oxygen levels during weaning and it was not acceptable for RT staff to use their own equipment to "spot check" a patient's oxygen level during the weaning process.
- He was not aware that Staff G, RT, had used her own pocket pulse oximetry monitor on Patient #1 during her 12 hour night shift from 5:30 PM on 06/24/18 to 6:00 AM on 06/25/18 when the patient was being weaned off the vent.
- He could not guarantee Staff G's own personal pocket pulse oximetry monitor gave accurate readings.
- He verbally talked to RT staff after the incident with Patient #1's pulse oximetry monitor with alarms being off but he did not document what education was provided, did not document the date/time presented or what staff attended.

2. Review of current Patient #4's medical record showed:
- She was admitted to the facility on 07/03/18 with complaints of respiratory failure.
- The H&P dated 07/04/18 showed the patient was admitted to the facility for ventilator weaning status post stroke. The patient arrived on TC (trach collar) and will wean as tolerates per pulmonology.
- Admission orders dated 07/03/18 showed:
- Code Status: Full Code-all indicated methods of resuscitation are to be used;
- Telemetry-Set high rate at 125 beats per minute (BPM) and low rate at 45 BPM; and
- Pulmonology to consult.
- 24 Hour Patient Record & Plan of Care Nursing Progress/Narrative Notes dated 07/20/18 at 2:44 PM showed that nursing staff documented that the patient was now on two liters (2L) of oxygen per nasal cannula (NC - a medical device placed into the nares to deliver supplemental oxygen) per RT due to desaturation.
- Mechanical Ventilator Flowsheet dated 07/20/18 showed that RT staff did not document why the patient required being placed back on 2L of oxygen after being maintained on room air.

During an interview on 07/25/18 at 11:01 AM, Patient #4's family stated that:
- The patient was admitted to the facility on 07/03/18 and staff does not answer the call light or respond to the pulse oximetry monitor alarms in a timely manner.
- On Friday, July 20, 2018 physical therapy had the patient sitting up at the edge of the bed, after sitting up for a while; staff assisted the patient back in bed and exited the room.
- The family was at the patient's bedside talking to the patient when the patient became unresponsive and the pulse oximetry monitor alarm went off.
- Staff did not respond to the alarm and family began calling out the patient's name and shook the patient but the patient did not respond to either verbal or tactile stimulation and did not appear to be breathing.
- A family member exited the patient's room and called out for help but no staff was in the vicinity of the patient's room. The family member went to the nurse's station and told staff the patient was unresponsive and the monitor was alarming and they needed help.
-After the family summoned staff, they arrived at the patient's room and attended to the patient and the patient started to "come around".

During an interview on 07/26/18 at approximately 4:30 PM, Staff A, RN, Director of Risk/ Quality and Staff B, RN, CNO, stated that they were unaware that staff did not respond timely to Patient #4's pulse oximetry monitor alarm last Friday, July 20, 2018. Both Staff A and Staff B stated that not all staff to date had received the re-training/re-education after the incident with Patient #1's pulse oximetry monitor with alarms being turned off.

The facility failed to ensure that:
- Staff G, RT, followed physician/pulmonology orders for continuous pulse oximetry monitoring for Patient #1 during vent weaning when his pulse oximetry monitor with alarms was turned off the morning of 06/25/18.
- Staff G, RT, did not "spot check" Patient #1 during vent weaning without prior orders from the physician/pulmonology.
- Staff G, RT, did not use her unauthorized personal pocket pulse oximetry monitor on Patient #1 to "spot check" his oxygen levels.
- Staff G, RT, documented changes in Patient #1's condition during her 12 hour night shift from 5:30 PM on 06/24/18 to 6:00 AM on 06/25/18 when the patient experienced desaturation levels throughout the shift.
- Staff G, RT, notified Patient #1's physician/pulmonologist or assigned nurse of his desaturation levels during her 12 hour night shift from 5:30 PM on 06/24/18 to 6:00 AM on 06/25/18 during the vent weaning process.
- RT staff documented the event that caused Patient #4 to require oxygen at 2L per nasal cannula after being maintained on room air.
- Staff respond timely to Patient #4's pulse oximetry monitor alarm on 07/20/18.
- Administrative staff did not ensure all staff received education/trainingin a timely manner afer the incident of Patient #1's pulse oximetry monitor with alarms being turned off.
- RT Director did not document the education/training provided, date/time or record of RT staff that attended.

These failed practices by the facility had the potential to place all patients' that required respiratory services at increased risk including death.