HospitalInspections.org

Based on interview and record review, the facility failed to ensure patient care was provided to warrant the safety and well-being of the patients when:

1. For Patient 4, nursing staff used the Aspira pleural drainage system (a medical device specifically designed to manage pleural effusions, which are accumulations of fluid in the pleural space surrounding the lungs. This system facilitates the removal of fluid through a soft, flexible tube that is inserted through the skin and into the pleural space, and allows for regular drainage of the fluid buildup, thereby alleviating symptoms such as shortness of breath and discomfort) without training or competency (having the right knowledge, and skills);

2. Patient 11 had three episodes of chest pain following a cardiac procedure and it was not reported to the physician. In addition, a stat EKG (electrocardiogram, a test that records your hearts electrical activity) was not performed and the rapid response (a specially trained team that provides immediate care for hospitalized patients whose condition is rapidly deteriorating) team was not notified to assist in Patient 11's change in condition; and

3. For Patient 12, the rapid response form was not documented with details of Patient 12's change in health status and there was no documentation of family notification of the rapid response.

The cumulative effects of these facility failures had the potential to place patients' at risk for harm, compromise their safety, delay critical interventions, negatively impact health outcomes, and contribute to the subsequent death of Patient 11.

Based on interview and record review, the facility failed to ensure the facility's policies and procedures were implemented, for three of 20 sample patients (Patients 4, 11, and 12), when:

1. For Patient 4, nursing staff used the Aspira pleural drainage system (a medical device specifically designed to manage pleural effusions, which are accumulations of fluid in the pleural space surrounding the lungs. This system facilitates the removal of fluid through a soft, flexible tube that is inserted through the skin and into the pleural space, and allows for regular drainage of the fluid buildup, thereby alleviating symptoms such as shortness of breath and discomfort) without training or competency (having the right knowledge, and skills);

2. Patient 11 had three episodes of chest pain following a cardiac procedure and it was not reported to the physician. In Addition, a stat EKG (electrocardiogram, a test that records your hearts electrical activity) was not performed and the rapid response (a specially trained team that provides immediate care for hospitalized patients whose condition is rapidly deteriorating) team was not notified to assist in Patient 11's change in condition.

3. For Patient 12, the rapid response form was not documented with details of Patient 12's change in health status and there was no documentation of family notification of the rapid response.

The cumulative effects of these facility failures had the potential to place patients' at risk for harm, compromise their safety, delay critical interventions, negatively impact health outcomes, and contribute to the subsequent death of Patient 11.

Findings:

1. On August 19, 2025, at 1:30 p.m., Patient 4's record was reviewed with the Quality and Patient Safety Specialist (QPSS). A facility document, titled, "History and Physical [H&P]," dated April 2, 2025, was reviewed and indicated Patient 4 was admitted to Unit 1 for generalized weakness, urinary tract infection, increased congestion, and right sided pleural effusion (extra fluid that builds up in the pleural space between the lungs and the chest wall making it harder for a person to breath).

A facility document, titled, "IR [Interventional Radiology] Pleural Drain Perc [Percutaneous] Cath [Catheter] [small chest tube placed through the skin into the pleural space to drain extra fluid]," dated April 7, 2025, was reviewed and indicated, Patient 4 underwent placement of a right sided tunneled (placed under the skin) Aspira pleural catheter for recurrent right pleural effusions.

A facility document, titled, "IR Thoracentesis [procedure where a physician uses a small tube to remove extra fluid from around the pleural space]," dated April 14, 2025, was reviewed and indicated Patient 4 underwent aspiration of fluid due to a left pleural effusion.

A facility document, titled, "IR Insert [Insertion of] Pleural Cath [Catheter]," dated April 23, 2025, was reviewed and indicated, Patient 4 underwent placement of a left sided tunneled Aspira pleural catheter for recurrent left pleural effusions.

An untitled facility document, "View Flowsheet," dated April 11, 2025, through April 26, 2025, was reviewed and indicated:

-On April 11, 2025, at 12:40 p.m., RN (Registered Nurse) 1 drained "Chest Tube Right...Output (mL, milliliter, unit of measure)...950 mL;
-On April 14, 2025, at 4 p.m., RN 2 drained "Chest Tube Right...Output...900 mL;
-On April 16, 2025, at 4:43 p.m., RN 3 drained "Chest Tube Right...Output...1000 mL;
-On April 19, 2025, at 3:20 a.m., RN 4 drained "Chest Tube Right...Output...675 mL;
-On April 21, 2025, at 9:44 a.m., RN 5 drained "Chest Tube Right...Output...1100 mL;
-On April 24, 2025, at 11:45 a.m., RN 6 drained "Chest Tube Left...Output...350 mL;
-On April 24, 2025, at 6:45 p.m., RN 6 drained "Chest Tube Right...Output...1000 mL;
-On April 25, 2025, at 6:21 p.m., RN 7 drained "Chest Tube Right...Output...150 mL;
-On April 25, 2025, at 6:21 p.m., RN 7 drained "Chest Tube Left...Output...400 mL;
-On April 26, 2025, at 5 p.m., RN 8 drained "Chest Tube Right...Output...450 mL; and
-On April 26, 2025, at 6 p.m., RN 8 drained "Chest Tube Left...Output...250 mL;

A facility document, titled, "Multidisciplinary Progress Note," dated, April 18, 2025, at 5:55 p.m., and authored by RN 7 was reviewed and indicated, "With the help of [Name of RN 4]...attempted to drain...Order states to drain 3 times a week...When I called IR earlier in the shift I was told IR is not able to come up and assist...IR provided Aspira drainage bottle which is not compatible with the patient's drain, there is a missing adaptor piece..."

A facility document, titled, "Multidisciplinary Progress Note," dated, April 18, 2025, at 6:15 p.m., authored by RN 4 was reviewed and indicated, "...Was requested to assist with the drainage of a Aspira pleural drain. Supplies at bedside were incompatible..."

On August 19, 2025, at 1:45 p.m., an interview was conducted with the Director of Quality (DOQ). The DOQ stated while Patient 4 was admitted, the nursing staff on Unit 1 did not have the necessary training to use the Aspira pleural drain. Only the Interventional Radiology (IR) nurses were trained and competent in its use. After Patient 4 was discharged, the Aspira representative was contacted and provided Unit 1 staff training. The DOQ further stated Unit 1 staff should not have attempted to drain Patient 4's pleural drain without proper training and competencies.

On August 19, 2025, at 3 p.m., an interview was conducted with the IR Charge Nurse (RN 9). RN 9 stated, the facility utilizes two brands of pleural drains, Aspira and Pleurx. RN 9 stated each brand has different connectors and they are not interchangeable. RN 9 further stated nurses should not have attempted to use the Aspira drain unless they had the necessary training.

On August 19, 2025, at 3:15 p.m., an interview was conducted with the Manager of Unit 1 (Manager 1). Manager 1 stated that the facility did not have documentation of competency or training for Unit 1 nurses who performed the drainage of Patient 4's Aspira pleural drain. Manager 1 further stated RNs 1, 2, 3, 4, 5, 6, 7, and 8 had not received training until after Patient 4 was discharged.

On August 20, 2025, at 11:15 a.m., an interview was conducted with RN 6. RN 6 stated Patient 4 had a pleural drain and was not aware that the facility had two brands of pleural drains. RN 6 stated in-service training on Aspira pleural drainage system was provided after Patient 4 was discharged.

On August 20, 2025, at 11:45 a.m., an interview was conducted with the Director of Patient Care Services (DPS). The DPS stated that the nursing staff should not have attempted to drain Patient 4's Aspira drain using incompatible equipment. The DPS further stated nursing staff should have had the proper training before using the equipment. The facility has a process for introducing new equipment, which involves notifying the professional practice/clinical practice committee to ensure proper training and supplies are available. However, the DPS stated this process was not followed. The DPS concluded that Unit 1 nursing staff received training on the Aspira pleural system after Patient 4 was discharged.

On August 20, 2025, at 12 p.m., an interview was conducted with RN 3. RN 3 stated they received training on the Pleurx brand of pleural drain system but only received training on the Aspira system after Patient 4 was discharged.

On August 20, 2025, at 1:20 p.m., an interview was conducted with RN 2. RN 2 stated they received training on the Pleurx brand of pleural drain system but only received training on the Aspira system after Patient 4 was discharged.

On August 20, 2025, at 1:30 p.m., an interview was conducted with IR technician (IRT). IRT stated the Aspira pleural drainage system is different from the Pleurx pleural drainage system and the supplies for each are not compatible. IRT stated the connector was damaged from use of incompatible equipment and needed to be replaced.

On August 21, 2025, at 8:45 a.m., an interview was conducted with the rapid response nurse (RN 4). RN 4 stated the rapid response nurse is a resource for nurses and was contacted on April 18, 2025, due to the incompatibility of supplies and trouble with lung drainage of Patient 4's pleural drain system. RN 4 stated Patient 4 was experiencing respiratory distress and was lethargic (sleepy) and needed to have lung drained urgently. RN 4 stated supplies for the Aspira system were difficult to find and IR did not provide them when asked. RN 4 further stated training for the Aspira pleural drainage system was never provided and there was no policy or procedure in place for its use. RN 4 stated Patient 4's home discharge supplies were utilized to drain the Aspira pleural drain system.

On August 21, 2025, at 9:20 a.m., an interview was conducted with RN 8. RN 8 stated they received training on the Pleurx brand of pleural drain system but only received training on the Aspira system after Patient 4 was discharged.

On August 21, 2025, at 9:45 a.m., an interview was conducted with RN 7. RN 7 stated they received training on the Pleurx brand of pleural drain system but only received training on the Aspira system after Patient 4 was discharged. RN 7 further stated IR and the rapid response nurse was contacted on two shifts due to "broken" connections and incompatibility issues with the Aspira drainage system.

On August 21, 2025, at 11:45 a.m., an interview was conducted with RN 1. RN 1 stated they received training on the Pleurx brand of pleural drain system but only received training on the Aspira system after Patient 4 was discharged.

A review of the facility document titled, "Job Description," was conducted and indicated, "...Job title: Clinical Nurse B-Inpatient...Job Summary...Meets qualifications, licensure, certifications and competencies as defined in the unit/department-specific Plan for Providing Care...Demonstrated basic competencies in clinical nursing..."

A review of the facility document titled, "Plan For Providing Care [Name of Facility] Medical and Surgical Services," dated September 2022, was reviewed and indicated, "...Qualifications/Licenses/Certifications Required of Staff...All employees are required to complete a department specific orientation upon hire and maintain hospital-wide required competencies as indicated by hospital policy...Registered Nurses...Initial and annual competencies are performed as determined by the need of the department, high risk low volume, standardized procedure, regulatory, process improvement, or new product..."

A review of untitled document, dated May, 2025, flowchart process for new equipment was reviewed and indicated, "...New Device or Equipment: Supply Chain update, Pilot, Institution Implementation, SOS [standardization of supplies] Committee...Frontline Staff Identified Need - Proposed Change / Update to Practice from Professional Governance Committees...Update to Policy...Education Need Identified...Education Needed...Forward to Nursing Oversight Council..."

2. On August 19, 2025, at 9 a.m., a review of Patient 11's medical record was conducted with the Regulatory Specialist (RS).

A review of the facility document titled, "ED [Emergency Department] Provider Notes," dated July 19, 2025, authored by MD 1, indicated Patient 11 was brought into the facility by ambulance with chest pain radiating to the left chest and arm. Further review of the document indicated, MD 2 agreed to a STEMI (ST-segment elevation myocardial infarction, a type of heart attack where there is a blockage in one of the major arteries that supplies blood to the heart muscle) activation and Patient 11 was admitted for acute MI (myocardial infarction).

A review of the facility document titled, "Cardiology [study of heart diseases] Consult Note," dated July 20, 2025, at 12:19 a.m., authored by MD 2, was reviewed. The document indicated, "...On arrival patient [Patient 11] continues to have chest pain. Patient [Patient 11] will be taken to Unit B immediately for PPCI [Post Percutaneous Coronary Intervention, involves using a catheter to open blocked arteries, often with the placement of a stent [tube], to restore blood flow to the heart muscle]..."

A review of an untitled facility document dated July 21, 2025, at 11:07 a.m., indicated, "Transfer Patient...Level of Care: Unit 1..."

A review of a facility document titled "Multidisciplinary Progress Note," dated July 21, 2025, at 12:06 a.m., indicated, "...Patient [Patient 11] called stating she [Patient 11] is feeling cold and sweaty...Vital signs normal. HR [heartrate] tends to go to 120s when patient [Patient 11] is anxious...Patient [Patient 11] has been complaining of being hot and then cold at other times...Patient [Patient 11] stated she at home has anxiety as well and can't sleep well at home as well [sic]. But now she is getting scared that when she sleeps she might not wake up..."

There was no documented evidence the physician was notified of Patient 11's symptoms.

A review of the facility document titled, "View Doc flowsheet," dated July 21, 2025, at 12 p.m., indicated, "...pain assessment [a process of collecting detailed information to identify pain with 0 being the least pain experienced and 10 the highest pain] 0-10 pain score 8...pain type acute pain pain location chest...pain descriptors pressure pain onset ongoing..."

There was no documented evidence the physician was notified Patient 11 had chest pain.

A review of an untitled facility document, dated July 21, 2025, at 1:54 a.m., indicated, "DC [discontinue] Telemetry monitoring [a system that continuously measures and transmits heart data from a remote location to a central station ..."

A review of the facility document titled, "View Doc Flowsheet," dated July 21, 2025, at 8:01 p.m., indicated, "...pain assessment 0-10...pain score 2...pain type Acute pain, pain location chest...pain descriptors dull; Pressure pain onset On-going..."

A review of the facility document titled, "View Doc Flowsheet," dated July 22, 2025, at 8:20 a.m., indicated, "...pain assessment 0-10 pain score 7...pain type acute pain pain location chest...pain descriptors aching ..."

There was no documented evidence the physician was notified Patient 11 had chest pain.

A review of the facility document titled, "Rapid Response Note," dated July 22, 2025, indicated, "...Primary RN [Registered Nurse] called me to inform me that the pt [Patient 11] was about to be discharged and then started c/o [complaint of] chest pain. EKG [electrocardiogram, a test that records your hearts electrical activity] was performed showing changes compared to previous EKG and STEMI...I arrived and saw pt [Patient 11]...Pt [Patient 11] was c/o 9/10 chest pain..I called a rapid overhead just to initiate the process...I waited with Pt [Patient 11] until Unit 2 arrived which was within minutes. Pt [Patient 11] was awake and conversing, vitals stable, still having chest pain ...Unit 2 took pt [Patient 11] down...Once I arrived in Unit 2 with chart a code blue [a hospital emergency code indicating an adult patient with a life-threatening medical emergency] was called 1724 [5:24 pm]..."

A review of the facility document titled, "Discharge Summary," dated July 22, 2025, authored by MD 3, indicated, "...pt [Patient 11] became unresponsive...ACLS [Advanced Cardiac Life Support, advanced medical training to include airway management, medication administration, reading EKGs and using the defibrillator [a machine that shocks the heart into a normal heartbeat] protocol patient intubated, patient remained in pulseless electrical activity (PEA) [a condition where the heart shows electrical activity on an EKG, but there is no pulse or blood pressure], CPR [cardiopulmonary resuscitation, an emergency treatment that's done when someone's breathing or heartbeat has stopped] continued...Ultimately code was called off after 30 minutes and patient expired..."

On August 20, 2025, at 10:04 a.m., a review of the medical record and concurrent interview was conducted with Registered Nurse (RN) 10 and the director of Patient Care Services (DPS). RN 10 stated, the protocol if a patient has chest pain is to get a stat EKG, a set of vital signs and call the physician. RN 10 stated, on July 21, 2025, at 8:20 a.m., Patient 11 complained of chest pain and the physician was called but it wasn't documented. RN 10 stated a stat EKG and a rapid response was not called for Patient 11.

On August 21, 2025, at 2 p.m., an interview was conducted with MD 3. MD 3 stated any chest pain episode should be reported to the physician or the Residents who are caring for the patient. MD 3 stated the policy should have been followed to the letter and the Acute Coronary Syndrome Guideline is an accurate account of the practice that should have been followed.

3. On August 20, 2025, at 8:20 a.m., a review of Patient 12's record was conducted with the RS.

A facility document titled, "ED Provider Notes," dated July 19, 2025, at 12:33 p.m., was reviewed. The document indicated, Patient 12 was admitted to the ED with leg swelling and worsening discoloration to both legs for one week. Further review of the document indicated Patient 12 had a history of hypertension (high blood pressure) and CHF (congestive heart failure, a chronic condition in which the heart doesn't pump blood as well as it should).

A facility document titled, "Progress Notes," dated July 23, 2025, at 7:46 a.m., authored by Provider 1 was reviewed. The document indicated, " ...Pulmonary embolism [a condition where a blood clot travels to and blocks one or more arteries in the lungs]: Active-Noted on CT [Computed Tomography, known as a CAT scan is an imaging technique that uses X-rays to create detailed images of the body's internal structures] chest 7/22 [July 22]-Pulmonary [refers to the lungs] artery thrombectomy [a medical procedure that involves removing a blood clot from a blood vessel] performed 7/22 [July 22]- IVC filter [Inferior Vena Cava filter is a small, umbrella shaped metal device implanted in the large vein that carries blood from your lower body to your heart and lungs] placed 7/22 [July 22]..."

A review of the facility document titled, "Multidisciplinary Progress Note," dated July 25, 2025, at 8:02 p.m., was reviewed. The document indicated, "At 1821, [6:21 pm] Rapid response was activated, Patient [Patient 12] SOB [shortness of breath] at rest worsening, show breathing, currently on oxygen NC [nasal cannula, a thin flexible tube used to deliver oxygen directly into the nostrils] at 2L [liters, unit of measurement] at 98%, VSS [vital signs stable, physiological measurements such as temperature, blood pressure, heart rate and respiratory rate are normal]. Patient mildly anxious..."

On August 20, 2025, at 1p.m., a record review and concurrent interview was conducted with the Quality and Patient Safety Specialist 1 (QPSS) 1. The QPSS 1 stated, a rapid response code was called for Patient 12 due to breathing difficulty but there is no documentation on the rapid response template with the details what occurred. The QPSS 1 further stated there was no documented evidence family was notified of the rapid response and per the policy the family must be notified for any change in condition.

On August 21, 2025, at 4 p.m., an interview was conducted with the Rapid Response Nurse (RRN). The RRN stated the rapid response template must be filled out by the rapid response team or primary/charge nurse with an account of vital signs, medications given and patients response. The RRN stated the family must be notified of what happened during the rapid response and it must be documented.

A review of the facility's P&P titled, "Rapid Response Team Management for Adults," dated September 2023, indicated "...The Rapid Response Team is to facilitate necessary immediate care to patients in which a healthcare provider continues to have concerns about patient condition...Rapid Response Team Member Responsibilities: ...Speak with physician/family/employee about the situation...documentation using Code/Rapid Response Narrator in EMR [electronic medical record]..."