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Based on medical record review, physician and staff interviews, the nursing staff failed to follow physician orders in applying continuous positive airway pressure (CPAP) in 1 of 5 patients reviewed. (Patient #6).

The findings include:

Requested policy on 11/06/2024 revealed was not available for review.

Closed medical record review on 11/06/2024 revealed Patient #6, a 56-year-old female transferred on 08/31/2024 at 0150 for rehabilitation for acute on chronic respiratory failure with hypoxia (low levels of oxygen), a chronic tracheostomy (surgical airway opening in the trachea), acute pneumonia (infection in the lung) with Obstructive Sleep Apnea (upper airway collapses repeatedly causing low oxygen levels). Review of the History and Physical on 08/31/2024 at 0453 by Rehabilitation (rehab) Medical Doctor (MD) #1 revealed "... She has a primary rehab impairment classification of pulmonary with acute diagnoses including acute on chronic respiratory failure with hypercapnia (carbon dioxide retention) and hypoxia, tracheostomy, pneumonia, diabetes type II (high sugar levels in the blood), hypertension (high blood pressure), hyperglycemia (high blood sugar), intellectual disability (cognitive delay), and severe hiatal hernia (part of the stomach bulges into the chest). ... Abnormalities of gait, ADLs (activities of daily living), and mobility, impaired balance, decreased strength, endurance, activity tolerance, the patient continues to require 24-hour nursing and physician availability...." Review of the admission Physician Orders revealed on 08/30/2024 at 2002, Rehab Doctor of Osteopathic Medicine (DO) #2 ordered CPAP, Respiratory therapy to treat and evaluate, incentive spirometry, and oxygen 2 liters per nasal cannula for Patient #6. The respiratory evaluation was completed 08/31/2024 at 1518 by Respiratory Therapist (RT) #3, "... Patient still has a pinhole stoma. Patient had removed oxygen at some point this morning, SPO2 (oxygen saturation) via ear proe [sic] 70% (normal 95-100%), placed back on 2.0 L/ Nasal Cannula SPO2 96%. Stoma (surgically created opening in the neck) cleaned and dressed with foam dressing. Spoke with mom and explained stoma (sic) and that CPAP will be set up in about four days to allow the stoma to heal. Mom stated she understood. Respiratory will continue to monitor... " Review of the medical record on 08/31/2024, 09/01/2024, 09/02/2024, 09/03/2024, 09/04/2024 revealed the physician CPAP ordered 08/30/2024 was not implemented or changed. On 09/05/2024 at 0806 RT #3 documented "... CPAP set up and sterile water placed, placed on CPAP while sleeping ..." Review failed to reveal communication to update the physician on the CPAP ordered 08/31/2024 through 09/05/2024. Review of the medical record failed to reveal Patient #6 had CPAP applied at bedtime on 09/05/2024 by nursing staff. Review of the Discharge Summary dated 09/06/2024 at 1144 by Rehab DO #2 revealed " ... At approximately 5 AM on 09/06/2024 patient was found in room with no pulse at that time CPR (cardiopulmonary resuscitation) was administered for 30 minutes, with no return of spontaneous circulation. ...Condition at the time of discharge: deceased." Patient #6's discharge disposition was to the funeral home on 09/06/2024 at 1230. Review of the medical record failed to reveal physician orders for CPAP were followed for Patient #6.

Interview on 11/07/2024 at 0803 with Licensed Practical Nurse (LPN) #6 revealed "... the CPAP was not on because the outgoing nurse reported she (Patient #6) was always removing it. ..." The interview revealed LPN #6 did not apply the CPAP on 09/05/2024 - 09/06/204 for Patient #6 during sleep. The interview revealed LPN #6 did not notify the Physician of not applying the CPAP as ordered. The interview revealed Physician orders were not followed for Patient #6.

Interview on 11/07/2024 at 1040 with the Chief Medical Officer, (CMO) #4 revealed "... the Physician should be notified when physician orders for CPAP cannot be completed, absolutely. ..." The interview revealed if physician orders for CPAP cannot be implemented when ordered, the physician should be notified to ensure patient care options can be evaluated as needed. The interview revealed physician orders for CPAP for Patient #6 were not followed.

Interview on 11/07/2024 at 1300 with the Chief Nursing Officer (CNO) #5 revealed "... this CPAP order was an incomplete order. This order would not generate any work tasks for the nursing staff to address. If an order was not clear, the Nurse should call the Physician for clarification. ..." The interview revealed if the CPAP order for Patient #6 needed clarification of when the CPAP was to be administered, the Nurse should contact the Physician to clarify the order, and/or let the Physician know the CPAP was not applied as ordered. The interview revealed Physician Orders for Patient #6 was not followed by the Nurse.

NC00222350

Based on medical record review, physician and staff interviews, the nursing staff failed to document nursing notes following a code blue event, physician notification and/or a disposition for Patient #6. And failed to document reports of CPAP (continuous positive airway pressure) treatments ordered in 5 of 5 medical records reviewed. (Patient #5, Patient #6, Patient #9, Patient #10, and Patient #11)

The findings include:

Requested policy on 11/07/2024 revealed was not available for review.

1. Open medical record review 11/07/2024 revealed Patient #5, an 84-year-old female admitted on 10/28/2024 at 1410 to rehabilitation for impaired immobility status post subdural hematoma (bleeding near the brain). Review of the Admission Physician Orders dated 10/28/2024 at 1515 revealed Patient #5 was ordered "CPAP" by Chief Medical Officer (CMO) #4. Review of the Nursing Assessment and Flowsheet revealed 10/30/2024 - 11/05/2024 (7 days) no reports of CPAP treatment were documented by the nursing staff. Review revealed 7 out of 7 days reviewed, nursing staff failed to document CPAP treatments for Patient #5.

Interview on 11/06/2024 at 1637 with Charge Nurse #6 revealed they were assigned to be Patient #5's nurse 1900-2100 (2 hrs.) on 10/30/2024. The Nurse and Respiratory Therapist completes CPAP ordered. ...Respiratory is not scheduled midnight (0000) to 0600. ..." The interview revealed the nurse assigned completes all respiratory care when the respiratory therapist was not working. The interview revealed Charge Nurse #6 did not apply CPAP for Patient #5 while assigned.

Interview on 11/07/2024 at 1300 with the Chief Nursing Officer #5 revealed "... CPAP care was a treatment ordered and should be documented by the nurse. Documentation and clarifying orders around CPAP is an opportunity for us. I round all shifts, CPAP's are applied by Nursing staff as ordered. ..." The interview revealed CPAP treatment ordered for Patient #5 was not documented by the nurse.

2. Policy review on 11/06/2024 of Resuscitation and Evaluation, last reviewed 09/19/2024 revealed "...Purpose. Define process to follow when resuscitation becomes necessary. Policy ... Nurse assigned to the patient 1. Completes medical record of event and patient transfer/disposition in the medical record. ..."

Closed medical record review on 11/06/2024 revealed Patient #6, a 56-year-old female transferred on 08/31/2024 at 0150 for rehabilitation for acute on chronic respiratory failure with hypoxia (low levels of oxygen), tracheostomy (surgical airway opening in the trachea), and pneumonia (infection in the lung) and Obstructive Sleep Apnea (upper airway collapses repeatedly causing low oxygen levels). Review of the Admission Physician Orders revealed on 08/30/2024 at 2002, Rehab Doctor of Osteopathic Medicine (DO) #2 ordered "CPAP" for Patient #6. A Respiratory Evaluation was completed 08/31/2024 at 1518 by Respiratory Therapist (RT) #3, "... Patient still has a pinhole stoma. Patient had removed oxygen at some point this morning, SPO2 (oxygen saturation) via ear proe [sic] 70% (normal 95-100%), placed back on 2.0 L (liters)/ Nasal Cannula SPO2 (oxygen) 96%. Stoma (surgically created opening in the neck) cleaned and dressed with foam dressing. Spoke with mom and explained stoma and that (sic) CPAP will be set up in about four days to allow the stoma to heal. Mom stated she understood. respiratory will continue to monitor..." Review failed to reveal documentation of communication with a physician to update the existing CPAP treatment ordered. Review failed to reveal documentation of reports of CPAP treatment ordered 08/31/2024 through 09/04/2024 by the nurse. On 09/05/2024 at 0806 RT #3 documented "... CPAP set up and sterile water placed, placed on CPAP while sleeping ..." Review failed to reveal nursing documentation on 09/05/2024, Patient #6's CPAP was applied/not applied as ordered. (7 of 7 days). Review of the Discharge Summary dated 09/06/2024 at 1144 by Rehab DO #2 revealed " ... At approximately 5AM on 09/06/2024 patient was found in room with no pulse at that time CPR (cardiopulmonary resuscitation) was administered for 30 minutes, with no return of spontaneous circulation. ...Condition at the time of discharge: deceased." Review of the record failed to reveal nursing notes documented of the event (finding Patient #6 unresponsive) by LPN #6 assigned, notification of a physician, or notification of the family. Patient #6's discharge disposition was to the funeral home on 09/06/2024 at 1230.

Interview on 11/07/2024 at 0803 with Licensed Practical Nurse (LPN) #6 revealed he was the assigned nurse of Patient #6 on 09/05/2024 1900 through 09/06/2024 0700. The interview revealed "... the CPAP was not on because the outgoing nurse reported (Patient #6) was always removing it. ..." The interview revealed LPN #6 did not apply the CPAP on 09/05/2024 - 09/06/204 for Patient #6 during sleep as ordered. The interview revealed LPN #6 did not document applying the CPAP as ordered. The interview revealed LPN #6 did notify a physician of the Code Blue event, with a voice mail once the event was over, and did notify the family by telephone, however, did not document any of the care he provided for Patient #6 in the medical record during the event in which Patient #6 died.

Interview on 11/07/2024 at 1040 with the Chief Medical Officer, (CMO) #4 revealed "... the Physician should be notified when physician orders for CPAP cannot be completed, absolutely. ..." The interview revealed if physician orders for CPAP cannot be implemented when ordered, the physician should be notified to ensure patient care options can be evaluated as needed. The interview revealed physician communication should be documented in the medical record.

Interview on 11/07/2024 at 1300 with the Chief Nursing Officer #5 revealed "... CPAP care was a treatment ordered and should be documented by the nurse. Documentation and clarifying orders around CPAP is an opportunity for us. I round all shifts, CPAP's are applied by Nursing staff as ordered. ..." The interview revealed CPAP treatment ordered for Patient #6 was not documented by the nurse.

3. Open medical record review 11/06/2024 revealed Patient #9, a 72-year-old female patient admitted to rehabilitation on 10/25/2024 at 1200 for Septic Arthritis (painful infection in the joint). Review of the Admission Physician Orders dated 10/25/2024 at 1527 revealed Patient #9 was ordered "CPAP" by CMO #4. Review of the Nursing Assessment and Flowsheet revealed 10/25/2024 - 10/28/2024 (4 days), 10/31/2024 - 11/05/2024 (6 days), no reports of CPAP treatment were documented by the nursing staff. Review revealed 10 out of 13 days reviewed, nursing staff failed to document CPAP treatments ordered for Patient #9.

Interview on 11/07/2024 at 1300 with the Chief Nursing Officer #5 revealed "... CPAP care was a treatment ordered and should be documented by the nurse. Documentation and clarifying orders around CPAP is an opportunity for us. I round all shifts, CPAP's are applied by Nursing staff as ordered. ..." The interview revealed CPAP treatment ordered for Patient #9 was not documented by the nurse.

4. Open medical record review 11/07/2024 revealed Patient #10, a 77-year-old female patient admitted to rehabilitation on 11/04/2024 at 1555 for Acute Congestive Heart Failure (the heart can't pump blood well enough) and Chronic Obstructive Pulmonary Disease (lung disease that blocks airflow, making it difficult to breathe). Review of the Admission Physician Orders dated 11/05/2024 at 1250 revealed Patient #10 was ordered "CPAP" by CMO #4. Review of the Nursing Assessment and Flowsheet revealed 11/04/2024 through 11/05/2024 (2 days), no reports of CPAP treatment were documented by the nursing staff. Review revealed 2 out of 3 days reviewed, nursing staff failed to document CPAP treatments ordered for Patient #10.

Interview on 11/07/2024 at 1300 with the Chief Nursing Officer #5 revealed "... CPAP care was a treatment ordered and should be documented by the nurse. Documentation and clarifying orders around CPAP is an opportunity for us. I round all shifts, CPAP's are applied by Nursing staff as ordered. ..." The interview revealed CPAP treatment ordered for Patient #10 was not documented by the nurse.

5. Open medical record review 11/07/2024 revealed Patient #11, an 80-year-old male patient admitted to rehabilitation on 10/30/2024 at 1915 for Atrial Fibrillation (irregular heart rhythm), chronic indwelling catheter, Diabetes (high blood sugar), and Obstructive Sleep Apnea (upper airway collapses during sleep causing low oxygen levels). Review of the Admission Physician Orders dated 10/31/2024 at 1003 revealed Patient #11 was ordered "CPAP" by Rehab Physician, DO #2. Review of the Nursing Assessment and Flowsheet revealed 10/31/2024 - 11/01/2024 (2 days), and 11/03/2024 - 11/05/2024 (3 days), no reports of CPAP treatment were documented by the nursing staff. Review revealed 5 out of 7 days reviewed, nursing staff failed to document CPAP treatments ordered for Patient #11.

Interview on 11/07/2024 at 1300 with the Chief Nursing Officer #5 revealed "... CPAP care was a treatment ordered and should be documented by the nurse. Documentation and clarifying orders around CPAP is an opportunity for us. I round all shifts, CPAP's are applied by Nursing staff as ordered. ..." The interview revealed CPAP treatment ordered for Patient #11 was not documented by the nurse.

NC00222350