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The facility failed to fully analyze an adverse event and implement critical initial preventative measures following an incident that resulted in a patient death (Patient # 10).

The facility failed to:

1. Correct audibility of unit intercom in Intensive Care Unit (ICU) rooms 16-18.

2. Establish intercom availability in the staff break room and Respiratory Therapy office.

3. Educate Unit Secretary on ventilator response post-incident.

4. Effectively educate ICU staff regarding alarm response post incident.

5. Establish a documented monitoring system of ventilator alarm response.

6. Check audibility of ventilator alarms from room to room in ICU.

Findings include:

Intake # TX 00169135

Record review of Intake # TX 00169135 revealed Patient # 10 became disconnected from the ventilator on 11-05-12. According to the narrative, the physician visited his patient in the ICU on 11-05-12 at 5:25 p.m. and found the ventilator tube disconnected. The ventilator & cardiac monitor alarms were sounding. No staff was in attendance of patient.

Interview on 11-29-12 at 1:45 p.m. with Director of Respiratory Therapy (RT/ ID # 9) he stated that as part of the investigation process it was discovered the ventilator alarm had been sounding on Patient # 10 ventilator for 20 minutes on 11-05-12. He stated the supporting data was retrieved by the ventilator representative who was onsite at the time.

Interview on 11-30-12 at 2:20 p.m. with Staff ID # 4 she stated that she was the Acting Chief Nursing Offier (CNO) at the time of the incident and she and the Director of Respiratory Services were primarily responsible for the investigation of the incident. Staff ID # 4 stated the incident occurred on Monday 11-05-12; facility administration became aware of what actually happened on Tuesday 11-06-12. According to Staff ID # 4 initial measures taken were as follows: all ventilators & alarms in ICU were checked; all individuals associated with the event were suspended; and the RCA (Root Cause Analysis) Call Tree was initiated. RCA meetings were initiated, as well as conference calls to corporate officials. All staff involved in incident were interviewed; many were officially disciplined. Staff ID # 4 stated no one was terminated as a result of the incident.

During the same interview, Staff ID # 4 stated the facility determined " it was a horrible and unfortunate human error; the staff just didn't answer the alarms. " Actions taken by the facility in addition to the above included " alot of education."

Review of staff education and attendance records revealed the following:

Event Reporting/ Change of Condition All staff:
Alarm Response: ICU staff, Respiratory Therapy, MTs, and Supervisors
Serious/Sentinel Event Algorithm: Nursing Supervisors/leadership

Record review on 11-28-12 of attendance records/sign-in sheets revealed that education on the above policies remained on-going at the facility.

1 and 2: Audibility of intercom system

Record review on 11-29-12 of facility Root Cause Analysis (RCA) revealed the following identified causative factors

Equipment factors: "intercom not audible in some (ICU) rooms (16-18) in nurse's break room or RT office. "

Interview on 11-29-12 with ICU Coordinator (ID # 11) revealed the intercom system had not been worked on as yet, and not yet been extended to the break room or RT offices.

3. Unit Secretary Education

Interview on 11-30-12 at 940 a.m. with Unit Secretary (ID # 20) she stated she was on duty on 11-05-12 at the time of the incident involving Patient # 10. She went on to say she heard a loud alarm at the desk that sounded like " Pac-Man " that day but ignored it. She reported that she had been told a long time ago that this alarm was related to the computer and " not to worry about it. " Unit Secretary # 20 said she could not recall the name of the person who told her this. She went on to say she had not received education at the facility regarding the ventilator alarms since the incident happened. Staff ID # 20 said she " took it upon myself to ask an RT to explain it so it would not happen again."

Record review on 11-28-12 of attendance records/sign-in sheets (dated 11-08-12, 11-09-12, 11-10-12, 11-16-12, and 11-19-12) failed to reveal that Unit Secretary (ID # 20) had attended any of the in-services following the incident.

4: Staff Education

On 11-27-12 and 11-28-12, seven (7) licensed ICU nurses (ID # 6, 7, 8, 15, 16, 17, and 18) were interviewed. The nurses were asked about their knowledge of the recent incident involving the ventilator alarms and if any new processes had been put in place following the incident:

Two (2) nurses (ID # 16, # 17) stated the process for ventilator alarm response had changed recently: it was new for the monitor tech and the unit secretary to announce patient alarms over the intercom system.

Five (5) nurses (ID # 6, # 7, # 8, # 15, # 18) reported there were no new process put in place regarding ventilator alarm response.

Interview on 11-27-12 at 12:50 p.m. with ICU Unit Coordinator (ID # 11) he stated following the incident with Patient # 10, all ICU staff was in-serviced regarding : Sentinel Events Reporting, Change of Condition, and Alarm Response. He went on to say there were no changes made in any policies or processes; education was based on reinforcing existing policies.

ICU Coordinator (ID # 11) went on to say the staff was informed that responding to alarms was " everyone's job and they were not to be ignored. " ICU Coordinator ( ID # 11) provided the education material used for the "Alarm Reponses " in-services: a flow chart tiled " Telemetry Interruption Algorithm. " The algorithm detailed the steps for staff to follow when the monitor showed that leads were off and there was a telemetry interruption. ICU Coordinator ID # 11 acknowledged this flow chart did not describe the process for response to ventilator alarms in the ICU.

5.

Interview on 11-30-12 at 3: 25 p.m. with Staff ID # 4 she stated the house supervisors made rounds and observations but she was unsure if there was documentation.

Interview on 11-30-12 at 3:40 p.m. with House Supervisor (ID # 21) she stated there was no official documentation of on-going alarm response monitoring. She went on to say if there was a problem identified with alarm response on rounds, it would be documented and reported.

6.

Observation on 11-28-12 at 2:00 p.m. was made of audibility of ventilator alarms in the ICU from room-to-room.

Per surveyor request, Director of RT (Staff ID # 9) set up a ventilator in empty ICU room # 18 and sounded the ventilator alarm .CNO (staff ID # 2) and surveyor observed alarm audibility in ICU room # 17 . CNO (Staff ID # 2) acknowledged the " alarm was audible bur muffled. "

Director of RT (Staff ID # 9) acknowledged the ventilator alarm was not as loud as he thought it would be. In addition, he stated that after the incident, he and Staff ID # 4 checked that all ventilator alarms were set at the loudest volume possible. He went on to say the facility had not checked the ventilator alarm audibility from room-to-room.

Record review of facility policy titled " Investigating Serious and Sentinel Events, " dated 06-2011, read: " ...each event is analyzed for improvement opportunities using a systems approach ...and safe work habits, such as through competencies ...safe communication and specialized skills ... "

Based on observation, interview and record review, the nursing staff failed to supervise and evaluate care of 5 of 14 sampled patients (Patient ID# 1, 4, 5, 7 and 9). Nursing staff failed to: provide oral care and grooming, follow facility's policy on skin assessment and physician orders on wound care.
Findings include:
TX00167724
Observation on 11/28/12 at 9:05 am of Patient ID# 1 during initial hospital tour revealed poor oral care and grooming. Patient had long and dirty finger and toe nails, and dry lips. Patient ' s nurse Staff ID# 28 who was at the bedside acknowledged that patient needed oral and nail care. Interview with Patient # 1's daughter at the time of observation, she stated that she had complained about her mother's poor oral care in the past and it was better but it still needed some improvement.
Observation of Patient ID# 4 on 11/28/12 at 9:25 am during the hospital tour revealed that patient was totally care dependent and was noted with long and dirty finger nails. Further observation revealed several scratch marks to the left inner knee area .
Observation of Patient ID# 5 on 11/28/12 at 9:55 am during the hospital tour, revealed patient had dirty teeth, dry lips, dry and flaky skin on the legs, and dirty nails. Patient stated that staff assisted with bathing two times a week, and it" had been a while" since staff helped with brushing his teeth. Patient spat out corn kernels while talking with the surveyors.
Interview with Staff ID# 13, Nurse Manager for Medical Surgical Unit 1 on 11/28/12 during the tour of the hospital, she acknowledged that the patients ' oral care and grooming was unacceptable as observed.
Record review of medical records for Patient ID# 7 on 11/29/12 revealed 61 year old female was admitted on 7/30/12 with the diagnoses: Acute Respiratory Failure, Gram-negative Septicemia, Acute Renal Failure and Encephalopathy. Admission nursing assessment revealed that patient was completely immobile and totally dependent. Skin assessment showed perineal redness and right upper extremity bruises on admission. Skin assessment on 7/31/12 at 10:00 am by wound care nurse revealed blanchable redness to left heel. No assessment of the heel redness on the nursing flow sheet from 7/30/12 - 8/1/12.
Physician order dated 7/31/12 at 0750 read " heel protectors per wound care protocol.". No record of heel protectors from 7/31/12 - 8/2/12. Patient developed a stage II ulcer in the left heel by 8/8/12. Further record review revealed the following missed skin assessment: morning shift: 8/11/12, 8/12/12 and 8/14/12, evening shift: 8/10/12, and 8/13/12. Patient's record was reviewed with Staff ID# 24. On 11/30/12 at 3:40 pm, Staff ID# 3, Director of Quality Management was unable to locate documentation that indicated heel protectors were applied from 7/31/12-8/2/12.

Record review of medical records for Patient ID# 9 on 11/29/12 revealed she was a 68 years old and admitted on 8/2/12 with the diagnoses: Renal failure, Diabetes type II and acute renal failure. Patient # 9 was post right below the knee amputation and also had a left foot ulcer. Wound care order dated 8/3/12 at 10:20 am read " apply adaptic dressing to incision, foam dressing, abdominal pad and kerlix and tape to secure, change once daily. Apply dry dressing to left heel, kerlix and tape to secure. Prevelon boots to left heel at all times." Further review of the record failed to reveal documentation of wound care on 8/5/12 and 8/7/12 .Record reviewed with Staff ID# 24 on 11/29/12. Staff ID# 26 ,Wound Care Nurse on 11/30/12 at 2:00 pm was unable to locate documentation of wound care on 08/05/12 and 08/07/12 .
Record review of medical record for Patient ID# 1 on 11/29/12 revealed she was 82 years old and admitted on 11/18/12 with diagnosis: Cellulitis NOS peg site. She had partial thickness skin loss coccyx and mid upper abdominal surgical incision. During recorded review on 11/29/12 ,Staff ID # 24 was unable to locate documentation of nursing skin assessment on 11/19/12 and 11/20/12 for the evening shift per facility policy.
Record review on 11-29-12 of facility policy titled " Oral Hygiene " dated 02/2012, read"" Patients will receive oral hygiene at a minimum twice a day in the morning and in the evening " . Review of facility policy titled" Skin and Wound Care Team ," dated 05/2012 revealed nursing will perform initial skin/wound upon admission and on each shift, and carry out routine treatment, including dressing changes as ordered.