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Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation (CoP) for Nursing Services. The deficient practice was evidenced by:
1) failure of nursing staff to document vital signs as ordered by the physician and/or hospital policy for 3 (#1-#3) of 3 (#1-#3) patient medical records reviewed (see findings in A0395);
2) failure of nursing staff to document hourly neuro checks as ordered by the physician for 1 (#2) of 3 (#1-#3) patient medical records reviewed (see findings in A0395);
3) failure to document hourly level of consciousness for 2 (#1, #3) of 2 (#1, #3) patient's reviewed receiving Continuous Renal Replacement Therapy (CRRT) per hospital policy (see findings in A0398); and
4) failure of nursing staff to document a physician notification for alterations in vital signs that represent a deteriorating patient condition for 2 (#2, #3) of 3 (#1-#3) patient medical records reviewed per hospital policy (see findings in A0398).

50453


Based on record review and interview, the governing body failed to ensure contracted services were provided in a safe and effective manner. This deficient practice is evidenced by failing to ensure contracted services are following hospital policy for the services provided in 2 (#1, #3) of 2 (#1, #3) patient records reviewed who received Continuous Renal Replacement Therapy (CRRT).
Findings:

Review of hospital policy # Critical Care 12, titled, "Critical Care Continuous Renal Replacement Therapy," last revised: 09/2021, revealed in part: "STANDARD OF PROFESSIONAL PRACTICE: Both the Critical Care Registered Nurse and the Dialysis/Renal Registered Nurse are responsible to monitor the patient's vital signs and mechanical operation of the CRRT machine during the first hour of CRRT therapy. Thereafter, it is the responsibility of the Critical Care Registered Nurse to monitor the patient, the CRRT machine and efficacy of CRRT treatment. Procedures: PRETREATMENT: The Critical Care Nurse and Dialysis/Renal Nurse are responsible for the following: iv. Hemodynamically assess patient: vital signs, fluid status, level of consciousness, and weight of patient before treatment. INITIATING THERAPY: iv. Both the Critical Care Registered Nurse and the Dialysis/Renal Registered Nurse are responsible for monitoring the patient's vital signs during the first hour of therapy. DURING THERAPY: i. Hemodynamically monitor patient - vital signs, fluid status, and level of consciousness on an hourly basis. v. Calculate I&O's each hour and set the ultrafiltration rate on the CRRT machine to meet the UF goal of the patient. Documentation: Documentation of CRRT is performed hourly in the EMR. The following parameters must be documented every hour: Arterial Pressure, Venous Pressure, Effluent Pressure, UF Rate, Therapy Fluid Potassium Bath, Blood Flow Rate, All I&O's are documented under the Input and Output Flowsheet. Based upon the I&O's that hour the nurse calculates the goal UF to program on the CRRT machine."

Review of Patient #1's CRRT Initiation Therapy Report revealed in part the following documentation by the dialysis nurse:
Arrival Date/Time: 05/01/2025 at 11:30 PM.
Timeout Date/Time: 05/01/2025 at 11:30 PM.
Pre-Therapy Vitals Date/Time: 05/01/2025 at 11:30 PM.
Therapy Start Date/Time: 05/01/2025 at 11:30 PM.
Post Report Date/Time: 05/01/2025 at 11:30 PM, report given to critical care nurse.
Departure Date/Time: 05/02/2025 at 12:30 AM.

In an interview on 05/07/2025 at 3:36 PM, S11DN confirmed he was able to recall initiating CRRT on Patient #1. S11DN further verbalized that he stayed with this patient for 20-30 minutes and then reported care off to the critical care nurse. S11DN stated that when he initiates CRRT on a patient that vital signs are obtained every 15 minutes.

In an interview on 05/08/2025 at 9:28 AM, S3RM confirmed the policy states the dialysis nurse and Critical Care nurse should remain with the patient for the first hour of CRRT after initiation. S3RM confirmed that S11DN documented he stayed with Patient #1 for the first hour of CRRT. S3RN further confirmed that during the interview with S11DN, S11DN verbalized he only remained with the Patient #1 for 20-30 minutes.

Review of Patient #3's CRRT Initiation Therapy Report revealed in part the following documentation by the dialysis nurse:
Arrival Date/Time: 05/03/2025 at 6:27AM.
Timeout Date/Time: 05/03/2025 at 6:27AM.
Pre-Therapy Vitals Date/Time: 05/03/2025 at 6:27AM.
Therapy Start Date/Time: 05/03/2025 at 6:27AM.
Post Report Date/Time: 05/03/2025 at 6:27AM, report given to critical care nurse.
Departure Date/Time: 05/03/2025 at 7:00 AM.
Further review revealed documentation that the dialysis nurse only remained with Patient #3 for 33 minutes after initiating CRRT.

In an interview on 05/08/2025 at 1:39 PM, S7CSM confirmed that the dialysis nurse did not remain with Patient #3 for the entire first hour after initiating CRRT per policy.

50453


Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:
1) failure of nursing staff to document vital signs as ordered by the physician and/or hospital policy for 3 (#1-#3) of 3 (#1-#3) patient medical records reviewed; and
2) failure of nursing staff to document hourly neuro checks as ordered by the physician for 1 (#2) of 3 (#1-#3) patient medical records reviewed.
Findings:

1) Failure of nursing staff to document vital signs as ordered by the physician for 3 (#1-#3) of 3 (#1-#3) patient medical records reviewed.

Review of hospital policy number Critical Care 13, titled "Critical Care General Nursing Care," last reviewed 10/2024, revealed in part: "Purpose: This policy is intended to outline how general nursing care will be delivered to all patients within critical care units. The outcome of this policy will be delivery of excellent nursing care to all patients within critical care units. Procedure: VITAL SIGNS: blood pressure, pulse, respiratory rate, and O2 saturation will be taken and documented on admission, then every hour for at least 24 hours. Temperatures will be taken on admission, and then every four hours. Hourly temperatures are required for patients with a temperature less than 36C or greater than 38C and for those on cooling blankets or warming devices."

Patient #1
Review of Patient #1's medical record revealed Patient #1 was a 52 year old male admitted to ICU on 04/30/2025 at 3:16 PM for Post-Cardiac Arrest Management. Review of Patient #1's vital signs revealed the following:
04/30/2025
4:00 PM: HR 122, RR 15, 97% O2, no BP or temperature documented.
5:00 PM: HR 126, RR 24, Temperature 93.6F (34.2C), no BP or O2 documented.
6:00 PM: HR 121, RR 24, Temperature 93.2F (34C), no BP or O2 documented.
7:00 PM: HR 118, RR 24, Temperature 93F (33.9C), BP 104/90, no O2 documented
8:00 PM: HR 114, RR 24, Temperature 91.4F (33C), BP 108/97, no O2 documented
9:00 PM: HR 108, RR 24, Temperature 90.5F (32.5C), BP 123/106, no O2 documented
05/01/2025
12:00 AM: HR 111, RR 23, Temperature 92.7F (33.7C), BP 151/100, no O2 documented
3:00 AM: HR 113, R 24, Temperature 95.4F (35.2C), BP 105/88, no O2 documented
4:00 AM: HR 110, RR 24, Temperature 96.1F (35.6C), BP 97/58, no O2 documented
5:00 AM: HR 110, RR 24, Temperature 96.4F (35.8C), BP 94/79, no O2 documented
6:00 AM: HR 97, RR 24, Temperature 97.2F (36.2C), BP 101/74, no O2 documented
7:00 AM: HR 95, RR 24, Temperature 97.5F (36.4C), BP 98/67, no O2 documented
8:00 AM: HR 96, RR 24, Temperature 97.7F (36.5C), no BP or O2 documented
9:00 AM: HR110, RR 24, Temperature 97.7F (36.5C), BP 84/29, no O2 documented
10:00 AM: HR 104, RR 24, Temperature 97.7F (36.5C), no BP or O2 documented
11:00 AM: HR 106, RR 24, Temperature 97.7F (36.5C), BP 94/77, no O2 documented
12:00 PM: HR 98, RR 24, Temperature 97.5F (36.4C), BP 110/79, no O2 documented
1:00 PM: HR111, RR 24, Temperature 96.8F (36C), no BP or O2 documented
2:00 PM: HR 112, RR 24, Temperature 97.2F (36.2C), BP 95/59, no O2 documented
3:00 PM: HR 108, RR 24, Temperature 95.9F (35.5C), BP 94/71, no O2 documented
4:00 PM: HR 105, RR 24, Temperature 97F (36.1C), BP 98/85, no O2 documented
5:00 PM: HR 105, RR 24, Temperature 97F (36.1C), BP 82/31, no O2 documented
6:00 PM: HR 107, RR 24, Temperature 96.8F (36C), BP 88/53, no O2 documented
7:00 PM: HR 109, RR 24, Temperature 96.8F (36C), no BP or O2 documented
9:00 PM: HR 112, RR 24, BP 119/90, O2 95%, no temperature documented
10:00 PM: HR 115, RR 28, O2 95%, no BP or temperature documented
11:00 PM: HR 97, RR 22, BP 104/78, O2 95%, no temperature documented
05/02/2025
12:00 AM: HR 86, RR 24, Temperature 95F (35C), O2 92%, no BP documented
1:00 AM: HR 93, RR 24, Temperature 95.1F (35.1C), O2 90%, no BP documented
2:00 AM: HR 92, RR 28, BP 101/63, O2 90%, no temperature documented
3:00 AM: HR 97, RR 28, no BP, O2, or temperature documented
4:00 AM: HR 87, RR 28, Temperature 95.2F (35.1C), O2 90%, no BP documented
5:00 AM: HR 41, RR 0, no BP, O2, or temperature documented

Further review of Patient #1's medical record revealed documentation by provider at 1:33 AM on 05/02/2025 a code blue was called a response to Patient #1's cardiac arrest. Patient #1 underwent manual CPR compressions until 1:39 AM, when a pulse check revealed a sinus rhythm of 94 beats per minute and return to spontaneous circulation was declared. Patient #1 was given 3 rounds of epinephrine at 1:34 AM, 1:36 AM, 1:39 AM. Patient was provided with 2 amps of Bicarb at 1:35 AM, 1:36 AM, Calcium chloride was given at 1:37 AM.
On 05/02/2025 at 4:02 AM Patient #1 was palliatively extubated and subsequently expired at 5:45 AM.

In an interview on 05/08/2025 at 11:15 AM, S7CSM confirmed the above mentioned findings. S7CSM also verified that blood pressure, pulse, respiratory rate, and O2 saturation should be documented each hour when obtaining vital signs.

Patient #2
Review of Patient #2's medical record revealed Patient #2 was a 37 year old male admitted to ICU on 05/02/2025 at 8:41 PM for Sepsis with Acute Organ Dysfunction and Encephalopathy. A physician order to start Q1H vital signs was entered on 05/02/2025 at 8:00 PM.
Review of Patient #2's vital signs revealed the following:
05/02/2025
9:00 PM: BP 93/57, HR 104, RR 18, 100% O2, temperature 95F (35C).
10:00 PM: BP 78/58, HR 105, RR 18, 99% O2, no temperature documented.
11:00 PM: BP 95/51, HR 108, RR 22, 100% O2, no temperature documented.
05/03/2025
12:00 AM: BP 107/50, HR 109, RR 19, 100% O2, no temperature documented.
1:00 AM: BP 74/44, HR 112, RR 19, 100% O2, no temperature documented.
2:00 AM: BP 79/43, HR 119, RR 21, 100% O2, no temperature documented.
3:15 AM: BP 123/96, HR 122, RR 28, no O2 saturation or temperature documented.
4:00 AM: BP 94/69, HR 137, RR 26, 100% O2, no temperature documented.
5:00 AM: BP 96/77, HR 147, RR 26, no O2 saturation or temperature documented.

Further review of Patient #2's medical record revealed documentation by the provider that a rapid response was called 05/03/2025 at 5:35 AM. Patient #2 received CPR and 2 rounds of epinephrine. Time of Death was called on 05/03/2025 at 5:49 AM.

Review of Patient #2's vital signs failed to reveal that a repeat temperature was obtained or documented after 9:00 PM on 05/02/2025. The last O2 saturation documented on Patient #2 was 05/03/2025 at 4:00 AM. Further review failed to reveal that a complete set of vital signs were obtained per physician order and policy.

In an interview on 05/08/2025 at 11:54 PM, S7CSM confirmed the above mentioned findings. S7CSM also verified that blood pressure, pulse, respiratory rate, and O2 saturation should be documented each hour when obtaining vital signs.

Patient #3
Review of Patient #3's medical record revealed Patient #3 was a 65 year old male who was admitted for a Pulmonary Embolism on 04/29/2025. Patient #3 was moved to ICU on 05/02/2025 at 10:00 PM and was intubated and placed on vasoactive IV medication for hypotension and elevated lactic acidosis. On 05/03/2025 at 6:27 AM CRRT was initiated on Patient #3. Review of Patient #3's vital signs revealed the following:
05/05/2025:
12:00 AM: BP 76/54, HR 90, RR 31, 95% O2, 96.3F (35.7C) temperature.
1:00 AM: BP 96/75, HR 97, RR 31, 93% O2, 95.7F (35.4C) temperature.
2:00 AM: no BP documented
3:00 AM: no BP documented
4:00 AM: BP 63/15, HR 89, RR 25, 93.7F (34.3C) temperature, no O2 saturation documented.
Further review of Patient #3's vital signs failed to reveal a repeat documented blood pressure after 4:00 AM on 05/05/2025 or a repeat O2 saturation after 3:00 AM on 05/05/2025.

Patient #3's medical record revealed on 05/05/2025 at 8:13 AM that the patient went into cardiac arrest and CPR was initiated. Patient #3 expired on 05/05/2025 at 8:42 AM.

In an interview on 05/08/2025 at 2:25 PM, S7CSM confirmed the above mentioned findings. S7CSM also verified that blood pressure, pulse, respiratory rate, and O2 saturation should be documented when obtaining vital signs.


2) Failure of nursing staff to document hourly neuro checks as ordered by the physician for 1 (#2) of 3 (#1-#3) patient medical records reviewed.

Patient #2
Review of Patient #2's medical record revealed Patient #2 was admitted to ICU on 05/02/2025 at 8:41 PM. Further review of Patient #2's medical record revealed a physician order for Q1H Neuro checks entered on 05/02/2025 at 9:00 PM.
Review of Patient #2's nursing assessments revealed the following documented neurological assessments:
05/02/2025 at 9:00 PM.
05/03/2025 at 12:00 AM and 4:00 AM.
Further review failed reveal a neurological assessment documented on Patient #2 for the following times:
05/02/2025 at 10:00 PM or 11:00 PM.
05/03/2025 at 1:00 AM, 2:00 AM, 3:00 AM, or 5:00 AM.

In an interview on 05/08/2025 at 11:50 AM, S7CSM confirmed the above mentioned findings. S7CSM also confirmed neurological checks were not obtained every hour per physician order for Patient #2.

50453


Based on record review and interview, the hospital failed to ensure licensed nurses adhered to policies and procedures of the hospital as evidenced by:
1) failure to document hourly level of consciousness for 2 (#1, #3) of 2 (#1, #3) patient's reviewed receiving Continuous Renal Replacement Therapy (CRRT) per hospital policy; and
2) failure of nursing staff to document a physician notification for alterations in vital signs that represent a deteriorating patient condition for 2 (#2, #3) of 3 (#1-#3) patient medical records reviewed per hospital policy.
Findings:

1) Failure to document hourly level of consciousness for 2 (#1, #3) of 2 (#1, #3) patient's reviewed receiving Continuous Renal Replacement Therapy (CRRT) per hospital policy.

Review of hospital policy # Critical Care 12, titled, "Critical Care Continuous Renal Replacement Therapy," last revised: 09/2021, revealed in part: "STANDARD OF PROFESSIONAL PRACTICE: Both the Critical Care Registered Nurse and the Dialysis/Renal Registered Nurse are responsible to monitor the patient's vital signs and mechanical operation of the CRRT machine during the first hour of CRRT therapy. Thereafter, it is the responsibility of the Critical Care Registered Nurse to monitor the patient, the CRRT machine and efficacy of CRRT treatment. Procedures: PATIENT ASSESSMENT AND MONITORING: The standard nurse to patient ration for patients receiving CRRT will be 1 nurse to 1 patient. This ratio can only be altered by the ICU nurse director based on patient safety considerations. PRETREATMENT: The Critical Care Nurse and Dialysis/Renal Nurse are responsible for the following: iv. Hemodynamically assess patient: vital signs, fluid status, level of consciousness, and weight of patient before treatment. INITIATING THERAPY: iv. Both the Critical Care Registered Nurse and the Dialysis/Renal Registered Nurse are responsible for monitoring the patient's vital signs during the first hour of therapy. DURING THERAPY: i. Hemodynamically monitor patient - vital signs, fluid status, and level of consciousness on an hourly basis. v. Calculate I&O's each hour and set the ultrafiltration rate on the CRRT machine to meet the UF goal of the patient. Documentation: Documentation of CRRT is performed hourly in the EMR. The following parameters must be documented every hour: Arterial Pressure, Venous Pressure, Effluent Pressure, UF Rate, Therapy Fluid Potassium Bath, Blood Flow Rate, All I&O's are documented under the Input and Output Flowsheet. Based upon the I&O's that hour the nurse calculates the goal UF to program on the CRRT machine."

Patient #1
Review of Patient #1's medical record revealed Patient #1 was a 52 year old male who was admitted to ICU on 04/30/2025 with a diagnosis of cardiac arrest. Patient #1 was intubated and on multiple vasoactive IV medications. On 05/01/2025 at 11:30 PM CRRT was initiated on Patient #1.
Review of Patient #1's nursing assessments revealed documented levels of consciousness for the following times during CRRT:
05/02/2025 at 12:00 AM.
Review of Patient #1's nursing assessments failed to reveal documented levels of consciousness for the following times:
05/01/2025 at 11:00 PM prior to initiating CRRT.
05/02/2025 at 1:00 AM during CRRT.

Further review of Patient #1's medical record revealed on 05/02/2025 at 1:33 AM that the patient went into cardiac arrest and CPR was initiated and ROSC (return of spontaneous circulation) was obtained at 1:39 AM. Patient #1 was made a DNR (do not resuscitate) and expired on 05/02/2025 at 5:45 AM.

In an interview on 05/08/2025 at 10:52 AM, S3RM and S7CSM confirmed that the nurse did not document the level of consciousness on Patient #1 prior to initiating CRRT or hourly per hospital policy.

In an interview on 05/08/2025 at 11:15 AM, S1CVP confirmed that the CRRT policy states the level of consciousness is part of the required documentation for patients receiving CRRT.

Patient #3
Review of Patient #3's medical record revealed Patient #3 was a 65 year old male who was admitted for a Pulmonary Embolism on 04/29/2025. Patient #3 was moved to ICU (intensive care unit) on 05/02/2025 at 10:00 PM and was intubated and placed on vasoactive IV medication for hypotension and elevated lactic acidosis. On 05/03/2025 at 6:27 AM CRRT was initiated on Patient #3.
Review of Patient #3's nursing assessments revealed documented levels of consciousness for the following times during CRRT:
05/03/2025: 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM.
05/04/2025: 12:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM.

Review of Patient #3's nursing assessments failed to reveal hourly documented levels of consciousness for the following times during CRRT:
05/03/2025: 9:00 AM, 10:00 AM, 11:00 AM, 1:00 PM, 2:00 PM, 3:00 PM, 5:00 PM, 6:00 PM, 7:00 PM, 9:00 PM, 10:00 PM, or 11:00 PM.
05/04/2025: 1:00 AM, 2:00 AM, 3:00 AM, 5:00 AM, 6:00 AM, 7:00 AM, 9:00 AM, 10:00 AM, 11:00 AM, 1:00 PM, 2:00 PM, 3:00 PM, 5:00 PM, 6:00 PM, 7:00 PM, 9:00 PM, 10:00 PM, or 11:00 PM.
05/05/2025: 1:00 AM, 2:00 AM, 3:00 AM, 5:00 AM, 6:00 AM, 7:00 AM.

Further review of Patient #3's medical record revealed on 05/05/2025 at 8:13 AM that the patient went into cardiac arrest and CPR(cardiopulmonary resuscitation) was initiated. Patient #3 expired on 05/05/2025 at 8:42 AM.

In an interview on 05/08/2025 at 2:23 PM, S7CSM confirmed the above mentioned findings on Patient #3. S7CSM also verified that during CRRT the level of consciousness should be documented hourly by the nurse per policy.


2) Failure of nursing staff to document a physician notification for alterations in vital signs that represent a deteriorating patient condition for 2 (#2, #3) of 3 (#1-#3) patient medical records reviewed per hospital policy.

Review of hospital policy number Critical Care 13, titled "Critical Care General Nursing Care," last reviewed 10/2024, revealed in part: "Purpose: This policy is intended to outline how general nursing care will be delivered to all patients within critical care units. The outcome of this policy will be delivery of excellent nursing care to all patients within critical care units. Procedure: VITAL SIGNS: blood pressure, pulse, respiratory rate, and O2 saturation will be taken and documented on admission, then every hour for at least 24 hours. Unstable patients: vital signs will be taken relative to the patient's condition and nursing interventions such as manipulation of vasoactive drips, fluid and blood replacement, etc. Documentation of frequent vital signs (such as every 15 minutes, etc.) will occur via electronic health record (EHR). When titrating drips, continuous assessment of every 5-minute vital signs is needed to determine patient reaction and stabilization. Physician notification is required for altercations in vital signs that represent a deteriorating patient condition. Documentation of physician notification must be included in the EHR. INTAKE and OUTPUT: Accurate intake & output will be maintained on all critical care patients. IV infusion pumps will have "volume infused" cleared every 12 hours at 6 PM and 6 AM. Urine outputs will be monitored and recorded every hour. Daily weights will be done at the same time each day between 4 and 6 AM and recorded in the patient's EHR."

Patient #2
Review of Patient #2's medical record revealed documentation by the provider that a rapid response (an activation team who responds when called for any significant change in the assessment, including but not limited to significant changes in vital signs, respiratory status and/or mental status) was called 05/03/2025 at 5:35 AM. Patient #2 received CPR and 2 rounds of epinephrine. Patient #2 expired on 05/03/2025 at 5:49 AM.
Review of nursing documentation failed to reveal documented evidence that the physician was notified by the nurse of an alteration in vital signs or that Patient #2 was deteriorating prior to the event on 05/03/2025 at 5:35 AM. .

In an interview on 05/08/2025 at 11:54 AM, S7CSM confirmed that there was no nursing documentation that the provider was notified for alterations in vital signs per hospital policy on Patient #2.

Patient #3
Review of Patient #3's medical record revealed on 05/05/2025 at 8:13 AM that the patient went into cardiac arrest and CPR was initiated. Patient #3 expired on 05/05/2025 at 8:42 AM.
Review of nursing documentation failed to reveal documented evidence that the physician was notified by the nurse of an alteration in vital signs or that Patient #3 was deteriorating prior to the event on 05/05/2025 at 8:13 AM.

In an interview on 05/08/2025 at 2:25 PM, S7CSM confirmed that there was no nursing documentation that the provider was notified for alterations in vital signs per hospital policy on Patient #3.

50453


Based on record review and interview, the facility failed to ensure medical records contained documentation of all procedures performed. The deficient practice is evidenced by failure to document the entire Code Blue event for 1 (#2) of 2 (#1, #2) reviewed records of a patient who experienced cardiopulmonary arrest.
Findings:

Review of hospital policy # 5026, titled, "Clinical Emergency Activations (Code Blue, Rapid Response, Stroke Activation, and Code AMI)," last revised 04/2024, revealed in part: "Policy Statement: III. Documentation of all Clinical Emergency Activations (Code Blue, Rapid Response, Stroke Activation, and Code AMI) events should be completed in the patient's EHR. During EHR Down time, the nurse shall document interventions and outcomes in the EHR on the appropriate down time form electronically linked to this policy. Once completed and signed by members of the "Activation Team" the form will be scanned into the patient's EHR. Procedure: I. It is the responsibility of the designated nursing staff to document each "Code Blue" occurrence, on the Code Blue Flow Sheet or in the electronic health record (EHR) under the Code Narrator/Navigator. Any paper document including the Code Blue Flow Sheet and EKG strips must be scanned into the EHR. If the Code Blue Flow Sheet is utilized instead of the Code Narrator in the EHR, the flowsheet must be transcribed into the Narrator upon completion of the event. The name and signature of the "Code Blue" Team Leader and nurse recorder is required."

Review of Patient #2's medical record revealed a death summary that was completed by the physician on 05/03/2025 at 6:31 AM. The death summary for Patient #2 revealed in part: Patient admitted overnight for acute encephalopathy. Despite aggressive interventions, patient went into cardiac arrest at 5:44 AM on 05/03/2025. After 2 rounds of CPR and Epinephrine, family decided to cease interventions, so CPR was stopped. Time of death 5:49 AM. Further review of Patient #2's medical record, failed to reveal documentation by nursing staff of the code blue.

In an interview on 05/08/2025 at 11:56 AM, S7CSM confirmed there was no code blue nursing documentation in Patient #2's medical record. S7CSM also confirmed that the only documentation that Patient #2 was a code blue was by the provider.