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Based on interview, record review, policy review and review of the American Heart Association 2015 Guidelines, the facility failed to ensure nursing staff:
- Responded timely to requests to check on one of one patient (#1) with a tracheostomy (trach, plastic tube surgically placed within the windpipe), when the patient's oxygen saturation (percentage which indicates whether a patient is receiving adequate amounts of oxygen) fell below normal limits. (A-0395)
- Called for a "Rapid Response" (notification to respond to a patient's decline in health, before an injury or life-threatening event occurs), when one of one patient's (#1) condition significantly declined. (A-0395)
- Timely checked one of one patient (#1) for a pulse (heartbeat) during a life-threatening event.
- Were educated in a timely manner on failures found during the hospital's internal investigation of a sentinel event (any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients), when Patient #1 expired unexpectedly, due to nursing staff's inaccurate use of respiratory equipment. (A-0395)
- Who were contracted through a nursing agency, were oriented and verified to be competent in the patient care they provided. (A-0398)

Patient #1, with a tracheostomy (trach, plastic tube surgically placed within the windpipe), experienced lower than normal oxygen levels on 12/23/16, after Staff G, Agency Registered Nurse (RN), incorrectly modified the patient's oxygen delivery system, which cause the patient to rebreathe his expired air. Staff failed to respond in a timely manner to multiple requests to check on the patient, and a rapid response was not called. When staff did respond, the patient had significantly decreased oxygen levels, and a slow, non-life sustaining heart rate . Staff failed to check the patient for a pulse (heart beat felt at the neck, wrist or groin, and indicates that the heart is beating), began to manually ventilate (to force oxygenated air into the lungs), but the patient deteriorated and died.

An internal hospital investigation was initiated, and hospital administration recognized several failures related to the event surrounding Patient #1's death, but failed to initiate necessary steps, and education in a timely manner to ensure the events did not occur again. This resulted in placing all patient's at risk for injury or death. There were eight patients with trachs and there were 14 agency staff contracted for patient care at the time of the survey. The facility census was 19.

The severity and cumulative effect of these systemic practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

As of 1/05/17, at the time of survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- A mock rapid response was immediately conducted and observed by the survey team, to ensure appropriate response and follow-through was completed. Any identified issues or opportunities for improvement were addressed through real-time education.
- All rapid response and code blue events, no less than two per day, will be audited through direct observation by the CCO/designee with real-time education provided for any noted opportunities.
- To ensure critical alarms are responded to immediately, education and training is required for all clinical staff (agency, contract or employed) currently on staff or prior to their next working shift. No less than two alarm drills per day for each shift, in which an alarm will be sounded and response timed and documented with the staff who participated.
- An orientation to respiratory therapy will be conducted in full for all clinical staff. There will be documentation of verbal understanding and/or return demonstration.
- Respiratory equipment education will be conducted. All clinical staff, (agency, contract or employed) will review the respiratory equipment that is used at at the facility and complete a return demonstration on the equipment that their license allows them to use.
- Equipment that is designated to be worked with solely by respiratory therapy will be clearly designated.
- The equipment that requires only respiratory therapy involvement will be identified and able to be verbalized by the staff.
- Sign in sheets with the educational materials will be maintained in each employee's education file. This will be monitored concurrently by the Human Resources.
- Related policies will be reviewed and revised and approved to allow for clear guidance to all staff.
- All monitoring for compliance will be reported to the Quality Committee.

Based on interview, record review, policy review and review of the American Heart Association 2015 Guidelines, the facility failed to ensure nursing staff:
- Responded timely to requests to check on one of one patient (#1) with a tracheostomy (trach, plastic tube surgically placed within the windpipe) when the patient's oxygen saturation (percentage which indicates whether a patient is receiving adequate amounts of oxygen) fell below normal limits.
- Called for a "Rapid Response" (notification to respond to a patient's decline in health, before an injury or life-threatening event occurs), when one of one patient's (#1) condition significantly declined.
- Timely checked one of one patient (#1) for a pulse (heartbeat felt at the neck, wrist or groin) during a life-threatening event.
- Were educated in a timely manner on failures found during the hospital's internal investigation of a sentinel event (any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients) that lead to one of one patient's (#1) unexpected death.
These failed practices had the potential to affect all patients, and placed them at risk for serious injury or death. There were eight patients with trachs and 14 agency staff contracted for patient care at the time of the survey. The facility census was 19.

Findings included:

1. Record review of Patient #1's discharge medical record showed:
- A History and Physical (H&P) dated 12/06/16, documented by Staff J, Hospitalist, that the patient was admitted on 12/06/16 with anoxic brain injury (lack of oxygen causing irreversible damage to the brain) and respiratory failure (inability to breathe on own), post tracheostomy on mechanical ventilator (machine used to assist or completely control breathing, when someone cannot breathe on their own). The patient was admitted to the hospital for ventilator weaning (to gradually remove from).
- A Nursing Assessment dated 12/23/16 at 8:44 AM, documented by Staff F, Agency Registered Nurse (RN), that the patient was "waking up more today", tolerated the ventilator settings, with "good strong cough", tan to yellow secretions (drainage, typically from the nose, mouth or lungs during cough) and course lung sounds (used to describe lung sounds heard when a stethoscope is placed over the chest) which were "somewhat clearing".
- A Respiratory Therapy Note dated 12/23/16 at 2:23 PM, documented by Staff L, Respiratory Therapist (RT), that at 9:20 AM, the patient was removed from the ventilator (as part of the weaning process) and placed on 40 percent oxygen (amount of oxygen administered to the patient) by Aerosol Trach Collar (ATC, mask that supplies humidified or moist oxygen to a breathing patient with a trach).
- A Nursing Note dated 12/23/16 at 11:00 AM, documented by Staff F, that the patient was opening his eyes, was having copious (large) amounts of secretions from nose, mouth and trach, so the nurse attached inline suction (suction catheter or tube, contained inside of a sterile, closed oxygen circuit, used to pass through the windpipe and into the lungs to remove secretions) to ATC, and suctioned patient (removed secretions).
- A Respiratory Therapy Note dated 12/23/16 at 2:30 PM, documented by Staff L, RT, that at 11:20 AM, the patient was found cyanotic (blue in color, due to lack of oxygen) with a heart rate around 40 beats per minute (normal heart rate is 60 - 100 beats per minute). Staff assisted the patient in breathing by manual ventilation (forcing oxygen into the lungs by squeezing an oxygen filled bag over the mouth or trach, in attempt to restore breathing), but the patient continued to become more cyanotic and his heart rate continued to drop. The patient was considered "Do Not Resuscitate" (DNR, restrict certain or all measures to restore normal heart rate or breathing) and after Charge Nurse (confirmed by Hospital Administration as Staff E) consultation with Staff J, Hospitalist, no medication was to be administered, and manual ventilation was discontinued while the patient's heart rate was 30 - 40 beats per minute.
- A Nursing Note dated 12/23/16 at 11:49 AM, documented by Staff F, RN, that at 11:25 AM the patient's oxygen level and heart rate continued to drop.
- A Death Note dated 12/23/16, documented by Staff J, that the patient died on 12/23/16 at 11:30 AM.

During an interview on 01/04/17 at 9:10 AM, Staff C, Interim Chief Clinical Officer, and Staff A, Director of Quality Management, stated that:
- The facility had completed an internal investigation related to the 12/23/16 unexpected death of Patient #1.
- Based on staff interviews, written statements and closed circuit video recordings, It was believed the Staff F, Agency RN, incorrectly attached Patient #1's oxygen delivery system to a closed oxygen circuit (tubing which oxygen is delivered through), which caused the patient to rebreathe his exhaled air.
- Because the patient was not able to exhale properly, it caused the patient's oxygen saturation (percentage which indicates whether a patient is receiving adequate amounts of oxygen) and heart rate to significantly drop below normal limits, which would require life sustaining measures (resuscitation, to revive someone from near death or death).
- The patient was not to be resuscitated with life-saving medications per physician's order, and attempts to resuscitate the patient by manual ventilation were unsuccessful and the patient died.

2. Record review of the facility's closed circuit video recording timeline for 12/23/16 showed that at:
- 11:08 AM, Staff F, Agency RN, entered Patient #1's room and remained there until 11:12 AM. The facility's internal investigation believed that during this time, Staff F placed Patient #1 on an oxygen delivery system that caused him to rebreathe his exhaled air, when she connected inline suction to the patient's oxygen delivery device, and then attached it to the patient. This prevented the patient from receiving adequate oxygen.
- 11:12 AM, Staff M, Patient Care Technician (PCT) entered the patient's room.
- 11:15 AM, Staff M exited the patient's room.
- 11:19 AM, Staff E, Charge Nurse (sitting at patient monitors), appeared to say something to Staff D, Respiratory Manager, and Staff D started toward Patient #1's room. (Due to camera angles, the facility was unable to verify Staff E's actions prior to this time).
- 11:20 AM, Staff D entered the patient's room, followed by Staff L, Respiratory Therapy.

During an interview on 01/05/17 at 1:00 PM, Staff F, Agency RN, stated that she had attached inline suction to the patient's oxygen delivery system because she had done this before at other facilities she had worked for.

During an interview on 01/04/17 at 1:40 PM, Staff A, Director of Quality Management, stated that she had worked in an intensive care setting for many years and would never attempt to change out the respiratory equipment to allow for the inline suction. Staff A stated that changing the respiratory equipment would be the responsibility of respiratory therapy staff.

During an interview on 01/04/17 at 1:50 PM, Staff C, Interim Chief Clinical Officer, stated that it was not "normal procedure" for a nurse to change out respiratory therapy equipment.

During an interview on 01/05/17 at 8:55 AM Staff E, Charge Nurse, stated that on 12/23/16 (time not verified), he observed Patient #1's oxygen level drop below normal on a monitor (computer screen which displays several patients' heart rhythm and oxygen level) at the central nurses station. Staff E stated that he made a request for staff over a portable radio communication device, to check on the patient's plethysmograph (pleth, instrument which monitors oxygen levels). When staff did not respond (over approximately one to two minutes), he made two more requests for staff to check on the patient's pleth, but there was still no response. Staff E stated that Staff N, RN, who was nearby, stated she would respond to Patient #1's room, but by this time, the patient's heart rate and oxygen level had both decreased below normal, so Staff E requested Staff D, Respiratory Manager, to also check on the patient.

During an interview on 01/05/17 at 11:04 AM, Staff L, RT, stated that she had heard two of the requests for Patient #1's pleth check but did not respond immediately because it was not an emergency and everyone was expected to do these checks. "Pleth check is not a big emergency. There are many pleth checks all day long".

During an interview on 01/04/17 at 1:50 PM, Staff C, Interim Chief Clinical Officer, stated that she expected nursing staff to respond to the first pleth check request, and by the second or third request, someone should have been sent to Patient #1's room. Staff C stated that she expected Staff E to have called a rapid response for Patient #1 after there was no response from nursing to the first pleth check request, and did not understand why a rapid response was not called.

3. Record review of the facility's policy titled, "Rapid Response," dated 09/2015, showed that staff will intervene when an individual's condition starts to decline and before an injury or life-threatening event occurs. This applies to anyone with deteriorating clinical signs and symptoms, and includes changes in heart rate and oxygen saturation. The concerned staff member will overhead page stating "rapid response to Room #__" three times. The Rapid Response Team will assess the patient's condition and respond to interventions.

During an interview on 01/05/17 at 8:55 AM Staff E, Charge Nurse, stated that he did not request emergent staff response (such as to call a Rapid Response or Code Blue, requires immediate response of patient care staff to perform life saving measures when a patient is near death or lifeless) to Patient #1's room, because the patient was a DNR.

During an interview on 01/04/17 at 10:45 AM and 2:22 PM, Staff D, Respiratory Manager, stated that he believed nursing culture was that it was the responsibility of respiratory therapy staff to respond to pleth check requests, and not nursing staff. Staff D verified that Staff E made three requests for Patient #1's pleth check without staff response, so Staff E specifically requested him to respond (a period of two or three minutes from the time of Staff E's initial requested pleth check) to the patient. Staff D stated that when he arrived to Patient #1's room he found the patient diaphoretic (sweaty), pale with cyanotic (blue in color, indicated lack of oxygen) lips, a low heart rate and low oxygen saturation (around 20 percent), and it was noticed that the patient's oxygen delivery setup was not set up correctly. Staff D stated he grabbed the Ambu bag (bag that is squeezed by hand to force oxygenated air into the lungs, also known as manual ventilation) and began to manually ventilate the patient and the patient initially improved, but would not completely recover. The patient continued to deteriorate, staff stopped manual ventilation of the patient, and the patient's heart rate slowed and eventually stopped. Staff D stated that he did not check for a perfusing pulse (heart beat felt at the neck, wrist or groin, and indicates that the patient's heart is actively beating), and did not remember other staff checking the patient for a pulse.

4. Record review of the "American Heart Association Basic Life Support 2015 Guidelines" showed that the first step in basic life support is to simultaneously check for breathing and a pulse.

During an interview on 01/05/17 at 8:55 AM Staff E, Charge Nurse, stated that he did not check Patient #1 for a perfusing pulse, and did not remember staff checking the patient for a pulse.

During an interview on 01/05/17 at 11:04 AM, Staff L. Respiratory Therapist (RT), stated that she did not check Patient #1 for a perfusing pulse.

During an interview on 01/05/17 at 1:00 PM, Staff F, Agency RN, stated when she arrived to Patient #1's room, his oxygen saturation was 78 percent with a heart rate of 48 beats per minute. Staff F stated that she did not check if the patient had a perfusing pulse, and added none of the staff checked for a pulse until the patient went into an agonal rhythm (final heart rhythm before death, does not indicate the heart is beating), when it was determined that he was pulseless.

5. Record review of the facility's policy titled, "Incident Reporting," dated 10/15/14, showed that risk management should be notified of a potential or an actual problem, error, adverse outcome or injury (regardless of the severity), and included equipment or device problems involving a patient and sentinel events (unexpected occurrence involving death or serious physical or psychological injury). All incidents are risk rated using the Safety Event Classification Levels of Harm (SSE 1, most severe, is defined as a deviation resulting in death). Where appropriate, a Root Cause Analysis (RCA, to investigate all factor and determine the causes of the incident) and/or action plan will be developed for change of process, practice, policy and/or education.

Record review of the facility's policy titled, "Sentinel Event," dated 09/2009, showed that a Sentinel Event signaled the need for immediate investigation and response.

During an interview on 01/04/17 at 9:10 AM, Staff C, Interim Chief Clinical Officer, and Staff A, Director of Quality Management, stated that
- Staff F, Agency RN continued to work the remainder of the shift and provided care for patients, without corrective education related to the sentinel event.
- The facility identified several failures during the internal investigation which included: staffs' failure to respond to pleth checks in a timely manner, failure to request a rapid response when indicated and education related to proper use of respiratory equipment.
- Hospital staff education specific to prevent inaccurate use of respiratory equipment, sent by email, did not begin until 01/03/17 around 7:00 PM (11 days after the event).
- Education for the additional identified failures had not begun.

6. Record review of an email dated 01/03/17 at 7:05 PM, showed that details and education related to the sentinel event which occurred on 12/23/16, was sent by administration to 14 employed nurse and respiratory staff. Of the 14 employed staff, only five staff had read the email by 01/04/17 at 10:40 AM. The email was not sent to agency staff.

7. Record review of the facility's form titled, "Staff Education on Respiratory Equipment, Escalation of Concerns Policy and Rapid Response," dated 01/04/17, showed that 23 of 33 nursing staff (19 employed and 14 contracted) had not yet received education related to the sentinel event which occurred on 12/23/16, to ensure the sentinel event would not reoccur.

During an interview on 01/05/17 at 1:00 PM, Staff F, Agency RN, stated that she did not receive education related to the proper set-up of respiratory equipment until she received an educational e-mail on 01/04/17 (12 days after the sentinel event occurred).

During an interview on 01/05/17 at 8:55 AM Staff E, Charge Nurse, stated that it was likely the sentinel event that occurred with Patient #1, could happen again.

Based on interview, record review and policy review, the facility failed to ensure that contracted (agency) nursing staff were oriented and verified to be competent in the patient care they provided. This resulted in the death of one patient (#1) of one patient death reviewed, when agency nurse (F) incorrectly connected the patient's oxygen delivery system to respiratory equipment, which prevented the patient from receiving adequate oxygen. This failed practice had the potential to affect all patients cared for by contracted nursing staff. There were 14 agency staff contracted for patient care at the time of the survey. The facility census was 19.

Findings included:

1. Record review of the facility's policy titled, "Contract Personnel Orientation," dated 05/2015, showed that all clinical contract service personnel will receive orientation to the facility, roles and responsibilities and (ensure) they meet all provisions outlined in the policy. This applies to staff that provide direct patient care and/or directly support the provision of patient care.

Record review of the facility's policy titled, "Clinical Competencies," dated 05/2015, showed that it did not include a process to ensure contracted nursing staff were assessed for clinical competence.

2. Record review of the facility's undated, "Agency Nurse Orientation," showed it did not contain competency checklists or verification of competencies to ensure the nurse was able to provide appropriate care to the patient's he or she cared for.

3. Record review of Staff F, Agency Registered Nurse (RN), education file, showed no hospital based education or competency completed related to the respiratory care of patients with a ventilator (machine that supports or completely controls a patients breathing) or tracheostomy (trach, plastic tube surgically placed within the windpipe).

During an interview on 01/05/17 at 1:01 PM, Staff F verified that her orientation did not include education related to the respiratory care of patients in the facility.

During an interview on 01/04/17 at 3:00 PM, Staff P, Agency Licensed Practical Nurse (LPN), stated that he did not receive orientation related to the respiratory care of patients in the facility.

During an interview on 01/05/17 at 3:09 PM, Staff O, Agency LPN, stated that when she arrived for orientation to the facility, she "walked in the door and had four patients (assigned to her) within ten minutes". Staff O stated it "has happened several times" in the facility, and referred to other agency nursing staff who had never worked in the facility before.

During an interview on 01/05/17 at 8:55 AM Staff E, Charge Nurse, stated that:
- The facility supplemented staffing with a significant amount of agency nurses.
- Some shifts, agency nurses made up greater than 50 percent of the total staffed nurses.
- Agency orientation consisted of signing a confidentiality agreement, spending 30 to 45 minutes with the pharmacist, and education to document in the electronic health record.
- There were no hands on or return demonstrations included in agency orientation to ensure agency nurses were competent to care for the facility's patients.

During an interview on 01/04/17 at 9:10 AM, Staff C, Interim Chief Clinical Officer, and Staff A, Director of Quality Management, stated that:
- The facility had completed an internal investigation related to the 12/23/16 unexpected death of Patient #1.
- Based on staff interviews, written statements and closed circuit video recordings, It was believed the Staff F, Agency RN, incorrectly attached Patient #1's oxygen delivery system to a closed oxygen circuit (tubing which oxygen is delivered through), which caused the patient to rebreathe his exhaled air.
- Because the patient was not able to exhale properly, it caused the patient's oxygen saturation (percentage which indicates whether a patient is receiving adequate amounts of oxygen) and heart rate to significantly drop below normal limits, which would require life sustaining measures (resuscitation, to revive someone from near death or death).
- The patient was not to be resuscitated with life saving medications per physician's order, and attempts to resuscitate the patient by manual ventilation were unsuccessful and the patient died.
- Staff F continued to work the remainder of the shift and provided care for patients, without corrective education.
- Staff A was informed of the death of the patient on 12/23/16, but was not informed that Staff F user error was believed to result in the patient's death.
- Staff A was informed by email on 12/26/16, the details of Patient #1's death, and began an internal investigation.
- The facility identified failures with agency staff orientation, education and verification of competencies, and specifically education related to proper use of respiratory equipment.
- Hospital staff education specific to prevent inaccurate use of respiratory equipment, sent by email, did not begin until 01/03/17 around 7:00 PM (11 days after the event).
- Education for the additional identified failures related to agency staff orientation, education and verification of competencies, had not yet begun.

During an interview on 01/04/17 at 3:20 PM Staff C stated that the education email sent on 01/03/17, was not sent to contracted nursing staff.

4. Record review of an untitled form (presented by administration as nurse staffing), dated 12/23/16 through 01/04/17, showed there were 29 full or partial shifts covered by contracted nursing staff. This indicated that contracted nursing staff continued to work without education to prevent the inaccurate use of respiratory equipment, which placed patients at risk.

During an interview on 01/05/17 at 8:55 AM Staff E, Charge Nurse, stated that it was likely the sentinel event that occurred with Patient #1, could happen again.