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Based on record reviews and interview, the hospital failed to ensure a registered nurse evaluated the nursing care of each patient. This deficient practice was evidenced by failing to ensure the RN documented assessment findings of a patient (#1) that had a reported change in respiration pattern for 1 (#1) of 3 (#1 - #3) sampled patients.
Findings:

Review of the hospital policy titled "Early Response to Deteriorating Patient Condition," last revised 04/01/2024 revealed, in part: "Policy: This facility identifies unexpected acute illnesses which pose life-threatening situations for our patients. This policy defines the procedure for identifying and addressing the following deteriorating conditions that require early response: Abnormal changes/fluctuations in a patient's status. A Registered Nurse (RN) is immediately available as needed to provide bedside care to each patient. The RN shall be qualified through a combination of education, licensure, and training to conduct an assessment that enables recognition of a need for emergency care and/or assistance.

Review of Patient #1's medical record revealed admit date 12/29/2024. The patient had past medical history of, in part, cerebrovascular accident, hypertension, and asthma.

Review of Patient #1's "Multidisciplinary Progress Note" by S2RN dated 01/11/2025 at 8:39 AM revealed, in part: "At approximately 3:30 AM MHT's stated that the patient's breathing pattern was different, and I assess the patient, and vitals was stable. 5:04 AM Patient's last set of vitals read: 130/84, HR: 103. At approximately 6:50 AM the MHT stated that the patient wasn't breathing. At 6:54 AM 911 was called and CPR started." Further review of Patient #1's medical record revealed no evidence S2RN documented Patient #1's assessment findings and no evidence of Patient #1's respiratory status and assessment.

In an interview on 01/28/2025 at 1:53 PM, S1Quality Director indicated that the time documented in the "Multidisciplinary Progress Note" of 3:30 AM by S2RN was incorrect. S1Quality Director indicated that S2RN was notified by MHT of change in breathing pattern and assessed Patient #1 at approximately 4:54 AM. S1Quality Director confirmed S2RN did not document Patient #1's assessment findings and respiratory assessment findings.

Based on record review, video review, and interview, the hospital failed to ensure licensed nurses adhered to policies and procedures of the hospital. This deficient practice was evidenced by failing to ensure hospital Code Blue Response policy and procedure was implemented by nursing staff for 1 (#1) of 1 unresponsive patient from a total sample of 3 (#1 - #3) patients.
Findings:

Review of the hospital policy titled "Code Blue Response," last revised 08/01/2021 revealed, in part: "Policy: It is the policy of this facility to administer cardiopulmonary resuscitation (CPR) when a person's breathing and/or pulse cease. CPR shall continue until person resumes cardiopulmonary functions or the emergency medical services arrive. Procedure: 1. The first provider or employee to arrive at the patient's side will assess patient for symptoms of cardiopulmonary failure, such as unconsciousness, absent respiration, absent heartbeat (check carotid pulse), dilated or constricted pupils, or change in skin color. 2. Stay with the victim, never leaving them unattended. Instruct a staff member to announce Code Blue, and to telephone 911 for emergency medical services, and obtain the emergency cart which has necessary supplies such as an Automated External Defibrillator (AED). 3. Initiate CPR to include the use of an AED. 4. Continue CPR until patient resumes cardiopulmonary functioning or emergency medical services arrives and takes over the code blue response."

Review of Patient #1's medical record revealed admit date 12/29/2024. The patient had past medical history of, in part, cerebrovascular accident, hypertension, and asthma.

Review of Patient #1's "Multidisciplinary Progress Note" dated 01/11/2025 revealed, in part: "At approximately 6:50 AM the MHT stated that the patient wasn't breathing. At 6:54 AM 911 was called and CPR started and initiated AED attached to the patient."

Review of Patient #1's "Code Blue/CPR Flow Sheet" dated 01/11/2025 revealed, in part: "Reason for code: Patient was found unresponsive with no pulse and no observed breathing. Time CPR initiated 6:55 AM. Assessment: Pulseless, unresponsive. Summary: At approximately 6:50 AM the MHT stated that the patient wasn't breathing. At 6:54 AM patient assessed by RNs after tech notified RN that they had concern over the patient's condition. Both RNs came to assess the patient. CPR initiated immediately and 911 called. CPR started and initiated AED attached to the patient, which informed staff to continue CPR. CPR continued until EMS arrived and they began resuscitation efforts. 7:15 AM EMS arrived on the scene after 911 was called and transported the patient to ER at 7:25 AM after resuscitation efforts as well as CPR were performed on the patient. 8:23 AM spoke with ER on phone and was given update that the patient passed in the ER."

A review of the hospital video footage for 01/11/2025 and Patient #1 was done with S1Quality Director on 01/28/2025 at 2:06 PM. At approximately 5:15 AM, S2RN, S3MHT, and S4MHT exited a room with Patient #1 in a Geri-chair and wheeled Patient #1 into the hospital day room. At approximately 6:53:21 to 6:53:50 AM, S5MHT, S4MHT, S2RN, and S3MHT seen observing and touching Patient #1. At approximately 6:54:50 AM, S6RN exited nurses' station with vital sign machine and S6RN attached it to Patient #1. At approximately 6:55:24 and 6:55:42 AM, S6RN pressed button on vital sign machine. At approximately 6:56:36 AM, S7RN performed sternal rubs on Patient #1. At approximately 6:56:51 AM, S6RN exited nurses' station with backboard and AED. At approximately 6:57 AM, S7RN began CPR on Patient #1 while in Geri-chair. CPR continued on Patient #1 while in Geri-chair. At approximately 6:59:48 AM, AED applied to Patient #1's chest. At approximately 7:01:39 AM, EMS entered the day room. At approximately 7:02:06 AM, Patient #1 moved to the ground and EMS assumed control of code. At approximately 7:22:58 AM, patient transferred off unit by EMS. Review of video footage failed to reveal staff obtained the emergency cart which had necessary CPR supplies. Review of video footage failed to reveal staff obtained oxygen, bag valve mask, suction device, and airway management tools.

In an interview on 01/29/2025 at 10:44 AM, S1Quality Director and S8Regional DON confirmed that hospital Code Blue Response policy not implemented by staff. S8Regional DON confirmed staff did not obtain the emergency cart which had all necessary supplies and did not obtain and apply AED timely.