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Based on record review and interview the facility failed to track as part of it Quality Improvement activities adverse patient events in 1 out of 1 record reviewed. These finding have to potential to cause harm to all patients receiving care at the facility by the facility failure to identify and make corrective actions to prevent reoccurrence of the events.

In review of record of patient # 1 in the facility on 07/12/2010, for the date of 10/20/2010- through the time of death on 10/22/2010 at 2050. the following fact were determined during the record review. Review of the Medical record revealed the patient was admitted to the hospital to Observation Status form the Emergency Department (ED). The record indicated she was admitted to the emergency department at 10/20/2010 at around 11 a.m. She presented with complaints of weakness and Shortness of breath (SOB) she was alert oriented and reported the symptoms started a few hours before arrival. The physician diagnosis after studies was pneumonia and dehydration. She was palace on the medical surgical unit in observation status. She was started on Intravenous antibiotics , an IV of Normal bolus of 250 ml and then to run at 50 ml per hour and had orders for respiratory treatment every four hours treatments Vital signs in the ED were recorded as Temperature ( T) 96.8, Pulse (P) 74 Respirations ( R) 22 unlabored and Blood Pressure (BP) 132/71 and O2 Saturation ( 96% (a measure to indicate the amount of oxygen in the blood) she was not placed on telemetry monitor to monitor her heart rate after admission. On the day shift on 10/21/2009 starting at 1620 the nurse # 4 documents a change in the patient condition, she documents the patient was vomiting patient was lethargic, skin cool and clammy color pale, Head of Bed (HOB) elevated, Blood Pressure (BP) 84/58 and respiration shallow. She doesn't ' assess the patients Oxygen ( O2) saturation, the patients lung sounds, or the quality and rate of the pulse. There is also no evidence the nurse asked the patient about her pain status. She documents she notifies the Charge Nurse ( she failed to list the name of the Charge Nurse) who she documents is in the room, but the charge nurse # 8 does not document an assessment and the there is no evidence that either nurse called the physician with this patients change in condition. There was also no evidence that the respiratory department was notified of the change in condition and preferment an assessment of the patient ' s O2 saturation. The respiratory therapy department documents a treatment at 1630 on 10/21/2009 and there was no evidence they assessed the patients O2 saturation at the beginning or the end of the therapy. The record reveals that no one in the respiratory department documented an O2 saturation assessment at any time after 1900 on 10/20/2009. They recorded on the record on 10/20/2009 at 0000, 0400, 10/21/2009 at 0800, 1200, 1600, 2000, and 12/22/2009 at 0000, and recorded the O2 was running at 2 liters per nasal cannula but failed to document the O2 saturation. At 0400 after the recorded patient death they document the Oxygen was running at 2 liters and they document a refusal of treatment by the patients after her recorded death at 0250.

The record indicated the patient was given a respiratory treatment of an aerosol of Albuterol (a medication to treat breathing difficulty every four hours starting on 10/20/2010 at 1740 which is the same as 5:40 p.m. This medication is given every four hours until 10/22/2010 at 0000 (12 midnight) and 0400 which is documented as the patient refusal of both treatments. The patient was pronounced dead by the Emergency Department Physician at 0250 on 10/22/2009 and this time before the respiratory staff # 9 documented the patients refusal at 0400 on 10/822/2009. The nurse on the night shift Staff # 5, documented on the patient starting at 1845 on 10/22/2009 that the patients was lying in bed alert and oriented x three, Side rail (SR) up times 2, head of bead elevated (HOB) , wheels locked complained of mild nausea. The remaining times charted by this staff are eligible due to writing over the numbers. The documentation indicates she was resting with eyes closed breathing normally. He documents she was found expired at an illegible time by 6 an 7 . The Emergency physician documents that the patient was found expired for an undetermined amount if time at 0250 on 10/22/2009. This record has other discrepancies, charted by Staff # 5 such as the changing of several time by writing over the time which according to facility policy should be corrected by a single line noting the correction and then initialing the change. The record also show he documented the condition of the IV site assessment starting at 2200 on 10/21/2009 and at 0000, 0200, 0040, and 0600 on 10/22/2009. The time of the 0400 and 0600 assessment was after the patient was noted to have died at 0250.

Review of Quality Improvement meeting minutes from July 2009 through December 2009 revealed they had not reviewed any mortality cases (death cases) including the above patient # 1 case.

Interview with staff # 1 on 07/12/2010, confirmed the facility had not review death charts from July 2009 through December 2010. He stated that they had a management staff turn over and they had identified that the mortality review had not been done. He stated the were in the process of reviewing all events and had identified this case in May 2010 and had conducted a Root cause analysis. In addition he confirmed the conflicting documentation found in the record after the patients death.