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Based on record review, policy review, and staff interview, the Chief Executive Officer (CEO) failed to establish a mechanism to ensure the quality of care provided as evidenced by: delay in transfer when the patient experienced an emergency requiring transfer to a higher level of care in one of 10 patients (Patient #1); failing to ensure a doctor was available in house twenty-four hours a day to assist in an emergency per medical staff rules and regulations; and failure to have a policy for the appraisal of emergencies.


Findings included ...


The Bridgepoint National Harbor Medical Staff Rules and Regulations provided by the surveyor on 05/09/17 and approved on December 2015, showed, "Emergency Services ...A doctor is available in house twenty-four (24) hours a day to assist in an emergency ..."


The Bridgepoint National Harbor policy entitled Nursing Flow Sheet effective 12/14 stipulated, "Documentation of nursing care in the medical record shall be pertinent, concise, and accurately reflect the patient's status. It should address the patients' needs, problems, capabilities and limitations, noting any nursing intervention and patient response ..."


Review of the medical record revealed that Patient #1 was admitted on 02/24/17 after a fall from a ladder with resulting respiratory failure status post tracheostomy placement, Embolic Stroke, Airway Malacia, and a history of Obstructive Sleep Apnea.


Review of the discharge summary dated 1/17/17 from the transferring facility showed that Patient #1 underwent multiple procedures related to his tracheostomy. He was having large volume positional cuff leaks and was taken to the Operating Room (OR) for a tracheostomy placement of a size 9 tube on 12/20/16. He was returned to the OR for tach exchange on 12/21/16 secondary to persistent cuff leak. On 01/10/17, a Trascheostomy Exchange was performed and Patient #1 was fitted with an 8 XL Shiley (XL tracheostomy tubes are extra-long tubes for patients with thick necks, long trachea anatomies, tracheal stenosis or malacia). He was transferred to Bridgepoint National Harbor on 02/24/17.


Review of a physician order dated 03/06/17 directed a tracheostomy tube change to a #6XLT. There is no corresponding note from the pulmonologist that wrote the order. Review of Respiratory Therapy Care Assessment documentation dated 03/07/17 at 2:30 PM showed that Patient #1's trach was changed to a "#6" without complication.


During a face to face interview on 05/09/17 at 11:45 AM with Employee #7, Registered Nurse, she stated that she cared for Patient #1 on two consecutive days; 03/06/17 and 03/07/17. She went on to say that on 03/07/17 Patient #1's tracheostomy was changed by two Respiratory Therapists (RT's). Patient #1's daughter came to visit and summoned Employee #7 to the room. When she got to the door she could hear audible wheezing, Patient #1 was tachypneic and tachycardic. A pulse oximetry reading showed that the patient was not hypoxic. Employee #6, Respiratory Therapist, and Employee #4, Respiratory Therapy Director tended to Patient #1. According to Employee #7, Patient #1 was mildly diaphoretic. Employee #4 was attending to the patient and tried to change the trach back to the previous size. Employee #7 stated, "I remember him [Employee #7] saying it closed" when discussing what Employee #4 said when attempting to replace the #8 Shiley. Employee #7 stated that Patient #1 was transferred to the Intensive Care Unit (ICU).


During a face to face interview conducted on 05/09/17 at 12:15 PM with Employee #6, Respiratory Therapist, she stated that she and another therapist performed the tracheostomy change for Patient #1 on 03/07017. She stated that later after the change she noticed his increased work of breathing and notified the nurse.


During a telephone interview conducted on 05/10/17 at 12:40 PM with Employee #7, Director of Respiratory Therapy, he stated that Employee #6 notified him between 6:00 PM and 6:30 PM that Patient #1 was experiencing shortness of breath after a tracheostomy change that took place at 2:30 PM. "I went to change the trach back to an 8 XL and met some resistance." He emphasized that all he did was tug at the tracheostomy tube, he did not remove it. When asked for his documentation of the event, he stated that he did not complete documentation. He stated that the Physician Assistant came to the bedside and the decision was made to transfer the patient to the Intensive Care Unit (ICU). After the patient was transferred he left for the evening.


Review of the ventilator flow sheet dated 03/07/17 at 8:05 PM showed a respiratory assessment completed at 7:40 PM and 7:45 PM. There are no additional respiratory assessments documented in the record. The note attached to the flow sheet is timed 7:40 PM and shows that Patient #1 was placed on the ventilator after transfer to the ICU. He was changed to a "#6 shiley cuffed" by two respiratory therapists (RT); was assessed by the Physician's Assistant (PA) and a Nasogastric (NG) tube was placed. The RT noted that the patient had pink frothy sputum and a respiratory rate in the high 40's. " ...911 was called, [patient was transferred out for further evaluation ..."


During a face to face interview on 05/08/17 with Employee #3, Intensivist, she stated that one of the major issues with the patient once he was transferred to the ICU was his abdominal distention. He started to go downhill, he began to have mental status changes and the decision was made to transfer Patient #1 to a higher level of care. Employee #3 went on to say that there was a delay of about an hour and 15 minutes because the family did not want the patient sent to the acute care facility that was closest to them. Employee #3 was not present in the facility at the time of the emergency, she was in telephone communication with the PA. There is no documentation from Employee #3 regarding the decompensation or transfer of Patient #1.


Review of a progress note completed by the PA on 03/07/17 at 10:10 PM showed that once the decision was made to transfer the patient to the ER, the family did not want the patient sent to [named emergency room]. " ...Attempts were made to get the patient into other facilities ...there were no beds available.


Review of a transfer note written by the PA on 03/15/17 regarding the transfer of Patient #1 to a higher level of care showed, " ...The patient also began to exhibit acute abdominal distention after being placed on continuous mechanical ventilation. The decisions were made to transfer the patient to the nearest ER ...patient's family members initially did not want the patient sent to [Name Emergency room]. After about an hour of deliberation, family asked to send the patient to [Closest Emergency Room].


Review of the EMS report dated 03/07/17 showed that the crew was dispatched to the facility at 9:19 PM on 03/07/17; they arrived to the facility at 9:25 PM. The EMS crew took over care of the patient at 10:00 PM and arrived at the facility. The report showed that facility attempted to get patient an inter facility transport but was unsuccessful and would not be possible for several hours. The report went on to say " ...The delay in obtaining [patient] care from facility was due to facility failing to make immediate decisions.


Review of the report dated 03/07/17 from the Emergency room that Patient #1 was transported to showed that a code blue was called for the patient at 10:57 PM and he was pronounced dead at 11:17 PM.


During a face to face interview on 05/09/17 with Employee #1, Chief Medical Officer, he surveyor asked what the hospitals policy and procedure was regarding the appraisal of emergencies and patient transfer. He stated that the hospitals main goal was to satisfy the family of the patient first. When asked about the delay in transfer for the patient, he stated "maybe they used that time to stabilize the patient", he went on to say that the policy is the moment the decision is made to transfer the patient emergently a stat call goes out to the ambulance. When asked for a copy of the facility policy on emergency transfers, he could offer no further insight.


During a face to face interview on 05/09/17 at 2:30 PM with Employee #2, Chief Clinical Officer, she stated that the facility did not have a policy regarding the appraisal of and transfer during emergencies. She acknowledged the above findings.

Based on record review, policy review, and staff interview, the hospital failed to develop policies and procedures for the appraisal of emergencies. The failed practice has the potential to impact all patients admitted to the facility.


Findings included ...


Review of the medical record revealed that Patient #1 was admitted on 02/24/17 after a fall from a ladder with resulting respiratory failure status post tracheostomy placement, Embolic Stroke, Airway Malacia, and a history of Obstructive Sleep Apnea.


Review of a physician order dated 03/06/17 directed a tracheostomy tube change to a #6XLT. There is no corresponding note from the pulmonologist that wrote the order. Review of Respiratory Therapy Care Assessment documentation dated 03/07/17 at 2:30 PM showed that Patient #1's trach was changed to a "#6" without complication.


During a face to face interview on 05/09/17 at 11:45 AM with Employee #7, Registered Nurse, she stated that she cared for Patient #1 on two consecutive days; 03/06/17 and 03/07/17. She went on to say that on 03/07/17 Patient #1's tracheostomy was changed by two Respiratory Therapists (RT's). Patient #1's daughter came to visit and summoned Employee #7 to the room. When she got to the door she could hear audible wheezing, Patient #1 was tachypneic and tachycardic. She obtained a pulse oximetry reading and discovered that the patient was not hypoxic. The Employee #6, Respiratory Therapist, was going off duty and Employee #4, Respiratory Therapy Director took over. According to Employee #7, Patient #1 was mildly diaphoretic. Employee #4 was attending to the patient and tried to change the trach back to the previous size. Employee #7 stated, "I remember him saying it closed" when discussing what Employee #4 said when attempting to replace the #8 Shiley. Employee #7 stated that Patient #1 was transferred to the Intensive Care Unit (ICU).


During a face to face interview conducted on 05/09/17 at 12:15 PM with Employee #6, Respiratory Therapist, she stated that she and another therapist performed the tracheostomy change for Patient #1 on 03/07017. She stated that later after the change she noticed his increased work of breathing and notified the nurse.


Review of the nursing note from Employee #8, ICU RN receiving the patient, dated 03/07/17at 8:00 PM. He documented that Patient #1 was placed on the ventilator on arrival to the ICU and continued to demonstrate and increased respiratory rate and an increased heart rate in the 140's. After a change in the vent settings the nurse noted that Patient #1's abdomen became "significantly distended." The Physician's Assistant (PA) was called to the bedside, a Nasogastric (NG) tube was placed and connected to suction with minimal output. Employee #8 documented " ...The decision was made to send patient to the nearest [Emergency Department] ..."


Review of the EMS report dated 03/07/17 showed that the crew was dispatched to the facility at 9:19 PM on 03/07/17, they arrived to the facility at 9:25 PM. The EMS crew took over care of the patient at 10:00 PM and arrived at the facility. The report showed that facility attempted to get patient an inter facility transport but was unsuccessful and would not be possible for several hours. The report went on to say " ...The delay in obtaining [patient] care from facility was due to facility failing to make immediate decisions.


Review of the report dated 03/07/17 from the Emergency room that Patient #1 was transported to showed that a code blue was called for the patient at 10:57 PM and he was pronounced dead at 11:17 PM.


During a face to face interview on 05/09/17 with Employee #1, Chief Medical Officer, he surveyor asked what the hospitals policy and procedure was regarding the appraisal of emergencies and patient transfer. He stated that the hospitals main goal was to satisfy the family of the patient first. When asked about the delay in transfer for the patient, he stated "maybe they used that time to stabilize the patient", he went on to say that the policy is the moment the decision is made to transfer the patient emergently a stat call goes out to the ambulance. When asked for a copy of the facility policy on emergency transfers, he could offer no further insight.


During a face to face interview on 05/09/17 at 2:30 PM with Employee #2, Chief Clinical Officer, she stated that the facility did not have policies regarding the appraisal of and transfer during emergencies. She acknowledged the above findings.