Adventist Health Lodi Memorial

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 50633 Based on observation, interview and record review, the facility failed to ensure a patient’s right to participate in a medical discussion for plan of care regarding code status (a patient’s predetermined medical instructions regarding the type of life-saving measures they wish to receive if they stop breathing or their heart stops). This failure resulted in the patient being resuscitated (revived from apparent death or from unconsciousness) against her current preferences regarding life sustaining care. FINDINGS: During a review of the Electronic Medical Record (EMR) for Patient 1 (P1), titled, “Emergency Department (ED) Physician Note”, dated 9/16/25, 7:28 p.m., P1 arrived to ED by ambulance from a rehabilitation hospital and was assessed as alert upon arrival, with worsening shortness of breath and a medical history of chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently), and atrial fibrillation with rapid ventricular response (A-fib with RVR, a irregular and fast heart rhythm disorder, resulting in shortness of breath, chest pain, fatigue, dizziness or palpitations) and was admitted to the hospital. During review of P1’s EMR, the rehabilitation hospital’s transfer report titled, “Transfer/Discharge Report,” the report indicated, “CODE STATUS: NO CPR [cardiopulmonary resucsitation, a combination of chest compressions and rescue breathing used when someone’s heart or breathing stops] ... (REFER TO POLST).” During review of P1’s EMR titled, “Physician Orders for Life-Sustaining Treatment (POLST)” form, signed by P1 and dated 8/30/25, the form indicated the patient’s wishes as, “ ...if no pulse and is not breathing, Do Not Attempt Resuscitation / DNR (Allow Natural Death),... [and] Comfort-Focused Treatment ...Do not intubate [place breathing tube in throat] .....Generally avoid intensive care.” During review of P1’s EMR physician medical order, titled, “Code Blue: Selective DNR, Palliative Consult,” dated 9/17/25, 12:13a.m., the order indicated, “All reasonable efforts of resuscitation will be employed in the event of a cardiopulmonary [heart-lung] arrest ... Not Yet Discussed with Patient.” The EMR indicated a unit staff nurse validated the order on 9/17/25 at 3:59 a.m. During review of P1’s EMR, titled, “Code Blue Note,” dated 9/18/25, 4:23 a.m., the note indicated, “Rapid Response called as patient became acutely bradycardic and progressed to asystole. Nursing staff confirmed patient full code per electronic medical record (EMR) ... cardio-pulmonary resuscitation (CPR) performed ... Patient initially pronounced [dead] at 3:36 a.m.” The Code Blue note indicated at 3:45 a.m., P1’s heart began to beat on its own again and an endotracheal tube (ETT, tubing that keeps the airway open so oxygen can be delivered to the body) was inserted into the P1’s airway and connected to a ventilator (a machine that controls breathing and oxygen delivery to a patient’s body). The note indicated the Intensive Care Unit (ICU) charge nurse arrived at the bedside around the same time noting P1’s, “paper medical chart had a DNR/DNI POLST form signed and dated on 8/30/25.” During an interview on 11/4/25 at 10:25 a.m., with the ICU supervisor (ICUS), ICUS stated a patient paper copy chart is put together upon arrival to the admitting unit so paper copies of medical records accompanying the patient can be accessible to health care team. ICUS stated nurses are expected to communicate POLST information to physicians to ensure a physician Code Blue Order aligns with patient’s current preferences for life-sustaining treatment. ICUS stated this is to occur at the time of admission or as soon as possible. During an interview on 11/5/25 at 10:55 a.m., with the Telemetry and Med-Surgical Unit Manager (TNM) and Telemetry and Med-Surgical Service Director (TMSD), TMSD stated if a patient is admitted to the unit with paper copies of a POLST form, indicating “Do Not Resuscitate- Do Not Intubate (DNR/DNI), the nurse is expected to contact physician immediately to ensure Code Blue Order aligns with patient’s current preferences for life sustaining care. During an interview on 11/5/25 at 2:21 p.m., with the Chief Medical Officer (CMO), CMO stated he expects physicians to have the code blue discussion with patients in real-time during a patients’ initial assessment at admission; however if not feasible due to patient not medically stable, patient not capable of having a decision-making conversation with physician, or if the designated family decision-making person is not present, then discussion has to happen as soon as feasible and as soon as possible. During a review of the facility’s policy and procedure (P&P), titled, “Patient Rights and Responsibilities,” dated 1/23/2024, P&P indicated, “You [the patient] have the right to effective communication and to participate in the development and implementation of your plan of care.” During a review of the facility’s P&P, titled, “Physician Orders for Life Sustaining Treatment (POLST),” dated 6/1/2017, P&P indicated when patient is admitted to the hospital with a completed POLST form, “the admitting physician will document the existence of the POLST Form, and confirm with patient, if possible, or ...patient’s legally recognized health care decision-maker, that the POLST Form in hand has not been voided or superseded by a subsequent POLST Form. P&P indicated, “Discussion about revising or revoking the POLST should be documented in the medical record and dated and timed ...documentation should include the essence of the conversation and the parties involved in the discussion.””

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 38970 Based on interview, medical record review, and policy review, the hospital failed to ensure the effective delivery of nursing services to provide safe and quality care to patients when: A. The hospital failed to ensure a policy for telemetry (heart rate and rhythm) monitoring of patients in the Medical Surgical and Telemetry Unit (MSTU) was implemented for one of 20 sampled MSTU patients (Patient 1). Telemetry Technician (TT) 1 noted Patient 1’s telemetry monitor leads (cables connecting a patient to the telemetry monitor) were off, TT 1 contacted Patient 1’s Certified Nurse Assistant (CNA) 1 first, then contacted Patient 1’s Registered Nurse (RN) 1 to notify them the monitor leads for Patient 1 were off. RN 1 did not assess Patient 1’s telemetry monitor leads, did not call TT 1 with the patient’s status, and TT 1 did not document RN 1’s name on Patient 1’s monitor strip. Patient 1 was off the telemetry monitor for 45 minutes. (Refer to A0398) These failures resulted in a delay in care and treatment decisions, which potentially contributed to Patient 1’s death. The cumulative effect of these failures resulted in the hospital’s inability to provide effective, safe and quality nursing services in accordance with the statutorily-mandated Conditions of Participation Nursing Services.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 39700 Based on interview, clinical record review, and facility policy review, the facility failed to ensure a policy for telemetry (heart rate and rhythm) monitoring of patients in the Medical Surgical and Telemetry Unit (MSTU) was implemented for one of 20 sampled MSTU patients (Patient 1) when, the Telemetry Technician (TT) 1 contacted Patient 1’s Registered Nurse (RN) 1 and the Certified Nurse Assistant (CNA) 1 to notify them the monitor leads (cables connecting a patient to the telemetry monitor) for Patient 1 were off, RN 1 did not go to the bedside to assess Patient 1’s monitor leads and did not call the TT 1 with the patient’s status, and TT 1 did not write RN 1’s name on Patient 1’s monitor strip. These failures resulted in a delay in care and treatment decisions, which potentially contributed to Patient 1’s death. Findings: Review of Medical Doctor (MD) 1’s note, titled “Progress Notes,” dated 2/9/2024 at 1:39 p.m. indicated Patient 1 had a history of dementia (loss of thinking abilities), high blood pressure, breast cancer, irritable bowel syndrome (common disorder that affects stomach and intestines). The note further indicated Patient 1 was brought into the hospital for increased confusion. Review of Patient 1’s dietary note, titled “Nutritional Documents,” dated 2/14/2024 at 11:19 a.m., indicated Patient 1 was requesting water and ice cream. The note indicated Patient 1 was reminded of her no food or drink by mouth diet, except for medications. Review of the facility’s Vocera (hands-off communication device) record, dated 2/14/2024 at 11:56 a.m., indicated TT 1 called CNA 1 which ended at 11:57 a.m. At 12:13 a.m., TT 1 called RN 1 which ended at 12:14 p.m. At 12:25 p.m., TT 1 called CNA 1 which ended at 12:26 p.m. Review of Patient 1’s cardiac rhythm strip, titled “Cardiac Monitoring Strips,” dated 2/14/2024 at 12 p.m., indicated Patient 1 had an irregular heart rhythm and a heart rate of 107 beats per minute. The strip further indicated TT 1 documented they notified RN 1, CNA 1, and Charge Nurse (CN) 1, Patient 1 was off of the telemetry monitor, and there was no cardiac monitoring for Patient 1 after this printed strip for 45 minutes. The Cardiac Monitoring Strip indicated no documented evidence that TT 1 documented RN 1’s name on this strip, per facility policy. Review of Patient 1’s medication record dated 2/14/2024 at 12:20 p.m., indicated RN 1 administered medication to Patient 1 by scanning her arm band at 12:20 p.m. Review of Patient 1’s Code Blue (medical emergency) record, titled “Cardiac Respiratory Code Record,” dated 2/14/2024 at 12:55 p.m., indicated Patient 1 did not have a heart beat at 12:55 p.m. and was a code blue. The record further indicated Patient 1 was unsuccessfully resuscitated (revive a person that has lost consciousness) and died at 1:13 p.m. During an interview with CN 1 on 3/26/2024 at 2:30 p.m., CN 1 stated she came back from break at 12:35 p.m. when TT 1 called on the phone to check Patient 1’s leads. CN 1 stated she checked on two patients’ call lights and then checked on Patient 1 at approximately 12:37 p.m. CN 1 stated Patient 1 was “naked and unresponsive,” had a massive amount of vomit in her mouth, and had no pulse. CN 1 stated she called RN 1, grabbed the crash cart (resuscitation equipment), and a code blue was called on Patient 1. During an interview with RN 1 on 3/27/2024 at 10:30 a.m., RN 1 stated she was the primary nurse for Patient 1 who was confused. On 2/14/2024, RN 1 stated Patient 1 had multiple visitors in the morning and was requesting liquids often. RN 1 stated Patient 1 was reminded that she could not drink or eat. At 12:20 p.m., RN 1 stated that she scanned Patient 1’s armband for her antibiotic medication, and Patient 1 “looked good.” At 12:45 p.m., RN 1 stated she was in an isolation room, and CN 1 called RN 1 to go to Patient 1’s room for the code blue. RN 1 denied receiving a call from TT 1. During an interview with Quality Director (QD) on 3/27/2024 at 11:20 a.m., QD stated Patient 1’s visitor disclosed that they had given Patient 1 coffee on the morning of 2/14/2024. QD further stated RN 1, CN 1, and CNA 1 were contacted by TT 1, because there was no telemetry reading on the monitor. During an interview with Telemetry Technician Supervisor (TTS) on 3/27/2024 at 12:55 p.m., TTS stated that she was the supervisor for TT 1. TTS further stated, “She [TT 1] told her that she [TT 1] had made multiple calls to the RN, CNA, and the Charge Nurse....She [TT 1] said she [TT 1] could not print anything before or during the code blue.... No reading at all.” TTS stated Patient 1’s telemetry monitor indicated “lead failure” and stated this meant the patient did not have leads connected to them. During an interview with the QD on 3/27/2024 at 1:20 p.m., QD stated the appropriate process when patients have telemetry leads off should be for the telemetry technician to contact the RN first. QD further verified that TT 1 contacted CNA 1 first, and the facility failed to ensure the telemetry policy was implemented appropriately. Review of the facility’s policy titled, “Telemetry,” last revised 8/2/2022, indicated the telemetry monitor priority one level calls require the telemetry technician to call the RN on Vocera or the phone, the RN will go to the patient’s bedside and call the telemetry technician with the patient’s status, and the telemetry technician will document the name of the responding RN and time on the patient’s strip. The policy further indicated priority one level calls include monitor leads that are off of the patient.”