Franklin General Hospital

“PROVISION OF SERVICES CFR(s): §485.635 Condition of Participation: Provision of Services This Condition is not met as evidenced by: 47335 Based on review of the Critical Access Hospital’s (CAH) policies and procedures, medical records, and interviews, the hospital’s administrative staff failed to ensure 1 of 5 sampled patients (Patient #9) received health care services in accordance with written policies. The investigation revealed hospital staff failed to provide Patient #9 (P9), a patient with an acute on chronic medical condition, with appropriate nursing care during a medical emergency upon finding the patient pulseless and unresponsive. The effects of these failures and deficient practices resulted in the hospital staffs’ failure to initiate cardiopulmonary resuscitation (CPR) and activate the medical emergency response protocol, which directly resulted in the loss of opportunity for life-sustaining intervention and the death of Patient #9.”

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 47335 Based on review of the Critical Access Hospital’s (CAH) policies and procedures, medical records, interviews, and observations, the hospital’s administrative staff failed to ensure 1 of 5 sampled patients (Patient #9) received appropriate nursing care during a medical emergency upon finding the patient pulseless and unresponsive. The effects of these failures and deficient practices resulted in the death of Patient #9 (P9). The hospital’s failures placed all patients hospitalized at risk. Findings include: 1. Review of policy number 19954306, “Medical Emergency,” last revised 4/2026, revealed in part: a. “The phrase ‘Medical Emergency’ encompasses those emergency situations which affect individual patients... who are in immediate threat of life.” b. “ ...Our main objective for the ‘Medical Emergency’ policy is to alert colleagues that an immediate response to a medical situation is needed...” c. “ ...Activate the Medical Emergency response when a patient within the [CAH] is having an acute medical crisis that requires emergent medical assistance...” d. “ ...After activating the ‘Medical Emergency’ return to the patient and continue assessment and provide treatment as appropriate...” 2. Review of policy number 19429023, “Rounding,” last revised 12/2025, revealed in part: a. “Nursing rounds will be done every hour.” b. “Nursing rounds will be conducted hourly by the nurse caring for the patient and/or delegated to the CNA [Certified Nursing Assistant]...” 3. Review of the CAH’s, “Resuscitation Form,” revealed in part: a. “ ...Full Resuscitation Code Status: I understand that all medical efforts will be sought and carried out within our abilities in a life-threatening emergency. This may include the following interventions: Cardiopulmonary resuscitation/cardiac compression (chest compressions)...” 4. Review of P9’s medical record revealed: a. On 2/26/26 at 8:16 AM, P9 presented to the ED for a complaint of shortness of breath. P9 received a work-up in the ED by Hospital Provider F, with labs and imaging completed. b. On 2/26/26 at 11:50 AM, Provider F admitted P9 for a diagnosis of chronic obstructive pulmonary disease (COPD) with pneumonia. P9 had multiple co-morbidities including COPD requiring home oxygen (O2), congestion of upper respiratory tract, hypoxia, dependent edema, hypertension (HTN), stasis ulcer of the bilateral lower extremity, and obstructive sleep apnea (OSA). c. On 2/26/26 at 12:45 PM, P9 signed the Resuscitation Form identifying their wishes to receive full resuscitation in the event of a life-threatening emergency. d. On 2/26/26 at 1:01 PM, Provider F ordered full resuscitation for P9. e. On 3/1/26 at 8:58 AM, Provider F noted P9 required an increased O2 flow from 4 liters (L) to 5 L using an O2 mask. Provider F noted P9’s lung sounds were distant with wheezes. P9 remained on telemetry monitoring, and had a pending cardiology consult. f. On 3/1/26 at 2:21 PM, Hospital Nurse C assessed P9’s vital signs (VS) which showed a blood pressure (BP) of 142/103 (Reference Range: 120/80), pulse (P) of 84 (Reference Range: 60-100), respiratory rate (RR) of 20 (Reference Range: 12-20), temperature (T) of 98.1 Fahrenheit (F) (Reference Range: 96.8 F), oxygen saturations (SpO2) of 92% (Reference Range: greater than 90%) with 5 L of oxygen per mask. g. On 3/1/26 at 3:00 PM, CNA H completed routine rounding on P9. h. On 3/1/26 at 3:57 PM, Nurse C reassessed P9’s P 85 and RR 20. i. On 3/1/26 at 6:00 PM, CNA H completed routine rounding on P9. j. On 3/1/26 at 6:50 PM, P9’s telemetry monitor (a medical device used to continuously track a patient’s vital signs) alarmed, alerting staff that P9 was in asystole (cardiac arrest). Nurse C found P9 unresponsive without a detectable heartbeat or spontaneous respirations. Nurse C summoned Hospital Nurse B to P9’s room. Nurse C notified Provider F. Staff pronounced P9 deceased with date and time of death. Hospital staff failed to initiate resuscitation efforts. 5. Review of the CAH’s investigation of P9’s death revealed: a. On 3/1/26 at 4:48 PM, P9’s telemetry monitor showed P9’s SpO2 was 67. b. On 3/1/26 at 5:48 PM, P9’s telemetry monitor showed P9’s SpO2 was 78. c. On 3/1/26 at 6:25 PM, P9’s telemetry monitor showed P9’s P was 114, ventricular premature contractions (VPC) (extra, abnormal heartbeats that disrupt the regular heart rhythm) were 5 (number of extra beats in one minute), and SpO2 was 93%. d. On 3/1/26 at 6:30 PM, P9’s telemetry monitor showed P9’s P was 126, VPC were 10, and SpO2 was 92%. e. On 3/1/26 at 6:35 PM, P9’s telemetry monitor showed P9’s P was 94, VPC were 11, and SpO2 was 52%. f. On 3/1/26 at 6:40 PM, P9’s telemetry monitor showed P9’s P was 72, VPC were 2, and SpO2 was 72%. Management identified on video footage, Nurse B sitting at the nurse’s station where the telemetry monitor was located. g. On 3/1/26 at 6:45 PM, P9’s telemetry monitor showed P9’s P was 34, VPC was 0, and SpO2 was 35%. h. On 3/1/26 at 6:46 PM, Management identified on video footage, Nurse B looking at the telemetry monitor, and Nurse C presented to the nurse’s station. i. On 3/1/26 at 6:50 PM, P9’s telemetry monitor showed P9’s P was 0, VPC were 12, and SpO2 was 14%. Management identified on video footage, Nurse B and Nurse C walking down the hall (in the direction of P9’s room). j. On 3/1/26 at 6:52 PM, Management identified on video footage, Nurse B and Nurse C returning to the nurse’s station, and Nurse C calling someone on the phone. 6. Hospital nursing failed to address the warning alerts on P9’s telemetry monitor and assess P9’s condition. Nurse C failed to identify P9’s change in condition and failed to notify the hospital provider when P9 demonstrated a significant decline in condition starting at 4:48 PM. When nursing staff entered P9’s room after P9’s telemetry monitor alarmed showing P9 was in asystole and found P9 to be pulseless and unresponsive, nursing staff left P9’s room to notify Provider F. Nursing staff failed to activate the facility’s medical emergency response and initiate cardiopulmonary resuscitation (CPR). Upon Provider F’s arrival, P9 was pronounced deceased, and CPR was not initiated. 7. During observation on 6/2/26, it was identified that all patients’ code status’ visibly posted on the exterior of the patient’s room and on the communication board inside their rooms. At the same time the Acute Nurse Manager acknowledged the code status for all patients should be posted in both locations for staff reference. 8. During an interview on 6/2/26 at 12:30 PM, Nurse C recalled P9, and acknowledged Nurse C failed to activate the Medical Emergency Response when P9 was found pulseless and unresponsive. Nurse C reported requesting Nurse B come to P9’s room to perform an additional assessment of P9. Nurse C acknowledged leaving P9’s room to notify Provider F of P9’s condition. Nurse C returned to P9’s room to wait for additional staff to arrive. Nurse C acknowledged CPR was not initiated according to P9’s provider order. 9. During an interview on 6/2/26 at 11:30 AM, Nurse B recalled P9. Nurse B acknowledged being alerted to P9’s condition by Nurse C, but denied completing an assessment of P9. Nurse B explained they went to P9’s room, Nurse B placed their hand on P9’s shoulder, but then returned to care for another patient. Nurse B acknowledged they did not initiate CPR and could not speak to whether other hospital staff initiated CPR. 10. During an interview on 6/2/26 at 3:45 PM, Provider F recalled P9. Provider F reported they were not aware P9 was a full resuscitation. Provider F explained, they asked Hospital Nurse C if they were “calling a code,” and Nurse C said “no, [P9] was a do not resuscitate (DNR).” Provider F acknowledged CPR was not initiated by hospital staff when P9 was found unresponsive and pulseless. 11. During an interview on 6/2/26 at 2:30 PM, CNA H recalled P9. CNA H denied being in the room when staff first arrived at P9’s room, but acknowledged when CNA H arrived at P9’s room to assist, staff were not performing CPR on P9. 12. During an interview on 6/2/26 at 4:25 PM, the Acute Nurse Manager acknowledged resuscitation efforts were not initiated on P9 when staff found P9 unresponsive and pulseless. Acute Nurse Manager acknowledged P9 was a full resuscitation code status. Acute Nurse Manager acknowledged staff failed to follow the Medical Emergency Response policy. Acute Nurse Manager acknowledged their expectations would have been for staff to use their basic life support (BLS) training when P9 was found unresponsive and pulseless, and call for assistance.”