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NEUROPSYCHIATRIC HOSPITAL OF INDIANAPOLIS, LLC
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on document review, observation and interview, the facility failed to follow facility policy regarding Crash Cart and Emergency Medication Kit for 3 out of 3 Emergency Crash Carts.
Findings Include:
1. Review of policy titled: "Crash Cart and Emergency Medication Kit", PolicyStat ID: 9452267, last revised 05/2021. Purpose: To assure that an emergency cart containing supplies and monitoring equipment used in the care and initial treatment of cardiopulmonary arrest victims, including suction and defibrillator components are available and ready for use.
2. Reviewed Patient #1 medical record indicated the patient was admitted to the facility on 02/24/2022 with a tracheotomy that was capped. He/She used oxygen therapy at 2 liters via nasal canula. MR lacked documentation that patient # 1 needed to be suctioned throughout his/her stay. Patient # 1 was found unresponsive in F1 and required cardiopulmonary resuscitation.
3. During tour on 03/21/2022 with P50 (Director of Nursing) at approximately 10:15 A.M., this surveyor reviewed the contents of the 3 (three) crash carts on 100- unit, 200- unit, and 300- unit lacked an ambubag adaptor to be used in an emergency for patients that have a tracheotomy.
4. Interview on 03/21/2022 with P50 at 1040 A.M., confirmed that the facility (F1) does not stock an ambubag tracheotomy adaptor to use in an emergency in the crash carts. F1 failed to have a tracheotomy ambubag adaptor available during emergency situations.
QUALITY IMPROVEMENT ACTIVITIES
Tag No.: A0283
Based on document review and interview, the facility failed to follow their policy/procedure on grievance process. Review Grievance list provided for dates 10/01/2021 through 03/21/2022. Requested to review patient # 1 family grievance. Facility failed to provide for review by the end of survey.
Findings include:
1. Policy/procedure "Patient Grievance Procedure", PolicyStat ID: 8797046 last revised 01/2020. Policy indicated that this organization shall respond to such concerns in a timely, reasonable and consistent manner. Failed to provide documentation that this was done for the grievances requested.
2. On 2/10/22 at approximately 10:25 A.M., and 12:30 P.M. P50 (Director of Nursing) was requested to provide the surveyor, patient # 1 family grievance for review. At the time of this surveyors exit, this grievance was not provided for review.