HospitalInspections.org

Based on observation, interview and policy review, the facility failed to provide care in a safe setting for patients in 4 of 4 units as evidenced by nurses being unfamiliar with the location and use of emergency suction machines.

Findings included:

Review of facility policy titled "Code Blue Protocol", #POC-N194, last reviewed 3/29/2021 showed that all nursing staff would be oriented to medical emergency procedures and will know how to initiate CPR, which includes doing an airway check on the victim.

Observation on 4/19/22 at 12:05 pm of facility's Unit 2, a 'stepdown' type of Psychiatric Intensive Care Unit (PICU), showed there was a large bag containing emergency supplies, meant to be brought on site to an emergency event. The supplies included tubing used for suction machines, emergency drugs, breathing masks, oral airways, nasal cannulas, IV tubing, Normal saline, gauze pads, alcohol preps, and other important supplies. This bag was shared with an adjacent unit. There was no suction machine present in this room.

In an interview with ACNO #D at the time of observation, she stated that most of the facility units did not have typical crash carts as one might find in other hospitals and added that the bags containing emergency supplies were used instead. In addition, the bags were shared with two units, which surveyor observed to be stored in rooms adjoining two units.

In an interview on 4/19/22 at 12:10 pm with Registered Nurse (RN) #G who was caring for patients on Unit 2, she was asked where a suction machine was located and stated she was unsure. RN #G subsequently found the machine in the unit's medication room in a corner, underneath other supplies but was unfamiliar with how to turn-on the machine.

Observation on 4/19/22 at 12:15 pm on Unit 1, a PICU, showed it was adjacent to Unit 2 and shared an adjoining room. There was one nurse present (RN #H) caring for patients.

In an interview on 4/19/22 at 12:20 pm with RN #H, she stated she was unsure if there was a suction machine available and added that she would call the 'AOC' (supervisor) if one was needed.

Observation on 4/19/22 at 12:20 pm of Unit 5 showed it was a pre-adolescent unit and there was one nurse present (RN #I) caring for patients.

In an interview on 4/19/22 at 12:23 pm with RN #I, she stated she was unsure if there was a suction machine on the unit, then stated there was a suction machine on the crash cart for emergency use. ACNO #D who was present at the time, corrected RN #I and stated there was only an emergency bag, no crash cart.

Observation on 4/19/22 at 12:30 pm of Unit 7, an adolescent boys unit, showed there was a nurse present (RN #J) caring for patients.

In an interview on 4/19/22 at 12:32 pm with RN #J, she stated she was unsure if there was a suction machine present on the unit and did not know where to find one.