HospitalInspections.org

15036

Based on record review and interview, the provider failed:
*To assess and eliminate potential environmental safety hazards prior to relocating patients with psychiatric diagnoses and for 1 of 1 sampled patient (1) that committed suicide.
*To ensure close observation with 15 minute wellness checks for one of one sampled patient (1) identified with unpredictable behavior were performed and documented in accordance with facility policy.
Findings include:

1. Observation and interview on 8/25/14 at 1:50 p.m. with the administrator and the adolescent program manager revealed:
*Patient 1 was originally a patient on Birch 2, a unit for adolescents.
*Birch 2 housed adolescent patients with psychiatric diagnoses. Some of those patients' diagnoses included self-harm or harm to others and at risk for suicide.
*To complete a flooring replacement project on Birch 2 the adolescent patients were relocated to Pine 1.
*Pine 1 had previously been set-up as an adult unit, not an adolescent unit.
*Patient 1 while a patient on Pine 1 had been on close observation with 15 minute checks for unpredictable behavior.
*Patient 1 had committed suicide by hanging. He had tied his long sleeve shirt around his neck and attached it to the toilet plumbing above the toilet bowl in his bathroom.

Continued observation and interview on 8/25/14 at 1:50 p.m. with the administrator and the adolescent program manager of patient 1's bathroom located on Pine I revealed:
*The handrails along the bathroom walls and weather stripping from the door had been removed after patient 1's suicide.
*The bathroom had a button to call the nurse. When pushed by the administrator it did not work.
*The shower stall had the handle to turn the water on and off and the knobs to adjust the water temperature.
*This had been the first such incident for the hospital, there had been no environmental concerns identified during the recent CARF accreditation survey or any of the past federal surveys.
*They had started meeting to discuss other potential environmental issues within the facility.
*The administrator had contacted a company in Colorado to request a review of the hospital environment for potential safety concerns but had not received a response.
*The director of plant operations had contacted a company to have custom made plumbing covers for the toilets but he did not have a date of arrival.

Review of a receipt invoice dated 8/18/14 from Cape Cod Systems Company provided the hospital an estimate for the cost of six toilet plumbing covers from specifications supplied by the hospital. There was no information on anticipated arrival of the toilet plumbing covers.

Review of an email dated 8/26/14 from the administrator to the Western Interstate Commission for Higher Education revealed a handwritten note stating "Contacted for an Environment Review on." There was no other information regarding a facility environmental review on that email.

Review of the medical staff meeting minutes revealed:
*On 6/4/14, a risk audit was held on 5/12/14 by the risk management office, and only physical plant issues had been identified. "There were no major issues."
* The unapproved meeting minutes for 8/6/14 indicated:
-The flooring projected had started on; it was planned for Birch 2 patients to relocate to Pine 1. There was no information in the meeting minutes Pine 1 had been assessed for environmental safety concerns prior to relocation.
-Concern had been expressed Birch 2 patients were the ones that got shuffled around and put into a position to suffer more difficulties than other units.

2. Review of patient 1's physician's orders on 7/30/14 at 8:45 p.m. revealed orders to "Discontinue escort status, Start close observation with 15 minute checks in the room with the door open." Justification for the orders was "Unpredictable, increased agitation, threatening staff."

Review of patient 1's close observation monitoring form entries on 8/3/14 from 6:15 p.m. to 6:45 p.m. revealed the staff had documented his location/activities in the facility:
*At 6:15 p.m. the patient was sitting in his room and medications were given.
*At 6:30 p.m. the patient was sitting in his room writing in his journal.
*At 6:45 p.m. the staff had documented "ADLs [activities of daily living] completed."

Interview on 8/25/14 at 4:25 p.m. and again on 8/26/14 at 1:25 p.m. with mental health aide (MHA) F regarding the incident on 8/3/14 for patient 1 revealed:
*The patient had come out to the nurses' station and obtained his face wash.
*Youth counselor (YC) C had let him into the bathroom at approximately 6:33 p.m.
*At approximately 7:00 p.m. she and YC C went to check on the patient and found him with his shirt wrapped around his neck.
*The patient had not been wet from the shower, she had removed the shirt from around his neck, and RN A had assisted to lay him on the ground.

Interview on 8/26/14 at 1:35 p.m. with YC G revealed she had documented on 8/3/14 at 6:45 p.m. on patient 1's close monitoring form "ADL completed." At the time of that documentation she had entered the patient's room, heard the shower running, but did not visually see the patient.

Interview on 8/26/14 at 2:30 p.m. with program director (PD) B confirmed:
*The staff had not followed the provider's policy for close observation. Close observation required a visual of the patient's location and activity at the time of documentation.
*YC C should have documented the patient was in the bathroom at 6:33 p.m., but she had not documented at that time.
*YC G should have directly observed patient 1's whereabouts when she had documented at 6:45 p.m. "ADLs completed." She should not have taken the word of a coworker the patient was in the shower.

Interviews on 8/26/14 and 8/27/14 as listed above with the facility staff and review of patient 1's medical record revealed no documentation by the staff of direct observation from approximately 6:33 p.m. until found in the bathroom at 7:00 p.m. with a shirt tied around his neck.

Review of the provider's 6/6/14 Patient Care - Privileges/Precautions policy for close observation with 15 minute checks revealed:
*The policy "Requires staff accounting for patient's whereabouts and visually observing patient at lease every 15 minutes."
*Paragraph 5.2.4.3 Close Observation:
-"It shall be the policy of the SDHSC that close observation procedure shall be instituted when a patient demonstrates behaviors or medical problems/concerns that indicated the need for close supervision; Examples: elopement risk, self-destructive tendencies, assaultive behavior, physical illness, repetitive falls, and declining cognitive functioning, etc."
-"The patient shall be restricted to the treatment unit when on close observation unless otherwise specified by a Doctor's order and staff shall document observation at a minimum of every 15 minutes, including everything that has happened since the last documentation."

Refer to A385, finding 2.

Based on record review and interview, the provider's sentinel report investigation results for one of one sampled patient (1) that was unresponsive, had no pulse, and was not breathing failed to addressed:
*Eliminating the potential for future hangings on the toilet plumbing.
*Why the professional nursing staff had not initiated rescue breathing for him.
*Inconsistencies in documented times of events by the code blue recorder on the code blue documentation form.
*Staff members had not conducted close observation with 15 minute checks by direct observation monitoring.
Findings include:

1. Review of the provider's sentinel investigation report findings for patient 1 revealed it failed to address:
*Corrective action that should have been taken to prevent potential hangings from toilet plumbing.
*The staff had not followed the provider's policy for direct observation of the patient prior to documenting close observation monitoring.
*The professional staff had only performed chest compressions for the patient. Rescue breathing was not initiated until arrival of the automated external defibrillator (AED was a device that monitors a person heart rate and would advise a shock if the person had a shockable heart rate), eleven minutes later.
*The inconsistencies in documented times of events by the code blue recorder on the code blue documentation form.

Interview and tour of patient 1's bathroom on 8/25/14 at 1:50 p.m. with the administrator reveled they had thought the patient had tied his long sleeve shirt around the handrails along the bathroom wall. All handrails in the bathrooms had been removed. Plumbing covers the toilets had been ordered but had not arrived.

Interview and review of the picture of patient 1's bathroom on 8/26/14 at 4:35 p.m. with mental health aide F revealed she had found the patient in his bathroom with his shirt tied around his neck. The shirt had been attached to the plumbing fixture, and she pointed to the spot on the plumbing fixture. She confirmed the shirt had not been tied around the handrails on the bathroom walls.

2. Interview on 8/26/14 at 2:30 p.m. with program director (PD) B confirmed:
*The staff had not followed the provider's policy for close observation for patient 1. Close observation required a visual of the patient's location and activity at the time of documentation.
*Close observation monitoring meant the staff documenting an observation should have had eyes on the patient.
*YC C should have documented the patient was in the bathroom at 6:33 p.m., but she had not documented at that time.
*YC G should have directly observed patient 1's whereabouts when she had documented at 6:45 p.m. "ADLs completed." She should not have taken the word of a coworker the patient was in the shower.

3. Telephone conference on 8/26/14 at 2:35 p.m. with registered nurse (RN) E and in attendance the director of nursing and PD B revealed:
*It had taken him approximately less than six minutes to arrive at the scene of the cardiopulmonary resuscitation (CPR).
*When he arrived on the scene RN A and another nurse were performing CPR.
*He did not start recording right away as he went to get the clipboard to document the code blue.
*He had observed and documented the AED was placed on the patient at 7:11 p.m.
*He had documented times of events prior to his arrival by interviewing staff already at the scene.

Interview and review of the report of code blue form on 8/26/14 at 12:20 p.m. and again on 8/26/14 at 4:30 p.m. with the director of nursing regarding patient 1's code blue revealed:
*She had reviewed the form but had not noticed the inconsistencies in information documented on that form.
*The facility did not have many code blues, and the staff had received quarterly competency reviews for code blue.
*During code blues the documented the actual code blue on a worksheet, and then copied the information onto the report of code blue call form.
*RN E's documentation on the report of code blue call form was not accurate for:
-The time the first responder had initiated CPR. The first responder was on the scene at 7:00 p.m. and had initiated CPR at that time, not at 7:08 p.m. as documented on that form. RN E should have documented CPR reinitiating at 7:00 p.m.
-RN E had documented the AED had been applied at 7:11 p.m. and documented "Asystole - no shock advised." That entry was incorrect. The AED had arrived earlier, RN E had also documented on the form at 7:08 "Asystole - no shock advised."
-RN E was the recorder but did not immediately start recording, he had helped obtain the emergency supply cart, recalled he was the recorder, and obtained his information documented through staff interviews and observation once he started documenting.

Based on record review, interview, and policy review, the provider failed to ensure:
*Appropriate cardiopulmonary resuscitation (CPR) had been performed for one of one sampled patient (1) who was found in a bathroom with no respirations and no palpable pulse.
*Fifteen minute checks had been performed by the staff as indicated in the policy and procedure for one of one sampled patient (1) who was on close observation related to unpredictable behavior.
*As needed medication (PRN) administered for anxiety had been followed up on for effectiveness for one of one sampled patient (1). Findings include:

1. Interview on 8/26/14 at 8:15 a.m. with registered nurse (RN) A regarding an 8/3/14 medical emergency involving patient 1 revealed:
*She was currently advanced cardiac life support (ACLS) certified.
*She was working a twelve hour shift on 8/3/14 and was about to clock-out at approximately 7:00 p.m. for the day when she heard yelling down the hallway.
*She heard "Grab a scissors, we need scissors." from one of the staff members.
*She went down the hallway where the commotion was and entered patient 1's room:
-The patient was sitting on the floor beside the right side of the toilet.
-The staff had gotten the shirt untied from around the patient's neck.
-She felt for a pulse at the carotid artery (artery in the neck that pulsates), and there was no pulse.
-The patient's color was pale.
-He had no respirations.
-Staff held his head as they lowered him to a lying position on the floor.
-She felt for a pulse again, and no pulse was palpable (felt).
-One of the staff went and called a code blue.
*She started chest compressions but had not started rescue breathing.
*The crash cart from the Spruce wing arrived within three to four minutes.
*She felt for a pulse again, and there was no pulse.
*An intravenous (IV) line was started in his vein by a staff member.
*The Automatic External Defibrillator (AED) was placed on the patient, and there was no rhythm noted on the monitor and no shock had been advised on the AED. The AED was analyzed twice during the code.
*The night shift nurse then arrived, and they had switched off doing chest compressions. There was no rescue breathing performed.
*The ambulance arrived approximately nine minutes later.
*The ambulance crew performed CPR, intubated the patient, and then transported the patient to the hospital where he was pronounced dead.
*When RN A was asked why she had not done any rescue breathing she stated, "Chest compressions are the most important." That was what she had been taught in her CPR class.

Interview on 8/26/14 at 9:00 a.m. with Cedar II RN I regarding CPR and emergencies revealed:
*Rescue breathing would have been initiated if a patient had been found unresponsive and not breathing.
*There were microshield masks in the medication room and one placed in the fire extinguisher area in case of an emergency.

Interview on 8/26/14 at 9:20 a.m. with charge RN J for Oak I and Oak II regarding CPR and emergencies revealed:
*She would perform rescue breathing in a patient who was without respirations with the microshield mask.
*There was a code team available for emergencies twenty-four hours per day that would include a responder and a recorder.
*There was a schedule so all the nurses knew who was on the code team.

Interview on 8/26/14 at 10:30 a.m. with staff development RN D regarding CPR training revealed:
*She had been the staff development nurse for fourteen years.
*There was healthcare provider classes (CPR) taught for medical staff, nurses, and certified nurse practitioners/physician assistants.
*The teaching followed the format provided by the American Heart Association.
*Rescue breathing would have been taught along with the chest compressions. Thirty compressions to two breaths in cycles of five.
*Microshield masks were provided at the nurses station, at the fire extinguisher boxes, or staff could carry them with them if they had desired to do so.
*AED was also taught in this class.
*She agreed the incident on 8/3/14 involving patient 1 in which the AED had taken eleven minutes to apply was an extended amount of time.

Interview on 8/26/14 at 10:40 a.m. with the director of education and support services H regarding CPR training for staff revealed:
*Two classes were taught that included:
-Heart Saver that was taught to non-medical staff. They were taught adult and child CPR, and choking.
-Healthcare provider that taught nurses, physician's, and physician's assistants/certified nurse practitioner adult, child, and infant CPR, two man CPR, Ambu-bag, and AED training.
*Rescue breathing/how to use a face shield mask were taught in the class.
*Her expectation would have been to perform rescue breathing when a patient was found with no respirations.
*The community was taught chest compressions, but that was not taught here.
*The video the staff had watched instructed the staff that chest compressions were the most important, but also taught rescue breathing along with chest compressions.
*Thirty chest compressions to two respirations in cycles of five was the correct CPR.

Interview on 8/26/14 at 2:00 p.m. with the program director of adolescents regarding the incident on 8/3/14 that involved patient 1 revealed rescue breathing should have been initiated when the patient had been found unresponsive and with no respirations.

Interview on 8/26/14 at 3:15 p.m. with RN A regarding the incident on 8/3/14 involving patient 1 revealed:
*After the crash cart arrived the Ambu-bag was used and 100 percent (%) oxygen was provided. The second nurse that was coming on to work the twelve hour night shift had applied the Ambu-bag.
*No rescue breathing had been started until the crash cart arrived several minutes later.
*She would have notified the physician if there had been any increased behaviors exhibited by patient 1.
*She had administered Vistaril 25 milligrams orally on 8/3/14 at 6:15 p.m. because the patient was experiencing some anxiety. He was crying, rocking back and forth on his bed, and shaking.
*She would need to go back and check on the patient's response to the medication between fifteen and thirty minutes.
*Instead of checking on the patient herself, she had asked a youth counselor how he had been doing. So she had not physically checked on the patient's status after the Vistaril had been administered.

Review of the provider's 5/5/14 reviewed CPR policy revealed:
*It was the policy of the SDHSC [South Dakota Human Services Center] that CPR should have been administered according to the guidelines of the American Heart Association as taught by the certified instructors.
*CPR should have been initiated on all victims of respiratory or cardiac arrest - unless a NO Code Blue had been ordered.
*A victim might have been a patient, trusty, visitor, or a staff member.
*The purpose was to provide basic life support by supplying oxygen and providing circulation using artifical means of ventilation (breathing) and cardiac (heart) compressions.
*A microshield should have been used for ventilating victims.
*A microshield was readily available for use as needed by each employee.
*Adult CPR for one rescuer for a healthcare provider would include:
-Opening the airway using a head tilt-chin lift method.
-Look, listen, and feel for breathing (5-10 seconds). If no adequate breathing, give two breaths (one second each) using a barrier device. Watch the victim's chest rise with breaths.
-Check for a carotid pulse (5-10 seconds). If no pulse, start cycles of 30 chest compressions and 2 breaths.

Review of the provider's reviewed 5/5/14 Code Blue Response/Initiation policy revealed:
*It was the policy of the SDHSC that a Code Blue was called and procedures should have been initiated in the event that a victim experience an obstructed airway, respiratory arrest, cardiac arrest, and/or a potentially life threatening event. A victim might have been a patient, trusty, visitor, or staff.
*The purpose of that policy was to ensure emergency equipment, medication, supplies, and a trained team were available in cases of airway obstruction, respiratory arrest, cardiac arrest, and/or a potentially life threatening event.
*Responsible Parties included:
-Physician/PA/CNP.
-Automatic External Defibrillator (AED) RN.
-IV RN.
-Recording RN.
-Nurse Manager/House Supervisor.
-RNs/LPNs.
-Treatment Unit staff.
*First responders to the scene determined unresponsiveness and activated the Code Blue.
*Initiate CPR immediately.
*The first available RN should be the coordinator of the Code Blue Scene.
*Nurses arriving at the Code Blue should assist with:
-CPR.
-Delivery of oxygen at 100%/15 liters.
-Ensure CPR was effective by checking for the carotid pulse and the return of respirations.
-Vital signs (blood pressure, pulse, respirations) including oxygen saturation (how much oxygen was circulating in the blood stream).

Review of the provider's reviewed 5/5/14 Ambu-bag (manual resuscitation) policy revealed:
*It was the policy at SDHSC that an Ambu-bag should have been utilized for all victims needing ventilatory and/or respiratory assistance.
*To provide ventilatory assistance to a respiratory compromised victim.
*To provide an oxygen source with ventilatory enhancement to a respiratory compromised victim.

Review of the provider's reviewed 5/5/14 Semi-Automated External Defibrillator (AED) procedure revealed:
*It should be the policy of the (name of the provider) that a Semi-Automated External Defibrillator (AED) was used for Code Blue response by following a current American Heart Association Algorithm approved by the medical director.
*The purpose was to provide emergency defibrillation in cardiac arrest and/or monitoring of cardiac conditions.
*If a shockable rhythm was not detected, the AED told you "No Shock Advised." Analysis was suspended for two minutes while the patient was attended to and CPR was administered.

Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 8th Ed., St. Louis, Mo., 2013, pp. 565 and pp. 853 revealed:
*"In all settings, nurses are responsible for evaluating the effects of medications on the patient's ongoing health status.
*If a patient's hypoxia is severe and prolonged, cardiac arrest results. A cardiac arrest is a sudden cessation of cardiac output and circulation. When this occurs, oxygen is not delivered to tissues, carbon dioxide is not transported from tissues, tissue metabolism becomes anaerobic, and metabolic and respiratory acidosis occurs. Permanent heart, brain, and other tissue damage occur within 4 to 6 minutes."



15036

2. Review of patient 1's medical record revealed:
*He was admitted on 7/19/14 at 6:40 p.m. from another behavioral healthcare facility.
*Diagnoses included depression; family relational problems; polysubstance dependence of over-the-counter medications, prescription medications, cannabis, inhalants, alcohol; and borderline personality traits.
*Previous suicide attempts had occurred in May 2013, June 2014, and July 2014.

Review of patient 1's physician's orders on 7/30/14 at 8:45 p.m. revealed orders to "Discontinue escort status, Start close observation with 15 minute checks in the room with the door open." Justification for the orders was "Unpredictable, increased agitation, threatening staff."

Review of patient 1's close observation monitoring form entries on 8/3/14 from 6:15 p.m. to 6:45 p.m. revealed the staff had documented his location/activities in the facility:
*At 6:15 p.m. the patient was sitting in his room, and medications were given.
*At 6:30 p.m. the patient was sitting in his room writing in his journal.
*At 6:45 p.m. the staff had documented "ADLs [activities of daily living] completed."

Review of patient 1's Report of Code Blue Call form revealed at 7:00 p.m.:
*The patient had been found on the "Ground in bathroom."
*A code blue had been called at 7:01 p.m. The code blue called was to alert staff to bring the emergency crash cart to facilitate cardiopulmonary resuscitation (CPR) for patients that were not responding, had no heart beat, and not breathing.
*The first responder was registered nurse (RN) A, and she had initiated CPR at 7:09 p.m.
*The emergency medical system had been activated, and emergency medical staff arrived at 7:12 p.m.
*The code blue was discontinued at 7:33 p.m., the patient's condition was "Pt. in asystole [patient did not have a heartbeat]", and the patient was transferred to Avera Sacred Heart Hospital by the EMS crew.

Interview on 8/26/14 at 1:00 p.m. with youth counselor (YC) C regarding patient 1's incident on 8/3/14 revealed:
*She had returned from break at approximately 7:57 p.m. and stated "______ [patient 1] not out of the BR [bathroom] yet. We need to go check on him."
*She and mental health aide (MHA) F went into his bedroom, knocked on the bathroom door, but did not receive a response.
*She told MHA F to get into the bathroom.
*She had seen the patient with a shirt tied around his neck. He was on the right side of the toilet lying on the floor with his left arm hung over the toilet.
*She had called for RN A, and she had come to assist.
*The surveyors asked what was monitoring and she stated "Monitor to see where they are at. Observing and seeing them is monitoring. Which would be eyes on the patient if they are on 15 minute checks."

Interview on 8/26/14 at 1:25 p.m. with MHA F regarding patient 1's incident on 8/3/14 revealed:
*She and YC C had went to do checks at the "top of the hour [7:00 p.m.] and had found the patient hanging.
*YC C had went to get scissors, but she was able to untie the long sleeve shirt from around his neck.
*She was not sure but had thought the shirt had been tied to the toilet plumbing.
*RN A had arrived and assisted to lay him on the ground.
*A code blue had been called.

Interview on 8/26/14 at 1:35 p.m. with YC G regarding patient 1's incident on 8/3/14 revealed:
*Approximately at 6:15 p.m. she had returned to the unit, the patient had asked her if he could call his grandmother, "He was not comfortable telling staff."
*The patient entered his room, and she had asked him how did he want to make the call.
*The patient was "Breathing heavy, rocking back and forth, crying, wouldn't respond" and she had never seen him that way before. She had notified RN A who administered Vistaril.
*He wanted "chill time" he liked to journal.
*At 6:30 p.m. while at the desk RN A had asked how was the patient going to make his phone call to his grandmother. She had entered his room, heard the shower running, did not see the patient, but he was not on bathroom escort.
*At 6:45 p.m. she had documented on the close observation form "ADL completed." She did not have visual observation of the patient at the time of that documentation.
*He should have been checked on at 6:55 p.m. and was checked on at 7:00 p.m.
*Close observation by policy meant documenting what the patient had been doing within the last 15 minutes, not at the time of the observation.
*Every 15 minute checks were "Hard to meet if you have 5 patients."

Interview on 8/26/14 at 2:30 p.m. with program director (PD) B confirmed:
*The staff had not followed the provider's policy for close observation. Close observation required a visual of the patient's location and activity at the time of documentation.
*Staff used the close observation form to document monitoring of patients on every 15 minute checks.
*Close observation monitoring meant the staff documenting an observation should have eyes on the patient.
*YC C should have documented the patient was in the bathroom at 6:33 p.m., but she had not documented at that time.
*YC G should have directly observed patient 1's whereabouts when she had documented at 6:45 p.m. "ADLs completed." She should not have taken the word of a coworker the patient was in the shower.

Review of the provider's 6/6/14 Patient Care - Privileges/Precautions policy for close observation with 15 minute checks revealed:
*The policy "Requires staff accounting for patient's whereabouts and visually observing patient at lease every 15 minutes."
*Paragraph 5.2.4.3 Close Observation:
-"It shall be the policy of the SDHSC [South Dakota Human Services Center] that close observation procedure shall be instituted when a patient demonstrates behaviors or medical problems/concerns that indicated the need for close supervision; Examples: elopement risk, self-destructive tendencies, assaultive behavior, physical illness, repetitive falls, and declining cognitive functioning, ect."
-"The patient shall be restricted to the treatment unit when on close observation unless otherwise specified by a Doctor's order and staff shall document observation at a minimum of every 15 minutes, including everything that has happened since the last documentation.