HospitalInspections.org

Based on record review, observation, and interview, the hospital failed to meet the emergency needs of patients in accordance with acceptable standards of practice. Specifically, the hospital failed to have registered nurses (RNs) who were qualified through a combination of training and experience to initiate necessary treatment to patients who presented with a medical emergency at the hospital's Psychiatric Center Emergency Room. This deficient practice prevented the immediate availability of qualified nursing personnel to render Advanced Cardiac Life Support (ACLS) to Patient #1, who experienced a cardiac arrest at the Psychiatric Center Emergency Room, and jeopardized this patient's health and safety. The findings are:

A. Record review of the hospital's timeline of care and the local Fire Department's timeline of care for Patient #1 revealed that a span of 17 minutes occurred on 04/27/15 between 6:48 am when the facility RN Manager checked the pulse of Patient #1 and 7:05 am when Emergency Medical Services (EMS) first checked Patient #1's pulse (subsequent to the arrival of EMS at the hospital's Psychiatric Center at 7:03 am in response to the hospital's 9-1-1 call).

1. The hospital's timeline of the event (derived by the facility from a security camera video taken on 04/27/15) indicated the following:
a. At 6:41 am Patient #1 was found unresponsive in a prone position in 5-point restraints, pulse assessed.
b. At 6:45 am restraints released.
c. At 6:48 am RN Manager checks pulse and respiratory effort.
d. At 6:57 am local Fire Dept. arrives at the hospital.

2. The local (city) Fire Department "Patient Care Report" for Patient #1 dated 04/27/15 indicated the following:
a. Received call from the facility's Psychiatric Center at 6:51 am on 04/27/15; type of call ALS (advanced life support); nature of call "cardiac arrest"; dispatched at 6:54 am.
b. Arrived on scene at the facility's Psychiatric Center at 7:03 am; primary impression "cardiac arrest before arrival."
c. At 7:05 am no blood pressure was measurable; cardiac status was a pulseless electrical activity arrest; first measurable blood pressure 70/0 at 7:19 am (normal is 120 mm Hg over 80 mm Hg), pulse is 138 (normal is 80 to 100 beats per minute).
d. Additional notes: "No vitals obtained from providers."


B. Review of Patient #1's medical record confirmed his death on 04/29/15.


C. On 05/12/15 at 3:15 pm, during interview, the Director of the facility's Psychiatric Center confirmed that none of the registered nurses on the unit were ACLS qualified. She also confirmed that the unit uses Basic Life Support and the Rapid Response Team to manage an emergency until EMS arrives.


D. On 05/12/15 at 9:30 am, during interview, the Vice President of Clinical Affairs stated that the hospital depends on the [city] Fire Department to "support" the hospital team consisting of the facility's Psychiatric Center staff and the Rapid Response Team. By calling 9-1-1, a central dispatcher, the response could be either an ambulance service or the [city] Fire Department. When asked why the [city] Fire Department is requested to support the hospital team, the Vice President of Clinical Affairs responded that the [city] Fire Department has the ACLS equipment and trained personnel to provide immediate care in life-threatening circumstances. He stated further that the lead physician of the Psychiatric Center had only Basic Cardiac Life Support (BLS) training and that the Psychiatric Center did not have a fully stocked ACLS code cart in the unit.


E. On 05/12/15 at 2:15 pm, during interview, two Rapid Response Team members acknowledged that the facility's Psychiatric Emergency Service did not have a fully stocked ACLS crash cart on the unit. The Rapid Response team, from wherever within the hospital the team was located at a given time, had to bring a special kit with ACLS medications and equipment when called.


F. Review of the facility's policy and procedure titled "Cardiopulmonary Resuscitation (CPR) Procedure and Documentation" revised on 01/2015 indicated the following: "During an emergency situation, the Registered Nurse (RN) who is Advanced Cardiac Life Support (ACLS) certified is within the New Mexico Nursing Scope of Practice to assist the LIP [licensed independent practitioner] in a code situation. For the Ambulatory clinics, Children's Psychiatric Center and [the facility's] Psychiatric Center the senior medical clinician and the Rapid Response Team are responsible for the medical care and management of the situation until Emergency Medical Service (EMS) arrives...Children's Psychiatric Center and [the facility's] Psychiatric Center provide BLS/CPR and call 911."

Based on record review, observation, and interview, the hospital failed to initiate immediate Advanced Cardiac Life Support (ACLS) to meet the emergency needs of a patient (Patient #1) who experienced a cardiac arrest at the facility's Psychiatric Center Emergency Room. The hospital, in failing to have (1) qualified ACLS personnel in the Psychiatric Center Emergency Room (refer to A-092) and (2) a fully stocked ACLS code cart in the Psychiatric Center Emergency Room, created the likelihood of serious harm, injury or death for all patients, including Patient #1, arriving at the Psychiatric Center Emergency Room. Therefore, an Immediate Jeopardy (IJ) was identified on 05/12/15 at 12:00 pm.

On 05/12/15 at 1:30 pm, the Administrator submitted an acceptable plan of removal entitled "Hospital Campus Medical Emergency Response Plan," which stated in part that the hospital "will staff 2 paramedics" at the Psychiatric Center "24 hours a day 7 days a week" and that an "advanced cardiac life support cart will be deployed immediately" to the Psychiatric Center.

On 05/13/15 at 1:30 pm, during observation, the facility's Psychiatric Center was visited a 2nd time. A complete ACLS crash cart was found in the closed nursing station adjacent to the patient rooms, easily available for a patient emergency. These findings confirmed the actions to remedy the Immediate Jeopardy, and the Administrator and the Medical Director of Emergency Services were informed that the IJ had been removed.

A. Record review of the hospital's timeline of care and the local Fire Department's timeline of care for Patient #1 revealed that a span of 17 minutes occurred on 04/27/15 between 6:48 am when the facility RN Manager checked the pulse of Patient #1 and 7:05 am when Emergency Medical Services (EMS) first checked Patient #1's pulse (subsequent to the arrival of EMS at the hospital's Psychiatric Center at 7:03 am in response to the hospital's 9-1-1 call).

1. The hospital's timeline of the event (derived by the facility from a security camera video taken on 04/27/15) indicated the following:
a. At 6:41 am Patient #1 was found unresponsive in a prone position in 5-point restraints, pulse assessed.
b. At 6:45 am restraints released.
c. At 6:48 am RN Manager checks pulse and respiratory effort.
d. At 6:57 am local Fire Dept. arrives.

2. Record review of the local Fire Department "Patient Care Report" for Patient #1 dated 04/27/15 indicated the following:
a. Received call from the facility's Psychiatric Center at 6:51 am on 04/27/15; type of call ALS (advanced life support); nature of call "cardiac arrest"; dispatched at 6:54 am.
b. Arrived on scene at the facility's Psychiatric Center at 7:03 am; primary impression "cardiac arrest before arrival."
c. At 7:05 am no blood pressure was measurable; cardiac status was a pulseless electrical activity arrest; first measurable blood pressure 70/0 at 7:19 am (normal is 120 mm Hg over 80 mm Hg), pulse is 138 (normal is 80 to 100 beats per minute).
d. Additional notes: "No vitals obtained from providers."


B. Review of Patient #1's medical record confirmed his death on 04/29/15.


C. On 05/12/15 at 3:15 pm, during interview, the Director of the facility's Psychiatric Center confirmed that none of the Registered Nurses on the unit were ACLS qualified. She also confirmed that the unit uses Basic Life Support and the Rapid Response Team to manage an emergency until EMS arrives.


D. On 05/12/15 at 9:30 am, during interview, the Vice President of Clinical Affairs stated that the hospital depends on the [City] Fire Department to "support" the hospital team consisting of the facility's Psychiatric Center staff and the Rapid Response Team. By calling 9-1-1, a central dispatcher, the response could be either an ambulance service or the [City] Fire Department. When asked why the [City] Fire Department is requested to support the hospital team, the Vice President of Clinical Affairs responded that the [City] Fire Department has the ACLS equipment and trained personnel to provide immediate care in life-threatening circumstances. He stated further that the lead physician of the Psychiatric Center had only Basic Cardiac Life Support (BLS) training and that the Psychiatric Center did not have a fully stocked ACLS code cart in the unit.


E. On 05/12/15 at 2:15 pm, during interview, two Rapid Response Team members acknowledged that the facility's Psychiatric Emergency Service did not have a fully stocked ACLS crash cart on the unit. The Rapid Response team, from wherever within the hospital the team was located at a given time, had to bring a special kit with ACLS medications and equipment when called.


F. Review of the facility's policy and procedure titled "Cardiopulmonary Resuscitation (CPR) Procedure and Documentation" revised on 01/2015 indicated the following: "During an emergency situation, the Registered Nurse (RN) who is Advanced Cardiac Life Support (ACLS) certified is within the New Mexico Nursing Scope of Practice to assist the LIP [Licensed Independent Practitioner] in a code situation. For the Ambulatory clinics, Children's Psychiatric Center and [the facility's] Psychiatric Center the senior medical clinician and the Rapid Response Team are responsible for the medical care and management of the situation until Emergency Medical Service (EMS) arrives...Children's Psychiatric Center and [the facility's] Psychiatric Center provide BLS/CPR and call 911."


G. On 05/13/15 at 1:30 pm, during observation, the facility's Psychiatric Center was visited again. A complete ACLS crash cart was found in the closed nursing station adjacent to the patient rooms, easily available for a patient emergency. These findings confirmed the actions to remedy the Immediate Jeopardy.