HospitalInspections.org

Based on review of "2020 American Heart Association Guidelines for CPR [cardiopulmonary resuscitation] and ECC [emergency cardiac care]," hospital policies, medical records, video footage, and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) with an Emergency Medical Condition (EMC) received medical treatment, supervision and an ongoing medical screening exam for 1 of 20 (Patient #1) sampled patients who expired in the hospital's ED waiting room while waiting for treatment of an emergency medical condition.

The findings included:

Patient #1 presented to Hospital #1 Psychiatric Hospital ED on 6/5/2021 at 12:45 PM after being discharged from Hospital #1 Adult Hospital on 6/5/2021 at 11:25 AM for detoxification and treatment of withdrawal from alcohol and benzodiazepines. Patient #1 had multiple prior admissions for drug use and a history of polysubstance abuse including intravenous heroin, methamphetamine, benzodiazepines, cocaine, cannabinoids, and alcohol. Patient #1 was admitted to the intensive care unit (ICU) at Hospital #1 Adult Hospital on 6/2/2021 and discharged from the Hospital #1 Adult Hospital on 6/5/2021. At discharge, Patient #1 opted against inpatient residential treatment but then presented to Hospital #1 Psychiatric Hospital ED (Psychiatric Assessment Service [PAS]) 1 hour and 20 minutes after discharge for referral to a residential treatment program. Patient #1 was placed on 15 minute checks for observation precautions. Video observations showed the Behavioral Health Specialist was out of view of the Patient in order to conduct every 15 minute visual checks. Patient #1 was triaged with an Emergency Severity Index (ESI) of Level 4-Less Urgent. Patient #1 was found by Nurse #2 unresponsive in a chair in the waiting room on 6/5/2021 at 10:35 PM. The cardiopulmonary resuscitative efforts were unsuccessful, and Patient #1 was pronounced dead on 6/5/2021 at 10:50 PM, 10 hours and 5 minutes after arriving at the Psychiatric ED.
The hospital failed to provide an appropriate ongoing medical screening examination to Patient #1 while he waited in the ED waiting room for treatment. This failure posed an immediate and serious threat to Patient #1's health and safety and inappropriately delayed treatment for his emergency medical condition.

Refer to A-2406.

Based on review of "2020 American Heart Association Guidelines for CPR [cardiopulmonary resuscitation] and ECC [emergency cardiac care]," hospital policies, medical records, video footage, and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) with an Emergency Medical Condition (EMC) received medical treatment, supervision and an ongoing medical screening exam for 1 of 20 (Patient #1) sampled patients who expired in the hospital's ED waiting room while waiting for treatment of a psychiatric medical condition.

The findings included:

1. Review of the "2020 American Heart Association Guidelines for CPR and ECC" revealed, "...Adult Basic Life Support Algorithm for Healthcare Providers...Verify scene safety...check for responsiveness...shout for nearby help...activate emergency response system via mobile device (if appropriate)...Get AED [automated external defibrillator] and emergency equipment (or send someone to do so)...Look for no breathing or only gasping and check pulse (simultaneously). Is pulse definitely felt within 10 seconds?...No breathing or only gasping, pulse not felt...Start CPR...Perform cycles of 30 compressions and 2 breaths...Use AED as soon as it is available ..."

2. Review of the hospital policy, "Emergency Screening, Stabilization, and Transfer," revealed, "...[Hospital #1] provides MSEs [medical screening exams] within the capability of its emergency departments (ED) or Adult Psychiatric Assessment Service (PAS) in accordance with the Emergency Medical Treatment and Labor Act (EMTALA), federal statute 42 CFR [code of federal regulations] 489.24, mandate to determine whether an EMC [emergency medical condition], and (a) provide a medical examination and stabilizing treatment to individuals with an EMC, or (b) arrange for transfer of the individual to another medical facility in accordance with the procedures set forth within this policy..."

Review of the hospital policy, "Triage and Care of Psychiatric Patients in the Emergency Department," revealed, "...While in the ED, the primary RN [registered nurse] is responsible for assessment, ongoing monitoring, interventions, and documentation in the electronic medical record..."

Review of the hospital policy, "Patient Observation Precautions," revealed, "...It is the policy of [Hospital #1 Psychiatric Hospital] to provide the level of observation required to provide safety to patients and staff...Every 15 minute checks...This level of precaution means that staff make visual contact with the patient every 15 minutes..."

Review of the hospital "PAS Orientation Manual," revealed, "...Patient Re-Assessment...The RN will reassess the patient as needed...Abnormal assessment findings will need to be reassessed throughout shift and reported to QMP [qualified medical provider] or resident...Patients must have a CSSRS (Columbia screening) [Columbia Suicide Severity Rating Scale] re-assessment completed each shift and documented..."

3. Patient #1 presented to Hospital #1 Psychiatric Hospital ED on 6/5/2021 at 12:45 PM after being discharged from Hospital #1 Adult Hospital on 6/5/2021 at 11:25 AM. Patient #1 presented to the Hospital #1 Adult Hospital ED on 6/2/2021 for detoxification and withdrawal from alcohol and benzodiazepines. Patient #1 had multiple prior admissions for drug use and a history of polysubstance abuse including intravenous heroin, methamphetamine, benzodiazepines, cocaine, cannabinoids, and alcohol. Patient #1 was admitted to the intensive care unit (ICU) at Hospital #1 Adult Hospital on 6/2/2021 and discharged from the Hospital #1 Adult Hospital on 6/5/2021. At discharge, Patient #1 opted against inpatient residential treatment but then presented to Hospital #1 Psychiatric Hospital ED (Psychiatric Assessment Service [PAS]) on 6/5/2021 at 12:45 PM (1 hour 20 minutes after discharge) for referral to a residential treatment program. Patient #1 was placed on 15 minute checks for observation precautions.

Nurse #1 documented an initial assessment on 6/5/2021 at 1:22 PM which included high risk screening for transient ischemic attack/stroke and acute coronary syndrome.

Nurse #1 documented the following vital signs at 1:24 PM: temperature 98.4 degrees Fahrenheit, pulse rate 89, respirations 17, blood pressure 112/84, and oxygen saturation level 100%.

Review of the MSE initiated at 1:26 PM by Physician #1 revealed, " ...Asked to assess substance use in this 57-year-old man admitted 6/3/2021 s/p [status post] reported withdrawal seizure on 6/2/2021, seeking ...detoxification on arrival. History of severe opioid use disorder, with prior MOUD [medication for opioid use disorder] trials (methadone, buprenorphine); also with prescribed clonazepam and gabapentin, with limited outpatient engagement s/p prison release. Also with PTSD [post-traumatic stress disorder] related to rape in prison; reportedly responsive to clonazepam + gabapentin (though the former is relatively contraindicated in PTSD, generally) ...Referral to residential treatment ...Patient has been determined to require further observation to determine if EMC is present..."

Nurse #1 triaged Patient #1 at 1:32 PM with an Emergency Severity Index (ESI) of Level 4-Less Urgent and documented, " ...Pt [patient] presents to PAS [Psychiatric Assessment Service] as a walk in by himself and was discharged from [Hospital #1 Adult Hospital] earlier today after being treated in ICU [intensive care unit] for heroin overdose. Pt presents as hyper-verbal, is AAOx4 [awake, alert and oriented to person, place, time, and situation], is ambulatory, and denies COVID s/s [signs/symptoms] ...PT denies SI [suicidal ideation]/HI [homicidal ideation]/AH [auditory hallucinations]/VH [visual hallucinations]. Pt reports that he is wanting rehab for heroin use and states he was recently in rehab through a govt [government] grant at [Rehab Facility #1] 3 months ago ...Pt reports he is feeling like he is going to have a seizure again from BZO [benzodiazepine] withdrawal because he feels hot and sweaty and also relays that he was given BZO this AM in the medical center but it was not enough because he was prescribed Klonopin [clonazepam] 2 mg [milligrams] PO [by mouth] TID [three times daily] from the Medical prison called Special Needs ..."
There was no documentation the nurse notified the medical staff that the patient reported feeling hot and sweaty like he was going to have a seizure.

Nurse #1 documented on 6/5/2021 at 1:41 PM, "...patient is overheard vomiting and moaning in the PAS bathroom..." There was no documentation of an assessment the patient following the patient's moaning and vomiting.

Nurse #1 documented an assessment at approximately 4:14 PM (2 hours and 33 minutes after the patient's vomiting episode) which included a respiratory and cardiac assessment, Columbia Suicide Severity Rating Scale, fall risk scale, confusion assessment, observation monitoring, mental status exam, neurological assessment, pain assessment, and Broset Violence Checklist. There was no documentation the nurse identified any abnormalities during this assessment.

The psychiatric ED medication administration record dated 6/5/2021 revealed Patient #1 received clonazepam 0.5 mg and methadone 10 mg at 1:48 PM, and gabapentin 600 mg and a nicotine 14 mg/24 hours transdermal patch at 5:22 PM. There was no documentation of any other medications given until after the patient was found unresponsive and cardiopulmonary efforts were initiated at 10:36 PM.

Nurse #2 documented the following vital signs on 6/5/2021 at 7:15 PM: pulse 93, blood pressure 111/71, and oxygen saturation level 99% (vital signs were entered into the computer on 6/6/2021 at 2:59 AM). Nurse #2 documented the following vital signs on 6/5/2021 at 7:35 PM: temperature 98.2 degrees Fahrenheit, pulse 101, respirations 17, blood pressure 111/78, and oxygen saturation level 100%.

Nurse #2 documented an assessment with a timestamp of 8:10 PM which included a confusion assessment, neurological assessment, and Glasgow Coma Scale (these assessments were entered into the computer on 6/5/2021 at 11:46 PM which was after the patient had been pronounced dead at 10:50 PM.).

Nurse #2 documented an assessment with a timestamp of 9:05 PM which included a respiratory assessment, cardiac assessment, and vascular/perfusion assessment (these assessments were entered into the computer on 6/5/2021 at 11:45 PM which was after the patient had been pronounced dead at 10:50 PM.).

Patient #1 was found by Nurse #2 unresponsive in a chair in the waiting room on 6/5/2021 at 10:35 PM. Nurse #2 called a code and cardiopulmonary resuscitation (CPR) was initiated. The cardiopulmonary resuscitative efforts were unsuccessful, and Patient #1 was pronounced dead on 6/5/2021 at 10:50 PM.

The "Arrest Record/Cardiopulmonary Resuscitation Orders" dated 6/5/2021 revealed, "...10:38 [PM] ...HR [heart rate]/CPR ...112 ...SpO2 [oxygen saturation] ...49 [percent]..."

A blood glucose level taken on 6/5/2021 at 10:38 PM was 474 milligrams (mg)/deciliter (dL) with a normal reference range of 70-99 mg/dL.

An ED progress noted dated 6/5/2021 at 11:00 PM by Resident Physician #1 revealed, "Stat call to [Hospital #1 Psychiatric Hospital]. Patient was reported to have been having 5 rounds of CPR at the time of my arrival...Once we had arrived round 6 of CPR initiated. IV [intravenous] access was then obtained in the form of a left humeral IO [intraosseous] with 2nd attempt, first into soft tissue. Patient had copious emesis and fixed, dilated pupils. Continued with ACLS [advanced cardiac life support] upon arrival and despite several rounds with 2x doses of epi [epinephrine] patient remained in non-perfusable PEA [pulseless electrical activity] with rate <25. Supraglottic airway in place after copious emesis occurred with improvement in chest rise but no change in rhythm. Decision was made given no clinical signs of life such as spontaneous respirations, Nonreactive pupils and PEA rhythm to terminate resuscitative efforts ...Time of death 22:50 [10:50 PM]..."

An ED nurse's noted dated 6/6/2021 at 1:21 AM by Nurse #2 revealed, "...Pt found unresponsive sitting in Lobby recliner this evening at 2235 [10:35 PM]. Code blue [assistance from other units within Hospital #1 Psychiatric Hospital] and rapid response [assistance from Hospital #1 Children's Hospital ED] called and pt lifted to floor by nurses. Compressions started at 22:36 [10:36 PM]. Code team and rapid team assisted in attempt to resuscitate pt ...Two (2) medication bottles found in Pt pocket, gabapentin 600 mg tabs [tablets] (4 count in bottle) and clonazepam 0.5 mg tabs (7 count in bottle). Pt night dose of meds held due to pt being asleep in recliner and snoring loudly for approximately 1.5 hours prior..."

A Clinical Note dated 6/6/2021 at 1:52 AM by Resident Physician #2 revealed, "...Patient went to sleep at 8 PM on a chair in the common area of PAS. At around 10:45 PM nursing tried to wake the patient, since he had an unusual gray tone to his face. Patient was not breathing. A code blue was therefore called, CPR was started and a rapid [rapid response] was called. Patient continued to have non-reactive pupils and PEA rhythm despite resuscitative efforts. Time of death was called at 22:50 [10:50 PM] ..."

4. Review of the "PAS Q [every] 15MIN [minute] ENVIRONMENTAL SAFETY CHECKS" dated 6/5/2021 revealed Behavioral Health Specialist #1 documented 15 minute checks for Patient #1 from 7:15 PM through 12:30 AM on 6/6/2021 (Patient #1's time of death was 6/5/2021 at 10:50 PM).

5. Review of the video footage revealed Nurse #2 (started shift on 6/5/2021 at 7:00 PM) did not check Patient #1's vital signs and was not in proximity to Patient #1 to perform an assessment until after she found him unresponsive on 6/5/2021 at 10:35 PM.

Review of the video footage revealed Nurse #2 found Patient #1 unresponsive on 6/5/2021 at 10:35 PM. The first chest compression was initiated at 10:36:45 PM, but the first breath was not given until 10:39:36 PM (2 minutes 51 seconds after the first chest compression). The nursing staff did not follow American Heart Association guidelines for CPR to provide breaths when initiating CPR.

Review of the video footage revealed Behavioral Health Specialist #1 (started shift on 6/5/2021 at 7:00 PM) was in proximity of Patient #1 at 7:35 PM and at 7:56 PM. Behavioral Health Specialist #1 was viewed at 7:56 PM performing and documenting the 15 minute checks. Patient #1 sat down in a chair in the common area (lobby) at approximately 8:01 PM and appears to fall asleep at approximately 8:15 PM. Behavioral Health Specialist #1 was not in proximity to Patient #1 after 7:56 PM and was not viewed on the video footage performing the 15 minute checks after 7:56 PM.

6. In an interview on 6/29/2021 at 2:56 PM, the Nurse Manager of Psychiatric Assessment Services stated the staff member performing 15 minute checks for patient observation should check to make sure the patient was still physically present in the facility, check for any signs of stress or changes in behavior, and make sure the patient is breathing. The Nurse Manager of Psychiatric Assessment Services stated Patient #1 was on 15 minute checks. The Nurse Manager of Psychiatric Assessment Services stated Patient #1 had fallen asleep in a chair in the common room and was snoring loudly. The Nurse Manager of Psychiatric Assessment Services stated that when Nurse #2 realized she did not hear him snoring anymore, she went to check on him and found him unresponsive.

In an interview on 7/1/2021 at 8:44 AM, the Chief Nursing Officer stated the hospital determined in their investigation that at least one of the sets of vital signs documented by Nurse #2 for Patient #1 was incorrect. The Chief Nursing Officer stated that Nurse #2 tended her resignation during the process of the hospital investigation. The Chief Nursing Officer stated the staff member performing the 15 minute checks should monitor the patient, look in the room to make sure the patient is ok, make sure the patient is not hurting themselves or others, and make sure the patient is breathing. The Chief Nursing Officer stated Behavioral Health Specialist #1 admitted that he had not observed Patient #1 at all times during his shift (7:00 PM-10:50 PM [time of death]) for the 15 minute checks which was a violation of hospital policy.

In an interview on 7/1/2021 at 11:00 AM, Nurse #2 stated she started her shift at 6:45 PM (on 6/5/2021) and took care of Patient #1 from then on. Nurse #2 stated she would do an assessment of her patients on the shift. Nurse #2 stated she would do vital signs during the shift and observe the patients in the space where they were, either in their room or the day room. Nurse #2 stated Patient #1 sat in a recliner and went to sleep sometime after 8:00 PM. Nurse #2 stated Patient #1 was wrapped in a blanket, but his face was visible. Nurse #2 stated she assumed the 15 minute checks for Patient #1 were being done. Nurse #2 stated a room became available for Patient #1, and she went around the corner to get him to his room. Nurse #2 stated she found that Patient #1 was unresponsive, and she went back to the nurses' station to initiate a code blue. Nurse #2 stated she grabbed the vital sign machine and then assisted Patient #1 to the floor. Nurse #2 stated the code team arrived, initiated chest compressions, and took over the code. Nurse #2 stated the code team pronounced the time of death at 10:50 PM.

In an interview on 7/1/2021 at 12:39 PM, Behavioral Health Specialist #1 (terminated from employment) stated that while performing the 15 minute checks on patients, he would look to see if a patient was ok and look to see if they were breathing. Behavioral Health Specialist #1 stated he started the shift at 7:00 PM (6/5/2021), and Patient #1 was up and walking to the bathroom. Behavioral Health Specialist #1 stated Patient #1 was in the common area asleep in a chair at some time later. Behavioral Health Specialist #1 stated Patient #1 was covered with a blanket, but his face was visible. Behavioral Health Specialist #1 stated Patient #1 was snoring loudly, and the other patients in the room were complaining about the snoring. Behavioral Health Specialist #1 stated he had gone to the bathroom and when he came back they (nursing staff) told him they had called a code blue. Behavioral Health Specialist #1 stated he had been in the storage area for about 10 minutes before he went to the bathroom. Behavioral Health Specialist #1 stated that the last time he heard Patient #1, he was snoring (could not recall what time that was).

In an interview on 7/6/2021 at 8:35 AM, the Chief Nursing Officer stated that nurses should do vital signs on every patient each shift. The Chief Nursing Officer stated that Nurse #2 should have performed vital signs for Patient #1. While reviewing the video footage, the Chief Nursing Officer confirmed he did not see Nurse #2 in close proximity to Patient #1 until she found him unresponsive (6/5/2021 at 10:35 PM). While reviewing the video footage, the Chief Nursing Officer confirmed Behavioral Health Specialist #1 did not perform acceptable 15 minute checks. The Chief Nursing Officer stated it was not acceptable to do 15 minute checks from the nurses' station.

In an interview on 7/6/2021 at 9:57 AM, the Chief Regulatory Officer confirmed the staff at Hospital #1 Psychiatric Hospital ED were Basic Life Support certified and followed the American Heart Association guidelines for an unresponsive patient.

The hospital failed to provide an appropriate ongoing medical screening examination to Patient #1 while he waited in the ED waiting room for treatment. This failure posed an immediate and serious threat to Patient #1's health and safety and inappropriately delayed treatment for his psychiatric medical condition.