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Based on clinical record reviews, review of facility policies and procedures and interviews with facility personnel for one of twelve sampled patients who had a history of suicidal ideation, extensive abdominal surgery, history of chronic pain and receiving analgesia, (Patient #1), the governing body failed to be accountable for the quality of care provided to the patient including emergency treatment/assessments when the patient had expired and/or failed to ensure that the hospitalist's contract was reviewed and implemented to provide ample coverage on the off shifts.

(See A49 and A84)

Based on clinical record reviews, review of facility policies and procedures and interviews with facility personnel for one of twelve sampled patients who had a history of suicidal ideation, extensive abdominal surgery history chronic pain and receiving analgesia, (Patient #1), the medical staff failed to be accountable for the quality of care provided to the patient. The findings include:

1.
a. Patient #1 was admitted to the Emergency Department (ED) on 6/17/16 with abdominal pain and was a Full Code Status. Patient #1's admitting diagnosis was a small bowel obstruction/ileus. Patient #1's history included abdominal surgeries (14 previous surgeries), congestive heart failure, diabetes, anxiety disorder, depression, suicidal ideation (on a 10/25/15 previous ED admission), and usage of multiple narcotics, including Fentanyl 25 micrograms every 72 hours, Oxycontin 10 milligrams every 12 hours prior to admission to the hospital. Patient #1 was transferred to a medical floor pursuant to a CT scan 6/17/16 which identified a possible small bowel obstruction/ileus.

Review of the nursing admission assessment dated 6/17/16 failed to identify that an assessment including the patient's risk for suicidal ideation was completed upon admission per the facility's protocol.

Review of the nursing flowsheets dated 6/17/16-6/27/16 identified that Patient #1 had no bowel movement since 6/17/16 (10 days). On 6/27/16, Patient #1 was administered Lactulose 60 milligrams at 10:45 am, Miralax 17 grams at 10:45 am, and Senokot 17.2 milligrams at 10:45 am (laxative medications). In addition, Relistor for narcotic induced constipation was administered at 11:12 am. Although multiple medications were administered to promote bowel activity, an abdominal x-ray was not obtained until 2:47 pm on 6/27/16. The impression of the x-ray identified in part, a nonspecific bowel gas pattern with no obvious small bowel or colonic distension. Further review identified that Patient #1 also received Magnesium Citrate 300 milliters at 3:52 pm and a soap suds enema at 6:02 pm. Nursing notes dated 6/27/16, 6:02 pm indicated that 1000 cubic centimeters of fluid was infused with the soap suds enema with yellow colored fluid returned. Abdominal assessments were being conducted in accordance with the policy and procedure.

Further review of the nursing flowsheets dated 6/27/16 at 12:10 pm identified that Patient #1's pain level was a 7/10 as acceptable and aching. Patient #1 received Roxicodone 10 mg at 12:04 pm. At 1:00 pm, Patient #1's pain level was a 7/10 as shooting and unbearable. MD #1 was notified at 1:00 pm regarding increased abdominal pain and Patient #1 was medicated for nausea and a new Fentanyl patch was applied. At 2:47 pm, pain level was 10/10 and "unbearable." MD #1 was notified and gave an order for Dilaudid IV 1.0 mg. Patient #1 received another dose of Dilaudid 1.0 mg IV at 6:02 pm with the understanding that Patient #1 would not be able to receive anymore Dilaudid IV until after he/she had a bowel movement per the physician. Patient #1 also received Roxicodone 10 mg at 7:20 pm with indications to reassess in one hour. At 7:22 pm, Patient #1's pain level was 8/10 as sharp and unbearable. At 9:00 pm, Patient #1 vomited 200 cc of undigested food and continued to have "unbearable pain." Although review of the clinical record identified a change in condition, further review failed to identify that the physician was notified regarding the patient's current status.

Interview with Registered Nurse (RN) #1 on 7/6/16 identified that he/she had gone into Patient #1's room after 9:30 pm to obtain his/her blood sugar and noticed the patient was in the bathroom with the water running with the door shut. RN#1 indicated that he/she thought the enema had worked and the patient was in the bathroom having a bowel movement so he/she decided to come back in fifteen minutes. Further interview with RN #1 identified at 9:45 pm, he/she returned to Patient #1's room and the door was still shut so he/she knocked on the door with no answer. RN #1 indicated that he/she opened the door and found Patient #1 hanging by a bed sheet tied around a shower rod. RN #1 indicated that he/she had called for help, checked for a pulse while a Code 8 was called at 9:50 pm.


b. Review of the progress notes dated 6/27/16 identified that, although an abdominal assessment was documented by MD #3 at 11:30 am, the clinical record failed to identify any additional assessment conducted by a physician and/or a licensed independent practitioner when the patient had a change in condition including an assessment when the patient coded and expired. Additionally, the medical record lacked documentation to reflect an assessment by MD #2 when the patient coded and expired.

Review of the Discharge Summary dated 7/17/16 identified that Patient #1 started presenting with increasing abdominal pain as well of periods of burping. Further review indicated that abdominal x-ray was done to evaluate for possible complications/obstruction/aspiration however it continued to show the ileus.

Interview with MD #2 on 7/5/16 identified that he/she was first called regarding Patient #1 by responding to the code from the Emergency Department and found Patient #1 hanging from the shower rod. MD #2 indicated that his/her assessment was that Patient #1 had expired "a while ago" so the decision was made based on his/her assessment not to resuscitate the patient and the patient was pronounced at 10:00 pm. Review of the clinical record with MD #2 failed to identify a progress note had been written indicating MD #2's assessment and reason not to proceed with resuscitative efforts, although the clinical record identified that the patient was a full code. Further interview with MD #2 identified that he/she did not document the assessment in the progress note as he/she was instructed by administration that this was a police matter.

Interview with Pastoral Care Representative on 7/5/16 identified that he/she had visited with Patient #1 on 6/27/16 in the afternoon. Further interview identified that Patient #1 was lying on his/her side, scrunched over and groaning so loudly that you could hear him/her throughout the unit. In addition, the Pastoral Care Representative indicated that he/she had not seen anyone struggling and in so much pain.

Interview with Pharmacy Manager on 7/6/16 identified that laxatives are to be discontinued prior to administering Relistor. In addition, use is contraindicated in patients with known or suspected GI obstruction or at increased risk of recurrent obstruction.

Interview with MD #1 on 7/13/16 identified that he/she was aware of Patient #1's suicidal and psychiatric history, however, it was never communicated to the nursing staff and/or had no psychiatric consult was completed. Further interview with MD #1 on 7/13/16 identified that he was aware that MD #2 had not documented in the medical record regarding assessments and code response however he/she was told to wait until DPH finished their investigation.

Interview with MD #6 on 7/13/16 identified that he/she was aware of Patient #1's being on multiple psychiatric meds and previous psychiatric history from reviewing previous admissions however, did not feel the patient needed for a psychiatric consult while in the hospital.

Review of hospital policy identified that each patient has an initial assessment by a medical staff member who assesses the physical, psychological and social status of the patient and identifies appropriate care of the need for further assessment. The medical staff member is the leader of the patient care team in the planning and provision of care throughout the continuum.

Review of hospital patients' rights policy identified that patients will receive information about pain and symptom management. It further identified that "As healthcare professionals and concerned staff, we are committed to pain prevention and management and want to respond quickly to your reports of pain and related symptoms."

Review of hospital policy identified that the Physician-in-Charge/Adult Hospitalist directs the resuscitation efforts from ECG interpretation until final disposition. The I.V. Nurse/Critical Care Nurse/Staff Nurse is in charge of starting I.V.'s. and the Staff Nurse initiates CPR, calls for help, established respiratory support, and prepares equipment for cardiac monitoring and defibrillation. Cardiopulmonary resuscitation is initiated on all patients unless the physician records a DNR order. Resuscitation efforts are only terminated by the decision of the physician-in-charge or the attending physician. The cardiopulmonary resuscitation record is completed and the original becomes part of the patient record.


c. Review of the physician orders dated 6/18/16 identified that Patient #1 was to receive Oxycontin 10 mg every twelve hours for pain to be renewed every seven days. On 6/25/16, Patient #1's medication was due to be renewed, however, the hospitalist never renewed the medication. Patient #1 had not received the scheduled Oxycontin for 36 hours. On 6/26/16, the 7-3 nurse noticed the pain medication was not renewed and called the physician for a new order.

Review of hospital policy identified that all Schedule II narcotic ordered will automatically be removed for the Medication Administration Record at 12 midnight on the seventh day if not renewed.

Interview with MD #6 on 7/13/16 identified that he/she was not aware and/or educated of an alert on the computer identifying that a patients narcotics were up for renewal.

Interview with the Pharmacy Manager on 7/1/16 identified that pharmacy staff have no process in place to monitor when narcotics need to be renewed after seven days if the provider fails to renew the order. Further interview identified that the pharmacy relies on the provider to renew the narcotic when a purple tab in the computer that notifies the provider a narcotic needs to be renewed otherwise the narcotic order just drops off.

Review of hospital documentation dated 7/13/16 (16 days later) identified that a memo went out to all providers to remind them of renewing Schedule II Controlled Substances every 7 days per state law.

Based on review of hospital documentation and contracts, the hospital failed to provide hospitalist coverage based on the contract. The findings include:

Review of hospital documentation and the contracted service for hospitalist coverage identified that from 6/2016-7/2016 indicated that on 11:00 pm-7:00 am one physician, one on-call physician for the intensive care unit and one physician extender were covering the entire hospital. Review of the hospitalist contract identified that on 11:00 pm - 7:00 am shift, the hospital shall be staffed at night with no fewer than one FTE physician assigned to the intensive care unit and one FTE physician assigned to the hospital inpatient units.

In addition, review of hospital documentation identified that on 6/25/16-6/27/16 the range of hospital census was from 190-199 and from 5:00 pm -7:00 am, one physician covering the ED, codes and intensive care unit and one Advanced Practice Registered Nurses covering the entire hospital. Further review failed to identify an on-call physician for the intensive care unit. Interview and review of the hospitalist contract with the Chief Hospitalist on 7/13/16 identified that he/she was not aware of what coverage was needed per the contract. Further interview identified that they had one physician who covered the intensive care unit leave and the hospital was providing coverage with one physician and a physician extender (APRN) on the overnight shift.

Based on review of clinical records, hospital policies and procedures and interviews for one of twelve sampled patients (Patient # 1) with a Full Code status, the hospital failed to ensure that cardiopulmonary resuscitation (CPR) was initiated and/or when a patient presents with a risk for suicidal ideation and/or had an extensive history of abdominal surgeries, chronic pain and receiving analgesia, the facility failed to ensure that the patient received care in a safe setting.

See (A 130, A144)

Based on review of clinical records, hospital policies and procedures and interviews for one of twelve sampled patients (Patient # 1) with a Full code status, the hospital failed to ensure that cardiopulmonary resuscitation (CPR) was initiated when the patient presented without pulse and/or respirations. The findings include:

Patient #1 was admitted to the Emergency Department (ED) on 6/17/16 with a chief complaint of abdominal pain and diagnoses that included small bowel obstruction/ileus. Patient #1's history included abdominal surgeries (14 previous surgeries), congestive heart failure, diabetes, anxiety disorder, depression, suicidal ideation (on a 10/25/15 previous ED admission), and use of multiple narcotics, including Fentanyl 25 micrograms every 72 hours, and Oxycontin 10 milligrams every 12 hours prior to admission to the hospital. Patient #1 was transferred to a medical floor pursuant to a CT scan 6/17/16 which identified a possible small bowel obstruction/ileus.

Physician orders dated 06/17/16 at 6:33 PM identified that the patient's code status was discussed with Patient #1 who requested a Full Code. The Full Code status was consistent with the code status identified on previous hospital/ED admissions.

Interview with RN #1 on 7/6/16 identified that, on 06/28/16 at approximately 9:30 PM he/she had gone into Patient #1's room to obtain a fingerstick blood glucose and noticed the patient was in the bathroom with the water running and the door shut. RN#1 indicated that he/she thought that the enema, previously administered, had been effective, and the patient was in the bathroom having a bowel movement. RN #1 decided to return in fifteen minutes. Further interview with RN #1 identified at 9:45 pm, he/she returned to Patient #1's room. The door was still shut so he/she knocked on the door with no answer. RN #1 indicated that he/she opened the door and found Patient #1 hanging by a bed sheet around the shower curtain rod. RN #1 identified that he/she had called for help, and checked for a pulse while a Code 8 was called.

Interview with RN #7, the intravenous therapy (IV) nurse, on 07/06/16 at 2:45 PM identified that he/she was charting at the nursing station adjacent to the unit when he/she heard screaming and went to the patient's room to investigate. At the same time, RN #10, a nurse from the adjacent unit, was coming out of the room, heading towards the nursing station. RN #7 identified that he/she believed that RN #10 was going to call a Code 8. RN #7 entered the patient room and observed the clinical manager, RN #1, looking into the bathroom. RN #7 then entered the bathroom and observed Patient #1 suspended from the curtain rod. RN #7 checked the patient for movement, palpated the left and right carotid arteries for pulse, checked for respirations, assessed the pupils as fixed and dilated, and observed a dried substance consistent with blood at the right corner of the patient's mouth. RN #7 further identified that a staff member had reported that Patient #1 was a full code and RN #7 responded that the patient had expired and directed the staff not to touch Patient #1, but notify the Assistant Director of Nursing (ADNS), security, and the physician. RN #7 then left the room and observed many staff members coming down the hallway towards the room. RN #7 further identified that, based on his/her professional experience, the patient and his/her environment had become part of a crime scene.

Interview with MD #2 on 07/06/16 identified that he/she had been in the ED when summoned by the Code 8 to Patient #1's room. Patient #1 presented with mottling his/her soles of feet were white and multiple abrasions were visible around his/her neck. The body was already cooled and the patient appeared to have expired some time ago. Death was pronounced at 10:00 PM. Further interview with MD # 2 on 7/6/16 identified that he/she had been directed by administration not to document at that time and, therefore, failed to document the time of death, circumstances of death, and/or physical assessment in the clinical record. MD #2 returned to the ED.

Interviews with the Director of Patient Care Services (PCS) on 07/06/16 at 10:00 AM and 7/13/16 that on 06/28/16 at approximately 10:00 PM he/she had received a call from the Director on Call, who identified the circumstances of Patient #1's death. The PCS arrived at the hospital by 10:30 PM. The police had arrived and the PCS did not enter the room as it was considered to be a crime scene. According to the PCS, RN #7 had responded to the Code 8 and directed that the situation represented a crime scene and MD #2 agreed with that approach. In a later interview, the PCS identified that he/she had directed the staff to step out of the room so it could be secured as it was a crime scene. Patient #1 was not removed from the hanging position at that time. Interview with the Director of Risk Management on 07/07/16 at 3:00 PM identified that once the police cleared the scene, they removed the patient with assistance of the hospital's public safety staff and the body was removed by a representative of the Medical Examiner's office sometime before 2:00 AM on 06/29/16.

Interview with RN #5 on 07/05/16 identified that the code cart had been brought into the patient's room, however CPR was never initiated.

The hospital policy entitled Cardiopulmonary Resuscitation identified that CPR is initiated on all patients unless the physician records a "Do Not Resuscitate" order. The Physician-in-Charge/Adult Hospitalist directs the resuscitation efforts from ECG interpretation until final disposition. The I.V. Nurse/Critical Care Nurse/Staff Nurse is in charge of starting I.V.'s. and the Staff Nurse initiates CPR, calls for help, established respiratory support, and prepares equipment for cardiac monitoring and defibrillation. Cardiopulmonary resuscitation is imitated on all patients unless the physician records a DNR order. Resuscitation efforts are only terminated by the decision of the physician-in-charge or the attending physician.

Based on review of clinical records, hospital policies and procedures and interviews for one of one sampled patient (Patient # 1) with a Full Code, the hospital failed to ensure that cardiopulmonary resuscitation (CPR) was initiated when the patient presented without pulse and/or respirations. The findings include:

Patient #1 was admitted to the Emergency Department (ED) on 6/17/16 with a chief complaint of abdominal pain and diagnoses that included small bowel obstruction/ileus. Patient #1's history included abdominal surgeries (14 previous surgeries), congestive heart failure, diabetes, anxiety disorder, depression, suicidal ideation (on a 10/25/15 previous ED admission), and use of multiple narcotics, including Fentanyl 25 micrograms every 72 hours, and Oxycontin 10 milligrams every 12 hours prior to admission to the hospital. Patient #1 was transferred to a medical floor pursuant to a CT scan 6/17/16 which identified a possible small bowel obstruction/ileus.

Physician orders dated 06/17/16 at 6:33 PM identified that the patient's code status was discussed with Patient #1 who requested Full Code. The Full Code status was consistent with the code status identified on previous hospital/ED admissions.

Interview with RN #1 on 7/6/16 identified that, on 06/28/16 at approximately 9:30 PM he/she had gone into Patient #1's room to obtain a fingerstick blood glucose and noticed the patient was in the bathroom with the water running and the door shut. RN#1 indicated that he/she thought that the enema, previously administered, had been effective, and the patient was in the bathroom having a bowel movement. RN #1 decided to return in fifteen minutes. Further interview with RN #1 identified at 9:45 pm, he/she returned to Patient #1's room. The door was still shut so he/she knocked on the door with no answer. RN #1 indicated that he/she opened the door and found Patient #1 hanging from the shower curtain rod. RN #1 identified that he/she had called for help, and checked for a pulse while a Code 8 was called.

Interview with RN #7, the intravenous therapy (IV) nurse, on 07/06/16 at 2:45 PM identified that he/she was charting at the nursing station adjacent to the unit when he/she heard screaming and went to the patient's room to investigate. At the same time, RN #10, a nurse from the adjacent unit, was coming out of the room, heading towards the nursing station. RN #7 identified that he/she believed that RN #10 was going to call a Code 8. RN #7 entered the patient room and observed the clinical manager, RN #1, looking into the bathroom. RN #7 then entered the bathroom and observed Patient #1 suspended from the curtain rod. RN #7 checked the patient for movement, palpated the left and right carotid arteries for pulse, checked for respirations, assessed the pupils as fixed and dilated, and observed a dried substance consistent with blood at the right corner of the patient's mouth. RN #7 further identified that a staff member had reported that Patient #1 was a full code and RN #7 responded that the patient had expired and directed the staff not to touch Patient #1, but notify the Assistant Director of Nursing (ADNS), security, and the physician. RN #7 then left the room and observed many staff members coming down the hallway towards the room. RN #7 further identified that, based on his/her professional experience, the patient and his/her environment had become part of a crime scene.

Interview with MD #2 on 07/06/16 identified that he/she had been in the ED when summoned by the Code 8 to Patient #1's room. Patient #1 presented with mottling. His/her soles were white and multiple abrasions were visible around his/her neck. The body was already cooled and the patient appeared to have expired some time ago. Death was pronounced at 10:00 PM. Further interview with MD # 2 on 7/6/16 identified that he/she had been directed not to document at that time and, therefore, failed to document the time of death, circumstances of death, and/or physical assessment in the clinical record. MD #2 returned to the ED.

Interviews with the Director of Patient Care Services (PCS) on 07/06/16 at 10:00 AM and 7/13/16 that on 06/28/16 at approximately 10:00 PM he/she had received a call from the Director on Call, who identified the circumstances of Patient #1's death. The PCS arrived at the hospital by 10:30 PM. The police had arrived and the PCS did not enter the room as it was considered to be a crime scene. According to the PCS, RN #7 had responded to the Code 8 and directed that the situation represented a crime scene and MD #2 agreed with that approach. In a later interview, the PCS identified that he/she had directed the staff to step out of the room so it could be secured as it was a crime scene. Patient #1 was not removed from the hanging position at that time. Interview with the Director of Risk Management on 07/07/16 at 3:00 PM identified that once the police cleared the scene, they removed the patient with assistance of the hospital's public safety staff and the body was removed by a representative of the Medical Examiner's office sometime before 2:00 AM on 06/29/16.

Interview with RN #5 on 07/11/16 identified that the code cart had been brought into the patient's room, however CPR was never initiated.

The hospital policy entitled Cardiopulmonary Resuscitation identified that the Physician-in-Charge/Adult Hospitalist directs the resuscitation efforts from ECG interpretation until final disposition. The I.V. Nurse/Critical Care Nurse/Staff Nurse is in charge of starting I.V.'s. and the Staff Nurse initiates CPR, calls for help, established respiratory support, and prepares equipment for cardiac monitoring and defibrillation. Cardiopulmonary resuscitation is imitated on all patients unless the physician records a DNR order. Resuscitation efforts are only terminated by the decision of the physician-in-charge or the attending physician.

Based on clinical record review, review of policies and procedures and interviews with facility personnel for one of twelve sampled patients (Patient #1) who was at risk for suicidal ideation and/or had an extensive history of abdominal surgeries, chronic pain and was receiving analgesia, the facility failed to ensure that the patient received care in a safe setting. The findings include:

Patient #1 was admitted to the Emergency Department (ED) on 6/17/16 with abdominal pain. Patient #1's admitting diagnosis was a small bowel obstruction/ileus. Patient #1's history included abdominal surgeries (14 previous surgeries), congestive heart failure, diabetes, anxiety disorder, depression, suicidal ideation (on a 10/25/15 previous ED admission), and usage of multiple narcotics, including Fentanyl 25 micrograms every 72 hours, Oxycontin 10 milligrams every 12 hours prior to admission to the hospital. Patient #1 was transferred to a medical floor pursuant to a CT scan 6/17/16 which identified a possible small bowel obstruction/ileus.

Review of the nursing admission assessment dated 6/17/16 failed to identify that an assessment including the patient's risk for suicidal ideation was completed upon admission per the facility's protocol.

Review of the nursing flowsheets dated 6/17/16-6/27/16 identified that Patient #1 had no bowel movement since 6/17/16 (10 days). On 6/27/16, Patient #1 was administered Lactulose 60 milligrams at 10:45 am, Miralax 17 grams at 10:45 am, and Senokot 17.2 milligrams at 10:45 am (laxative medications). In addition, Relistor for narcotic induced constipation was administered at 11:12 am. Although multiple medications were administered to promote bowel activity, an abdominal X-ray was not obtained until 2:47 pm on 6/27/16. The impression of the X-ray identified in part, a nonspecific bowel gas pattern with no obvious small bowel or colonic distension. Further review identified that Patient #1 also received Magnesium Citrate 300 milliters at 3:52 pm and a soap suds enema at 6:02 pm. Nursing notes dated 6/27/16, 6:02 pm indicated that 1000 cubic centimeters of fluid was infused with the soap suds enema with yellow colored fluid returned. Abdominal assessments were being conducted in accordance with the policy and procedure.

Further review of the nursing flowsheets dated 6/27/16 at 12:10 pm identified that Patient #1's pain level was a 7/10 as acceptable and aching. Patient #1 received Roxicodone 10 mg at 12:04 pm. At 1:00 pm, Patient #1's pain level was a 7/10 as shooting and unbearable. MD #1 was notified at 1:00 pm regarding increased abdominal pain and Patient #1 was medicated for nausea and a new Fentanyl patch was applied. At 2:47 pm, pain level was 10/10 and "unbearable." MD #1 was notified and gave an order for Dilaudid IV 1.0 mg. Patient #1 received another dose of Dilaudid 1.0 mg IV at 6:02 pm with the understanding that Patient #1 would not be able to receive anymore Dilaudid IV until after he/she had a bowel movement. Patient #1 also received Roxicodone 10 mg at 7:20 pm with indications to reassess in one hour. At 7:22 pm, Patient #1's pain level was 8/10 as sharp and unbearable. At 9:00 pm, Patient #1 vomited 200 cc of undigested food and continued to have "unbearable pain." Although review of the clinical record identified a change in condition, further review failed to identify that the physician was notified regarding the patient's current status.

Interview with RN #1 on 7/6/16 identified that he/she had gone into Patient #1's room at 9:30pm to obtain his blood sugar and noticed the patient was in the bathroom with the water running and the door shut. RN#1 indicated that he/she thought the enema had worked and the patient was in the bathroom having a bowel movement so he/she decided to come back in fifteen minutes. Further interview with RN #1 identified at 9:45 pm, he/she returned to Patient #1's room and the door was still shut so he/she knocked on the door with no answer. RN #1 indicated that he/she opened the door and found Patient #1 hanging from the shower rod. RN #1 indicated that he/she had called for help, checked for a pulse while a Code 8 was called at 9:50 pm. Further review identified that the nursing staff failed to initiate CPR.

Interview with MD #2 on 7/5/16 identified that he/she was first called regarding Patient #1 by responding to the code and found Patient #1 hanging from the shower rod. MD #2 indicated that his/her assessment was that Patient #1 had expired "a while ago" so the decision was made based on his/her assessment not to resuscitate the patient and the patient was pronounced at 10:00 pm. Review of the clinical record with MD #2 failed to identify a progress note had been written indicating MD #2's assessment and reason not to proceed with resuscitative efforts, although the clinical record identified that the patient was a Full Code. Further interview with MD #2 identified that she/he did not document the assessment in the progress note as he/she was directed it was a police matter by Administration.

Interview with Pastoral Care Representative on 7/5/16 identified that he/she had visited with Patient #1 on 6/27/16 in the afternoon. Interview identified that Patient #1 was lying on his/her side, scrunched over and groaning so loudly that you could hear him/her throughout the unit. In addition, the Pastoral Care Representative indicated that he/she had not seen anyone struggling and in so much pain.

Interview with RN #6 on 07/06/16 at 2:00 PM identified that although he/she was not assigned to care for Patient #1 on 06/28/16, he/she had a patient assignment on the same unit and observed RN #1 and RN #5 frequently responding to the patient's needs. Additionally, he/she heard the patient calling out and moaning loudly throughout the shift.

Interview with Pharmacy Manager on 7/6/16 identified that laxatives are to be discontinued prior to administering Relistor. In addition, use is contraindicated in patients with known or suspected GI obstruction or at increased risk of recurrent obstruction.

Review of hospital patients' rights policy identified that patients will receive information about pain and symptom management. It further identified that "As healthcare professionals and concerned staff, we are committed to pain prevention and management and want to respond quickly to your reports of pain and related symptoms."

Based on clinical record reviews, review of facility policies and procedures and interviews with facility personnel for one of twelve sampled patients who had a history of suicidal ideation, extensive abdominal surgery history chronic pain and receiving analgesia, (Patient #1), the medical staff failed to be accountable for the quality of care provided to the patient including emergency treatment/assessments when the patient had expired. (See A347)

Based on clinical record reviews, review of facility policies and procedures and interviews with facility personnel for one of twelve sampled patients who had a history of suicidal ideation, extensive abdominal surgery history chronic pain and receiving analgesia, (Patient #1), the medical staff failed to be accountable for the quality of care provided to the patient. The findings include:

1a. Patient #1 was admitted to the Emergency Department (ED) on 6/17/16 with abdominal pain. Patient #1's admitting diagnosis was a small bowel obstruction/ileus. Patient #1's history included abdominal surgeries (14 previous surgeries), congestive heart failure, diabetes, anxiety disorder, depression, suicidal ideation (on a 10/25/15 previous ED admission), and usage of multiple narcotics, including Fentanyl 25 micrograms every 72 hours, Oxycontin 10 milligrams every 12 hours prior to admission to the hospital. Patient #1 was transferred to a medical floor pursuant to a CT scan 6/17/16 which identified a possible small bowel obstruction/ileus.

Review of the nursing admission assessment dated 6/17/16 failed to identify that an assessment including the patient's risk for suicidal ideation was completed upon admission per the facility's protocol.

Review of the nursing flowsheets dated 6/17/16-6/27/16 identified that Patient #1 had no bowel movement since 6/17/16 (10 days). On 6/27/16, Patient #1 was administered Lactulose 60 milligrams at 10:45 am, Miralax 17 grams at 10:45 am, and Senokot 17.2 milligrams at 10:45 am (laxative medications). In addition, Relistor for narcotic induced constipation was administered at 11:12 am. Although multiple medications were administered to promote bowel activity, an abdominal x-ray was not obtained until 2:47 pm on 6/27/16. The impression of the x-ray identified in part, a nonspecific bowel gas pattern with no obvious small bowel or colonic distension. Further review identified that Patient #1 also received Magnesium Citrate 300 milliters at 3:52 pm and a soap suds enema at 6:02 pm. Nursing notes dated 6/27/16 at 6:02 pm indicated that 1000 cubic centimeters of fluid was infused with the soap suds enema with yellow colored fluid returned. Abdominal assessments were being conducted in accordance with the policy and procedure.

Further review of the nursing flowsheets dated 6/27/16 at 12:10 pm identified that Patient #1's pain level was a 7/10 as acceptable and aching. Patient #1 received Roxicodone 10 mg at 12:04 pm. At 1:00 pm, Patient #1's pain level was a 7/10 as shooting, unbearable. MD #1 was notified at 1:00 pm regarding increased abdominal pain and Patient #1 was medicated for nausea and a new Fentanyl patch was applied. At 2:47 pm, pain level was 10/10 and "unbearable." MD #1 was notified and gave an order for Dilaudid IV 1.0 mg. Patent #1 received another dose of Dilaudid 1.0 mg IV at 6:02 pm with the understanding that Patient #1 would not be able to receive anymore Dilaudid IV until after he/she had a bowel movement per the physician. Patient #1 also received Roxicodone 10 mg at 7:20 pm with indications to reassess in one hour. At 7:22 pm, Patient #1's pain level was 8/10 as sharp and unbearable. At 9:00 pm, Patient #1 vomited 200 cc of undigested food and continued to have "unbearable pain." Although review of the clinical record identified a change in condition, further review failed to identify that the physician was notified regarding the patient's current status.

Interview with RN #1 on 7/6/16 identified that he/she had gone into Patient #1's room after 9:30 pm to obtain his blood sugar and noticed the patient was in the bathroom with the water running with the door shut. RN#1 indicated that he/she thought the enema had worked and the patient was in the bathroom having a bowel movement so he/she decided to come back in fifteen minutes. Further interview with RN #1 identified at 9:45 pm, he/she returned to Patient #1's room and the door was still shut so he/she knocked on the door with no answer. RN #1 indicated that he/she opened the door and found Patient #1 hanging by a bed sheet around the shower rod. RN #1 indicated that he/she had called for help, checked for a pulse while a Code 8 was called at 9:50pm.

1b. Review of the progress notes dated 6/27/16 identified that although an abdominal assessment was documented by MD #3 at 11:30 am, the clinical record failed to identify any additional assessment conducted by a physician and/or a licensed independent practitioner when the patient had a change in condition including an assessment when the patient coded and expired. Additionally, the medical record lacked documentation to reflect an assessment by MD #2 when the patient coded and expired.

Interview with MD #2 on 7/5/16 identified that he/she was first called regarding Patient #1 by responding to the code from the Emergency Department and found Patient #1 hanging from the shower rod. MD #2 indicated that his/her assessment was that Patient #1 had expired "a while ago" so the decision was made based on his/her assessment not to resuscitate the patient and the patient was pronounced at 10:00 pm. Review of the clinical record with MD #2 failed to identify a progress note had been written indicating MD #2's assessment and reason not to proceed with resuscitative efforts, although the clinical record identified that the patient was a full code. Further interview with MD #2 identified that he/she did not document the assessment in the progress note as he/she was instructed by administration that this was a police matter.

Interview with Pastoral Care Representative on 7/5/16 identified that he/she had visited with Patient #1 on 6/27/16 in the afternoon. Further interview identified that Patient #1 was lying on his/her side, scrunched over and groaning so loudly that you could hear him/her throughout the unit. In addition, the Pastoral Care Representative indicated that he/she had not seen anyone struggling and in so much pain.

Review of the Discharge Summary dated 7/17/16 identified that Patient #1 started presenting with increasing abdominal pain as well of periods of burping. Further review indicated that abdominal x-ray was done to evaluate for possible complications/obstruction/aspiration however it continued to show the ileus.

Interview with Pharmacy Manager on 7/6/16 identified that laxatives are to be discontinued prior to administering Relistor. In addition, use is contraindicated in patients with known or suspected GI obstruction or at increased risk of recurrent obstruction.

Interview with MD #1 on 7/13/16 identified that he/she was aware of Patient #1's suicidal and psychiatric history, however, it was never communicated to the nursing staff and/or had no psychiatric consult completed. Further interview with MD #1 on 7/13/16 identified that he was aware that MD #2 had not documented in the medical record regarding assessments and code response however he/she was told to wait until DPH finished their investigation.

Interview with MD #6 on 7/13/16 identified that he/she was aware of Patient #1's being on multiple psychiatric meds and previous psychiatric history from reviewing previous admissions however, did not feel the patient needed for a psychiatric consult while in the hospital.

Review of hospital policy identified that each patient has an initial assessment by a medical staff member who assesses the physical, psychological and social status of the patient and identifies appropriate care of the need for further assessment. The medical staff member is the leader of the patient care team in the planning and provision of care throughout the continuum.

Review of hospital patients' rights policy identified that patients will receive information about pain and symptom management. It further identified that "As healthcare professionals and concerned staff, we are committed to pain prevention and management and want to respond quickly to your reports of pain and related symptoms."

Review of hospital policy identified that CPR is initiated on all patients unless the physician records a "Do Not Resuscitation" order. The Physician-in-Charge/Adult Hospitalist directs the resuscitation efforts from ECG interpretation until final disposition. The I.V. Nurse/Critical Care Nurse/Staff Nurse is in charge of starting I.V.'s. and the Staff Nurse initiates CPR, calls for help, established respiratory support, and prepares equipment for cardiac monitoring and defibrillation. Cardiopulmonary resuscitation is initiated on all patients unless the physician records a DNR order. Resuscitation efforts are only terminated by the decision of the physician-in-charge or the attending physician. The cardiopulmonary resuscitation record is completed and the original becomes part of the patient record.

1c. Review of the physician orders dated 6/18/16 identified that Patient #1 was to receive Oxycontin 10 mg every twelve hours for pain to be renewed every seven days. On 6/25/16, Patient #1's medication was due to be renewed, however, the hospitalist never renewed the medication. Patient #1 had not received the scheduled Oxycontin for 36 hours. On 6/26/16, the 7:00 AM-3:00 PM nurse noticed the pain medication was not renewed and called the physician for a new order.

Review of hospital policy identified that all Schedule II narcotic ordered will automatically be removed for the medication administration record at 12 midnight on the seventh day if not renewed.

Interview with MD #6 on 7/13/16 identified that he/she was not aware and/or educated of an alert on the computer identifying that a patient's narcotic was up for renewal.

Interview with the Pharmacy Manager on 7/1/16 identified that pharmacy staff have no process in place to monitor when narcotics need to be renewed after seven days if the provider fails to renew the order. Further interview identified that the pharmacy relies on the provider to renew the narcotic when a purple tab in the computer that notifies the provider a narcotic needs to be renewed otherwise the narcotic order just drops off.

Review of hospital documentation dated 7/13/16 (16 days later) identified that a memo went out to all providers to remind them of renewing Schedule II Controlled Substances every 7 days per state law.

Based on clinical record review, review of policies and procedures and interviews with facility personnel for one of twelve sampled patients (Patient #1) who was at risk for suicidal ideation and/or had an extensive history of abdominal surgeries, chronic pain and was receiving analgesia, the facility failed to ensure that a nursing admission assessments, comprehensive nursing care plans, pain assessments, physician notification with a change in condition and Cardiopulmonary Resuscitation were conducted per hospital policy. (See A395 and A396)

Based on review of clinical record, review policies and procedures and interviews with facility personnel, the facility failed to ensure that pain assessments were completed for three of twelve patients ( P#1, #2 and #6) and/or for one of one sampled patients (Patient #1) who was at risk for suicidal ideation and/or had an extensive history of abdominal surgeries, chronic pain and was receiving analgesia, the facility failed to ensure that a nursing admission assessment was conducted when the patient was admitted to the hospital and/or the physician was notified when the patient had a change in condition and/or failed to perform CPR. The findings include:

1a. Patient #1 was admitted to the Emergency Department (ED) on 6/17/16 with abdominal pain. Patient #1's admitting diagnosis was a small bowel obstruction/ileus. Patient #1's history included abdominal surgeries (14 previous surgeries), congestive heart failure, diabetes, anxiety disorder, depression, suicidal ideation (on a 10/25/15 previous ED admission), and usage of multiple narcotics, including Fentanyl 25 micrograms every 72 hours, Oxycontin 10 milligrams every 12 hours prior to admission to the hospital. Patient #1 was transferred to a medical floor pursuant to a CT scan 6/17/16 which identified a possible small bowel obstruction/ileus. Review of the nursing admission assessment dated 6/17/16 failed to identify that an assessment including the patient's risk for suicidal ideation was completed upon admission per the facility's protocol.

Review of the nursing flowsheets dated 6/17/16-6/27/16 identified that Patient #1 had no bowel movement since 6/17/16 (10 days). On 6/27/16, Patient #1 was administered Lactulose 60 milligrams at 10:45 am, Miralax 17 grams at 10:45 am, and Senokot 17.2 milligrams at 10:45 am (laxative medications). In addition, Relistor for narcotic induced constipation was administered at 11:12 am. Although multiple medications were administered to promote bowel activity, an abdominal X-ray was not obtained until 2:47 pm on 6/27/16. The impression of the X-ray identified in part, a nonspecific bowel gas pattern with no obvious small bowel or colonic distension. Further review identified that Patient #1 also received Magnesium Citrate 300 milliters at 3:52 pm and a soap suds enema at 6:02 pm. Nursing notes dated 6/27/16, 6:02 pm indicated that 1000 cubic centimeters of fluid was infused with the soap suds enema with yellow colored fluid returned. Abdominal assessments were being conducted in accordance with the policy and procedure.

Review of the nursing flowsheets dated 6/27/16 at 12:10 pm identified that Patient #1's pain level was a 7/10 as acceptable and aching. Patient #1 received Roxicodone 10 mg at 12:04 pm. At 1:00 pm, Patient #1's pain level was a 7/10 as shooting and unbearable. MD #1 was notified at 1:00 pm regarding increased abdominal pain and Patient #1 was medicated for nausea and a new Fentanyl patch was applied. At 2:47 pm, the patient's pain level was 10/10 and "unbearable." MD #1 was notified and gave an order for Dilaudid IV 1.0 mg. Patient #1 received another dose of Dilaudid 1.0 mg IV at 6:02 pm with the understanding that Patient #1 would not be able to receive anymore Dilaudid IV until after he/she had a bowel movement. Patient #1 also received Roxicodone 10 mg at 7:20 pm with indications to reassess in one hour. At 7:22 pm, Patient #1's pain level was 8/10 as sharp and unbearable. At 9:00 pm, Patient #1 vomited 200 cc of undigested food and continued to have "unbearable pain." Although review of the clinical record identified a change in condition, further review failed to identify that the physician was notified regarding the patient's current status.

Interview with RN #1 on 7/6/16 identified that he/she had gone into Patient #1's room at 9:15 pm to obtain his/her blood sugar and noticed the patient was in the bathroom with the water running with the door shut. RN#1 indicated that he/she thought the enema had worked and the patient was in the bathroom having a bowel movement so he/she decided to come back in fifteen minutes. Further interview with RN #1 identified at 9:45 pm, he/she returned to Patient #1's room and the door was still shut so he/she knocked on the door with no answer. RN #1 indicated that he/she opened the door and found Patient #1 hanging by a bed sheet from the shower rod. RN #1 indicated that he/she had called for help, checked for a pulse while a Code 8 was called. Interview with MD #2 on 7/5/16 identified that he/she was first called regarding Patient #1 by responding to the code and found Patient #1 hanging with a bed sheet around a shower rod. MD #2 indicated that his/her assessment was that Patient #1 had expired "a while ago" so the decision was made based on his/her assessment not to resuscitate the patient and the patient was pronounced at 10:00 pm. Nursing staff failed to initiate CPR when the patient was found hanging from the shower rod.

Review of hospital policy identified that at the time of admission, each patient has their needs assessed by a registered nurse and must be completed within eight hours of admission.

Interview with Nurse Manager #1 on 7/1/16 identified that the nursing admission assessment was completed by two nurses at the change of shift, however, it was never saved in the computer.

1b. Patient #1 was admitted to the Emergency Department (ED) on 6/17/16 with abdominal pain. Patient #1's admitting diagnosis was a small bowel obstruction/ileus. Patient #1's history included abdominal surgeries (14 previous surgeries), congestive heart failure, diabetes, anxiety disorder, depression, suicidal ideation (on a 10/25/15 previous ED admission), and usage of multiple narcotics, including Fentanyl 25 micrograms every 72 hours, Oxytocin 10 milligrams every 12 hours prior to admission to the hospital. Patient #1 was transferred to a medical floor pursuant to a CT scan 6/17/16 which identified a possible small bowel obstruction/ileus.

Review of the nursing flowsheets dated 6/27/16 at 12:10 pm identified that Patient #1's pain level was a 7/10 as acceptable and aching. Patient #1 received Roxicodone 10 mg at 12:04 pm. At 1:00 pm, Patient #1's pain level was a 7/10 as shooting and unbearable. MD #1 was notified at 1:00 pm regarding increased abdominal pain and Patient #1 was medicated for nausea and a new Fentanyl patch was applied. At 2:47 pm, pain level was 10/10 and "unbearable." MD #1 was notified and gave an order for Dilaudid IV 1.0 mg. Patient #1 received another dose of Dilaudid 1.0 mg IV at 6:02 pm with the understanding that Patient #1 would not be able to receive anymore Dilaudid IV until after he/she had a bowel movement. Patient #1 also received Roxicodone 10 mg at 7:20 pm with indications to reassess in one hour. At 7:22 pm, Patient #1's pain level was 8/10 as sharp and unbearable. At 9:00 pm, Patient #1 vomited 200 cc of undigested food and continued to have "unbearable pain." Further review failed to identify that pain reassessments were completed per hospital policy. The clinical record failed to reflect that the patient's pain was reassessed within one hour of the intervention in accordance with hospital policy. Review of the pain policy directed that the patient's pain should be reassessed within 30 minutes of receiving an IV medication to determine efficacy of the intervention.

2. Patient #2 was admitted to the facility on 6/26/16 with chronic back pain, abdominal pain, nausea and vomiting. Review of a physician's order directed Dilaudid 4 milligrams (mg.) intravenously every four hours as needed for pain. Review of the clinical record dated 7/2/16 at 7:44 PM identified that the patient rated pain as a four (4) on a scale of 1-10 (10 being the worst possible pain). Review of the Medication Administration Record dated 7/2/16 at 9:40 PM identified that Dilaudid 4 mg IV was administered. The clinical record failed to reflect that the patient's pain was reassessed within one hour of the intervention in accordance with hospital policy. The next documented pain assessment was recorded on 7/3/16 at 12:34 AM (2 hours, 54 minutes later). Review of the pain policy directed that the patient's pain should be reassessed within 30 minutes of receiving an IV medication to determine efficacy of the intervention.

3. Patient #6 was admitted on 7/1/16 at 8:00 PM with right lower leg cellulitis. Review of the pain assessments for the period of 7/1/16 through 7/3/16 failed to reflect that pain assessments were completed every shift per the policy. Review of the record indicated that the first pain assessment was completed on 7/3/16 at 10:44 AM. Interview with the Clinical Coordinator on 7/3/16 at 10:55 AM stated pain levels should be assessed every shift. Review of the pain policy directed that a baseline pain assessment should be completed every shift with reassessments completed at least every shift.

Based on clinical record review, review of policies and procedures and interviews with facility personnel for one of one sampled patients (Patient #1) who was at risk for suicidal ideation and/or had an extensive history of abdominal surgeries, chronic pain and was receiving analgesia, the facility failed to ensure that a comprehensive plan of care was completed for the patient on admission to the hospital. The findings include:

Patient #1 was admitted to the Emergency Department (ED) on 6/17/16 with abdominal pain. Patient #1's admitting diagnosis was a small bowel obstruction/ileus. Patient #1's history included abdominal surgeries (14 previous surgeries), congestive heart failure, diabetes, anxiety disorder, depression, suicidal ideation (on a 10/25/15 previous ED admission), and usage of multiple narcotics, including Fentanyl 25 micrograms every 72 hours, Oxycontin 10 milligrams every 12 hours prior to admission to the hospital. Patient #1 was transferred to a medical floor pursuant to a CT scan 6/17/16 which identified a possible small bowel obstruction/ileus.
Review of the nursing admission assessment dated 6/17/16 failed to identify that an assessment including the patient's risk for suicidal ideation was completed upon admission per the facility's protocol. Review of the nursing plan of care failed to indicate the patient's suicidal risk and/or pain management issues including interventions.

Review of the nursing flowsheets dated 6/27/16 at 12:10 pm identified that Patient #1's pain level was a 7/10 as acceptable and aching. Patient #1 received Roxicodone 10 mg at 12:04 pm. At 1:00 pm, Patient #1's pain level was a 7/10 as shooting and unbearable. MD #1 was notified at 1:00 pm regarding increased abdominal pain and Patient #1 was medicated for nausea and a new Fentanyl patch was applied. At 2:47 pm, pain level was 10/10 and "unbearable." MD #1 was notified and gave an order for Dilaudid IV 1.0 mg. Patient #1 received another dose of Dilaudid 1.0 mg IV at 6:02 pm with the understanding that Patient #1 would not be able to receive anymore Dilaudid IV until after he/she had a bowel movement. Patient #1 also received Roxicodone 10 mg at 7:20 pm with indications to reassess in one hour. At 7:22 pm, Patient #1's pain level was 8/10 as sharp and unbearable. At 9:00 pm, Patient #1 vomited 200 cc of undigested food and continued to have "unbearable pain." Although review of the clinical record identified a change in condition, further review failed to identify that the physician was notified regarding the patient's current status.

Interview with RN #1 on 7/6/16 identified that he/she had gone into Patient #1's room at 9:30 pm to do his blood sugar and noticed the patient was in the bathroom with the water running with the door shut. RN#1 indicated that he/she thought the enema had worked and the patient was in the bathroom having a bowel movement so he/she decided to come back in fifteen minutes. Further interview with RN #1 identified at 9:45 pm, he/she returned to Patient #1's room and the door was still shut so he/she knocked on the door with no answer. RN #1 indicated that he/she opened the door and found Patient #1 hanging with a bed sheet around a shower rod. RN #1 indicated that he/she had called for help, checked for a pulse while a Code 8 was called at 9:50pm. Interview with MD #2 on 7/5/16 identified that he/she was first called regarding Patient #1 by responding to the code and found Patient #1 hanging from the shower rod. MD #2 indicated that his/her assessment was that Patient #1 had expired "a while ago" so the decision was made based on his/her assessment not to resuscitate the patient and the patient was pronounced at 10:00 pm.

Review of hospital policy identified that the patient plan of care serves as a rapid reference for the active problems, interventions and measurable goals the care team addresses. In addition, the plan of care is reviewed at least every 24 hours and revised as necessary.

Interview with Nurse Manager #1 on 7/1/16 identified that the plan of care did not address the patient ' s history of suicidal ideation and pain management including narcotic usage concerns.

Based on a review of the clinical record, review of hospital policies and procedures and interviews with facility personnel for one of twelve sampled patients (Patient #1), the pharmacy failed to ensure that narcotic renewals were monitored and reordered if necessary. The findings include:

Patient #1 was admitted to the Emergency Department (ED) on 6/17/16 with abdominal pain. Patient #1's admitting diagnosis was a small bowel obstruction/ileus. Patient #1's history included abdominal surgeries (14 previous surgeries), congestive heart failure, diabetes, anxiety disorder, depression, suicidal ideation (on a 10/25/15 previous ED admission), and usage of multiple narcotics, including Fentanyl 25 micrograms every 72 hours, Oxytocin 10 milligrams every 12 hours prior to admission to the hospital. Review of the physician orders dated 6/18/16 identified that Patient #1 was to receive Fentanyl 25 micrograms every 72 hours and Oxycotin 10mg every 12 hours for pain to be renewed every seven days. On 6/25/16, Patient #1's medication was due to be renewed, however, the hospitalist never renewed the medication. Patient #1 had not received the scheduled Oxycotin for 36 hours. On 6/26/16, the 7:00 am - 3:00 pm nurse noticed the pain medication had not been renewed and called the physician for a new order.

Review of hospital policy identified that all Schedule II narcotic ordered will automatically be removed for the Medication Administration Record at 12:00 am on the seventh day if not renewed.


Interview with MD #6 on 7/13/16 identified that he/she was not aware and/or educated of an alert on the computer identifying that a patient's narcotic medications was up for renewal.

Interview with the Pharmacy Manager on 7/1/16 identified that pharmacy staff have no process in place to monitor when narcotics need to be renewed after seven days if the provider fails to renew the order. Further interview identified that the pharmacy relies on the provider to renew the narcotic when a purple tab in the computer that notifies the provider a narcotic needs to be renewed otherwise the narcotic order just drops off.

Review of hospital documentation dated 7/13/16 (16 days later) identified that a memo went out to all providers to remind them of renewing Schedule II Controlled Substances every 7 days per state law.