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Based on record review and interview, the hospital's Governing Body failed to ensure the members of the Medical Staff were held accountable to the Governing Body for the quality of care provided to patients. This deficient practice is evidenced by a deceased patient's death being pronounced remotely by an ER physican, based upon emergency responder's telephone report of patient status, and not by direct assessment by a member of the Medical Staff, for 1 of 1 (#2) death records reviewed out of a total patient sample of 5 (#1- #5).

Findings:

Review of the LSBME Newsletter, Volume 22, Number 2, Fall 2010, revealed the following, in part: In this issue of the newsletter we provide timely updates on rules that may affect your practice. Further review revealed the following: Guidance: Pronouncement of Death: The statutory authority governing the pronouncement of death in this state is R.S. 9:111. It provides as follows: A. A person will be considered dead if in the announced opinion of a physician, duly licensed in the state of Louisiana, based on ordinary standards of approved medical practice, the person has experienced cessation of spontaneous respiratory and circulatory functions. In the event that artificial means of support preclude a determination that these functions have ceased, a person will be considered dead if in the announced opinion of a physician duly licensed in the state of Louisiana, based upon ordinary standards of approved medical practice, the person has experienced irreversible total cessation of brain function. Death will have occurred at the time when relevant functions ceased. Additional review revealed the following LSBME opinion: On this particular issue, however, the Board is firmly committed to the view that the pronouncement of death is one of the most significant diagnoses a physician is called upon to make and should be preceded by his personal evaluation and diagnosis. We believe R.S. 9:111A is consistent with that view. (Advisory Opinion April 5, 2005, September 28, 2005, reaffirmed 2009).

Review of the Governing Board AD HOC meeting minutes, dated 11/20/19, revealed Policy Number: NU 402A "Death of Patient" was revised and approved by the hospital's Governing Board.

Review of the hospital policy titled, "Death of a Patient", Policy Number: NU 402A, last revised 11/20/19, revealed in part: I. Policy: For an unexpected death of a patient that may occur on the unit, the charge nurse is responsible for proper response and preparation of the deceased. III. Procedure: A. Physician will pronounce death of a patient if present on the unit at the time of death. Emergency responders will contact ER Physician to pronounce the patient deceased if no physician is present on the unit.

Review of Patient #2's medical record revealed the patient was admitted on 11/6/19 with diagnoses including Schizoaffective Disorder, Bipolar Type, chronic with acute exacerbation of symptoms - Catatonia. Further review revealed the patient was found in her room, unresponsive on 11/11/19 at 8:30 a.m. by S6RN. CPR was initiated and a Code Blue was called.

Review of Patient #2's discharge summary dated 11/11/19 revealed the following, in part: 11/11/19 at 8:30 a.m. Patient found unresponsive in her room in her bed. CPR initiated, Code Blue called, 9-1-1 alerted. Paramedics arrived on scene and continued resuscitation efforts. Paramedics called physician and physician pronounced patient deceased.

Review of S6RN's grievance investigation witness statement, dated 11/11/19 at 1:45 p.m., revealed the following, in part: While waiting for the ambulance to arrive, S6RN and S2DON used the AED and it instructed them to continue CPR. They continued until the ambulance arrived and took over CPR. The emergency responders continued until 9:14 a.m. when they called an ER physician to pronounce the patient deceased.

In an interview on 12/11/19 at 3:13 p.m. with S6RN, he reported he and S2DON had initiated CPR on Patient #2 and continued CPR until the ambulance arrived and the emergency responders took over. He indicated they shocked her 2-3 times with no response and they pushed medications. S6RN reported "after a while they (emergency responders) called the ER and the physican there pronounced the patient."

In an interview on 12/12/19 at 8:04 a.m. with S1COO, she indicated the hospital's previous policy had indicated the physician would assess the patient to pronounce death. S1COO indicated the hospital's current policy was for the emergency responders to call the ER physician to pronounce patients if there was no physician present in-house when a patient death occurred. She reported they had revised the policy in 11/2019, after Patient #2's death, to indicate emergency responders would contact the ER Physician to pronounce the patient deceased if no physician was present on the unit.

In an interview on 12/12/19 at 11:08 a.m. with S4MedDir, he confirmed Patient #2 had been found to be unresponsive, in her room, by staff on the morning of her death. He indicated he had received a call on the day she died to inform him of what had happened. S4MedDir reported he thinks the EMTs called an ER physician and he pronounced Patient #2.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with orders of the practitioners' responsible for the patient's care. This deficient practice is evidenced by failure of the nursing staff to administer as needed Clonidine per ordered parameters and failure to administer Synthroid as ordered for 1 (#2) of 5 (#1-#5) sampled patient records reviewed.

Findings:

Review of Patient #2's medical record revealed the patient was admitted on 11/6/19 with diagnoses including Schizoaffective Disorder, Bipolar Type, chronic with acute exacerbation of symptoms -Catatonia. Further review revealed the patient had co-morbid diagnoses of Hypertension and Hypothyroidism.

Review of Patient #2's physican's orders revealed an order, dated 11/6/19, for Clonidine (anti-hypertensive medication) 0.1 mg p.o. PRN for a systolic blood pressure greater than or equal to 160 and/or a diastolic blood pressure greater than or equal to 90. Further review revealed the dose could be repeated times one in an hour if needed.

Review of Patient #2's Graphics/ Intake and Output flowsheet revealed the following vital sign results:
11/8/19 at 6 a.m.: Blood pressure: 154/92; 8:00 p.m.: Blood pressure: 148/98;
11/10/19: 6 a.m.: 166/110; 2 p.m: Blood Pressure: 164/101 Blood pressure recheck: 159/97.

Review of Patient #2's medication administration record revealed no documented evidence that the PRN Clonidine had been administered when the patient's blood pressure had fallen within the ordered parameters for administration of Clonidine.

In an interview on 12/12/19 at 8:15 a.m. with S3RN, she confirmed she had worked on 11/10/19 from 7:00 a.m. - 7:00 p.m. S3RN explained MHTs obtained patient vital signs and gave copies of the vital sign results to the charge nurse and medication nurse. S3RN reviewed Patient #2's Graphics/Intake and Output flowsheet and Medication Administration Record and confirmed on 11/10/19 at 2:00 p.m. Patient #2's blood pressure had been 164/101 with a recheck result of 159/97. S3RN indicated Patient #2 probably should have received the PRN Clonidine dose and confirmed the medication had not been administered as ordered. S3RN further indicated if a patient's routine blood pressure medication was due and the blood pressure reading fell within the parameters for administration of Clonidine, she usually gave the scheduled antihypertensive medication, and re-checked the patient's blood pressure. She indicated if the repeat blood pressure was still elevated then she would probably give the PRN Clonidine. She indicated she usually did this without calling the physician or LIP for clarification or instructions.

Further review of Patient #2's medication record revealed Levothyroxin (Synthroid) 112 mcg - 1 tablet p.o. daily was due to have been administered at 6:00 a.m. on 11/11/19. Additional review revealed the space where the 6:00 a.m. dose should have been documented was left blank on 11/11/19. There was no documented evidence in the patient's medical record as to the reason the dose may not have been given.

In an interview on 12/12/19 at 1:17 p.m. with S5RN, she confirmed she had taken care of Patient #2 for 4 nights ( from 11/7/19 - 11/10/19). S5RN reviewed Patient #2's medication administration record and confirmed the patient was to have received Levothyroxin (Synthroid) 112 mcg - 1 tablet p.o., at 6:00 a.m. on 11/11/19. S5RN indicated she had not administered Patient #2's Synthroid at 6:00 a.m. on 11/11/19 because she was sleeping. She explained she "had pulled the medication but didn't give it because Patient #2 was sleeping so deeply." S5RN indicated she had assumed the morning medication nurse would come in and give the Synthroid dose to Patient #2 with her morning medications.

In an interview on 12/12/19 at 3:27 p.m. with S2DON, she confirmed patient medications should have been administered as ordered. S2DON indicated the nurses should have clarified whether or not to administer PRN Clonidine when a patient's blood pressure fell within the parameters for administration of Clonidine if the reading had occurred when the routine blood pressure medication was due. She further indicated, after review of Patient #2's Graphics/Intake and Output flowsheet and Medication Administration Record, that there were times that the PRN dose of Clonidine should have been administered as ordered for systolic blood greater than or equal to 160 and diastolic blood pressure of greater than or equal to 90. S2DON confirmed the medication had not been administered. S2DON also confirmed Patient #2's Synthroid dose that had been due at 6:00 a.m. on 11/11/19 should have been administered as ordered and if it was held then the nurse should have indicated why it wasn't given at the scheduled time.