HospitalInspections.org

Based on interviews and the review of documents, it was determined facility staff failed to provide a safe environment for one (1) of fifteen (15) sampled patients (Patient #9).

The findings include:

The facility staff failed to ensure Patient #9 was unable to get access and make changes to his/her ventilator after the staff became aware of the patient manipulating the device.

On 3/26/19 at 1:15 p.m., Staff Member (SM) #14 (a PICU respiratory therapist (RT)) was interviewed about the RT care of Patient #9. SM #14's interview indicated that it was not common practice to lock ventilator screens but that staff had started doing that for Patient #9 because he/she had been noted to manipulate equipment.

Facility electronic communication documents to the "Respiratory Care Peds" group provided to the survey team indicated that facility staff were aware as early as August of 2018 that Patient #9 was manipulating his/her medical equipment and using cords to help move/pull himself/herself.

The following information was found in Patient #9's clinical record documented by a nurse practitioner on 11/12/18 at 3:23 p.m.: "Nurse walked by (patient's name) room, heard vent alarm, looked in and (patient name) was lying still in (his/her) bed. Checked on (him/her), found (him/her) cyanotic, called for help and started bagging child. Unsure of time, but later it was noted that vent settings had NAVA changed to 0 at 14:15pm [sic]... It is presumed that patient changed (his/her) (ventilator) setting, as the screen was facing the bed when we arrived in the room, but it had been facing the door when nurse was in room several minutes prior." (NAVA is a ventilator process that stimulates the patient's diaphragm to assist with breathing.) This nurse practitioner (SM #40) reported he/she assessed Patient #9 after the event and found the patient had recovered and returned to the patient's baseline level of health.

Staff Member (SM) #17 (a registered nurse) was working the PICU at the time of the event referenced in this complaint. SM #17 reported he/she responded to Patient #9's ventilator alarm going off. SM #17 stated the Patient #9 was found unresponsive and cyanotic. SM #17 reported he/she and a nurse practitioner (SM #40) started CPR and the patient recovered in less than two (2) minutes.

During an interview on 3/26/19 at 1:40 p.m., SM #16 (a respiratory manager) was asked about the event documented in the aforementioned note. SM #16 reported the patient was determined to have turned his/her ventilator toward himself/herself allowing him/her access to the ventilator controls. SM #16 reported Patient #9 had been known to manipulate equipment controls prior to the aforementioned event.

During an interview with SM #25 (a registered nurse) on 3/27/19 at 9:20 a.m., SM #25 reported prior to the aforementioned event the ventilator was placed away from the patient with the screen not toward the patient but that the patient would pull the ventilator to himself/herself; SM #25 reported prior to leaving Patient #9's room that the ventilator was turned away from the patient and the ventilator screen was locked.

The following information was found in Patient #9's clinical record documented by a registered nurse on 11/12/18 at 4:42 p.m.: "(Respiratory therapist) found NAVA to have been turned down to 0 at 1415, although the last time an RN was in the room the (ventilator) screen had been facing away from the patient."

On 3/27/19, observations of a ventilator, which was not attached to a patient, was made with a group that included SM #2 (a facility vice-president) and SM #23 (a respiratory therapist). It was noted during this observation that to unlock the ventilator screen only required one (1) button to be pressed. After the ventilator was unlocked, changes could be made to ventilator settings by manipulating other ventilator controls/buttons.

This is a complaint deficiency.