HospitalInspections.org

Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to ensure that medications ordered and administered to a patient included the dose and route for one of one medical record reviewed (MR1).

Findings include:

Review on December 9, 2011, of the facility's "Code Blue Manual," last approved June 2010, revealed "... Objectives: The Code Blue Manual has been established to meet the following objectives: 1. To establish a workable system of providing high quality Emergency Care to patients who have experienced respiratory or cardiac arrest. 2. To provide a source of information for Schuylkill Medical Center - South Jackson Street associates regarding established policies and procedures pertaining to Cardiopulmonary Resuscitation. ... Responsibilities Of Code Blue Team Members: ... will be a part of the patient's permanent chart and will serve as a [sic] accurate record of the types, dosages and times medications are given ..."

Review on December 12, 2011, of the facility's "Physician/Allied Health Professionals Orders" policy, last revised November 2011, revealed "... Procedure: ... 3. Verbal Order A verbal order will be accepted by an RN only in emergency situations. The verbal order must be dated, timed and countersigned as soon as the emergency situation is resolved. ..."

Review on December 9, 2011, of MR1's Code Blue Report Sheet revealed the facility administered Versed (a medication used as a sedative or anesthetic). There was no documentation on MR1's Code Blue Report Sheet indicating the dose or route of the versed administration. Further review revealed no documentation the physician of record authenticated the order for versed.

Interview with EMP6 on December 9, 2011, at approximately 3:20 PM confirmed there was no documentation on MR1's Code Blue Report Sheet indicating the dose or route for the administration of versed, and there was no documentation the physician of record authenticated the order for versed.

Based on review of facility documents, observation, medical record review (MR) and staff interview (EMP), it was determined that the facility failed to maintain a safe environment for one of one medical record reviewed (MR1) by failing to identify and maintain the air vents in a safe manner in the Behavioral Health Unit (A0701).

The cumulative effect of this failure resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Cross reference
482.41 (a) Buildings

Based on review of facility documents, observation, medical record review (MR) and staff interview (EMP), it was determined that the facility failed to identify and maintain the air vents in a safe manner in the Behavioral Health Unit.

This deficient practice resulted in an Immediate Jeopardy situation.

Findings include:

Review on December 9, 2011, of the facility's "Institute For Behavioral Health Policy and Procedure Subject: Safety" policy, last reviewed January 2010, revealed "Policy Statement: The Behavioral Health unit shall be equipped, operated and maintained so as to sustain its safe and sanitary characteristics. The purpose is to prevent or minimize all health hazards in the facility for the protection of both patients and personnel. To maintain a safe and secure therapeutic environment. ..."

Observation on December 9, 2011, at approximately 9:50 AM revealed a cut white bed sheet measuring approximately two feet in length tied in a knot to a six slotted louvered wall vent measuring approximately 8" x 6". The louvered vent was located on the wall approximately 4" from the ceiling and above the commode. There were six 1" gaps between each slot in the louvered vent. There was a black plastic garbage can turned with the open side to the floor near the commode.

Review on December 9, 2011, of the facility's internal investigation report dated December 8, 2011, revealed MR1 was found unresponsive and cyanotic. This patient was found with a bed sheet wrapped around the neck and hanging with feet off of the ground. Further review revealed facility staff cut MR1 down. A code blue was called. MR1 was not breathing. MR1 had a radial pulse.

Observation on December 9, 2011, of the facility's adult behavior health unit revealed patient rooms 550, 552, 553. 554, 555 and 556 occupied with patients. Further review of these patients' rooms revealed these rooms had the same slotted louvered wall vents measuring approximately 8" x 6"; that these louvered vents were located on the wall approximately 4" from the ceiling and above the commode. These louvered vents also had six 1" gaps between each slot in the louvered vent.

Interview with EMP1, EMP2, EMP3, EMP4 and EMP5 on December 9, 2011, at approximately 10:15 AM revealed the facility did not identify the slotted louvered wall vent as a potentially unsafe device in the behavioral health unit and that the facility did not maintain the safety of MR1 while a patient in the behavioral health unit.

Immediate Jeopardy was initiated on December 9, 2011. Seven rooms on the adult behavior unit were closed on December 9, 2011, at approximately 10:15 AM. The facility submitted a written Plan of Correction to the state agency at approximately 12:00 PM on December 9, 2011. The facility completed removing the louvered wall vents and replaced these wall vents with a perforated covering at approximately 3:30 PM on December 9, 2011. A full tour of the facility's adult and adolescent behavior health units was conducted. The Immediate Jeopardy was discontinued at this time.

Cross reference
482.41 Physical Environment