HospitalInspections.org

Based on staff interviews, review of pertinent hospital wide policies and procedures, review of medical records, and review of digital video recordings, it was determined that the Governing Body failed to demonstrate that it is effective in carrying out the operation and management of the hospital. The facility did not provide the necessary oversight and leadership as evidenced by the lack of compliance with:

42 CFR 482.13: Patient Rights.

Based on review of the facility's policies and procedures, tours of the facility, staff interview, reviews of medical records, and other facility documents, it was determined that the facility failed to protect and promote the rights of each patient.

Findings include:

1. Facility staff failed to immediately respond to a patient with an apparent medical emergency. (Cross refer to Tag 0144)

Based on a review of the hospital policy and procedure, review of the medical record of one patient, and review of related documentation, it was determined that the patient was not provided care in a safe environment.

Findings include:

Reference #1: Facility policy and procedure titled "Medical Emergency Code 66" stated:
"I. POLICY:
An immediate response to a victim of any medical emergency is provided that requires a coordinated team effort trained in Cardio Pulmonary Resuscitation (CPR) and First Aid. Physiological stabilization is attempted prior to transfer to a general hospital in the community for continued care.
II. DEFINITION:
Medical Emergency/Code 66 - an emergency that requires medical attention with immediate application of skilled techniques, medications, and special equipment.
III. PROCEDURE:
1. If a change in patient's baseline status is noted by any personnel (Social Worker, Psychologist, Housekeeper, etc.) the unit charge nurse is notified immediately .....
.....
4. The initial employee, who finds the victim, immediately assesses the scene and follows the Emergency First Aid Policy (NURS 5.23) and CPR protocol. If assessment determines that a person requires immediate medical care, a call for help is given to another employee who dials 6666 to initiate a Code 66. .....
....."

Reference #2: Facility policy and procedure titled EMERGENCY FIRST AID stated:
"POLICY/STANDARD: Nursing staff help maintain a safe environment and render emergency care according to guidelines of current certification.
PROCEDURE: 1. Emergency first aid occurs in situations requiring quick and appropriate intervention to prevent serious injury or death, until medical help and/or more advanced life-support arrives.
2. The scene is surveyed for safety prior to intervening. The victim is checked to determine if immediate medical care is required.
....."

1. On 12/14/16, a review of two video surveillance views recorded concurrently of Unit Holly 1 on 12/3/16 indicated (times referenced are those of the time stamp on the videos):
* At 1:07:11 - Patient #1 is observed to fall to the ground near a water fountain in the area in front of the nurse's station.
* At 1:07:26 - Patient #1 is still moving on the ground.
* At 1:07:30 - Staff #14, a Human Services Assistant, in a hallway across a hallway from the patient is observed to see the patient on the floor from the Dorm III hallway. The patient at the same time is observed to be shaking as if having a seizure.
* At 1:07:39 - Three staff members, including Staff #14, are observed walking out of the Dorm III hallway into the area in front of the door to the nurse's station.
* At 1:07:47 - The three staff members are in front of the nurse's, and one female staff enters the nurse's station. The other two staff members, including Staff #14, were still in front of the nurse's station until one female staff member returned to the dorm.
* At 1:07:59 - Staff #14 is observed to go into the nurse's station. The patient is lying face down, still appearing to be having seizure-like motions.
* At 1:08:04 - Staff #15, the female Human Services Assistant who did not return to the dorm is observed standing in front of the nurse's station door. Staff #16, a registered nurse, is observed wheeling out a vital signs machine and left it in front of the nurse's station.
* At 1:08:14 - Staff #16 walks towards the patient while donning gloves. Another staff member is observed walking in the hallway.
* At 1:08:28 - Staff #16 is observed bending over the patient.

a. The videos revealed that the patient was observed by staff to be lying on the floor at 1:07:30 by Staff #14. It was not until 1:08:28 that a staff member was observed to go to the patient to determine whether there was a medical emergency. The referenced facility policies require that an immediate response is required. The polices were not adhered to.