HospitalInspections.org

Based on a facility tour, interviews with staff, medical record review, a review of facility policies and procedures, and review of other related documentation, it was determined that the facility failed to protect and promote the rights of the patients.

Findings include:

1. The facility failed to ensure that patients receive care in a safe setting (Cross refer to Tag A 0144).

2. The facility failed to ensure that personal privacy is provided to all patients (Cross refer to Tag A 0143).

Based on observation, staff interview and review of one (1) out of one (1) medical record, it was determined that the facility failed to ensure that personal privacy is provided to all patients.

Findings include:

1. On 2/16/21 at 1:35 PM, during a tour of the 6 East unit conducted in the presence of Staff #2, Staff #7 and Staff #17, it was observed that Room 6 E003, occupied by Patient #9, did not contain a privacy curtain and the patient was in full view through the hallway window.

a. At 1:40 PM, Staff #12 confirmed that the privacy curtain was removed during the cleaning of the room prior to the patient's arrival to the unit.

b. Review of Patient #9's medical record with Staff #21 at 1:50 PM, revealed that the patient was admitted to Room 6 E003 on 2/15/21 at 10:22 PM.

(i) Staff #21 confirmed that there was no privacy curtain in the patient's room when he/she started their shift on 2/16/21 at 7:00 AM.

2. The above findings were confirmed by Staff #1 on 2/17/21 at 3:39 PM.

Based on staff interview, review of one (1) out of one (1) medical record and review of facility documents, it was determined that the facility failed to ensure safety measures are implemented and that the chain of command is initiated when a change in patient status exists that has the potential for an adverse effect.

Findings include:

Reference #1: Facility policy titled, "Tele-Sitter Video Monitoring" states: "... Procedure: 1. Patient Inclusion Criteria selection for initiation of tele-sitter continuous visual monitoring includes but is not limited to: ... f) Potentially aggressive/violent patients g) Safety issue identified by the primary nurse ... i) Risk of self harm ... j) Other as clinically appropriate ..."

Reference #2: Facility policy titled, "Chain of Command" states: "Purpose: This document provides guidelines for implementing the chain of command to address clinical/.../safety issues ... that affect patient care, patient safety, or delays in treatment. Initiating the chain of command ensures that: -The appropriate people are aware of the situation; ... 4. The physician chain of command is identified as: a. Resident in charge of the patient/resident on call ... c. Private Attending, Hospitalist, ... 6. All steps taken in the chain of command for a clinical issue will be documented in the patient's medical record. ..."

1. On 2/16/21 at 10:48 AM, review of Patient #1's medical record, in the presence of Staff #2 and Staff #29, revealed the following:

a. Patient #1 arrived to the Emergency Department (ED) via ambulance on 11/9/20 at 8:45 AM and was admitted to the 6 East unit at 11:09 AM with a diagnosis of congestive heart failure, pleural effusion bilateral.

b. There was order for a tele-sitter (remote continuous visual monitoring) entered on 11/10/20 at 11:16 PM by the RN (Registered Nurse). Order details state, "Attempts to pull tubes."

(i) On 11/10/20 at 6:23 PM, the form titled "Telesitter Patient Admission Report Form" indicated a tele-sitter was initiated by the RN for delirium/restlessness and patient removing BIPAP (bi-level positive airway pressure) mask. On 11/11/20 at 6:25 PM, the tele-sitter was discontinued upon acuity change and transfer to the ICU (Intensive Care Unit).

c. There was a physician order for Patient Watch 1:1 (one to one) Observation on 11/15/20 at 2:47 PM. Order details states, "Patient is danger to Self or Others, ..."

d. On 11/21/20 at 9:38 AM, the Nurse Progress Note states, "Patient with periods of confusion. moaning and mumbling words. (Physician name) made aware, came to assess patient. ... Will continue to monitor."

e. On 11/21/20 at 7:00 PM, Staff #9 documented in the "Psychosocial" section of the medical record that the patient's behavior was "combative." The medical record lacked documentation that a physician was notified of a change in patient behavior or if a patient safety intervention was implemented. On 11/22/20 at 7:30 AM, Staff #10 documented in the "Psychosocial" section of the medical record that the patients behavior was "combative." The medical record lacked documentation that a physician was notified of the patient's behavior or if a patient safety intervention was implemented.

f. Documentation in the Nurse Progress Note, dated 11/22/20 at 10:00 AM, by Staff #10 stated, "Tele (Telemetry) tech (technician) had asked Rn to replace tele leads on patient. RN walked in 910am to find patient with frank blood on floor. The sheets were saturated with blood. Source of bleeding was the R (Right) femoral permacath (catheter) which had been pulled by patient. Tele leads were off. Patient unresponsive and pulseless. CPR (Cardiopulmonary Resuscitation) initiated and CODE called. ...Time of death 0931."

(i) The "Report of Death" states, "Cause of Death: Cardiopulmonary Arrest 2/2 (secondary to) Hypovolemic Shock."

2. Staff #9 and Staff #10 failed to ensure safety measures were implemented and that the chain of command was initiated when a change in patient status existed that had the potential for an adverse effect.

3. The above findings were confirmed on 2/17/21 at 3:39 PM by Staff #1, Staff #2, Staff #3, and Staff #5.

A. Based on observation, staff interview, review of one (1) out of three (3) facility documents, and review of facility policies and procedures, it was determined that the facility failed to ensure that all code carts in the Emergency Department (ED) are checked daily in accordance with the facility policy titled "Guideline Code Carts: Contents, Maintenance and Exchange."

Findings include:

Reference: Facility policy titled "Guideline Code Carts: Contents, Maintenance and Exchange" states, " ...Procedure: ...2. Code Cart checks will be performed at a minimum of once a day and documented on the 'Resuscitation Cart Check List' (See appendix F) ...9. At a minimum of once a day, a qualified member of the staff checks the Code Cart, using the 'Code Cart Checklist.' a. Documentation of cart/intubation box lock number on the checklist indicates that the lock is intact."

1. On 2/17/21 at 10:15 AM, during a tour of the ED, three (3) code carts were observed. One (1) of three (3) Code Cart Check Lists were found to be incomplete.

a. The "Adult Code Cart Check List" located on top of the code cart in the main ED was reviewed and revealed the following:

(i) The checklist lacked documented evidence that the code cart was checked on 2/14/21 and 2/15/21, in accordance with the facility policy referenced above.

(ii) On 2/16/21, in the column titled "Cart Lock # (number)" was written 4001472. The actual lock on the code cart was 4001429 and did not match the number on the checklist.

2. The above finding was confirmed by Staff #23, the Director of the ED, at the time of the finding.

B. Based on two (2) out of three (3) observations, staff interview and review of facility policies and procedures, it was determined that the facility failed to ensure that all Intravenous (IV) Carts containing needles and syringes, in the main ED, are kept locked in accordance with the facility policy titled "Medication Administration, Documentation & Storage."

Findings include:

Reference: Facility policy titled "Medication Administration, Documentation & Storage" states, " ...Process ...Administration ...9. Needles and syringes are to be kept in locked storage. ..."

1. On 2/17/21 at 10:15 AM, during a tour of the ED, in the presence of Staff #2 and Staff #23, three (3) IV carts were observed. Two (2) of the three (3) IV carts containing needles and syringes, were found unlocked and unattended, which is not in accordance with the above referenced facility policy.

2. The above finding was confirmed by Staff #23 at the time of the finding.

C. Based on one (1) out of one (1) medical record review, staff interview and review of facility policies and procedures, it was determined that the facility failed to ensure that nurse documentation on central lines is completed each shift in accordance with facility policy titled "Insertion and Maintenance of Central Venous Catheters (CVC)."

Findings include:

Reference: Facility policy titled "Insertion and Maintenance of Central Venous Catheters (CVC)" states, "...Central Catheter Management...2. the insertion site is to be inspected per shift for signs of patency, blood return, tenderness, redness, exudate and intactness of the dressing..."

1. On 2/16/21 at 10:48 AM, Medical Record #1 was reviewed in the presence of Staff #2 and Staff #29.

a. The "Vascular Access" section of the medical record, lacked documented evidence that Patient #1's right femoral permacath (catheter) was assessed on the following dates/times:

(i) 11/13/20 for the 7:00 PM to 7:00 AM shift

(ii) 11/14/20 for the 7:00 AM to 7:00 PM shift

(iii) 11/17/20 for the 7:00 AM to 7:00 PM shift

(iv) 11/20/20 for the 7:00 AM to 7:00 PM shift

(v) 11/21/20 for the 7:00 PM to 7:00 AM shift

2. The above finding was confirmed by Staff #2 and Staff #29 at the time of discovery.