HospitalInspections.org

Based on record reviews and interview, the governing body failed to assure that the medical staff had written policies and procedures for appraisal of emergencies, initial treatment, and referral when appropriate as evidenced by failure to have documented evidence of a written medical staff policy and procedure that addressed the appraisal of emergencies, initial treatment, and referral.

Findings:

Review of the "Medical Services Manual June 2015", presented as the current medical services information by S1CEO, revealed that the hospital does not include an emergency department. Emergency services provided consist of patient stabilization, arranging emergency medical transport, and providing appropriate medical hand-off to the acute care receiving facility personnel.

Review of the "Rules And Regulations Of The Medical Staff", presented as the current rules and regulations by S1CEO, revealed that the table of contents included no documented evidence of a section related to the provision of emergency medical services.

Review of the policy titled "Management of Acute Clinical Deterioration of Patient", presented as one of two emergency services policies by S1CEO, revealed the purpose of the policy was to assure that there is a clear mechanism in place to manage changes in the patient's medical or psychological status through early recognition of clinical deterioration.

Review of the policy titled "Code Blue", presented as one of two emergency services policies by S1CEO, revealed the purpose of the policy is to provide clear and consistent protocol to secure immediate medical response and coordination of care, including necessary mobilization of additional medical services for patients, visitors, and hospital staff and to provide staff the additional assistance for immediate medical assistance when there is a concern of change in an individual's medical status.

No documented evidence of medical staff policies and procedures were provided during the survey for the following: appraisal of emergencies by the physician or medical direction of onsite staff conducting appraisals; provision of initial treatment needed by persons with emergency conditions; provisions for situations in which a person's emergency needs exceed the hospital's capabilities with procedures that enable hospital staff who respond to emergencies to recognize when a person requires a referral or transfer and assure appropriate handling of the transfer.

In an interview on 03/03/17 at 2:25 p.m. with S1CEO and S15NE present, S1CEO indicated the deterioration of the patient and the code blue policies were the hospital's emergency services policies. He confirmed he did not have any other policies and procedures to present related to the provision of emergency services.

Based on observations, record reviews, and interviews, the hospital failed to ensure patients had the right to receive care in a safe setting as evidenced by failure to have developed a policy that included this right and by having multiple ligature and safety risks observed on the Oakcrest Unit 2 (described by S1CEO as a maximum security, competency restoration unit) on 02/24/17 and 03/03/17.

Findings:

Observation on Oakcrest Unit 2 on 02/24/17 from 8:50 a.m. through 10:15 a.m. with S1CEO present revealed the following ligature and safety risks:

1) Dayroom has 2 metal bars where seats were attached and have been removed leaving 4 sharp metal edges on the bar that could cut a patient if the patient fell on or was pushed on the bar. The bar that had 2 seats still attached had sharp metal edges on each side of the chair.

2) Patient bathroom has 5 toilet stalls and 4 sinks with all toilets and sinks with exposed plumbing. The faucets on the sink are not ligature-proof. The screws attaching the mirrors to the wall are not tamper-resistant. The entrance door hinge has spaces between each hinge that presents a ligature risk.

3) The bed in the seclusion room has 4 open bars (where restraints are attached) on each side of the bed that could be a ligature risk when a patient is in seclusion and not restrained.

4) Shower room has a door to the plumbing/water valves that was open. The water knobs/pipes could be used as ligature points. The toilet in the room has exposed plumbing. The toilet is located around a wall separating the toilet from the sink area and is not visible when standing at the entrance door.

5) The bedroom area has 4 beds in each open section separated by a half wall with one section having one bed. Each bed has a rusted metal cabinet next to it with multiple bent, sharp metal edges that could cut a person. Some cabinets were open, some were locked, and some were closed with the key in the lock. The key could be used as a weapon.


Observation on Oakcrest Unit 2 on 03/03/17 at 10:05 a.m. with S17CCS, S7RNS, S3RNM, and S8RN present on the unit revealed the following ligature and safety risks:

1) The bedside cabinets have combs, toothbrushes, toothpaste, lotion, pens, and markers in the opened cabinets that could present a safety risk.

2) The bathroom doors have 3 of the stall doors with open spaces between each hinge that could be used as a ligature point.

3) The outdoor area has a swing with an approximate 2 foot chain attached to one end of the swing and the remaining end of the chain unattached. The chain was long enough to be wrapped around a person's neck causing suffocation.


Review of the hospital policy titled "Patient Rights", presented as a current policy by S1CEO, revealed 8 patient rights are listed. The right to care in a safe setting is not listed as a patient right.


Review of the "Patient Handbook", presented as the current handbook by S1CEO, revealed no documented evidence that care in a safe setting was listed as a patient right.


In an interview on 02/24/17 at 9:10 a.m., S16CGT indicated the door to the plumbing/water valves in the shower room hasn't been locked since he has worked on the unit. S1CEO, who was present during this interview, indicated the entrance door to the shower room remains locked, and when a patient is in the shower room, a CGT is posted inside the room at the door.


In an interview on 02/24/17 at 9:15 a.m., S16CGT indicated if there's 4 patients showering and a patient on the toilet, there's usually 1 CGT in the shower room. He confirmed the toilet area is not visible if the CGT is standing at the entrance door.


During the above observations from 8:50 a.m. to 10:15 a.m., an interview was conducted with S3RNM. She indicated sometimes the bedside cabinets are locked, and security has a key. She couldn't explain why some of the cabinets had a key in the lock.


In an interview on 03/03/17 at 10:05 a.m. during the observation of the outdoor area, S17CCS confirmed the presence of the approximate 2 foot chain that was unattached on one end that was a suffocation/safety risk.

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:

1) Failing to ensure an RN was present on Oakcrest Unit 2 (described by S1CEO as a maximum security, competency restoration unit) at all times to ensure the immediate availability of a RN for bedside care of any patient as evidenced by observation on 03/07/17 at 3:30 p.m. revealing patients were in the day room and in the bedroom area with no RN present on the unit. Interviews throughout the survey with multiple RNs revealed an RN is not always present on the unit when patients are on the unit (see findings in tag A0392).

2) Failing to ensure the Oakcrest Unit 2 had an adequate number of CGTs when patients were ordered to be on CVO and 1:1 observation for 9 (01/01/17, 01/02/17, 01/03/17, 01/04/17, 01/06/17, 01/07/17, 02/17/17, 02/18/17, 02/19/17) of 14 days reviewed for staffing. There was a total of 14 shifts with inadequate coverage of CGTs in accordance with the hospital's core staffing (see findings in tag A0392).

3) Failing to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:

a) Failing to develop a policy and procedure for the evaluation of patients that addressed the frequency of RN assessments for 4 (#1, #2, #3, #4) of 4 patient records reviewed for RN assessment from a sample of 5 patients. The hospital had a policy that allowed documentation of a progress note by the nurse every shift for 72 hours, then weekly for 4 weeks, and then monthly for the remainder of the patient's hospital stay.

b) Failing to ensure the RN thoroughly assessed a patient at the initiation of a code situation (#1), with complaints of chest and stomach pain (#2), after physical altercations between patients (#3, R1), 72 hours after admission (#1, #2, #3, #4, #5), and assessed a patient for suicide and homicide risk at admission (#3) for 5 (#1, #2, #3, #4) of 5 sampled patients and 1 (R1) of 1 random patient.

c) Failing to ensure the CGT observed a patient as ordered by the physician as evidenced by failure to have documented evidence of the observations made by the CGT from 01/17/17 at 12:45 p.m. until 01/17/17 at 6:00 p.m., from 02/17/17 at 6:15 p.m. through 02/18/17 at 5:45 a.m., and from 02/20/17 at 6:15 a.m. through 2:20 p.m. for 1 (#3) of 1 patient record reviewed with orders for 1:1 observation from a sample of 5 patients (see findings in tag A0395).

4) Failing to ensure:

a) The RN assigned the nursing care of each patient to the CGTs as evidenced by having contradictory policies for nursing and security that resulted in 14 shifts with inadequate CGT coverage on the Oakcrest 2 Unit (described by S1CEO as a maximum security, competency restoration unit) on 01/01/17, 01/02/17, 01/03/17, 01/04/17, 01/06/17, 01/07/17, 02/17/17, 02/18/17, and 02/19/17 with no documented evidence of action by the RN to correct the staffing shortage.

b) The RNs were evaluated for competency in the performance of patient assessment during a code situation once the need had been identified by administration after a Code Blue occurred on 01/02/17 (see findings in tag A0397).

Based on observation, record reviews, and interviews, the hospital failed to ensure:

1) A RN was present on Oakcrest Unit 2 (described by S1CEO as a maximum security, competency restoration unit) at all times to ensure the immediate availability of a RN for bedside care of any patient as evidenced by observation on 03/07/17 at 3:30 p.m. revealing patients were in the day room and in the bedroom area with no RN present on the unit. Interviews throughout the survey with multiple RNs revealed an RN is not always present on the unit when patients are on the unit.

2) The Oakcrest Unit 2 had an adequate number of CGTs when patients were ordered to be on CVO and 1:1 observation for 9 (01/01/17, 01/02/17, 01/03/17, 01/04/17, 01/06/17, 01/07/17, 02/17/17, 02/18/17, 02/19/17) of 14 days reviewed for staffing. There was a total of 14 shifts with inadequate coverage of CGTs in accordance with the hospital's core staffing.

Findings:

1) A RN was present on Oakcrest Unit 2 at all times to ensure the immediate availability of a RN for bedside care of any patient:
Observation on Oakcrest Unit 2 on 03/07/17 at 3:30 p.m. revealed patients were in the day room and in the bedroom area with no RN present on the unit upon the surveyor's entrance on the unit. This observation was confirmed by S7RNS who accompanied the surveyor on the unit.

In an interview on 02/24/17 at 9:30 a.m., S3RNM indicated the RN is off the unit when he/she goes into the medication room, which is located outside the locked door of the unit approximately 123 feet down the hall, to prepare medications or when he/she attends staffing on Mondays and Tuesdays. She further indicated medications are routinely administered during the day and night shifts which allows for the nurse to be off the unit for approximately 2 to 2 1/2 hours a day.

In an interview on 03/03/17 at 10:25 a.m., S8RN indicated she was the only nurse assigned to Oakcrest Unit 2 on the day shift. She further indicated when she prepared medications this morning, she left 25 patients on the unit with only the CGTs present. She confirmed there was no nurse present on the unit during this time. S8RN indicated there are 4 units on Oakcrest Unit, each with 25 patients. She further indicated each of the 4 units are left with no nurse on the unit when the nurse goes to the medication room to prepare medications.

In an interview on 03/03/17 at 11:10 a.m., S7RNS confirmed that an RN is not always on the unit when patients are present.

In an interview on 03/03/17 at 2:25 p.m. with S1CEO and S15NE present, S1CEO indicated the goal was to have a nurse on the unit at all times that patients are present on the unit.

In a telephone interview on 03/06/17 at 10:50 a.m., S6RN indicated on staffing days or when she has to do computer charting, she is usually in the medication room. She further indicated she spends about 1 to 1 1/2 hours off the unit preparing medications and 30 to 45 minutes documenting on the medication administration record and cleaning the medication cart. She further indicated she could possibly spend 2 to 3 hours off the unit during staffing, depending on the number of patients being staffed and the number of physicians conducting staffing.


2) The Oakcrest Unit 2 had an adequate number of CGTs when patients were ordered to be on CVO and 1:1 observation:
Review of the policy titled "Nursing Staffing Plan", presented as a current policy by S1CEO, revealed that the purpose of the policy was to assure that adequate coverage is provided to meet the nursing care needs of the clients and to maintain unit security. Staffing ratios are based on the following factors: population served; level of care; geographics of the unit.

Review of the policy titled "Core Staffing Coverage Assignment", presented as a current policy by S1CEO, revealed that core staff is considered to be the number of staff required to safely care for clients without exception or greater client requirements or need. The shift captains are responsible for scheduling the correctional guard, therapeutic daily assignments. The core staffing coverage is determined by the number of factors, such as client acuity, transportation needs, appointments, and other various issues that demand increased staff for the delivery of care. Shift captains will review and identify specific requirements for CGT staffing coverage based on RPM. Further review revealed core coverage for Oakcrest Unit 2 was 3 CGTs on the day shift and night shift each.

Review of the policy titled "Management of Assignments and Accountability", presented by S1CEO as one of 2 policies with this title, revealed the effective date was February 2008 with a revision date of September 2012. Further review revealed that the RN shall assume hospital and legal responsibility for the delegation of duties and the supervision of the delivery of care during their shift. The RN shall assign duties to CGTs on their unit in accordance with their building program. Staff assignments shall be based on level of acuity as well as staff competency.

Review of the second policy titled "Management of Assignments and Accountability", presented by S1CEO, revealed the effective date was April 2004 with a revision date of September 2012. Further review revealed the RN shall assign duties to the CGTs. The RN shall work in collaboration with the unit Captain/Lieutenant in the delegation of duties to CGTs in accordance with their building program.

Review of the staffing assignment sheets provided by S2FND revealed the following days with no documented evidence of adequate CGT coverage in accordance with hospital policy:

01/01/17 night shift (6:00 p.m. to 6:00 a.m.) - 3 patients on CVO and 1 patient on 1:1 with 4 CGTs present (should have had 5 CGTs); day shift (6:00 a.m. to 6:00 p.m.) had 4 CGTs with same patients on RPM ( should have had 5 CGTs);

01/02/17 night shift - 3 patients on CVO and 1 patient on 1:1 with 4 CGTs present (should have had 5 CGTs); day shift with 4 CGTs (should have had 5 CGTs);

01/03/17 day shift - 3 patients on CVO and 1 patient on 1:1 with 4 CGTs (should have had 5 CGTs); night shift had 2 patients on CVO and 1 patient on 1:1 with 3 CGTs present (should have had 4 CGTs);

01/04/17 day shift - 2 patients on CVO and 1 patient on 1:1 with 3 CGTs present (should have had 4 CGTs); night shift with 2 patients on CVO and 1 patient on 1:1 with 3 CGTs present (should have had 4 CGTs);

01/06/17 night shift - 3 patients on CVO and 1 patient on 1:1 with 3 CGTs (should have had 5 CGTs);

01/07/17 day shift - 3 patients on CVO and 1 patient on 1:1 with 4 CGTs (should have had 5 CGTs); night shift with
3 patients on CVO and 1 patient on 1:1 with 4 CGTs (should have had 5 CGTs);

02/17/17 night shift - one patient on 1:1 with 2 CGTs (should have had 3 CGTs);

02/18/17 night shift - 1 patient on 1:1 with 2 CGTs (should have had 3 CGTs);

02/19/17 night shift - 1 patient on 1:1 with 2 CGTs (should have had 3 CGTs).


In an interview on 03/07/17 at 11:30 a.m. with S2FND and S19Major present, S19Major indicated they have 1 CGT observe 2 patients on CVO, and when 3 patients were ordered on CVO, there should have been an additional CGT assigned to the unit. He further indicated with 3 patients on CVO and 1 on 1:1, there should have been 2 CGTs to observe the 3 patients on CVO, 1 CGT to observe the patient 1:1, and an additional 2 CGTs to observe the other patients on the unit. He confirmed the above-listed days' staffing was not in accordance with hospital policy. S2FND indicated she would expect a unit to be staffed at a minimum every day. She confirmed the RN should have been involved with the staffing assignments on the above-listed days. S2FND confirmed the above-listed shifts did not have adequate CGT coverage.

Based on observation, record reviews, and interviews, the hospital failed to ensure a RN supervised and evaluated the nursing care for each patient as evidenced by:

1) Failing to develop a policy and procedure for the evaluation of patients that addressed the frequency of RN assessments for 4 (#1, #2, #3, #4) of 4 patient records reviewed for RN assessment from a sample of 5 patients. The hospital had a policy that allowed documentation of a progress note by the nurse every shift for 72 hours, then weekly for 4 weeks, and then monthly for the remainder of the patient's hospital stay.

2) Failing to ensure the RN thoroughly assessed a patient at the initiation of a code situation (#1), with complaints of chest and stomach pain (#2), after physical altercations between patients (#3, R1), 72 hours after admission (#1, #2, #3, #4, #5), and assessed a patient for suicide and homicide risk at admission (#3) for 5 (#1, #2, #3, #4) of 5 sampled patients and 1 (R1) of 1 random patient.

3) Failing to ensure the CGT observed a patient as ordered by the physician as evidenced by failure to have documented evidence of the observations made by the CGT from 01/17/17 at 12:45 p.m. until 01/17/17 at 6:00 p.m., from 02/17/17 at 6:15 p.m. through 02/18/17 at 5:45 a.m., and from 02/20/17 at 6:15 a.m. through 2:20 p.m. for 1 (#3) of 1 patient record reviewed with orders for 1:1 observation from a sample of 5 patients.

Findings:

1) Failing to develop a policy and procedure for the evaluation of patients that addressed the frequency of RN assessments:
Review of the policy titled "Documentation in the Patient's Chart", presented as a current policy by S1CEO, revealed that the nurse shall make a progress note every shift for 72 hours on all acute or admit units/wards. The nurse shall make a progress note entry when a patient is transferred from one ward to another or from one building to another. Licensed personnel shall complete a nursing progress note on all patients weekly, following the B.I.R.P format ( Behavior-Intervention-Response-Plan). Licensed staff shall complete a patient progress summary according the length of time the patient has been in the hospital (if more than 4 weeks, the nursing progress summary will be completed monthly).

No documented evidence of a policy was presented throughout the survey that addressed the required frequency of RN assessments (policy above related to documentation).

Patient #1
Review of Patient #1's medical record revealed he was admitted on 02/12/16. Review of the RN nursing documentation revealed the RN admit nursing assessment was conducted on 02/12/16 at 10:40 a.m. Further review revealed the 72 hour nursing assessment was done on 02/14/16 at 12:00 p.m. (49 hours and 20 minutes after admit). There was no documented evidence that a nursing progress note or 72 hour progress note was completed on 02/15/16 (required a note every shift for 72 hours after admit).

Patient #2
Review of Patient #2's medical record revealed he was admitted on 01/04/17. His RN admit assessment was documented at 9:45 a.m. Further review revealed no documented evidence of an RN progress note on the night shift of 01/05/17. The 72 hour progress note was documented on 01/06/17 at 1:00 p.m. (51 hours and 15 minutes after admit rather than 72 hours). There was no documented evidence of an RN progress note on 01/07/17.

Patient #3
Review of Patient #3's medical record revealed his RN admit assessment was documented on 01/11/17 at 10:30 a.m. Further review revealed his 72 hours RN progress note was documented on 01/13/17 at 3:00 p.m. (52 hours and 30 minutes after admit rather than in 72 hours).

Patient #4
Review of Patient #4's medical record revealed his RN admit assessment was documented on 01/31/17 at 2:30 p.m. Further review revealed no documented evidence of an RN progress note on 02/03/17. The 72 hour RN progress note was documented on 02/02/17 at 2:00 p.m. (less than 48 hours after admit rather than in 72 hours).


In an interview on 03/03/17 at 10:25 a.m., S8RN indicated patients are assessed when they return from a pass. She indicated her assessment in this situation consisted of her asking the patient if he was alright and taking the patient's VS. She further indicated "otherwise I think the night shift assesses them every so often." She indicated she would also assess a patient "if the patient complains or if I notice the patient limping or if they scratch themselves."


In an interview on 03/03/17 at 11:10 a.m., S7RNS was asked how often the RN assesses the patient. She indicated "it depends." She explained that if there's a complaint or an incident, the RN does an assessment. She indicated that a routine RN assessment is done monthly. S7RNS confirmed that the RN does not assess each patient every 24 hours. She further indicated she didn't know what the LSBN's requirement was related to time intervals for an RN assessment.


In an interview on 03/03/17 at 11:45 a.m., S9RN indicated he does not work Oakcrest Unit 2. He further indicated that on the unit he manages, the RN assesses the patient monthly and completes a progress note.


In a telephone interview on 03/06/17 at 10:50 a.m., S6RN indicated "if nothing is wrong with the patient", assessments by the RN are done once a month. When asked how she would know whether something was wrong or not if an assessment isn't done but monthly, S6RN indicated "these patients all walk and talk and can tell you if something's wrong." When asked how often patients are assessed by the RN for suicide risk, she indicated "I guess monthly too unless the patient says they're feeling suicidal."


In an interview on 03/07/17 at 2:35 p.m., S11RN indicated patients are assessed by the RN at admit, monthly, and after a complaint by the patient, a fall, and after a hospital visit. She further indicated the RN has to document an assessment (not head-to-toe) every shift for the first 2 days after admit and assess 72 hours after admit. When asked what the assessment should include, she indicated the presence or absence of suicidal and homicidal ideations, appetite, sleep pattern, whether anyone is bothering the patient, patient's orientation, and the presence or absence of hearing voices. S11RN indicated the monthly assessment is a head-to-toe assessment. She further indicated she isn't familiar with the LSBN's guidelines regarding RN assessments.


2) Failing to ensure the RN thoroughly assessed a patient at the initiation of a code situation (#1), with complaints of chest and stomach pain (#2), after physical altercations between patients (#3, R1), 72 hours after admission (#1, #2, #3, #4), and assessed a patient for suicide and homicide risk at admission (#3):

Code Situation:
Review of the policy titled "Code Blue", presented as the policy in place at the time of the event by S1CEO (has since been revised), revealed a code blue is initiated when there is a requirement for ACLS (advanced cardiac life support), BLS (basic life support), use of Heimlich maneuver, or any other medical emergency that requires restoration of respiration., Code blue treatment and interventions shall be guided by BLS and ACLS guidelines, ACLS algorithms, and hospital policy. The most qualified medical personnel who arrives at the scene will be the code leader, and the MD is always the code leader upon arrival and directs the code process. The code leader assures availability of the code blue bag and the AED (automatic external defibrillator) and determines and authorizes the need for ambulance services. The code recorder documents on the official Code Blue record form through the complete code event.

Review of Patient #1's "Progress Notes" revealed documentation of "Code Blue" on 01/02/17 at 9:25 a.m. by S6RN as follows: "at approximately 0817 (8:17 a.m.) this writer was called to Oakcrest-2 (described by S1CEO as a maximum security, competency restoration unit) by security staff after hearing a loud noise in the patient bathroom. Upon arrival client (Patient #1's name) was found lying on the bathroom floor alone with his eyes closed, breathing, pulse present, verbally unresponsive with a laceration approx (approximately) 2 inches noted forehead/R (right) eye and approximately 1 cm (centimeter) laceration noted to upper lip. At 0826 (8:26 a.m.) S5MD was called. At approx 0826 the client stopped breathing, a code blue was called and CPR was initiated. (name of) ambulance was called at 0835 (8:35 a.m.). Refer to code blue notes for further documentation." Further review of the progress notes revealed on 01/02/17 at 9:30 a.m. S6RN documented that per the ambulance attendant, Patient #1 was pronounced dead by Hospital A's emergency room doctor after being coded in the ambulance by the emergency medical technicians.

Review of Patient #1's "Code Blue Record" documented by S6RN revealed a Code Blue was called on 01/02/17 at 8:26 a.m. Further review revealed the following documentation:

8:25 a.m. - patient on floor in bathroom; breathing stopped; CPR initiated by S6RN;

8:26 a.m. - Code Blue called; S7RNS notified S5MD;

8:27 a.m. - patient breathing on his own; BP unsuccessful with machine;

8:33 a.m. - manual BP 130/86; accucheck 123;

8:35 a.m. - patient stopped breathing; carotid pulse 40; CPR resumed by S18CGT; ambulance called;

8:38 a.m. - AED (automatic external defibrillator) in place; no shock advised; O2 at 2 liters per NC; CPR resumed by lieutenant;

8:41 a.m. - patient breathing; manual BP 130/50; O2 saturation 85%;

8:43 a.m. - patient stopped breathing again; CPR resumed; O2 at 15 liters per non-rebreather mask;

8:46 a.m. - S5MD on unit; CPR continues; IV initiated with 18 gauge in left antecubital with Normal saline;

8:53 a.m. - ambulance on unit; CPR continued;

8:58 a.m. - Epinephrine 1 mg (milligram) IV (intravenous) administered per EMS (emergency medical service); CPR continues;

9:00 a.m. - patient intubated per EMS; analyzed with no shock advised; O2 connected to intubation tube and continued at 15 liters per minute. CPR continues;

9:09 a.m. - Epinephrine 1 mg IV administered per EMS; CPR continues;

9:14 a.m. - Epinephrine 1 mg IV per EMS; CPR continues;

9:20 a.m. - faint carotid pulse per EMS; bradycardia on monitor; EMS to transport patient to Hospital A;

9:30 a.m. - EMS had patient in ambulance in Oakcrest parking lot and reported that emergency MD at Hospital A pronounce patient dead at 9:30 a.m.


Review of the entire documentation of the above event revealed the RN arrived to the patient 8 minutes after she received the call. Patient #1 stopped breathing 8 minutes after S6RN was notified, and the code was called 9 minutes after she received the call. The first VS assessment was documented 8 minutes after S6RN arrived at the code, VS were assessed twice, once at 8:33 a.m. and again 8 minutes later at 8:41 a.m. The IV was initiated 21 minutes after S6RN was notified of the event, and the ambulance was called 10 minutes after Patient #1 had coded. Further review revealed S6RN attempted to take the BP with a machine rather than conducting a quick assessment manually. Further review revealed O2 was administered per NC and a non-rebreather mask when the patient was not breathing and receiving CPR.


In a telephone interview on 03/03/17 at 2:05 p.m., S5MD indicated she arrived on the unit about 10 to 20 minutes after she received the call of notification of the event. She further indicated that upon her arrival, Patient #1 was in the hall, CPR was in progress, and the AED was attached showing "no shock." She indicated the ambulance had been called. S5MD indicated she thinks (didn't have records with her for review) when the ambulance attendants arrived, Patient #1 had a heart beat but coded before the ambulance traveled 500 feet. She indicated she did not have any hands-on contact with the patient during the event, and she didn't order the IV that was started. When asked about the delay in assessing VS, she indicated if the patient was not breathing and had no pulse, he wouldn't have a BP and pulse. She offered no comments when informed that documentation revealed Patient #1 was responsive and breathing when S6RN arrived. She further indicated the coroner's report revealed the cause of death was a pulmonary embolus, and the staff did everything they could.


In an interview on 03/03/17 at 11:45 a.m., S9RN indicated he came to the code, because he was scheduled as the code responder that day. He further indicated, as a nurse, cleaning the eye isn't important during the code. The RN needed to assess the BP, oxygen saturation, and conduct an assessment."


In an interview on 03/03/17 at 2:25 p.m. with S1CEO and S15NE present, S1CEO indicated no RN at the hospital is ACLS certified. Surveyor asked if the nursing assessment policy was revised after the event in January 2017, and S1CEO answered "no." He indicated the Code Blue policy was changed, and the nursing competency had added a component for the nursing assessment. S15NE indicated they had conducted education on the new assessment tool, but no competency evaluation had been conducted as of the date of this interview. S15NE indicated the hospital has no emergency drugs available. He said EMS should be summoned when its "deemed necessary according to the patient's condition." He further indicated he had not reviewed the event regarding Patient #1's death (was out on leave at time and returned at end of January). Surveyor asked S15NE at what point should the AED/emergency equipment be employed, and he indicated "when the patient's condition is a potential cardiopulmonary event."


In a telephone interview on 03/06/17 at 10:50 a.m., S6RN indicated when she arrived on the unit, Patient #1 was in 1st bathroom stall between the toilet and the wall on the right side of the toilet when facing the toilet. He was laying on his side with his head by the toilet and his feet at the door. His head was against the wall and not on the floor. When she saw the patient, she asked him if he was ok. He tried to verbalize but didn't answer, but his eyes were open. She further indicated the guards moved him out of the stall with one grabbing his feet and one grabbing his shoulders or arms and moved him in front of stall. She further indicated she could see "a gash in his forehead and a busted lip." S6RN indicated she tried to clean the cuts. He started to shake, and she couldn't get a BP with the machine, so she took a manual BP. Surveyor asked if she cleaned cuts first before assessment and S6RN indicated said she didn't remember if they had a BP machine at the time she was cleaning the cuts. She further indicated the machine kept reading "error". S6RN then indicated she remembered she had the BP machine, and while waiting for the BP to register, she was cleaning the cuts. Surveyor asked if they usually use the BP machine during a code, and she answered "yes." Surveyor asked when she checked for a pulse, and she indicated when she was getting the BP, she checked for a carotid and radial pulse. She further indicated it took about 1 minute for the pulse and about a couple minutes to get a BP. Surveyor asked what type of assessment was done, and she indicated she checked O2 sat. (70%) and that "was pretty much it." She further indicated she didn't do a head-to-toe assessment. She just checked airway, breathing, and circulation. Surveyor asked how it was determined to call the MD, and she indicated S11RN and the supervisor arrived, and once she couldn't get a BP, they called the MD. She indicated she didn't immediately call the MD, because no one had assessed the patient. Surveyor asked how and when it was determined to call ambulance, and she indicated the MD tells us when to call the ambulance. S6RN indicated the Code Blue wasn't called until the patient stopped breathing. She further indicated O2 per NC was used when the patient was breathing. She further indicated they ended up going to a non-rebreather mask when he was still breathing. When he stopped breathing, they used CPR, AED, and Ambu bag. S6RN had no comment when informed that documentation revealed that the nasal cannula and non-rebreather mask were used while Patient #1 was not breathing and CPR was in progress.


Complaint of chest and stomach pain:
Review of Patient #2's medical record revealed a physician order on 01/24/17 at 6:47 p.m. to send to Hospital B for evaluation of abdominal distention and pain. Further review revealed no documented evidence of a physician's order upon the return of Patient #2 from the emergency room.

Review of the physician's progress note dated 01/24/17 at 6:47 p.m. revealed Patient #2's abdomen was tense and distended with positive hyperactive bowel sounds with some discomfort with palpation.

Review of S6RN's progress note on 01/24/17 at 4:45 p.m. revealed Patient #2 was complaining of discomfort in his chest and stomach. Abdomen "was assessed & (and) was firm to touch. Patient stated he hadn't had a bowel movement in a couple of days." Further review revealed his VS were assessed and documented. He was administered Maalox 30 ml (milliliters) and Biscodyl. There was no documented evidence that S6RN assessed whether he had abdominal distention and the presence or absence of bowel sounds. There was no documented evidence that S6RN reported Patient #2's complaints to a MD.

In an interview on 03/07/17 at 2:35 p.m., S11RN indicated if a patient complained of chest and abdominal pain and reported that he did not have a bowel movement for 2 days, she would assess bowel sounds, VS, heart sounds, the presence of other symptoms such as nausea and vomiting, and symptoms of a heart attack. She further indicated she would palpate the abdomen and document the presence or absence of abdominal distention. S11RN indicated the RN has to notify the physician when the patient returns from an emergency department visit and obtain orders for continued treatment or changes to treatment.

In an interview on 03/07/17 at 2:50 p.m., when asked what "firm" meant when she documented on 01/24/17 at 4:45 p.m. that Patient #2's abdomen was "firm to touch", S6RN indicated it was "hard but not rock hard." She confirmed her assessment did not include whether the abdomen was distended, the presence or absence of bowel sounds, and an auscultation of heart sounds. She indicated she did notify the physician, but she didn't document the notification. S6RN indicated when a patient returns from the emergency department, the RN should assess the patient, notify the physician of the patient's return, and obtain orders for treatment. S6RN indicated if the patient is sent to the emergency department and returns without staying overnight or being admitted, the RN doesn't need to get physician orders (this statement was contradictory to S6RN's prior statement).

In an interview on 03/07/17 at 4:15 p.m., S2FND indicated they had not been obtaining physician orders upon a patient's return from an emergency department visit.


Physical altercation:
Patient #3
Review of Patient #3's medical record revealed an entry on 01/14/17 at 5:00 p.m. by S6RN that Patient R1 had hit Patient #3 on the left side of his head. Further review revealed S6RN documented "no injuries noted." There was no documented evidence of the assessment that was conducted to determine that no injuries were present.

Review of Patient #3's progress note documented by S14RN on 01/14/17 at 6:58 p.m. revealed Patient #3 hit Patient R1 in retaliation to the previous altercation earlier in the day. Further review revealed no documented evidence of an assessment by the RN for injury.

In an interview on 03/07/17 at 2:50 p.m., S6RN confirmed she did not assess Patient #3 after the physical altercation with Patient R1.

Patient R1
Review of Patient R1's medical record revealed an entry by S6RN on 01/14/17 (no time documented) that Patient R1 had hit Patient #3 on the left side of the head, and no injuries were noted to either patient. There was no documented evidence of the assessment that was conducted to determine that no injuries were present.

Review of S14RN's documentation on 01/14/17 at 6:20 p.m. revealed Patient #3 hit Patient R1 in retaliation to the previous altercation earlier in the day. Further review revealed no documented evidence of an assessment by the RN for injury.

In an interview on 03/07/17 at 2:50 p.m., S6RN confirmed she did not assess Patient R1 after the physical altercation with Patient #3.

In an interview on 03/07/17 at 2:35 p.m., S11RN indicated if there was a patient altercation, she would assess each patient and determine whether the hit was with an open or closed fist and would document what area of the body was assessed.


72 hours after admission:
Patient #1
Review of Patient #1's medical record revealed he was admitted on 02/12/16. Review of the RN nursing documentation revealed the RN admit nursing assessment was conducted on 02/12/16 at 10:40 a.m. Further review revealed the 72 hour nursing assessment was done on 02/14/16 at 12:00 p.m. (49 hours and 20 minutes after admit).

Patient #2
Review of Patient #2's medical record revealed he was admitted on 01/04/17. His RN admit assessment was documented at 9:45 a.m. Further review revealed the 72 hour progress note was documented on 01/06/17 at 1:00 p.m. (51 hours and 15 minutes after admit rather than 72 hours).

Patient #3
Review of Patient #3's medical record revealed his RN admit assessment was documented on 01/11/17 at 10:30 a.m. Further review revealed his 72 hours RN progress note was documented on 01/13/17 at 3:00 p.m. (52 hours and 30 minutes after admit rather than in 72 hours).

Patient #4
Review of Patient #4's medical record revealed his RN admit assessment was documented on 01/31/17 at 2:30 p.m. Further review revealed the 72 hour RN progress note was documented on 02/02/17 at 2:00 p.m. (less than 48 hours after admit rather than in 72 hours).

Patient #5
Review of Patient #5's medical record revealed his RN admit assessment was done on 12/06/16 at 12:10 p.m. His 72 hour nursing assessment was done on 12/08/16 at 9:30 a.m. (less than 48 hours after admit).

In an interview on 03/07/17 at 2:50 p.m., when informed the RN 72 hour assessment was done in 48 hours of admit and not 72 hours, S6RN indicated if Patient #5 was admitted on 12/06/16, that day is considered day 1, and 12/08/16 would be considered day 3.

In an interview on 03/07/17 at 4:15 p.m., S2FND indicated the 72 hour RN assessment after admit should be conducted in 72 hours and not 48 hours as noted above.


Suicide and homicide risk assessment at admit:
Review of Patient #3's medical record revealed no documented evidence that S6RN assessed his suicide and homicide risk at admit on 02/12/16 at 10:40 a.m. as evidenced by no check mark made indicating whether or not suicide and homicide ideations were present.

In an interview on 03/07/17 at 4:15 p.m., S2FND confirmed Patient #3's suicide and homicide risk was not assessed at admit.

3) Failing to ensure the CGT observed a patient as ordered by the physician:
Review of the policy titled "Observation and Precaution", presented as a current policy by S1CEO, revealed that when 1:1 is ordered by the physician, one staff member is to monitor the patient at no more than 8 feet in distance. The 15 minute flow sheet shall be maintained with entries every 15 minutes, and the staff shall initial and sign all observational patient records.

Review of Patient #3's medical record revealed a physician's order on 01/14/17 at 6:58 p.m. to place client on 1:1 direct at 8 ft for protection of self and others. 1:1 observation was ordered to be discontinued on 01/23/17 at 2:45 p.m. An order was given by the physician on 02/15/17 at 5:25 p.m. to place him on 1:1 direct for safety of others and ordered discontinued on 02/20/17 at 2:20 p.m.

Review of observation sheets (not filed in patient's medical record) revealed no documented evidence that he observed 1:1 from 01/17/17 at 12:45 p.m. until 01/17/17 at 6:00 p.m., from 02/17/17 at 6:15 p.m. through 02/18/17 at 5:45 a.m., and from 02/20/17 at 6:15 a.m. through 2:20 p.m. This was evidenced by failure of the hospital to provide observation records for these time periods.

In an interview on 03/06/17 at 12:30 p.m., S1CEO indicated if a patient is on a RPM (1:1 or CVO ordered), the CGT completes an observation flow sheet which is filed in the patient's chart.

In an interview on 03/07/17 at 4:15 p.m., S2FND confirmed no observation records for the time periods listed above had been located.

Based on record reviews and interviews, the hospital failed to ensure:

1) The RN assigned the nursing care of each patient to the CGTs as evidenced by having contradictory policies for nursing and security that resulted in 14 shifts with inadequate CGT coverage on the Oakcrest 2 Unit (described by S1CEO as a maximum security, competency restoration unit) on 01/01/17, 01/02/17, 01/03/17, 01/04/17, 01/06/17, 01/07/17, 02/17/17, 02/18/17, and 02/19/17 with no documented evidence of action by the RN to correct the staffing shortage.

2) The RNs were evaluated for competency in the performance of patient assessment during a code situation once the need had been identified by administration after a Code Blue occurred on 01/02/17.

Findings:

1) The RN assigned the nursing care of each patient to the CGTs:
Review of the policy titled "Nursing Staffing Plan", presented as a current policy by S1CEO, revealed that the purpose of the policy was to assure that adequate coverage is provided to meet the nursing care needs of the clients and to maintain unit security. Staffing ratios are based on the following factors: population served; level of care; geographics of the unit.

Review of the policy titled "Core Staffing Coverage Assignment", presented as a current policy by S1CEO, revealed that core staff is considered to be the number of staff required to safely care for clients without exception or greater client requirements or need. The shift captains are responsible for scheduling the correctional guard, therapeutic daily assignments. The core staffing coverage is determined by the number of factors, such as client acuity, transportation needs, appointments, and other various issues that demand increased staff for the delivery of care. Shift captains will review and identify specific requirements for CGT staffing coverage based on RPM. Further review revealed core coverage for Oakcrest Unit 2 was 3 CGTs on the day shift and night shift each. There was no documented evidence that the CGT staffing assignments were the responsibility of the RN.

Review of the policy titled "Management of Assignments and Accountability", presented by S1CEO as one of 2 policies with this title, revealed the effective date was February 2008 with a revision date of September 2012. Further review revealed that the RN shall assume hospital and legal responsibility for the delegation of duties and the supervision of the delivery of care during their shift. The RN shall assign duties to CGTs on their unit in accordance with their building program. Staff assignments shall be based on level of acuity as well as staff competency.

Review of the second policy titled "Management of Assignments and Accountability", presented by S1CEO, revealed the effective date was April 2004 with a revision date of September 2012. Further review revealed the RN shall assign duties to the CGTs. The RN shall work in collaboration with the unit Captain/Lieutenant in the delegation of duties to CGTs in accordance with their building program.

Review of the staffing assignment sheets provided by S2FND revealed 14 shifts with inadequate CGT coverage on 01/01/17, 01/02/17, 01/03/17, 01/04/17, 01/06/17, 01/07/17, 02/17/17, 02/18/17, and 02/19/17 with no documented evidence of action by the RN to correct the staffing shortage (see specifics in tag A0392).

In an interview on 03/06/17 at 11:27 a.m. with S1CEO and S2FND present, S1CEO indicated the CGT Lieutenant makes the assignment of the specific patient to the CGT. He further indicated the assignment is delegated to the Lieutenant, but the RN can make changes if needed. He offered no explanation for the conflicting policies about CGT assignments.

In an interview on 03/06/17 at 10:37 a.m., S2FND indicated the RN is responsible for the care provided by the CGTs on the unit. She further indicated the assignment of CGTs for RPM is done in collaboration with the nurse.

In an interview on 03/06/17 at 11:35 a.m., S13CGT indicated the CGT picks which RPM patient they'll observe and notifies the Lieutenant. She further indicated the RN is not involved in that part of the assignment.

In an interview on 03/07/17 at 11:30 a.m. with S2FND and S19Major present, S19Major indicated they have 1 CGT observe 2 patients on CVO, and when 3 patients were ordered on CVO, there should have been an additional CGT assigned to the unit. He further indicated with 3 patients on CVO and 1 on 1:1, there should have been 2 CGTs to observe the 3 patients on CVO, 1 CGT to observe the patient 1:1, and an additional 2 CGTs to observe the other patients on the unit. He confirmed the staffing on the above-listed shifts was not in accordance with hospital policy. S2FND indicated she would expect a unit to be staffed at a minimum every day. She confirmed the RN should have been involved with the staffing assignments on the above-listed days, and there was no evidence that the RN had been involved.


2) The RNs were evaluated for competency in the performance of patient assessment during a code situation once the need had been identified by administration after a Code Blue occurred on 01/02/17:
Review of the "Opening Summary Report regarding the death of client (Patient #1)" revealed changes to the Code Blue policy were made. The target date for completion of the Code Blue policy improvements, including an education component, was 02/17/17. Further review revealed an additional component of practical application will be provided in the form of mock codes

Review of the "RN and LPN (licensed practical nurse) Competency Assessment Plan 2016-2017", presented as the current p[lan by S1CEO, revealed that all nursing staff shall have physical assessment training and documentation biannually. Each nurse must complete a return back demonstration that ensures competence.

No documented evidence of a competency evaluation of performing physical assessments was presented for any RN working on the Oakcrest Unit 2.

In an interview on 03/03/17 at 2:25 p.m. with S1CEO and S15NE present, S15NE indicated the RNs had not been evaluated for competency on performing physical assessments using the new assessment tool that was developed after the Code Blue event of 01/02/17. He further indicated the plan is to do the competency evaluations at the time of each RN's annual evaluation.

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Nursing Services (482.23) as evidenced by:


1) Failing to ensure an RN was present on Oakcrest Unit 2 (described by S1CEO as a maximum security, competency restoration unit) at all times to ensure the immediate availability of a RN for bedside care of any patient as evidenced by observation on 03/07/17 at 3:30 p.m. revealing patients were in the day room and in the bedroom area with no RN present on the unit. Interviews throughout the survey with multiple RNs revealed an RN is not always present on the unit when patients are on the unit (see findings in tag A0392).


2) Failing to ensure the Oakcrest Unit 2 had an adequate number of CGTs when patients were ordered to be on CVO and 1:1 observation for 9 (01/01/17, 01/02/17, 01/03/17, 01/04/17, 01/06/17, 01/07/17, 02/17/17, 02/18/17, 02/19/17) of 14 days reviewed for staffing. There was a total of 14 shifts with inadequate coverage of CGTs in accordance with the hospital's core staffing (see findings in tag A0392).


3) Failing to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:

a) Failing to develop a policy and procedure for the evaluation of patients that addressed the frequency of RN assessments for 4 (#1, #2, #3, #4) of 4 patient records reviewed for RN assessment from a sample of 5 patients. The hospital had a policy that allowed documentation of a progress note by the nurse every shift for 72 hours, then weekly for 4 weeks, and then monthly for the remainder of the patient's hospital stay.

b) Failing to ensure the RN thoroughly assessed a patient at the initiation of a code situation (#1), with complaints of chest and stomach pain (#2), after physical altercations between patients (#3, R1), 72 hours after admission (#1, #2, #3, #4, #5), and assessed a patient for suicide and homicide risk at admission (#3) for 5 (#1, #2, #3, #4) of 5 sampled patients and 1 (R1) of 1 random patient.

c) Failing to ensure the CGT observed a patient as ordered by the physician as evidenced by failure to have documented evidence of the observations made by the CGT from 01/17/17 at 12:45 p.m. until 01/17/17 at 6:00 p.m., from 02/17/17 at 6:15 p.m. through 02/18/17 at 5:45 a.m., and from 02/20/17 at 6:15 a.m. through 2:20 p.m. for 1 (#3) of 1 patient record reviewed with orders for 1:1 observation from a sample of 5 patients (see findings in tag A0395).


4) Failing to ensure:

a) The RN assigned the nursing care of each patient to the CGTs as evidenced by having contradictory policies for nursing and security that resulted in 14 shifts with inadequate CGT coverageon the Oakcrest 2 Unit (described by S1CEO as a maximum security, competency restoration unit) on 01/01/17, 01/02/17, 01/03/17, 01/04/17, 01/06/17, 01/07/17, 02/17/17, 02/18/17, and 02/19/17 with no documented evidence of action by the RN to correct the staffing shortage.

b) The RNs were evaluated for competency in the performance of patient assessment during a code situation once the need had been identified by administration after a Code Blue occurred on 01/02/17 (see findings in tag A0397).