HospitalInspections.org

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Based on observation, interview, and document review, the hospital's governing body failed to provide effective oversight of the hospital.

Failure to ensure staff had the knowledge, skills, training, and equipment to respond to a patient's medical emergency puts patients at risk for treatment delays and inadequate resuscitation efforts that could lead to injury or death.

Findings included:

1. The hospital failed to ensure that processes implemented to ensure emergency equipment and supplies were available and accessible to staff during critical medical emergencies were sustained.

2. During an onsite complaint investigation, the medical record of a patient who died on 09/24/19 of an apparent self-strangulation was reviewed. The review by the hospital showed that availability of emergency equipment was a concern of the staff interviewed.

Cross Reference: A093

3. The Governing Body was previously cited on 05/29/19 for failure to ensure emergency equipment and supplies were available and accessible to staff as a result of a complaint investigation involving the death of a patient.

4. The Governing Body was previously cited on 08/22/19 for failure to ensure all emergency equipment outlined in their Plan of Correction were included in their emergency equipment daily inventory checklists as result of a complaint investigation revisit involving the death of a patient.

Due to the scope and severity of deficiencies, the Condition of Participation for Governing Body was NOT MET.
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Based on observation, interview, and record review, the hospital failed to address previously cited deficiencies related to code blue response and emergency equipment availability during critical medical emergencies.

Failure to provide emergency medical equipment and supplies places patients at risk of inadequate resuscitation efforts that could lead to injury or death.

Reference: WAC 246-322-180 2(d) Patient Safety and Seclusion Care. The licensee shall provide adequate emergency supplies and equipment including airways, bag resuscitators, intravenous fluids, oxygen, sterile supplies, and other equipment identified in the policies and procedures, easily accessible to patient care staff.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Code Blue," Policy #1000.13, revised 06/19, showed that staff are to respond to the location with backboard, oxygen and code blue bag from each unit and the automated external defibrillator (AED).

a. The code blue bag inventory includes:

- Bandages and dressings.

- Airway management supplies: a CPR mask, ambu bag (a self-refilling bag-valve-mask unit, used for artificial respiration), plastic bite stick (used during seizures), nasal cannula and mask with tubing (for oxygen delivery).

- EMS supplies (sting swabs, alcohol prep pads, eyewash solution, ice packs, antimicrobial hand wipes, instant glucose, antibiotic ointment, iodine prep pads, etc.).

-Intravenous therapy supplies (intravenous (IV) catheter, IV start kit, IV administration set,
etc.).

-Documentation: Code Blue Record, Code Blue Debriefing, Code Blue Bag Inventory.

b. The review showed the code blue bag inventory list did not include airways as required by Washington State law.

2. A review of a hospital document titled, "Instructions for Emergency Medical Equipment Daily (EME) Checklist - Unit based," no date, showed actions staff will perform when checking the code blue bag. Those actions include looking for a red tear away lock. Annotating the expiration date on the back of the lock onto the EME checklist. If the lock is not present or the expiration date has passed, staff will inventory the bag using the inventory provided inside the bag. Staff will notify the house charge or nurse manager of replacement items needed.

3. On 11/15/19 at 11:35 AM, during a tour of the inpatient unit on the Monroe campus, Investigator #3 and a registered nurse (Staff #301) inspected the code blue bag and associated emergency medical equipment. The investigator observed the code blue bag was not secured with the red tear away lock. Inspection of the code blue bag showed there were no airways in the code blue bag as required by Washington law.

4. A review of the emergency medical equipment daily checklist logs showed the tear away lock and expiration date for the code blue bag was missing for 5 of 30 days in September 2019, for 23 of 31 days in October 2019, and for 14 of 14 days in November 2019.

5. On 11/15/19 at 1:35 PM, Investigator #3 interviewed a registered nurse (Staff #301) about checking of the code blue bag. Staff #301 stated the night shift personnel check the code blue bag and emergency medical equipment daily. She was not aware that the code blue bag required a red tear away lock to indicate the bag's contents are present.

6. On 11/15/19 at 2:30 PM, Investigator #3 interviewed the hospital educator (Staff #302) about the code blue inventory list. Staff #302 stated she was unaware that airways were a required part of the emergency supplies. She did not know why the code blue bag was not secured with a red tear away lock as required by policy.

7. On 11/15/19, Investigator #10 reviewed the medical record of Patient #1003 who died during a Code Blue (emergency resuscitation) on 09/24/19. Review of the Code Blue form showed that no airway was applied and was marked "not applicable" with no assisted ventilation attempted. Subsequent review of the Code Blue by the hospital showed the emergency medical equipment brought to the code blue event included the code blue bag, the automated external defibrillator, oxygen and suction. The backboard was unavailable on the unit and was locked in the supervisor's office.

THIS IS A REPEAT CITATION PREVIOUSLY CITED ON 05/29/19.
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Based on interview, medical record review, and review of policies and procedures, the hospital failed to ensure staff implemented appropriate interventions to prevent patient to patient sexual incidents, by a patient (Patient #1002) while he was under continuous direct visual (1:1) observation.

Failure to implement appropriate interventions to prevent patient to patient sexual incidents risks psychological harm to patients and an unsafe therapeutic environment.

Findings included:

1. Document review of the hospital's policy titled, "Sexual Aggression/Victimization Precautions," Policy #1000.80, dated 05/19, showed that upon admission, all patients are assessed for sexual aggression (or victimization) and the admission nurse will complete a high risk notification alert (IDs the patient as aggressive or victim). Patients identified as at risk for sexual aggression will be placed on Sexual Aggression Precautions (SAP). The policy stated that:

-Observation Rounds Sheets will accurately reflect the precaution type and level of monitoring

-Communication to all unit staff of the patient's precautions and appropriate level of monitoring

-Assign specific bedroom, adjust based on identified risk factors

-A sexually inappropriate behavior treatment plan will be initiated

-Staff will observe patients for specific behavior to sexual acting out behaviors

-Maintain awareness of the patient's location and communicate/document signs of concerns

-Separate patients who have been identified at risk for sexual acting out behaviors

-Staff will maintain awareness of the patient's location at all times

-Communicate and document sexually inappropriate behaviors

-Initiate a sexually inappropriate behavior treatment plan

-Separate patients who are at increased risk to engage in inappropriate behavior

Staff are to round on these patients as ordered and check isolated areas of the unit, to ensure unoccupied rooms are locked.

2. On 11/14/19 at 2:40 PM, Investigator #10 reviewed Patient #1002's medical record that showed a 47 year-old patient who was admitted, involuntarily to the 2-West unit on 08/14/19. The initial psychiatric note showed a diagnosis of major depressive disorder, plus medical comorbidities including diabetes, hypertension.

Review of admission records showed the level of observation, monitoring and precautions ordered for this patient were:

-monitor every 15 minute checks
-unit restriction (not allowed off the unit)
-suicidal watch.

The admission sheet titled, "High Alert Areas" showed that the high risk indicators (homicidal, suicidal, sexual aggressive, etc) were left unchecked and not completed.

The master treatment plan dated 08/23/19 (plan for one week) showed his precautions:

-suicide precautions
-fall precautions
-medically compromised.

Review of the patient's observation record reflected the ordered level of monitoring.

The master treatment plan dated 10/25/19 (updated for the week) showed new ordered precautions:

-suicide precautions
-sexual victim precaution (SVP)
-sexual aggressive precaution (SAP)
-assault precautions
-fall precautions.

Further review of the 24-hour registered nurse (RN) focused assessment on 10/25/19 & 10/26/19 showed that SAP was not circled or documented in his medical record.

Review of the patient's observation record dated 10/26/19 showed that none of the prescribed precautions were marked or documented.

Review of the observation record dated 10/27/19 showed that the 1:1 level of monitoring continued and precautions were only marked for suicide, fall, and medically compromised (sexually aggressive precautions were not included as reflective in his weekly treatment plan). Further review of the observation record showed a handwritten note that showed that the patient was trying to touch female staff and peers.

Review of physician order sheet dated 10/28/19, showed that the patient will be placed on a "5-foot rule, from other patients," continue 1:1 observation (should be a male staff member), and continue/start sexual aggressive precautions.

A staff member's hand written note dated 10/28/19 at 6:21 PM, showed that the patient was unable to keep his hand off other patients that lead to their agitation.

a. On 11/13/19 at 3:10 PM, Investigator #10 reviewed Patient #1001's medical record that showed a 36 year-old patient who was admitted, involuntarily to the 2-West unit on 10/21/19. The review showed that she was assigned to room #913 (room next to Patient #1002's room) and it was reported that she was inappropriately touched by Patient #1002.

Record review showed that on 10/28/19 at 10:30 AM, Patient #1001 wrote on her check-in sheet, during the unit's Case Management Group, that she felt helpless, powerless, uneasy, anxious and angry because she was sexually assaulted. Patient also wrote that she felt hospital staff did not follow-up on her case and that she did not sleep all night.

A staff member's note dated 10/28/19 (day after incident) showed that Patient #1001 told staff that a patient (Patient #1002) came up behind her and grabbed her breasts, but staff did not discuss the incident with her. The note showed that the patient did not feel safe after this event.

Review of hospital documents dated 10/28/19 at 9:18 PM showed a report was initiated related to Patient #1001's incident and that Patient #1001 was asked if she wanted to call the police to press charges, but declined.

3. On 11/14/19 at 11:15 AM, Investigator #10 interviewed the Risk Manager (Staff #1001) regarding incidents during Patient #1002's inpatient care. The Risk Manager stated that the patient had several reported patient - to - patient incidents in October. The patient displayed sexually inappropriate behaviors twice in one day. The Risk Manager added that there is no hospital policy related to the "5-foot rule."
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