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Based on observation, document review and interviews, on December 8-13, 2016, it was determined that the governing body failed to ensure that a patient received care in a safe setting and failed to ensure patient care policies and procedures were adhered to appropriately.
The finding includes:
The Hospital failed to assure that a patient received care in an environment that promoted and protected the physical and emotional safety. See Condition of Participation Patient Rights, Tag A-0114, for further information.
The Hospital failed to ensure that policies and effective protocols were in place regarding patient care and safety in regards to room searches for illicit/dangerous items.
Hospital policy 20.083, titled: Patient Search Policy stated: "A search may be conducted if there is a reasonable belief that the patient is in possession of illegal substances, paraphernalia, or weapons ..." The policy then stated: "The patient's attending physician or charge nurse may authorize a search to be conducted by clinical staff designated by the attending physician or charge nurse." And also stated; "All searches must be fully documented in the patient's medical record so this can be communicated to subsequent providers of care." Additionally; this policy under the heading "DOCUMENTATION OF PATIENT SEARCHES", stated: "the search must be documented in the patient's record and documentation shall include: ... 2. Staff involved in authorizing the search and staff involved in the actual search; ... 4. Documentation of the patient plan of care, including any behavior contract. 5. Security must generate an RL incident report to document their involvement in any search." Under the heading: "procedures for conducting all patient searches:" it stated "Security staff must be called so they can be available to assist."
The policy fails to require a written order for the search, indicating; who authorized the search, how often the search(s) are to be conducted and who will conduct the search.
Documentation in the patient record failed to follow the documentation requirements noted in the aforementioned policy. During an interview with a staff nurse on December 9, 2016 at approximately 11:30 AM, regarding the patient and associated searches, the nurse responded (related to documentation); "I would tell charge nurse and seek direction."
Interviews with nursing staff indicated that the nurses were advised that security does not perform searches, and this action is the responsibility of nursing. Several nurse interviews indicated that these nurses were not trained or provided direction regarding conducting a search. A nursing technician stated on December 9, 2016 at approximately 11:50 AM, "No, not trained, went in and did it daily ...I know what drug paraphernalia is ...I would recognize it." Another Registered Nurse stated on December 9, 2016 at 11:30 AM; "Honestly I'm not[trained] ...it's very tricky ...how to approach a patient without getting the patient defensive and destroying their trust." On December 12, 2016 at approximately 6:00 AM, during a telephonic interview a Registered Nurse stated; "Never been trained to search a room. But anything suspicious, any meds ..."
The patient record contains a nursing order dated December 1, 2016 at 5:13 PM, which stated: "Order Details: Start: 12/01/16 17:13:00 EST, Daily room checks - pt high risk. All visitor possessions to be left at nursing station. Visitors to be searched prior to visiting pt."
All "RL incident reports" related to this patient were requested. A report dated December 1, 2016 at 11:02 PM was provided related to a search of the room and belongings. No additional "RL incident reports" were provided regarding searches, although the nursing order was written for daily room checks and that all visitors are searched. The only "RL incident report" provided after December 1, 2016 was written on December 5, 2016 at 3:45 PM, related to the patient being found in the bathroom in cardiac arrest.
Policy 10-007, titled: Visitation; defines "Justified Restriction" as "Any clinically necessary or reasonable restriction or limitation imposed by EMMC on a patient visitation rights which restriction or limitation is necessary to provide safe care to the patient or other patients." However; this policy fails to identify who is responsible to order into effect a "justified restriction" and how that restriction will be communicated to all staff caring for the patient. This policy was updated following this incident, however the update does not address responsibility for ordering, or how the restriction will be communicated.
Policy 21-026, Titled: "Assessment and Response to Disruptive Behavior by a Patient or Visitor", stated under section "procedure" regarding "patient focused interventions" that a Level 0 intervention "... Concerns in outcomes should be documented in the patient's chart." or Level 1 intervention, "... Reasonable alternative care options should be offered and acted upon with the patient's consent. This discussion, in any other attempts to address the disruptive behavior, should be fully documented in the medical record."
In this case, Physician and nurse progress notes randomly addressed concerns regarding the patient's possession of contraband and patient/visitor searches; no order was written and therefore no specific directive was documented in the record until December 1, 2016.

Based on record reviews and interviews, it was determined that the Condition of Participation (CoP) for Patient Rights was not met. The facility failed to ensure that patient access to contraband and/or intravenous flushes/syringes was denied/curtailed. The patient was found on several occasions during hospitalization in possession of syringes and medications/pharmaceutical compounds.

The finding includes:

This facility has failed to comply with the CoP for Patient Rights as evidenced by the deficiency identified as follows:

§482.13(c) Standard: Privacy and Safety, also known as A-0142: Based on record review, policy review, and interview, the facility failed to ensure that patient safety requirements were met. See A-0142 for details.

§482.13(c)(2) Element: The patient has the right to receive care in a safe setting, also known as A-1044: Based on record review, policy review, and interview, the facility failed to ensure that Hospital Policies pertaining to patient safety and monitoring were followed. See A-0144 for details.

The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on observations, document review and interviews with key personnel on December 8-9, 2016, it was determined that the facility failed to ensure patient safety requirements were met.

The finding includes:

Patient A was admitted to the hospital for the purpose of receiving intravenous antibiotic/antifungal therapy for a period of approximately 6 weeks, which was determined necessary prior to patient A receiving surgery.

While admitted to the hospital, the facility failed to provide required safety measures and close monitoring after contraband and chemical substances were found either in the possession of/within access of patient A. Documentation indicated that the hospital was aware of patient A's history of intravenous drug abuse. Items commonly known as drug paraphernalia as well as pharmacological substances were found on multiple occasions in patient A's bed and/or possession. The hospital failed to provide written orders and direction to the nursing staff regarding prevention of continued substance abuse/diversion by the patient. As a result of this failure, patient A was found in cardiac arrest, in the bathroom in possession of 2 syringes. See tag A-0144 for additional details.

Based on observations, document review and interviews with key personnel on December 9, 2016, it was determined that the facility failed to develop a systematic response with written orders, effective protocols to address the patient's actions and failed to provide interventions necessary to assure patient safety.

The finding includes:

Patient A was admitted to the hospital on November 11, 2016, for initiation of intravenous antifungal therapy which was scheduled to last approximately six weeks. The documentation indicates that a pre hospitalization plan had indicated the placement of a peripherally inserted central catheter line. On November 18, 2016, a Hickman central catheter line was inserted. Starting on November 20, 2016, and again on several additional occasions the patient was found to be in possession of possible drug paraphernalia and/or undetermined pills/substances. No order or instruction was documented in the record until December 2, 2016 to address searching the patient's room/visitors, or to restrict visitor access (thus prevent possible access to substances/paraphernalia). On December 5, 2016, the patient was found in the bathroom in cardiac arrest, reportedly in possession of 2 syringes containing an unknown substance, the patient was not able to be resuscitated.

A review of the patient record and interviews with key staff provided the following information:

On November 20, 2016, the record reported: "Nursing tech reported a syringe with unidentified medication found in bed. Tech asked patient if it was a medication that was forgotten about, patient replied no and said to just put it in the sharps, tech said that [he/she] had to give it to the nurse, pt took it from techs hands and placed syringe in sharps [himself/herself]. Tech reported the situation to me [RN] and I reported it to the charge nurse [charge nurses name]. Pt (patient) is a known IV [intravenious] drug user ...[visitor] is unhappy about him/her becoming clean because [visitor] uses as well and came to visit pt last night." A nursing progress note entered in reference to the night shift on November 22, 2016, stated; "all visitors to "check in" at the nurses station prior to entering the patient's room. Frequent rounding. Will continue to support and monitor closely." This would require that all individuals caring for the patient would need to read all previous progress notes to understand the need to restrict visitor access into monitor the patient closely.

Interviews conducted on December 9, 2016 with staff nurses assigned to the patient on that date, verified the information in the patient record.

Case Management note dated November 22, 2016, stated: "Per nursing report, syringes found in patient's room. Plan for security to screen and search all visitors prior to entering patient's room."

A nursing progress note dated November 26, 2016 amended at 5:00 PM reported that the patient had a visitor who reportedly entered the unit and went directly to the patient's room. The note indicates that the visitor started to go into the patient room and that the unit secretary said something to the visitor. The note indicates that the visitor replied: "Oh, it's fine, I'll put my jacket out here." The visitor then entered the patient room and closed the door. The note then stated that the RN went to the patient room awaiting security. The note then documrnted; "Security came and stated this RN must search pt/room. This RN searched around room and bathroom and visualized pt's pockets. This RN then reported to security that nothing was found. This RN unsure of proper procedure for room searches."

On November 27, 2016, the record reported: "Room searched: dirty straight, unprotected blade found in pt's insulin kit. Tube, lighter, and 2-inch thin metal piece with resin on the end found in pt's coloring pencil/pen bag."

This information was verified on December 9, 2016 at approximately 9:20 AM, during an interview with the nurse assigned to the patient on the date these items were found. The nurse also indicated that the visitor later told the nurse "The razor blade had been missed in previous searches." Additionally; it was reported that the patient room was moved to a different room closer to the nurses station in an effort to increase the level of observation and security. (The previous room was at the end of the hallway near the entrance to the unit, the new room was diagonally across from the nurse's station and in full view of the nurses station at all times).

On December 1, 2016, the patient had surgical repair of the right hip and upon discharge from the post anesthesia care unit, the patient was transferred to the orthopedic unit.

A nursing order entered on December 1, 2016, which stated: "Start: 12/1/16 5:13:00 PM EST, Daily room checks - pt high risk. All visitor possessions to be left at nursing station. Visitors to be searched prior to visiting pt."

Nursing documentation on December 2, 2016 at 1:38 AM reported: "Patient has order for daily room checks. Lighter and stress ball removed from belongings. Locked up in med room. Charge nurse and security present. Nursing supervisor aware lighter and stress ball locked up in med room."

Case Management (CM) note dated December 2, 2016, stated: "12/2/16 Social work referral made as patient is requiring room searches and visitor searches due to continued substance abuse. Discussed UDS [urine drug screen] with Family practice. Nursing reporting finding one of patient's pills in bed, [visitor] present and "grabbed it" Requested to have charge nurse ask [nurses name], Nurse Manager to elevate this patient to management level to discuss safety contract per Social workers request. CM will continue to follow."

Case Management note dated December 5, 2016, stated: "12/5/16 Nursing notes indicate a lighter was found in the patients room over the weekend and was locked up on the floor. Discussed with [nurses name], nurse manager and [nurses name], ANM [Assistant Nurse Manager] of Grant 5 a safety contract that nursing can follow to assist patient with her care and safety."

On December 5, 2016, the patient was found in the bathroom of [his/her] patient room not breathing and without a pulse. The nursing note for that event stated: "Patient was pulled out of the bathroom, at this time two empty syringes with leftover unknown orange substance within were found on the patient, one on patient's abdomen, one in [his/her] pocket."