HospitalInspections.org

Based on observation, interview, and policy review the hospital failed to ensure a safe environment when
hospital staff failed to ensure that the patient servers (medical supply carts, a durable mobile cart used in
medical facilities for storing and transporting medications, emergency equipment, and medical supplies)
which contained sharps (a term used for devices with sharp points or edges that can puncture or cut the
skin), lab collection tubes, and packaged syringes that contained normal saline (a mixture of salt and water)
were secured and contents were not accessible to patients, visitors or unauthorized personnel for four units
Emergency Department (ED), Neurosurgery ICU (Neuro ICU, an intensive care unit devoted to the care of patients with immediately life-threatening neurological problems), and two Medical Units #5300 and #5400 of seven units observed. These failures had the potential to place all patients in an unsafe environment and at risk for their health and safety. The hospital census was 1006.

Findings included:

Review of the hospital's policy titled, "Patient Server," dated 12/2020, showed that:
- Supplies housed in the server were provided as backup for unanticipated patient care supply needs for a
specific patient room. It was not intended as an additional routine supply storage area.
- Patients, families and visitors should not access the server.
- Items which should not be located in an unlocked server included but not limited to: syringes,
needles, lab tubes, any glass items.
- Medications should never be stored in a server, locked or unlocked.

Observation on 01/19/21 at 3:45 PM, on Medical Unit #5300, showed unsecured servers inside patient rooms with numerous patient supplies that included syringes with needles, lab collection tubes, butterfly hypodermic needles (a sharp device used to draw blood from a person that is connected to a flexible transparent tubing), chlorhexidine scrub (a disinfectant and antiseptic that is used to clean the skin), and packaged syringes that contained normal saline.

Observation on 01/20/21 at 10:00 AM, on Medical Unit #5400, showed one unsecured server inside a patient room with numerous patient supplies which included syringes with needles, lab collection tubes, and butterfly hypodermic needles (a sharp device used to draw blood from a person that is connected to a flexible transparent tubing).

Observation on 01/20/21 at 9:30 AM, on the 24-bed Neuro ICU, showed unlocked, easily accessible servers outside of each patient room that contained medical sharps.

Observation on 01/20/21 at 11:20 AM, between hallway one and two of the ED, showed an unlocked server that contained sharps that was accessible to patients and visitors.

Observation on 01/20/21 at 11:23 AM, in ED patient room four, showed an unlocked server that contained sharps.

Observation on 01/20/21 at 12:10 PM, in ED patient room three, showed an unlocked server that contained sharps.

Observation on 01/20/21 at 12:20 PM, in ED patient room eight, showed an unlocked server that contained sharps.

During an interview on 01/20/21 at 12:20 PM, Staff UUU, Registered Nurse (RN), stated that each ED patient room had an unlocked server that contained lab collection blood tubes and intravenous (IV, in the vein) supplies.

During an interview on 01/20/21 at 3:55 PM, Staff A, RN, Assistant Nurse Manager, stated that:
- The patient servers were used to hold supplies that may be needed in the patient rooms.
- No one was responsible to ensure the servers were locked or to ensure the supply dates had not expired.
- When not monitored, the servers should be locked.
- The servers were not locked as the batteries in the lock mechanisms were dead.
- The servers did lock a year ago when the unit first opened.

During an interview on 01/21/21 at 12:20 PM, Staff TTT, Chief Nursing Officer (CNO), stated that she expected the nurse managers to know the policies and procedures for their units and that servers with sharps and supplies accessible to patients or visitors should be locked.



39563

Based on interview, record review, policy review and review of hospital video recording, the hospital failed to ensure:
- Nursing staff assessed, monitored and observed one patient (#46) of one patient reviewed for alcohol withdrawal (symptoms that occur when someone stops using alcohol after a period of heavy drinking) who was found unresponsive and was later pronounced dead while he was a patient at the freestanding (separate building from the main hospital campus) psychiatric (related to mental illness) center. (Refer to A-0395)
- Psychiatric precaution and sleep rounds (15 minute visualization and documentation of the safety of each patient) were documented as they were completed and performed appropriately with visual assessment of the rise and fall of the patient's chest for one patient (#46) of four patients' safety rounding sheets reviewed at the freestanding psychiatric center. (Refer to A-0395)

Patient #46 was transferred from an outside hospital for admission to the freestanding psychiatric center on 01/09/21 at approximately 4:00 PM, for alcoholism (an addiction to the consumption of alcoholic liquor), alcohol withdrawal, a blood alcohol level (BAL, the amount of alcohol in the blood) of 96 (a level of 100 to 300 is acute intoxication; most fatalities occur with levels over 400), positive urine drug screen (UDS, a urine test that is used to identify illegal drugs in a patient's system) for fentanyl (a medication used to treat severe pain, and is a high risk drug for theft and personal use) and suicidal ideations (SI, thoughts of causing one's own death). The previous day, he had presented to the outside hospital for alcohol intoxication with a BAL of 505. During the early morning hours on 01/10/21, nursing staff failed to assess/observe/monitor Patient #46 for alcohol withdrawal, per protocol, with false documentation that the patient had refused to allow his vital signs to be taken. Nursing staff and mental health technicians (MHTs) failed to appropriately perform psychiatric precaution and sleep rounds when they failed to observe the patient for rise and fall of the chest. Patient #46 was found unresponsive at approximately 6:45 AM on 01/10/21, and pronounced dead at 7:05 AM, approximately 15 hours after his admission to the hospital.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

The hospital had additional failures to ensure that nursing staff:
- Followed physicians' orders when they failed to suction the tracheostomy (trach, an opening created in the neck in order to place a tube into a person's windpipe that allows air to enter the lungs) every two to three hours, as ordered by the physician, for one tracheostomy patient (#47), of one tracheostomy patient reviewed. (Refer to A-0395)
- Correctly entered the type of urinary catheter (a small flexible tube inserted into the body through an opening of the urinary tract to drain urine) into the electronic medical record (EMR) for one patient (#32) of one patient reviewed that resulted in the EMR not prompting the staff that the urinary catheter was a suprapubic catheter (a tube that is surgically inserted through the skin of the abdomen and into the bladder, and allows urine to drain from the body) that required the dressing to be checked at a minimum of every eight hours and the dressing changed, if needed. (Refer to A-0395)
- Followed policy and procedure for blood administration and obtain vital signs during the initial 15 minutes of blood administration for two patients (#26 and #29) of five patients reviewed with blood administrations. (Refer to A-0395)
-Followed policy and procedure for intravenous (IV, in the vein) tubing maintenance for five patients (#1, #4, #17, #19 and #36) of 25 patients with IVs. (Refer to A-0395)

These failures also placed all patients within the hospital at risk for their health and safety and had the potential to lead to poor outcomes. The hospital census at the freestanding psychiatric center was 20 and the hospital main campus census was 1006.

On 01/20/21, after the survey team informed the hospital of the IJ, staff created educational tools and began educating all hospital nursing, MHT and patient care technician (PCT) staff and put into place interventions to protect patients within the entire hospital.

As of 01/21/21, at the time of the survey exit, the hospital had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Immediate education teaching sheets on Alcohol Withdrawal Protocol were provided to directors and clinical nurse managers of all inpatient divisions on evening/night shift on 01/20/21. Key points of the protocol were clinical manifestations of withdrawal (symptoms/severity); order set review of criteria-based nursing assessment to obtain score; based on score, the medications to administer and the timing of the next nursing assessment/scoring to be completed; correct flowsheet to use and additional notes including awakening patients, document refusals, implement additional precautions ordered by the provider of seizures and falls. Key points made to PCTs and MHTs were points of symptoms of alcohol withdrawal, potential severity including death, and the importance of escalation to a Registered Nurse (RN) if changes in vital signs or symptoms were observed.
- Education rolled out on the evening/night shift on 01/20/21 by unit leadership, unit clinical nurse specialists and/or unit educators to currently working RNs, MHTs and PCTs of each inpatient unit. This continued with oncoming day shift prior to starting their shift, and would continue with subsequent shifts until all staff education was completed.
- Education efforts were to continue so that all staff would be educated by the goal date of February 3, 2021. Staff on leave or Family Medical Leave Act (FMLA) were to be educated prior to the start of their next scheduled shift.
- To ensure that vital signs and assessments/reassessments for all patients on the alcohol withdrawal protocol admitted to the freestanding psychiatric center were completed and documented accordingly, a staff member, RN/assistant nurse manager (ANM), would observe the staff member taking the vital signs. Direct observation would alleviate the need for video review and allow for in-the-moment coaching/re-education. After documentation of the vital signs, the observer/ANM would indicate by double signatures in the patient's chart (vital signs flowsheet for that time column) that the vital signs were completed as ordered.

Based on interview, record review, policy review and review of hospital video recording, the hospital failed to ensure:
- Nursing staff assessed, monitored and observed one patient (#46) of one patient reviewed, for alcohol withdrawal (symptoms that occur when someone stops using alcohol after a period of heavy drinking) who was found unresponsive and was later pronounced dead while he was an inpatient at the freestanding (separate building from the main hospital campus) psychiatric (related to mental illness) center.
- Psychiatry precautions and sleep rounds (15 minute visualization and documentation of the safety of each patient) were documented as they were completed and performed and appropriately with visual assessment of the rise and fall of the patient's chest for one patient (#46), of four patients' safety rounding sheets reviewed at the freestanding psychiatric center.
- Physicians' orders were followed when nursing staff failed to suction the tracheostomy (trach, an opening created in the neck in order to place a tube into a person's windpipe that allows air to enter the lungs) every two to three hours, as ordered by the physician, for one tracheostomy patient (#47), of one tracheostomy patient reviewed.
- The correct type of urinary catheter (a small flexible tube inserted into the body through an opening of the urinary tract to drain urine) was entered into the electronic medical record (EMR) for one patient (#32) of one patient reviewed that resulted in the EMR not prompting the staff that the urinary catheter was a suprapubic catheter (a tube that is surgically inserted through the skin of the abdomen and into the bladder, and allows urine to drain from the body) that required the dressing to be checked at a minimum of every eight hours and the dressing changed, if needed.
- Nursing staff followed policy and procedure for blood administration and obtained vital signs during the initial 15 minutes of the blood administration for two patients (#26 and #29) of five patients reviewed with blood administrations.
- Nursing staff followed policy and procedure for intravenous (IV, in the vein) tubing maintenance for five patients (#1, #4, #17, #19 and #36) of 25 patients with IVs.

These failures had the potential to place all patients admitted to the hospital at risk for their health and safety. The hospital census was 1,006, with a census at the freestanding psychiatric center of 20.

Findings included:

1. Review of the undated hospital document titled, "Alcohol Withdrawal Assessment Protocol: Tip Sheet for Registered Nurses (RNs)," showed the following direction:
- Assess the patient for tremors, sweating, hallucinations, orientation, contact (ability to hold conversation) and agitation. (Each assessment category gets a score based on the assessment findings.)
- Staff should obtain the initial score and then assess the patient and document scores every one hour for four hours.
- After the fifth initial assessment, continue monitoring with reassessment every hour for score greater than or equal to 13, reassess every two hours for score of six to 12, and reassess every four hours for a score of zero to five.
- Obtain vital signs with specific instructions not to estimate respirations but to count them.
- Document vital signs and assessment on the alcohol withdrawal flowsheet.
- If patient sleeping at scheduled assessment time, awaken patient for assessment and administer medication, if necessary.

Review of the hospital's policy titled, "Psychiatry Precaution and Sleep Rounds," dated 07/2020, showed the following direction:
- The purpose of the policy is to ensure the safety of all patients on the inpatient psychiatry units at the main campus and at the freestanding psychiatric center.
- All patients will be observed at regular intervals at least four times per hour.
- Sleep rounds are conducted from 10:00 PM to 7:00 AM to assess for breathing in addition to location and safety.
- Assess the quality of inspiration (inhalation of air into the lungs) and expiration (the process of releasing air from the lungs through the nose or mouth) of each patient who appears to be sleeping.

Review of Patient #46's medical record showed that the patient:
- Arrived per ambulance from an outside hospital for direct admission to the freestanding psychiatric center on 01/09/21 at 4:08 PM;
- Presented to the outside hospital on 01/08/21 at 6:48 PM, for alcohol intoxication with a blood alcohol level (BAL, the amount of alcohol in the blood) of 505 which had decreased to 96 prior to transfer for admission at the freestanding psychiatric center; and
- Was admitted on suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) and seizure precautions (precautions designed to protect a patient from injury and to reduce stimuli that may trigger the onset of a seizure) and he was to be monitored/assessed per the alcohol withdrawal protocol.

During an interview on 01/20/21 at 10:42 AM, Staff FFF, Psychiatrist, stated that she was the on-call psychiatrist that accepted the transfer of Patient #46 for inpatient admission to the freestanding psychiatric center. She stated that she wasn't concerned with his BAL because it had dropped to 96 prior to the transfer and she felt he was stable for admission. She also stated that the criteria for admission was a BAL of 200 or lower. Staff FFF stated that the patient's vital signs were stable at 8:00 PM on 01/09/21, and she wouldn't have expected them to have changed significantly through the night and she expected for staff to follow the alcohol withdrawal protocol.

Review of Patient #46's History and Physical (H&P) performed by Staff III, Physician, Hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients), showed that:
- The consultation was requested for medical management of the psychiatric patient.
- The patient's chief complaint was suicidal ideation (SI, thoughts of causing one's own death) and alcoholism.
- The patient had a past medical history of substance abuse and alcoholism, with a longstanding drinking problem that had worsened with the recent loss of his mother, and he had recently lived with a friend but was now homeless.
- Clinical impression and plan was SI with plan for patient to be seen by the psychiatrist and further management of care as per the psychiatrist in-house.
- Alcoholism and alcohol intoxication with a plan to watch the patient for any withdrawal symptoms.
- Fentanyl (a medication used to treat severe pain, and is a high risk drug for theft and personal use), and opiate (highly addictive narcotics) abuse. The patient was urine-positive for fentanyl and he was to be monitored for any withdrawal symptoms.

During a telephone interview on 01/25/21 at 12:48, Staff III, Physician, Hospitalist, stated that he examined and performed the H&P on Patient #46 for medical consultation of the psychiatric patient. He stated that he felt the patient was medically stable as he was walking, talking, and moving around appropriately. He stated that the patient's neurological (neuro, relating to or affecting the nervous system) exam was normal and that he did not exhibit any signs of withdrawal. Staff III stated that he had no concerns that the patient was at the freestanding center versus the main campus as it had been a couple of days since his initial BAL that was over 500.

A psychiatric evaluation was not completed for Patient #46 prior to his death.

During an interview on 01/20/21 at 8:51 AM, Staff GGG, Psychiatrist, stated that he was not on call the night of Patient #46's admission. He stated that he arrived to the third floor of the freestanding psychiatric center early morning on 01/10/21, to perform the psychiatric evaluation when he learned that the patient had been found unresponsive and that staff were currently performing cardiopulmonary resuscitation (CPR, emergency life-saving procedure performed when a person's breathing or heartbeat has stopped) upon his arrival. Staff GGG stated that he expected vital signs to be obtained on patients on the alcohol withdrawal protocol and that this patient should not have been admitted to the freestanding center due to the high level of his BAL, with his initial intoxication and the positive Fentanyl within his urine. He also stated that the most critical timeframe for alcohol withdrawal was the first 24- to 48-hours.

Review of nursing documentation on 01/09/21 at 8:36 PM, by Staff DDD, RN, showed the patient was calm, cooperative and medication compliant. The patient rated his depression/anxiety 7/10, endorsed he was SI without a plan and contracted for safety. Alcohol withdrawal protocol vital signs maintained with 99.3 temperature (degree of hotness or coldness of the body, normal is 98.6 °F), 76 pulse rate (the number of heart beats per minute, normal range for adults is 60 to 100 bpm), 16 respirations (inhalation and exhalation of air; breathing) and a blood pressure (BP, a measurement of the pressure of blood flow in two different parts of the heart, normal is approximately 90/60 to 120/80) of 140/98. Will continue to monitor every 15-minute safety checks.

Review of alcohol withdrawal flowsheet dated 01/10/21, showed documentation at 1:35 AM by Staff DDD, RN, that the patient refused alcohol withdrawal protocol vital signs because he was sleeping. There was no documentation of an assessment of respirations, tremor, sweating, hallucinations, orientation or contact for the 1:35 AM assessment time.

Review of alcohol withdrawal flowsheet dated 01/10/21, showed documentation at 5:00 AM by Staff DDD, RN, that the patient refused alcohol withdrawal protocol vital signs. The time that this documentation was entered was 6:36 AM. There was no documentation of an assessment of respirations, tremor, sweating, hallucinations, orientation or contact for the 5:00 AM assessment time.

Review of Patient #46's psychiatry precaution and sleep rounds dated 01/10/21, showed documentation that Staff SSS, RN, documented her initials that indicated she had completed the safety rounds at 4:00 AM through 5:30 AM at 15-minute intervals.

Review of the video recordings titled, "01/10/21 0400 - 0500, 3rd floor male hallway," of the freestanding psychiatric center showed the camera view of the male hallway with Patient #46's room at the end of the hallway on the right side. The review showed:
- 4:28:28 AM Staff SSS, RN, walked into camera view and stopped at the first patient room with a clipboard in her hand. She stood in the doorway and briefly looked into the patient's room;
- 4:29:37 AM Staff SSS stopped at Patient #46's room, opened the door and briefly looked into the room while she stood in the doorway;
- 4:29:39 AM Staff SSS closed Patient #46's door and walked across the hall and continued to perform patient safety rounds and walked down the hallway and out of camera view.
- 4:46:16 AM Staff SSS walked into camera view and stopped at the first patient room with a clipboard in her hand. She stood in the doorway and briefly looked into the patient's room;
- 4:46:55 AM Staff VVV, Patient Safety Officer, walked into camera view and walked towards Staff SSS, RN. Staff VVV walked with Staff SSS while she performed the patient safety rounds;
- 4:47:07 AM Staff SSS stopped in the doorway to the room located just before Patient #46's room and appeared to be talking to the patient; and
- 4:48:48 AM Staff SSS turned away from the patient's doorway and walked across the hall while she appeared to be talking to Staff VVV. Both Staff SSS and Staff VVV walked towards the camera while Staff SSS briefly stopped at the doorways of patient rooms for patient safety rounds. They continued down the hallway until out of camera view.

Staff DDD, RN, failed to perform an assessment for alcohol withdrawal symptoms on Patient #46 at 4:30 AM, per his documentation that the patient had refused this assessment. Staff DDD had last entered Patient #46's room at 1:30 AM. Failure to assess him at the next scheduled time of 4:30 AM exceeded the minimum of every four hours assessment, per the hospital alcohol withdrawal protocol. Staff SSS, RN, failed to perform the psychiatry precaution and sleep rounds for Patient #46 as she did not walk to his room during her rounds at 4:48 AM. These combined failures placed Patient #46 at risk for his health and safety for potential alcohol withdrawal symptoms.

Review of video recording titled, "01/10/21 0500 - 0530, 3rd floor male hallway," (with same view as described above) showed:
- 5:04 AM Staff SSS, RN, walked into camera view and stopped at the first patient room with a clipboard in her hand;
- 5:05:34 AM Staff SSS stopped at the patient room just before Patient #46's room; and
- 5:08:04 AM Staff SSS left the patient's doorway and walked directly across the hallway.

Staff SSS, RN, failed to perform the psychiatry precaution and sleep rounds for Patient #46 as she did not walk to his room during her rounds at 5:05 AM. Patient #46 had not been rounded on since 4:29 AM, a total of 36 minutes.

Review of video recording titled, "01/10/21 0530 - 0600, 3rd floor male hallway," (with the same view as described above) showed:
- 5:47:44 AM Staff BBB, MHT, walked into camera view and stopped at the doorway of the first patient room with a clipboard in his hand;
- 5:48:33 AM Staff BBB stopped in the hallway at what appeared to be approximately two feet in front of Patient #46's doorway and stood while he appeared to write on his clipboard; and
- 5:48:38 Staff BBB turned and walked across the hall and continued to stop at patient room doorways and write on his clipboard.

Staff BBB failed to perform appropriate psychiatry precaution and sleep rounds as he did not assess for the rise and fall of Patient #46's chest.

Staff SSS, RN documented on the psychiatric precaution and sleep rounds that she rounded on Patient #46 at 4:00 AM; 4:15 AM, 4:30 AM; 4:45 AM; 5:00 AM; 5:15 AM and at 5:30 AM. Video review showed that Staff SSS rounded on Patient #46 at 4:29 AM. She performed the precaution and sleep rounds again at 4:47 AM but missed rounding on Patient #46. Staff SSS performed the psychiatry precaution and sleep rounds again at 5:05 AM but again missed the observation of Patient #46. Per video review Staff SSS, RN failed to perform any precaution and sleep rounds for Patient #46 from 5:05 AM to 5:30 AM. The next time that Patient #46 was observed was when Staff CCC, MHT completed psychiatry precaution and sleep rounds at 5:47 AM. Patient #46 was last observed at 4:29 AM and not observed again until 5:47 AM, a total of one hour and 28 minutes. Patient #46 was not observed for his safety when Staff SSS, RN failed to perform the psychiatry precaution and sleep rounds but falsely documented that she had completed such rounds.

Review of video recording titled, "01/10/21 0600 - 0700, 3rd floor male hallway," (with same view as described above) showed:
- 6:04:49 AM Staff CCC, MHT, walked into camera view and stopped at the doorway of the first patient room with a clipboard in his hand;
- 6:05:45 AM Staff CCC stopped in front of Patient #46's door and appeared to write on the clipboard;
- 6:05:51 AM Staff CCC then turned toward the camera and walked across the hall;
- 6:44:27 AM Staff CCC walked down the hallway and entered Patient #46's room;
- 6:45:13 AM Staff CCC walked out of Patient #46's room into the hallway and appeared to be talking moving his right arm and appeared he was attempting to get someone's attention with immediate visualization of multiple staff members running into camera view, down the hallway, and into Patient #46's room;
- 6:46:20 Staff DDD, RN, walked down the hallway and entered Patient #46's room;
- 6:47:06 Staff SSS, RN, pushed the code cart (cart on wheels that contained emergency resuscitative equipment and supplies used for CPR but did not contain emergency drugs) into Patient #46's room then she ran back toward camera view; and
- 6:57:06 EMS walked onto the unit and into Patient #46's room.

During an interview on 01/20/21 at 12:05 PM, Staff BBB, MHT, stated that when he had performed patient safety rounds on Patient #46, he observed for the rise and fall of his chest and he appeared to be sleeping. He stated that when he did the safety rounds at night he would listen for snoring or watch to see if the covers moved to ensure a patient was okay and that he didn't always go into the patient's room.

During an interview on 01/20/21 at 11:13 AM, Staff CCC, MHT, stated that he had completed patient safety rounding on Patient #46 at approximately 5:30 AM on 01/10/21, and the patient appeared to be sleeping as he heard him snoring. He stated that the snoring wasn't loud as with a patient who may have had sleep apnea (a potentially serious sleep disorder where breathing repeatedly stops and starts) but noisy, kind of "gurgling." He assumed he was breathing since he could hear him making noises, so he felt he was okay. Staff CCC stated that he entered Patient #46's room to obtain a blood draw at approximately 6:30 AM, and the patient again appeared to be sleeping. He stated the patient did not awaken when he called his name so he touched his arm and it was cold. Staff CCC stated that he immediately called out for help and initiated CPR. Staff CCC stated that Staff BBB, MHT, responded to the patient's room and they took turns providing CPR. He stated that Staff DDD, RN, entered the room but just stood there "frozen," he didn't assess the patient or offer to take over CPR. He stated that Staff DDD attempted to get out the automated external defibrillator (AED, a device that automatically analyzes the heart rhythm and treats with an electric therapy if necessary) pads, but he wasn't able to get them untangled to put them on the patient, another RN came into the room and applied the pads to the patient. Staff CCC stated that the AED advised not to deliver any electric therapy so the staff continued CPR until emergency medical services (EMS, ambulance) arrived.

Review of the ambulance report dated 01/10/21, showed that the ambulance arrived at the freestanding psychiatric center at 6:57 AM, and found a male patient supine (lying horizontally with the face and torso facing up) on the floor, unresponsive, pulseless, apneic (a temporary cessation of breathing called apnea), cyanotic (blue to purplish discoloration of the skin) from the shoulders up, extremely pale, his arms were in a fixed position above his head and were completely unmovable. The patient had rigor mortis (stiffening of the joints and muscles of a body a few hours after death) in his arms, jaw, wrist and ankles. The patient was cool to the touch, and was in asystole (heart stops beating) on the monitor. Per hospital staff, the patient refused to have his vital signs taken at 1:00 AM and again at 5:00 AM, as it appeared the patient was sleeping with rise and fall of the chest. Patient #46 was pronounced dead at 7:02 AM.

Patient #46 was not observed/monitored for 36 minutes consecutively when Staff SSS, RN, failed to perform the psychiatry precaution and sleep rounds appropriately for two consecutive rounds. Staff SSS additionally failed to perform psychiatry precaution and sleep rounds for Patient #46 for an additional 52 minutes consecutively but falsely documented that she had completed those rounds. Staff DDD, RN, failed to assess the patient at the required minimum of every four hours for alcohol withdrawal symptoms. Staff CCC, MHT, stated that he heard Patient #46 make a "gurgling" sound, but assumed he was snoring. This "gurgling" sound could have indicated that Patient #46 was experiencing seizure activity or respiratory difficulties. Patient #46 was pronounced dead approximately 15 hours after he was admitted for alcohol withdrawal monitoring.

2. Review of Patient #47's medical record showed the following:
- She was brought to the Emergency Department (ED) on 12/14/20, for altered mental status (changes in the way the brain functions, such as confusion, memory loss, loss of alertness, judgement, thoughts and emotions).
- On 01/14/21, she was admitted to the neuro step down unit (an intermediate level of care between the intensive care unit [ICU] and the general medical surgical unit) with orders for nursing to suction (to remove thick mucus and secretions from the airway, that a person is not able to clear by coughing) her tracheostomy every two to three hours.
- On 01/14/21, there was no documentation of suctioning being performed for six hours, from Midnight to 6:00 AM, and then again for five hours, from 3:00 PM until 8:00 PM.
- On 01/15/21, there was no documentation of suctioning being performed for 13 hours, from 4:21 AM until 5:30 PM.
- On 01/16/21 at 6:47 PM, one of the patient goals for nursing was for suctioning to be performed every two hours due to the amount of secretions.
- On 01/17/21, there was no documentation of suctioning being performed for three hours and 24 minutes, from 11:00 PM until 2:24 AM.

During an interview on 01/20/21 at 2:10 PM, Staff UU, RN, stated that Patient #47 was on the Neuro ICU for a few weeks, then transferred to the step down unit where they didn't suction her as often as she needed; the patient became hypoxic and had to be transferred back to the Neuro ICU.

3. Review of the hospital's undated practice guideline titled, "Suprapubic Catheter Care," showed that the suprapubic catheter site should be observed for erythema (redness), edema (swelling), discharge, and tenderness, and that the dressing should be checked at a minimum of every eight hours.

Review of the H&P for Patient #32, dated 01/12/21, showed that he was a 58-year-old male with a history of testicular cancer (cancer of the male organs) and was admitted to the hospital with acute myeloid leukemia (cancer of the blood and bone marrow).

Observation on 01/20/21 at 10:53 AM, showed that the old dressing which was removed from the suprapubic catheter site was undated and discolored.

Review of Patient #32's medical record on 01/20/21 at 11:00 AM, showed that the wrong catheter type had been placed into the EMR, which prevented the care prompts for a suprapubic catheter from being generated.

During an interview on 01/20/21 at 11:10 AM, Staff PPP, RN, Clinical Nurse Specialist (CNS), stated that:
- When the suprapubic catheter type is selected in the EMR, the system generates care orders for the site which includes dressing changes every eight hours.
- The oncology unit does not treat patients with suprapubic catheters very often.
- Dressings for suprapubic catheters should be checked and changed at a minimum of every eight hours.
- Dressings should always be signed and dated by the nurse after application.

4. Review of the hospital's policy titled, "Blood Administration," revised 07/2019, showed that the nurse administering the transfusion must remain with the patient during the initial fifteen minutes of the transfusion and they are to assess and document temperature, heart rate, respiratory rate, and blood pressure on the vital signs flow sheet within fifteen minutes after the transfusion has begun.

Review of the H&P for Patient #26, dated 01/19/21, showed that she was a 58-year-old female with a history of endometrial cancer (cancer in the lining of the uterus) and was admitted with metastatic (the spread of cancer cells from the place where they first formed to another part of the body) endometrial cancer.

Review of Patient #26's blood administration flowsheets, dated 01/20/21, showed that the transfusion began on 01/20/21 at 07:20 AM, and the first set of vital signs captured after the transfusion began was at 07:55 AM, 35 minutes later.

Review of the H&P for Patient #29, dated 01/08/21, showed that he was a 45-year-old male that had presented to the ED with complaints of fatigue (weakness or tiredness), shortness of breath, nausea, and dark colored urine. He had a history of brain cancer and was admitted for leukopoiesis (the formation and development of white blood cells through stem cells).

Review of Patient #29's blood administration flowsheets, dated 01/20/21, showed that the transfusion began on 01/20/21 at 09:40 AM, and the first set of vital signs captured after the transfusion began was at 9:59 AM, 19 minutes later.

During an interview on 01/20/21 at 10:00 AM, Staff RRR, RN Educator, stated that vital signs should always be assessed and documented no later than fifteen minutes after the start of blood transfusions and that this would be a topic for them to add to their education.

5. Review of the hospital's document titled, "IV Therapy: Insertion, Maintenance, and Discontinuation," dated 08/2020, showed the following:
- All IV tubing must be changed every 96 hours, with each new IV start, and any time sterility (without bacteria) of the closed system is compromised.
- Attach a label to tubing with the date/time changed and the initials of the nurse.
- Peripheral IV dressings with transparent dressings were to be changed every seven days and as needed.
- Label dressing with size, type of catheter, date and initials of staff performing the dressing change.

Observation on 01/19/21 at 3:36 PM, showed Patient #4 received IV medication and the IV tubing was not labeled.

Observation on 01/19/21 at 4:00 PM, showed Patient #1's IV tubing was not labeled and the IV site dressing was not dated or timed.

Observation on 01/20/21 at 9:30 AM, showed Patient #36's IV tubing was not labeled.

Observation on 01/20/21 at 10:20 AM, showed Patient #17 received IV medication and the IV tubing was not labeled.

Observation on 01/20/21 at 10:30 AM, showed Patient #19 received IV medication and the IV tubing was not labeled.

During an interview on 01/19/21 at 4:15 PM, Staff C, RN, stated the IV tubing should be labeled and she thought the IV tubing should be changed every 96 hours.

During an interview on 01/20/21 at 10:20 AM, Staff V, RN, stated that the IV tubing for Patient #17 should have been labeled, but it was not.

During an interview on 01/20/21 at 10:30 AM, Staff X, RN, stated that the IV tubing for Patient #19 should have been labeled, but it was not.

During an interview on 01/20/21 at 9:45 AM, Staff OO, RN, stated the IV tubing should be labeled and the dressing should be timed and dated. She was unsure of when the IV tubing should be changed. She thought there was a recent policy change, but she could not remember the policy directive.

During an interview on 01/21/21 at 12:20 PM, Staff TTT, Chief Nursing Officer (CNO), stated that she was very concerned regarding the lack of assessments and the quality of the patient safety rounds. She also stated that she would expect physicians' orders to be followed unless there was an exception, and that would need to be documented. She also stated that staff should follow hospital policies, the unit based leaders and educators were aware of these policies and were responsible for auditing and ensuring education was provided and compliance was achieved.






40710




41474




39563