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Based on review of the hospital's policies and procedures, document review and interview, it was determined that the hospital's governing body failed to ensure that the QAPI program includes all hospital departments and services.
Reference deficiencies written at Tag A0115 - Patient Rights
Reference deficiencies written at Tag A0263 - Quality Assessment/Process Improvement

Based on interview, review of the medical record and review of the hospital's policy and procedures, it was determined that the hospital's governing body failed to ensure that the rights of all patients in the hospital were protected and that their safety was assured.

As evidenced in the findings detailed throughout this report, the cumulative effect of these systemic problems resulted in the hospital failing to protect the safety of Patient #1 and failing to implement corrective measure where necessary to assure the safety of all patients in the hospital.

Failure to assure the safety of Patient #1. Reference Tag-A0144.

Failure to notify the patient's family of an unexpected death. - Reference Tag-A0131

Failure to investigate and evaluate safety concerns related to the safety of Patient #1, and to subsequently develop and implement corrective actions to protect the safety of all patient in the hospital. Reference Tag-A0263

Based on review of the hospital's policies and procedures, document review and interview, it was determined that the hospital did not protect the patient (family) right to be kept informed of the patient's health status. The hospital's failure do to so violated the patient (family) rights.

Findings include:
At the time of death on February 3, 2014, the family was not notified by Providence St. Peter Hospital (PSPH). In PSPH ' s Postmortem Care Policy, it states that it is " the attending physician ' s responsibility to inform the family of the patient ' s death " . In the 'Death of a Patient-DBHR Notification' policy, the procedure states, " PSPH staff will notify family/responsible persons as soon as possible when a patient has a medical emergency or expires " .

Based on interviews, review of the medical record for Patient #1, review of hospital policy and review of internal hospital documents, it was determined that the hospital failed to protect the safety of Patient #1. The hospital failed to follow facility policies and procedures related to following physician orders and performing patient reassessments in accordance with standard of care, potentially placing all patients in the hospital at risk for injury or death.

Findings include:
Patient #1 was admitted to Providence St. Peter Hospital at midnight 2/1/2014 for detoxification of alcohol. The physician's orders state that vital signs are to be taken every three hours times three and then every shift. Vital signs at 1708 on February 2nd, 2014 indicated a blood pressure measurement of 85/54. Prior vital sign readings:

2/1/14
0100 129/92 First documented BP in medical record
0500 112/69
0906 131/87
1330 184/116
1751 108/71

2/2/14
0500 101/69
0941 199/105
1708 85/54

2/3/2014
0620 Patient found deceased

The physician orders state to "Notify Provider for hypotension (DPB < 60 or MAP < 65) (diastolic blood pressure less than 60 or a mean arterial pressure less than 65).

Visual checks of Patient #1 are documented at 2006 and 2109 on the February 2, 2014. The CIWA assessment documentation contains a number of elements that would indicate the nurse observed the patient. At 2006, the patient complaint of a mild headache but no corresponding pain medication was given. Librium was giving at 2010 and is the last medication charted. At 2109, the pain assessment documentation states "appears comfortable, sleeping".

No reassessment of vital signs were taken for thirteen hours when the patient was found dead by a phlebotomist.

The investigator interviewed three registered nurses, two that were involved in the care of Patient #1. During the individual interviews on the morning of March 18, 2014, the investigator asked about the criteria for reassessment for patients in detox. No specific criteria could be identified. The investigator asked if there was a policy/procedure/standard of care defining reassessment criteria and the three nurses could not identify a policy.

On review of the 'Nursing Care for the Patient in Detox or Rehab' policy, the Vital Signs requirement is stated, " on admission, then every 3 hours X three, then every shift and prn, for detox patients " . On chart review, five of the ten records did not show compliance with this requirement.

Based on review of the hospital's policies and procedures, document review and interview, it was determined that the hospital's governing body failed to ensure that the QAPI program includes all hospital departments and services.

Reference Tag - A-0267
Reference Tag - A-0288

Based on interview and document review, it was determined that the hospital failed to include all hospital services in their hospital-wide quality assurance program.

Findings:

On March 13, 2014, the investigator interviewed four Chemical Dependency Center (CDC) personnel on their involvement with the hospital improvement program. The personnel did not indicate they were aware of CDC's involvement with the hospital plan. On interview with the CDC nurse manager and quality director, they acknowledged the exclusion of CDC specific quality indicators.

On document review, the CDC identified areas of needed improvement during an October 2013 staff meeting with CDC employees. No evidence of measurement, analysis or tracking of these identified areas of needed improvement could be found.

Based on interview and policy review, it was determined that the hospital failed to analyze the circumstances and implement preventative actions on an adverse patient event.

Findings:
At the time of investigation on March 14, 2014, no internal investigation could be demonstrated. Providence St. Peter Hospital's (PSPH) Sentinel/Adverse Events Policy defines an adverse event as "an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof " . The policy outlines the procedure following an adverse event and the investigator found no evidence that the policy was followed.

Based on interview, document review and policy and procedure review, the hospital failed to evaluate patient care needs on an ongoing basis. Failure to perform A reassessment of patient's conditions puts patient's at risk of harm.

Findings include:
The physician orders for patient's entering the Chemical Dependency Center for detoxification from alcohol require vital signs to be taken every three hours time three. On review of Patient #1's medical record, vital signs were not taken every three hours. On review of nine other records, vital signs did not meet the physician's orders 4 out of 9 records.

On interview of three staff registered nurses on March 18, 2014, each stated vital signs are taken by the registered nurse. Two of the three nurses stated that if the patient is sleeping, the vital signs are not taken. The investigator asked for the policy and/or physician protocol that changes the original order requirement and no policy could be found.

The investigator asked about the requirement of vital signs every shift after the initial three times and all three stated they were at least every eight hours as the nursing staff work eight hour shifts and this was the intention of the physician orders. On record review, it was noted that the vital signs are not taken at least every eight hours and varied beyond the parameter.

Physician #1 stated on March 18, 2014, that because there are only two nurses for forty patients, the patients are required to come to the nursing desk for vital signs and the nurses do not wake up sleeping patients. This was not confirmed by the three nurses interviewed.

The investigator asked the three registered nurses about the policy requirements for reassessment of patients. They could not identify a policy and were not aware where a policy could be located. The Chief Nursing Officer provided the policy on 'Nursing Care for the Patient in Detox or Rehab'. The policy states that the nursing assessment frequency is to be determined by the patient's condition. On March 18, 2014, nurses #1, #2 and #3 stated that a change in vital signs would constitute an indication for more frequent assessments. This assessment was not performed on Patient #1.

The policy on medication administration states that the reason a PRN medication is given will be documented on the medication record and will include the response to the medication after administered. 10 out of 10 medical records contained no documentation of response to a PRN medication.