HospitalInspections.org

An authorized substantial allegation survey concluded on 9/19/19 at Connecticut Valley Hospital in response to
CT# 26079.

The Condition of Participation reviewed included:

CFR 282.23 Nursing Services


Based on a review of clinical records, observations, review of facility documentation, review of facility policies, and interviews, it was determined that the hospital did not meet the Condition of Participation for Nursing Services by failing to:

1. Ensure that cardiopulmonary resuscitation was initiated when one patient (#1) was identified as unresponsive and without a pulse resulting in a delay in care and treatment.

2. Ensure that patient's were assessed and/or monitored and/or implemented physician's orders for a patient with a fall and/or change in condition.

3. Ensure medications were administered in accordance with physician orders.

Refer to A-395 and A-405

Connecticut Valley Hospital
Silver Street
Middletown, CT 06457

1. Based on clinical record reviews, observations, review of facility documentation, review of facility policies, and interviews for (a.) one of ten sampled patients (Patient #1) who was reviewed for medical emergencies, the facility failed to initiate Cardiopulmonary resuscitation (CPR). The finding includes:

Patient (P) # 1 was admitted to the facility on 10/31/18 with diagnoses that included schizoaffective disorder, a history alcohol, cannabis, and opioid use/dependence, chronic Hepatitis C, hypothyroidism, chronic constipation, and asthma.

The Integrated Treatment Plan (ITP) dated 8/15/19 identified P#1 had a problem with constipation. Interventions directed the staff to notify the physician of the increased usage of bowel medications, if the patient reports constipation or unrelieved constipation, administer medications as needed and to assess further.

The facility's Emergency Medical Patient Record dated 8/23/19 at 10:10 PM identified vital signs were monitored every five minutes. The patient was found sitting on the toilet at 10:10 with a blood pressure (BP) of 86/27, pulse 72 beats per minute (bpm), respirations 14 per minute, and oxygen saturation (SaO2) was 75% on room air. At 10:15 PM, at which time emergency medical services (EMS) assumed care of P#1, P#1's BP was 86/25, pulse 26 bpm., respirations 14 per minute and SaO2 was 79% on 15 liters per minute (L/min.) of oxygen. At 10:20 PM P #1's BP was unrecordable, pulse had decreased to 21 bpm, respirations were 12 minute and the SaO2 was 75% on 15 L/min. of oxygen. Additionally, the report identified that P#1 was not conscious. Review of the medical record failed to indicate that CPR had been initiated. Additionally the Report failed to identify if P#1 was suctioned during the medical emergency. The facility's emergency response stopped monitoring the Patient's vital signs when EMS arrived and took over.

The Emergency Service's Pre Hospital Care Report Summary identified EMS arrived on scene on 8/23/19 at 10:14 PM with patient contact at 10:15 PM. Upon arrival P#1 was sitting upright on the toilet, unconscious with facility staff holding the patient upright. A non-rebreather mask was on the patient at 15 L/min.. P#1 was assessed by EMS. EMS assessment identified P#1's airway was partially obstructed, he/she was apneic with absent bilateral lung sounds, the patient was pale, diaphoretic and no capillary refill was noted. Additionally, the patient was unconscious and both pupils were non reactive. P#1's BP was 160/120, there was no pulse or respirations noted. P#1 was immediately moved from the toilet to a stretcher, compressions were initiated by EMS, the AED pads were placed and an oropharyngeal airway was set in place by EMS. A bag valve mask was used for ventilation and the patient was transported to the ED.

A Physician's Progress Note (MD#1) dated 8/23/19 at 10:25 PM identified that during the incident the staff were holding P#1's head up and food and vomitus was noted on the Patient's shirt. When EMS arrived the Patient was transferred to a stretcher, the AED was applied by EMS and the AED device indicated no shock was required, and compressions were initiated. MD#1's assessment indicated P#1 was exhibiting cardiac arrest with or without aspiration and asystole verses ventricular tachycardia. P#1 was then transferred to the nearest ED at approximately 10:20 PM.

An Incident Report dated 8/23/19 at 10:50 PM identified MD#1 documented that the patient was sitting upright on the toilet when MD#1 arrived. The patient's carotid pulse was absent and blood pressure was unrecordable.

A Nurse's progress noteby RN #1 dated 8/23/19 at 11:00 PM identified that P#1 had been constipated for a few days. At 3:30 PM the patient received Magnesium citrate, one bottle with no effect. At 8:40 PM P#1 received a Dulcolax suppository. At 10:05 PM P#1 was assisted to the toilet. While sitting on the toilet P#1 vomited, his/her color changed, and he/she appeared to be unresponsive. A medical emergency was activated. The Patient's vital signs at 10:10 PM noted a BP of 86/27 and an oxygen saturation of 75% on room air. Oxygen 15 L/min. was initiated via non rebreather mask.

MD#1's progress note dated 8/23/19 at 11:45 PM identified the ED notified the facility that P#1 had expired.

The ED documentation dated 8/24/19 at 12:16 AM identified the patient arrived with cardiopulmonary resuscitation (CPR) in progress. The initial physical exam identified a large amount of vomitus noted within the oropharynx and required suctioning. P#1's abdomen was soft and distended. Resuscitative efforts continued for thirty minutes without return of spontaneous pulse/respirations. P#1 was pronounced dead on 8/23/19 at 11:01 PM. The final diagnosis was cardiopulmonary arrest of unclear etiology, terminal event, constipation, and episodic vomiting.

Interview and review of the clinical record on 9/4/19 at 1:45 PM and 9/17/19 at 10:00 AM with MD#1, identified that on 8/23/19 at 10:13 PM MD#1 arrived and observed P#1 was unresponsive, sitting on the toilet with the staff holding his/her head up. There was vomit down the front of P#1's shirt and around his/her mouth. MD#1 instructed the nurses to place the patient on the floor in the recovery position but, the nurses stated they were afraid the P#1 would aspirate, and failed to follow MD#1's direction. Further interview with MD#1 on 9/18/19 at 9:30 AM identified that although he did not assess the P#1's carotid pulse, one of the nurses identified that no carotid pulse was present. MD#1 indicated that two BP machines were not correctly measuring the patient's blood pressure. Although he was monitoring the patient's vital signs he failed to conduct an assessment of the patient's airway, breathing, circulation and/or neurological status. Additionally MD#1 indicated that CPR was not initiated until EMS arrived because P# 1's vital signs were still present.

Interview on 9/11/19 at 11:00 AM with Mental Health Associate (MHA) #3 identified that he assisted P#1 to the bathroom. P#1 then vomited a large amount on his/her clothes and on the floor, and complained of stomach pain. The patient then became unresponsive. MHA#3 called for the nurse who activated the medical emergency. MHA #3 stated that he had to hold the patients head up to prevent the patient from choking and vomit was draining from the patients mouth.

Interview and review of the clinical record on 9/11/19 at 1:30 PM with Registered Nurse (RN)#2, who was the second nurse on site during the medical emergency and who obtained the patients vital signs during the emergency, identified that when she arrived she observed two MHA's in P#1's bathroom holding up P#1. RN #2 noted the patient had vomited and was unresponsive. RN#2 immediately obtained the emergency cart and proceeded to obtain P#1's vital signs. RN#2 stated that P #1's mouth was full of vomit and required suctioning. RN #2 indicated that she was unable suction P#1 because there were no functioning electrical outlets in the bathroom to plug the suction machine into. An additional interview on 9/17/19 at 1:00 PM identified that RN #2 failed to do a finger sweep of the patient's mouth to ensure a clear airway and/or failed to place the patient on the floor in the recovery position as directed by the physician.

Interview and review of the clinical record on 8/18/19 at 1:00 PM with RN# 3 identified that during the medical emergency she was responsible for documenting the incident on the Medical Emergency Patient Record. RN #3 indicated that she heard MD#1 and other staff present discussing moving P#1 to the floor. RN#3 indicated although the suction machine was on the cart in the bathroom, staff present did not attempt to plug the suction machine in so that P#1 could be suctioned.

Interview and review of the clinical record on 9/18/19 at 3:00 PM with RN# 1, who was the charge nurse on the unit, identified that MHA #3 notified her that P#1 was on the toilet, vomited and had become unresponsive. RN#1's initial assessment of the patient identified infrequent respirations, however RN#1 did not determine P#1's breaths per minute. RN#1 then left the Patient to activate a facility medical emergency which also notified local EMS. MHA #3 remained with the Patient. Additionally RN#1 indicated that she did not do a complete set of vital signs and/or a physical assessment of P#1. RN#1 then left P#1 in the room with two other nurses so she could complete transfer documentation. RN #1 failed to conduct an assessment of the patient's airway, breathing, circulation and/or neurological status. and/or as the first to respond RN #1 failed to take charge of the medical emergency as directed in the facility's policy.

Interview on 9/19/19 at 10:00 AM with the facility Medical Director identified that during her investigation of the incident it was difficult to determine the sequence of events during the medical emergency on 8/23/19. The Medical Director indicated she would have expected the physician and nurses to initially conduct a thorough assessment of the patient and to place the patient on the floor in the recovery position.

Interview on 9/19/19 at 11:30 AM with the Acting Chief Operating Officer identified that if staff had placed P#1 on the floor in the recovery position, the electrical outlet in the hall could have been accessed to operate the suction machine. The Acting CMO indicated during a review of the incident it was identified there was a problem with leadership during the emergency situation as evidenced by the fact that a person in charge of the medical emergency had not been established.

The Facility's Medical Emergency policy directs that the first clinical staff member on the scene assesses the patient's general appearance, the level of responsiveness, and checks the airway, breathing and circulation. The First RN responder assumes charge until the physician responds. The Charge nurse directs nursing staff to prepare the emergency cart for use, plug in suction machine, and secure the emergency cart, AED, and oximeter. Upon arrival to the scene the physician becomes the team leader, delegates tasks as needed, and orders all medications/interventions.

The facility failed to follow hospital policy during a medical emergency including initiation of CPR, use of an AED, and suctioning.





2. Based on clinical record reviews, observations, review of facility documentation, review of facility policies, and interviews for three of ten patients reviewed for assessments (Patient # 1, Patient #4, Patient #10), the facility failed to conduct bowel assessments in the absence of bowel elimination and/or conduct orthostatic blood pressures and/or neurological assessments after a fall.

a. Patient (P) # 1 was admitted to the facility on 10/31/18 with diagnoses that included schizoaffective disorder, a history alcohol, cannabis, and opioid use/dependence, chronic Hepatitis C, hypothyroidism, chronic constipation, and asthma.

The Integrated Treatment Plan (ITP) dated 8/15/19 identified P#1 had a problem with constipation. Interventions directed the staff to notify the physician of the increased usage of bowel medications, if the patient reports constipation or unrelieved constipation, administer medications as needed and to assess further.

Physician's orders dated 7/25/19 and 8/22/19 directed the administration of Milk of Magnesia (MOM) 30 ML every twenty four hours if P#1 had no bowel movement (BM) in twenty four hours, Magnesium Citrate, one bottle if no BM in forty eight hours and if refusing MOM, Bisacodyl 10mg orally every twenty four hours if no BM in seventy two hours and if the patient is refusing the Magnesium Citrate. Additionally, Bisacodyl 10 mg suppository every twenty four hours as needed (prn) for constipation and Fleets enema every twenty four hours if suppository was not effective.

The Vital Signs flow record identified that P #1 had no BM on 8/17/19, 8/18/19, and 8/19/19.

The Medication Administration Record for 8/2019 identified that although the P#1 had not had a BM in three days, MOM had not been administered daily as ordered for three doses, Magnesium Citrate had not been administered on 8/18/19 after forty eight hours of no BM and, Bisacodyl 10 mg was not given on 8/19/19 after seventy two hours with no BM. Additionally, the prn Bisacodyl 10 mg suppository and/or Fleets enema had not been given for constipation.

A Nurse's Progress note dated 8/21/19 at 8:45 PM identified P#1 had not had a BM in five days. According to the note P#1 had refused Bisacodyl Suppository, Magnesium Citrate, and fleets enema but accepted Bisacodyl 10 mg by mouth. The Vital Signs Flow record for 8/21/19 identified the Patient had no effect from the medication and had not had a BM.

A Nurse's Progress note dated 8/22/19 identified P#1 had not had a BM in six days and P#1 refused all bowel medications. Further review of the Progress notes identified that although the patient had not had a BM in five or six days, the medical record lacked bowel assessments.

During and interview on 9/11/19 at 10:30 PM with MD#2 identified that she expected that bowel assessments to be completed when the patient went days without a BM. The Physician indicated that she was aware of the bowel issues and/or refusal of medication. It had been discussed daily in morning rounds.

The facility failed to monitor, assess and/or implement physician's orders for a patient with a change in gastrointestinal status.


b. The Integrated Treatment Plan (ITP) dated 8/15/19 identified P#1 was at risk for falls and had a history of recent falls. Intervention directed to continue to reinforce with the patient to secure wheelchair brakes as appropriate, allow vital sign monitoring, avoid sudden positional changes, and request assistance when necessary.

A Facility Incident Report dated 8/21/19 identified the Patient #1 had an unwitnessed fall at 11:15 AM on 8/21/19. The patient reported that he/she was getting up to go to the bathroom and fell. Patient #1 was assessed by a registered nurse, vital signs were 94/68, pulse 88, respirations 18, and oxygen saturation was 98% on room air. No visible injuries were identified upon initial assessment.

During a review of the clinical record and interview with RN#11 on 9/11/19 at 2:00 PM, RN #11 was unable to provide documentation that orthostatic blood pressures and/or neurological assessment were completed after Patient #1 fell, as directed by the facility's policy.

The Vital Signs Notification and the Neurological Assessment policies directs that after a fall the RN will implement the Nursing measure of orthostatic vital sign checks every four hours for twenty four hours and neurological assessment every 15 minutes for 1 hour, every 30 minutes for 1 hour, every hour for four hours and every 4 hours for 24 hours.


c. P# 4's diagnoses included schizoaffective disorder. Review of the ITP dated 6/5/19 identified P#4 had a history of seizures and had no seizure activity since admission (3/30/17). Review of the clinical record identified the patient was on Keppra 500mg twice a day but P#4 had refused the medication since admission and the medication was subsequently discontinued.

Review of nurse's notes dated 7/2/19 at 3PM identified the patient was found unresponsive. The patient was observed laying on the bed with the head facing the ceiling and repetitive swallowing movements. The note further identified the patient was responsive but not at baseline, speech was not clear and s/he was speaking slowly. A medical emergency code was called for a possible seizure.

Review of the Emergency Medical Patient record dated 7/2/19 at 2:40 PM identified the form lacked documentation that the patient neurological status was assessed.

Interview with RN # 12 on 9/11/19 at 2 PM stated that she was called to the patient's room after staff checked on the patient and s/he didn't seem right. RN # 12 stated that she assessed the patient and identified the patient lying in bed not moving except for his/her mouth and was not arousable from sleep at first. RN # 12 stated that she just assumed the patient was having a seizure because s/he had a history of seizures.

Review of the Emergency Medical Patient record with RN # 12 indicated s/he failed to identify that a comprehensive assessment was conducted that included a complete neurological assessment.

Interview with the COO on 9/12/19 at 10AM stated that patients are to be assessed fully with any change of condition.

Althought he facility medical Emergency policy did not indicate when to initiate CPR the policy identified the first clinical staff on the scene assesses the patient's general appearance, level of responsiveness, airway, breathing, and circulation. Additionally, the RN assumes responsibility and assess the patient until the MD arrives.

d. Patient #10's diagnoses included schizoaffective disorder. According to the medical record P#10 had no previous history of falls. Review of the incident report dated 9/10/19 at 12:55PM identified the patients chair flipped backwards while the patient was sitting in it and the patient fell hitting the back of the head. The report identified the patient was assessed, no visible injury and was able to ambulate and move extremities. Nurse's notes dated 9/10/19 at 4:00 PM identified while the patient was sitting in the plastic chair the chair flipped backwards and the patient fell hitting his/her head. The note identified the patient was assessed, neuro vital signs done and the patient was medicated for pain and was up ambulating in the hallway.

A nurse's note dated 9/12/19 at 1:30PM noted the patient exited the room in morning holding the hand rail. Upon assessment appeared lethargic, unsteady on feet vital signs were completed and the temperature was 100.4. The MD was made aware and the patient was transferred to the hospital for evaluation for possible pneumonia.

Physician progress note dated 9/12/19 at 9:30AM identified patient noted to be lethargic, temperature 100.4, Oxygen saturation level at 93%. Patient sent to hospital for evaluation.

Review of the hospital report dated 9/12/19 identified the patient was brought in for decreased mental status. The staff that accompanied the patient reports that over the past 1 to 2 days the patient was somewhat confused and unsteady and a chest x-ray revealed a large right upper lobe infiltrate.

Review of the clinical record with DON #1 on 9/17/19 at 11 AM identified after the patient fell and hit his/her head on 9/10/19 the clinical record lacked documentation of the patients neurological status being assessed until 9/12/19 at 9:30AM when the patient was noted to be lethargic with mental status changes and was transferred to the hospital. DON 3 1 stated that they only have to do neuro checks if the physician orders them.

Review of the hospital policy for Neurological assessment identified when a patient falls and hits their head or has an unwitnessed fall they will have the following assessment schedule, vital signs and neurological assessment every 15 minutes for 1 hour, every 30 minutes for 1 hour, every hour for four hours and every 4 hours for 24 hours.

Based on clinical record reviews, review of facility documentation, review of facility policies, and interviews for one sampled patient (Patient #1) who was reviewed for an untimely death, the facility failed to administer medication as directed by the physician. The findings include:

Patient (P) # 1 was admitted to the facility on 10/31/18 with diagnoses that included Schizoaffective disorder, a history alcohol, cannabis, and opioid abuse/dependence, chronic Hepatitis C, hypothyroidism, chronic constipation and asthma.

The Integrated Treatment Plan (ITP) dated 8/15/19 identified a problem with constipation. Interventions directed the staff to notify the physician of the increased usage of bowel medications and/or if the patient reported constipation or unrelieved constipation. Medications were to be administered as needed P#1 was to be assessed as applicable. Physician's orders dated 7/25/19 and 8/22/19 directed the administration of Milk of Magnesia (MOM) 30 ML every twenty four hours if P#1 had no bowel movement (BM) in twenty four hours, Magnesium Citrate, one bottle if no BM in forty eight hours and if refusing MOM, Bisacodyl 10mg orally every twenty four hours if no BM in seventy two hours and if the patient is refusing the Magnesium Citrate. Additionally, Bisacodyl 10 mg suppository every twenty four hours as needed (prn) for constipation and Fleets enema every twenty four hours if suppository is not effective.

The Vital Signs flow record identified that P #1 had no BM on 8/17/19, 8/18/19, and 8/19/19.

The Medication Administration Record for 8/2019 identified that although the P#1 had not had a BM in three days, MOM had not been administered daily as ordered for three doses, Magnesium Citrate had not been administered on 8/18/19 after forty eight hours of no BM and, Bisacodyl 10 mg was not given on 8/19/19 after seventy two hours with no BM. Additionally, the prn Bisacodyl 10 mg suppository and/or Fleets enema had not been given for constipation.

During an interview on 9/11/19 at 10:30 AM with Medical Doctor (MD) # 2, P#1's primary physician, identified that the patient should have received all the medications as ordered due to his/her history of constipation and a history of two hospitalizations for constipation.(?did the patient refuse)

Interview and review of the clinical record on 9/11/19 at 2:30 PM with the Nurse Executive identified that medications should be administered as directed by the physician.

The Facility's policy directs that the third shift Registered Nurse (RN) is to communicate elimination needs to the first shift Head Nurse.