HospitalInspections.org

Based on medical record (MR) review and interview, in one (1) of 12 medical records reviewed, the facility did not ensure that staff in the Comprehensive Psychiatric Emergency Program (CPEP) provided appropriate intervention to a choking patient. (Patient #1)


Findings include:


Medical Record (MR) review documentation identified this 49 year old brought in by ambulance to the Emergency Department (ED) on 1/16/16 at 7:16 AM and was subsequently admitted to the Comprehensive Psychiatric Emergency Program (CPEP) due to increased agitation and irrational behavior at the group home.
On 1/17/16 at approximately 4:15 AM, the Certified Nurse Assistant (CNA) assigned, observed the patient vomiting while eating a sandwich and notified the primary Registered Nurse (RN). From initial vomiting episode, the patient's condition progressed to unresponsiveness. Rapid Response Team was activated at 4:23 AM after finger sweep was done by the Physician Assistant (PA), followed by Cardiac Code Team (711 Code) at 4:24 AM. Emergency resuscitation was provided, and patient was emergently transferred to the medical ED at 4:45 AM. Resuscitative measures provided were unsuccessful. Patient subsequently expired on 1/17/16 at 5:17 AM.

There was no record of assessment of the patient's airway by Nursing staff or the implementation of maneuvers to relieve the obstruction.


Intubation Procedure Note dated 1/17/16 at 4:45 AM documented: "Indication for intubation: Code 711...ET Placement Verification: bilateral breath sounds; no breath sounds at epigastric area; chest rise movements; End Tidal CO2 (Carbon Dioxide) Detection by color."


There was no documented evidence in the medical record that continuous ventilatory assessment and reassessment including bilateral breath sounds, were conducted to validate proper placement of the Endotracheal Tube (ET).


An autopsy report dated January 18, 2016, documented that the ET tube was found in the esophagus. Cause of death: Asphyxia due to obstruction of airway by food bolus and Manner of death: Accident (choked on food).


Interview with Staff B, ED Director of Psychiatry on 8/2/16 at 11:30 AM, staff acknowledged there was a problem with intubation and ET placement.