HospitalInspections.org

Based on observation, staff interviews, medical record review, and review of facility documents, it was determined that the facility failed to ensure the rights of each patient is protected.

Findings include:

1. The facility failed to ensure patients give informed, written consent prior to treatment. (Refer to Tag A117)

2. The facility failed to ensure information is obtained from the patient regarding advanced directives. (Refer to Tag A132)

3. The facility failed to ensure patients have the right to personal information privacy. (Refer to Tag A143)

4. The facility failed to ensure that patients receive care in a safe setting. (Refer to Tag A144)

5. The facility failed to ensure the patients plan of care is updated when patients are placed in restraints. (Refer to Tag A166)

6. The facility failed to ensure that patients in restraints are monitored according to facility policy. (Refer to Tag A175)

A. Based on staff interview, review of four (4) of four (4) medical records (#2, #3, #4, and #5), and review of facility policy and procedure, it was determined the facility failed to ensure patients give informed, written consent prior to treatment.

Findings include:

Reference: Facility policy titled, "Patient Rights and Responsibilities" states, "... To give informed, written consent prior to the start of specified nonemergency procedures or treatments ... If the patient is incapable of giving informed, written consent, consent shall be sought from the patient's next of kin ... If the patient does not give written consent, a physician or clinical practitioner shall enter an explanation in the patient's medical record ..."

1. Upon review of the "Consent to Treatment, Financial Payment and Information Exchange" form for Medical Records #2, #3, and #4, the following was noted:

a. The section titled "Patient Certification" states, "... patient unable to sign ... due to medical condition."

b. There was no documented evidence that consent was sought from next of kin.

c. There was no documented evidence that a physician or clinical practitioner entered an explanation of why the patient did not give written consent.

2. Upon review of the "Consent to Treatment, Financial Payment and Information Exchange" form for Medical Record #5, the following was noted:

a. The section titled "Patient Certification" states, " ...Verbal Permission Given." There was no documented evidence of who gave verbal permission."

b. There was no documented evidence that consent was sought from next of kin.

c. There was no documented evidence that a physician or clinical practitioner entered an explanation of why the patient did not give written consent.

3. The above findings were confirmed by Staff #2.

B. Based on staff interview, review of four (4) of four (4) medical records (#2, #3, #4, #5), and review of facility policy and procedure, it was determined the facility failed to ensure patients receive a copy of the patient bill of rights upon admission.

Findings include:

Reference: Facility policy titled "Patient Rights and Responsibilities" states, "... Upon admission, a copy of the Patient Bill of Rights is given to the patient or when appropriate, the patient's representative, during patient registration. ..."

1. Upon review of Medical Records #2, #3, #4, and #5, the following was noted:

a. There was no documented evidence that the "Patient Bill of Rights" was given to the patient or patient representative during patient registration.

2. The above findings were confirmed by Staff #2.

Based on staff interview, review of two (2) of four (4) medical records (#3 and #5), and review of facility policy and procedure, it was determined the facility failed to ensure information is obtained from the patient regarding advanced directives.

Findings include:

Reference: Facility policy titled "Advance Directive" states, "... The Patient Access Representative (PAR) is responsible for obtaining information regarding Advance Directive and for providing the patient with the brochure ... All 'Unable to Ask' entries will be posted into Epic at the time of registration. It then becomes the responsibility of the Nursing staff to follow up on those patients who were not issued materials due to condition ..."

1. Upon review of Medical Record #3, the following was noted:

a. The 'Consent to Treatment' form, in the section titled "Patient Certification" states, "... patient unable to sign ... due to medical condition."

b. The patient face sheet, in the section titled, "Advance Directive" states, "Unable to Ask."

(i) There was no documented evidence that nursing staff followed up.

2. Upon review of Medical Record #5, the following was noted:

a. The 'Consent to Treatment' form, in the section titled "Patient Certification" states, "... patient unable to sign ... due to medical condition."

b. The patient face sheet, in the section titled, "Advance Directive" states, "No Information."

(i) There was no documented evidence that nursing staff followed up.

3. The above findings were confirmed by Staff #2.

Based on observation and interview with administrative staff, it was determined that patients are not provided the right to personal information privacy.

Findings include:

1. A tour of the Emergency Department on the morning and afternoon of January 20, 2021 revealed:

a. Low Side Nurses Station: A bin on the side of an EKG (electrocardiogram) cart in the hallway contained an abnormal ECG Report dated "4-Oct-2019" with the name, age, and medical record number of Patient #25. Administrator #28 agreed with the finding at 11:06 AM on January 20, 2021.

A. Based on review of policies and procedures, review of the medical record of one patient, and interview with administrative staff, it was determined that the hospital failed to implement policies and procedures regarding patients at risk for suicide.

Findings include:

Reference #1: Policy and procedure titled, "Suicidal/Homicidal Patient Risk Assessment" states:
"I. PURPOSE
This policy provides guidance on the identification of patients at risk for suicide or homicide through utilization of a risk assessment process which includes identification of specific factors and features that may increase or decrease risk of suicide.
.....
III. DEFINITIONS
Suicidal Ideation: thoughts of serving as the agent of one's own death. Suicidal ideation may vary in seriousness depending on the specificity of suicide plans and the degree of suicidal intent._ [sic]
.....
Constant Observation (CO): Observer is within constant visual sight of the patient(s).
Continuous 1:1 Observation: 1:1 monitoring with continuous visual observation.
.....
IV. POLICY
.....
3. Patients identified at risk for suicide or homicide will be protected by having their immediate safety needs met by the most appropriate action(s) based on the setting.
4. Nursing staff responsible for the care of patients at risk for suicide are trained upon hire and annually.
.....
V. PROCEDURE
.....
6. Patient Observation
a. Refer to the UH Policy: Patient Observation.
.....
VI. RESPONSIBILITIES
All personnel (physicians, nurses, technicians, students and volunteers) are responsible for complying with this policy to ensure a safe environment.
....."

Reference #2: Policy and procedure titled, "PATIENT OBSERVATION" states:
"I. PURPOSE
This policy provides guidance for observation of patients at risk for danger to self, others, and property.
II. SCOPE
This policy is a Patient Care Services policy that applies to all relevant programs, services and settings within University Hospital (UH) and its related entities as well as all patients.
III. DEFINITIONS
Suicidal Ideation: thoughts of serving as the agent of one's own death. Suicidal ideation may vary in seriousness depending on the specificity of suicide plans and the degree of suicidal intent.
Constant Observation (CO): Direct patient observation with continuous visual observation of the patient(s).
IV. CLINICAL CRITERIA
Constant (1:1) Observation is used only for the following:
.....
2. Verbal expression of a suicidal or homicidal plan.
.....
Constant (1:2) Observation is used for the following:
1. Suicide-Low Risk (Provider order only)
.....
3. Agitated behavior
.....
V. POLICY/PROCEDURE
1. Initiation of Orders
a. A Licensed Independent Practitioner (LIP) order is required for assigned staff observations, and must [sic] renewed every 24 hours.
.....
6. Constant Observation - for Suicide/Homicide Risk Mitigation
a. Patient observers must maintain continuous visual observation of the patient at all times.
.....
e. The Patient Record for Constant Observation for Suicide/Homicide Precautions will be completed by the observer and signed by the RN.
.....
8. Documentation
a. Every patient on observation will have documentation on the appropriate Patient Observation Record. The record shall be signed by the observer and the RN.
b. All information must be completed on the appropriate Patient Observation Record including patient identification label.
c. The following information is documented on the Patient Observation Record by placing a check mark and initials in the corresponding boxes:
* Date and time of observation in 15 minute increments
* Location in 15 minute increments
* Behavior in 15 minute increments
* Mobility in 15 minute increments
* Safety Measures (as performed)
d. The Patient Observation Record is to accompany the patient at all times
.....
VI. All personnel (physicians, nurses, technicians, students, and volunteers) are responsible for complying with this policy to ensure a safe environment.
....."

Reference #3: Policy and procedure titled, "Supervision and Accountability of Housestaff" states: ".....
Purpose: To establish an institutional supervision policy to ensure all residency/fellowship training programs provide progressive responsibility with appropriate supervision for all Housestaff.
Scope: This policy is applicable to all postgraduate training programs.
.....
Policy:
1. Although the attending physician is ultimately responsible for the care of the patient, every physician shares in the responsibility and accountability for their efforts in the provision of care. Effective programs, in partnership with their Sponsoring Institutions, define, widely communicate, and monitor a structured chain of responsibility and accountability as it relates to the supervision of all patient care.
2. Supervision in the setting of graduate medical education provides safe and effective care to patients; ensures each resident's development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine; and establishes a foundation for continued professional growth.
.....
4. Each program must demonstrate that the appropriate level of supervision is in place for all residents who care for patients. .....
....."

Review of the medical record of Patient #23 revealed:

1. December 13, 2020:

a. A Resident PGY1 (Physician Graduate Year 1) note opened at 9:16am stated:
"Attending Note: ..... She/He was very upset and reports SI (Suicidal Ideation). Cos (Constant observation suicide) 1:1 placed. .....
.....
Subjective:
..... Pt (Patient) was upset at the fact that she/he can't get juice with her/his meals. Pt started shouting [sic] 'I want to kill myself, I can't live like this, I'm just going to take off my oxygen". [sic] Psych (Psychiatry) was called again and 1 to 1 was assigned for SI [sic] ideation. ....."

b. A Registered Nurse (RN) note opened at 12:18pm stated: "Patient is very anxious and verbally abusive [sic] the nursing staff, calling the staff abusive name [sic]. ..... [he/she] verbalized suicidal ideation, wanted to remove the 02 (oxygen) and' [sic] stated I want to die, just let me die'. [sic] Close supervision is maintained." The note was signed at 12:22pm.

c. A 1:1 order dated 12/13/20 at 12:03pm for "Agitated Behavior." The "Comment" section of the order stated: "Suicidal Statements." The "Reprint Order Requisition" section of the order stated: "Constant Observation (Non-Homicidal/Non-Suicidal Risk) (Order #104507099) on 12/13/20" The order was time limited to 24 hours. The order was entered by a resident physician and authorized (cosigned) by a physician at 4:07pm.

d. "PATIENT OBSERVATION RECORD FOR CONSTANT OBSERVATION FOR SUICIDE/HOMICIDE PRECAUTIONS" forms indicated that the first entry was made at 12:03pm.

(i) Although a resident documented at 9:16am that 1:1 was placed, an order was not entered until 12:03pm - 2 hours and 47 minutes later. Documentation by an observer on the OBSERVATION RECORD did not begin until 12:03pm. There was no evidence that the patient was monitored on 1:1 supervision between 9:16am and 12:03pm.

(ii) The resident who entered the order for 1:1 did not enter the correct type of order for 1:1.

(iii) Although a resident entered an incorrect type of order and documented having placed a patient on 1:1 supervision prior to placing the order, the order and note were cosigned by a supervising physician without correction/revision.

(iv) The inaccurate order was acknowledged by a registered nurse.

2. December 14, 2020:

a. A Registered Nurse note dated 12/14/20 and signed at 4:55am stated: "In bed on one to one observation per protocol."

b. A 1:1 order for "Constant Observation (Non-Homicidal/Non-Suicidal Risk) ..... (Order 104535345)" dated 12/14/20 at 1:48pm ("Released On") and "Scheduled For" 2:00pm. The "Reason for Observation: (check all that apply)" section of the order included the sole entry: "Agitated Behavior." The order was time limited to 24 hours.

c. A "Psychiatry Progress Note" dated 12/14/20 at 4:48pm stated: ".....
Subjective:
When interviewed today the patient was uncomfortable and short of breath. She/He reported continued passive suicidal ideation without intent or plan. He/She wanted to get better and wishes to be hopeful, but at this time she/he feel hopeless. She/He reports issues with her/his sleep as well as anxiety that worsens over the course of the day. Responsive to supportive therapy and medication education. Reports passive death wishes.
.....
Mental Status Examination:
.....
Thought Content: Reports passive suicidal ideation .....
....."

(i) The resident who entered the order for 1:1 did not enter the correct type of order for 1:1. The previous 1:1 order had expired at 12:14pm and the new order was not entered until 1:48pm, to be released 12 minutes later at 2:00pm. The patient was without a 1:1 order for 1 hour and 46 minutes.

(ii) Although a resident entered an incorrect type of order and did not ensure a new order prior to the expiration of the previous order, the order was cosigned by a supervising physician.

(iii) The inaccurate order was acknowledged by a registered nurse.

(iv) There was no documentation that nursing staff attempted to contact medical staff prior to the expiration of the previous order for a new order.

3. December 15, 2020:

a. An "Internal Medicine Progress Note" begun at an undocumented time by a Resident PGY1 on 12/15/20 stated:
"Subjective:
Patient was seen and examined at bedside. ..... She/He continues to note fear and anxiety regarding his/her condition and continues endorsing SI. She/He notes that her/his anxiety is severe enough that she/he picks the skin on her/his fingers/palms to help calm himself/herself down. .....
.....
Review of Systems
.....
Psychiatric/Behavioral: Positive for dysphoric mood and suicidal ideas. Negative for hallucinations and self-injury. The patient is nervous/anxious.
.....
Physical Exam
.....
Psychiatric:
.....
Thought Content: Thought content includes suicidal (passive) ideation.
.....
Assessment/Plan:
.....
3. Suicidal Ideation
- Patient continues SI in the setting of his/her frustrations with the current hospitalization.
- As per psychiatry, patient continues to endorse passive SI as well.
.....
Will continue patient on COS (Constant Observation Suicide) 1:1.
- Given patient worsening anxiety today, will require further psychiatric management, to be discussed with CL (Consultation Liaison) - Psychiatry for further recommendations. ....." An addendum by the supervising physician stated: "I have discussed the patient's plan of care with the residents, and I have personally seen and examined this patient. I agree with the resident's findings assessment, and plan as documented, with the following comments/clarifications/corrections:
Most active issues:
.....
2. Passive Suicidal ideations, Severe MDD (Major Depressive Disorder) with recurrence with Anxiety
- Due to difficulty coping with her/his illness, context/details eloquently summarized by Dr. ______ (surname of PGY1 physician) above in his/her A/P (Assessment/Plan).
- 1:1
- Psychiatry on board - recs (recommendations appreciated - would appreciate continued input.
....."

2. An RN "Progress Notes" entry dated 12/15/20 at 4:26am stated: "..... 1:1 for SI continued. ....."

3. A 1:1 order for "Constant Observation (Non-Homicidal/Non-Suicidal Risk) ..... (Order 104570390)" dated 12/15/20 at 2:15pm ("Released On") and "Scheduled For" 2:30pm. The "Reason for Observation: (check all that apply)" section of the order included the sole entry: "Agitated Behavior." The order was time limited to 24 hours.

(i) The resident who entered the order for 1:1 did not enter the correct type of order for 1:1.
The previous 1:1 order had expired at 1:59pm and the new order was not entered until 2:15pm, to be released 15 minutes later at 2:30pm. The patient was without a 1:1 order for 31 minutes.

(ii) Although a resident entered an incorrect type of order and did not ensure a new order prior to the expiration of the previous order, the order was cosigned by a supervising physician.

(iii) The inaccurate order was acknowledged by a registered nurse.

(iv) There was no documentation that nursing staff attempted to contact medical staff prior to the expiration of the previous order for a new order.

4. December 16, 2020:

a. An RN "Discharge Planning" note dated 12/16/20 at 2:20pm stated: "Patient not medically stable for discharge - 1:1 for suicidal ideation. No accepting facility currently. Per Dr. _____ (surname of physician), plan is to stabilized [sic] patient psychiatrically while monitoring his/her medical progress. ....."

b. There was no order to discontinue 1:1 or an order for the patient to be continued on 1:1 written on this date, although the previous order had expired at 2:29pm.

c. "PATIENT OBSERVATION RECORD FOR CONSTANT OBSERVATION FOR SUICIDE/HOMICIDE PRECAUTIONS" forms indicated that although there was no order to continue 1:1, the observations were continued.

d. There was no documentation that nursing staff attempted to contact medical staff for a new order prior to the expiration of the previous order.

5. December 17, 2020:

a. A "Psychiatry Progress Note" signed by a Resident PGY4 at 11:09am on 1/17/20 stated: ".....
Interval History:
Patient was interviewed today. She/He continued to feel depressed about her/his situation and has passive suicide ideation. She/He does not have any specific plans of how to commit suicide when asked. .....
.....
Mental Status Examination:
.....
Behavior: Cooperative
.....
Thought Content: Reports passive suicidal ideation, .....
....."
The Note was cosigned by a supervising physician on 12/21/20 at 10:16am.

b. A 1:1 order for "Constant Observation (Non-Homicidal/Non-Suicidal Risk) ..... (Order 104613608)" dated 12/17/20 at 1:47am ("Released On") and "Scheduled For" 2:00am. The "Reason for Observation: (check all that apply)" section of the order included the sole entry: "Agitated Behavior." The order was time limited to 24 hours.

c. A "PATIENT OBSERVATION RECORD FOR CONSTANT OBSERVATION FOR SUICIDE/HOMICIDE PRECAUTIONS" dated 12/17/20 did not include any entries between 11:45am and 1:15pm documenting the patient's "BEHAVIOR."

(i) The resident who entered the order for 1:1 did not enter the correct type of order for 1:1.
The previous 1:1 order had expired at 2:29pm on 12/15/20 and the new order was not entered until 1:47am, to be released 13 minutes later at 2:00am. There was no 1:1 order for 35 hours and 30 minutes, nor was there an order to discontinue the 1:1 during this time frame.

(ii) The inaccurate order was acknowledged by a registered nurse.

(iii) There was no documentation that nursing staff attempted to contact medical staff for a new order prior to the expiration of the previous order, or at any time during the 35 hours and 30 minutes that the patient was without an order.

(iv) Although a resident entered an incorrect type of order, the order was cosigned by a supervising physician.

6. December 18, 2020:

a. An "Internal Medicine Progress Note" dated 12/18/20 at 7:02am, by a Resident PGY1, stated: ".....
Subjective:
Patient was seen and examined bedside. ..... Did not endorse SI today, but noted continued frustrations with her/his care.
.....
Review of Systems
.....
Psychiatric/Behavioral: Positive for dysphoric mood (improving). Negative for agitation, behavioral problems and hallucinations. .....
Physical Exam
.....
Psychiatric:
.....
Behavior: Behavior normal. Behavior is not agitated or slowed. Behavior is cooperative.
Thought Content: Thought content includes suicidal ideation. Thought content does not include homicidal ideation. Thought content does not include homicidal or suicidal plan. .....
.....
Assessment/Plan:
Principal Problem:
Decompensated hepatic cirrhosis
.....
Patient continues to endorse SI but now endorsing less often, anxiety continues to improve. Continues to request benadryl [sic] for sleep and other sleep aids, despite discussion of concerns for oversedation.
.....
3. Suicidal Ideation: improving
- Patient is endorsing SI less. Anxiety improving.
- As per psychiatry, patient continues to endorse passive SI as well.
.....
- Will continue COS 1:1. .....
.....
Dispo (Disposition): LTACH (Long Term Acute Care Hospital) once psychiatrically clear
....."

b. A 1:1 order for "Constant Observation (Non-Homicidal/Non-Suicidal Risk) ..... (Order 104634395)" dated 12/18/20 at 3:09am and "Scheduled For" 3:15am. The "Reason for Observation: (check all that apply)" section of the order included the entries: "Agitated Behavior" and "Pulling out medical devices." The order was time limited to 24 hours.

(i) The resident who entered the order for 1:1 did not enter the correct type of order.

(ii) The inaccurate order was acknowledged by a registered nurse.

(iii) Although a resident entered an incorrect type of order, the order was cosigned by a supervising physician on 1/5/20 at 11:55am.

Administrators #6 and #12 agreed with the findings.

B. Based on observation, review of policy and procedure, and interview with administrative staff, it was determined that the facility failed to provide care in a safe physical environment.

Findings include:

Reference #1: Policy and procedure titled GENERAL SAFETY states: ".....
PURPOSE:
Safety procedures are developed to protect the staff, patients and visitors of the hospital. The Director of Pharmaceutical Services is responsible for maintaining safety standards, developing safety rules, supervising and training personnel in departmental standards.
RESPONSIBILITY:
The Director of Pharmaceutical Services must assure compliance with this policy.
POLICY:
.....
2) All department employees shall notify the Director of Pharmaceutical Services or their supervisor of any defective equipment, unsafe conditions, acts, or safety hazards that they observe.
.....
4) All equipment and supplies must be properly stored. Scissors, knives, and other sharp instruments must be safely stored.
5) All personal electric appliances shall be inspected by the Engineering Department for safe use. All electric machinery with heat producing elements shall be turned off when not in use.
6) Minor spills (i.e., water) shall be cleaned by the employee who discovers the spill. This shall be done immediately. Major spills will be cleaned by Environmental Services personnel.
....."

Reference #2: Section 19.7.8 of the "2012 Edition NFPA (National Fire Protection Association) LIFE SAFETY CODE states: "Portable Space-Heating Devices. Portable space-heating devices shall be prohibited an all health care occupancies, unless both of the following are met:
(1) Such devices are used only in nonsleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212°F (Fahrenheit) (100°C) [Celsius]."

1. The above referenced policy and procedure, GENERAL SAFETY, allows for the use of space heaters in patient care areas, is in contradiction to LIFE SAFETY CODE.

2. A tour of the Emergency Department on the morning and afternoon of January 20, 2021 revealed:

a. Low Side Nurses Station:

(i) A dust covered specimen bag containing a used nasal swab and collection tube with a lab sticker for Patient #24 was found atop a cabinet with copiers on it. Administrator #28 agreed with the finding at 10:46am.

(ii) A drawer beneath the nurses station desk contained two space heaters.

(iii) An electrical junction box under the Nurses Station counter, behind a moveable cabinet, was found to be without a cover. There were napkins, papers, and a paper glue trap beneath and around the box.

(iv) In the hallway behind the Nurses Station, a wall shelf holding sealed Difficult Airway Kits was found to have an Adult Airway Kit that had had the seal broken and at least two items taken from the box. The individual plastic packaging was left in the box. Administrator #28 agreed with the finding at 11:02am.

b. High Side Nurses Station: There were needles atop an unattended WOW (Workstation of Wheels) UHUPEDC350P02 in the hallway.

c. Behavioral Health Area: Two collection tubes containing urine in a biohazard bag with an identification sticker for Patient #26, a patient who was no longer on the unit, were in the middle drawer under the desk. The admission date on the patient sticker on the bag was "1/15/21."

3. A tour of the Behavioral Health Unit (G Yellow) on January 21, 2021 revealed:

a. Quiet Room (G323): A Phillips head screw was on the bathroom door.

b. "Patient Shower" room (G317A): There were a total of four Phillips head screws on the door hinge and a rail on the wall.

c. "Patient Shower" room (G336A):

(i) There were two Phillips head screws on the door jamb.

(ii) The base of a safety rail on the wall next to the toilet had a screw with the head broken off, a Phillips head screw, and a Phillips Head screw with hardened putty in the screw drive.

(iii) Three railings on the wall had Phillips head screws in them.

d. Treatment Room (G339): There were multiple slotted screws and Phillips head screws in the room.

D. Review of the CPR (Cardiopulmonary Resuscitation) Training Manual, the medical record of one patient (#1), review of the personnel files of two employees who underwent CRP training, and observation, it was determined that two employees who observed a patient who had either fallen or jumped from the window of a patient room on the 6th floor (Unit H Yellow) of the hospital, and landed in the area of the Main Entrance, failed to check if the patient was responsive.

Findings include:

Reference #1: The "American Heart Association Heartsaver CPR AED (Automated External Defibrillator) STUDENT WORKBOOK" states: ".....
Heartsaver CPR AED Course
.....
The skills you learn in this course will help you to recognize cardiac arrest, get emergency care on the way quickly, and help the person until more advanced care arrives to take over.
.....
Heartsaver Knowledge and Skills
Your Student Workbook contains all of the information that you need to be able to understand and perform lifesaving skills correctly. During this course, you will be given the opportunity to practice these skills and receive valuable coaching from your instructor.
.....
Sudden Cardiac Arrest or Heart Attack?
.....
Sudden cardiac arrest results from an abnormal heart rhythm. This abnormal rhythm causes the heart to quiver so that it can no longer pump blood to the brain, lungs, and other organs.
Within seconds, the person becomes unresponsive and is not breathing or is only gasping. Death occurs within minutes if the victim does not receive immediate lifesaving treatment.
.....
Cardiopulmonary Resuscitation (CPR)
CPR stands for cardiopulmonary resuscitation. It is made up of 2 skills:
* Providing compressions
* Giving breaths
When a person's heart stops suddenly, providing CPR can double or even triple the chances of survival.
.....
Responsive vs (versus) Unresponsive
To decide what to do in an emergency, you will need to see if the person is responsive or unresponsive.
* Responsive: Someone who is responsive will move, speak, blink, or otherwise react to you when you tap him and ask if he's OK.
* Unresponsive: Someone who does not move, speak, blink, or otherwise react is unresponsive.
.....
Assess and Phone 9-1-1
When you encounter an adult who may have had a cardiac arrest, take the following steps to assess the emergency and get help:
* Make sure the scene is safe
* Tap and shout (check for responsiveness)
* Shout for help
.....
Make Sure the Scene Is Safe
Before you assess the person , make sure the scene is safe. Look for anything nearby that might hurt you. You can't help if you get hurt too.
Some places that may be unsafe are
* A busy street or parking lot
* An area where power lines are down
* A room with poisonous fumes
As you give care, be aware if anything changes and makes it unsafe for you or the person needing help.
Tap and Shout (Check for Responsiveness)
Tap and shout to check if the person is responsive or unresponsive .....
Lean over the person or kneel at his side. Tap his shoulders and ask if he is OK.
If
The person moves, speaks, blinks, or otherwise reacts when you tap him
Then
He is responsive.
Ask the person if he needs help.
If
The person doesn't move, speak, blink, or otherwise react when you tap him.
Then
He is unresponsive.
Shout for help so that if others are nearby, they can help you.
.....
Shout for Help
In an emergency, the sooner you realize that there's a problem and get additional help, the better it is for the person with a cardiac arrest. When more people are helping, you are able to provide better care to the person.
If the person is unresponsive, shout for help ..... .
....."

Reference #2: The "Healthcare Security Professional (Unarmed) - Job Description" states:
"Facility/Location: University Hospital - Newark, NJ
.....
Description: The Security Professional (Unarmed) is responsible for providing protective services to the healthcare facility, patients, visitors, and staff in a courteous, friendly and professional manner.
.....
Minimum Qualifications:
.....
Education and Experience:
.....
* Ability to handle typical and crisis situations efficiently and effectively.
.....
Competency Requirements: Security Professionals are required to pass initial and annual competency evaluations consisting of the following topics:
.....
* CPR/Basic First Aid (required every two years)
....."

Reference #3: Policy and procedure titled, "MANDATORY LIFE SUPPORT CERTIFICATIONS FOR PCS (Patient Care Services) STAFF" states:
"I. PURPOSE
To provide guidance on the expectations for life-saving certifications required for staff who work within the Department of Patient Care Services at University Hospital.
II. This policy applies to all Patient Care Services staff including direct-care and indirect-care providers.
III. POLICY
1. All Patient Care Services must comply with the expectations of certification upon hire.
.....
IV. PROCEDURE
A. American Heart Association (AHA) or American Red Cross (ARC), Basic Life Support (BLS) certification is required upon hire for all Patient Care Services staff members who have direct patient contact.
....."

1. A "Surgical ICU (Intensive Care Unit) Admission Note" dated 1/15/2021 at 2:43am in the medical record of Patient #1 stated:
"Hospital Day: 3
HPI (History of Present Illness):
The patient is a 43 yo (year old) M (male), with PMH (past medical history) of ETOH (ethyl alcohol) use disorder and steatosis, who jumped out the window of his H yellow [sic] room this evening around 5:30pm. As per chart review, patient was noted to be anxious and agitated, and CRT (Crisis Response Team) was called. Upon arrival of the psychiatry team, patient was found to have smashed out the window of his room with a chair and jumped out. Patient was found on the ground outside the hospital, facedown for an unknown period of time, and transferred to the trauma bay. ....."

2. A "BASIC LIFE SUPPORT" certificate, issued on 12/23/2020, in the personnel file of Staff #35, a PCT (Patient Care Technician), stated: "(first and surname of Staff #35) has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) Program." The "Renew By" date was documented as "12/2022."

3. A "BASIC LIFE SUPPORT" certificate, issued on 10/31/2020, in the personnel file of Staff #37, a security supervisor, stated: "(first and surname of Staff #37) has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Basic Life Support Program." The "Renew By" date was documented as "10/2022."

4. An American Heart Association HEARTSAVER CPR AED card, issued on 11/03/2018 in the personnel file of Staff #36 stated: "The above individual has successfully completed the objectives and skills evaluations in accordance with the curriculum of the AHA Heartsaver CPR AED Program. Optional completed modules are those NOT marked out. The "Recommended Renewal Date" was entered as "11/2020." There were no mark outs on the card.
Administrator #1 stated that the delay of the employee's renewal of the certification was due to the Covid 19 pandemic through an executive order from the Governor.

5. On 1/16/21, review of a video recording of Patient #1 falling to the ground near the Main Entrance of the hospital, from a sixth floor window, revealed (times listed are time stamped from the video):

a. 17:27:48: Patient is seen hitting the ground.

b. 17:28:16: Staff #36, a security officer, is observed seeing the patient on the ground, turning around, and running back into the Main Entrance.

c. 17:29:00: Staff #35, a PCT, is observed seeing the patient on the ground and goes back into the Main Entrance.

d. 17:29:08: Staff #37, a security supervisor, is observed running out of the Main Entrance with Staff #35 following behind. Staff #37 goes to there area where the patient is lying and motions a forming crowd to move back.

e. 17:29:41: Staff #38 is observed checking the patient for responsiveness.

Staff #35, #36, and #37 failed to check the patient for responsiveness.

Based on staff interview, review of two (2) of four (4) medical records (#2 and #5), and review of facility policy and procedure, it was determined the facility failed to ensure the patients plan of care is updated when patients are placed in restraints.

Findings include:

Reference: Facility policy titled "Use of Restraints for Non-Violent of Non-Self-Destructive Behavior" states, "... The Plan of Care will be updated, as appropriate."

1. Upon review of Medical Record #2, the following was noted:

a. Restraints were ordered on 1/16/21 at 6:28 PM.

b. The Plan of Care was reviewed on 1/20/21 and was not updated to include the use of restraints.

2. Upon review of Medical Record #5, the following was noted:

a. Restraints were ordered on 1/10/21 at 9:21 AM.

b. The Plan of Care was reviewed on 1/20/21. The Plan of Care was not updated to include the use of restraints until 1/16/21. This was six (6) days after the restraints were ordered.

3. The above findings were confirmed by Staff #12.

Based on staff interview, review of two (2) of four (4) medical records (#2 and #5), and review of facility policy and procedure, it was determined the facility failed to ensure that a patient in restraints is monitored according to facility policy.

Findings include:

Reference #1: Facility policy titled "Use of Restraints for Non-Violent of Non-Self-Destructive Behavior" states, "... Monitoring of the patient is completed and documented as follows at a minimum: ... Every (1) hour ..."

Reference #2: Facility policy, Restraint and Seclusion for Violent or Self-Destructive Behavior, states, "... Non-Behavioral Health Units ... Monitoring of the patient is completed and documented as follows ... Every (1) hour ..."

1. Upon review of Medical Record #2, the following was noted:

a. The patient was in Non-Violent/Non-Self Destructive Restraints from 1/16/21 at 18:28 until 1/18/21 at 11:27. The patient monitoring was not documented at the following times:

(i) 1/16/21 at 19:30, 20:30, 21:30, 22:30 and 23:30

(ii) 1/17/21 at 00:30, 01:30, 02:30, 03:30, 04:30, 05:30, 0:630, 15:15, and 17:15

2. Upon review of Medical Record #5, the following was noted

a. The patient was in Violent/Self-Destructive Restraints from 1/19/21 at 17:00 until 1/19/21 at 19:41. The patient monitoring was not documented at the following times:

(i) 1/19/21 at 18:00 and 19:00

3. The above findings were confirmed by Staff #12.

Based on observation, interviews with administrative staff, review of policy and procedure, and review of related documentation, it was determined that the facility failed to be constructed and maintained to ensure the safety of patients and to provide facilities appropriate to the needs of the patient community.

Findings include:

1. The facility failed to ensure the overall hospital environment was maintained for the safety and well-being of the patients, staff, and public. (Refer to Tag A701)

2. The facility failed to maintain equipment to ensure an acceptable level of safety and quality. (Refer to Tag A724)

3. The facility failed to ensure hazardous areas are protected. (Refer to Tag A710)

4. The facility failed to ensure fire sprinkler systems are maintained. (Refer to Tag A710)

5. The facility failed to ensure that all exits were marked with internally lit EXIT signs or photoluminescence signs are properly lit in accordance with the manufactures instructions for use. (Refer to Tag A710)

6. The facility failed to ensure EXIT door signage in maintained. (Refer to Tag A710)

Based on observation on 1/21/21, it was determined that the facility failed to ensure walls, ceilings, and floors are in good repair.

Findings include:

1. At 10:45 AM in the presence of Staff #7, the floor in Emergency Room Bay #6 was peeling at the seam creating a surface that cannot be properly cleaned.

2. At 10:50 AM in the presence of Staff #7, the floor in Emergency Room Bay #14 was torn creating a surface that cannot be properly cleaned.

3. At 11:42 AM in the presence of Staff #7, the paint on the ceiling in Room #E 334 was peeling .

4. At 11:48 AM in the presence of Staff #7, medical supplies including two (2) 2000 mL saline bottles, various plastic caps and clear plastic tubing as well as paper clips and dust was found on the floor in Equipment Room #E 343.

A. Based on observation, it was determined that the facility failed to ensure hazardous areas are protected.

Findings include:

1. On 1/21/21 at 10:50 AM in the presence of Staff #7, a penetration was found in the fire resistive wall of Electrical Room #C 343.

B. Based on observation, it was determined that the facility failed to ensure fire sprinkler systems are maintained.

Findings include:

1. On 1/21/21 at 11:25 AM in the presence of Staff #7, the sprinkler head inside Soiled Utility Room # E413 had visible corrosion and has turned from a black to a green color.

2. On 1/21/21 at 11:25 AM in the presence of Staff #7, the sprinkler head outside in the Corridor by Soiled Utility Room # E413 had visible corrosion and has turned from a black to a green color.

C. Based on observation, and staff interview, it was determined that the facility failed to ensure two (2) out of two (2) exits were marked with internally lit EXIT signs or photoluminescence signs are properly lit in accordance with the manufactures instructions for use.

Findings include:

1. On 1/21/21 at 11:32 AM in the presence of Staff #7, two out of two exit paths in the PACU on Level E were not marked with internally lit EXIT signs.

a. During an interview at 11:32, Staff #7 was unable to provide the manufacture's instruction for use to determine the type of light required to maintain a "charge."

D. Based on observation, it was determined that the facility failed to ensure EXIT door signage in maintained.

Findings include:

1. On 1/21/21 at 11:48 AM in the presence of Staff #7, one of two required EXIT doors was labeled "Not an EXIT."

A. Based on tours of 4 of 4 patient care units and interview with administrative staff, it was determined that facilities are in disrepair and unclean.

Findings include:

1. A tour of the Emergency Department on January 20, 2021 revealed:

a. Low Side Nurses Station:

(i) In the hallway behind the Nurses Station there were backboards on the floor leaning against the wall behind and between carts. There was dust on the backboards and heavy dust and refuse beneath and behind the carts. The face of a wall shelf used to store Difficult Airway Kits was raw plywood - an uncleanable surface.

(ii) The borders around the counter tops had tape, tape residue, grit, and dust on them.

(iii) There was a heavy coat of dust on the call bell receiver. The rear of the cabinet on which the call bell receiver was placed had a heavy coat of dust, tape, and tape residue. Some of the pigeon hole in the cabinet were broken.

(iv) A metal cabinet beneath the counter top had a heavy coat of dust atop it. There was heavy dust, grit, a plastic spoon, paper clips, a scalpel, condiment packets, dried raised stains, paper scraps, pretzel pieces, patient stickers, and other refuse on the floor beneath and behind the cabinet.

b. Supply Room (C384):

(i) The interior of drawers closest to the sink had stains, raised tacky stains, paper scraps, stickers, sticker residue, hair, grit, and other refuse in them.

(ii) The floor beneath a wall storage rack containing plastic bins had heavy dust, dust clumps, grit, vial caps, syringe caps, dried raised stains, paper scraps, The rack itself, was broken in areas and some of the bins containing wrapped supplies (sterile and non-sterile) were on the floor. The interior of some of the bins were heavily encrusted with dried stains, dust, grit, paper scraps, and other refuse.

(iii) The interior of the Covid swabs refrigerator had stains and grit in it. The floor beneath and behind the refrigerator had a heavy accumulation of dust, dust clumps, grit, vial caps, syringe caps, supply wrappers, dried stains, cellophane wrappers, a scalpel, supplies in packaging, an opened IV catheter, and other refuse. The refrigerator had dust and stains atop it.

c. High Side Nurses Station:

(i) There was white and black tape and tape residue on the counter top borders and heavy dust, grit, and other refuse under the counter.

(ii) At least eleven (11) entangled electrical wires and cords, some connected to two surge protectors, under the counter had heavy dust on them. Wires and cords between the counter top an the counter top border had dust and dust clumps on them.

(iii) There was white and black tape and tape residue on the counter top border.

(iv) There was heavy dust atop the cabinet above the sink.

(v) There was storage of a Sani-Cloth container and two suction canisters in the cabinet beneath the sink.

d. Midtrack Soiled Utility Room: There was heavy dust on the cabinet base ledge and a backboard on the floor.

2. A tour of the Behavioral Health Unit (G Yellow) on January 21, 2021 revealed:

a. Nurses Station:

(i) The recessed areas at the base of a step stool contained at least an inch of dust in them.

(ii) There was dust atop wall cabinets above the code cart and in the secretarial area.

(iii) There were clumps of dust, dust, paper scraps, and hair on the floor in front of the pigeonhole cabinet.

(iv) The face of a drawer was missing in the secretarial area.

(v) There was a broken floor tile in front of the door to the Staff Lounge.

b. Quiet Room (Room G323): A substance appearing to be dried toothpaste was in the window locks.

c. "Patient Shower" room (G336A): The temperature of the water from the shower reached a maximum temperature of 77 degrees Fahrenheit after three minutes.

d. Supply Room (G337): A screw was missing from the bolt plate on the door.

e. Pantry:

(i) Beneath and behind two refrigerators was heavy dust, spillage, packets of saltine crackers, dried and raised stains, deteriorated sugar packets, plastic utensils, paper scraps, grit, and other refuse. There was heavy dust atop the two refrigerators.

(ii) A white refrigerator in the corner had dust atop it.

(iii) There was dust atop the stainless steel shelf.

f. Medication Room:

(i) The temperature of the water from the handwashing sink reached a maximum temperature of 100 degrees Fahrenheit after three minutes.

(ii) An Ethernet outlet was separated approximately an inch and a half from the wall.

3. A tour of the Neonatal Intensive Care Unit (F5) on January 22, 2021 revealed:

a. Patient Care Area: (There were no patients being treated in this area at the time of the tour.)

(i) There was a coat of dust, cellophane tape, and tape residue on a plastic supply cart.

(ii) There was a white, powdery substance on the base of a computer desk. The paint was worn away and there were grooves into the gypsum on the wall behind the desk at the points where the desk touched the wall. There were also brown, raised, splatter stains on the wall behind the desk.

(iii) There was exposed gypsum on the wall behind the portable sharps container.

b. Nurses Station:

(i) There was an accumulation of biohazard bags, patient stickers, paper clips, dust, clumps of dust, grit, pencils, candy wrappers, a clump of hair, paper scraps, and other refuse beneath the desk top counter floor and a space abutting the floor. The names of Patient #27, with a birth date and admit date of 12/272018 and Patient #28, with a birth date and admit date of 7/4/2020 were on two of the patient stickers.

(ii) Alarm System Desk: There was an accumulation of dust, dust clumps, paper scraps, a roll of gold wrapping paper, grit, candy wrappers, and other refuse beneath the desk.

(iii) Medication Room: Pieces and particles of ceiling tile and paint chips were on the base, drawers, and on top of the supply cabinet and on the floor.

(iv) A hands-free trash container was overflowing with trash.

4. A tour of Medical Surgical Unit (F Yellow) on January 22, 2021 revealed:

a. Hallway: A hands-free trash container was overflowing with trash.

b. Nurses Station: There was dust, dust clumps, grit, and other refuse under the counter.

4. Administrator #4 agreed with the findings.

B. Based on observation, review of policy and procedure, and interview with administrative staff, it was determined that the facility failed to ensure that supplies and equipment are maintained to ensure protection against damage, contamination, or deterioration.

Findings include:

1. A tour of the Emergency Department on January 20, 2021 revealed:

a. Low Side Nurses Station: An EKG cart in the hallway behind the Nurses Station had various dried spillage stains, paper scraps, and dust on it. A bin on the side of the cart had an accumulation of dust, grit, paper scraps, a syringe cap, and other refuse in it.

b. Supply Room (C384): The floor beneath a wall storage rack containing plastic bins had heavy dust, dust clumps, grit, vial caps, syringe caps, dried raised stains, paper scraps, and other refuse on it. There were numerous sterile and non-sterile supplies laying on the dirty floor, some with soiled and stained packaging.

c. High Side Nurses Station: The gasket around the Pyxis refrigerator door was ripped.

2. A tour of the Neonatal Intensive Care Unit (F5) on January 22, 2021 revealed pieces and particles of ceiling tile and paint chips were on the base, in drawers, and on top of the supply cabinet in the Medication Room.