HospitalInspections.org

Based on interview, record review, and policy review the facility staff failed to:
- Immediately initiate cardiopulmonary resuscitation (CPR, an emergency medical procedure for restoring a heart beat and breathing) when one patient (#1) of one patient was found unresponsive (without a heartbeat and breath).
- Follow their Code Blue (a code announcing the existence of life threatening emergency) policy.
- Prevent contraband from being brought into the facility for one patient (#27) of one patient who injected heroin (a narcotic drug which can be addictive) and overdosed.
These failures had the potential to affect the safety and quality of care of all patients admitted to the facility. The facility census was 88.

The severity and cumulative effects of these systemic failures resulted in the facility being out of compliance with 42 CFR 482.23 - Condition of Participation: Nursing Services.

The facility was informed on 04/09/15 that the cumulative effect of these systemic practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 04/09/15, after the survey team informed the facility of the Immediate Jeopardy (IJ), the facility began educating all staff.

As of 04/10/15, the facility provided an immediate action plan sufficient to remove the IJ by implementing the following:
-Immediate education to staff related to the revised Contraband Policy.
-Education to staff related to Contraband to be included in annual training.
-Critical Event Review Process to be reviewed by the Chief Executive Officer (CEO) or the Vice President of Medical Affairs within 48 hours after an event to ensure that any required immediate corrective action has occurred.
-Code Blue Drills to begin on 04/10/15 and then drills on all three shifts for 12 months.
-Annual education to staff related to Code Blue
-30 random one on one quizzes to staff monthly for 12 months related to Code Blues.




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Based on interview, record review, and policy review the facility failed to follow their Code Blue/CPR (a code announcing the existence of a life threatening emergency/ cardiopulmonary resuscitation, an emergency medical procedure for restoring normal heart beat and breathing), policy when caring for one patient (#1) of one patient who required CPR and was later pronounced dead at an acute care facility. The facility also failed to prevent contraband (any item deemed potentially dangerous to patients) from being brought into the facility for one patient (#27) of one patient who injected heroin (a narcotic drug which can be addictive) and overdosed. These failures had the potential to affect the safety and quality of care for all patients admitted to the facility. The facility census was 88.

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

Findings included:

1. Record review of the facility's policy titled "Code Blue/CPR," dated 02/11/14, showed directives for the first staff member on the scene to attempt to awaken the patient, shout Code Blue, and initiate CPR following the American Heart Association Guidelines.

2. Record review of Patient #1's Discharge Summary, dated 04/07/15, showed that on the morning of 03/14/15, he was found not breathing and was transferred to a hospital where he was pronounced dead.

Record review of Patient #1's Progress Note, dated 03/14/15 at 5:32 AM showed that Staff Z, Registered Nurse (RN) documented:
- A Mental Health Technician (MHT, Staff P) was making rounds at 4:38 AM and found the patient unresponsive.
- Staff called Code Blue and immediately started CPR.
- He (Staff Z) called 911 while the code team continued CPR.
- The ambulance crew arrived at approximately 4:52 AM; they took over CPR, and transported the patient to the hospital.

During an interview on 04/07/15 at 10:15 AM, Staff P, (MHT), stated that:
- While conducting observation rounds (staff observe and document the location and clinical status of each patient) on 03/14/15 at 4:38 AM, he found Patient #1 unresponsive with his jaw wide open and his skin pale white.
- He checked the patient and found no pulse and no respirations.
- He did not shout code blue and he did not initiate CPR.
- He left the patient's room and requested an expert opinion from the charge nurse (Staff Z).
- He confirmed that according to policy and training he was instructed to call out for help and initiate CPR.
- He attended a critical event review meeting (a meeting that reviewed the death of Patient #1) on 03/17/15 and found that everything was done per policy and that staff immediately responded.
- No one had since educated him that during the event he should have called out code blue and initiated CPR per policy and training.

During an interview on 04/07/15 at 3:40 PM, Staff Z, RN, Charge Nurse, stated that:
- On 03/14/15, at approximately 4:38 AM, Staff P, came into the hall in front of the nurses' station and stated that Patient #1 did not look good and wanted him to check the patient.
- Staff Z checked Patient #1 who was unresponsive. He did not start CPR.
- He (also) left the room, called out code blue, and two of the unit's nurses (Staff X and BBB) immediately responded with the emergency cart and went into the patient's room.
- He paged the Code Blue overhead and called 911.
- He did not know why he did not call out from the room for help and immediately start CPR as per policy and training.

Staff P failed to initiate CPR when he found the patient non-responsive. Staff Z, the second person to respond, also failed to immediately initiate CPR and left the room.

During an interview on 04/08/15 at 10:00 AM, Staff BB, MHT, stated that:
- She observed Patient #1 breathing with the rise and fall of his chest at 4:18 AM.
- She was making copies at the nurses station when the code blue was called.
- She ran into the patient's room and two nurses followed her with the emergency cart.
- She found Staff P at the bedside not performing CPR.
- She helped get the patient's roommate out of the room while two nurses began CPR.
- She attended a critical event review meeting on 03/17/15 that determined CPR was not delayed.
- The procedure when finding a patient unresponsive was to call for help and start CPR compressions.
- She had no further education or training since the event except what was discussed during the event review meeting.

Record review of the ambulance report, dated 03/14/15, showed:
- The ambulance was dispatched at 4:40 AM.
- They arrived at the facility at 4:56 AM.
- They had to wait two minutes at the (main entrance) door for it to be unlocked and taken to the patient.

During a telephone interview on 04/08/15 at 11:05 AM, Staff CC, RN Night Supervisor, stated that:
- She was on duty the night of 03/14/15 when Patient #1 was found unresponsive.
- She was not on Patient #1's unit when CPR was initiated.
- She did not know if there was anyone who initiated compressions or respirations (CPR) before Staff BBB and Staff X.
- Staff P, MHT, found the patient unresponsive and she did not ask him if he started CPR.
- She was aware that Staff Z went into the patient's room after Staff P; she did not know if Staff Z initiated CPR or not.
- She immediately assigned a MHT to go to the front door to meet the ambulance.
- She was not aware that the ambulance crew had to wait at the front door to enter.
- She attended the critical event review meeting on 03/17/15 and she thought that everything was done according to policy.
- The nurse educator planned to develop refresher cards (for codes) for the staff to carry but she had not yet received one.

Record review of the code blue drill reports from 04/10/14 to 03/14/15 and concurrent interview on 04/08/15 at 1:50 PM with Staff DD, RN, showed that:
- She conducted code blue drills in conjunction with the Director of Nursing and completed a report on each drill.
- The staff present during the drills were not identified in the reports.
- During the code blue drill on 04/10/14 during the night shift, staff delayed calling a code blue. The first staff member to respond to the code left the room and did not initiate CPR. She reeducated staff who were present during the drill but did not provide refresher training to other staff.
- During a code blue drill on 12/17/14, during the day/night shift change, the RN who found the patient unresponsive, left the room and did not initiate CPR. She reeducated staff who were present during the drill but did not provide refresher training to other staff.
- During a code blue drill in 02/2015 during the day shift, she found that the RN who found the patient left the room and not initiate CPR. She reeducated staff who were present during the drill but did not provide refresher training to other staff.
- She was not involved with the code blue event on 03/14/15 but she expected staff who found the patient unresponsive to call for help and initiate CPR.

During an interview on 04/08/15 at 2:15 PM, Staff R, Nurse Educator, stated that:
- She attended the critical event review meeting on 03/17/15.
- The code blue (occurred 03/14/15) was not reviewed and evaluated in detail during the meeting.
- After the meeting, she met with the Director of Nursing, who directed her to revise the skills checklist for code blue according to policy.
- Staff were not educated or retrained after the event.
- She planned to start retraining staff on 04/13/15.

Record review of the facility's Critical Event Review form dated 03/17/15 showed that facility staff did not immediately initiate CPR. The MHT who found the patient unresponsive left the room and went to the charge nurse for a second opinion and the nurse responded within one minute.

Record review of the facility's undated Critical Event Review summation, showed that:
- The review did not find any significant quality of care issues that may have contributed to the patient's death.
- An autopsy had been requested for further analysis and peer review.
- The review team recommended more code blue drills.

During an interview on 04/08/15 at 1:40 PM, Staff A, Chief Nursing Officer (CNO)/Chief Operating Officer (COO), stated that when a patient was found unresponsive a delay to initiate CPR was unacceptable. She stated the first responder should have shouted Code Blue three times and started chest compressions on Patient #1.

During an interview on 04/09/15 at 10:00 AM, Staff Y, Chief Executive Officer and Chief Medical Officer, stated that;
- He expected the first staff member who found the patient unresponsive to call out for help and initiate CPR.
- He had no knowledge that Staff Z also had not initiated CPR. He expected the second staff member to initiate CPR if the first staff member had not.
- He had no knowledge that the ambulance crew had to wait two minutes at the front door before staff unlocked the door.
- Staff should have received further education/training after the critical event.
- He had received no detailed reports of code blue drills over the past year.
- He had no knowledge that the drills identified delays in initiating CPR.

3. Record review of the facility's policy titled, "Assessment for Contraband" revised 10/14/14 showed in order to provide a safe and therapeutic environment for patients, visitors and staff:
-Routine searches would be conducted on all patients on admission.
-Any items brought to the patient after admission should be searched prior to delivering them to the patient.
-Other searches may be conducted when there is reasonable cause to believe a patient may possess an item that is potentially hazardous.

4. Record review of incident reports related to contraband showed that:
- On 01/31/15 a patient turned in two duffle bag handles that were tied together and she stated she had plans to commit suicide with them.
-On 02/11/15, staff found a razor in an open container in a patient's room.
-On 03/03/15, staff found tweezers and strings during room check.
- On 03/08/15, a patient turned in a putty knife scraper that housekeeping staff had left in her room. She had hidden it in her room because she wanted to harm herself with it.
- On 03/14/15, a patient was found with a bottle nitroglycerin tablets and stated that she wanted to keep them with her.
- On 03/20/15, drawstrings were found on a patient's pajamas.
- On 03/21/15, a razor was found in a patient's room and not locked up.
- On 03/31/15, marijuana was found in a patient's jacket pocket that had not been found when it was brought to the hospital.
There were no investigative or other reports found to show that further action was taken to prevent contraband in patient care areas.

5. Record review of Patient #27's medical record showed:
- The History and Physical (H&P) showed the patient was admitted on 03/19/15 with diagnosis of fatigue, malaise and Benzodiazepine (a medication used for anxiety) and heroin (a narcotic drug) addiction.
- The Admission Psychiatric Evaluation of Patient #27 showed the patient was depressed with suicidal ideation with a plan to overdose on intravenous (IV, through the vein) heroin.
-The Health Screen dated 03/19/15 showed patient had used 10 to 20 pills a day of heroin and four to eight mg of Xanax (a medication used to treat anxiety) a day.
- The Progress Record dated 03/21/15 at 10:35 PM showed Patient #27 was overheard talking on the phone and stated "I can sneak it in, in my bra and if you won't do it, I'll find someone who will."

Record review of the Progress Record dated 03/22/15 at 3:00 AM showed documentation by Staff X, Registered Nurse (RN) that the patient should be restricted from having visitors due to her plan to bring drugs onto the unit.

Record review of the Progress Record dated 03/22/15 at 12:20 PM showed documentation by Staff AAA, RN, that she had reported to the House Supervisor the concerns of the staff that the patient had plans to have her boyfriend bring drugs onto the unit. The documentation showed that the House Supervisor had left a voice mail for the physician for an order restricting the boyfriend's visitation. No documentation was found that physician's order was given.

Further documentation on 03/22/15 at 12:20 PM showed the patient had been found with three pills in the elastic band of her pajamas. Two of the pills appeared to be Librium (a drug used for anxiety) and one appeared to be Restoril (a drug used for sleep disturbances). The documentation stated that the patient said she thought she was being discharged and wanted the pills for after she was discharged. The House supervisor was made aware of the hidden pills. Later, the patient came to the RN and stated that her "manager" was bringing her some things that evening. When asked what things the patient stated "I don't know just some things and maybe a pillow." Documentation stated that the patient was overheard on the phone saying "They're going to check everything no matter what you bring."

Record review of the Progress Record dated 03/22/15 at 6:52 PM showed that Patient #27 was found sitting on the floor of her bathroom. She did not respond when her name was called. A code blue was called. As the code progressed, the patient became more responsive. The patient responded to questions by stating that she had injected heroin which was brought into the facility by an outside person and the needle was in her jacket pocket.

Record review of the Psychiatric Practitioner Progress Record dated 03/23/15 showed Patient #27 stated that she had someone bring her eight buttons (drugs packaged in gel capsules) of heroin in a pillow.

6. Record review of the facility's "Morning Nursing Report" dated 03/23/15 and attended by Administrative staff showed documentation that Nursing Supervisors were to inform staff to not allow patients with drug issues to have stuffed items brought into the hospital.

During an interview on 04/09/15 at 10:00 AM, Staff WW, House Supervisor (HS), stated that she went to the Acute Unit after the incident and there was a general discussion of the incident but she stated that she was not able to do anything official [education on heightened awareness of contraband] because a revised policy had not gone to the Medical Executive Committee.

During an interview on 04/09/15 at 3:05 PM, Staff WW, RN, House Supervisor, stated that:
- There had been lots of problems with contraband. They wanted the patients to feel comfortable but the risk was much more evident.
- After the heroine over-dose there had been a group meeting and discussion about what measures could be put in place; limiting clothing to three items, everything else locked up and patients not allowed in the locked area.
- Nothing had been put in place because a space has not been identified for storage.
- A formalized policy did not go out after the March incident and there had not been any formal training for staff.

During an interview on 04/09/15 at 1:45 PM, Staff II, HS, stated that "Our patients are allowed to bring so many items in that it is impossible," [to keep track]. She stated that all items brought to a patient were to be checked for contraband before the items were given to the patient. Staff II stated that she learned from law enforcement that the drugs and syringe had been brought into the facility in a pillow.

During an interview on 04/09/15 at 3:00 PM, Staff QQ, RN, Acute Unit stated that she was not aware the patient had been found with pills in her pajamas while on the Adult Unit before she was transferred to the Acute Unit. She stated that had she known she would have been highly suspicious of anything which had been brought in to the patient. She stated that no education on heightened awareness for contraband was received after the patient overdosed on heroin.

During an interview on 04/09/15 at 3:30 PM, Staff RR, Mental Health Tech (MHT) of the Acute Unit stated that:
- The patient came up to her and introduced herself.
- The patient then told her she had asked someone to bring drugs to her but she had changed her mind.
- She reported this to the House Supervisor.
- She stated that she did not document this in the record because she was told others would be documenting and there was no need for her to also document.
(No documentation was found in the medical record concerning this admission by the patient.)
- She did not receive any education that night or since the incident on heightened awareness for contraband which might be brought to patients.

During an interview on 04/09/15 at 5:50 PM, Staff, II, HS, stated that the MHT did not tell her the patient had admitted asking someone to bring drugs to her.







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