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Based on records reviewed and interviews, for 1 of 14 sampled patients (Patient #1), the Hospital failed to ensure a thorough response when review during the Hospital's quality improvement activities (Root Cause Analysis) identified that staff members failed to document assessment findings of Patient #1 who, on 8/30/15, was found unresponsive and without a heartbeat.

In addition, the Hospital failed for 3 of 14 patients (Patient #1, #8, and #10), to ensure that comprehensive assessments were performed in accordance with Hospital policy.

In addition, although the Hospital's corrective action plan included implementation of emergency carts on 6 of the units, as of the date of survey (more than five months later), the Hospital implemented use of only one cart.

Findings include:

1. The Hospital policy titled Assessment/Reassessment, dated 10/2015, indicated that all re-assessments were documented in the patient's medical record.

Resident #1's record indicated that at 5:10 A.M. on 8/30/15, staff found Patient #1 not breathing and without a heartbeat (abnormal assessment findings), and staff initiated cardiopulmonary resuscitation. There was no documentation to indicated that when Patient #1 was found without a heartbeat or respirations, that staff performed re-assessment of Patient #1's vital signs, (pulse, breathing, blood pressure), skin color, level of consciousness or response to cardio-pulmonary resuscitation efforts.

2. The Hospital policy titled Patient Comprehensive Assessment, dated October 2015, indicated a History and Physical examination was to be completed by the physician or nurse practitioner within twenty-four hours of admission. The policy indicated that if there was a delay in completing the History and Physical examination within twenty-four hours, the physician must document the reason for the refusal with the date and time on the physical examination form. The policy indicated that the physician should attempt to complete the History and Physical examination every twenty-four hours until it was completed.

Surveyors #1 and #2 interviewed the Chief Executive Officer (CEO), Risk Manager, and Director of Nurses (DON) at 10:00 A.M. on 1/26/16. The CEO, Risk Manager, and DON said a Root Cause Analysis was completed regarding Patient #1 being found without a pulse. The CEO, Risk Manager, and DON said that the Root Cause Analysis, dated 9/2/15, identified that a psychiatric evaluation, a component of a comprehensive assessment, was not completed.

The Root Cause Analysis indicated Patient #1's psychiatric evaluation was not completed and additional attempts had not been made to complete the psychiatric evaluation. The Root Cause Analysis indicated that the Medical Staff would be re-educated regarding the expectation that the psychiatric assessment be completed. This education was to be completed by 2/2/16, which was five months after Patient #1's death. The Root Cause Analysis indicated that the Comprehensive Assessment Policy would be revised by 1/27/16, but was not revised at the time of the Survey, more than five months after the incident.

A review of two additional records indicated the comprehensive assessments were not completed, which was not consistent with the Hospital's policy. This was not consistent with the findings from the Root Cause Analysis regarding Patient #1's incident on 8/30/15, and the related corrective action plans in response to the Root Cause Analysis.

Patient #8's record was reviewed during survey. The Consultation/Physical Evaluation form, dated 1/13/16, 1/14/16, 1/15/16, and 1/21/16, (reviewed on 1/26/15) indicated Patient #8 refused physicians to perform the History and Physical examination. The Consultation/Physical Evaluation form did not indicate a physician attempted to perform the History and Physical examination, as required by Hospital policy.

Patient #10's record was reviewed during survey. The Consultation/Physical Evaluation form, dated 1/15/16, 1/18/16, 1/21/16, and 1/25/16, (reviewed on 1/26/15) indicated Patient #10 refused physicians to perform the History and Physical examination. The Consultation/Physical Evaluation form did not indicate a physician attempted to perform the History and Physical examination, as required by Hospital policy, every twenty-four hours until the History and Physical examination was completed.

The CEO, Risk Manager, and DON said the Root Cause Analysis, the Hospital's response to Patient #1's adverse event included implementation of medical emergency carts on all 6 patient care units. The Hospital failed to ensure implementation of its correction action plan because at the time of survey, it was observed that only one medical emergency cart was in place.

Based on observations, records reviewed, and interviews for 1 of 3 patient observations (Non-sampled Patient #1), the Hospital failed to ensure nursing staff followed the Hospital's policy for safe patient identification when administering medications. In addition, the Hospital failed to ensure multi-dose injectable medication was stored in accordance with Hospital policy.

Findings include:

1. The Hospital policy titled Medication Administration, dated 10/15, indicated patient verification was done through the use of two identifiers i.e. the patient photo identification, asking the patient their full name or their date of birth.

Surveyor #1 observed Registered Nurse #2 during her administration of medications on West 2 at 7:15 A.M. on 1/26/16. Registered Nurse #2 greeted the patients using their first names and then proceeded to deliver the non-sampled Patient #1's medications. After the medication was administered, Registered Nurse #2 told the Surveyor that she did not use a second identifier, other than the patient's photo identification, because she knew non-sampled patient #1. Registered Nurse #2 said she was aware that Hospital policy was to use two identifiers but said that sometimes the patients would become agitated because they were repeatedly asked their name or date of birth.

The Nurse Manager was interviewed at 1:00 P.M. on 1/27/16. The Nurse Manager said the Registered Nurses were well aware of the requirement to use two patient identifiers to ensure patient safety when administering medications. The Nurse Manager said during survey, Registered Nurse #2 told the Nurse Manager that she failed to follow the Hospital policy for safe patient identification when administering medications.

2). At 10:00 A.M. on 1/25/16, Surveyor #1 observed four open multi-dose medication vials. The Surveyor observed that two of the four opened multi-dose vials, which contained the medications insulin and Tuberculin, Purified Protein Derivative, were not dated to indicate when the multi-dose vial was first opened for use. This was not consistent with Hospital policy.
The Nurse Manager said it was the Hospital policy to date the medication vial to indicate it would expire in 28 days, from the time the vial was opened.