HospitalInspections.org

Based on medical record review, facility policy, and staff interviews, the Governing Body:

i. Failed to ensure that nursing care and services were administered in a safe and effective manner;

ii. Failed to promote and protect a patient's right in the proper application of restraints, for one (1) patient ( #1), which resulted in the death of the patient.

Cross refer A0385 as it relates to the facility's failure to ensure that nursing care and services were administered in a safe and effective manner.

Cross refer A0115 as it relates to the facility's failure to protect and promote each patient's rights.

Based on medical record review, facility policy, and staff interviews, the facility failed to protect and promote patient's rights in the administration of restraints in a safe and effective manner for one (1) patient ( #1), which resulted in the death of the patient.

Cross refer A0385 as it relates to the facility's failure to ensure that nursing care and services were administered in a safe and effective manner.

Cross refer A0043 as it relates to the failure of the Governing body to ensure that nursing services were provided in a safe and effective manner and that patient's rights were promoted and protected.

Based on medical record review, facility policy, and staff interviews, the facility failed to ensure that one (1) patient (#1) of twelve (12) sampled patients was evaluated by a Medical Doctor within one (1) hour of the application of physical restraints.

Findings:

Review of the facility policy, no number, "Restraints", last revised 04/07/17, revealed that an MD must see and evaluate the need for restraint within one (1) hour after the initiation of the intervention. The condition of the restrained patient will be continually assessed, monitored and re-evaluated at observed intervals not greater than fifteen (15) minutes.

Review of the facility Restraint Log revealed that restraints were used for Patient #1 on 12/30/17 and ordered by MD #2.

Review of the Physician Order for Restraint dated 12/30/17 at 20:24 revealed the reason for restraint was marked as confusion/agitation resulting in high risk for fall or injury. Reasons also indicated were disorientation/agitation posing an increased threat to self or others, and to maintain the integrity of therapeutic interventions. A continued review revealed the restraint was indicated for high risk for disrupting the treatment environment, and to maintain the integrity of invasive monitoring equipment. The form indicated that pain/comfort measures, the concealing of therapeutic devices, reorientation, call light within reach, and the patient's proximity to the nurse's station was attempted before the restraint order. The type of restraints indicated on the Physician Order for Restraint was marked bilateral soft wrist and ankle and soft vest. The duration was marked as twenty-four (24) hours. The form was signed by MD #2 on 12/30/17 at 20:24.

During an interview with the Administrator/Director of Nursing (DON) (Employee #1) on 01/19/18 at 10:39 a.m. in the facility Conference Room, the DON stated that there were mistakes made by the staff, including the fact that MD #2 did not perform a face to face evaluation of Patient #1 within an hour of ordering the restraints.

During an interview with the physician (MD #2) on 01/19/18 at 11:43 a.m. in the facility Conference Room, the MD acknowledged that he/she did not perform a face to face evaluation with the patient one hour after the restraints were applied. The MD stated that he/she knows now that he/she should have, but did not do it.

Based on medical record review, facility policy, and staff interview, the facility failed to ensure that the Center for Medicare and Medicaid Services (CMS) Regional Office was notified of the death of a patient (#1) while in restraints, and within twenty-four (24) hours from the day that the facility was made aware of the patients death.

Findings

Review of the facility policy, no number, "Restraints", last revised 04/07/17, revealed that each death that occurs while a patient is in restraint would be reported to CMS by telephone no later than the close of the next business day following knowledge of the patient's death.

Review of the facility's Notification of Death to CMS revealed that CMS was notified of Patient #1's death on 01/5/18 at 11:39 a.m.

Review of the facility Death Log revealed the patient died at the facility on 12/31/17 at 3:40 a.m. while in physical restraints.

During an interview with the Administrator/Director of Nursing (DON) (Employee #1) on 01/19/18 at 10:39 a.m. in the facility Conference Room, the DON revealed that he/she had been on vacation and out of the state during Patient #1's admission on December 30 -31, 2071. The DON stated that the facility staff did call and inform him/her that a patient had expired, but the DON stated that he/she was never made aware that Patient #1 had been in restraints at the time of his/her death. The DON explained that he/she only became aware of death occurring while the patient was in restraints until 01/05/18 while auditing Patient #1's medical record. He/she indicated that he/she immediately notified the State Office and CMS to report the death. The DON stated that he/she had not had anyone trained to deal with the reporting of a death of a patient while in restraints. He/she acknowledged that the reporting of Patient #1's death to the State Office and CMS was outside of the time frame allotted for reporting the event.

Based on medical record review, facility policy, and staff interviews, the facility failed to ensure nursing care and services were administered in a safe and effective manner for one (1) patient ( #1), which resulted in the death of the patient.

Findings:

Cross refer A0115 as it relates to the facility's failure to protect and promote each patient's rights.

Cross refer A0043 as it relates to the failure of the Governing body to ensure that nursing services were provided in a safe and effective manner and that patient's rights were promoted and protected.

Review of the Facility Patient Admission Log revealed that Patient #1 was admitted to the facility's ED on 12/30/17 at 16:10 and admitted to the facility as an inpatient on 12/30/17 at 18:10.

Review of the MD (MD #2) orders on 12/30/17 revealed an order for admission, oxygen via NC at 2L, and telemetry at 18:06.

Review of the Patient Progress Notes dated 12/30/17 at 18:30 revealed that Patient #1 was admitted to his/her room and placed on telemetry. The patient was noted to be confused on arrival.

Review of the Patient Progress Notes dated 12/30/17 revealed the last full set of vital signs were documented on 12/30/17 at 20:14. Vitals were documented as BP 151/96, oxygen saturation 97 percent (on 2L NC), respirations 18, pulse 81, and temperature 98.1. The last oxygen saturation documented for the patient was 97 percent (on 2L NC) on 12/30/17 at 23:25.

Review of the Patient Progress Notes/Physical Assessment dated 12/30/17 revealed that the following:

19:20 - RN (Employee #4) documented that Patient #1 was climbing over the bed rails. The patient had pulled off the telemetry leads and was combative with staff. The patient was noted to be pulling at the Foley catheter. MD #2 was notified and an order for 20 mg of Geodon was administered IM. Per the note, the telemetry monitoring was left off as the patient was pulling them off.

20:15 - RN (Employee #4) documented the patient continues to be combative and agitated. The patient climbed over the rails and went into the bathroom and found pulling IV out. Blood noted all over the bathroom floor and walls. Bleeding controlled and the patient returned to bed. MD #2 notified and Geodon 20 mg IM administered. Posey vest ordered PRN. All four side rails up.

21:10 - RN (Employee #4) documented that Posey vest applied. The patient continues to be combative and agitated. All four side rails up, and the bed alarm is set.

21:19 - CNA charts unable to obtain vital signs due to patient combativeness. Will check on the patient every two (2) hours to loosen restraint.

21:50 - RN (Employee #4) documented that the patient had moved to the foot of the bed with the Posey vest on. Pt remained combative and agitated. MD #2 ordered soft wrist/ankle restraints. Staff at bedside trying to keep the patient in bed. Order for Ativan 3 mg IM obtained.

22:00 - RN (Employee #4) documented that patient's vest restraint reapplied. Staff at the bedside to keep patient in bed. Ankle and wrist restraints applied. Ativan 3 mg IM administered. Pt is fighting against restraints. Bed alarm on and all four side rails up. Oxygen 2L NC remains on the patient.

23:01 - RN (Employee #4) documented that patient is snoring but fighting restraints. All side rails up. Bed alarm on. Staff at the bedside.

23:36- CNA documented unable to obtain vitals due to patient combativeness.

23:38 - RN (Employee #4) documented that MD #2 notified that patient is fighting against restraints but is snoring. MD ordered Geodon 20 mg IM but wants to Morphine 5 mg IM administered first and repeat Morphine 5 mg in 20 minutes if the first dose has not calmed patient down. Morphine 5 mg IM administered, and Geodon on hold for now.

A continued review of the Patient Progress Notes/Physical Assessment dated 12/31/17 revealed that the following:

00:08 RN (Employee #4) documented that patient continues to fight against restraints although snoring. Oxygen saturation recorded at 97 percent with 02 at 2L NC. Morphine 5 mg IM repeated per MD #2 order. All four side rails up and bed alarm on. Staff at the bedside.

01:00 - RN (Employee #4) documented that patient is snoring but still fighting against restraints. Vest restraint release as vest became tight across the patient's chest due to movement. All four side rails on and bed alarm on.

02:08 - RN (Employee #4) documented that the patient is aroused and yelling out, cursing, and fighting against restraints. Geodon given per MD #2 order. All four side rails up and bed alarm on.

02:47 - RN (Employee #4) documented that patient is calm at present. Oxygen continued at 2L NC. The patient is snoring. Slight movement of hands. Restraints in place with good range of motion. Vest restraint is loosely in place.

03:13 - LPN (Employee #7) documented patient found lying in bed. No respirations or pulse. Code blue called. ED staff to room. CPR started.

03:16 - RN (Employee #4) documented MD #2 notified. CPR in progress.

03:20 - RN (Employee #4) MD #2 in room attempting intubation. Pt is in asystole. CPR continued.

03:40 - RN (Employee #4) Patient remains in asystole. MD #2 called the code. Time of death 03:40.

A review of the Medication Administration Record (MAR) dated 12/30/17 revealed that Patient #1 received Geodon 20 mg IM in the left deltoid at 19:20 and in the right gluteus maximus at 20:15. A continued review revealed Ativan 3 mg IM was administered to the patient in the left vastus lateralis at 22:37. Morphine 5 mg IM was administered in the right vastus lateralis at 23:37. A further review of the MAR dated 12/31/17 revealed that Patient #1 received Morphine 5 mg IM in the right vastus lateralis at 00:08 and Geodon 20 mg IM in the right deltoid at 02:08.

Review of the Progress Note dictated by MD #2 on 12/31/17 at 03:50 revealed that MD #2 was notified of a possible code blue for Patient #1 at 03:05. The Progress Note showed that the patient was last seen by a nurse before 3:00 a.m. on 12/31/17. Per the Progress Note, a nurse found the patient unresponsive and apneic. CPR was initiated, and an Ambu Bag (a self-inflated bag used for respiratory assistance or resuscitation) needed to be located. A continued review revealed that Patient #1 was difficult to intubate due to a thick neck and overall body condition. An airway was secured late in the code. A further review revealed the cardiac monitor displayed asystole throughout the code, and several rounds of resuscitation medications were given during the event. The code was called at 03:40 a.m.

During an interview with the Administrator/Director of Nursing (DON) (Employee #1) on 01/19/18 at 10:39 a.m. in the facility Conference Room, the DON stated that Patient #1 had been combative during his/her entire inpatient admission. He/she confirmed that Patient #1 had an MD order to be monitored via telemetry, and the DON acknowledged that the patient had not been on telemetry for most of his/her admission due to the patient's combativeness. The DON indicated that the staff did have another nurse (Employee #7) at the patient's bedside for much of the patient's admission, but the DON acknowledged that Employee #7 had left the patient's bedside, and the patient remained alone on 12/31/17 from 2:47 a.m. until 3:15 a.m., when the patient was discovered unresponsive, and a code blue was called. The DON stated that there were mistakes made by the staff and that the nurse in charge (RN #4) was the nurse caring for Patient #1, and RN #7 was also on duty. The DON stated that RN #4 should have instructed RN #7 to take her other two (2) patients and remained at Patient #1's bedside as the patient was too combative to keep the telemetry monitor in place. The DON stated that staff should have remained at the bedside until the patient was calm enough to be monitored or until the order for telemetry had been discharged.

During an interview with the physician (MD #2) on 01/19/18 at 11:43 a.m. in the facility Conference Room, the MD The MD stated the patient was admitted for Altered Mental Status (AMS), and the patient was placed in a room close to the nurse's station. The MD stated that Patient #1 was admitted to the floor on telemetry monitoring and was placed on 2L of oxygen administered by NC. The MD explained that shortly after admission, the patient was reported to be kicking the staff, and the patient had become combative. The MD stated that Patient #1 had pulled his/her lines out, and it took three (3) staff members to get the patient back into bed. The MD stated that he/she ordered a total of 60 mg of Geodon, 3 mg of Ativan, and a total of 10 mg of Morphine IM between 8:15 p.m. on 12/31/17 and 2:08 a.m. on 12/31/17. The MD stated that the patient was 300 pounds and had a history of narcotic use. The MD stated that due to those factors, he/she felt comfortable with the medications used to calm the patient down. The MD added that restraints were ordered to protect the patient from him/herself and to protect the staff. The MD explained that despite the medications given, the patient would sleep for a short time and wake up combative. The MD stated that if the patient were unable to remain on telemetry, it would have been best to have staff remain at the bedside.

During an interview with the Pharmacist (Employee #3) on 01/19/18 at 12:11 p.m. in the Conference Room, the Pharmacist revealed that he/she had reviewed Patient #1's chart. The Pharmacist acknowledged that 60 mg of Geodon, 3 mg of Ativan, and 10 mg of Morphine had been ordered and administered to Patient #1 via IM injection. The Pharmacist acknowledged that 60 mg of Geodon would be considered a high dose. The Pharmacist indicated that a patient with a history of drug use might have a tolerance issue, requiring higher doses to reach the desired level of sedation. The Pharmacist stated that Morphine and Ativan could cause a decrease in respiratory function. The Pharmacist stated that if a patient had a history of sleep apnea and was administered medications that cause sedation, the patient would need to be monitored for respiratory function. The Pharmacist added that a combination of Geodon, Ativan, and Morphine would cause sedation.

During an interview with the Registered Nurse (RN) (Employee #4) on 01/19/18 at 12:11 p.m. in the Conference Room, the RN revealed that he/she remembered Patient #1. The RN stated that he/she was working the 7:00 p.m. to 7:00 a.m. shift on 12/20/17. The RN stated that Patient #1 became agitated and combative towards the staff shortly after being admitted to his/her room. The RN stated that Patient #1 attempted to strike the staff with his/her fists. The RN explained that Patient #1 had managed to get to the bathroom where he/she had pulled his/her IV tubing in half, and blood was observed all over the walls and floor of the bathroom. The RN stated he/she called for help and notified MD #2. MD #2 ordered 20 mg of Geodon, and the RN stated he/she administered the medication in the patient's left deltoid (arm) at 7:20 p.m. The RN stated that about an hour later the patient was still combative, and he/she notified MD #2. The RN stated that MD #2 ordered another 20 mg of Geodon, which he/she administered in the patient's right hip at 8:15 p.m. The RN stated that the patient had pulled off his/her telemetry leads and was trying to hit the staff. The patient then went into the bathroom and tried to remove his/her Foley catheter. The RN stated he/she notified MD #2. The RN stated that MD #2 responded to the room and helped staff return the patient to bed. MD #2 ordered a Posey vest, which was applied to the patient. The RN stated that the patient positioned him/herself at the bottom of the bed and was on his/her stomach. The RN stated he/she notified MD #2, and the MD ordered soft wrist and ankle restraints and 3 mg of Ativan IM. The RN stated the restraints were applied and the RN administered 3 mg of Ativan in Patient #1's left leg. The RN stated the patient was still wearing his/her oxygen, but the patient was fighting against the restraints. The RN stated that the LPN (Employee #7) came into the room and remained at the patient's bedside while he/she left the patient's room. The RN stated the patient was snoring, but he/she was still fighting against the restraints, and he/she notified MD #2. The RN stated that MD #2 ordered another 20 mg of Geodon, but MD #2 wanted him/her to administer 5 mg of Morphine IM first to see if that would work. The RN stated that MD #2 stated if the Morphine did not work, he/she could administer another 5 mg of Morphine PRN (if needed.) The RN stated he/she administered 5 mg of Morphine IM at 11:38 p.m. The RN explained that 12:08 a.m. on 12/31/17, the patient was still fighting, so he/she administered the second dose of 5 mg of Morphine IM. The RN stated that the patient had on his/her oxygen and the patient's oxygen saturation was 97%. The RN stated that at 1:00 a.m. the patient was snoring, but the patient was still fighting the restraints. The RN added that the Posey vest had become tight around the patient's chest due to the combativeness, so the Posey vest was left on the patient but untied to ensure the patient's safety. The RN stated that at 2:08 a.m. the patient started fighting against the restraints and cursing at staff. The RN stated that he/she administered the 20 mg of Geodon that MD #2 had ordered at 11:38 p.m. on 11/30/17. The RN stated that at 2:47 a.m. the patient had calmed down. The RN stated that the patient's hands were still moving, and the patient was snoring. The RN added that the Posey vest was still on, but it was not secured, and the wrist and ankle restraints remained in place. The RN stated the oxygen monitor and telemetry had not been placed back on the patient as she was worried the simulation of placing it back on would cause Patient #1 to start fighting again. The RN acknowledged that telemetry was ordered for the patient, but the RN stated he/she felt didn't want to arouse the patient. The RN stated that at 3:15 a.m. the LPN (Employee #7) went to check on Patient #1 and found him/her unresponsive. The RN stated that a code blue was called as soon as the patient was found down. The RN stated he/she was unaware that the patient had sleep apnea, and the RN stated that he/she had been unable to look at the chart very much as the patient had been combative through most of his/her shift. The RN stated that although the patient had 60 mg of Geodon, 3 mg of Ativan, and 10 mg of Morphine, he/she didn't feel the amount would be a problem as the patient was so large and continuously combative. The RN explained that the patient was positioned close to nurse's station and the patient's bed alarm was on. The RN stated that the patient was left alone for twenty-eight (28) minutes, and the RN acknowledged that he/she was not being monitored. The RN stated he/she felt the patient was clinically safe to leave alone. The RN stated that Patient #1 should probably have not been left alone.

During an interview with the Respiratory Therapist (RT) (Employee #5) on 01/19/18 at 2:03 p.m. in the Conference Room, the RT revealed that he/she was working the 11:00 p.m. to 7:00 a.m. shift on 12/30/17. The RT stated that he/she remembered Patient #1. The RT stated that he/she had not evaluated the patient before the code blue that was called for Patient #1.The therapist acknowledged that patients with a history of sleep apnea, especially if sedated, would require monitoring for oxygen saturation. The RT added that most patients with sleep apnea snore.