HospitalInspections.org

Based on staff interview, review of Occurrence log 2014, Memo to Quality Assurance Subcommittee form dated 6/14/14 and Restraint log: Patients who have expired in 2 point restraints, it determined, that the facility failed to ensure that the regulatory requirement of reporting Death in restraints to CMS was met.

Findings include:

The facility's Occurrence log 2014 was reviewed on 3/04/2015. It was documented on the Occurrence log: "Pt (patient) was bought in by EMS (Emergency Medical Services)/Police in handcuffs, pt. combative uncontrollable, given Ativan and placed in 4 pts (points) restraints, when MD attended restraints removed. Pt's condition warranted intubation. Pt then coded and died".

Memo to Quality Assurance Subcommittee report form dated 6/14/2014 was reviewed on 3/04/2015. It was documented on this form that "Pt restrained while in the ED (Emergency Department) for emergent situation when MD attended restraints removed, pt. condition deteriorated & intubated pt. coded & died."

Staff #7 was interviewed on 3/10/2015. This staff stated that the facility was not required to report the patient's death to CMS as the patient died in 2 points restraints.

The facility's Restraint log: Patients who have expired in 2 points restraints was reviewed on 3/10/2015. It was documented on the form that the patient was brought in by "NRPD (New Rochelle Police Department) in hand cuffs, cuffs removed and restraints applied and removed non-contributory". It was noted that the type of restraints applied was not documented on this form.

The documentation reviewed indicated that the patient in MR #12 was placed on restraint while in the facility's ED. However, there was no documented evidence that the type of restraints was a 2 point restraints.

Based on staff interview, the review of medical record, hospital's policy and other documents, it was determined that the registered nurse responsible for the nursing care, of the patient in MR #12, who was seen in the Emergency Department, failed to ensure that all nursing care and/or interventions provided to the patient were properly documented. This was evident in one of three applicable medical records reviewed (#12).

Findings include:

The Occurrence Investigation report dated 6/14/14 was reviewed on 3/4/2015. It was documented in the report that the patient was brought in by EMS (Emergency Medical Services)/Police in handcuffs and the patient was combative, uncontrollable; the patient was given Ativan and placed in 4 pts (points) restraints emergently".

MR #12 was reviewed on 3/10/2015. It was noted that, on 6/14/2014 18:44 (6:44 PM), the nurse noted "pt. bib (brought in by ambulance) pt. found at bus stop combative acting irrationally. On arrival pt. had a white powder around his nose. Police on hand to control pt. pt. extremely combative. Denies drug or alcohol use. Pt came in had cuffs to keep him from injuring ems. Security called immediately to place patient on 1 to 1 observation". It was noted that the assessment did not include that the hand cuffs were removed and that the patient was placed in restraints. The type of restraints applied, the time the restraints were applied, and the staff who applied the restraints, was not documented in the medical record. In addition, the interventions provided while the patient was placed on restraints was not documented.

Staff #7 was interviewed on 3/10/2015 and stated that in an emergency situation a registered nurse can apply a physical restraint. Staff #7 also stated that the patient was placed in two point restraints.

Based on medical records reviews, document reviews, policies reviews and staff interviews, it was determined the facility failed to ensure that the nursing staff documented medications that were administered. This was found in 1 of 14 medical records (MR) reviewed. This was found in MR #1.


Findings include:


Nursing Staff #1, who is a registered nurse failed to document on the electronic medication administration record (eMAR) that narcotics were administered.


A review of MR #1 (patient #1) on March 9, 2015 revealed the patient presented to the emergency room on 11/17/14 with a complaint of bleeding, HTN, HLD, chest pain and dizziness for the past 3 days. The patient was admitted to PCU/Telemetry. The patient was treated with IV saline, Meclizine for dizziness and pain management. On 11/19/14 at 8:59 AM and 7:56 PM the pain assessment states "denies pain" this was entered by Staff #1 RN on the day shift.


A review of a narcotic report revealed Staff #1 removed 1 Percocet tablet from the Pyxis at 7:13 AM on November 19, 2014. A review of the medical record on March 9, 2015 revealed there was no evidence that this dose of Percocet was documented on the eMAR.


A review of the facility's policy titled "Pyxis Medication Administration" which was last reviewed 11/13 states, "Once meds are removed from the Pyxis (a brand of an automated dispensing cabinet or ADC - a computerized drug storage device or cabinet designed for hospitals which allow medications to be stored and dispensed near the point of care while controlling and tracking drug distribution), they are to be immediately administered'".


During staff interviews conducted on March 9, 2015 at approximately 11:30 AM, Staff #5 the Nurse Manager of PCU stated that Staff #1 did not document on the eMAR that this medication that she had withdrawn from the Pyxis had been administered.

Based on the review of medical records, Occurrence log 2014, hospital policy and other hospital documents, it was determined that the facility failed to ensure: that the medical staff, responsible for caring for the patient in MR #12, conducted an initial medical assessment before providing treatment; that it had an effective Emergency Department Policy; and that its Emergency Department policy was properly implemented. This was evident in one of three applicable medical records reviewed (MR #12).

Findings include:

The facility's Occurrence log 2014 and Memo to Quality Assurance Subcommittee report form, dated 6/14/14, were reviewed on 3/04/2015. It was documented on the Occurrence log: "Pt (patient) was bought in by EMS (Emergency Medical Services)/Police in handcuffs, pt. combative uncontrollable, given Ativan and placed in 4 pts (points) restraints, when MD attended restraints removed. Pt's condition warranted intubation. Pt then coded and died". It was documented on the Memo to Quality Assurance Subcommittee form "pt. was brought in by EMS/police in handcuffs was combative uncontrollable. Pt restrained while in the ED (Emergency Department) for emergent situation when MD attended restraints removed, pt. condition deteriorated & intubated pt. coded & died "

MR #12 was reviewed on 3/10/2015. It was noted that the patient, 40 year old male, was brought to the facility's Emergency Department (ED) by ambulance on 6/14/2014 18:33 (6:33 PM). The triage nurse noted the chief complaint: "the patient was found at bus top combative acting irrationally". It was noted that the patient's vital signs were: Temperature 99 degrees Fahrenheit, Heart rate 170 beats per minute (bpm), Respirations 28, Systolic Blood Pressure (BP) 245, Diastolic BP 163 and Pulse Oximeter 97. It was noted that the nurse documented the past medical history: none. The patient was placed in triage category 2. The medication task, documentation in the record, indicated that the patient was given Ativan 2 milligrams per milliliter (Mg/ml), on 6/14/2014 at 7:00 PM. It was noted that the patient went into cardiac arrest on 6/14/2014 1915 (7:15 PM). The patient expired on 6/14/2014 1944 (7:44 PM). There was no documentation, in the record, that the patient had an initial medical assessment or medical evaluation (no physical examination, laboratory and/or diagnostic test ordered or performed), prior to the administration of the Ativan on 6/14/2014 at 7:00 PM.

The physician's Addition Information dated 15-Jun-2015 08:52 (8:52 AM) was reviewed. The physician noted "called to see patient at 7 pm - the start of my shift - because he began suddenly pouring frothy sputum from his nose and mouth". It was documented that 2 mg of Ativan was administered to the patient on 6/14/2014 at 7:00 PM. It's unclear if this provider was called directly after the medication was administered. The physician noted "patient had already been given 2 mg of Ativan by initial provider". There was no documentation in the medical record from the prior medical provider.

The Memo to Quality Assurance Subcommittee form dated 6/14/14, reviewed on 3/4/2015, indicated that the patient's condition deteriorated and the MD ordered restrains to be removed. It was noted that the date and time that the restraints were ordered to be removed was not documented in the record.

The facility's Emergency Department Five Level Triage policy was reviewed on 3/13/2015. This policy indicated that patients placed in triage level two should be seen by a physician within 30 minutes. It was noted that, although, there was an intervention and the patient was administered with Ativan 2 mg, this patient was not seen within 30 minutes, as per policy. The section of the policy titled "Definition of Danger Zone Vital Signs" was reviewed. It was noted that there was no danger zone vital signs listed for blood pressure. It was also noted that the danger zone vital signs listed were only for pediatric patients.