HospitalInspections.org

Based on record review, interview, and observation, the facility failed to meet the Condition of Participation (CoP) for Patient Rights by failing to comply with the requirements as evidenced by the following:

A. The facility failed to ensure the patients' right to receive care in a safe setting. Refer to 0144.

B. The facility failed to ensure least restrictive restraint interventions were attempted or implemented. Refer to 0164.

C. The facility failed to ensure violent restraint parameters meet federal guidelines. Refer to 0171.

Based on record review, interview, and observation, the facility failed to ensure the patients' right to receive care in a safe setting while in 4-point restraints, and to be free from neglect and harm by violating the patient right to least restrictive measures according to facility policy, and death for 1 patient (P)1 of 10 (P1-P10) patients reviewed. This failed practice may have led to patient death.
The findings are:

A. Record review of P1, Death Forms, dated 11/27/2022 at 7:41 am, reveals, "Admit Diagnosis and major event: ... Developed agitation in setting of TBI (traumatic brain injury: brain injury caused by trauma), SAH (subarachnoid hemorrhage: bleeding in specified area of the brain), SDH (subdural hematoma: bleeding in specified area of the brain) and hospital acquired delirium. Required restraints. Found unresponsive by nursing staff at 0605 (6:05 am)."

B. Record review of P1, Provider Notes, dated 11/26/2022 at 6:29 am, documents, "Assessment/Plan: ... #Acute Delirium ... #Agitation ... 4 point restraints for agitation."

C. Record review of P1, Provider Orders, dated 11/19-11/27/2022, reveals the following restraint orders for P1:
a. "11/20/2022 at 12:39 am: Order Details: ... Soft, No longer interfering w/ Nec Med Care(necessary medical care) Criteria for Release, Interfering with medical care.
b. 11/20/2022 at 12:39 am: Restraint monitoring: q 2 hours (every 2 hours).
c. 11/20/2022 at 9:03 am: Order Details: ... Soft, No longer exhibits violent behavior Criteria for Release, Interfering with medical care ... If the restraint indication is for violent behavior, order must be renewed q 8 hours for adults.
d. 11/21/2022 at 10:02 am: Order Details: ... Soft, No longer exhibits violent behavior Criteria for Release, Interfering with medical care ... If the restraint indication is for violent behavior, order must be renewed q 8 hours for adults.
e. 11/23/2022 at 10:37 am: Order Details: ... Soft, No longer interfering w/ Nec Med Care Criteria for Release, Interfering with medical care.
f. 11/23/2022 at 11:01 pm: Order Details: ... Soft, No longer exhibits violent behavior Criteria for Release, Interfering with medical care ... If the restraint indication is for violent behavior, order must be renewed q 8 hours for adults.
g. 11/25/2022 at 2:18 am: Order Details: ... Soft, No longer interfering w/ Nec Med Care Criteria for Release, Interfering with medical care.
h. 11/25/2022 at 12:47 pm: Order Details: ... Soft, No longer interfering w/ Nec Med Care Criteria for Release, Interfering with medical care.
i. 11/26/2022 at 10:48 am: Order Details: ... Soft, No longer interfering w/ Nec Med Care Criteria for Release, Interfering with medical care. "

D. Observation of Facilities video of [name of unit] hallway, dated 11/26/2022 7:00 pm-11/27/2022 7:30 am, reveals Registered Nurse (RN)1 enters P1 room at 04:06:18 am and exits P1's room at 04:06:30 am. No one enters P1's room until 05:39:34 am when Charge Nurse (CRN)2 enters (to update whiteboard, per staff interview), and exits P1's room at 05:40:26 am. At 05:59:28 am RN1 enters P1's room and re-emerges in P1's doorway at 06:00:41 am. At 06:00:43-06:00:57 am Patient Care Technician (PCT) and RN intern enter P1's room. At 06:01:28 am PCT exits P1's room, walks across hallway (to check P1's code status, per staff interview) and re-enters room at 06:01:35 am. RN1 exits P1's room at 06:01:41 am, walks to end of hallway, enters farthest room and re-emerges with CRN1 and CRN2, all three enter P1's room at 06:02:23 am. At 06:04:43 am Charge RN2 exits P1's room. At 06:05:23 am CRN1 exits P1's room. At 06:06:25 am RN2 enters P1's room. At 06:12:30 am RN1 exits P1's room, walks across hall, retrieves a rolled towel (used in post-mortem care), and re-enters P1's room at 06:13:09 am. At 06:18-06:20 am RN1, RN2, RN intern, and PCT exit p1's room. At 06:45 am RN1, RN2, RN intern, PCT and Provider enter P1's room, and all exit at 06:51-06:52 am, all exit P1's room.

Least Restrictive Interventions:
E. Record review of facilities policy titled "Patient Restraints," dated 05/23/2022, reveals page 1 Para 1, "Restraints are only used when less with appropriate and adequate clinical justification and when less restrictive interventions have been determined to be ineffective or inappropriate. Patients will not be restrained for convenience, discipline, retaliation, or coercion and when restraint is necessary, the least restrictive method of restraint will be utilized. Restraints will be discontinued at the earliest possible time based on the patient's assessment, regardless of scheduled expiration of the order ... Intervention/implementation:
a. Consider alternative, nonphysical interventions that may eliminate the need for restraint.
b. Pain, anxiety, or other comfort measures ...
c. Place close to the nurse's station ...
d. Use of 1:1 observation."
e. Refer to tag A-0164 regarding least restrictive measures.

F. Record review of facilities education module titled "Patient Restraint for Nurses," no date present, reveals slide 6 & 7, "Intervention/implementation.
a. Alternatives and Preventative strategies:
i. the presence and support of family members, caregivers, or significant others with frequent visual, verbal, and tactile contact
ii. placing the patient near the nurse's station
iii. orienting frequently to time and place
iv. addressing physical and emotional needs and comfort measures such as via pain or anxiety medications, food, drink, toilet, room temperature, pastoral services ...
v. arranging tubes out of reach or using options to cover sites
vi. orienting to environment: call button, clock, calendar, objects within reach
vii. providing mobilization opportunities ...
b. The least restrictive type of restraint necessary to protect the patient must be ordered."

G. Record review of P1, Electronic Medical Record (EMR) dated 11/19-11/27/2022, shows no documentation of attempts at least restrictive interventions according to facility policy.

Assessment and Range of Motion (mobility exercises done to preserve a person's joint and muscle function, and prevent Deep Vein Thrombosis (blood clot), performed either as active: independent mobility exercises; or passive: when someone else is moving a joint for you):
H. Observation of facilities video footage for [name of unit] dated 11/26/2022 7:00 pm-11/27/2022 7:30 am, reveals RN1 assigned to P1's care enters pt (patient) room on 11/27/2022 at 04:06:18 am and exits P1's room at 04:06:30 am; for a total of 12 seconds inside P1's room. RN1 does not re-enter P1's room until 05:59:28 am.

I. Record review of facilities policy titled "Patient Restraints," dated 05/23/2022, reveals page 3.d "Monitoring:
a. The restrained patient is monitored and reassessed every 2-4 hours or more frequently according to patient need.
b. The patients physical needs will be met.
c. Ongoing monitoring and re-evaluation includes but not limited to the following.
1. Rationale for continuation of restraint
2. Integument (skin) or skin integrity and condition of extremities
3. Respiratory and circulatory status
4. Fluid and nutritional needs
5. Hygiene and toileting needs
6. Range of motion needs
7. Evaluation of status in restraints."

J. Record review of facilities education module titled "Patient Restraint for Nurses," no date present, reveals slide 11, "Monitoring: Nursing staff will assess patients who are placed in restraints every 2-4 hours or more frequently according to patient need. The physical needs of the patient will be met by ongoing monitoring and evaluation: readiness for discontinuation of restraint, rationale for continuation of restraint, vital signs, skin and extremity condition, respiratory status, circulation, nutrition and hydration, elimination, hygiene, positioning, range of motion, and psychological well-being."

K. Record review of facilities education module titled "Patient Restraint for Nurses," no date present, reveals slide 13, "Accurate Documentation is Required ... Ongoing monitoring documentation must include:
a. Vital signs, skin condition, respiratory status, circulation, nutrition and hydration, elimination, hygiene, positioning, and range of motion every 2 hours,
b. Rationale for continued use of restraint
c. When criteria is met for discontinuation of restraint."

L. Record review of P1, EMR, dated 11/19-11/27/2022, shows no documentation that range of motion needs were met for P1, while being restrained to bed with 4-point restraints, thereby restricting P1's active range of motion. Refer to finding I.

M. Record review of P1, EMR, dated 11/19-11/27/2022, reveals RN assigned to care of P1 nightshift 11/26-11/27/2022 charted the following assessment:
a. "11/26/2022 at 8:00 pm: Best motor response- localizes to noxious stimuli (painful stimuli). Activity assistance- Moderate assistance. Activity- Bedfast (a person who is unable to independently transfer into, out of, or turn themselves in bed).
b. 11/27/2022 4:12 am:
i. Restraint ROM (Range of Motion)- active range of motion.
ii. Restraint skin assessment- Pulses intact, Skin intact, Skin Breakdown (no further assessment description of skin break down documented)
iii. Restraint Nutrition/Hydration- Offered, Other: Tumi syringe and thickened liquids.
iv. Evaluation of status in Restraints- No evidence of injury related to restraint, restraints applied properly.
c. Refer to finding E regarding observation of RN in P1's room for total of 12 seconds to perform and assess all documented activities.
d. Refer to finding I regarding active range of motion.
e. 11/27/2022 at 5:40 am:
i. Restraint ROM (Range of Motion)- active range of motion.
ii. Restraint skin assessment- Pulses intact, Skin intact, Skin Breakdown.
iii. Restraint Nutrition/Hydration- Offered, Other: Tumi syringe and thickened liquids.
iv. Evaluation of status in Restraints- No evidence of injury related to restraint; Restraints applied properly.
f. Refer to finding A regarding observation of RN entering room at 05:59:28, when P1 was found unresponsive.

N. Record review of P1, Provider Orders, dated 11/19-11/27/2022 reveals, "Turn Patient ... Q 2 hours (every 2 hours)." Initiated 11/19/2022 at 8:58 pm; discontinued 11/27/2022 at 2:41 pm.

O. Record review of facilities education module titled "Patient Restraint for Nurses," no date present, reveals slide 10, "intervention/Implementation:
a. Application (Continued) Potential physical and psychological harm are risks associated with restraint use even when properly applied. Potential complications include: ... Joint injury, strain, fractures
ii. Restriction of blood flow
iii. Difficulty breathing
iv. Risk of aspiration
v. Inability to communicate
vi. Loss of control and feeling helpless ...
vii. Death from strangulation or asphyxiation."

Patient Death:
P. During an interview with Staff (S)22, Medical Doctor (MD) on 12/06/2022 at 2:01 pm, when asked if S22 felt P1 was clinically improving (from the subdural, subarachnoid hemorrhages, and pneumocephalus), S22 states "yes."

Q. Record review of P1, "Death Packet," dated 11/27/2022 at 7:15 am, reveals, "Presumed cause of death: traumatic intracranial hemorrhage. Other significant conditions: acute myocardial infarction (heart attach)."

R. During an interview with S23, MD, MD Resident Program Director, on 12/06/2022 at 2:01 pm, when asked what S23 thought the primary cause of death was for P1, S23 sates, "The most likely scenario is that [P1] had a big PE (Pulmonary Embolism: when a blood clot travels from a part of the body and becomes lodged in the lungs, preventing gas exchange, which can cause death) or a cardiac event. [P1] was definitely at risk for PE because [P1] was a trauma patient."

S. Record review of National Library of Medicine's peer reviewed article titled "Incidence of deep vein thrombosis in restrained psychiatric patients," dated 07/09/2013 [authors names identified], reveals, "The incidence of DVT (deep vein thrombosis) in restrained ... patients was not low (DVT detected in 11.6%) in spite of prophylaxis. These findings emphasize the importance of regular screening of and thorough assessments of DVT, especially in restrained psychiatric patients."

T. Record review of P1, Provider Orders, duration of admission dated 11/19-11/27/2022, reveals the following orders:
a. Olanzapine (Zyprexa: a medication under the drug class antipsychotic, used to treat psychotic features) 2.5 mg (milligrams: a unit of measurement) IV (intravenous, administered directly into the blood stream through an intravenous catheter) Q4hr (every 4 hours). Ordered 11/21/2022 at 10:58 pm; discontinued 11/26 at 4:49 pm.
b. Seroquel (Quetiapine: under the drug class antipsychotic, used to treat psychotic features) 25mg PO (by mouth) QHS (at bedtime). Ordered 11/22/2022 at 9:00 pm; Discontinue 11/27/2022 at 2:41 pm.
c. Refer to finding S.

U. Record review of P1, Provider Notes, dated 11/19/2022 at 12:56 pm, reveals, "Possible retracted and malpositioned (sic) pacemaker lead projecting over left chest wall ... Consider cardiology evaluation." Signed by Doctor of Osteopathy (DO).

V. Record review of P1, EMR, dated 11/19-11/27/2022, shows no evidence of cardiology consult or evaluation performed.

W. Record review of P1, EMR, dated 11/19-11/27/2022 reveals ECG (electrocardiogram: diagnostic test performed to view electrical conduction within the heart):
a. 11/19/2022 at 4:59 am: "Ventricular-paced rhythm ... 193 BPM (beats per minute: normal rate is 70-100) ... Left inferior infarct, age undetermined ... Abnormal ECG."
b. 11/21/2022 at 10:29 am: "AV (Atrioventricular) dual-paced rhythm ... Abnormal ECG."

X. Record review of P1, Provider Notes, dated 11/20/2022 at 8:48 am, reveals, "Hx, (history) of RV (right ventricle) failure with pacemaker placement, atrial fibrillation, CAD (coronary artery disease) with cardiac stents, HTN (hypertension)."

Y. In an interview with S23, MD on 12/06/2022 at 2:41 pm, when asked if sub-acute care (SAC) level of care normally has cardiac monitoring, S23 confirms, "Correct."

Z. In an interview with S7, RN on 12/05/2022 at 8:55 am, when asked if patients in restraints are required to be on a monitor (cardiac/telemetry monitor), S7 states, "yeah, they should be on a monitor."

AA. In an interview with S10, Charge RN, on 12/02/2022 at 10:40 am, when asked how frequently a patient is assessed while in restraints, S10 states, "We're required to chart it every 2 hours." When asked, how a patient (in restraints) is assessed when asleep, S10 states, "You still assess them. You can undo the restraints and check restraints. They should be on monitors as well so you can see the O2 (oxygen) and heart rate. The monitor allows us to check those things even if the patient is asleep."

BB. Record review of P1, Provider Orders, dated 11/19/2022-11/27/2022, reveals two separate orders:
a. "Cardiac Monitoring- Ok to be off monitor? No, suggested duration: indefinite. Ordered 11/19/2022 at 7:54 am; discontinued 11/26/2022 at 8:41 am.
b. Cardiac Monitoring- Continuous. Ordered 11/19/2022 at 7:45 am; discontinued 11/27/2022 at 2:21 pm."

CC. Record review of P1, Provider Orders, dated 11/26/2022 at 8:41 am, reveals an order for vital signs Q 4 hours (every 4 hours). Discontinue 11/27/2022 at 2:41 pm.

DD. Record review of P1, EMR, dated 11/19-11/27/2022, shows last set of documented vital signs occurred on 11/27 at 12:00 am, for a total lapse in 5 hours 59 minutes.

EE. Record review of P1, Provider orders, dated 11/19/2022 at 7:45 pm, discontinue 11/27/2022 at 2:41 pm, documents, "Presumed Full Code."

FF. Observation of facilities video footage for [name of unit] dated 11/26/2022 7:00 pm-11/27/2022 7:30 am, reveals RN1 assigned to P1's care does not re-enter P1's room until 05:59:28 am. At 06:00:41 am RN1 is visible in doorway, RN intern enters room at 06:00:43 am and PCT1 (patient care technician) enters room at 06:00:57 am. PCT1 exits P1's room at 06:01:28, cross hall to PCT workstation and re-enters P1 room at 06:01:35 (See finding on PCT checking code status). at 06:01:41 RN1 exits P1's room, walks to far end of hallway and returns with Charge RN(CRN)1 and CRN2. RN1, CRN1, and CRN2 enter P1's room at 06:02:23.

GG. Observation of facilities video footage for [name of unit] dated 11/26/2022 7:00 pm-11/27/2022 7:30 am, reveals no attempt to perform lifesaving efforts were made on P1, in alignment with P1's ordered "Full Code" status.

HH. Record review of P1, Discharge Summaries, dated 11/27/2022 at 1:44 pm, reveals, "[P1] was pronounced deceased on 11/27/2022 at 0640 (6:40 am). The patient's family was notified of his death and updated at bedside. At this time they declined an autopsy. His body will be transferred to the office of the medical investigator until transfer to his funeral home."

Based on record review and interview, the facility failed to attempt to implement the least restrictive restraint interventions for 1 patient (P1) of 10 (P1-P10) patients reviewed. This failed practice may have led to a violation of the patients' rights and patient death.
The findings are:

A. Record review of P1, Death Forms, dated 11/27/2022 at 7:41 am, reveals, "Admit Diagnosis and major event: ... Developed agitation in setting of TBI (traumatic brain injury: brain injury caused by trauma), SAH (subarachnoid hemorrhage: bleeding in specified area of the brain), SDH (subdural hematoma: bleeding in specified area of the brain) and hospital acquired delirium. Required restraints. Found unresponsive by nursing staff at 0605 (6:05 am)."

B. Record review of P1, Provider Notes, dated 11/26/2022 at 6:29 am, documents, "Assessment/Plan: ... #Acute Delirium ... #Agitation ... 4 point restraints for agitation."

C. Record review of P1, Provider Orders, dated 11/19-11/27/2022, reveals the following restraint orders for P1:
a. "11/20/2022 at 12:39 am: Order Details: ... Soft, No longer interfering w/ Nec Med Care(necessary medical care) Criteria for Release, Interfering with medical care.
b. 11/20/2022 at 12:39 am: Restraint monitoring: q 2 hours (every 2 hours).
c. 11/20/2022 at 9:03 am: Order Details: ... Soft, No longer exhibits violent behavior Criteria for Release, Interfering with medical care ... If the restraint indication is for violent behavior, order must be renewed q 8 hours for adults.
d. 11/21/2022 at 10:02 am: Order Details: ... Soft, No longer exhibits violent behavior Criteria for Release, Interfering with medical care ... If the restraint indication is for violent behavior, order must be renewed q 8 hours for adults.
e. 11/23/2022 at 10:37 am: Order Details: ... Soft, No longer interfering w/ Nec Med Care Criteria for Release, Interfering with medical care.
f. 11/23/2022 at 11:01 pm: Order Details: ... Soft, No longer exhibits violent behavior Criteria for Release, Interfering with medical care ... If the restraint indication is for violent behavior, order must be renewed q 8 hours for adults.
g. 11/25/2022 at 2:18 am: Order Details: ... Soft, No longer interfering w/ Nec Med Care Criteria for Release, Interfering with medical care.
h. 11/25/2022 at 12:47 pm: Order Details: ... Soft, No longer interfering w/ Nec Med Care Criteria for Release, Interfering with medical care.
i. 11/26/2022 at 10:48 am: Order Details: ... Soft, No longer interfering w/ Nec Med Care Criteria for Release, Interfering with medical care. "

D. Record review of facilities policy titled "Patient Restraints," dated 05/23/2022, reveals page1. Para 1, "Restraints are only used when less with appropriate and adequate clinical justification and when less restrictive interventions have been determined to be ineffective or inappropriate. Patients will not be restrained for convenience, discipline, retaliation, or coercion and when restraint is necessary, the least restrictive method of restraint will be utilized. Restraints will be discontinued at the earliest possible time based on the patient's assessment, regardless of scheduled expiration of the order ... Intervention/implementation:
a. Consider alternative, nonphysical interventions that may eliminate the need for restraint.
i. Pain, anxiety, or other comfort measures ...
ii. Place close to the nurse's station ...
iii. Use of 1:1 observation."

E. Record review of facilities education module titled "Patient Restraint for Nurses," no date present, reveals slide 6 & 7, "Intervention/implementation.
a. Alternatives and Preventative strategies:
i. the presence and support of family members, caregivers, or significant others with frequent visual, verbal, and tactile contact.
ii. placing the patient near the nurse's station.
iii. orienting frequently to time and place.
iv. addressing physical and emotional needs and comfort measures such as via pain or anxiety medications, food, drink, toilet, room temperature, pastoral services.
v. providing music or other distracting activities while preventing over-stimulation.
vi. arranging tubes out of reach or using options to cover sites.
vii. orienting to environment: call button, clock, calendar, objects within reach.
viii. providing mobilization opportunities.
b. The least restrictive type of restraint necessary to protect the patient must be ordered."

F. Record review of facilities policy titled "Patient Restraints," dated 05/23/2022, shows no addressment of differentiating between 2-point or 4-point restraint orders (a method of mechanical restraint in which a device is wrapped around an individual's limbs: wrists (2-point) or wrists and ankles (4-point) to limit mobility in order to prevent self-harm or harm to others; 2-point is less restrictive than 4-point), and is tethered to an immovable object e.g., the patients bed).

G. Record review of facilities [name of unit] map, shows P1's room is a distance of 4 patient rooms away from nurses' station, and no attempts to move patient closer to nurses' station as a least restrictive intervention. Refer to finding D.a.ii.

H. Record review of P1, Electronic Medical Record, dated 11/19-11/27/2022 shows no attempt to use least restrictive measures according to finding D.

I. In an interview with Staff (S)6, Associate Chief Nursing Officer (CNO), on 12/05/2022 at 4:13 pm, when asked how a Nurse will know a restraint order is for 2-point or 4-point restraints, S6 states, "I think it's implied that the restraint order is for 4-point unless a different specific order is put in for 2-point. I believe that's how the order set is set up."

J. In an interview with S7, RN, on 12/02/2022 at 8:25 am, when asked if a sitter (1:1 observation, refer to D.a.iii.) had been requested for P1, S7 states, "Not that I'm aware of. So even if we have a sitter, then we'll have to self-cover. We have to pull one of our techs from the floor. And even then, getting a sitter order from a doctor is like pulling teeth."

K. In an interview with S27, RN on 12/07/2022 at 12:04 pm, when asked what less restrictive measures may be used before escalating to restraints, S27 states, "Least restrictive is a telesitter, to remind them to stay in bed if they're redirectable. If they're not redirectable, then we have to resort to restraints. Also, we have mitts (a large, soft glove that covers the hand to prevent inadvertent dislodgement of medical equipment, it may be considered a restraint if used under certain circumstances or may be used as a less restrictive intervention than a mechanical restraint) if it's something small they can pull out mitts might work. If they pull the tube out (e.g., nasogastric tube: a medical device inserted through the nose into the stomach; endotracheal tube: a medical device inserted through the mouth (or nose) and trachea (the part of the body that leads from the mouth and nose to the lungs) in order to deliver oxygen to the lungs as a life-support measure, etc.) then we have to do the restraint." When asked if a restraint order specifies between 2-point and 4-point restraints, S27 states, "I don't think it specifies if its either 2-point or 4-point, I think its if they are in 2-point restraints initially, and then the patient starts kicking then you can put them in 4-point restraints. I don't like restraints because it increases agitation."

Based on record review and interview, the facility failed to meet the requirement by implementing a policy less stringent than the federal requirement A-0171 stipulating under §482.13(e)(8)(i): Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1 hour for children under 9 years of age, for all patients. This deficient practice may lead to a violation of the patients' rights, physical harm, psychosocial harm, and death.
The findings are:

A. Record review of facility's policy titled "Patient Restraints," dated 05/23/2022 reveals page 2.b.v "A physician or LIP (Licensed Independent Provider) must reassess the patient prior to renewal of restraints due to violent and aggressive behavior every 4 hours for children less than 17 years of age (yoa) and every 8 hours for adults 18 yoa and older."

B. In an interview with Staff (S)20, Director of Clinical Education, on 12/07/2022 at 1:04 pm, when asked what changes were made to the facilities Patient Restraint policy during the most recent review (occurring on 05/23/2022), S20 states, "We updated to talk about the time of the requirements ... the age of the person, how to initiate for patient exhibiting violent or aggressive behavior, and the age for how to monitor them."

Based on record review, interview, and observation, the facility failed to meet the Condition of Participation (CoP) for Nursing Services by failing to comply with the requirements as evidenced by the following:

A. The facility failed to ensure there was an appropriate number of Licensed Staff to meet patient needs for 24-hour nursing care. Refer to 0392.

B. The facility failed to initiate and assign lifesaving interventions as ordered. Refer to 0397.

C. The facility failed to ensure adherence to hospital policies and procedures. Refer to 0398.

Based on record review, interview and observation, the facility failed to meet the staffing and delivery of care requirement by not providing adequate numbers of Licensed Registered Nurses to provide nursing care to all patients as needed, in accordance with CMS guidelines, the International Journal for Quality in Health Care and the National Institute of Nursing Research. This failed practice may lead to patient neglect, harm, and death.

The findings are:

A. Record review of facilities policy titled, "Staffing of Patient Care Areas," dated 11/02/2020, reveals page 2.1, "Each patient care area maintains a staffing plan based on the acuity (level of care a patient requires) of the patient's condition, the level and scope of care to be provided, the frequency of the care to be provided, and a determination of the level of staff that can most appropriately (competently, comfortably, and confidently) provide the type of care needed."

B. Record review of facilities policy titled, "Staffing of Patient Care Areas," dated 11/02/2020 shows no patient to nurse ratio parameters based on patient acuity or needs.

C. Record review of the International Journal for Quality in Health Care's peer reviewed article titled, "Nurse staffing and patient safety: current knowledge and implications for action," dated August 2003, reveals page 1 para 1, "The addition of one patient to a registered nurse's workload was associated with a 7% increase in mortality ... [name of reference et al.] found an association between nurse staffing levels and 'failure to rescue', defined in that study as death among patients who had one of five complications (pneumonia, sepsis, shock or cardiac arrest, upper gastrointestinal bleeding, and deep vein thrombosis) ... therefore, on balance we believe the conclusion that should be drawn from these studies is that there is a strong ... case for an impact of nurse staffing on mortality."

D. Record review of the National Institute of Nursing Research's peer reviewed article titled, "Evidence that Reducing Patient-to-Nurse Staffing Ratios Can Save Lives and Money," dated 05/01/2021, [names of authors acknowledged], reveals, "A recent study ... examined variation in patient-to-nurse staffing in NY hospitals and its association with adverse outcomes (i.e., mortality and avoidable costs) ... importantly, each additional patient per nurse increased the likelihood of death, length of hospital stays and chances of being readmitted to the hospital within 30 days. The authors concluded that improving hospital nurse staffing would likely save thousands of lives per year."

E. In an interview with Staff (S)10, Registered Nurse (RN), on 12/02/2022 10:40 am, when asked how many patients S10 typically cares for per shift, S10 states, "Per shift I would say 5. The day of the incident (Refer to Tag-0144), I was relief charge (Supervisory RN), so I was required to also take 5 patients, and be at the desk, so a HUC (Health Unit Coordinator) basically, answering phone calls and telling nurses this room is calling or support them, and having to chart for my own patients as well." When asked if S10 felt it is safe to have 5 patients (at the sub-acute care (SAC) level of care), S10 states, "No. I would say why, is situations like this (refer to Tag-0144). When we have codes, the charge (RN) is the one supposed to direct codes, have your own patients, and be at the desk as well." When asked if S10 felt anything may have caused a different outcome (refer to 0144), S10 states, "Yes, Covid has really struck this hospital bad because there's no core staff. We get floated because every other unit is not able to have core staff. When we get floated, we see every other unit is travel nurses and they are in disarray. They're not hiring staff appropriately ... incidents like this will continue to happen because of not hiring. And unfortunately, because our ICU is overrun, we'll take ICU patients and have to upgrade them like two days later."

F. Observation of [name of unit] on 12/05/2022 at 11:20 am, revealed patient assignment board designating 4 RN's on shift (including Charge RN), and 20 patient census. Each RN, to include Charge RN was assigned 5 patients.

G. In an interview with S25, RN, on 12/05/2022 at 11:30 am, when asked if S25 felt they were able to safely care for assigned patient load, S25 states, "It's hard with 5 patients and a covid patient. Normal patient ratio should be 4:1 (four patients to 1 RN) We were sent an email that 5:1 was going to be the ratio for now ... I don't think that's safe. It feels like it's just clearing out the task list. It's a patient safety issue."

H. In an interview with S28, Charge RN, on 12/05/2022 at 12:45 pm, when asked about patient census and assignments, S28 states, "unit is a 25-patient capacity, with 25 patient census today. Each RN is assigned 5 patients, Charge RN has 5 patients as well. We have 1 tech (Patient Care Technician). Epilepsy monitoring has 1 tech. no HUC (Health Unit Coordinator). No restrained patients today. Typically, we have 3 techs. Ideally charge (RN) is free. Used to be 4:1 but has changed in last few months."

J. In an interview with S7, RN on 12/02/2022 at 8:25 am, when asked how many patients S7 typically cares for in a shift, S7 states, "5. That is not normal. That is a consequence of staffing ratios. But typically, on the [name of unit] floor, all nurses will have 4 patients."

K. In an interview with S15, Executive Director of Clinical Services, on 12/05/2022 at 3:15 pm, S15 states, "We don't have any patient ratios built into any of our policies." When asked at what point the facility begins to cap beds (limit the number of beds that can be filled based on resources available), S15 states, "There's only two things you can do when you're critical, you can either add more beds or you can add more human resources."

L. Refer to tag 0144 regarding care in a safe setting, patient neglect, and death.

Based on record review, interview, and observation, the facility failed to assign and initiate cardiopulmonary resuscitation (CPR), and Advanced Cardiac Life Support (ACLS) on an ordered full code (all life saving measures to be taken) patient for 1 patient (P)1 of 10 (P1-P10) patients reviewed. This failed practice led to a violation of the patients' right to informed consent, and death.

The findings are:

A. Record review of facilities policy titled, "Code Status Orders and Advance Directives," dated 10/19/2022, reveals page 1, "1. Code Status Orders: ...
b. A Code Status Order should be obtained for all adult patients admitted to the hospital regardless of the reason for admission ...
c. A Code Status Note is required for all adult patients. In the event the patient is not decisional, a surrogate decision maker should be identified. This should be documented in the Code Status Note ...
g. In the event the patient's decisional capacity is impaired and there is no Advance Directive available nor is a surrogate decision-maker available, the patient is presumed to be Full Code. Staff will continue attempts to locate an appropriate decision-maker for the patient as soon as possible. The code status order will be rewritten once confirmed. If the patient or surrogate wishes the "Full Code" order to remain, it will be re-written as "Full Code (confirmed)" ...
h. For the purposes of this procedure, a Code Status Order stating "Do Not Resuscitate" or "No Code" means that in the event of a cardiopulmonary arrest, none of the following interventions will be initiated:
i. Cardiopulmonary resuscitation (CPR)
ii. Electrical defibrillation/cardioversion
iii. Cardiac pacing
iv. Mechanical ventilation
v. Intubation (endotracheal or nasotracheal)
vi. Manual bag/mask ventilation
vii. Tracheostomy
viii. Administration of medications for the purpose of cardiopulmonary resuscitation (this includes, but is not limited to, vasoactive agents, pressor agents, antiarrhythmic agents, or sodium bicarbonate)."

B. Record review of P1, Provider Orders, dated 11/19/2022 at 7:45 am; discontinue 11/19/2022 at 7:47 pm, documents, "Presumed Full Code."

C. Record review of P1, Provider orders, dated 11/19/2022 at 7:45 pm, discontinue 11/27/2022 at 2:41 pm, documents, "Presumed Full Code."

D. Observation of Facilities video of [name of unit] hallway, dated 11/26/2022 7:00 pm-11/27/2022 7:30 am, reveals registered nurse (RN)1 enters P1 room at 04:06:18 am and exits P1's room at 04:06:30 am. No one enters P1's room until 05:39:34 am when Charge Nurse (CRN)2 enters (to update whiteboard, per staff interview), and exits P1's room at 05:40:26 am. At 05:59:28 am RN1 enters P1's room and re-emerges in P1's doorway at 06:00:41 am. At 06:00:43-06:00:57 am patient care technician (PCT) and RN intern enter P1's room. At 06:01:28 am PCT exits P1's room, walks across hallway (to check P1's code status, per staff interview) and re-enters room at 06:01:35 am. RN1 exits P1's room at 06:01:41 am, walks to end of hallway, enters farthest room and re-emerges with CRN1 and CRN2, all three enter P1's room at 06:02:23 am. At 06:04:43 am Charge RN2 exits P1's room. At 06:05:23 am CRN1 exits P1's room. At 06:06:25 am RN2 enters P1's room. At 06:12:30 am RN1 exits P1's room, walks across hall, retrieves a rolled towel (used in post-mortem care), and re-enters P1's room at 06:13:09 am. At 06:18-06:20 am Rn1, RN2, RN intern, and PCT exit p1's room. At 06:45 am Rn1, RN2, RN intern, PCT and Provider enter P1's room, and all exit at 06:51-06:52 am, all exit P1's room.

E. Observation of Facilities [name of unit] Video dated 11/26/2022 7:00 pm-11/27/2022 7:30 am, shows no evidence of "Code Blue" (initiation of lifesaving measures, refer to A.h.) being called or performed for P1.

F. Record review of P1, Electronic Medical Record (EMR), dated 11/19-11/27/2022, shows no documentation that a Code Blue or rapid response was initiated or performed for P1.

G. In an interview with Staff (S)7, RN on 12/02/2022 at 8:25 am, when asked when a code blue is called, S7 states, "Whenever you find someone down or unresponsive, in asystole (no cardiac conduction evident). It doesn't necessarily just have to be that too. You can run a code if the patient is in a lethal rhythm, if oxygen is de-sating (drop in oxygen saturation), anything that we feel is going to impede with life- we'll run a code."

H. In an interview with S10, RN on 12/02/2022 at 10:40 am, when asked whose responsibility it is to call a code, S10 states, "anyone who finds the patient. It can be the nurse, the tech, whoever finds the patient first is allowed to call a code blue."

I. In an interview with S12, RN intern, on 12/02/2022 at 12:00 pm, S12 states, "[RN1] stepped out of the room (P1's room) and asked if this patient is dead. Immediately, looking at the patient, I thought this guy looked like he had been dead for awhile." When asked what made S12 think that, S12 states, "just his skin tone, his skin coloration. He had lost that color. Super pale. His mouth was dropped. His chest wasn't rising. It looked like he had been gone for awhile ... he was cool."

J. In an interview with S12, RN intern, on 12/02/2022 at 12:00 pm, when asked whose responsibility it is to call a code, S12 states, "Anyone can call a code." When asked why S12 didn't call a code, S12 states, "I think I was just kind of struck. After I listened to him and felt all his pulses one of my first questions was is he a full code? The tech said yes and so did [RN1]. That's when it was determined he was a full code. No one started a full code."

K. Record review of P1, Provider Notes, dated 11/27/2022 at 7:00 am, documents, "Trauma team notified that patient found deceased at 0605 (6:05 am) by nursing staff. Staff reported patient last observed in bed at 0545 (5:45 am). Trauma provider to bedside to evaluate patient. Confirmed time of death 0640 (6:40 am) family notified of event."

L. Refer to tag A-0144 regarding patients' right to care in a safe setting, and patient death.

Based on record review, interview, and observation, the facility failed to ensure the adherence of policies and procedures by Licensed Nursing staff, Telemetry Technicians, and Medical Records Staff within the facility for patient (P)1 of 10 (P1-P10) patients reviewed. This failed practice is likely to lead to adverse events, patient neglect, harm, and death.

The findings are:

A. Record review of facilities policy titles, "Cardiac Hardware and Telemetry Monitoring-admit, discharge and documentation," dated 11/06/2020, reveals page 2 para 2, "Process: inpatient and procedural areas
1. Institution of hardware or telemetry monitoring
1.1. Hardware or telemetry monitoring will be instituted with a Licensed Independent Providers (LIP's) order.
1.2. Hardware or telemetry monitoring may also be instituted without an order if the nurse deems it medically necessary ...
3. Routine patient monitoring and documentation: ...
3.2.2. At the beginning of every shift, with a change in caregiver, or with every new admission, the monitor tech and assigned nursing personnel on inpatient units are required to:
3.2.2.1. For patients on cardiac or telemetry monitoring, graph and measure rhythm strips, documenting:
3.2.2.1.1. HR (Heart Rate)
3.2.2.1.2. QRS (a measurement of a specified interval in the electrical conduction of the heart)
3.2.2.1.3. PR interval (a measurement of a specified interval in the electrical conduction of the heart)
3.2.2.1.4. QT interval (a measurement of a specified interval in the electrical conduction of the heart)
3.2.2.1.5. ST segment abnormalities (a measurement of a specified interval in the electrical conduction of the heart)
3.2.2.1.6. Interpretation of rhythm
3.2.2.1.7. Any abnormalities noted
3.2.2.1.8. SpO2 (oxygen saturation in the blood) if not indicated on strip
3.2.2.2. For patients on SpO2 monitoring only, graph and document SpO2%.
3.2.2.3. Rhythm strips need to become part of the electronic medical record
3.2.2.3.1. Print strip, document the above (3.2.2.1) on the strip and place in hard chart to get scanned into the electronic medical record upon discharge
3.2.2.3.2. Nursing can also document the measurements in the I-View in the EMR."

B. Record review of P1, Provider Orders, dated 11/19/2022-11/27/2022, reveals two separate orders:
1. "Cardiac Monitoring- Ok to be off monitor? No, suggested duration: indefinite. Ordered 11/19/2022 at 7:54 am; discontinued 11/26/2022 at 8:41 am.
2. Cardiac Monitoring- Continuous. Ordered 11/19/2022 at 7:45 am; discontinued 11/27/2022 at 2:21 pm."

C. Record review of P1, EMR, 11/19/2022-11/27/2022, shows no Telemetry Strips documented or scanned into patient chart.

D. In an interview with Staff (S)3, Regulatory Consultant, on 12/06/2022 at 10:51 am, when asked to procure telemetry strips for P1 that have not yet been scanned into P1's chart, S3 states, "We cannot find them."