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Based on record review, staff interview, facility policy and videotape review, the facility failed to assure the Medical Director and Director of Nursing adequately monitored the appropriateness of care provided to a patient (C1) who died on 7/3/11. The facility began a root cause analysis following the death of patient C1, who was found unresponsive in bed by nursing staff at 3a.m. on 7/3/11, and pronounced dead with rigor mortis at 3:16a.m. on 7/3/11. However, the draft of the root cause analysis shown to the surveyor on 7/19/11 did not clearly identify several deficiencies found by the surveyor as problems needing correction. Review of a videotape from the unit where C1 was housed revealed that nursing staff did not properly perform 15 minute patient rounds/checks, and did not begin timely CPR/Code procedures when patient C1 was found unresponsive. Nursing staff were not sufficiently aware of the seriousness of the patient's condition to immediately proceed with CPR/code blue procedures. Although administrative staff acknowledged these deficiencies and stated that they planned to retrain nursing staff on patient rounds/checks and CPR/code blue procedures, at the time of the survey (2 weeks after the patient's death), the retraining had not been scheduled and there was no documentation that any staff had received the retraining. These failures led to an IMMEDIATE JEOPARDY for the facility on 7/19/11 at 2:30p.m., and the Director of Quality Assurance/Director of Nursing and the Director of Inpatient Care were notified of the IJ.


Refer to B144 for the Medical Director's failure ensure the quality of medical services, and refer to B148 for the Director of Nursing's failure to assure adequate nursing care.