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Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to meet the Patient Right's Condition of Participation by failing to maintain constant observation for patients and ensure care in a safe setting for 4 of 4 patients observed for constant observation in the Emergency Department.

Findings are as follows:

The facility failed to maintain constant observation for patients who were identified as suicidal risk and required constant observation (Patient ID#'s 12,15,16,and 17).
(refer to F 144).











41728

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide care in a safe setting, relative to patient observation in the Emergency Department (ED) for 4 of 4 patients observed (Patient ID #s 12, 15, 16 and 17).

Findings are as follows:

The Hospital's policy for Safety Sitter, last revised on 5/22/2017 states in part;

"Purpose: To establish guidelines for the care of patients requiring increased observation in order to maintain safety.

Safety Sitter-Suicidal Ideation/Attempt
- All patients presenting with Suicide Ideation/Attempt will have a constant observation by a sitter until the behavioral health provider deems it is no longer necessary ...
- The patient's hands, arms, neck and face will be visualized at all times by the sitter, including when patient is sleeping, using the bathroom, and when visitors are present...

Documentation: Safety checks are documented on a Constant Observation flow sheet which will be scanned into the patient's electronic medical record ..."

The Procedures section of the policy describes hospital approved Lippincott procedures as resource material to be utilized, including, but not limited to:

Lippincott Procedure: Special Nursing Observation, Psychiatric Patient which includes the following:

"-Keep the patient under constant visual observation to prevent the acutely disturbed patient from causing harm to self or others. Position yourself close enough to the patient that you can intervene immediately...
-Rotate staff observers at least every 2 hours (and possibly more frequently for more challenging patients) and as needed for meals and other tasks to maintain continuous attentive observation..."

On 12/5/2019 surveyor reviewed the "Constant Observation Log" which is to be utilized by each shift sitter to document the patient's status in 15-minute increments. The sitter is also responsible for initialing the 15-minute check, when completed.

1. Record review for Patient ID #12 revealed s/he presented to the hospital ED reporting suicidal ideation, anxiety, depression and substance abuse.

Review of the "Sitter Need Evaluation" dated 12/4/2019 describes the patient as agitated, a danger to self and others, and as a wandering/flight risk. The evaluation determined a sitter was required for this patient.

On 12/5/19 at 9:45 AM, upon entering the area where patient ID #12's room was located, surveyor observation revealed that there was no staff member present observing patient ID #12. Approximately 5 minutes later, upon the sitters return to the observation area, review of the "Constant Observation Log" revealed the log lacked documentation from 9AM-9:45AM.

During an interview on 12/5/2019 at 9:50AM, with Staff A, who was responsible for providing sitter services, she acknowledged that she did not document the patient observations at 9:00AM, 9:15AM, 9:30AM and 9:45AM, as per policy. Staff A could not provide evidence that she was in the observation area during this timeframe.

During an interview on 12/5/2019 at 10:00AM with the ED Nursing Director and the ED Professional Development Nurse, both acknowledged that the sitter was not in the observation area when surveyor was present. They stated the expectation is for the sitter is to remain in the area of observation and/or is responsible for requesting relief if leaving the area.

2. Record review for Patient ID #15 revealed s/he presented to the hospital ED reporting suicidal thoughts stating, "I just don't belong in this world." S/he also stated s/he has a history of PTSD (Post traumatic stress disorder) and had been drinking heavily all day because of thoughts of suicidal ideation.
Review of the "Sitter Need Evaluation" dated 12/9/2019 at 9:20AM indicated the patient was described as a danger to self and others. The evaluation determined a sitter was required for this patient. .

Record review for Patient ID #16 revealed s/he presented to the hospital ED after overdosing on Heroin. Once alert, the patient acknowledged having suicidal thoughts and a plan to commit suicide.
Review of the "Sitter Need Evaluation" dated 12/9/2019 described the patient as a danger to self and others. The evaluation determined a sitter was required for this patient.

Record review for Patient ID #17 revealed s/he presented to the hospital ED after cutting his/her wrist with an unknown object and feeling suicidal.
Review of the "Sitter Need Evaluation" dated 12/8/2019 described the patient as a danger to self and others, a high risk for fall, and a wandering/flight risk. The evaluation determined a sitter was required for this patient.

Surveyor observation on 12/9/2019 at approximately 9:20AM revealed one sitter, Staff B, sitting on the opposite side of the hallway, in the area of Patient ID #'s 17 and 16 rooms, and out of the line of vision for Patient ID #15, who was approximately 15-20 feet away from the sitter.

During a surveyor interview with Staff B on 12/9/2019 at 9:30AM, she acknowledged that she was responsible for providing sitter services for Patient ID #'s 15, 16 and 17. She also acknowledged that she was not able to provide constant supervision, as ordered, to all 3 patients. She further stated that she would "get up every 15 minutes" to check on the patient she could not visualize. Staff B stated she was aware that as a sitter, it was her responsibility to have the patient in her line of sight, but that it's not realistic when a sitter is assigned more than 2 patients to observe.

During an interview on 12/9/2019 at 10:00AM with the ED Nursing Director, he acknowledged that the sitter was not able to provide direct observation for all 3 patients simultaneously.

During an interview with the ED Professional Development Nurse on 12/9/2019 at 10:10AM, she stated that the expectation is that a sitter should never be assigned to more than 2 patients.

During an interview with the ED Professional Development Nurse on 12/10/2019 at approximately 11:00AM, she was unable to provide evidence that the facility's policy and procedure was followed relative to the constant supervision criteria for the suicidal patient, the sitter maintaining line of sight observation for the suicidal patient, and staff rotation for the sitter position.


















41728

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to implement action plans, measure its success and track performance to ensure that improvements were sustained related to the medication error on 9/19/2019 for Patient ID #1.

Findings are as follows;

Record review revealed that on 9/19/2019 Patient ID #1 presented to the hospital Emergency Department (ED) with syncope (fainting) and severe bradycardia (low heart rate). His/her past medical history included, but is not limited to, permanent atrial fibrillation, coronary artery disease, and severe pulmonary hypertension.

Additional record review of the cardiology Clinical Consultation Report from 9/19/2019 revealed "unfortunately, s/he accidentally received a dose of Digoxin 0.5mg IV in the ER", instead of Digibind. Following the hospital's identification of this error on 9/19/2019, an incident report was complete, and the hospital implemented a plan of correction including the following interventions which were to be implemented by the pharmacy:

-Stock Digibind in the ED with a minimum quantity of 10 vials
-Digibind and Digoxin will be marked as look alike, sound alike drugs

During a surveyor observation of the ED Medication Room with the Associate Vice President (AVP) of Quality and Regulatory Compliance and the charge nurse,
Staff F, on 11/29/2019 at 8:55AM, there was no Digibind medication stocked in the ED nor was there a look alike/sound alike notification when the charge nurse attempted to dispense Digoxin.

During an interview with the Pharmacist responsible for Medication Safety on 11/29/2019, he could not provide evidence that Digibind was stocked in the ED or that the warning for lookalike sound alike medication was implemented as per the plan of correction.

Additional surveyor observations on 12/23/2019 at approximately 12:00 PM revealed 10 vials of Digibind stocked in the ED medication refrigerator. Review of the pharmacy stock log revealed this medication had been stocked on the ED unit medication room on 11/29/2019 immediately following the surveyor's previous observation.

During an interview with the ED nurse manager on 12/23/2019 at approximately 12:50 PM, the nurse manager completed a removal of the digibind from the pyxis, to show that the look-a-like warning would display on the computer screen before the medication was dispensed.

During an interview with the Risk Manager on 12/23/2019 at approximately 2:00 PM, she stated after review of the policy by leadership, there will be no changes to the policies. There will be an emphasis placed on training nurses.









41728

The following failures resulted in a Nursing Services Condition level citation.

Findings are as follows;

1.The hospital failed to follow their own "Provider Orders" policy relative to medication administration for 1 of 3 patient's, Patient ID #1, in the Emergency Department.(refer to A-0405)

2. The hospital failed to follow their own policy relative to the "Rapid Response Team" policy for 1 of 1 patient's, Patient's ID #1 (refer to A-0405).

3. The hospital failed to follow their own policy relative to "Safety Sitter" for 4 of 4 patient's, Patient ID #'s 12, 15, 16 and 17 (refer to A-0392).

4. The hospital failed to provide an adequate number of other personnel to provide safety sitter care for 4 of 4 patient's, Patient ID #'s 12, 15, 16 and 17 (refer to A-0392).





41728

Based on surveyor observation, record review and staff interview, it has been determined that the hospital failed to provide adequate numbers of other personnel to provide safety sitter care to all patients as needed for 4 of 4 who required constant observation (Patients ID #s 12, 15, 16 and 17).

Findings are as follows;

The Hospital's policy for "Safety Sitter", last revised on 5/22/2017 states in part;

"Procedures: Staff follows procedures and skills in hospital approved resource material included but not limited to:
...Lippincott Procedure: Special Nursing Observation, Psychiatric Patient
-Keep the patient under constant visual observation to prevent the acutely disturbed patient from causing harm to self or others. Position yourself close enough to the patient that you can intervene immediately...
-Rotate staff observers at least every 2 hours (and possibly more frequently for more challenging patients) and as needed for meals and other tasks to maintain continuous attentive observation..."

1. Record review for Patient ID #12 revealed s/he presented to the hospital ED reporting suicidal ideation, anxiety, depression and substance abuse.

Review of the "Sitter Need Evaluation" dated 12/4/2019 describes the patient as agitated, a danger to self and others, and as a wandering/flight risk. The evaluation determined a sitter was required for this patient.

Review of the "Continuous Observation Log" for Patient ID # 12 revealed that the sitter, Staff D, was assigned to provide constant observation to the patient on 12/4/2019 during the 3PM-11AM shift. During that time, the "Constant Observation Log" has Staff D's initials for the entire 8-hour shift.

Additionally, review of the "Continuous Observation Log" for Patient ID #12 revealed that the sitter, Staff E, was assigned to provide constant observation to the patient on 12/5/2019 during the 11PM-7AM shift. During that time, the "Constant Observation Log" has Staff E's initials for the entire 8-hour shift.

During a surveyor telephone interview with Staff D on 12/5/2019 at 11:10AM, she stated that she recalled sitting for the patient on that evening. She stated that in the role of sitter, she generally does not take breaks/lunch as there is no one available to relieve her. She recalled that on this shift she was relieved one time in order to use the restroom.

During a surveyor telephone interview with Staff E on 12/5/2019 at 11:00AM, she stated that she recalled sitting for Patient ID #12 during the night shift. She recalled it was a busy night and that short breaks are allowed only if "someone takes over", which is rare.

The record lacked evidence that staff switched off with another staff person after the completion of 2 consecutive hours per the facility's policy.

2. Record review for Patient ID #15 revealed the "Sitter Need Evaluation" dated 12/9/2019 described the patient as a danger to self and others and determined a sitter was required for this patient.
Record review for Patient ID #16 revealed the "Sitter Need Evaluation" dated 12/9/2019 described the patient as a danger to self and others and determined a sitter was required for this patient.
Record review for Patient ID #17 revealed the "Sitter Need Evaluation" dated 12/8/2019 described the patient as a danger to self and others, a high risk for fall, and a wandering/flight risk and determined a sitter was required for this patient.

During a surveyor interview with registered nurse (RN), Staff C, she stated that she was the RN responsible for Patient ID #'s 15, 16 and 17 and that "all of the patients should have a 1:1 sitter." She stated that staffing is generally the issue as to why the patients are not monitored as recommended.

During an interview with the ED Professional Development Nurse on 12/9/2019 at 10:10AM, she stated that the expectation is for a sitter to never be assigned to more than 2 patients; however, sitter staffing availability has been challenging.

During an interview with the ED Professional Development Nurse on 12/10/2019 at approximately 11:00AM, she was unable to provide evidence that the facility's policy and procedure was followed relative to the constant supervision criteria for the suicidal patient, maintaining line of sight observation for the suicidal patient, and staff rotation for the sitter position.








41728

Based on record review and staff interview, it has been determined that the hospital failed to administer medication in accordance with physician's order for 1 of 3(Patient ID #1) in the Emergency Department.

Findings are as follows:

Surveyor review of the hospital's internal investigation and plan of correction dated 9/26/2019 for a medication error which occurred on 9/19/2019 in the Emergency Room (ED). The document revealed an error in communication regarding verbal orders from the physician to the nurse(s), resulting in the patient receiving the wrong medication. The patient recieved in error, Digoxin medication instead of Digibind medication.

During an interview with the Associate Vice President of Quality and Regulatory Compliance, she confirmed that Patient ID #1 received the Digoxin medication in error.






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