HospitalInspections.org

Based on staff interview, open and closed record reviews, and policy and procedure review,
the hospital failed to implement a system to provide care in a safe setting for each patient who needed a sitter constantly with the patient when it failed to provide a sitter to continually observe a patient, known by facility staff to abuse drugs, when an unidentified white-colored substance was found in the patient's IV (intravenous) line. Although the physician ordered that Patient #15 was to have a sitter continually with the patient (a "constant sitter"), the facility did not provide one and the patient died. Although by 11/18/09 hospital staff had identified the procedure regarding a constant sitter failed and resulted in many variations of practice, at the time of this survey, the hospital staff had failed to implement any corrective action. This failure left patients who required this special care and service to be in immediate jeopardy for their health and safety.

The severity and cumulative effect of the systemic practice resulted in the hospital being found out of compliance with 42 CFR (Code of Federal Regulations) 482.13 - Condition of Participation: Patient's Rights.

See the deficiency at A-0144.

Based on interviews, closed record review, policy review, and review of the procedure for a sitter to stay constantly with a patient, the facility failed to provide a safe environment for one of one (Patient #15) patients who expired after being assessed as needing a constant observation sitter and the physician's order for such an individual. Fifteen open and two closed records were reviewed The facility census was 345.

Findings included:

1. The hospital admitted 26 year-old Patient #15 to the hospital on:

- 08/24/09 with a Grade 2B open right tib/fib (tibia or shin bone of the leg and fibula or calf bone in the leg) fracture after a motorcycle accident;
- 09/25/09 with wound dehiscence (separation of the layers of a surgical wound) and dressing changes;
- 10/13/09 with ulceration (break in the skin), wound dehiscence, persistent drainage and cellulites (an inflammatory process caused by bacterial infection of the dermis and underlying subcutaneous tissues of the skin), a limb-threatening problem, and potential life-threatening infection; and
- on 10/15/09 the patient was again admitted for hardware removal, debridement (removal of dead, damaged, or infected tissue), and wound irrigation.

Review of the documented timeline of events on Patient #15 provided by hospital staff revealed it was suspected that the patient had been tampering with his Morphine PCA (patient controlled analgesia [painkilling] pump) and intravenous (IV) site throughout his/her stay.

Review of the patient timeline documentation revealed the following events:

- On 10/17/09 at 7:30 p.m., with end of IV tubing in hand, the patient requests an alcohol swab because "my tubing popped off of the PICC [peripherally inserted central catheter] line." The nurse noted a foreign object in the tip of the tubing. The physician was paged.
- 7:50 p.m., the physician telephoned orders to the nurse for a constant observation sitter and to discontinue the IV, however no sitter was available and none was provided.
- 8:30 p.m., stafff administered the patient Oxycontin CR (pain medication with controlled release) and Ambien (sedative medication for short-term insomnia).
- 9:10 p.m., the patient's C-pap (a machine used for respiratory ventilation) alarms and it was discovered that the IV tubing had been pulled off. Nursing staff replaced the IV tubing.
- 11:30 p.m., Staff Nurse W, RN (Registered Nurse) informed the Nursing Supervisor, Staff T, RN, of the suspected IV tampering, the physician's order for a constant sitter, and that no sitter was available. The patient was then given Oxy IR (immediate-release oxycodone tablets) 2 tabs (tablets) for pain.
- On 10/18/09 at 4:14 a.m., nursing staff administered the patient Oxy IR 2 tabs for pain.
- 4:25 a.m. - 4:35 a.m. reveals that the BiPap (breathing apparatus that helps get more air into the lungs) alarm sounded and nursing staff found Patient #15 in distress, resisting face mask, and requesting intubation. The CAT (critical assessment team) team was called for a code blue (term for cardiopulmonary arrest).
- 5:04 a.m. the code was terminated and Patient #15 expired.

Review of the Coroner's Report "FINAL DIAGNOSES OF THE BODY OF [name of patient]", dated 10/10/09, and signed by the Green County Medical Examiner found it stated in part:

I. Lungs, Abundant Intravascular Foreign Polarizable Crystalline Material Consistent with Talc
a. Foreign Substance Consistent with Crushed Oxycodone Tablets Placed in Morphine Pump Tubing (Record)
b. [Coroner's] OPINION: In my opinion, the cause of death of [name of patient] is a Pulmonary Embolism due to Intravenous Talc, and the manner of death is Accident.

During an interview on 04/05/10 at 3:25 p.m., Staff M, RN, Director of Nursing, Nursing Administration, stated that sitters are "always covered". Staff M stated there is no written policy for the constant observation procedure. Staff M also stated that nursing always covers if a sitter is not available.

Registered nurses T, U, V, and W were interviewed on 04/07/10 at 8:35 a.m. Staff Nurse W stated that the patient was received from the 8th floor by bed transfer. She stated that very soon afterward a white substance could be seen in the patient's IV line, and, "We knew the patient's history of drug use." Staff Nurse W stated the inability to obtain a sitter as ordered was discussed with supervisor Staff T, and their supervisor Staff V, RN. Staff V stated during this interview that she informed staff they needed to be with the patient as much as possible. Staff T stated the policy/procedure "we currently have does not really fit". Staff W stated that we "thought we were supposed to cover with a sitter if available, but if not available, we just did the best we could". Staff T stated that "when we got the order [for Patient #15 to have a constant sitter] we had a suicide patient that we covered". Regarding observation of the patient, "We try to make every step to cover but can't always do this." Staff Nurse W stated, "Yes, it would make a difference if our policy stated it must be followed, then I could understand it clearly."

Review of the hospital's internal investigation report, not dated, states under "Contributing Factors":

3. Not enough oversight during the medication administration process - unsure if patient "pocketed" the medication [retained medication in the mouth and did not swallow it] or if patient used own source.
4. Lack of sitter availability for constant observation - order written after patient tampered with the IV.
- No sitter available: nursing acted as sitter during all IV medication administration
- Only 6 full time; 44 prn (as needed) sitters
Actions: Nursing working on outline of the process, issues, and recommendations to address sitter shortage.

Based on interviews, open and closed record reviews, and policy and procedure review, the hospital failed to have a system in place when it:

- failed to deliver appropriate supervision of nursing care and nursing staff or other personnel for one of one patients (Patient #15) who had a known history of IV (intravenous, meaning within a vein) drug abuse and suspected tampering of the IV line (A-0392);
- failed to provide adequate staffing for continuous safety monitoring of a constant sitter as ordered by the physician (A-0144 and A-392); and
- failed to timely update and clarify written policy and procedures after the events of 11/18/09 when it was recognized that the constant observation procedure failed and resulted in many variations of practice (A-392).

The severity and cumulative effect of the systemic practice resulted in the hospital being out of compliance with 42 CFR (Code of Federal Regulations) 482.23 - Condition of Participation: Nursing Services, and resulted in the facility's failure to provide a sitter to constantly observe Patient #15 as ordered by the physician, and failure to clarify this procedure with written policies for all patients requiring this service. This leaves all patients who need this special care and service, but who do not receive it, in immediately jeopardy to their health and safety.

The census was 345 patients.

See the deficiencies at A-392 and A-144.

Based on interviews, closed record review, policy review, and review of the procedure for a constant sitter, the facility failed to have an adequate number of nursing and other personnel to provide a sitter to constantly observe Patient #15 as ordered by the physician for one of one patient's who expired. The facility census was 345.

Findings included:

Review of Patient #15's medical record revealed the timeline of when Registered Nurse (RN) W discovered the Patient had tampered with the IV (intravenous) tubing on 10/17/09 at 7:30 p.m. RN Staff W obtained a physician's order on 10/17/09 at 7:50 p.m. for a constant observation sitter. At 11:30 p.m. on 10/17/09 Staff W informed her supervisor of failure to provide a constant observation sitter. Patient #15 expired on 10/18/09 at 5:04 a.m..

During an interview on 04/05/10 at 3:25 p.m., Staff M, RN, Director of Nursing, Nursing Administration, stated that sitters are "always covered". Staff M stated there is no written policy for the constant observation procedure. Staff M also stated that nursing always covers if a sitter is not available.

Registered Nurses T, U, V and W were interviewed on 04/07/10 at 8:35 a.m. Staff Nurse W stated that the patient was received from the 8th floor by bed transfer. She stated that very soon afterward a white substance could be seen in the Patient #15's IV line. "We knew the patient's history of drug use." Staff Nurse W stated the inability to obtain a sitter as ordered by the physician was discussed with supervisor, Staff T, Nurse Supervisor, and their supervisor, Staff V. Staff V stated during this interview that she informed staff they needed to be with the patient as much as possible. Staff T stated the current hospital policy/procedure does not really fit. Staff W stated that she "thought we were supposed to cover with a sitter if available, but if not available, we just did the best we could". Staff T stated that "when we got the order [for Patient #15 to have a constant sitter] we had a suicide patient that we covered". Regarding observation of the patient, "We try to make every step to cover but can't always do this." Staff Nurse W stated, "Yes, it would make a difference if our policy stated it must be followed, then I could understand it clearly."

Review of the hospital's internal investigation report, not dated, it states under "Contributing Factors":

4. Lack of sitter availability for constant observation - order written after patient tampered with the IV.
- No sitter available: nursing acted as sitter during all IV medication administration
- Only 6 full time; 44 prn (as needed) sitters
- Actions: Nursing working on outline of the process, issues, and recommendations to address sitter shortage.

See A-0144.