HospitalInspections.org

Based on observation, interview and record review, the hospital failed to ensure nursing supervised and evaluated the needs for one patient (Patient A) when the patient was found lying on the floor unresponsive on August 13, 2010 at 1 PM with the batteries dead in the telemetry monitor (a device used to monitor the heart's rhythm which is transmitted to a screen) and the bed with three ? side rails up without an appropriate assessment for the need.

Findings:

The hospital report was reviewed on August 19, 2010 at 12:45 PM and read in part, "Patient's telemetry monitor indicated poor connection. The RN (Registered Nurse) responded to assess the reason for the poor connection and found patient on floor unresponsive with shackles attached to his legs per CDCR (California Department of Correction and Rehabilitation) regulation. Patient was immediately assessed to have no blood pressure apneic, no pulse, and was pronounced dead by his physician..."

An unannounced visit was made on August 19, 2010 at 2 PM, due to the above hospital reported adverse event.

During an interview with the Director Risk and Compliance (DRC) on August 19, 2010 at 2 PM, she indicated Patient A was on a secure unit. On the day of the occurrence (August 13, 2010) Patient A was found by the registered nurse (RN 1) lying perpendicular to the bed, on the floor, left side of the bed, breathless and with no pulse, CPR was started. DRC also indicated the hospital does not consider side rails a restraint if there is access for the patient to get out of bed. Side rails are only considered a restraint if "all four side rails are up".

During an interview with RN 1, on August 19, 2010 at 2:30 PM, he stated prior to finding Patient A unresponsive on August 13, 2010 at 1 PM he was in the patient's room at 12 PM. There was another registered nurse (RN 2), who had seen Patient A around 12:30 PM, and she told him Patient A's intravenous (IV) pump was alarming. Because each room is locked on this secure unit, he proceeded to find an officer to unlock the door and that was when Patient A was found on the floor unresponsive. He indicated he called the Telemetry Monitor Technician (TMT) at the desk to ask what the patient's Telemetry Monitor was reading and he was told "it wasn't picking up". He indicated when the monitor is not picking up, it usually means the leads are off or the battery is dead, so he sent someone out to get batteries. He replaced the old battery with a new one and the monitor started working, "...of course it was asystole." RN 1 indicated the nurse's are notified the TM batteries are low by the TMT since it will show up on the monitor the batteries are low.

During an interview RN 2, on August 19, 2010 at 3 PM, she indicated she went in to Patient A's room to examine another patient and she heard Patient A's IV pump "was going off" so she went to tell RN 1. The patient (Patient A) was fine at the time. She indicated, if the battery is low on the Telemetry Monitor, the TMT will inform you and we will go in and change them."

During an interview with TMT 1, on August 19, 2010 at 3:15 PM, she indicated, she had been paging overhead the batteries needed to be changed to Patient A's TM. She indicated, the screen she monitors, will signal when a new battery is needed. The alarm that is signaled is both audible and visible.

During an interview with TMT 2, on August 19, 2010 at 3:45 PM, she indicated when the battery for a telemetry monitor needs to be changed, the telemetry screen will signal the battery is weak and then there will be no signal.

The clinical record for Patient A was reviewed on August 19, 2010 at 3 PM. The physical assessment conducted by RN 1, on August 13, 2010 in the morning indicated, under the section titled, "SAFETY/RISK" it indicated there were "No Restraints" and under the comments section it read, "NO CLINICAL INDICATION FOR RESTRAINTS." There was also no documentation nursing assessed the need for the three half side rails or assessed if less restrictive measures would be appropriate for the patient.

The clinical record for Patient A was further reviewed. A "Post Fall Assessment" completed by RN 1 on August 13, 2010 at 1300 read in part, "PT (Patient A) WAS FOUND SUPINE (on back) ON FLOOR, UNRESPONSIVE AND PULSELESS AT 1300...NO INJURIES NOTED AT TIME OF FALL...DR._____ WAS AT BEDSIDE IMMEDIATELY AFTER PT. WAS FOUND DOWN AND PULSELESS...WHEN FOUND, PT. WAS APNEIC, PULSELESS AND NO BLOOD PRESSURE."

The physical assessment completed on August 13, 2010 on Patient A by RN 1 documented, "...UPON ARRIVAL PT. WAS PULSELESS, CPR INITIATED." Under the "Telemetry Comments it read, BATTERY IN TELE (telemetry) BOX DEAD, UPON REPLACEMENT, ASYSTOLE NOTED."

A nursing note by RN 1 was noted in Patient A's clinical record dated August 13, 2010 at 1300 which read in part, "ENTERED PT'S ROOM BECAUSE OTHER RN INSTRUCTED ME THAT LAST TIME SHE HAD BEEN IN THE ROOM, HIS IV PUMP WAS ALARMING. I ENTERED ROOM AND FOUND PT LYING IN A SUPINE POSITION ON THE FAR SIDE OF HIS BED ...WITH HIS HEAD TOWARDS THE BED ADN (sic) HIS FEET AWAY FROM IT, ALMOST IN A PERPENDICULAR POSITION TO THE BED. AT THE TIME OF DISCOVERY PT WAS UNRESPONSIVE, PULSELESS AND APNEIC, SKIN COLOR WAS PALE, NO CYANOSIS NOTED AT THIS TIME. NO OBVIOUS INJURY NOTED FROM FALL...CPR IMMEDIATELY STARTED BY MYSELF, DR. ______ AT BEDSIDE WITHIN A MINUTE OR TWO ....CDCR MANAGER .....ENTERED ROOM A COUPLE MINUTES LATER AND INFORMED US THAT EARLIER ...SHE HAD RECEIVED AN ADVANCE DIRECTIVE FROM PRISON THAT STATED PT. WAS TO BE A DNR (do not resuscitate) ...AS SOON AS DR. ______VERIFIED THE PAPERWORK AND GAVE THE ORDER TO DISCONTINUE CPR, CPR WAS STOPPED. TIME OF DEATH FOR PT. WAS DECLARED TO BE 1305 BY DR. _____. "

The hospital policy and procedure titled, "RESTRAINT, USE OF" read in part under the policy statement, "B. The decision to use restraint will be driven...by comprehensive individual assessment, which concludes that for a specific patient at a specific time, the use of less restrictive interventions poses a greater risk than the risk of using a restraint...C. It is recognized that patients in the Guarded Care Unit setting have a population that require additional standards that are required by the California Department of Corrections and Rehabilitation Department (CDCR). When restraints are required for clinical control purposes, the CDCR staff will follow...Hospital Restraint policy..." Under the "Scope and Applicability" subheading it read in part, "A. Restraint may only be used if needed to improve the patient's well being AND less restrictive interventions have been assessed to be ineffective in protecting the patient or others from harm...B. 7. Utilizing devices which serve multiple purposes such as...side rails, when they have the effect of restricting a patient's/resident's movement and cannot be easily removed by the patient, thus constituting a restraint."