HospitalInspections.org

Based on medical record (MR) review, interview, and document review, facility staff/medical staff failed to promptly escalate concerns relating to a patient's unanticipated death in 1 of 10 MRs reviewed. As a result, the investigation was not immediately undertaken and was therefore limited in scope. This could lead to inadequate investigation of care related concerns.

Findings include:

-- Per MR review, on 6/13/2023 Patient #1, a 91 year old, presented to the ED and was admitted to the hospital with diagnosis of severe sepsis. Patient was treated and was showing some signs of improvement. For example, attending physician noted on 6/21/2023 at 10:53 am, "I think she is improving overall."

-- On 6/23/2023 physician documentation revealed Patient #1 "appeared frail, normal cardiac rate, rhythm irregular. No respiratory distress, breath sound normal, no wheezing. Oriented to herself and knows she is in the hospital, no obvious deficits on exam. As white blood cell continues to trend up plan is to do indium scan (imaging to help identify regions of inflammation) to rule out abscess. Discussed with nursing staff and test is ordered and likely to be performed on Monday (6/26/2023)."

-- On 6/24/2023 at 11:16 am nursing documentation noted patient was "alert but forgetful, able to swallow without difficulty, Glasgow Coma Scale (GCS) 15, Richmond Agitation Sedation Scale (RASS) alert and calm, Respiratory status - breathing without difficulty, regular depth and rhythm, fair respiratory effort, dyspnea with exertion. Interventions: Encouraged cough and deep breathe. Cardiac rhythm irregular, no jugular vein distention, no cardiac symptoms, no telemetry in use."

-- Last set of vital signs on 6/24/2023 at 1:40 pm revealed temperature 36.4 Celsius, pulse 47 (lower than normal), blood pressure 108/41, respirations 20, O2 saturation 98%.

-- Nursing documentation on 6/24/2023 noted the attending physician was notified of patient's death at 4:52 pm.

-- Per interview of Staff F, LPN, on 8/10/2023 at 4:00 pm, he/she/they cared for Patient #1 multiple times throughout her stay including the day Patient #1 was found deceased. Staff F and Staff M, Registered Nurse (RN) found Patient #1 on her back with a pillow over her face, oxygen off, with no pulse. Patient #1 was alert and oriented to herself and place but could be intermittently confused. Patient #1 could make her needs known but needed assistance when moving (required help turning). Patient #1 was on 2 liters of oxygen via nasal cannula on the day of her death, which she typically left in place. Patient #1 was roomed with Patient #2 who was alert, oriented to person, place, time, situation, and independent with ambulating. Staff F also cared for Patient #2. Patient #2 requested a private room several times, as Patient #1 moaned at night and kept her awake. When Patient #2 arrived back from a procedure on 6/24/2023, she again asked about having her own room. At that time, Staff F did Patient #2's vitals and Staff M, administered Patient #2's medications. Staff F recalled Patient #2 saying she did God's work and Patient #1 was in pain. He/she/they thought it was an odd comment. Staff F then checked on Patient #1 who stated she was in pain. (Pain location not documented. Previous complaints of pain were in her left lower extremity.) Staff F and Staff M retrieved pain medication for Patient #1 and when they returned to administer it, (15-20 minutes later), Patient #1 was on her back with a pillow over her face, oxygen off, with no pulse. Patient #1 was a DNR/DNI (do not resuscitate/do not intubate). A rapid response (medical emergency team) was called . A non-rebreather (oxygen mask) was placed on Patient #1 with no response. Staff J, Attending Physician was called and he/she/they notified Patient #1's family of her death.

Staff F had concerns with how Patient #1 was found deceased, so he/she/they shared their concerns with Staff J at this time. Staff F further indicated that after the weekend (on 6/26/2023), he/she/they felt uneasy about the circumstances surrounding Patient #1's death. In addition to the position Patient #1 was found in, Staff F also felt Patient #2's demeanor was unusual. She was very chatty before, then didn't speak much after Patient #1's death. Patient #2 was put in the hallway (staff were in the room preparing Patient #1's body), and she appeared very relaxed. He/she/they felt it was an odd response to her roommate's death. On 6/26/2023 he/she/they brought these concerns to Staff G, RN Coordinator.

-- Per interview of Staff M on 8/1//2023 at 3:05 pm, Staff M recalls Patient #1 being confused at times and unable to get out of bed independently. Staff M and Staff F came in to get Patient #1 ready for dinner and found Patient #1 deceased. Staff M called a rapid response. Staff M spoke with Staff J about the position Patient #1 was found in. Staff M stated the circumstances surrounding Patient #1's death "was a weird situation".

-- Per interview of Staff J on 8/11/2023 at 12:10 pm, he/sh/they indicated Patient #1 was stable. Staff J was in to see Patient #1 twice during that day (6/24/2023), once during rounds and a second time to speak with Patient #1's son. Patient #1 was due for a scan to help find the source of infection. Although not out of the realm of possibility, Staff J did not expect to find Patient #1 deceased. Staff J was told about the positioning Patient #1 was found in but was unsure what to do with that information. Staff J also cared for Patient #2. Staff J indicated Patient #2 was not mentally ill and understood her surroundings. Staff J described Patient #2 as having different beliefs, but not acting aggressive nor inappropriate.

-- Per interview of Staff G on 8/10/2023 at 4:25 pm, Staff G was the Interim RN Manager at the time of Patient #1's death. Staff G recalled speaking with Staff F regarding Patient #1.

-- Per interview of Staff H, Director of Operations for Musculoskeletal Line, on 8/11/2023 at 9:46 am. He/she/they received a message from Staff G regarding Patient #1's death. Staff H met with Staff F who was uncomfortable regarding the position Patient #1 was found in. Staff H reached out to Staff A, Chief Nursing Officer and Staff D, Director of Risk, who then coordinated with a larger group involving the hospital's legal team and local police department, Syracuse Police Department (SPD). When the police department arrived, they spoke with Staff F, Staff G, and Staff H regarding Patient #1. Staff H indicated the hospital's investigation is ongoing.

-- Per interview of the SPD Detective assigned to the investigation on 8/21/2023 at 12:30 pm, he/she/they indicated that because the death was not immediately reported as suspicious, it limited the department's investigation to interviews with the involved parties as Patient #1's room had been cleaned following her death.

-- Per review of Patient #1's autopsy report, received on 9/13/2023, her cause of death was "natural causes".

-- During interview of Staff P, Accreditation and Regulatory Specialist, on 9/22/2023 at 3:15 pm, he/she/they acknowledged the above findings.