HospitalInspections.org

Based on interview and record review, the facility failed to reporti the death of a patient while in a restraints to CMS for 1 of 5 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. An entry in "Restraint Documentation" of 2/10/2021 at 3:06 PM indicated the restraint of "bedrails enclosure" was put in place. The order was officially entered at 10:58 PM on the same day. The medical record revealed that the patient remained in this type of restraint through the point in which a Code Blue was called.

The facility created a timeline of the patient's stay on 2/10/2021 and 2/11/2021 which was based on video. On 5/03/2021 at 2 PM, the Director of Patient Safety & Quality stated the video itself was no longer available. She stated that it showed a view down the hallway that easily showed entry and exit into the patient's room. Review of the log revealed a log entry of 2/11/2021 at 7:32 AM which read, "(Registered Nurse A) sees rhythm change on monitor and goes in to look in room. Looks out of room, calls Code Blue. CNA (Certified Nursing Assistant) and nurse responded to the room and found the patient at the foot of the posey bed in a horizontal position with no chest rise. RN (Registered Nurse) opened the zipper on the Posey bed and shook the patient but there was no response, no pulse, called Code Blue and started CPR (cardiopulmonary resuscitation)...."

The "Cardiopulmonary Resuscitation Record" indicated that CPR was initiated on 2/11/2021 at 7:35 AM, that the Code was unsuccessful, and that it was stopped at 8 AM on 2/11/2021.

During an interview of the Director of Patient Safety & Quality on 5/04/2021 at 11:48 AM, she confirmed that they had not reported to CMS the death of the patient in restraints.