HospitalInspections.org

Based on review of medical records, review of facility policies and procedures, interviews with administrative staff, review of staff credentials, and review of related documentation, it was determined that the facility failed to protect and promote the rights of each patient.

Findings include:

1. The facility failed to ensure that patients had the right to receive care in a safe setting. (Refer to Tag A 144)

2. The facility failed to develop a patient plan of care to meet the patient's psychological needs. (Refer to Tag A 130)

3. The facility failed to ensure that written orders for physical restraint were time limited. (Refer to Tag A 171)

Based on medical record review, staff interview, review of video surveillance, review of related documentation and review of facility documents, it was determined that the facility failed to develop a patient plan of care to meet the patient's psychological needs.

Findings include:

Reference: Facility document titled, "Documentation/Treatment Plan Manual," states, "The purpose of the UTP/ITN (Update Treatment Plan/ Interdisciplinary Plan) is to document any significant changes in the patient that warrants change to the Treatment Plan/ Interdisciplinary Plan and/or Master Treatment Plan."

1. On 3/21/19 and 3/29/19, a review of video surveillance views recorded of Cedar Hall on 3/18/19 indicated the following: (times referenced are those of the time stamp on the videos)

a. At 12:50:40 (PM), Patient #2 is observed sitting in a chair, next to a water fountain in view of the nurse's station. Patient #1 is observed falling on the floor in front of Patient #2.

b. At 12:52:03 (PM), Staff #4 is observed pushing a food cart and reaching over Patient #1, handing a cup to Patient #2.

c. At 12:53:48 (PM), Staff #23 is observed approaching Patient #2 and directing him/her to step away.

d. Patient #2 is observed getting up and with the use of a walker, stepping away from the scene, unescorted, three (3) minutes and eight (8) seconds after Patient #1 fell to the floor in front of him/her.

2. During a tour of Cedar Hall on 3/21/19 at 12:25 PM, Staff #13 identified Patient #2 as the patient in the video surveillance, sitting next to the water fountain, witnessing the fall of Patient #1 on 3/18/19. Staff #13 stated that Patient #2 was a long time companion to Patient #1. Furthermore, Staff #13 stated that Patient #2 was having a difficult time coping with the witnessing of Patient #1's death.

3. Review of Medical Record #2, on 3/29/19, failed to show any documentation of an updated plan of care for Patient #2 until 3/25/19, seven (7) days after witnessing the death of Patient
#1.

a. Review of the Treatment Plan Update for Patient #2 dated 3/25/19 at 11:21 AM, states, "Reason for Description: On 3/22/19,, [sic] (name of Patient) was agitated and began to exhibit self injurious [sic] behavior by banging head, the redirections and counseling were not effective. He/she was placed in two points [restraints] at 6.50pm [sic] and ended 8,47pm [sic]. He/she again began to exhibit SIB (Self Injurious Behavior) and continue to refuse redirection [sic], placed in two points restraint 10.50pm [sic] till 11.55pm [sic.] On 3/23/19, [sic] (name of Patient) was reported agitated, refused oral meds, head banging and became combative with staff during redirection, she/he was placed in 2 point chair cloth restraint from 10.20am [sic] to 12.20pm [sic.] He/she was continous [sic] to exhibit SIB behavior, not responding redirections [sic,] attempted to scratch face, was placed in two points cloth restraint from 2.20pm [sic] to 3.30pm [sic] same day (3/23/19)."

4. As per interview with Staff #13, significant changes in Patient #2's behavior were identified prior to 3/22/19 and the plan was not updated.

Based on review of facility policy and procedure, medical record review, and review of related documentation, it was determined that the patient was not provided care in a safe environment.

Findings include:

Reference #1: Facility policy and procedure titled, "Medical Emergency," states,
"I. Standard:
An immediate response to a victim of any medical emergency is provided that requires a coordinated team effort by employees who are trained in Cardio Pulmonary Resuscitation (CPR) and First Aid/Basic Life Support (BLS.) Physiological stabilization is attempted prior to transfer to a general hospital in the community for continued care.
II. Definitions: a. Medical Emergency - an emergency that requires medical attention with immediate application of skilled techniques, medications, and special equipment. .....
III. 1. Any hospital staff member who initially recognizes a victim of Medical Emergency takes immediate action by:
* Checking scene for safety.
* Immediate approach and check patient to determine if medical emergency medical care/emergency first aid is required.
* Immediately direct another employee to initiate Medical Emergency Code by dialing 6666 (provide nature of Medical Emergency, [sic] Exact location of the emergency and caller's name). .....
* First clinical responder will immediately begin CPR/First Aid/BLS, as indicated. .....
3. Initially, roles are assigned during a Medical Emergency by the RN/SNS/PCM (Registered Nurse/Supervisor of Nursing Services/Patient Care Manager). The NCC (Nursing Care Coordinator) continues this process upon his/her arrival on the scene. Roles include the following:
* First clinical responder: Immediately begin CPR/First Aid/BLS, as indicated. .....
Vital Sign Monitor:
Obtains vital signs throughout code
Relays information to physician and recorder .....
* Recorder: Documents on Medical Emergency Worksheet information pertinent to medical code including medications used. .....
4. The Medical Emergency Worksheet is initiated and completed by the documenting recorder at the scene of every Medical Emergency, whether or not the crash cart was utilized.
.....
9. Comprehensive progress notes are written in the patient's medical record by the medical physician and RN. The note includes the Medical Emergency location, vital signs, assessment findings, outcome, pertinent information related to the incident and summary of Medical Emergency situation. All clinical record documentation is legible, dated, timed, written in black ink, and authenticated with the author's signature and credential/title. ....."

Reference #2: The American Safety & Health Institute "CPR and AED (Automated External Defibrillator) INSTRUCTOR GUIDE," states, "..... Purpose of this Guide
This ASHI (American Safety & Health Institute) CPR and AED Version 8.0 Instructor Guide is solely intended to give information on the presentation and administration of ASHI CPR and AED certified training classes. The information in this book is furnished for that purpose and is subject to change without notice. .....
Primary Assessment - Unresponsive Person
Assess Scene
* Pause and assess scene for safety.
* If unsafe, or it becomes unsafe at any time, GET OUT!
Check for Response
* Tap or squeeze shoulder and ask loudly, 'Are you all right?'
* If unresponsive, have someone activate EMS and get an AED, if one is available.
Look for Normal Breathing
* Position person face-up on a firm, flat surface.
* Look at face and chest for normal breathing. Take no longer than 10 seconds. If unsure, assume breathing is not normal.
* Weak, irregular gasping, snorting, or gurgling is not normal breathing.
Provide Indicated Care
* If person is not breathing, or only gasping, the indicated care is CPR and the use of an AED.
* If normal breathing is found, place an uninjured person in recovery position. ....."

1. Review of video surveillance views of patient care unit Cedar Hall on the afternoon of 3/18/19 revealed the following: (times referenced are those of the time stamp on the videos)

12:50:40: Patient #1 is observed falling down to the floor in a hallway to a prone position.
12:50:51: Staff #4, an HSA (Human Services Assistant) is observed checking the patient for responsiveness. The patient appeared to be unresponsive. Staff #4 then appears to summon other staff for assistance.
12:51:40: Staff #5, an LPN (Licensed Practical Nurse) brings an electronic vital signs monitor to the patient.
12:52:29: Staff #6, an RN, is observed touching the patient's arm.
12:52:38: Staff #6 has his/her hand on the patient's wrist.
12:53:16: Staff #6 places the blood pressure cuff on the patient's arm.
12:53:58: Staff #6 is observed placing a pulse oximeter sensor on the patient's finger.
12:54:27: A code cart is brought to the scene of the fall.
12:54:32: Staff #6 is observed shaking the patient's back.
12:55:03: Staff #13, an ADN (Assistant Director of Nursing) arrives to the scene.
12:55:22: Code cart is opened.
12:55:44: A staff member is observed preparing an intravenous.
12:56:34: Staff #20, a physician, arrives to the scene.
12:56:44: Staff #11, a physician, arrives to the scene.
12:56:48: Staff #11 and Staff #20 are observed conversing with one another.
12:56:59: Staff #11 bends down to the patient.
12:57:00: Staff #13 places a CPR board on the back of the prone patient.
12:57:07: Staff #11 stands up, steps back, and observes the patient.
12:57:30: Staff #13 removes the CPR board off of the patient's back.
12:57:52: Staff #11 and Staff #13 are preparing to auscultate the patient's back.
12:58:00: Staff #11 and Staff #13 auscultate the patient's back.
12:58:19: Patient is rolled onto his/her back.
12:58:27: Staff #13 begins chest compressions.
13:03:40: CPR continues with additional staff assistance.
13:32:22: CPR stopped.

2. Review of the medical record of Patient #1 revealed the following:

a. An MD note, written by Staff #3, dated 3/18/19 at 1:47 PM stated, "..... Noted patient was face down on the floor in the hallway near water fountain. Reported by the witness who saw the patient was drinking water at the water fountain. (He/She) tried to stop (him/her) as (he/she) is a water intox (intoxication) patient. Reported that patient pulled (his/her) arm away from (him/her), staggered backward and slowly dropped to the floor. RN in the unit upon reporting about the patient came over to check the vitals. By that time medical physicians, including myself were at the patient. Reported by the medical doctor that there was no pulse. Immediately patient was turned over and noted that (his/her) lips were blue. CPR was initiated. AED was hooked up and non-rebreather mask was put on. In few minutes changed to ambubag as CPR continued. IV (intravenous) access was established and initiated on IV NS (normal saline) wide open. .....
Blood glucose WNL (within normal limits) at the initiation of the medical code. AED was on and it was reported Asystole with CPR to be continued. Continued code for > (greater than) 40 mins (minutes) until paramedics arrived. Code was called off and pronounced dead at 13:39PM by the paramedics after confirming with EKG (electrocardiogram) by Dr. _______ (surname) @ (at) ________ ____ (specific name) Hospital @ 13:39PM. ....."

b. A Nursing note dated 3/18/19 at 3PM (3:00 PM) stated, "Witnessed fall, 0 (no) pulse, 0 respiration, unresponsive. Medical emergency called. Pt (patient) was found face down - per direction from medical emergency code leader (he/she) was turned over to (his/her) back, CPR initiated, pt had large amount of emesis coming from (his/her) mouth - 0 BP (blood pressure), 0 respirations, BS (blood sugar) 131, 0 pulse palpable ..... CPR continued; 0 shockable rhythm noted by AED machine, several suction attempts made (with) Yankauer suction filled greater than one canister with emesis; unable to establish shockable rhythm per AED. ....."

c. The "Vital Signs" section of a MEDICAL EMERGENCY WORKSHEET dated 3/15/19 [sic] included no entries regarding Respiration, Pulse, Blood Pressure, or Continuous EKG.

d. There was no documentation in the medical record to indicate that the patient had a pulse, respirations, blood pressure, or consciousness at any time after falling to the ground on 3/18/19.

3. Interview with Staff #6, an RN at 1:45 PM on 3/20/19, while reviewing the video of the fallen patient, revealed:

a. At 12:53:58 (PM), the employee is observed attempting to get a pulse oximetry reading. The RN stated that there was no reading.

b. At 12:57:24 (PM), the employee appears to be taking a radial pulse. The employee confirmed that (he/she) was attempting to get a pulse, but that there was no pulse.

c. The employee stated that at no time did the patient have a palpable pulse, consciousness, blood pressure, or Sp02 (peripheral capillary oxygen saturation) value.

4. Staff #4, at 1:55 PM on 3/20/19, stated that he/she had no recollection of anyone reporting the presence of any vital signs during the medical emergency.

5. Staff #12, at 2:25 PM on 3/20/19, while reviewing the video of the fallen patient, revealed:

a. At 13:03:25 (PM), he/she arrived on the scene.

b. At 13:03:34 (PM), he/she noticed that no one was documenting on a code sheet, so he/she took a blank one from one of the code carts and began documenting.

6. Administrative Staff #1 agreed that:

a. Staff failed to appropriately assess the patient for the need for CPR.

b. Staff failed to implement the CPR protocol as dictated by the referenced CPR training manual utilized by the facility.

c. Facility staff failed to completely document the medical emergency on a MEDICAL EMERGENCY WORKSHEET.

These findings resulted in an Immediate Jeopardy (IJ) on 3/21/19. A written removal plan was requested.
On 3/29/19, during an onsite visit it was determined the removal plan for the IJ was fully implemented and the IJ was removed.


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Reference #3: Facility document titled, "Protocol for Conducting Emergency Mock Code Drill," states: "Objective: In the process of establishing uniformity in the method of conducting emergency mock code, this protocol is aimed at: ...improving staff response and patient care during emergencies ... 4. Staff responds to the code and brings their emergency equipment which include Crash cart, ... 5. Roles are assigned ... a. First Responder - initiates and renders emergency care upon assessment. b. Equipment monitor - attaches cardiac monitor, prepares defibrillator for use, opens crash cart; prepares oxygen and suction machine, connects ambu-bag to oxygen, provides physician with airway equipment. ..."

Reference #4: Facility policy titled, "Checking of Emergency Equipment," states, "Emergency equipment and supplies are checked in clinical areas by the nurse to ensure their readiness for emergency use. ...6. A cardiac board is located on the back of each cart. A longboard, Cervical Immobilization Device (CID), and collar are located in the immediate area of the crash cart."

Reference #5: Facility document titled, "American Heart Association, Basic Life Support," states, "Compression pump the blood in the heart to the rest of the body. To make compressions as effective as possible, place the victim on a firm surface, such as the floor or a back board [cardiopulmonary resuscitation- CPR board.]"

Reference #6: ACLS Certification Institute, "https://acls.com/free-resources/knowledge-base/bls-articles/bls-positioning-best-practices" states, "Backboards are vital in the positioning of BLS [Basic Life Support] patients. ...Beds, dirt, and other soft surfaces do not provide this squeezing, and it can impact how well the compressions move blood through the victim's body. For this reason, backboards are used to ensure that the compressions are effective and help with the overall survival of the patient."

1. On 3/21/19, a review of video surveillance views recorded of Cedar Hall on 3/18/19 indicated:

a. At 12:50:40 (PM), Patient #1 is observed falling to the ground in front of a water fountain in view of the nurse's station. Patient #1 is lying in the prone position (face down).

b. At 12:54:27 (PM), the crash cart is brought to the scene.

c. At 12:55:03 (PM), Staff #13 arrives at the scene.

d. At 12:55:22 (PM), Staff #13 is observed opening the crash cart drawer, looking for supplies.

e. Upon interview on 3/21/19 at 11:00 AM, Staff #13 stated he/she was looking for a re-breather mask. When questioned if Patient #1 was breathing, he/she stated that he/she "didn't know" but stated, "the patient's color was off."

f. At 12:56:33 (PM), Staff #13 is observed going through the crash cart bottom drawer [drawer #4], pulling supplies out and throwing them on the floor.

g. Upon interview on 3/21/19, Staff #13 stated he/she was looking for the neck immobilizer.

h. At 12:57:00 (PM), the CPR (cardiopulmonary resuscitation) backboard is placed on Patient #1's back, while the patient was in the prone position.

i. At 12:57:30 (PM), Staff #13 removes the CPR backboard from Patient #1's back.

j. Upon interview on 3/21/19, Staff #13 stated he/she placed the CPR backboard on the patient's back to immobilize the patient before turning him/her over on their back. Staff #13 stated that the backboard was too small and he/she removed it.

2. During a tour of Cedar Hall on 3/21/19 at 12:50 PM, in the Emergency Equipment room, a crash cart was observed. At the request of the surveyor, Staff #13 opened the cart.

a. At 12:55 PM, Staff #13 was asked to identify a Laryngeal Mask Airway (LMA) #4 and an LMA #5. Staff #13 was not able to immediately identify the LMAs.

b. At 12:57 PM, Staff #13 was asked to locate the neck immobilizer, he/she searched through the supplies in crash cart drawer #4. Staff #13 stated, "There's no neck immobilizer [cervical collar]. They used to have one here [crash cart drawer #4]."

c. Review of the emergency crash cart contents form does not list a neck immobilizer [cervical collar] as part of the contents in the crash cart.

3. Upon interview, Staff #19 stated neck immobilizers/collars were never kept in the crash cart. Staff #19 stated that they are kept with the long board (Cervical Immobilization Device) in the Emergency Equipment room on the unit.

4. During a tour of the unit on 3/21/19, in the corner of the Emergency Equipment room, a Cervical Immobilization Device with a neck immobilizer [collar] attached to it, was observed.

5. Staff #7 stated on 3/21/19 at 12:59 PM, during the time Patient #1 coded, the Cervical Immobilization Device and collar were not in the Emergency Equipment room. Staff #13 stated, "There should have been a backboard [Cervical Immobilization Device] in this room [Emergency Equipment room]."

6. Staff #13 stated, "When I called for a backboard [Cervical Immobilization Device], staff were searching, but never found one." Staff #13 stated, "that is why they tried using the one from the CPR backboard."

Based on review of the medical records of three of five patients (Medical Records #2, #3, #5) who were physically restrained for behavior management, review of facility policy and procedure, and interview with administrative staff, it was determined that not all written physician orders for physical restraints are time limited.

Findings include:

Reference: Policy and procedure titled, "Restraint Prevention and Use," states: ".....
C. Initiating a Restraint .....15. .....c. The order for mechanical restraint may specify 'up to' one hour rather than a pre-determined amount of time; however, in no instance shall the order for mechanical restraint exceed one hour. ..... e. The order is timed from when the patient is placed in a restraint. Holds used to place an individual in restraint are considered part of the restraint process and timing of the restraint order begins when the individual is held for the purpose of restraint. ....."

1. Review of the medical record of Patient #2 revealed:

a. A PHYSICIAN'S RESTRAINT ORDER sheet indicated that a telephone order for 4-point cloth wrist restraints for behavior management was obtained by an RN from a physician at 2:15 PM on 1/29/19. The order was not time limited.

b. A PHYSICIAN'S RESTRAINT ORDER sheet indicated that a telephone order for 4-point cloth wrist restraints for behavior management was obtained by an RN from a physician at 3:30 PM on 1/29/19. The order was not time limited.

c. A PHYSICIAN'S RESTRAINT ORDER sheet indicated that a telephone order for 2-point cloth wrist restraints for behavior management was obtained by an RN from a physician at 3:55 PM on 1/30/19. The order was not time limited.

d. A PHYSICIAN'S RESTRAINT ORDER sheet indicated that a telephone order for 4-point cloth wrist restraints for behavior management was obtained by an RN from a physician at 11:00 AM on 1/31/19. The order was not time limited.

e. A PHYSICIAN'S RESTRAINT ORDER sheet indicated that a telephone order for 4-point cloth wrist restraints for behavior management was obtained by an RN from a physician at 2:40 PM on 2/8/19. The order was not time limited.

f. A PHYSICIAN'S RESTRAINT ORDER sheet indicated that a telephone order for 'PHYSICAL HOLD (ONLY)' for behavior management was obtained by an RN from a physician at 8:15 PM on 2/9/19. The order was time limited to 1 minute. Additionally, although the check box for MECHANICAL RESTRAINT was not checked off, entries were made that the patient be placed in 2-point cloth wrist restraints for behavior management for an undocumented time limit.

g. The check box for MECHANICAL RESTRAINT was not checked off on a PHYSICIAN'S RESTRAINT ORDER sheet, but entries were made indicating that a telephone order for 2-point cloth wrist restraints for behavior management was obtained by an RN from a physician at 9:45 PM on 2/9/19. The order was not time limited.

h. The check box for MECHANICAL RESTRAINT was not checked off on a PHYSICIAN'S RESTRAINT ORDER sheet, but entries were made indicating that an order for 4-point cloth wrist restraints for behavior management was obtained by an RN from a physician at 11:50 AM on 3/5/19. The order was not time limited.

i. The check box for MECHANICAL RESTRAINT was not checked off on a PHYSICIAN'S RESTRAINT ORDER sheet, but entries were made indicating that an order for 4-point cloth wrist restraints for behavior management was obtained by an RN from a physician at 1:00 PM on 3/5/19. The order was not time limited.

2. A PHYSICIAN'S RESTRAINT ORDER sheet in the medical record of Patient #3 indicated that a telephone order for 4-point cloth wrist restraints for behavior management was obtained by an RN from a physician at 12:55 AM on 2/2/19. The order was not time limited.

3. A PHYSICIAN'S RESTRAINT ORDER sheet in the medical record of Patient #5 indicated that a telephone order for 4-point cloth wrist restraints for behavior management was obtained by an RN from a physician at 8:10 AM on 3/7/19. The order was not time limited.

4. Review of the medical record of Patient #3 revealed:
a. The check box for MECHANICAL RESTRAINT was not checked off on a PHYSICIAN'S RESTRAINT ORDER sheet, but entries were made indicating that a telephone order for 2-point cloth wrist restraints for behavior management was obtained by an RN from a physician at 6:50 PM on 3/22/19. The order was not time limited.

b. A PHYSICIAN'S RESTRAINT ORDER sheet included entries that the patient be placed in 2-point cloth wrist restraints at 10:55 PM on 3/22/19. The order was not time limited.

c. A PHYSICIAN'S RESTRAINT ORDER sheet included entries that the patient be placed in 2-point cloth wrist restraints at 11:50 PM on 3/23/19. The order was not time limited.

5. A PHYSICIAN'S RESTRAINT ORDER sheet in the medical record of Patient #5 indicated that a telephone order for 4-point cloth wrist restraints for behavior management was obtained by an RN from a physician at 8:10 AM on 3/7/19. The nurse who entered the order, and indicated that he/she read the order back to the physician, entered "N/A" (Not Applicable) in the space for the time limit of the order. The order was not time limited.

6. Administrator #21 confirmed the findings.

Based on a review of the medical record of 1 of 3 patients who expired at the facility (Medical Record #1), review of facility policy and procedure, and interview with administrative staff, it was determined that the facility failed to notify the OPO (Organ Procurement Organization) of the death of a patient at the facility.

Findings include:

Reference: Policy and procedure titled, "Procedure in the Event of Death," states:
"I. POLICY:
Care for a patient's body is provided after death, along with emotional support for family members/significant others.
II. PROCEDURE FOR DEATH ON HOSPITAL GROUNDS: .....
1. An attempt to resuscitate a patient occurs as per Medical Emergency Policy (AD-EC-#0650); unless a do not resuscitate (DNR) order is documented. Pronouncement of death is made by the physician.
2. The pronouncing physician contacts the contracted Organ Procurement Organization (OPO), the Gift of Life Donor Program, at (800) _______ (1-800-___-____), as soon as possible but within one hour of death, except as otherwise required by law. The OPO determines medical suitability for organ and tissue donation. ....."

1. Review of the medical record of Patient #1 revealed:

a. A PROGRESS NOTE entry dated 3/18/19 at 1:47 PM stated: "Medical emergency was called at 12:58PM. ..... Continued code for > (greater than) 40 mins (minutes) until paramedics arrived. Code was called off and pronounced dead at 13:39PM (1:39pm) by the paramedics after confirming with EKG (Electrocardiogram) by Dr. ______ (surname) @ (at) ________ ____ Hospital @ 13:39PM."

b. There was no documentation in the medical record that anyone notified the OPO of the patient's death.

2. Administrator #1 confirmed the findings. Additionally, he/she confirmed that it was the responsibility of Ancora Hospital staff to notify the OPO, not a physician offsite at another hospital.