HospitalInspections.org

Based on Hospital policy/procedure review, Hospital administrative staff interview, medical record review, video still shot review, video/audio footage review, hospital investigative documentation review, observations and staff interviews the hospital failed to have an effective Governing Body by failing to ensure a safe patient environment.

The findings include:

1. The hospital nursing staff failed to ensure nursing supervision of care per the hospital policy and procedure to monitor for signs of life (rise and fall of chest, snoring) in 1 of 1 patients that expired .

~cross refer to 482.13 Patient Rights Condition: Tag A 115.

2. The hospital nursing staff failed to ensure nursing supervision of care per the hospital policy and procedure when the staff failed to monitor 1 of 1 patients that expired .


~cross refer to 482.23 Nursing Services Condition: Tag A 385.

Based on Hospital policy/procedure review, Hospital administrative staff interview, medical record review, video still shot review, video/audio footage review, hospital investigative documentation review, observations and staff interviews the hospital nursing staff failed to ensure nursing supervision of care per the hospital policy and procedure to monitor for signs of life (rise and fall of chest, snoring) in 1 of 1 patients that expired .

The findings include:

1. The hospital staff failed to ensure the patient's right to a safe environment by failing to follow policy and procedure when the nursing staff failed to monitor for signs of life for 55 minutes in 1 of 1 patients (#6) that expired.

~cross refer to 482.13 Patient Rights Condition: Tag A 115.

Based on policy and procedure review, closed medical record review, video review, observation, hospital document review, and staff interviews, the hospital staff failed to ensure the patient's right to a safe environment by failing to follow policy and procedure when the nursing staff failed to monitor every 15 minutes for signs of life in 1 of 1 expired patients (# 6).

The findings include:

Review of hospital policy, "PATIENT RIGHTS SUMMARY-ADULTS" effective date August 27, 2012 revealed, "3. Basic Civil Rights, Protections and Freedoms (j.) The right to live and receive care and treatment in a safe and sanitary environment."

Review of hospital policy, "ACCOUNTING FOR PATIENTS" effective date April 2014 revealed, "rounds must involve visual contact with the patient...Additionally, when patients appear to be sleeping, staff must observe for signs of life (i.e. chest rise and fall, snoring)."

Review of hospital policy, "LEVELS OF PATIENT OBSERVATION" effective date August 26, 2013 revealed, "Q (every) 15 Minute Close Observation Level - Staff interact with, observe and document location and activities of the patient every 15 minutes."

Interview with administrative staff on 09/08/2014 at 1545 revealed the hospital had an occurrence on 08/22/2014 with a patient death. The interview revealed the hospital completed an investigation of the event. The interview revealed on 08/22/2014 on the C-2 (Adult Admissions Female unit) a patient that had been admitted the day before had expired. The interview revealed the results of the investigation revealed the patient was eating her dinner meal in a recliner near the phones. The interview revealed the physician had ordered the patient to be on close observation for every 15 minute checks. The interview revealed the staff thought the patient was asleep after eating. The interview revealed policy and procedure requires if the patient appears to be sleeping the staff are to check for signs of life (chest movement rise and fall). The interview revealed the staff failed to assess the patient for signs of life from 1748 until 1844. The interview revealed when the staff assessed the patient at 1844 the patient was found lifeless and the staff initated life saving measures (code /CPR). The interview revealed the patient expired.

Closed medical record review of Patient #6 revealed a 54 year old female admitted to the hospital on 08/21/2014 for catatonia (a state of apparent unresponsiveness to external stimuli in a person who is apparently awake) and schizoaffective disorder (a mental disorder characterized by abnormal thought process). Record review revealed the patient was ordered by the physician for every 15 minute close observation on 08/22/2014. Record review revealed documentation on the "Behavioral Observation Flow Sheet" the patient was awake at 1730, 1745, 1800, 1815, and 1830. Record review revealed further documentation the patient was asleep at 1845 and 1900. Record review revealed documentation at 1850 RN #1 (registered nurse) found the patient "non-responsive to verbal and painful stimuli." Record review revealed documentation at 1852 CPR (Cardiopulmonary resuscitation) was started on Patient #6. Record review revealed documentation at 1915 EMS (Emergency medical service) arrives and continues CPR. Record review revealed documentation at 1935 Patient #6 was "asystole (no heartbeat)". Record review revealed documentation at 1935 Physician #1 pronounced the patient deceased.

Review of video still shots of Patient #6 taken on 08/22/2014 revealed at 17:32:26 Patient #6 receives a meal tray from TSS (Therapeutic support staff) #1. Review revealed the patient was seated in a reclining chair in telephone area beside the Day Room. Still shot reviews at 17:41:32 revealed the patient leaned forward, at 17:49:17 revealed TSS #2 removes the meal tray and leans over the patient touching the patient on the leg. Still shot review at 18:44:36 (55 minutes later) revealed RN #1 hand placed the patient's shoulder. Still shot review at 18:47:20 revealed a resuscitation cart in the hall.

Review of video footage with audio of Patient #6 recorded on 08/22/2014 revealed at 17:32:55 the patient sitting in a recliner in the telephone area beside the Day Room and TSS #1 placing a meal tray on the patient's lap. At 17:33:13 the patient was observed eating from the meal tray. Video footage review revealed at 17:41:13 the patient sat up and appeared to coughed. Video review revealed the patient continued to eat and at 17:41:30 the patient appeared to cough a second time (17 seconds after first cough). At 17:41:34 the patient appears to cough a third time. At 17:42:00 (26 seconds after third cough) the patient appears to cough a forth time. Video review revealed during the time frame when the patient appeared to cough four times staff were observed in sight of the patient. Video review did not reveal any staff physically making contact with patient. Video review at 17:49:18 (17 minutes after last staff contact with patient), TSS #2 is observed removing the meal tray. During this time TSS #2 leans over the patient and touches the patient on the leg. Video review revealed no movements from the patient after the tray was removed. Video review revealed the laundry room door (approximately 10 feet) was the closest the staff were observed with the patient. Video review revealed no staff physically contacting the patient until 18:44:36 (55 minutes later). Video review revealed the RN reaching down touching the patient and appears to try arousing the patient. Video review revealed at 18:45 the RN calling out to staff for help.

During tour of unit C-2 on 09/09/2014 from 1541 - 1610 the area where Patient #6 was seated was observed. Observation revealed a 12 foot long rectangular area off to the side of the dayroom. Observation revealed visualization of the area could be seen from the nurses desk, the laundry room door (located approximately halfway inside of the rectangular area) and the dayroom. Observation revealed the laundry room door was approximately 10 feet from the area in which patient #6 was sitting in the recliner.

Review of the hospital's investigative documentation revealed an interview of TSS #3 on 08/26/2014. Documentation review revealed TSS #3 was responsible for the every 15 minute checks for the patient between 1730 -1900. Review of the documentation of the interview revealed, "I saw the patient resting showing no signs of distress @ (at) 1830 while opening the laundry room for a patient." Interview did not reveal TSS #3 monitored Patient #6 for signs of life.

Review of the hospital's investigative documentation revealed an interview of TSS #2 on 08/27/2014. Review of the documentation the staff member who removed the meal tray. Interview by the hospital revealed, "I said to pt (patient), 'Are you done.' and there was no verbal response. I stared at her for sign of respiration or breathing. There was visible rise and fall of the chest with no distress."

Interview with the Director of Quality on 09/08/2014 at 1546 revealed the policy states to check for signs of life when a patient appears to be sleeping. Interview revealed the staff monitored the patient visually but did not check for signs of life. Interview revealed the staff believed Patient #6 was sleeping. Interview revealed Patient #6 was known to staff based on previous admissions and staff believed she was in her catatonic state.

Interview with Administrative nursing staff on 09/09/2014 at 1555 revealed the staff member (TSS #3) assigned to monitor Patient #6 on 08/22/2014 from 1730 - 1745 was not available for interview.

Based on Hospital policy/procedure review, Hospital administrative staff interview, medical record review, video still shot review, video/audio footage review, hospital investigative documentation review, observations and staff interviews the hospital nursing staff failed to ensure nursing supervision of care per the hospital policy and procedure when the staff failed to monitor 1 of 1 patients that expired .

The findings include:

1. The hospital nursing staff failed to monitor for signs of life (rise and fall of chest, snoring) for 55 minutes in 1 of 1 patients that expired (#6).

~cross refer to 482.23(b)(3) RN Supervision of Nursing Care: Tag A 395.

Based on policy and procedure review, Hospital administrative staff interview, closed medical record review, video still shot review, video/audio footage review, hospital investigative documentation review, observations and staff interviews the hospital staff failed to monitor for signs of life (rise and fall of chest, snoring) for 55 minutes in 1 of 1 patients expired (#6) .

The Findings include:

Review of hospital policy, "ACCOUNTING FOR PATIENTS" effective date April 2014 revealed, "rounds must involve visual contact with the patient...Additionally, when patients appear to be sleeping, staff must observe for signs of life (i.e. chest rise and fall, snoring)."

Review of hospital policy, "LEVELS OF PATIENT OBSERVATION" effective date August 26, 2013 revealed, "Q (every) 15 Minute Close Observation Level - Staff interact with, observe and document location and activities of the patient every 15 minutes."

Interview with administrative staff on 09/08/2014 at 1545 revealed the hospital had an occurrence on 08/22/2014 with a patient death. The interview revealed the hospital completed an investigation of the event. The interview revealed on 08/22/2014 on the C-2 (Adult Admissions Female unit) a patient that had been admitted the day before had expired. The interview revealed the results of the investigation revealed the patient was eating her dinner meal in a recliner near the phones. The interview revealed the physician had ordered the patient to be on close observation for every 15 minute checks. The interview revealed the staff thought the patient was asleep after eating. The interview revealed policy and procedure requires if the patient appears to be sleeping the staff are to check for signs of life (chest movement rise and fall). The interview revealed the staff failed to assess the patient for signs of life from 1748 until 1844. The interview revealed when the staff assessed the patient at 1844 the patient was found lifeless and the staff initated life saving measures (code /CPR). The interview revealed the patient expired.

Closed medical record review of Patient #6 revealed a 54 year old female admitted to the hospital on 08/21/2014 for catatonia (a state of apparent unresponsiveness to external stimuli in a person who is apparently awake) and schizoaffective disorder (a mental disorder characterized by abnormal thought process). Record review revealed the patient was ordered by the physician for every 15 minute close observation on 08/22/2014. Record review revealed documentation on the "Behavioral Observation Flow Sheet" the patient was awake at 1730, 1745, 1800, 1815, and 1830. Record review revealed further documentation the patient was asleep at 1845 and 1900. Record review revealed documentation at 1850 RN #1 (registered nurse) found the patient "non-responsive to verbal and painful stimuli." Record review revealed documentation at 1852 CPR (Cardiopulmonary resuscitation) was started on Patient #6. Record review revealed documentation at 1915 EMS (Emergency medical service) arrives and continues CPR. Record review revealed documentation at 1935 Patient #6 was "asystole (no heartbeat)". Record review revealed documentation at 1935 Physician #1 pronounced the patient deceased.

Review of video still shots of Patient #6 taken on 08/22/2014 revealed at 17:32:26 Patient #6 receives a meal tray from TSS (Therapeutic support staff) #1. Review revealed the patient was seated in a reclining chair in telephone area beside the Day Room. Still shot reviews at 17:41:32 revealed the patient leaned forward, at 17:49:17 revealed TSS #2 removes the meal tray and leans over the patient touching the patient on the leg. Still shot review at 18:44:36 (55 minutes later) revealed RN #1 hand placed the patient's shoulder. Still shot review at 18:47:20 revealed a resuscitation cart in the hall.

Review of video footage with audio of Patient #6 recorded on 08/22/2014 revealed at 17:32:55 the patient sitting in a recliner in the telephone area beside the Day Room and TSS #1 placing a meal tray on the patient's lap. At 17:33:13 the patient was observed eating from the meal tray. Video footage review revealed at 17:41:13 the patient sat up and appeared to coughed. Video review revealed the patient continued to eat and at 17:41:30 the patient appeared to cough a second time (17 seconds after first cough). At 17:41:34 the patient appears to cough a third time. At 17:42:00 (26 seconds after third cough) the patient appears to cough a forth time. Video review revealed during the time frame when the patient appeared to cough four times staff were observed in sight of the patient. Video review did not reveal any staff physically making contact with patient. Video review at 17:49:18 (17 minutes after last staff contact with patient), TSS #2 is observed removing the meal tray. During this time TSS #2 leans over the patient and touches the patient on the leg. Video review revealed no movements from the patient after the tray was removed. Video review revealed the laundry room door (approximately 10 feet) was the closest the staff were observed with the patient. Video review revealed no staff physically contacting the patient until 18:44:36 (55 minutes later). Video review revealed the RN reaching down touching the patient and appears to try arousing the patient. Video review revealed at 18:45 the RN calling out to staff for help.

During tour of unit C-2 on 09/09/2014 from 1541 - 1610 the area where Patient #6 was seated was observed. Observation revealed a 12 foot long rectangular area off to the side of the dayroom. Observation revealed visualization of the area could be seen from the nurses desk, the laundry room door (located approximately halfway inside of the rectangular area) and the dayroom. Observation revealed the laundry room door was approximately 10 feet from the area in which patient #6 was sitting in the recliner.

Review of the hospital's investigative documentation revealed an interview of TSS #3 on 08/26/2014. Documentation review revealed TSS #3 was responsible for the every 15 minute checks for the patient between 1730 -1900. Review of the documentation of the interview revealed, "I saw the patient resting showing no signs of distress @ (at) 1830 while opening the laundry room for a patient." Interview did not reveal TSS #3 monitored Patient #6 for signs of life.

Review of the hospital's investigative documentation revealed an interview of TSS #2 on 08/27/2014. Review of the documentation the staff member who removed the meal tray. Interview by the hospital revealed, "I said to pt (patient), 'Are you done.' and there was no verbal response. I stared at her for sign of respiration or breathing. There was visible rise and fall of the chest with no distress."

Interview with the Director of Quality on 09/08/2014 at 1546 revealed the policy states to check for signs of life when a patient appears to be sleeping. Interview revealed the staff monitored the patient visually but did not check for signs of life. Interview revealed the staff believed Patient #6 was sleeping. Interview revealed Patient #6 was known to staff based on previous admissions and staff believed she was in her catatonic state.

Interview with Administrative nursing staff on 09/09/2014 at 1555 revealed the staff member (TSS #3) assigned to monitor Patient #6 on 08/22/2014 from 1730 - 1745 was not available for interview.

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