HospitalInspections.org

Based on record reviews and interviews, the hospital failed to ensure that patients received care in a safe setting. This deficient practice was evidenced by:

1.) the staff failing to use emergency medical equipment during a medical emergency for 1 (#1) of 1 (#1) patients reviewed that had a medical emergency of a total sample of 3; and

2.) the nurse failing to stay with the patient during a medical emergency until emergency medical service arrived for 1(#1) of 1 (#1) patients reviewed that had a medical emergency of a total sample of 3.

Findings:


1.) The staff failing to use emergency medical equipment during a medical emergency for 1 (#1) of 1 (#1) patients reviewed that had a medical emergency of a total sample of 3.

Review of the hospital's policy titled "BHU-Medical Emergency and Emergency Bag", effective date 03/27/2023, revealed in part, In the event of a medical emergency requiring cardiopulmonary resuscitation, the BHU staff will follow Basic Life Support protocol, and begin CPR on all patients unless the patient is identified as having a "Do Not Resuscitate" order executed through the Advance Directive. Staff will bring the Emergency Medical Bag, AED, Oxygen tank with ambu-bag, and portable suction to the location of the medical emergency. Available staff are to contact Emergency Medical Service (EMS) for emergency transport. Staff continues CPR until EMS arrive to assume control of emergency measures.

Review of the self-report to State Office dated 03/05/2024 revealed in part, On 03/05/2024 at 2:15 p.m. S6MHT found Patient #1 in patient's room closet with a sheet wrapped around his neck hanging from the fire sprinkler. The sheet was removed from Patient #1's neck, CPR started, and EMS was called. EMS arrived, took over care, and pronounced Patient #1 deceased.

Review of the video surveillance footage on 03/13/2024 at 2:46 p.m. revealed the following:
On 03/05/2024 at 2:15 p.m. S6MHT looks into Patient #1's room, starts to go to the next room and then returns and enters Patient #1's room. At 2:16 p.m. S6MHT exits Patient #1's room calling for help. S9LCSW is first to enter Patient #1's room, followed by other staff members. S10LPN is with them, walking, and also enters Patient #1's room. At 2:17 p.m. S10LPN exits Patient #1's room stands outside the door for approximately 15 seconds, then returns to Patient #1's room for several seconds, and then exits again and retrieves a vital sign machine. At 2:18 p.m. S11RN was seen walking to Patient #1's room and then enters the room. At 2:19 p.m. S6MHT leaves Patient #1's room and returns with the emergency bag. At 2:23 p.m. S11RN exits Patient #1's room, stopping in the hallway, and then returns to nurse station. At 2:25 p.m. S10LPN exits Patient #1's room. At 2:27 p.m. Law Enforcement Officers enter through the intake doorway on way to Patient #1's room (which is across the hallway). At 2:28 p.m. EMS personnel arrive. 2:30 p.m. S11RN leaves the nurse's station and walks to Patient #1's room and speaks to Law Enforcement Officer. EMS exits Patient #1's room with an empty stretcher. At 2:33 p.m. S11RN returns to nurse's station.

Observation on 03/13/2024 at 4:01 p.m. - 4:45 p.m. of the BHU revealed the emergency medical bag, 2 oxygen tanks, and ambu-bags were present in the physician's office. Further observation of the emergency medical bag revealed the AED inside the bag.

In an interview during the observation, S5AVPN verified the staff brought the emergency medical bag and ambu-bag to Patient #1's room during the medical emergency. S5AVPN verified the emergency medical bag was not opened by the staff during the medical emergency due to the locks on the bag still being intact. S5AVPN verified the AED was not used during Patient #1's medical emergency due to the AED being inside of the emergency medical bag. S5AVPN verified the emergency medical bag should have been opened and the AED should have been connected to Patient #1 during the medical emergency.

In an interview on 03/14/2024 at 9:30 a.m. S5AVPN verified the ambu-bag was used during Patient #1's medical emergency using room air. S5AVPN verified the staff did not bring an oxygen tank to Patient #1's room to be used with the ambu-bag. S5AVPN verified the ambu-bag should have been connected to the oxygen tank during Patient #1's medical emergency.

2.) The nurse failing to stay with the patient during a medical emergency until emergency medical service arrived for 1(#1) of 1 (#1) patients reviewed that had a medical emergency of a total sample of 3.

Review of the hospital's policy titled "BHU-Medical Emergency and Emergency Bag", effective date 03/27/2023, revealed in part, Charge nurse will lead emergency measures and stay with the patient until ambulance crew arrives to take over care.

Review of the self-report to State Office dated 03/05/2024 revealed in part, On 03/05/2024 at 2:15 p.m. S6MHT found Patient #1 in patient's room closet with a sheet wrapped around his neck hanging from the fire sprinkler. The sheet was removed from Patient #1's neck, CPR started, and EMS was called. EMS arrived, took over care, and pronounced Patient #1 deceased.

Review of the video surveillance footage on 03/13/2024 at 2:46 p.m. revealed the following:
On 03/05/2024 at 2:15 p.m. S6MHT looks into Patient #1's room, starts to go to the next room and then returns and enters Patient #1's room. At 2:16 p.m. S6MHT exits Patient #1's room calling for help. S9LCSW is first to enter Patient #1's room, followed by other staff members. S10LPN is with them, walking, and also enters Patient #1's room. At 2:17 p.m. S10LPN exits Patient #1's room stands outside the door for approximately 15 seconds, then returns to Patient #1's room for several seconds, and then exits again and retrieves a vital sign machine. At 2:18 p.m. S11RN was seen walking to Patient #1's room and then enters the room. At 2:19 p.m. S6MHT leaves Patient #1's room and returns with the emergency bag. At 2:23 p.m. S11RN exits Patient #1's room, stopping in the hallway, and then returns to nurse station. At 2:25 p.m. S10LPN exits Patient #1's room. At 2:27 p.m. Law Enforcement Officers enter through the intake doorway on way to Patient #1's room (which is across the hallway). At 2:28 p.m. EMS personnel arrive. 2:30 p.m. S11RN leaves the nurse's station and walks to Patient #1's room and speaks to Law Enforcement Officer. EMS exits Patient #1's room with an empty stretcher. At 2:33 p.m. S11RN returns to nurse's station.

In an interview on 03/14/2024 at 8:44 a.m. S5AVPN verified the RN did not stay continuously with Patient #1 until EMS arrived during the medical emergency.