HospitalInspections.org

Based on document review, interview, and observation, it was determined for 1 of 10 (Pt. #1) records reviewed, that the Hospital failed to ensure that the patient's rights were protected. This potentially affects current and future patients admitted to the Hospital. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to provide care in a safe setting by failing to conduct a contraband search and failing to keep syringes secured and unavailable to unauthorized users. This has the potential to affect all patients and visitors to the Hospital. See deficiency cited at A-144.

The Immediate Jeopardy (IJ) was identified on 7/29/2022, at 42 CFR 482.13, Patient Rights, due to the Hospital's failure to provide care in a safe setting by failing to conduct a contraband search and failing to keep syringes secured and unavailable to unauthorized users. The Immediate Jeopardy was announced on 7/29/2022 at 2:20 PM in a meeting with the President, Director of Quality and Chief Nursing Officer. The IJ was not removed by the survey exit date of 7/29/2022.

2. The Hospital failed to ensure a Sentinel Event was completed for the incident to ensure safety for future patients experiencing similar circumstances. See deficiency cited at A-142.

Based on document review and interview, it was determined that for 1 of 1 Patient (Pt. #1) who allegedly expired due to overdose, the Hospital failed to ensure a Sentinel Event was completed for the incident to ensure safety for future patients experiencing similar circumstances.

Findings include:

1. On 7/29/2022, the Hospital's "Never Event / Sentinel Event Policy," dated 9/14/2021, was reviewed. The policy required, "II Definitions... D. Sentinel Event - A patient safety event (not primarily related to the natural course of the patient's illness or underlying condition that results in death, permanent harm, or severe temporary harm... an action plan will be developed which is designed to reduce risk [provide safety].

2. On 7/29/2022, Pt. #1's clinical record was reviewed. Pt. #1 came to the Emergency Department (ED) on 7/29/2022, with a complaint of leg edema and a history of substance abuse. Pt. #1 was "admitted for cellulitis. She is going to be on IV [intravenous] antibiotic."

A nursing note on 6/8/22 at 6:05 PM, included Pt. #1 was sitting in chair, eating, and had no complaints.

Another nursing note on 6/8/22 at 7:00 PM, included, "Pt. locked in bathroom, IV beeping, opened door with key, found Pt lying prone in floor with face in vomit, not responding, code blue activated." Pt. #1 expired on 6/8/22 at 7:34 PM.
A nursing note dated 6/8/22 at 8:20 PM, stated "unknown substance found in cig (cigarette) box powdered substance. Small syringe attached to IV tubing that was bagged ..."

3. On 7/29/2022, the Hospital Sentinel Event Log for 2022 (1/1/2022 - 7/29/2022) was reviewed. There were 3 sentinel events listed, but nothing regarding Pt. #1's demise on 6/8/2022.

4. On 7/29/2022 at 10:36 AM, an interview was conducted with the Patient Safety Specialist (E #12). E #12 stated that a sentinel event was not completed for Pt. #1's death because, "There was no deviation that lead to a sentinel event." A Deficiency was cited at A-142.

Based on observation, document review and interview, it was determined that for 1 of 1 (Pt. #1) clinical records reviewed of patient's that had expired in the Hospital, the Hospital failed to provide care in a safe setting by failing to conduct a contraband search and failing to keep syringes secured and unavailable to unauthorized users. This has the potential to affect all patients and visitors to the Hospital.

Findings include:

1. Pt #1's medical record was reviewed throughout the survey (07/21/22, 07/22/22 and 07/29/22). Pt #1 was admitted thru the Emergency Department (ED) with a Diagnoses of Cellulitis of Leg with a past medical history of Drug Abuse. The Emergency Department Physician Report dated 6/7/22 stated, " ...Physical Exam... healed pitting of skin consistent with prior popping .... " The patient was started on Intravenous (IV) antibiotics. Patient was in isolation due to being COVID 19 positive. A "Patient Belongings Checklist" was completed on 6/7/22 at 8:44 PM which stated Pt #1 had "Pants, Shirt/Blouse, Shoes/Slippers, and Other Valuables: Cellphone, charger" that were in the patient's room. The Infectious Disease Consultation note dated/ signed 6/8/22 at 2:31 PM stated, "Laboratory data: Tox (toxicology) screen positive for cocaine and opiates ... patient says has been clean since 3/22 and quit drugs 3 months ago." A nursing note on 6/8/22 at 6:05 PM, stated "pt sitting in chair, eating, no complaints offered." A nursing noted on 6/8/22 at 7:00 PM stated, "pt. locked in bathroom, IV beeping, opened door with key, found pt lying prone in floor with face in vomit, not responding, code blue activated." Patient expired on 6/8/22 at 7:34 PM. A nursing note dated 6/8/22 at 8:20 PM, stated "unknown substance found in cig (cigarette) box powdered substance. Small syringe attached to IV tubing that was bagged ... Officer notified ... Drug items kept on unit in biohazard bag with patient's name. Coroner requested items to be sent with body." A Toxicology Report from the Coroners Office stated, "Fentanyl Result 6.9 ng/ml (micrograms/milliliter) ... Reference Comments ... 3. Fentanyl ... In fatalities from fentanyl, blood concentrations are variable and have been reported as low as 3 ng/ml. Postmortem blood fentanyl concentrations ranged from 0.30-110 .... obtained from accidental drug overdose death investigations."

2. The Policy titled "Contraband Policy - For ED and Non-Behavioral Health Units (revised 04/19/2022)" was reviewed on 07/29/22 at approximately 10:15 AM. The policy stated " II. Policy It is the policy of AMIA Health to remove unsafe and prohibited items from a patient's belongings through a search process that honors a patient's rights to privacy and dignity. III. Definitions Policy-Specific Definitions .... C. Illegal Contraband - means items that are prohibited under laws applicable to the general public, such as illegal drugs and items readily capable of being used to cause death or serious physical injury, including firearms, cartridges, explosives, or knives, other than small pocketknives ... IV. Required Procedures. A. Belongings Searches. Belonging Searches must be done ... Illegal Contraband will be given to Security to deliver to law enforcement without identifying the patient from whom it was taken .... 1. Screening for Contraband .... Trained and qualified associate should review the immediate area for Contraband at regular intervals, including, upon admission, when visitors leave and at change of shifts. 2. Patients in the Emergency Department and Non-Behavioral Health Inpatient Units. Based on assessment and potential risk to self or others, the patient's belongings will be removed.

3. A tour of the 8 east nursing unit (medical/surgical/telemetry/observation) was conducted on 7/29/2022 at 10:35 AM. A long hallway heading away from the nurse's station contained a patient supply cabinet (between rooms 805 and 807) that was unlocked, connected to the cabinet was a desk area with flip up cabinets above the desk. The desk had an open glucometer (machine that measures blood sugar) case that had 2 unused insulin syringes available. The flip up cabinet was unlocked and contained a plastic basket containing multiple insulin syringes and 3 milliliter syringes with needles.
The unit had three locked rooms for storage of supplies. Each room had a number lock with the entry code taped above the lock for easy access. The clean supply room contained opened cabinets that contained the units supply of all syringes and needles.

4. During an interview on 7/29/22 at 10:50 AM with a Medical/Surgical Registered Nurse (E #11). E #11 stated "We keep the storage cabinet down this hallway supplied as the supply room is at the opposite end of the hallway. We keep IV (intravenous) supplies, syringes and other supplies in the cabinet. It is not locked. We try to keep someone in the hall but do not always have someone in the hall."

5. During an interview on 7/29/2022 at 10:55 AM, the Director of Medical/Surgical/Telemetry (E#10) stated, "There is a potential for theft of anything from the cabinets, including syringes." E#10 stated that there is usually someone in the hallway; however, not always.

6. During an interview on 7/29/2022 at 11:37 AM, the Patient Safety Specialist (E #12) reviewed Pt #1's "Patient Belongings Checklist" and stated, "Staff didn't go through pockets as the patient was diagnosed with cellulitis and did not have a diagnosis of substance abuse."