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Based on policy review, and staff interview it was determined the facility failed to ensure the development of effective nursing policies and procedures related to nursing care of patients in cardio-pulmonary arrest.

Findings include:

The policy titled Medical Emergency Response Plan, number II.B15.11.CFL, dated 11/2/18 indicated the hospital will manage medical emergencies only until the county's EMS arrives to evaluate, treat and transport the person to an Acute Care Hospital emergency department. The policy indicated all RN's, LPN's and physicians functioning in these capacities, as well as all personnel currently certified in CPR located on the unit or in the facility of the event are responsible for an immediate response. The staff will evaluate respiratory and cardiac activity. If the patient is unresponsive, staff will call for immediate assistance and will not leave the patient. Staff will begin CPR/first aid/ AED immediately.

An interview was conducted with the Laboratory Manager, who indicated she was in training as the Risk Manager designee, and the Risk Manager on 6/13/19 at 2:00 p.m. In response to questions regarding the facility Emergency Response Plan, the Laboratory Manager indicated a team had determined that having all CPR certified individuals respond to medical emergencies would leave no staff available to take care of other patients. The Laboratory Manager indicated the current practice was for each unit to designate a person and assign a role to respond to medical emergencies, and only those designated personnel responded. The Laboratory Manager indicated the team also determined an assigned person should be responsible for acting in the role of a recorder or scribe to document the details of each medical event. She was unable to identify where in the medical record such documentation would be placed. Both the Laboratory Manager and the Risk Manager indicated there was no form or policy related to documentation associated with medical emergencies or responses. The Laboratory Manager indicated notes were taken on any available paper. Neither the Laboratory Manager nor the Risk Manager provided any indication the Director of Nursing, who oversaw the nursing department of the hospital, was aware of, or involved in, any need for change or any actual changes to the current practice related to medical emergencies.

Based on medical record review, policy review, and staff interview it was determined the nursing staff failed to assess and reassess one (#1) of three sampled patients in compliance with facility policies and the physician-ordered plan of treatment, and failed to provide emergency care and services within generally accepted standards of care for one (#1) of three sampled patients.

Findings included:

The review of the Physician/ARNP Documentation Information Only dated 6/2/19 at 10:00 a.m. was signed by the resident psychiatrist and reviewed by the attending psychiatrist. The note indicated as the on-call resident, the author was notified of the death of Patient #1. The note included documentation Patient #1 was found unresponsive when the staff entered the room to take vital signs. The resident physician wrote, "Nursing was notified, CPR was performed, and 911 was called. EMS (Emergency Medical Services) arrived to the unit and pronounced the patient dead."

The Inpatient Psychiatric Evaluation dated 5/29/19 at 9:45 a.m. was signed by the resident physician and reviewed by the attending psychiatrist. The note indicated Patient #1 presented to the facility on a voluntary basis the previous evening requesting admission for treatment of withdrawal from Fentanyl (an opioid medication). The patient reported the last use of Fentanyl was the previous day prior to admission. The note included Patient #1's urine drug screen was positive for Fentanyl. The patient reported body aches and cramps, gastric problems, and nausea, indicating the patient was actively withdrawing from opioid. The note included documentation indicating Patient #1 was an inpatient 10 days previously at an acute care hospital for treatment of shortness of breath and muscle weakness associated with the patient's known diagnosis of myasthenia gravis (an auto-immune mediated progressive, degenerative, neuro-muscular disease).

The Inpatient Shift Notes dated 5/29/19 - 6/1/19 included an area designated Nutrition with space to record the patient's intake at each meal and a snack. Each of the Shift Notes included an area to indicate Withdrawal Symptoms. On 5/29/19, the documentation indicated Patient #1 refused Breakfast, Lunch, and Dinner. Withdrawal symptoms included nausea and vomiting. On 5/30/19, there was a notation Patient #1 did not eat. Withdrawal symptoms included nausea and vomiting. On 3/31/19, there was no documentation of the patient's food intake for breakfast, lunch, or dinner. The patient ate 25% of a snack. Withdrawal symptoms included nausea and vomiting. A note indicated the patient's appetite had been poor due to signs and symptoms of withdrawal. On 6/1/19 at 7:24 p.m. the patient did not eat breakfast or lunch, but ate 25% of her dinner. Withdrawal symptoms were nausea and vomiting.

The Service Progress Notes dated 5/30/19 at 5:00 a.m. were signed by the RN (Registered Nurse). The notes included Patient #1 was asking to go to the hospital. The patient complained of seeing blood in her vomit. The nurse documented she gave medication for vomiting with little to no effect. The nurse notified the physician, and complied with instructions to administer a different medication for vomiting. The notes indicated the patient continued to complain of vomiting after administration of the second medication. The nurse documented the patient's vital signs were stable and the nurse did not observe any blood in the patient's vomit.

The Service Progress Notes dated 6/2/19 at 8:55 a.m. were signed by the RN. The notes indicated the Behavioral Health Tech (BHT) entered the room of Patient #1 at approximately 6:25 a.m. and found the patient unresponsive. The author wrote, "She notified the detox nurse who then notified the charge nurse. Additional nursing staff from another unit were called for assistance. The Charge nurse called 911. [The] 911 operator called the charge nurse back on her cell phone so the charge nurse could go the client's room. While the 911 operator was on the line, staff used the AED (Automatic Electronic Defibrillator) to assess heart rhythm. Heart rhythm indicated "no shock advised". Client did not respond to CPR (cardiopulmonary resuscitation). Vital signs were nil. EMS arrived and pronounced the client dead."

The detailed review of the medical record failed to reveal evidence of the names or titles of the persons involved in the attempted resuscitation efforts for Patient #1. There was no evidence of any nursing assessment of the patient's condition at the time the patient was discovered; whether femoral or carotid pulses were checked, whether the patient was visibly cyanotic at the time of discovery, or whether the patient's skin was warm or cool to the touch. There was no evidence of the time chest compressions and/or assisted ventilation was initiated or terminated, and no evidence of the duration of the resuscitative efforts provided to this patient. There was no evidence of the method used to provide assisted ventilation to the patient or if oxygen was administered during these efforts.

The detailed review of the medical record failed to reveal any evidence of a comprehensive nursing re-evaluation at any time following the initial nursing assessment on 5/28/19 at 10:22 a.m., of the patient with myasthenia gravis, who had refused to take her medication for two consecutive days that was prescribed for treatment of the disease, who had no evidence of nutrition intake for the entirety of her five day admission, and who had been vomiting throughout her five day admission with only partial relief from prescribed medications.

The policy titled Medical Emergency Response Plan, number II.B15.11.CFL, dated 11/2/18 indicated the hospital will manage medical emergencies only until the county's EMS arrives to evaluate, treat and transport the person to an Acute Care Hospital emergency department. The policy indicated all RN's, LPN's and physicians functioning in these capacities, as well as all personnel currently certified in CPR located on the unit or in the facility of the event are responsible for an immediate response. The staff will evaluate respiratory and cardiac activity. If the patient is unresponsive, staff will call for immediate assistance and will not leave the patient. Staff will begin CPR/first aid/ AED immediately.

An interview was conducted with the Risk Manager on 6/13/19 at 2:00 p.m. The Risk Manager confirmed the finding the nursing staff failed to document Withdrawal symptoms included nausea and vomiting, appropriately assess and re-assess Patient #1, failed to provide nursing care and services to meet the needs of Patient #1, and failed to comply with facility policies related to medical emergencies.