HospitalInspections.org

Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. This deficient practice is evidenced by:
1) Failing to appropriately monitor and ensure the safety of a suicidal patient;
2) Observation of a non-functioning nurse call button on each side railing of 5 (#a, #c, #e - #g) of 10 (#a - #j) hospital beds observed for nurse call button functioning.(See tag A- 0144); and
3)Patients' identification labels remaining in a room after the patient was discharged and prepared for next patient use (see Tag A-0143).

Based on observation, policy review and interview, the hospital failed to ensure patients had a right to personal privacy. This deficient practice is evidenced by patients' identification labels remaining in a room after the patient was discharged and prepared for next patient use.
Findings:

A review of hospital policy, "Patient's Rights and Responsibilities," #SMH.R1-010, with an effective date: 11/27/2023, revealed in part, Policy: I. Overview of Patient's Rights. A. To the extent permitted by law, hospital policy or medical concerns, the patient (or whoever has the legal responsibility to make decisions regarding medical care for the patient) has the right to: 4. Be treated with consideration, respect, and recognition of their individuality, including the need for privacy in treatment. 14. Have his/her medical records, including all computerized medical information, kept confidential ... Procedure: D. Staff will know and respect the patient's rights. All staff received orientation to the Patient's Rights and Responsibilities at Hospital Orientation and in a timely manner when changes occur. Employees review their understanding of Patient's Rights annually.

An observation during a tour on 05/08/2024 from 10:43 a.m. - 10:55 a.m. of the 3rd floor ICU, revealed the following rooms have been cleaned and ready for patient use:
1. Room #c revealed a Cotton Tip Applicator with a patient label attached to it. This label contained the patient's name, date of birth, admission date, and medical record number.
2. Room #e revealed a sheet of patient identification labels in a wall mounted basket. These labels contained the patient's name, date of birth, admission date, and medical record number.

In an interview on 05/08/2024 during the tour, S4RN confirmed the above mentioned findings and the rooms were clean and ready for a new patient.


50453

Based on observation, record review and interview, the hospital failed to ensure the patient's right to receive care in a safe setting. This deficient practice is evidenced by:
1) Failing to appropriately monitor and ensure the safety of a suicidal patient;
2) Observation of a non-functioning nurse call button on each side railing of 5 (#a, #c, #e - #g) of 10 (#a - #j) hospital beds observed for nurse call button functioning.
Findings:

1) Failing to appropriately monitor and ensure the safety of a suicidal patient

A review of hospital policy, "Patient's Rights and Responsibilities," #SMH.R1-010, with an effective date: 11/27/2023, revealed in part, Policy: I. Overview of Patient's Rights. A. To the extent permitted by law, hospital policy or medical concerns, the patient (or whoever has the legal responsibility to make decisions regarding medical care for the patient) has the right to: 18. Receive care in a safe setting. Procedure: D. Staff will know and respect the patient's rights. All staff received orientation to the Patient's Rights and Responsibilities at Hospital Orientation and in a timely manner when changes occur. Employees review their understanding of Patient's Rights annually.

A review of hospital policy, "Physician's Orders," #SMH.PC-135, with an effective date: 06/28/2023 revealed in part, Purpose: To define interdisciplinary team members' responsibilities related to practitioner's; mid-level provider's; pharmacist's orders. Policy: A. Members of ... Medical Staff shall be responsible for the medical care and treatment of each patient in the hospital. All orders for in-patient treatment will be entered via Computerized Physician order Entry (CPOE). Procedure: A. CPOE Orders: 1. The physician/mid-level provider/pharmacist will enter orders electronically via the CPOE process ... 2. Any order which is not sent immediately upon submission (auto-processed) to the department responsible for carrying out the order will be manually processed by the RN. 3. Order which are manually processed must be checked for completeness by the RN before being processed. This type of order typically requires additional input/action by the person processing the order, such as notifying a physician of consult request, completing a diet order, etc. 4. The nurse caring for the patient is responsible for electronically acknowledging all order entered via CPOE in order to ensure that the orders are appropriate and complete.

A review of hospital policy, "Clinical Alarm Management," # SMH.SMHE.PI.004, with an effective date: 07/25/2022, revealed in part, I. Purpose: A. This policy establishes procedures for managing Clinical Alarms that address 1. Clinically appropriate setting for Clinical Alarm signals. 2. When Clinical Alarm signals can be disabled. 3. When Clinical Alarm parameters can be changed. 4. Who is the organization has the authority to set Clinical Alarm parameters. 5. Who in the organization has the authority to change Clinical Alarm parameters. 6. Who in the organization has the authority to set Clinical Alarm parameters to "off." 7. Monitoring and responding to Clinical Alarm signals. 8. Checking individual Clinical Alarm signals for accurate settings, proper operation, and detectability. 9. Educate staff and licensed independent practitioners about the purpose and proper operation of Clinical Alarm systems. II. Scope: B. This policy shall apply to Clinical Alarms for ... that are triggered by: 1. Physical or physiologic monitoring of the patient; 2 variations in established parameters of medical equipment applied to the individual; 3. Self-activation by the patient to alert staff that the patient is at increased risk or needs immediate assistance. IV. Policy Statements: A. The hospital shall evaluate essential or unnecessary Clinical Alarms in order to address Alarm Fatigue. B. the hospital shall identify the Clinical Alarm signals to manage based on input from the medical staff and clinical departments to reduce risk to patients. C. The hospital shall continuously assess the effectiveness of Clinical Alarms for proper activation, effective communication and appropriate clinical staff response. D. The hospital staff members or Medical Staff shall not bypass alarm functions. V. Policy Implementation: A. Each department has the responsibility for operational management of all equipment with Clinical Alarms. E. The hospital staff member and/or physician assigned to or treating the patient must immediately respond to medical equipment Clinical Alarms based upon the following priority strategy: 1. Alarms with high priority for immediate evaluation by staff have a continuous audible alarm until staff attention to patient occurs at with time the alarm will be reset. 2. Alarms with medium priority for staff evaluation have an initial audible alarm in conjunction with a visual reminder until alarm reset occurs. F. Clinical Alarm parameters are determined by manufacturers recommended defaults, unit specific characteristics, patient population specific and physician recommendations. G. Clinical Alarms should only be disabled when staff is physically present at the bedside or departure from the unit for diagnostic testing, procedures, etc. The clinical alarm shall be reconnected, if appropriate, when the staff have completed their bedside task and/or the patient returns to the unit from the diagnostic testing, procedures, etc. H. Medical staff providers and advanced practice providers are authorized to adjust Clinical Alarm parameters based upon individual patient assessment. I. All Clinical Alarms shall be assessed at the beginning of each shift and when the level of care changes to assure that they are activated and that the alarm limit parameters are appropriate for the patient and the current condition. Staff shall provide documentation of alarm assessment and any changes that occur during the shift. K. Orientation and Training of Equipment Users on Devices with Clinical Alarms shall be provided to each new employee and employees that float in accordance with facility specific orientation.

A review of hospital policy, "Assessment and Reassessment," # OHS.NURS.OS.017, with an effective date: 12/13/2021, revealed in part, IV. Procedure: G. The Patient is reassessed as necessary based on his/her plan of care for changes in his/her condition. Patients will be reassessed at the following times: 3. When a significant change in the patient's condition occurs. 4. As per department standards. 5. As per physician orders. 6. Response to intervention. H. Essential elements of reassessment include: 2. Mental status evaluation.

A review of the hospital's, "Department Scope of Service: Intensive Care Unit," Cost Center: 1413006, and no effective date, revealed in part, Types of patients served or services provided include patients with changing mental or physical status or life-threatening conditions that require continuous assessment, technology, and immediate intervention and prompt treatment. Staffing includes RN assigned to patients based on patient needs and skill competency of the RN. The ratio of RN to patient is depending on acuity of patient needs quantified by an acuity scoring system. Unit assistants are available. Recognized practice guidelines or standards of care in the ICU provides specialized monitoring and surveillance of patients using advanced technology 24 hours per day. Department goals include: the continuous assessment and prompt intervention by professional registered nurses; immediate medical, nursing, and other professional interventions to address life threatening events; collaboration between professionals an ancillary staff to meet individual patient care needs and plan for future care needs.


Patient #1

A review Patient #1's ED Provider Note from 05/02/2024 at 12:47 p.m. by S12MD revealed the patient was received via EMS from jail where the patient was found unresponsive 30 minutes after being placed in a cell for booking. Upon arrival to the ED, the patient was noted to be obtunded with decreased respiratory rate. No other history was available and police reported the patient did not appear unwell when she was placed in the cell. Patient was intubated due to bradypnea and airway protection. Pulmonary consult was ordered and care of the patient was assumed by hospitalist.

A review of the History and Physical from 05/02/2024 at 2:23 p.m. by S13MD revealed in part, Principle Problem: Acute Hypoxemic Respiratory Failure. Chief Complaint: Patient presents with: unresponsive. "Patient found in jail in an unresponsive state," "there were some empty bottles of muscle relaxants nearby?" and "further history was unavailable."
A review of orders initiated by S13MD from 05/02/2024 at 5:07 p.m. revealed an order for Cardiac Monitoring.
A review of orders revealed a verbal order from S14MD and initiated by S8RN on 05/03/2024 at 8:05 a.m. for Inpatient Consult to Psychiatry.
A review of notes entered by S8RN on 05/03/3034 revealed a note at 8:09 a.m., "Pt extubated and able to talk asking a lot of questions about her family and her personal effects. Only pants and shirt and shoes. Unable to get in contact with daughter." Note at 8:33 a.m., "Spoke with security and they spoke with Slidell PD and they will be notified when pt medically stable. Room air at this time. Respirations wnl." Note at 9:15 a.m., "S10MD made rounds and pt clearly is suicideL (suicidal). Expressed to doctor that she wants to go to heaven."
A review of Pulmonary Provider Note by S14MD on 05/03/2024 at 10:49 am revealed a discussion between the provider and patient. "I had a discussion with her and she admits to taking a bottle of Xanax and Zanaflex with the intention killing herself because she did not want to go to jail. We discussed this further and I explained that she will need to see psychiatry (d/w nursing)." S14MD further included in the Active Hospital Problems/Diagnosis: overdose with undetermined intent and concluded with, "The patient has life threatening illness with a high risk of decompensation and/or death.
A review of Hospital Medicine Progress note S10MD, on 05/03/2024 at 11:02 a.m. revealed in part, Subjective: Principle Problem: Intentional drug overdose. The patient was extubated, but clearly suicidal, states she still wants to die and she has a DNR and does not want to be resuscitated. Psych consult has been ordered. The provider indicated the patient saying, " ... had a bottle of tizanidine in her purse and she drank it all because she would rather die than going to jail." She was tired of this life and wants to go to heaven to her mom. The patient further stated, " ... they should not have bought me back yesterday." The notes also reflected under Assessment/Plan: Intentional Drug Over-patient overdosed on Zanaflex. Suicidal Ideations: Patient currently has active suicidal ideas, 1:1 direct observation, Suicide precautions, Psych consult, resumed Cymbalta.
A review of orders by S10MD on 05/03/2024 revealed an order for a Sitter at Bedside being initiated at 10:08 a.m., an order for Direct Psych Observation being initiated at 10:27 a.m., an order for the Transfer of the patient to Med/Surg being initiated at 10:27 a.m. and an order for Suicide Precautions being initiated at 10:48 a.m. These orders were acknowledge by S8RN on 05/03/2024 at 1:32 p.m. which is approximately 2.5 to 3.5 hours after the orders were initiated by the physician.
A review of a note entered by S8RN on 05/03/3034 at 2:03 p.m. revealed, "Went to put tele box on pt and found the room empty. Only blankets on bed. Pt eloped. Called charge nurse."
A review of a note entered by S15RN on 05/03/2024 at 2:38 p.m. revealed, "Spoke with Slidell PD. Notified of pt elopement."
An observation on 05/08/2024 at 1:10 p.m. with S3DQ present and navigating the video recorded on 05/03/2024 from 1:46 p.m. to 1:50 p.m., revealed the time frame the patient exited her room and SICU. The video included a female with dark hair sitting at the nursing station directly across from this patient's room. The nurse was currently eating and appeared to be looking at a computer screen during the entire video reviewed. This female identified by S3DQ and S5RN as S8RN. The patient exited her room at 1:48:08 p.m. with street clothes on. As the patient walks out of the ICU room and toward camera view, S8RN did not appear to look in the direction of the patient or make any body movement that would appear to notice someone walking in front of her. The S8RN appeared to be involved with the computer and eating. The video did identify an IV access hanging from the patient's left arm. This would be the arm closest to S8RN as the patient was walking in front of her and noticeable. The recorded video from floor #1 revealed Patient #1 at 1:49 p.m. and 1:50 p.m. as she walked towards an exit of the building. However, hospital exterior cameras did not capture any images of the patient.

In an interview on 05/09/2024 at 8:30 a.m., Charge Nurse S11RN confirmed new orders being initiated for an Inpatient Consult to Psychiatry, a current patient being placed under a PEC, a Sitter at Bedside, Direct Psych Observation and Suicide Precautions would need to be verbally communicated to her by the initiating physician or the nurse assigned to the patient.

In a telephone interview on 05/09/2024 at 11:05 a.m., S10MD confirmed after assessing the patient on 05/03/3034, she identified the patient would need a Sitter at Bedside, Direct Psych Observation and Suicide Precautions. Further, she confirmed she assumed there was a PEC already in place.

In an interview with S8RN and S5RN on 05/09/2024 from 1:25 p.m. to 2:00 p.m., S8RN confirmed she was the primary nurse responsible for Patient #1. S8RN confirmed the bed alarm was turned off by her, she was unaware the patient was out of the bed with no bed alarm, the patient was on fall precautions due to being recently extubated and the bed alarm should not be turned off. She confirmed the ECG monitor alarms were not silenced, however she does not remember the audible alarm notification of Patient #1's monitor and further confirmed if the patient were to remove the leads from their chest, the monitor would alarm. She confirmed she was aware the patient was not admitted under a PEC and does not remember placing the order for an Inpatient Consult to Psychiatry. She confirmed she did not identify the new orders placed by S10MD and the charge nurse was never informed of Patient #1's current psychological condition. Further in this interview, S5RN confirmed the bed alarm and ECG alarm were functioning in Room #k. S5RN further confirmed it was unit protocol that bed alarms remain activated because all of the ICU patients are considered to be on fall precautions. S5RN confirmed unit protocol dictates it is the primary nurse's responsibility to inform the charge nurse of changes in a patient's condition that would involve the need of a Sitter at Bedside, Direct Psych Observation and Suicide Precautions.

In an interview on 05/09/2024 at 8:25 a.m. S2RN confirmed the police department notified the hospital of Patient #1's death. Further, the police department indicated the patient had died of a self-inflicted gunshot wound within 30 -60 minutes of them being notified of the elopement.

2) Observation of a non-functioning nurse call button on each side railing of 5 (#a, #c, #e - #g) of 10 (#a - #j) hospital beds observed for nurse call button functioning

Observations made on 05/08/2024 between 10:15 a.m. and 11:15 a.m., revealed Rooms #a, #c, #e, #f, and #g had patient beds available for use with a non-functional nurse call features (a button with a red cross-shaped symbol located on the side railing of the beds).

In an interview during the tour on 05/08/2024, S4RN confirmed the above mentioned findings.


50453

Based on record review and interview the hospital failed to ensure the Registered Nurse evaluated the care of each patient on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy. This deficiency is evidenced by the failure to provide a Patient Safety Checklist on 2 (#2, #3) of 2 patient medical records reviewed for a Patient Safety Checklist.
Findings:

Review the hospital policy, revised 06/19/2023, titled "SMC.PC-090: Physician Emergency Commitment (PEC), Coroner's Emergency Commitment (CEC), and Order of Protective Custody (OPC)" revealed in part: To provide safety and prevent injury to self and others J. The Patient Safety checklist (Addendum B) or EMR Sitter flowsheets will be completed by the staff assigned to observe the patient. C. SMH Main and SMH East (i.) Staff will document observations every 15 minutes utilizing the Patient Safety Checklist (Addendum B) or in the EMR utilizing sitter flowsheets.

A review of Patient #2 medical record failed to reveal every 15 minute observation checks via a Patient Safety Checklist from time of PEC 03/05/2024 at 1:00 p.m. throughout ER stay and failed to reveal a Patient Safety Checklist from the time of arrival to ICU on 03/05/2024 at 4:05 p.m. until initiated at 6:30 p.m.

A review of Patient #3 medical record failed to reveal every 15 minute observation checks via a Patient Safety Checklist since arrival on CEC to the ER on 04/04/2024 at 8:53 p.m. Further review failed to reveal a Patient Safety Checklist while inpatient on 04/05/2024 and 04/06/2024.

In an interview on 05/08/2024 at 2:10 p.m. and 2:40 p.m. by S4RN and S7ERD confirmed the above mentioned findings.

In an interview on 05/09/2024 at 9:18 a.m. S1CNO confirmed that they are not able to locate the Patient Safety Checklist for Patient #2 and #3 in medical records.

Based on observation, policy review, and interview, the hospital failed to ensure the facilities, supplies, and equipment were maintained to an acceptable level of safety and quality.
This deficient practice was evidenced by failing to ensure hospital equipment was inspected per hospital policy.
Findings:

Review the hospital policy, revised 02/28/2023, titled "SMH.EC-031: Medical Equipment Management" revealed in part:
B. Maintenance Program d. When equipment is added to the inventory, the biomedical department will assign a P.M. code following the initial inspection performed upon receipt of the equipment into the Hospital. e. Each piece of equipment is tested prior to use and at least annually thereafter.
F. Departmental Responsibilities: 1. Do not use a piece of equipment with an expired safety inspection sticker. Equipment with expired safety inspection stickers shall be tagged and taken out of service. Each piece of equipment that is on Bio-Med's inventory has a sticker with the date it was inspected, the date it is due to be inspected again and the initials of the Bio-Med staff who has inspected it.

An observation during a tour on 05/08/2024 from 10:59 a.m. - 11:15 a.m. of the 2nd floor ICU, revealed a portable telemetry monitor #8561 found and ready for patient use in the ICU with a last date of inspection of June 2022 and a due date for Bio-Med inspection of June 2023.

In an interview on 05/08/2024 at 11:10 a.m., S5RN confirmed the above mentioned findings.

An observation during a tour on 05/09/2024 from 8:25 a.m. - 8:40 a.m. of the 2nd floor ICU, revealed a portable telemetry monitor #8562 found and ready for patient use in the ICU with a last date of inspection of June 2022 and a due date for Bio-Med inspection of June 2023.

In an interview on 05/09/2024 at 8:32 a.m., S2RN confirmed the above mentioned findings.

In an interview on 05/09/2024 at 1:00 p.m., S3QD confirmed the above mentioned policy states equipment should be taken out of service if the Bio-Med sticker is out of date.