HospitalInspections.org

Based on a review of documentation and an interview with staff, the governing body failed to appoint a chief executive officer who is responsible for managing the hospital.

Findings were:

Upon admission, patient #1 was ordered to use a sleep wedge and 2 liters per minute of oxygen at bedtime, as she had scored "High Risk for Sleep Apnea" on her nursing admission assessment. Her nutritional screening tool indicated that she needed a dietitian consult due to a BMI [body mass index] >30, but no dietitian consult was located in the clinical record. Staff #3 was asked to locate the dietitian consult but was unable to do so. The patient was ordered to be observed on fall and respiratory/sleep apnea precautions. The order for the sleep wedge as well as observation on fall and respiratory/sleep precautions remained active throughout the patient's stay.

The "Mental Health Tech[nician] Daily Note" was completed every 24 hours. Areas on the form denoted such things as medical equipment (which included a CPAP machine, sleep wedge and oxygen concentrator) and a check-box next to each of those items to indicate what equipment the patient was/should be using. The form contained an area for precautions and contained such precautions as suicide, self-injury, elopement, fall and sleep apnea. Each precaution had a check-box next to each item to indicate for what precautions the patient was/should be monitored.

A review of the "Mental Health Tech[nician] Daily Note" documentation throughout the patient's stay indicated the following precautions and medical equipment:

" 8-3-17 - no precautions or medical equipment noted
" 8-4-17 - fall precautions; no medical equipment noted
" 8-5-17 - fall precautions; no medical equipment noted
" 8-6-17 - fall precautions; no medical equipment noted
" 8-7-17 - fall and high risk sleep apnea precautions; no medical equipment noted
" 8-8-17 - fall precautions; no medical equipment noted
" 8-9-17 - fall precautions; no medical equipment noted
" 8-10-17 - fall precautions; no medical equipment noted

The "24-Hour Nursing Assessment and Patient Education" was completed by nursing staff every 12 hours. Areas on the form denoted such things as level of consciousness, behaviors, appearance and precautions. The precautions area included such things as suicide, self-injury, elopement, fall and sleep apnea. Each precaution had a check-box next to each item to indicate for what precautions the patient was/should be monitored. The form did not contain an area to denote any medical equipment the patient was/should be using.

A review of the "24-Hour Nursing Assessment and Patient Education" documentation throughout the patient's stay indicated the following precautions:

" 8-4-17, day shift - fall & high-risk sleep apnea precautions
" 8-4-17, night shift - fall precautions
" 8-5-17, day shift - fall & sleep apnea precautions
" 8-5-17, night shift - fall precautions
" 8-6-17, day shift - fall precautions
" 8-6-17, night shift - fall precautions
" 8-7-17, day shift - fall precautions
" 8-7-17, night shift - no precautions listed
" 8-8-17, day shift - fall & high-risk sleep apnea precautions
" 8-8-17, night shift - high-risk sleep apnea precautions
" 8-9-17, day shift - fall precautions
" 8-9-17, night shift - fall precautions
" 8-10-17, day shift - fall & sleep apnea precautions

On 8-10-17 at 5:05 pm, nurse's notes (for patient #1) read as follows:
"Nurse was rounding on patient since it was reported that patient had an incontinent episode, patient found unresponsive, called a code and charge nurse, checked pulse and breathing, no pulse, CPR[cardiopulmonary resuscitation] and AED[automated external defibrillator] started right away, while another nurse called 911, while CPR was still going on. Eye opening, chest compression still going on and patient still been(sic) bagged for oxygen @[at] 10L[liters] mask O2[oxygen] 91%, continuous compression. Pulse @ shit(sic) 104. House Supervisor present with multiple staff helping c[with] CPR and given(sic) breath. EMS arrived and took over the code and CPR and bagging and patient was intubated by EMS, IV[intravenous] medications given with multiple monitors and workup."

The patient (patient #1) was transported to a nearby emergency room shortly after 6:00 pm. Facility documentation revealed that the patient expired on 8-11-17.

A review of facility policy DT-120 titled "Nutrition Risk Assessment" states, in part:
"Policy:
Patients with a nutritional risk status will be assessed on admission and referrals for RD[registered dietitian] services will be made if nutrition risks are identified.
Procedure:
...
2. Nursing completes the nutrition risk assessment as part of the inpatient nursing admission assessment (Part III of Admission Assessment).
a) Nursing assess(sic) weight change, intake prior to admission, special diet needs, altered nutrition-related labs, food allergies/intolerance, and cultural/religious diet needs, dysphagia, chewing problems, and disordered eating patterns.
b) The nurse makes a referral for RD services by adding the patient name and room number to the Nutrition referral binder on the unit.
c) RD will complete a comprehensive assessment within 72 hours of referral."

A review of facility policy PC-164 titled "CPAP Machine Usage/Sleep Apnea" states, in part:
"Procedure:
...
5. Monitor patients who have a diagnosis of Sleep Apnea without a CPAP machine during hours of sleep in the following ways but not limited to as determined by physician order, which may include:
" Monitoring: At a higher level of observation
" Precautions: Medical Risk; Detox, Opioid, Respiratory
" Pulse Oximetry readings taken every hour of sleep
" Use of a Hospital bed
" Use of a wedge while sleeping"

A review of facility policy PC-154 titled "Level of Observation Protocols" states, in part:
"Policy:
The status and location of all patients shall be directly observed, assessed and documented a minimum of every 15 minutes (routine) in order to ensure maximum safety on the units ..."

A review of facility policy PC-150 titled "Levels of Precautions" states, in part:
"Procedure: A patient may be placed on specific levels of precautions when determined necessary by the physician.

Individualized levels of precautions:
...
F. Medically Compromised
G. Fall
...
A. Guiding Principles
...
G. Medically Compromised: Patients with identified a(sic) co-occurring medical conditions(s) which require frequent medical assessment and intervention."

The above was confirmed in an interview with the CNO, CEO and Director of Risk Management on the afternoon of 8-21-17.

Based on a review of documentation and an interview with staff, the facility failed to ensure the patient's right to receive care in a safe setting.

Findings were:

Upon admission, patient #1 was ordered to use a sleep wedge and 2 liters per minute of oxygen at bedtime, as she had scored "High Risk for Sleep Apnea" on her nursing admission assessment. Her nutritional screening tool indicated that she needed a dietitian consult due to a BMI [body mass index] >30, but no dietitian consult was located in the clinical record. Staff #3 was asked to locate the dietitian consult but was unable to do so. The patient was ordered to be observed on fall and respiratory/sleep apnea precautions. The order for the sleep wedge as well as observation on fall and respiratory/sleep precautions remained active throughout the patient's stay.

The "Mental Health Tech[nician] Daily Note" was completed every 24 hours. Areas on the form denoted such things as medical equipment (which included a CPAP machine, sleep wedge and oxygen concentrator) and a check-box next to each of those items to indicate what equipment the patient was/should be using. The form contained an area for precautions and contained such precautions as suicide, self-injury, elopement, fall and sleep apnea. Each precaution had a check-box next to each item to indicate for what precautions the patient was/should be monitored.

A review of the "Mental Health Tech[nician] Daily Note" documentation throughout the patient's stay indicated the following precautions and medical equipment:

" 8-3-17 - no precautions or medical equipment noted
" 8-4-17 - fall precautions; no medical equipment noted
" 8-5-17 - fall precautions; no medical equipment noted
" 8-6-17 - fall precautions; no medical equipment noted
" 8-7-17 - fall and high risk sleep apnea precautions; no medical equipment noted
" 8-8-17 - fall precautions; no medical equipment noted
" 8-9-17 - fall precautions; no medical equipment noted
" 8-10-17 - fall precautions; no medical equipment noted

The "24-Hour Nursing Assessment and Patient Education" was completed by nursing staff every 12 hours. Areas on the form denoted such things as level of consciousness, behaviors, appearance and precautions. The precautions area included such things as suicide, self-injury, elopement, fall and sleep apnea. Each precaution had a check-box next to each item to indicate for what precautions the patient was/should be monitored. The form did not contain an area to denote any medical equipment the patient was/should be using.

A review of the "24-Hour Nursing Assessment and Patient Education" documentation throughout the patient's stay indicated the following precautions:

" 8-4-17, day shift - fall & high-risk sleep apnea precautions
" 8-4-17, night shift - fall precautions
" 8-5-17, day shift - fall & sleep apnea precautions
" 8-5-17, night shift - fall precautions
" 8-6-17, day shift - fall precautions
" 8-6-17, night shift - fall precautions
" 8-7-17, day shift - fall precautions
" 8-7-17, night shift - no precautions listed
" 8-8-17, day shift - fall & high-risk sleep apnea precautions
" 8-8-17, night shift - high-risk sleep apnea precautions
" 8-9-17, day shift - fall precautions
" 8-9-17, night shift - fall precautions
" 8-10-17, day shift - fall & sleep apnea precautions

On 8-10-17 at 5:05 pm, nurse's notes (for patient #1) read as follows:
"Nurse was rounding on patient since it was reported that patient had an incontinent episode, patient found unresponsive, called a code and charge nurse, checked pulse and breathing, no pulse, CPR[cardiopulmonary resuscitation] and AED[automated external defibrillator] started right away, while another nurse called 911, while CPR was still going on. Eye opening, chest compression still going on and patient still been(sic) bagged for oxygen @[at] 10L[liters] mask O2[oxygen] 91%, continuous compression. Pulse @ shit(sic) 104. House Supervisor present with multiple staff helping c[with] CPR and given(sic) breath. EMS arrived and took over the code and CPR and bagging and patient was intubated by EMS, IV[intravenous] medications given with multiple monitors and workup."

The patient (patient #1) was transported to a nearby emergency room shortly after 6:00 pm. Facility documentation revealed that the patient expired on 8-11-17.

A review of facility policy DT-120 titled "Nutrition Risk Assessment" states, in part:
"Policy:
Patients with a nutritional risk status will be assessed on admission and referrals for RD[registered dietitian] services will be made if nutrition risks are identified.
Procedure:
...
2. Nursing completes the nutrition risk assessment as part of the inpatient nursing admission assessment (Part III of Admission Assessment).
a) Nursing assess(sic) weight change, intake prior to admission, special diet needs, altered nutrition-related labs, food allergies/intolerance, and cultural/religious diet needs, dysphagia, chewing problems, and disordered eating patterns.
b) The nurse makes a referral for RD services by adding the patient name and room number to the Nutrition referral binder on the unit.
c) RD will complete a comprehensive assessment within 72 hours of referral."

A review of facility policy PC-164 titled "CPAP Machine Usage/Sleep Apnea" states, in part:
"Procedure:
...
5. Monitor patients who have a diagnosis of Sleep Apnea without a CPAP machine during hours of sleep in the following ways but not limited to as determined by physician order, which may include:
" Monitoring: At a higher level of observation
" Precautions: Medical Risk; Detox, Opioid, Respiratory
" Pulse Oximetry readings taken every hour of sleep
" Use of a Hospital bed
" Use of a wedge while sleeping"

A review of facility policy PC-154 titled "Level of Observation Protocols" states, in part:
"Policy:
The status and location of all patients shall be directly observed, assessed and documented a minimum of every 15 minutes (routine) in order to ensure maximum safety on the units ..."

A review of facility policy PC-150 titled "Levels of Precautions" states, in part:
"Procedure: A patient may be placed on specific levels of precautions when determined necessary by the physician.

Individualized levels of precautions:
...
F. Medically Compromised
G. Fall
...
A. Guiding Principles
...
G. Medically Compromised: Patients with identified a(sic) co-occurring medical conditions(s) which require frequent medical assessment and intervention."

The above was confirmed in an interview with the CNO, CEO and Director of Risk Management on the afternoon of 8-21-17.

Based on a review of documentation and an interview with staff, the director of nursing service failed to be responsible for the operation of the service and properly supervise all nursing care provided.

Findings were:

Upon admission, patient #1 was ordered to use a sleep wedge and 2 liters per minute of oxygen at bedtime, as she had scored "High Risk for Sleep Apnea" on her nursing admission assessment. Her nutritional screening tool indicated that she needed a dietitian consult due to a BMI [body mass index] >30, but no dietitian consult was located in the clinical record. Staff #3 was asked to locate the dietitian consult but was unable to do so. The patient was ordered to be observed on fall and respiratory/sleep apnea precautions. The order for the sleep wedge as well as observation on fall and respiratory/sleep precautions remained active throughout the patient's stay.

The "Mental Health Tech[nician] Daily Note" was completed every 24 hours. Areas on the form denoted such things as medical equipment (which included a CPAP machine, sleep wedge and oxygen concentrator) and a check-box next to each of those items to indicate what equipment the patient was/should be using. The form contained an area for precautions and contained such precautions as suicide, self-injury, elopement, fall and sleep apnea. Each precaution had a check-box next to each item to indicate for what precautions the patient was/should be monitored.

A review of the "Mental Health Tech[nician] Daily Note" documentation throughout the patient's stay indicated the following precautions and medical equipment:

" 8-3-17 - no precautions or medical equipment noted
" 8-4-17 - fall precautions; no medical equipment noted
" 8-5-17 - fall precautions; no medical equipment noted
" 8-6-17 - fall precautions; no medical equipment noted
" 8-7-17 - fall and high risk sleep apnea precautions; no medical equipment noted
" 8-8-17 - fall precautions; no medical equipment noted
" 8-9-17 - fall precautions; no medical equipment noted
" 8-10-17 - fall precautions; no medical equipment noted

The "24-Hour Nursing Assessment and Patient Education" was completed by nursing staff every 12 hours. Areas on the form denoted such things as level of consciousness, behaviors, appearance and precautions. The precautions area included such things as suicide, self-injury, elopement, fall and sleep apnea. Each precaution had a check-box next to each item to indicate for what precautions the patient was/should be monitored. The form did not contain an area to denote any medical equipment the patient was/should be using.

A review of the "24-Hour Nursing Assessment and Patient Education" documentation throughout the patient's stay indicated the following precautions:

" 8-4-17, day shift - fall & high-risk sleep apnea precautions
" 8-4-17, night shift - fall precautions
" 8-5-17, day shift - fall & sleep apnea precautions
" 8-5-17, night shift - fall precautions
" 8-6-17, day shift - fall precautions
" 8-6-17, night shift - fall precautions
" 8-7-17, day shift - fall precautions
" 8-7-17, night shift - no precautions listed
" 8-8-17, day shift - fall & high-risk sleep apnea precautions
" 8-8-17, night shift - high-risk sleep apnea precautions
" 8-9-17, day shift - fall precautions
" 8-9-17, night shift - fall precautions
" 8-10-17, day shift - fall & sleep apnea precautions

On 8-10-17 at 5:05 pm, nurse's notes (for patient #1) read as follows:
"Nurse was rounding on patient since it was reported that patient had an incontinent episode, patient found unresponsive, called a code and charge nurse, checked pulse and breathing, no pulse, CPR[cardiopulmonary resuscitation] and AED[automated external defibrillator] started right away, while another nurse called 911, while CPR was still going on. Eye opening, chest compression still going on and patient still been(sic) bagged for oxygen @[at] 10L[liters] mask O2[oxygen] 91%, continuous compression. Pulse @ shit(sic) 104. House Supervisor present with multiple staff helping c[with] CPR and given(sic) breath. EMS arrived and took over the code and CPR and bagging and patient was intubated by EMS, IV[intravenous] medications given with multiple monitors and workup."

The patient (patient #1) was transported to a nearby emergency room shortly after 6:00 pm. Facility documentation revealed that the patient expired on 8-11-17.

A review of facility policy DT-120 titled "Nutrition Risk Assessment" states, in part:
"Policy:
Patients with a nutritional risk status will be assessed on admission and referrals for RD[registered dietitian] services will be made if nutrition risks are identified.
Procedure:
...
2. Nursing completes the nutrition risk assessment as part of the inpatient nursing admission assessment (Part III of Admission Assessment).
a) Nursing assess(sic) weight change, intake prior to admission, special diet needs, altered nutrition-related labs, food allergies/intolerance, and cultural/religious diet needs, dysphagia, chewing problems, and disordered eating patterns.
b) The nurse makes a referral for RD services by adding the patient name and room number to the Nutrition referral binder on the unit.
c) RD will complete a comprehensive assessment within 72 hours of referral."

A review of facility policy PC-164 titled "CPAP Machine Usage/Sleep Apnea" states, in part:
"Procedure:
...
5. Monitor patients who have a diagnosis of Sleep Apnea without a CPAP machine during hours of sleep in the following ways but not limited to as determined by physician order, which may include:
" Monitoring: At a higher level of observation
" Precautions: Medical Risk; Detox, Opioid, Respiratory
" Pulse Oximetry readings taken every hour of sleep
" Use of a Hospital bed
" Use of a wedge while sleeping"

A review of facility policy PC-154 titled "Level of Observation Protocols" states, in part:
"Policy:
The status and location of all patients shall be directly observed, assessed and documented a minimum of every 15 minutes (routine) in order to ensure maximum safety on the units ..."

A review of facility policy PC-150 titled "Levels of Precautions" states, in part:
"Procedure: A patient may be placed on specific levels of precautions when determined necessary by the physician.

Individualized levels of precautions:
...
F. Medically Compromised
G. Fall
...
A. Guiding Principles
...
G. Medically Compromised: Patients with identified a(sic) co-occurring medical conditions(s) which require frequent medical assessment and intervention."

The above was confirmed in an interview with the CNO, CEO and Director of Risk Management on the afternoon of 8-21-17.