HospitalInspections.org

Based on a review of facility documentation and medical records(MR), and staff interviews (EMP), it was determined the facility failed to follow their policy to maintain the safety of a patient for one of ten medical records reviewed (MR1).

Findings included:

On June 17, 2022, a review was completed of the facility policy titled, "Managing Adult Patient and Visitor Behavior that Disrupts the Healthcare Environment," dated, "December 31, 2021." The policy revealed, Section "III. Patient and visitor behavioral expectations...Some examples of behavior that may impair the providing of care or operation of the facility are:...Leaving the unit against medical advice creating a safety concern...Using alcohol, illegal drugs or tobacco in the clinical environment...Engaging in unlawful or inappropriate behavior, including, but not limited to purchasing or selling illegal drugs...Procedure for intervening with patients whose behavior disrupts or poses a threat to the healthcare environment: 1. If the situation cannot or should not be defused by the staff present, engage a supervisor or the Administrator on Duty [AOD] as appropriate...7. The Department Head (or designee) may search patient rooms and belongings and to remove medications or supplements not prescribed by the attending...or illegal substance or other items considered unsafe..."


On June 17, 2022, a record review was completed for MR1 and revealed a death summary dated June 11, 2022, Patient "with past medical history significant for Type 1 diabetes...prior myocardial infarction, substance abuse on Suboxone...presented to the ED with complaints of intractable nausea, vomiting, and right side abdominal pain for 2 weeks getting worse with time. He was found to have severe right hydronephrosis [a condition characterized by excess fluid in kidney caused by a blockage] and urology was consulted... He was found to be bacteremic [bacteria in the bloodstream]... He was noncompliant with recommendations to stay in his room. He would leave multiple times...On June 9, 2022, urine drug tox was done, which was only positive for marijuana. He was noncompliant with heart monitor. He would continue to wander out. He was found to be unresponsive in the evening in his bathroom... Patient was found in the bathroom with syringe and multiple white small mini bags in a round black container along with two round pills, unknown etiology...Condition A was called. Code team arrived...Patient was pronounced dead by the code team after attempt for resuscitation...Preliminary cause of death: Cardiac arrest under suspicious circumstances, packets of unknown substances ? drugs found next to patient. "

A further record review of MR1 revealed the patient was admitted on June 6, 2022.

An Infectious Disease progress note from MR 1 signed June 10, 2022, revealed, "Visit information ...6/9/2022: afebrile, complained of right lower abdominal pain, no flank pain ...overwhelming odor of marijuana upon entering the room."

The following were some of the nurses notes from MR 1:

June 6, 2022, at 4:25 AM Patient refused to wear cardiac monitor,

June 7, 2022, at 1:30 AM Patient left unit for cigarette and was gone for approximately 45 minutes. Security alerted and began looking for patient. Charge RN and nursing supervisor aware,

June 7, 2022, at 5:45 PM Report received from...RN. Per report, patient frequently goes out to smoke and has no order to do so, patient supposedly refusing to sign AMA paper,

June 7, 2022, at 5:55 PM Spoke with...[EMP10] with Crimson [medical team] regarding concern for patient leaving unit to smoke and refusal to sign AMA papers (per report). Also expressed concern for patient refusal to wear cardiac monitor,

June 7, 2022 at 6:14 PM...[EMP12] notified of concerns regarding patient AMA paperwork refusal, etc. - No interventions at this time-Per...[EMP12], call security if need be and notify AOD [Administrator on Duty] if we have issue on floor. Will pass along to...PM charge,

June 7, 2022, at 5:55 PM Per Crimson [medical team], will D/C [discontinue] cardiac monitor as patient not here for anything cardiac related. Team notified of concern for patient likely giving staff issues about staying on unit,

June 8, 2022, at 1:00 AM Patient not found in room. 9 PM Suboxone found on bedside table. Wasted suboxone with another RN,

June 8, 2022, at 1:00 AM...RN called...[nursing unit] stating patient is hunched over looking at his phone. RN...went to get patient. Patient A&Ox3 [alert and oriented], stating he was hunched over looking at his phone...Crimson [medical team] alerted of situation,

June 8, 2022, at 9:00 AM Spoke with...[EMP10] of Crimson [medical team] regarding patient's frequently ambulation outside to smoke. Crimson team aware. Urine THC ordered. Will obtain and continue to monitor this patient closely,

June 8, 2022, at 5:00 PM Patient continues to refuse insulin as well as several other medications and continues to exit the floor and spend large amounts of time in the bathroom. Patient informed urine sample in ordered, however, patient continues to flush sample,

June 9, 2022, at 2:31 AM patient refusing cardiac monitor, PA... made aware,

June 9, 2022, at 8:22 PM Patient refusing to wear cardiac monitor, explained reason for need of continuous cardiac monitoring, patient continues to refuse. Crimson team aware,

June 9, 2022, at 4:30 AM RN into give patient IV antibiotics/NS [normal saline] bolus, patient refusing at this time stating that he wants to go outside and then be placed on IV antibiotics,

June 9, 2022, at 7:30 AM...Patient continues to flush urine despite multiple education attempts regarding importance of urinalysis. Will continue to try to obtain samples,

June 9, 2022, at 8:00 AM Patient notified of septic [infected with microorganisms, especially harmful bacteria] workup. Patient leaving floor to smoke, notified of risks and educated on importance of timing of medications, specifically antibiotics,

June 10, 2022, at 9:00 AM Refused to wear cardiac monitoring,

June 10, 2022, at 9AM: Refused to wear cardiac monitoring,

June 10, 2022, at 10:15 PM patient refusing supplemental oxygen at this time (O2 Sat 92%),

June 11, 2022, at 11:23 AM refusing cardiac monitor,

June 11, 2022, at 11:30 AM Patient pleasant cooperative. Refusing heart monitor. Going off of floor often to smoke. Patient signed smoking form,

June 11, 2022, at 5:40 PM Patient found unresponsive in bathroom,

June 11, 2022, at 6:24 PM Condition A called at 1745 [5:45 PM].

On 6/17/2022, At 10:00 AM, Interview with EMP 1 was conducted. When asked why MR1's room was never searched for drug contraband, EMP 1 stated, "There was no evidence the patient was impaired...patient's have rights."

On 6/17/2022, at 1:42 PM, an interview with EMP 11 was conducted. When asked if anything could have been identified or recognized with this patient sooner that may have changed the outcome, EMP 11 replied, "We provided the safest and best care; the safest environment and the best care we could." When asked where the medical team's responsibilities come into play for this patient, EMP 11 replied, "In hindsight, maybe we could have consulted addiction medicine. There was no reason for a sitter and no reason to search the patient's room...We have to follow the patients' rights in Pennsylvania." Further interview with EMP 11 revealed, "Patients have a right to make bad choices."