HospitalInspections.org

Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights.

Findings include:

1. The hospital failed to provide care in a safe setting by failing to appropriately monitor a patient receiving medications with sedative and tranquilizing effects. See deficiency at A-144A.

2. The hospital failed to ensure 1:1 monitoring was completed thus failed to ensure the provision of care in a safe setting for all patients. See deficiency cited at A-144B.

3. The Hospital failed to ensure renewal restraint order was obtained within the required time frame. See deficiency cited at A-171.


The Immediate Jeopardy began on 02/28/24 due to the Hospital's failure to monitor a patient who had received sedative medications that can cause cardiovascular side effects which resulted in Pt #1 being found unresponsive not breathing and without a pulse. It was identified on 03/07/24, at 42 CFR 482.13, Patient Rights.

The IJ was not removed by the survey 03/07/24.

A. Based on observation, document review and interview, it was determined for 1 of 1 (Pt #1) patient, the Hospital failed to provide care in a safe setting by failing to appropriately monitor a patient receiving medications with sedative and tranquilizing effects. Pt. #1 was found unresponsive, cardiopulmonary resuscitation initiated and the patient was ultimately transferred to another hospital for a higher level of care. This has the potential to affect all patients in the Emergency Department.

Findings include:

1. Pt #1's record was reviewed throughout the survey. Pt #1 arrived by ambulance to the Emergency Department (ED) on 2/27/24 at 8:10 AM with a chief complaint of "Behavioral Problem." Pt #1's chart noted the following:
- 8:11 AM the "ED Triage Notes" stated, "Pt arrives bls (basic life support) per (local ambulance) with police escort. Patient is in paper scrubs, states (Pt #1) left (other local hospital) to find a way to Springfield for rehabilitation. Patient states that (Pt #1) has been using drugs but doesn't remember exactly when, states it was cocaine/heroin/meth .... Patient denies SI (suicidal ideations). Patient is also talking to people that are not in the room."
- 8:14 AM Vital signs were obtained. Blood pressure 120/91, heart rate 98, respiratory rate 18 with an oxygen saturation of 99% on room air.
- Patient was placed in room 20 and placed on close observation/elopement risk with a sitter (E #8) at 8:15 AM.
- 9:10 AM nursing note stated, "Patient is walking in room, yelling at staff while naked ... (ED MD #1) notified. Security at bedside." Pt #1 was given Versed (a central nervous system depressant used in anesthesia and for anxiety) 5 milligrams (mg) IM (intramuscular). Pt #1 was also given Zyprexa (a sedating antipsychotic) 10 mg IM at 9:11 AM.
- Urine drug screen was done which showed positive for Cannabinoids, Methamphetamine, and Amphetamine.
- 9:54 AM nursing note stated, "Labs and EKG (electrocardiogram) not completed yet due to patient not sitting still and fighting at this time."
- 10:10 AM Pt #1 was placed in 4-point (both wrists and both ankles) locking restraints due to Pt #1 being a "imminent risk of harm to self."
- 10:25 AM Pt #1 was given Zyprexa 10 mg IM and Versed 5 mg IM.
- 12:30 PM sitter documented Pt #1 "agitated; complaining; restless; screaming; tearful/crying."
- 12:37 PM Pt #1 was given Versed 5 mg IM
- 12:44 PM Pt #1 was given Zyprexa 10 mg IM.
- 1:28 PM nursing note stated, "Patient still very restless at times and pulling at restraints. Will attempt IV(intravenous) access for fluids and antibiotics once patient is calmer. (ED MD #1) notified and ok with holding fluids and antibiotics until patient is calmer."
- Sitter documentation indicated Pt #1 remained "agitated; restless; complaining; screaming: between 1:30 PM and 5:30 PM.
-5:45 and 6:00 PM sitter documentation indicated Pt #1 was "calm" and "awake".
- 6:00 PM nursing restraint monitoring documentation indicated, Pt #1 was "agitated/restless; hallucination; delusional, tearful.."
- 6:10 PM Pt #1 received Versed 5 mg
- per sitter documentation Pt #1 was "asleep" from 6:30 PM 7:15 PM and remained in restraints.
-7:30 PM nursing note stated, " ... Pt remains agitated, yelling/pulling at restraints. Pt writhing in bed, yelling 'don't do this to me again, '.. no evidence of learning from pt."
- 7:45 order was placed for Precedex (sedative) IV drip by ED MD #2.
- 7:51 PM ED Charge Nurse (E #5) started the Precedex drip at 0.2 mcg/kg/hr (microgram per kilogram per hour).
- 7:56 PM nursing note stated, "Patient awake and yelling out talking to people that (Pt #1) sees in the room ..."
- ED MD #2 note stated, "I went into the patient's room at 8:00 PM and found (Pt #1) unresponsive. A dexmedetomidine (Precedex) drip had been initiated at 7:51 PM. The patient was apneic and pulseless. A code was called .... 0.5 mg of IV flumazenil (benzodiazepine reversal medication) and 2 mg of iv naloxone (opioid reversal medication) ... a return of spontaneous circulation was achieved .... A 12 lead EKG was obtained and was noted to be unremarkable .... plan to transfer for admission of the patient for further management."

The record included a Precedex order at 7:45 PM, with the following parameters: notify provider if HR(heart rate) < 50 bpm, systolic bp (blood pressure)< 90mmHg, RR(respiratory rate)<10 bpm "or" with SpO2(oxygen saturation) < 92%. The record lacked any vital sign monitoring or cardiac monitoring between 8:14 AM and 8:00 PM even though pt had received a total of 30 mg Zyprexa IM, 17.5 mg Versed IM and was started on Precedex which can all cause cardiovascular side effects (i.e.. Low blood pressure and low heart rate).

2. An interview was conducted with ED RN (E #4) on 3/5/24 at approximately 3:00 PM. E #4 stated, "I came in that day at 10:30 AM. At that point I had this pt (Pt #1), another psych pt and 2 other pts including one with a GI (gastrointestinal) bleed. (PT #1) was already in restraints and had already been given Zyprexa and Versed IM at least once. When nightshift came in, I was given another psychiatric pt who was paranoid. (E #5 - Charge Nurse) started the Precedex and didn't tell me. (ED MD #2) and I walked into (Pt #1)'s room and found her unresponsive. I went to all the IV pumps and shut everything off. The patient should have at least had vitals taken before the Precedex but should have been placed on the monitor." When asked if E #4 filed an incident report, E #4 stated, "No, I did not.".

3. An interview with Pharmacist (E #6) was conducted on 3/6/24 at approximately 11:30 AM. E #6 stated, "Precedex carries cardiovascular risks including low blood pressure and decreased heart rate and therefore should be monitored. This is a new ED provider group. These providers order different medications than we are used to, such as in this case with the Precedex. Precedex used for anxiety at this time is new and unusual, but it can be used. I have reviewed this record. The medication dosages for the Zyprexa, Versed and Precedex are within the parameters for administration. The Zyprexa can cause prolonged QT (ekg changes that can potentially lead to death) which was noted on the second EKG after the event. The provider had confirmed the previous EKG from November of 23 did not show a prolonged QT."

4. An interview was conducted with ED Charge Nurse (E #5) on 3/6/24 at 1:00 PM. E #5 confirmed starting the administration of Precedex. When asked did you obtain vital signs before administering the Precedex, E #5 stated, "No, I did not." When asked if E #5 was aware when the last vitals had been taken, E #5 stated, "No, I don't." When asked if E #5 placed the pt on the cardiac monitor, E #5 stated, "No, I did not. All cords were removed due to patient was a psychiatric pt. I was going to talk to the primary nurse after leaving the room regarding the monitor as a pt who had received as much Zyprexa and Versed as (Pt #1) did, should have been on the monitor. I did not file an incident report."

5. An interview with ED MD #2 was conducted on 3/7/24 at approximately 8:45 AM. E #2 stated, "If I order Precedex, I usually order parameters and it would be titrated (adjusted to meet acceptable pt condition). I would put in vital sign parameters. Precedex requires close monitoring of blood pressure and pulse."

6. An interview was conducted with Quality Manager (E #10) on 03/06/24 at approximately 3:00 PM. E #2 confirmed the above findings and verbally agreed Pt #1 was not monitored and should have been. E #2 stated, "We were made aware of the incident over the weekend when (the other hospital filed a report). There should have been a report filed. There has been an IRIS(Incident Reporting Information System) report started today."


B. Based on document review and interview, it was determined for 2 of 2 (Pt #1 and Pt #3) Emergency Department (ED) patients reviewed for 1:1 continuous monitoring, the Hospital failed to ensure 1:1 monitoring was completed thus failed to ensure the provision of care in a safe setting for all patients.

Findings include:

1. On 03/05/24 the policy titled "Safety Precautions: Suicide and Self Harm (Non-Behavioral Health Units) Policy (effective 07/07/22)" was reviewed. The policy stated, "... Guidelines... D. For patients who screen positive for suicidal ideation, an evidence-based process will be utilized to conduct a suicide risk assessment... G. Patients who are at high risk for suicide will be monitored according to the protocol outlined below... Initial Risk level based on screening questions... High: Alert Provider, 1:1 Observations, Safety Plan..."

2. On 03/05/24 at approximately 11:00 AM an observational tour was conducted. The following was noted: a sitter was between rooms #1 and #2 (outside of the rooms). An interview was conducted with the ED RN (E # 7) who stated, "the sitter is observing both patients in room #1 and room #2. The patient in room #1 (Pt #7) is here for psychiatric evaluation, but denied suicidal ideations. The patient in room #2 is suicidal."

3. Pt #3 and Pt #7's records were reviewed and indicated:
-Pt #3 was admitted to the ED on 03/04/24 at 4:03 PM with a chief complaint of "Psychiatric Evaluation." The physician's medical screening exam stated, "... Psychiatric:... Thought Content includes suicidal ideation." 1:1 sitter documentation started at 4:15 PM.
-Pt #7 was admitted to the ED on 03/04/24 at 8:30 PM with a chief complaint of "Psychiatric Evaluation." Pt #7 was on close observation from time of arrival until discharge on 3/5/24 at 11:12 AM.

Both records indicated the same sitter provided all observations.

4. On 03/06/24 at approximately 3:00 PM an interview was conducted with Quality RN (E #12). E #12 reviewed the records and verbally agreed the sitters were observing more than 1 patient.

5. Pt #1, Pt #8 and Pt #9's clinical records were reviewed and indicated:
-Pt #1 was admitted to the ED on 2/27/24 at 8:10 AM with a chief complaint of "Behavioral Problem." Pt #1 was placed on "Close Safety Observation" upon admission. Sitter documentation was initiated at 8:15 AM and continued until 8:00 PM.
-Pt #8 was admitted to the ED on 2/27/24 at 4:44 AM with a chief complaint of "Toxidrome, Suicidal." Pt #8 had an order dated 2/27 at 4:48 AM for "Patient monitoring 1 staff 1 patient" and was continued until discharge 02/28/24 at 12:10 AM. Sitter documentation was completed throughout the time in the ED.
-Pt #9 was admitted to the ED on 2/27/24 at 7:20 PM with a chief complaint of "Substance Abuse, Psychiatric Evaluation." An order for "Suicide Precautions" was placed on 2/27 at 7:26 PM. Pt #9's sitter documentation started on 2/27 at 7:30 PM and continued until 2/27 at 11:00 PM.

All sitter documentation was conducted by the same sitter (E #8) from 7::00 AM until 5:45 PM. At 5:45 PM, sitter (E #9) was completing all sitter documentation for the three patients.

6. On 03/06/24 at approximately 1:00 PM, an interview was conducted with ED RN (E #5). E #5 stated, "Psychiatric patients who require a sitter should have a 1:1 sitter. Most of the time the staffing doesn't allow it. There was one sitter for 3 patients (the evening of 2/27/24). "

Based on document review and interview it was determined for 1 of 4 (Pt # 1) patients placed in a violent restraint, the Hospital failed to ensure renewal restraint order was obtained within the required time frame.

1. On 03/05/24 the policy titled, "HSHS Restraint and Seclusion Policy (effective 12/14/2020)" was reviewed. The policy stated, "... VI. Restraint Procedure: A. Violent or Self-Destructive Behavioral Restraints/Seclusion... 8. Orders for violent behavioral restraint or seclusion are limited to the duration listed below.... a new physician's order (phone order is acceptable) must take place: a. 4 hours for adults 18 and older...."

2. The clinical record for Pt #1 was reviewed on 03/05/24 thru 03/06/24. Pt #1 arrived to the ED (Emergency Department) on 02/27/24 at 8:00 AM with a chief complaint of "Behavioral Problem." Pt #1 was placed in violent restraints on 2/27/24 at 10:10 AM and was removed from the restraints at 8:00 PM.. A physician's order on 02/27/24 at 10:23 AM, noted 4 point restraints, "reason for restraint: Danger to self, Danger to others" Another order for 4 point restraints was then placed at 3:59 PM, greater than the 4 hour requirement. The record lacked any further restraint orders (Pt #1 remained in restraints for 9 hours and 50 minutes).

3. During an interview on 3/06/24 at approximately 2:00 PM, Infection Control/Quality (E #1) reviewed the record and verbally agreed the above re-order was not obtained in the required time frame and should have been E #1 stated, "I only see those 2 orders, there should have been another order for the restraints. The restraints should be ordered every 4 hours if the pt remains in the restraints."

Based on document review and interview, it was determined that for 17 of 36 days from January 28th 2024 thru March 3rd 2024 the Hospital's Emergency Department (ED), the Hospital failed to ensure that there was adequate number of nursing personnel qualified in emergency care to meet the needs anticipated by the Hospital, as required.

Findings include:

1. On 03/06/24, the Hospital's ED FY24 (fiscal year) Staffing Matrix was reviewed. The Matrix indicated the ED should be staffed with 5 RNs from 7:00 AM until 12:00 PM, 6 RNs from 12:00 PM until 12:00 AM, and 5 RNs from 12:00 AM until 7:00 AM.

2. On 03/06/24, the ED Daily Staffing Sheets dated 01/28/24 through 03/04/24 were reviewed. The staffing sheets indicated that for 17/ 36 days the ED was staffed with only 4 RNs. The dates included:
1/28 : 6:45 PM until 1/29 7:00 AM
1/30: 6:45 PM until 1/31 7:00 AM 3 RNs and 1 LPN
1/31 : 6:45 PM until 10:00 PM 4 RNs and 1 LPN, 10:00 PM until 2/1 7:00 AM 3 RNs and 1 LPN.
2/2 : 6:45 PM until 2/3 12:00 AM - 4 RNs, 12:00 AM until 7:00 AM 3 RNs
2/3 : 6:45 PM until 2/4 7:00 AM - 4 RNs
2/4 : 6:45 PM until 2/5 7:00 AM - 4 RNs
2/6 : 6:45 PM until 11:00 PM 5 RNs, 11:00 PM until 2/7 7:00 AM 4 RNs
2/7 : 6:45 PM until 11:00 PM 5 RNs, 11:00 PM until 2/8 7:00 AM 4 RNs
2/8 : 6:45 PM until 10:15 PM 5 RNs, 10:15 PM until 2/9 2:00 AM 4 RNs, 2:00 AM until 7:00 AM 3 RNs
2/9 : 6:45 PM until 2/10 7:00 AM 4 RNs
2/11 : 6:45 PM until 2/12 7:00 AM 4 RNs
2/17 : 6:45 PM until 11:00 PM 5 RNs, 11:00 PM until 2/18 7:00 AM 4 RNs
2/18 : 6:45 PM until 10:00 PM 5 RNs, 10:00 PM until 2/19 7:00 AM 4 RNs
2/20 : 6:45 PM until 2/21 7:00 AM 4 RNs
2/22 : 6:45 AM until 11:00 AM 4 RNs, 11:00 AM until 6:45 PM 5 RNs, 6:45 PM until 10:30 PM 4 RNS 10:30 PM until 2/23 7:00 AM 3 RNs
2/25 : 6:45 PM until 2/26 7:00 AM 4 RNs
2/27 :: 6:45 PM until 2/28 12:00 AM 5 RNs (1 was a Medical Surgical Nurse with no ED training), 5 RNs, 11:00 PM until 2/28 7:00 AM 4 RNs (with Medical Surgical nurse with no ED training)

On 2/10 : 7:00 AM until 7:00 PM - 4 RNs, from 7:00 PM until 2/11 - 3 RNs.

3. On 03/06/24 at approximately 2:00 PM, an interview was conducted with the Quality Manager (E #10). E # 10 reviewed the staffing sheets and verbally agreed the staffing does not meet the staffing grid requirement.