The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

MERIT HEALTH CENTRAL 1850 CHADWICK DR JACKSON, MS 39204 June 17, 2011
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on Governing Body Bylaws review, Emergency Department (ED) record review, ED staffing policy review, Reporting Suspected Abuse/Neglect of Vulnerable Adults policy review, staffing schedule review, Corrective Maintenance Work Reports review, inservice review and staff interview, the hospital failed to ensure that the medical staff was accountable to the Governing Body for the quality of care provided to Patient #1, one (1) of one (1) patients reviewed.

Findings include:

Cross Refer to A-0145 for the hospital's failure to ensure Patient #1's right to be free from all forms of abuse or harassment were assured.

Cross Refer to A-1112 for the hospital's failure to provide adequate nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility.


Review of the hospital's Governing Body Bylaws (approved March 2011), revealed:
"3.11 RESPONSIBILITIES page 8
The responsibilities and obligations of the Board shall include:
3.10(b) Requiring a process designed to assure that all individuals who provide patient care services, but who are not subject to the Medical Staff privilege delineation process, are competent to provide such services, and receiving reports of quality assurance information regarding competency of care providers not subject to the privilege delineation process;
3.10(e) In consultation with the Medical Executive Committee, the Corporation and the Chief Executive Officer, formulating programs for efficient delivery of care, compliance with applicable law (including Medicare regulations and other applicable regulations) and development, review and revision of policies and procedures;
8.3 PROFESSIONAL ACCOUNTABILITY OF THE BOARD page 19
The Medical Staff and the other health care professional staffs providing patient care services shall conduct, and be accountable to the Board for conducting activities that contribute to the preservation and improvement of the quality and efficiency of patient care provided in the Hospital. These activities shall include these functions:
8.3(d) Establishing a process designed to assure that all individuals responsible for the assessment, treatment, or care of patients are competent in the following, as appropriate to the ages of the patients served:
(i) the ability to obtain information and interpret information in terms the patients' needs;
(ii) a knowledge of cognitive, physical and emotional growth and development in the particular age group treated; and
(iii) an understanding of the range of treatment needed by the patients.
8.3(g) Reviewing the competency of care providers who are not subject to the Medical Staff privilege delineation process; and reporting to the governing body of findings with regard to such care providers;
8.3(h) Establishing a process to support the efficient flow of patients, such as a plan concerning the care of admitted patients who are in temporary bed locations."
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on Governing Body Bylaws review, Emergency Department (ED) record review, policy review, ED staffing schedule review, Corrective Maintenance Work Reports review, inservice review and staff interview, the hospital failed to ensure that Patient #1's rights were protected and promoted. Patient #1 was one (1) of one (1) patients reviewed.

Findings include:

Cross Refer to A-0049 for the hospital's failure to ensure that the medical staff was accountable to the Governing Body for the quality of care provided to Patient #1.

Cross Refer to A-0145 for the hospital's failure to ensure that Patient #1's right to be free from all forms of abuse or harassment was assured.

Cross Refer to A-0386 for the hospital's failure to ensure that the Chief Nursing Officer ensured adequate qualified and adequate numbers of nursing personnel necessary to provide nursing care for all patients in the ED.

Refer to A-1112 for the hospital's failure to ensure the provision of adequate nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on Emergency Department (ED) record review, ED staffing policy review, ED staffing schedule review, Patient's Rights and Responsibility Policy review, Vulnerable Person's Act policy review, inservice review and staff interview, the hospital failed to ensure that Patient #1, one (1) of one (1) patients reviewed, was given the right to receive care in a safe setting.

Findings include:

Cross Refer to A-1112 for the hospital's failure to provide adequate nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility.

Cross Refer to A-0145 for the hospital's failure to ensure that Patient #1's right to be free from all forms of abuse or harassment was assured.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review, Emergency Department (ED) staffing policy review, ED staffing schedule review, Patient's Rights and Responsibility Policy review, Reporting Suspected Abuse/Neglect of Vulnerable Adults policy review, inservice review and staff interview, the hospital failed to ensure that Patient #1, one (1) of one (1) patients reviewed, right to be free from all forms of abuse or harassment was protected and failed to report a 06/05/11 incident of the death of Patient #1 while in the ED.

Findings include:

Cross Refer to A-1112 for the hospital's failure to provide adequate nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility.


Review of ED documentation revealed no documented evidence that the hospital reported a 06/05/11 incident regarding the death of a ED patient. There was no documented evidence the hospital verbally reported or telephoned the appropriate agencies (Mississippi State Department of Health and the Medicaid Fraud Control Unit of the Attorney General's Office) within 24 hours of the alleged incident. There was no documented evidence the hospital submitted a written report within 72 hours of the alleged incident.

On 06/16/2011 an interview with the hospital's Risk Management Director confirmed that the hospital did not report the 06/05/11 incident as required.

Review of the hospital's policy for Reporting Suspected Abuse/Neglect of Vulnerable Adults (revised January 2011) revealed that the hospital also had these same reporting requirements. Review of this revised policy also revealed that it did not reflect the change of title from Adults to Persons as noted in the Vulnerable Persons Act, House Bill 640, Laws of 2010.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on Emergency Department (ED) staffing policy review, ED staffing schedule review and staff interview, the hospital failed to ensure that the Chief Nursing Officer had adequate qualified and adequate numbers of nursing personnel necessary to provide nursing care for all patients in the ED.

Findings include:

Review of the hospital's "Emergency Department Staffing" policy (dated January 2009) revealed that on the day shift and on the night shift seven (7) Registered Nurses (RNs) are required to be on duty. The policy also stated, "Purpose: To ensure that the nursing staff on duty at all times is sufficient in number, knowledge, and skills to meet the needs of the types and volume of patients serviced."

Review of the ED staffing pattern from June 1st through 14th, 2011 revealed:
1. On 06/03/2011, there was a total of five (5) RNs working the night shift
(7P-7A) and 35 patients were seen in the ED.
2. On 06/05/2011 there was a total of six (6) RNs working the day shift
(7A-7P) and 75 patients were seen in the ED.
3. On 06/09/2011 there was a total of six (6) RNs working the day shift
(7A-7P) and 72 patients were seen in the ED. Two (2) of the six (6)
RNs working the day shift had been pulled from the Intensive Care Unit
(ICU) to work in the ED.

An interview with the Interim ED Director on 06/16/2011 revealed that the two RNs pulled from ICU were not trained in the use of Pro-Med, the electronic charting system used in the ED.

On 06/17/2011 a 7A-7P ED nurse, RN #3, was interviewed regarding the the events of 06/05/2011 and the death of Patient #1. RN #3 stated, "On June 5, 2011 I was the charge nurse on duty in the (Hospital Name) ED. On this day, as with most days, administration had short staffed the ED by two (2) nurses. There were patients holding in the ED due to no Telemetry or ICU beds available. I called the ER (emergency room ) Interim Director and the ER Assistant Nurse Manager requesting assistance and never received any help. We were not staffed with a nurse to run our fast track unit until 3:00p.m., and by order of administration are not allowed to close the unit, so although I was charge nurse that day I was forced to run the fast track unit as well. As I was getting fast track patients back I heard the operator call overhead 'Code 99 ER 17'. (Meaning a patient had coded in room 17). The cardiac monitors at the nurses station never alarmed and at that time we were not staffed with monitor techs (technicians). I ran into Room 17 and found the patient (Patient #1) in full arrest with (RN #1) performing CPR (CardioPulmonary Resusitation). (Doctor #2) was at bedside giving verbal orders and (RN #2) was at patient's side administering medication. Approximately five (5) minutes later respiratory (Respiratory Therapy) came in and assisted with intubation. The patient was later pronounced dead."

A written statement from emergency room (ER) Technician #1 was received June 20, 2011. It stated, "I, (technicians name), was working at the secretary's desk on June 05, 2011. At approximately 1300 (1:00 p.m.) RN #2 asked me to 'stick your head in room 17, I think his leads came off.' I immediately went to room #17 and the patient appeared to be asleep. I called out his name and did a sternal rub with no response from the patient. About 30 seconds after I walked into room 17 (RN #1) came into the room and took over the patient. A code was called and CPR was started immediately...I am not EKG (Electrocardiogram) trained nor is monitoring the EKG board in my job description."

Review of Emergency Department Technician #1's personnel folder revealed a Job Description for an Emergency Department Technician which stated, "Section 2- Performs patient care activities as directed. Standards: B. Assists physicians/RN or perform #4 EKGs (electrocardiograms)."
This does not require the skill for interpretation of heart rhythms. There was no documented evidence of a CardioPulmonary Resuscitation (CPR) certification in the tech's personnel folder.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on Emergency Department (ED) record review, ED staffing policy review, staffing schedule review and staff interview, the hospital nursing service failed to ensure that the ED was staffed with adequate qualified and adequate numbers of nursing personnel necessary to provide nursing care for Patient #1 and all other patients in the ED. Patient #1 was one (1) of one (1) patients reviewed.

Findings include:

Cross Refer to A386 for the hospital nursing service's failure to ensure that the ED was staffed with adequate qualified and adequate numbers of nursing service personnel to provide nursing care for Patient #1 and all other patients in the ED.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
Based on Emergency Department (ED) record review, ED staffing policy and other policy review, staffing schedule review, review of the Biomedical Manager's documented Corrective Maintenance Work Reports, inservice review and staff interview, the hospital failed to ensure that the emergency needs of Patient #1 were met. Patient #1 was one (1) of one (1) patients reviewed.

Findings include:

Cross Refer to A-1112 for the hospital's failure to provide adequate nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility.

Cross Refer to A-0145 for the hospital's failure to ensure that Patient #1's right to be free from all forms of abuse or harassment was met.
VIOLATION: QUALIFIED EMERGENCY SERVICES PERSONNEL Tag No: A1112
Based on Emergency Department (ED) record review, staffing policy and other policy review, staffing schedule review, review of the Biomedical Manager's documented Corrective Maintenance Work Reports, inservice review and staff interview, the hospital failed to ensure adequate nursing personnel qualified in emergency care were provided to meet the EDs written emergency procedures, failed to ensure the needs anticipated by the facility were met and failed to ensure the emergency needs of Patient #1 were met. Patient #1 was one (1) of one (1 patients reviewed.

Findings include:

ED record review for Patient #1 revealed that on 06/05/2011 the patient presented to the ED and was triaged by a Registered Nurse (RN) at 6:41 a.m. He was triaged as '3/Urgent' with a chief complaint of 'Chest Pain-ATraumatic more than 35 years'.

Patient #1's ED record review revealed:
"Brief Assessment: (Patient #1) presents to the ER (emergency room /Department) with complaint chest pain, starts in stomach and moves, also complaint of vomiting that started after dialysis yesterday.
Vital Signs: Temperature: 98.0-orally, Pulse: 78-regular, Respirations: 78-unlabored,
Blood Pressure: 185/115 and Oxygen saturation: 95%
Pain Intensity Scale: 6/10. Pain Location: Multiple Areas. No Known Allergies.
06:42 a.m. (Patient #1) assigned to room 17. Cardiac monitor attached-normal sinus rhythm. EKG (Electrocardiogram) performed.
06:55 a.m. IV (Intravenous) insertion.
06:58 a.m. Exam by (Doctor #1).
07:08 a.m. reassessed and report given to (RN #1).
07:15 a.m. Aspirin given by mouth.
07:22 a.m. Laboratory: Critical Values: (Dr. #1) notified by (RN #1).
Creatinine of 8.6.
07:28 a.m. Chief Complaint and History of Present Illness (Doctor #1).
07:33 a.m. Review of Systems (Doctor #1).
07:50 a.m. Nitroglycerine chest pain.
07:55 a.m. IV Zofran 4 mg (milligrams) for nausea and IV Morphine 5 mg
for pain.
08:20 a.m. (Doctor #1) Consultation & (and) Critical Thinking: The
following diagnoses were considered based on the patient's
clinical presentation: Acute Coronary Syndrome, Pericarditits,
Pneumonia, Pneumothorax, and Acute Pleurisy. Case discussed
with (Doctor #2). Agrees that patient's condition merits
admission to hospital.
08:30 a.m. Admit orders: Diagnoses: Chest Pain, Hypertension out of
Control, Chronic Renal Failure. Schedule EKG, Stress Test,
Enteric coated Aspirin 325 mg PO (by mouth) daily. Hydralazine
20 mg IV Q (every) 6 hrs (hours) PRN (as needed) for SBP
(Systolic Blood Pressure) > (greater than) 160. Morphine 5 mg
IV Q 4 hr prn severe pain.
04:17 p.m. Addendum (Doctor #1). (Patient #1) was found unresponsive
in room ED #17 while waiting for transfer to hospital bed at 3:04
p.m., by RN. Cardiac monitor showed asystole. CPR was
initiated following ACLS (Advanced Cardiac Life Support)
protocol. (Doctor #1) intubated. Medications were given via IV.
(Patient #1) remained asystole, did not respond to CPR. (Patient
#1) was pronounced dead at 3:17 p.m., on 06/05/2011.

There was no documented evidence that Doctor #1 documented in Patient #1's ED record after 08:32 a.m. until his 06/05/11 4:17 p.m. Addendum. There was no documented evidence of Doctor #1 reassessing Patient #1.

Review of RN #1's documentation in Patient #1's ED record on 06/05/2011revealed:
At 11:31 a.m. Laboratory: Critical Values: Troponin of 0.56 (Doctor #1) notified. (The normal range for Troponin is 0.00-0.08)
At 12:34 p.m.: Laboratory: Critical Values: Troponin of 0.36 (Doctor #1) notified.
At 2:35 p.m.: Laboratory: Critical Values: Troponin of 0.56 (Doctor #1) notified.

Review of Patient #1's ED record revealed that on 06/05/2011 at 1:00 p.m. he had a Blood Pressure (BP) of 168/102 and at 2:15 p.m. he had a BP of 162/102. There was no documented evidence that RN #1 administered the patient Hydralazine 20 mg IV as ordered by Doctor #1 for SBP > 160.

Review of Patient #1's 06/05/11 cardiac monitor heart strips revealed that at 2:20 p.m. Patient #1 began to have ventricular fibrillation until 2:43 p.m., then went into asystole. At 3:04 p.m. Patient #1 was discovered unresponsive by a technician. A Code 99 was called, but resuscitation was unsuccessful. The code ended at 3:17 p.m. and Patient #1 was released to the morgue.

Review of Patient #1's death certificate dated 06/05/2011 revealed, "Cause of death: Cardiac Arrest, Chronic Renal Failure, Hypertension and Diabetes."

Review of the hospital's Emergency Department Staffing policy (reviewed January 2009) revealed that on day and night shift seven (7) RNs are required. The policy stated, "Purpose: To ensure that the nursing staff on duty at all times is sufficient in number, knowledge, and skills to meet the needs of the types and volume of patients serviced."

Review of the ED staffing pattern from June 1st through 14th, 2011 revealed:
1. On 06/03/2011 there was a total of five (5) RNs working the night shift
(7P-7A) and 35 patients were seen in the ED.
2. On 06/05/2011 there was a total of six (6) RNs working the day shift
(7A-7P) and 75 patients were seen in the ED.
3. On 06/05/2011 there was a total of six (6) RNs working the night shift
(7P-7A) and 47 patients were seen in the ED.
4. On 06/09/2011 there was a total of six (6) RNs working the day shift
(7A-7P) and 72 patients were seen in the ED. Two (2) of the six (6) RNs
working this shift had been pulled from the hospital's Intensive Care Unit
(ICU). On 06/16/2011 an interview with the Interim ED Director
revealed that the two (2) RNs pulled from the ICU were not trained in
the use of Pro-Med, the electronic charting system used in the ED.

On 06/17/2011 a 7A-7P ED nurse, RN #3, was interviewed regarding the the events of 06/05/2011 and the death of Patient #1. RN #3 stated, "On June 5, 2011 I was the charge nurse on duty in the (Hospital Name) ED. On this day, as with most days, administration had short staffed the ED by two (2) nurses. There were patients holding in the ED due to no Telemetry or ICU beds available. I called the ER (emergency room ) Interim Director and the ER Assistant Nurse Manager requesting assistance and never received any help. We were not staffed with a nurse to run our fast track unit until 3:00p.m., and by order of administration are not allowed to close the unit, so although I was charge nurse that day I was forced to run the fast track unit as well. As I was getting fast track patients back I heard the operator call overhead 'Code 99 ER 17'. (Meaning a patient had coded in room 17). The cardiac monitors at the nurses station never alarmed and at that time we were not staffed with monitor techs (technicians). I ran into Room 17 and found the patient (Patient #1) in full arrest with (RN #1) performing CPR (CardioPulmonary Resusitation). (Doctor #2) was at bedside giving verbal orders and (RN #2) was at patient's side administering medication. Approximately five (5) minutes later respiratory (Respiratory Therapy) came in and assisted with intubation. The patient was later pronounced dead."

RN #3 also stated that on 06/09/2011 the ED was staffed with four (4) RNs that were regular staff members and two (2) RNs were pulled from the ICU to help. RN #3 stated that these 2 RNs had no experience with the charting system in the ED (Pro-Med electronic nursing documentation) so these two (2) nurses were assigned two (2) rooms each with the intent of running fast track out of those rooms. RN #3 stated that there were 31 patients in the ED waiting area at one time and that ED was too short staffed to open fast track.


A written statement from emergency room (ER) Technician #1 was received June 20, 2011. It stated, "I, (technicians name), was working at the secretary's desk on June 05, 2011. At approximately 1300 (1:00 p.m.) RN #2 asked me to 'stick your head in room 17, I think his leads came off.' I immediately went to room #17 and the patient appeared to be asleep. I called out his name and did a sternal rub with no response from the patient. About 30 seconds after I walked into room 17, (RN #1) came into the room and took over the patient. A code was called and CPR was started immediately...I am not EKG (Electrocardiogram) trained nor is monitoring the EKG board in my job description."

Review of EDTechnician #1's personnel folder revealed a Job Description for an Emergency Department Technician which stated, "Section 2- Performs patient care activities as directed. Standards: B. Assists physicians/RN or perform #4 EKGs (electrocardiograms)."
This does not require the skill for interpretation of heart rhythms. There was no documented evidence of a Cardio Pulmonary Resuscitation (CPR) certification in the tech's personnel folder.

Review of the Biomedical Manager's documented Corrective Maintenance Work report revealed, "June 9, 2011 As you requested I have supplied you with the findings for the 2 (two) Central Station Monitors as well as the findings for the Monitor at Bedside 17. Also, attached are the history reports for all the Datascope monitors associated with the patient monitoring system in the Emergency Department. Planned maintenance is done on a yearly basis in the month of June. The schedule has been in place since the system was installed in the ED. The system was installed in September of 2007."

Review of the Biomedical Manager's Incident Investigation # for bed 17 revealed, "Inspect monitor in bed 17 and report findings. Did good visual inspection of monitor. Monitor appropriately displayed waveforms from simulator. Violated the alarm limits and bedside monitor alarmed both visually and audibly. Alarm volume set at about one third of maximum but could be heard in the room, and in the adjacent corridor. Alarm displayed at the Central monitor visually but no audible indication. Beside monitor worked as designed."

Review of the Incident Investigations for bedside monitors # and # done by the Biomedical Manager revealed, "Did good visual inspection of monitor. Monitor was displaying rooms, patients and waveforms correctly. Placed a bedside monitor in alarm noted screen flashed in alarm but no audible alarm present. Determined that speaker volume at the central monitor had been set to zero. Reset the volume and monitor alarmed normally."