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FORBES HOSPITAL 2570 HAYMAKER ROAD MONROEVILLE, PA 15146 April 3, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of the facility documents and medical records (MR), and staff interviews (EMP), it was determined that facility failed to ensure the protection and promotion of the rights of patients by failing to provide care in a safe setting (0144); by neglecting to respond immediately to a life threatening arrhythmia alert for one of 11 medical records reviewed. (MR1)

This situation constitutes an Immediate Jeopardy situation.

Findings include:

1) Review of facility documents and medical records, and staff interviews revealed that facility staff neglected to respond immediately to a life threatening arrhythmia alert (0144).

Cross reference with:
482.13 Patient Rights (c)(2) The patient has the right to receive care in a safe setting.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of facility documents and medical records (MR), staff interview (EMP), it was determined the facility failed to provide care in a safe environment by neglecting to respond immediately to a life threatening arrhythmia alert for one of 11 medical records reviewed. (MR1)

Findings include:

Review of facility policy "Patient Rights and Responsibilities" last reviewed August 20, 2013, revealed "...Copies of the patient rights and responsibilities...is provided to patients in their admission information booklet..."

Review of facility patient admission booklet page 38 "Statement of Patient Rights" revealed "...You have the right to expect emergency procedures to be implemented without unnecessary delay. You have the right to expect good quality care and high professional standards that are continually maintained and reviewed. You have the right to expect good management techniques to be implemented within the hospital and the avoidance of unnecessary delays and to avoid the personal discomfort of the patient..."

1) Review of MR1 Physician Progress Notes dated March 24, 2014, at 6:45 AM "...R3-Surgery Responded to Code Blue. Pt. (patient) found asystole by [EMP5] CPR initiated..."

2) Review of facility documentation regarding MR1 dated March 24, 2014, at 6:09 PM revealed "...This morning the patient [MR1]...alarmed asystole on the monitor. I informed the nurse taking care of the patient. [EMP4] did not go to check on him. I informed [EMP4] a second time. Then the third time I said to [EMP4] don't you care that your patient is dead and [EMP4] responded, 'I don't think that [the patient] is' and did not go check on [the patient]. I don't t know the time lapses but then [EMP5] came into the station and approached me and inquired about [the patient] and I told him [the patient] was off the monitor. He asked who the nurse was and I told him [EMP4] who was sitting beside me at the station. I didn't hear what [EMP5] said to [EMP4] but the two of them walked down the hall towards the patine's (sic) room and then [EMP4] came down the hall calling for the code..."

3) During interview on March 31, 2014, at approximately 8:20 AM EMP2 revealed "... 5 South Stepdown monitors trauma patients ...not a whole lot of cardiac...Staffing was 1:4 ...3 nurses and a monitor tech and a PCA (Patient Care Assistant)...all 12 patients were monitored ...EMP4 was the nurse...start date was... 5/1/13 ...From what I understand monitor tech noted pt asystole ....[EMP3] told the nurse verbally at the nursing station that your patient is asystole ...monitor tech sits right at the nurses station ...[EMP4] continued to chart ....and [EMP3] again said your patient is asystole ...(High Level Alarm) ...[EMP3] said don't you care your patient is asystole ....at that time the resident went into the patient's room and went to the nurses station and said there is something wrong with the patient and then went back to the room and called a code ...The alarms only alarm at the desk ...during this [EMP4] told [EMP3] that the leads were on and off through the night ...The patient pulled his NG tube out at night and that is probably why [EMP4] thought the leads were off ...Staff did not respond to high level alarm ...were probably in the room with their patients ....The resident [EMP5]....went back to room called a code ...code team came and resuscitated ...Alarm was going off for 8 and ? to 9 minutes ...patient was resuscitated ....sent to [outside hospital] for 24 hour EEG monitoring ....very little brain activity at that point ...."
4) During interview on April 3, 2014, at approximately 8:30 AM EMP3 revealed "...The patient was bradycardic on the monitor and the nurse was sitting at the nursing station ....I told [EMP4] [the patient] was bradycardic [EMP4] leaned over and looked at the monitor and had no response ...the monitor alarmed again and I told [EMP4] a second time, your patient is asystole on the monitor ...again no response ...it alarmed a third time and I said to [EMP4] ...don't you care that your patient is dead and [EMP4] responded, 'I don't think [the patient] is dead [the patient] is just off the monitor' ...then [EMP5] came to the nursing station and [EMP4] went to the room with [EMP5] ...I have never had this occur to me before ....the patient was never off the monitor during the night ...some artifact because he was jiggling in bed ..."
5) During interview on April 3, 2014, at approximately 8:55 AM by telephone EMP5 revealed, " ...I went into the room and asked how [the patient] was doing.... there was no response ....I gave [the patient] a sternal rub ....checked pulses [the patient] was pulseless ...went outside ...ran to the nursing station ....quickly looked at monitor. Saw [the patient] was asystole ...asked the monitor tech how long has [the patient] been asystole ...the nurse said [the patient] is just off the monitor ...both of us...ran to the room ...I started compression ...and shortly thereafter the rapid response team came..."

Cross reference with:
482.13 Patient Rights