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FORBES HOSPITAL 2570 HAYMAKER ROAD MONROEVILLE, PA 15146 March 3, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of facility documents and medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure the protection and promotion of the rights of patients by failing to provide care in a safe setting (0144); by disconnecting a patient from a cardiac monitoring device without a physician order, suspending the cardiac monitoring alarms against facility policy, and leaving the patient unattended and unmonitored in the bathroom for one record reviewed. (MR1)
This situation constitutes and Immediate Jeopardy.
Findings include:
1) Review of facility documents and medical records, and staff interviews revealed that facility staff disconnected a patient from a cardiac monitoring device without a physician order, suspended the cardiac monitor alarms against facility policy, and left the patient unattended and unmonitored in the bathroom for one record reviewed. (0144)
Cross reference with:
482.13 Patient Rights (c)(2) The patient has the right to receive care in a safe setting.
Repeat deficiency 4/03/2014.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to provide care in a safe environment by disconnecting a patient from a cardiac monitoring device without a physician order, suspending the cardiac monitoring alarms against facility policy, and leaving a patient unattended and unmonitored in the bathroom for one record reviewed (MR1).
Findings Include:
Review of facility policy "Patient's Rights and Responsibilities" last reviewed 8/29/2013, revealed " ...Copies of the patient rights and responsibilities ...is provided to patients in their admission information booklet ... "
Review of patient admission booklet page 38 "Statements of Patient Rights" revealed " ...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 avoidance of unnecessary delays and to avoid the personal discomfort of the patient ... "
Review of facility policy "Critical Care, Telemetry & Low Level Monitoring" last reviewed 1/2016 revealed " ...The purpose of the cardiac monitoring process is to provide monitoring to patients who are at risk for an arrhythmic event that would require intervention ...Critical Care and Telemetry monitoring units are for patients at risk of having life threatening arrhythmia as defined by the ACC (American College of Cardiologist) Guidelines for in hospital monitoring of adults for detection of arrhythmia ...Cardiac Monitor techs are not to place any patient in pause mode without verbal direction from a registered nurse ...The nurse discusses with MD to determine (telemetry patients) whether a nurse is required to accompany the patient to the test/procedure area. If the patient is cleared to be off monitor for testing, the nurse will remove the monitor and alert the cardiac monitor tech that the patient will be off monitor for testing ... "
Review of Physician Orders dated 2/27/2016, at 12:41 PM revealed "Cardiac Monitoring."
Review of Emergency Department Provider Notes dated 2/27/2016, at 2:37 PM revealed " ...Patient presents complaint of increasing shortness of breath, weakness ...Patient has long standing history of cardiac disease ... " Review of MR1 past medical history revealed diagnoses that included [DIAGNOSES REDACTED]
Review of Cardiology Consult Note dated 2/27/2016, at 5:10 PM revealed "evaluated for possible re-do-CABG (Coronary Artery Bypass Graft) ...felt not to be a candidate ...has increasing angina pain ...left heart Catherization on 1/27/2016 that showed severe three vessel disease of native 1st diagonal branch, ostium, and proximal LAD (left anterior descending) as well as total occlusion of two saphenous vein grafts and patent left mammary graft to the 1st diagonal branch of the LAD...Assessment & Plan I am very concerned about him. He is quite confused."
Review of Internal Medicine History and Physical dated 2/27/2016, at 7:16 PM revealed " ...past medical history significant for ...[DIAGNOSIS REDACTED] with a prior history of coronary artery bypass grafting, who was brought to the ...ER ...because of shortness of breath ...has been hallucinating on and off for the last few day, more so at night ...has been requiring more of a sublingual nitroglycerin ...because of increased chest pain ...felt to be in decompensated congestive heart failure ...noted to have renal deficiency and ...troponin levels was elevated at 0.18 ...decision was made to transfer patient to step-down ... "
Review of Significant Event note dated 2/28/2016, at 1:02 PM revealed " ...0812 Called to room by daughter whom stated that...[MR1]...was not responding. RN (Registered Nurse) and staff immediately assessed pt (patient). Pt. is pulseless and code blue was immediately called. Patient was lowered to floor with assistance and CPR (Cardiac Pulmonary Resuscitation) was initiated ... "
Review of Physician Significant Event Progress note dated 2/28/2016, at 9:00 AM revealed " ...Rapid response was called on the patient which was later turned into code blue. Patient was in the bathroom when he was found unresponsive by his [family member]. Down time was about 10 minutes. Patient was not on monitor at the time of the event. Upon arrival patient was unresponsive. Critical team arrived. Patient was found to be in ventricular fibrillation and ACLS (Advanced Cardiac Life Support) protocol started ...code was terminated after about 25 minutes ...patient was pronounced dead at 8:35 AM ... "
Review of facility documentation dated 2/29/2016, revealed that on 2/27/2016, at 6:23 PM, patient was transferred to a step down unit and assigned to a bed close to the nursing station. During the early morning hours of 2/28/2016, at 2:27 AM the date documented on the cardiac monitor rhythm strip, MR1 experienced a nine beat run of self-limiting [DIAGNOSES REDACTED]. Shift change occurred on the morning of 2/28/2016, at approximately 7:30 AM and a bedside report was conducted by staff. At approximately 8:00 AM on 2/28/2016, MR1 requested to use the bathroom. EMP15 disconnected MR1 from the monitor, escorted patient to the bathroom, and left MR1 unattended. EMP15 then notified EMP14 that MR1 was no longer on the monitor and requested that EMP14 suspend the monitor alarms while MR1 was in the bathroom off the monitor. At approximately 8:13 AM MR1's family member went to the bathroom to check on MR1 and found the patient unresponsive and immediately notified an RN who promptly called the Rapid Response Team who subsequently called a Code Blue. At approximately 8:35 AM on 2/28/2016, resuscitation efforts were deemed unsuccessful and a physician pronounced that MR1 had ceased to breathe.
During interview of March 3, 2016, at approximately 9:00 AM EMP1 confirmed the above findings and revealed "We did not follow our policy. "
Cross reference with:
482.13 Patient Rights
Repeat deficiency 4/03/2014