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.
| PARK ROYAL HOSPITAL | 9241 PARK ROYAL DR FORT MYERS, FL 33908 | Oct. 29, 2012 |
| VIOLATION: GOVERNING BODY | Tag No: A0043 | |
| Based on facility observations, record review and staff interviews, the facility administrator failed to effectively attain and maintain the highest practicable physical and medical well-being regarding the facility processes impacting patients' receiving care in a safe setting. The review of these records revealed the facility administration failed to identify the potential for inappropriate facility process integrity. The facility Administrator failed to provide effective staff and Quality Assurance & Performance Improvement (QAPI) resource management to promote and ensure the safe physical environment and health well-being of all facility patients. The Administrator failed to provide administrative oversight to ensure a complete and thorough investigation was conducted resulting in the lack of QAPI examination and root cause analysis resulting in a continuation of the systems failure regarding facility approaches and all staff had demonstrated understanding of facility expectations in the emergency access and egress of patients. This failure created a situation that is likely to result in serious injury, harm, impairment, or death to residents and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on 10/23/12 was identified on 10/26/12. The findings include: The governing body failed to maintain the hospital in a manner to ensure the safety of the patients as evidenced by the findings for deficient practice at standards A144 and A701. A review of The Board of Trustee Bylaws (November 21, 2011) finds: The Trustees have responsibility for: 3.9.3 Decisions regarding quality of service to be made available at the hospital. 3.10.1 QI Program - That the staff of departments/services in the hospital implement and report on the activities and mechanisms for monitoring and evaluating the quality of patient care, for identifying and resolving problems and for identifying opportunities to improve patient care. A review of the minutes of regularly-held management meetings, for dates of 10/8/12 10/15/12 and 10/22/12, finds there is no documentation that management was aware of the access and egress issues. The minutes of management meetings state risk factors related to the elevator project were considered. There is no documentation of discussion of the adverse incident of 10/23/12 and ongoing safety issues. The Managers' Meeting is held weekly on Monday at 11:30 a.m. -The 10/8/12 meeting addressed operational items including elevator work; reported by the Maintenance Director, who stated, "The new elevator installation will begin on 10/15 and completed on 10/19." The minutes state, "The following plans were discussed: Plans for moving patients to dining area; Lifesaving Preparedness, and Infection Control." -The 10/15/12 meeting addressed operational items including elevator work by the CEO, who said, "Elevator work begins on 10/15 and should be completed on 10/19." -The 10/22/12 meeting addressed operational items including, "Elevator Update," and the Chief Executive Officer (CEO) reported, "Elevator operation was delayed on 10/19. Continue using Elevator 1 until elevator is operational." In an interview on 10/26/12, at 2:30 p.m., the CEO stated he was unaware of the issue with stretcher not fitting into the available elevator on 10/23/12. He stated he was not aware of an access problem for emergency responders. The CEO confirmed that no measures were put into place for the safe evacuation of patients while the service elevator was shut down. An interview was conducted on 10/29/12, at 9:30 a.m., with the CEO, Chief Nursing Officer (CNO), and Director of Clinical Operations. The management staff stated they discussed the effects of the elevator construction on facility operations and tried to anticipate all risks. They stated that they did not consider not being able to load a stretcher in the available elevator. The minutes of the 10/8/12 Management Meeting noted the elevator work would be from 10/15/12 to 10/19/12. The CEO stated the elevator was not operational from 10/15/12 through 10/27/12. The CEO stated management staff did not do anything about the safety issue of getting a stretcher on the functioning elevator after the incident on 10/23/12. On 10/26/12, a new policy for assisting emergency personnel with access to the facility was implemented and in-services were held on all shifts through 10/29/12, with 110 staff attending. |
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| VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING | Tag No: A0144 | |
| Based on observation, record review, and staff interview, the facility failed to ensure the patients received care in a safe setting. The facility failed to: 1) develop and implement a procedure for assisting emergency personnel with access to the facility; 2) develop a contingency for evacuating patients by stretcher from the facility while the service elevator was shut down due to construction; and 3) address the egress issue until surveyor intervention, 3 days after an adverse incident, causing a distinct and immediate threat to the health and safety of the patients. This failure created a situation that is likely to result in serious injury, harm, impairment, or death to residents and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on 10/23/12 was identified on 10/26/2102. The findings include: On 10/15/12, the facility entered into a project to accommodate their Baker Act receiving facility status. This project involved converting a one-door service elevator into a two-door elevator that opens to the outside. The project required a sally-port type enclosure that the elevator opens into for egress. This project did have AHCA Office of Plans and Construction approval contingent upon approval of the local fire and building authorities and obtaining required local permits. The project was scheduled for completion on 10/19/12. The project was begun as scheduled, without obtaining the required local fire and building authorities permits. The permit had been applied for and this was the status until intervention by the Fire Department. Work was stopped and the elevator was shut down pending obtaining permits and completion of the project. By 10/23/12 the permitting and work had not been completed. On 10/23/12, a 911 emergency call resulted in the Iona McGregor Fire Department and a Lee County Emergency Medical Services (EMS) Ambulance responding, at 9:12 p.m., to the facility. This was a cardiac-arrest call. Upon arrival at the facility, the Fire Department and EMS had to pound on the doors of the facility, they could not get in and there was no one on the first floor to let them in the facility. The emergency responders had to call the emergency dispatcher to phone the facility and request facility staff to open the door. In an interview on 10/26/12, at 9:00 a.m., the Fire Inspector said that when the facility was constructed, an agreement was made between the facility and the Fire Department. The agreement was that the entrance doors to the facility would be labeled A, B, C, and D in order for the facility to direct the 911 responders to which door the facility staff would meet them to let them in the building and escort them to the patient. This facility is afforded special-locking arrangements for the clinical and security needs of the patients under the Fire Code. Utilizing these special locking arrangements necessitates specialized procedures for safety, security and emergency responders regarding access and egress for both non-emergencies and emergencies. In an interview on 10/26/12, at 12:29 p.m., the Chief Executive Officer (CEO) and Chief Nursing Officer (CNO) reported the facility never created a Policy and Procedure for assisting 911 call responders, and did not train the staff to follow any procedure. A Fire Department intra-office e-mail from the Duty Officer to the Fire Marshall, dated 10/26/12, states, "Tonight we ran a cardiac arrest at Park Royal. Upon arrival there was no one to meet us at the doors or the admissions' room. We had to beat on the doors and call dispatch to try and get someone to let us in. This has been a continued problem with them." The e-mail documented that once in the facility, they have at least four locked doors to get through to get to the patients. The issue with the cardiac arrest was that the Emergency Medical Technicians (EMTs) were performing cardio-pulmonary rescutation (CPR) on the patient and were proceeding to transport the patient from the psych hospital to an acute care hospital emergency room . The EMTs could not use the service elevator, which was the only elevator sized for a stretcher; that elevator was shut down. The patient was adjusted to a sitting position, during CPR, to get the stretcher in the only available elevator. The patient was transported to the hospital and pronounced dead. When the service elevator was shut down, the facility failed to put an interim plan in affect to safeguard patients from problem of emergency egress. During an interview the CEO, stating that after the incident happened on 10/23/12 until the survey on 10/26/12, nothing had been done to rectify the situation or come up with an interim plan to be used until the large service elevator is put back into service. The CEO was asked, "Since the incident, what interim measures have you put into place to prevent reoccurrence." The CEO replied, "Nothing, I didn't even know about it." The permits were obtained by the day of the survey. The work was performed to put the elevator back in service after a two-week down time. The large service elevator was back in service by 5:00 p.m. on 10/26/12. |
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| VIOLATION: QAPI | Tag No: A0263 | |
| Based on staff interview and record review, the Quality Assurance and Performance Improvement (QAPI) program failed to assure programs and procedures were in place to ensure the safety of the patients. The facility failed to: 1) develop and implement policies and procedures to assist emergency personnel with access to the facility; 2) risk factors were not considered with the large service elevator shut-down; and 3) safety measures were not put into place following an adverse incident. This failure created a situation that is likely to result in serious injury, harm, impairment, or death to residents and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on 10/23/12 was identified on 10/26/2102. The findings include: Based on staff interview and review of administrative records, policies and procedures, and physical environment observations, it was determined that the facility's QAPI program failed to focus on indicators related to improved health outcomes. The facility failed to: 1) develop and implement a procedure for assisting emergency personnel with access to the facility; 2) develop a contingency for evacuating patients by stretcher from the facility while the service elevator was shut down due to construction; and 3) address the egress issue for 3 days after an adverse incident and until surveyor intervention, causing a distinct and immediate threat to the health and safety of the patients. (refer to A144 and A701). A review of the facility's quality assurance plan documents:Quality Management Program - Risk Management Quality Improvement (QI) Council Calendar - meets monthly 3. The following issues will be addressed at every quality council due to their seriousness: a. Unanticipated deaths, adverse and/or sentinel events, and b. Other Serious Events. Organizational Quality Improvement Plan Goals of QI:6 d. Utilize the results of QI, patient safety and risk reduction activities;6 g. Necessary information communicated, and6 i. Information from QI activities used to detect trends, patterns and potential problems. Scope of QI Activities:7. The program consists of these focus components, including patient safety. The minutes of the QI Council were reviewed on 10/29/12. The QI Council is meeting monthly. The last regular meeting was held on 10/10/12. No mention was made of the construction project to modify the facility for Baker Act patients (patients held for involuntary examination under the Florida Baker Act), specifically. There was no mention documented of the large service elevator project and patient safety during the construction. A review of the facility records documenting there was an adverse incident on 10/23/12. An incident report was filled out by the senior staff member on duty documenting, "Unanticipated death, witnessed full cardiac arrest." Witness statements were obtained. There is no documentation of an investigation of the event. The incident report is not signed off by the Risk Manager or Chief Administrative Officer (CAO). During an interview on 10/29/12, at 3:20 p.m., the Chief Executive Officer (CEO) and CAO, stated incident reports are investigated by the Risk Manager and CAO within 72 hours. The CAO stated a QI root cause meeting with management and medical officers regarding the adverse incident is scheduled for 10/30/12. The CAO stated no action was taken immediately after the event. The CAO stated no one reported there was an issue with getting the stretcher in the elevator or that there were access issues for the emergency personnel. |
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| VIOLATION: PHYSICAL ENVIRONMENT | Tag No: A0700 | |
| Based on observation, record review and staff interview, the facility failed maintain the overall hospital environment in a manner to assure the safety and well-being of the patients. The facility failed to: 1) develop and implement policies and procedures to assist emergency personnel with access to the facility; 2) develop a contingency for evacuating patients by stretcher from the facility while the large service elevator was shut down due to construction; and 3) safe access and egress measures were not put into place following an adverse incident. This failure created a situation that is likely to result in serious injury, harm, impairment, or death to residents and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on 10/23/12 was identified on 10/26/12. The findings include: The facility failed to obtain permits for alterations to full-size hospital elevator. The elevator was shut down. Alternate plans for safe egress were not developed. A patient has a cardiac arrest. An effective means for emergency medical services (EMS) access was not established. EMS was delayed in gaining access to the facility. EMS had difficulty transporting the patient by stretcher in the remaining elevator. The patient died . The facility failed to maintain a safe environment for patients (refer to A043, A144 and A701). |
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| VIOLATION: MAINTENANCE OF PHYSICAL PLANT | Tag No: A0701 | |
| Based on observation, record review and staff interview, the facility failed maintain the overall hospital environment in a manner to assure the safety and well-being of the patients. The facility failed to: 1) develop and implement policies and procedures to assist emergency personnel with access to the facility; 2) develop a contingency for evacuating patients by stretcher from the facility while the large service elevator was shut down due to construction; and 3) safe access and egress measures were not put into place following an adverse incident. This failure created a situation that is likely to result in serious injury, harm, impairment, or death to residents and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on 10/23/12 was identified on 10/26/2102. The findings include: On 10/15/12, the facility entered into a project to accommodate their Baker Act receiving facility status. This project involved converting a one-door large service elevator into a two-door elevator that opens to the outside. The project required a sally-port type enclosure that the elevator opens to access the facility. This project did have AHCA Office of Plans and Construction approval contingent upon approval of the local fire and building authorities and obtaining local required permits. The project was scheduled for completion on 10/19/12. The project was begun as scheduled. The facility had applied for local required permits and continued to be in the application status until intervention by the Fire Department. Work was stopped and the elevator was shut down pending obtaining of permits and completion of the project. By 10/23/12 the required permits were not obtained and work had not been completed. On 10/23/12, a 911 emergency call resulted in the Iona McGregor Fire Department and a Lee County Emergency Medical Services (EMS) Ambulance responding at 9:12 p.m. to the facility. This was a cardiac-arrest call. Upon arrival at the facility, the Fire Department and EMS had to pound on the doors of the facility, they could not get in and there was no one on the first floor to let them in the facility. The emergency responders had to call the emergency dispatcher to phone the facility and request the facility staff to open the door. During an interview with the Fire Inspector, at 9:00 a.m. on 10/26/12, reporting that when the facility was constructed, an agreement was made between the facility and the Fire Department. The agreement was that the entrance doors to the facility would be labeled A, B, C, and D in order for the facility to direct the 911 responders to which door the facility staff would meet them to let them in the building and escort them to the patient. This facility is afforded special-locking arrangements for the clinical and security needs of the patients under the Fire Code. Utilizing these special locking arrangements necessitates specialized procedures for safety, security and emergency responders regarding access and egress for both non-emergencies and emergencies. During an interview the Chief Executive Officer (CEO) and Chief Nursing Officer (CNO), at 12:29 p.m., on 10/26/12, stated the facility never created a Policy & Procedure for assisting 911 call responders, and did not train the staff to follow any procedure. A Fire Department intra-office e-mail from the Duty Officer to the Fire Marshall, dated 10/26/12, documented, "Tonight we ran a cardiac arrest at Park Royal. Upon arrival there was no one to meet us at the doors or the admissions' room. We had to beat on the doors and call dispatch to try and get someone to let us in. This has been a continued problem with them." The e-mail noted that once in the facility, they have at least four locked doors to get through to get to the patients. The issue with the cardiac arrest was that the Emergency Medical Technicians (EMTs) were performing cardio-pulmonary resuscitation (CPR) on the patient and were proceeding to transport the patient from the psych hospital to an acute care hospital emergency room . The emergency medical personnel could not use the large service elevator, which was the one elevator sized for a stretcher; that elevator was shut down. The patient was adjusted to a sitting position (during CPR) to get the stretcher in the available elevator. The patient was transported to the hospital and pronounced dead. When the large service elevator was shut down, the facility failed to put an interim plan in affect to safeguard from the elevator problem. The interview with the CEO reported that after the incident happened on 10/23/12 until the survey on 10/26/12, nothing had been done to rectify the situation or come up with an interim plan to be used until the elevator is put back into service. The CEO was asked, "Since the incident, what interim measures have you put into place to prevent reoccurrence." The CEO replied, "Nothing, I did not even know about it." The permits were obtained by the day of the survey and the work was performed to put the large service elevator back in service after a two-week downtime. The large service elevator was back in service by 5:00 p.m. on 10/26/12. |
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