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.
|INTERMOUNTAIN HOSPITAL||303 NORTH ALLUMBAUGH STREET BOISE, ID 83704||Feb. 29, 2012|
|VIOLATION: PATIENT RIGHTS||Tag No: A0115|
|Based on observation, staff interview, and review of medical records, hospital policies, meeting minutes, and NIH documents, it was determined the hospital failed to protect and promote patient rights. This resulted in patients being placed in immediate jeopardy from the potential for suffering serious harm, impairment, or death from an inefficient CPR response. Findings include:
Refer to A 144 as it relates to the hospital's failure to ensure patients who suffered cardiopulmonary arrest received care in a safe setting.
Note: On Friday 2/24/12 at 12:00 noon, the CEO, CNO, and Director of Performance Improvement/Risk Management were notified in person of the immediate jeopardy related to the hospital's failure to ensure an efficient response was provided to patients who suffered cardiopulmonary arrest.
A plan of correction was received, reviewed, and accepted on 2/24/12 at 4:15 PM. The plan revised the Code Blue-CPR procedure so the staff member finding a victim who is in arrest will immediately notify staff and begin CPR. The procedure clarified the role of staff in the code blue and assigned specific staff to take charge of the CPR. The procedure also prompted staff to bring emergency equipment to the site. The hospital immediately began educating direct care staff on the new procedure and planned to in-service staff as they came on duty until all staff had been educated.
Administrative and direct care staff were interviewed on Monday, 2/27/12 to ensure staff had been trained on the current procedure. The immediate jeopardy was abated and the CEO was notified in person at that time.
|VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING||Tag No: A0144|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, staff interview, and review of medical records, hospital policies, meeting minutes, and NIH documents, it was determined the hospital failed to ensure efficient systems had been developed, and staff sufficiently trained, to provide a rapid and consistent response to patients who suffered cardiopulmonary arrest. This negatively impacted the care of 1 of 1 patient (Patient #3) who experienced cardiopulmonary arrest and had the potential to negatively impact all patients who experienced medical emergencies at the hospital. These failures limited the ability of the hospital to respond to medical emergencies and placed patients in immediate jeopardy of serious harm, impairment, or death. Findings include:
Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE]. He died on [DATE]. His diagnoses included schizoaffective disorder, post-traumatic stress disorder, alcohol abuse, hypertension, possible pulmonary embolism, a fractured right arm, post-traumatic amputation of left leg below the knee, and sores on his stump. He was admitted for suicidal ideation and alcohol detoxification. The "DISCHARGE SUMMARY" by the attending physician, dated 10/07/11, stated "At 6:45 AM [on 9/24/11] he was found unresponsive and CPR was initiated. He was not breathing and had no response. They continued CPR for a while with no response and it was felt that the patient had passed away sometime between 6:15 and 6:45 AM."
On 2/23/12 beginning at 7:45 AM, a video of the events on 9/24/11, from 6:00 AM through 7:27 AM, was viewed with RN C, who was the RN Charge Nurse who was on duty at the time of the event. There was no sound track to the video. The time on the video time stamp began at 00:00 (minutes, seconds) which corresponded to 6:00:00 AM. The timeline was as follows:
43:02 PT F entered Patient #3's room.
43:36 PT F left the room and summoned RN C. RN C entered the room at 43:58 with PT F.
44:10 RN C left the room and returned to the nursing station.
44:45 PT F left the room, leaving Patient #3 unattended. He got his clipboard and resumed his 15 minute bed checks.
46:15 RN C re-entered the room.
46:51 RN C left the room and looked around the hallway. At this point, staff from outside entered the unit and went to Patient #3's room.
46:59 RN C entered Patient #3's room with other staff, including RN A, immediately following him.
47:11 The House Supervisor, an RN, came on the unit and entered Patient #3's room.
47:24 The House Supervisor left the room and walked to the nursing station.
49:31 The House Supervisor re-entered Patient #3's room. She came back out and went to an examination room next to the nursing station. She retrieved the emergency cart, which included oxygen, airways, a bag valve mask, and suction equipment, and re-entered Patient #3's room at 50:48.
54:06 Fire department personnel arrived and entered Patient #3's room. At that point, they assumed care of Patient #3.
59:56 Emergency medical personnel and hospital nursing staff exited the room indicating the resuscitation efforts were over.
RN A, who assisted RN C with the resuscitation efforts, documented on the nursing flow sheet at 7:02 AM on 9/24/11 "Paramedics pronounced patient dead. CPR stopped."
The time hospital staff called 911 could not be ascertained by the video. However, the "CODE BLUE CLINICAL DOCUMENTATION FORM" for Patient #3 stated 911 was called 4 minutes after he was found unresponsive.
PT F, who found Patient #3 on the morning of 9/24/11, was interviewed on 2/23/12 beginning at 3:50 PM. He stated 3 people were on shift when the event occurred, an RN, an LPN, and himself. He said he had checked Patient #3 at 6:30 AM (the video showed this occurring at 6:31 AM) and Patient #3 was breathing at that time. PT F stated he tried to wake Patient #3 at 6:43 AM, to see if he wanted to go on a smoke-break, but Patient #3 did not respond and was not breathing. PT F stated he went to the nursing station and asked the RN C to assess Patient #3 and start CPR. PT F said he told the LPN to call 911. PT F said he then tended to the rest of the patients on the unit.
RN C, the Charge Nurse who was on duty at the time of Patient 3's death, watched the video on 2/23/12 beginning at 7:45 AM. He confirmed the times of the events. During a clarifying interview on 2/24/12 beginning at 7:50 AM, RN C stated he did not begin CPR until a second nurse, RN A, arrived at 46:59. RN C stated he and RN A transferred Patient #3 from the bed to the floor and initiated CPR. RN C stated CPR had not been started prior to this time. Including 5 seconds to transfer the patient, CPR was not started for at least 3 minutes and 28 seconds from the time PT F discovered Patient #3. He stated RN A performed artificial respiration. RN C confirmed oxygen, airways, a bag valve mask, and suction equipment were not available to staff performing CPR until 50:48, at least 7 minutes and 12 seconds from the time PT F discovered Patient #3.
The LPN who was on shift when Patient #3 arrested, was interviewed on 2/24/12 beginning at 7:35 AM. She stated PT F came to the desk and she heard him say something about 911. She stated it really did not register because there were patients milling around the nurse's station. The LPN stated RN C went to assess Patient #3 and then returned to the desk. She said RN C told her Patient #3 was not responsive and had no pulse and to call 911. The LPN stated she went to the back room to call 911 so she did not have to make the call in front of the patients. She stated she then announced "Code Blue" (the code for a medical emergency) over the hospital's public address system. She stated otherwise, she was not really involved in resuscitation efforts.
Delays in resuscitation efforts for Patient #3 occurred, including 3 minutes and 28 seconds to initiate CPR, 7 minutes and 12 seconds to transport critical equipment to the scene, and 4 minutes to call 911.
2. Written staff accounts of efforts to resuscitate Patient #3 on 9/24/11 were gathered and documented by the hospital. The accounts stated what various staff remembered after the event. However, an analysis of the information was not documented. No conclusions were documented.
Patient #3's "CODE BLUE CLINICAL DOCUMENTATION FORM," dated 9/24/11, was included in documents that were reviewed. The form stated:
"6:45 pt found unresponsive in bed.
6:49 911 called.
6:47 CPR started-AED advised no shock.
6:55 Paramedics arrived. CPR continued.
7:00 Heart monitored-asystole.
7:02 Paramedics pronounced dead. CPR stopped.
7:20 Coroner arrived.
7:25 Police Arrived."
The times for the Code Blue were not accurate. The hospital had saved video of the event and a comparison of the times with the video did not match. CPR was not started 2 minutes after the patient was found unresponsive, as noted above.
The hospital had a safety committee. "UHS Patient Safety Council Report" minutes for 10/27/11 and 11/21/11, the first 2 meetings following the attempted resuscitation of Patient #3 did not mention the resuscitation efforts. The minutes did state the CNO was "reformatting the code blue forms and will create an emergency cart for New Start [a chemical dependency unit]." The final committee meeting minutes of 2011, dated 12/14/11, also did not mention the resuscitation efforts.
The Policy "Code Blue," revised 10/2003, stated following an actual code or a drill, a "Code Blue/AED PI Tool" would be completed. The Director of Performance Improvement/Risk Management was interviewed on 2/27/12 beginning at 9:50 AM. She confirmed an evaluation of the efforts to resuscitate Patient #3 had not been done. She stated she had reviewed the video of the Code Blue but she had not identified problems. She stated a "Code Blue/AED PI Tool" did not exist. She stated the medical care and cause of death had been investigated regarding Patient #3 but she said CPR efforts had not been evaluated. She stated the discrepancies between the video and the "CODE BLUE CLINICAL DOCUMENTATION FORM" had not been identified.
The hospital did not analyze the resuscitation efforts for Patient #3 in order to improve processes and staff performance.
3. The Policy "Code Blue," revised 10/2003, stated "A facility Clinical Staff Member, trained in CPR, will implement the Code Blue in the event of cardiac or respiratory arrest." The policy stated the CPR trained staff member would "...assess the patient for the absence of ventilation and/or circulation. 2. Staff member will announce Code Blue, and give precise location over facility paging system. 3. Staff member trained in CPR will begin CPR..." The policy stated the Director of Clinical Services would conduct a "Code Blue Drill" on a quarterly basis "...as a training and educational opportunity for staff."
The "Code Blue" policy was not clear. The "Code Blue" policy did not address how staff should announce the code over the paging system or whether they should leave the patient to do so, since as a safety precaution patient rooms did not have telephones. The "Code Blue" policy did not specify roles for various staff members, such as the LPN and the PT. The policy did not state who was responsible to bring emergency equipment to the scene.
The CNO was interviewed on 2/24/12 beginning at 9:10 AM. He stated in a situation where the patient was in cardiopulmonary arrest, the PT should go to the nursing station to get the RN. He stated the PT should not yell to the nurse because it would panic the other patients. He stated no specific staff members were designated to get the emergency cart and bring it to the scene. The CNO stated the staff who discovered a patient in arrest should start CPR. He stated hospital staff were instructed to announce "Code Blue" for all medical emergencies including seizures because they wanted all RNs on duty to respond. He stated no "Code Blue" drills had been held in the past year.
The policy to do quarterly code blue drills was not implemented. The "Code Blue" policy did not provide sufficient direction to staff in the event a person required cardiopulmonary resuscitation. It did not address how to respond to other medical emergencies staff were expected to respond to when "Code Blue" was announced overhead.
4. Nursing staff were interviewed regarding their understanding of the CPR procedure. These included:
a. PT F, who found Patient #3 on the morning of 9/24/11, was interviewed on 2/23/12 beginning at 3:50 PM. After determining that Patient #3 was not breathing, PT F said he went to the nursing station to get RN C. He did not start CPR. He said he did not call out for help because he did not want to disturb the other patients. When he and RN C re-entered the room, they still did not start CPR. PT F left Patient #3 without performing CPR to attend to other patients.
When asked if he would do anything different if a similar situation arose, PT F stated he would take the same actions. He stated administrative staff came to the conclusion that the CPR participants "did pretty well considering the circumstances."
b. RN C, the Charge Nurse who participated in the CPR, was interviewed on 2/23/12 beginning at 7:45 AM. He stated the Director of Performance Improvement/Risk Management asked him about the CPR following the events. He stated he was not aware of how long it had taken to start CPR. He said nobody had informed him there might be problems with staff response to Patient #3's cardiopulmonary arrest.
During a follow-up interview with RN C on 2/24/12 beginning at 7:50 AM, he confirmed the delay in starting CPR and the delay in the arrival of emergency equipment. He stated he was not aware if changes had been made to the CPR procedure following the event on 9/24/11. He stated at present nobody was specifically assigned to bring the emergency cart to the scene.
c. The LPN, who was on duty at the time of Patient #3's arrest, was interviewed on 2/24/12 beginning at 7:35 AM. She was asked about her responsibilities in a "Code Blue" situation. She stated "Code Blues" were called for multiple situations where a possible medical emergency could be present, such as seizures, falls with injury, fainting, and cardiopulmonary arrest. The LPN stated she was not sure whose responsibility it was to get the emergency cart. The LPN said she did not have a specific role in a code situation. She stated she was not sure if there was a policy which specified her role or not. The LPN said she did not know what the hospital's Code Blue policy called for. She stated she was not sure if she should announce the code over the Public Address system at night because it might upset other patients. She stated she thought the response to cardiopulmonary arrest should be more organized but they happened so rarely it was hard to be consistent.
d. RN B, a Charge Nurse on duty on 2/23/12, was interviewed on 2/23/12 at 2:00 PM. When asked about her expectation for how a PT should handle a situation if he/she were to find a patient who was not breathing and did not have a pulse, she stated she expected the PT to get the RN and wait for guidance by the RN who would assess the patient. She would delegate responsibilities after she arrived at the scene. She did not indicate the PT should initiate CPR if there was a delay in getting the RN's attention. She stated she expected the PT to wait for the RN.
e. PT D, a staff member on duty on 2/23/12, was interviewed on 2/23/12 at 1:55 PM. When asked how he would handle a situation if he found a patient who was not breathing and did not have a pulse, he stated he would check the code status of the patient, notify the charge nurse by use of a call light and would wait for the nurse to arrive to give direction. He would avoid yelling out because he would not want to alarm other patients. He would stay with the patient but would "wait for the RN to direct the code."
Nursing staff were not consistent in their understanding of the "Code Blue" procedure at the hospital.
A study published by the NIH in April 2002, titled "Characteristics and outcome among patients suffering from in hospital cardiac arrest in relation to the interval between collapse and start of CPR." was reviewed. It concluded, when CPR was started within the first minute after collapse, "...survival to discharge was twice that of patients in whom CPR was started later. These results highlight the importance of immediate CPR after in-hospital cardiac arrest."
It took at least 3 minutes and 28 seconds to begin CPR on Patient #3. This placed him at significantly higher risk for death than if the CPR had been initiated within 1 minute. In addition, the hospital had not taken steps to analyze the CPR efforts for Patient #3, nor had they taken steps to improve response times for future events. This placed the health and safety of patients at risk of serious harm or death, should a similar event occur.
|VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION||Tag No: A0168|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on staff interview and review of records and hospital policy, it was determined the hospital failed to ensure seclusion was in accordance with the order of a physician for 1 of 3 restrained or secluded patients (#4) whose records were reviewed. This resulted in a patient being secluded without appropriate authorization. Findings include:
A hospital policy, "Restraint," dated 12/00, stated restraints require the order of a physician and have a maximum duration of 4 hours for adults 18 years and older.
Patient #4 was a [AGE] year old male who was admitted on [DATE] for psychosis after being incarcerated. Physician orders for seclusion, related to Patient #4's aggressive and assaultive behavior, were present in Patient #4's record for the following dates and times:
8/04/11 at 10:08 AM
8/04/11 at 4:35 PM (this was 6 hours and 27 minutes after the prior order, 2 hrs and 27 minutes more than the maximum duration of 4 hours allowed before a renewal order was required)
8/04/11 at 8:35 PM
8/05/11 at 12:30 AM
8/05/11 at 4:30 AM
8/05/11 at 8:20 AM
8/05/11 at 3:20 PM (this was 7 hours between renewal orders, 3 hours more than the maximum duration of 4 hours allowed)
Restraint flow sheets documented Patient #4 was in seclusion between 8/04/11 at 10:05 AM through 8/05/11 at 5:00 PM. Narrative documentation indicated Patient #4 continued to be secluded on 8/06/11. An RN's narrative, dated 8/06/11 at 8:15 AM, documented a nurse discussed with Patient #4 "because of his behavior the day prior, the door needed to remain locked for his safety." A psychiatric technician's progress note, dated 8/06/11 at 1:36 PM, stated Patient #4 remained in "Obs" and he was told to knock on window for any needs." A physician's progress note, dated 8/06/11 at 3:27 PM, stated Patient #4 was left behind locked doors and monitored on a one to one basis. He documented speaking with the CNO the day prior about the patient's status. The CNO indicated he had left documentation justifying the patient remaining behind locked doors given his level of aggression.
There were not valid physician orders for seclusion during the following times when Patient #4 was secluded:
8/04/11 2:08 PM until 4:35 PM
8/05/11 12:20 PM until 3:20 PM
8/06/11 for an undetermined period of time
In addition to physician orders, RN documentation on a physician order sheet, dated 8/05/11 at 12:50 PM, documented "per nursing supervisor, pt [Patient #4] to remain in seclusion by orders of DON. Call into a physician who is discussing matter with administration."
The CNO was interviewed on 2/22/12 at 11:20 AM. He explained Patient #4 was a danger to others and had already injured two staff members. He explained one staff member was hospitalized with a head injury as a result of Patient #4's assaultive behavior and had not been able to return to work. He described Patient #4 as violent, a risk to others, impulsive and compulsive and it was hard to predict when he would be violent. When asked about the documentation indicating he as the CNO had ordered continued seclusion, he stated it was his intention Patient #4 remain secluded in order to protect staff but that he was not qualified to give orders and he expected nursing staff to have obtained valid physician orders. He acknowledged physician orders were missing for some of the episodes of seclusion. He stated this had been discussed during a peer review process.
Patient seclusion was not in accordance with an order of a physician.
|VIOLATION: NURSING CARE PLAN||Tag No: A0396|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on staff interview and review of medical records, it was determined the hospital failed to ensure a nursing care plan was developed that addressed the nursing needs of 1 of 13 patients (#3) whose records were reviewed. This resulted in a lack of direction for nursing staff. Findings include:
Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE]. He died on [DATE]. His diagnoses included schizoaffective disorder, post-traumatic stress disorder, alcohol abuse, hypertension, possible pulmonary embolism, a fractured right arm, post-traumatic amputation of left leg below the knee, and sores on his stump.
Patient #3's "HISTORY AND PHYSICAL," dictated by the Nurse Practitioner on 9/18/11 at 11:58 AM, stated he fractured his right arm about a week prior to admission. The H&P stated the arm was in a cast. The H&P stated Patient #3's right arm was "very swollen" and "causes him a great deal of pain..." The H&P also stated Patient #3's prosthesis was rubbing on the stump on his left leg causing a "shear abrasion." The H&P stated the NP was ordering Bacitracin ointment to help heal the abrasion.
Patient #3's nursing care plan was incorporated into the "MASTER TREATMENT PLAN." Neither the "TREATMENT PLAN INITIAL MTP STAFFING," dated 9/17/11 nor the "MASTER TREATMENT PLAN," dated 9/20/11, included the arm fracture or stump abrasions in the plan. Subsequently, daily nursing notes from 9/18/11 through 9/24/11 did not document the condition of the arm or the stump wounds.
The Director of Performance Improvement/Risk Management was interviewed on 3/6/12 at 4:00 PM. She confirmed the treatment plans did not include direction to staff regarding care of Patient #3's fractured arm and stump wounds.
The hospital did not develop a complete nursing care plan for Patient #3.
|VIOLATION: CONTENT OF RECORD||Tag No: A0449|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of medical records, policies and procedures, and staff interviews, it was determined the hospital failed to ensure that nursing and medical staff documented condition changes and responses to medications and services in a timely manner for 1 of 13 patients (Patient #3) whose records were reviewed. This resulted in a lack of clarity about a patient's changing condition, response to treatment, and the provided interventions. Findings include:
Patient #3's medical record documented a [AGE] year old male who was admitted on [DATE]. He died on [DATE]. His diagnoses included schizoaffective disorder, post-traumatic stress disorder, alcohol abuse, hypertension, possible pulmonary embolism, a fractured right arm, post-traumatic amputation of left leg below the knee, and sores on his stump. He was admitted for suicidal ideation and alcohol detoxification. Documentation in Patient #3's medical record was not timely as follows:
1. On 9/27/11 at 2:23 PM, the family practice physician who cared for Patient #3 dictated a "PROGRESS NOTE". The first line of dictation was, "This is a late entry dictated on 09/27/2011 as I was called away from the hospital on the morning I had seen the patient and had intended to dictate this note when I returned to see him in followup." The date of the visit was not include in the note. After reviewing the physician orders for consultation in Patient #3's record on 2/29/12 at 10:40 AM, the CNO informed surveyors that the visit for the progress note dictated on 9/27/11 at 2:23 PM took place on 9/23/11. However, the exact date of the visit was unclear as the progress note documented "I asked that he be allowed to wear a sling on his right forearm, to keep elbow flexed at 90 degrees and plan to follow up with him on September 23rd."
The above referenced progress note included the following: "Had fractured his right arm and was getting inadequate pain relief." The plan documented by the physician included, "Start methadone 10 mg b.i.d. Discontinue Norco and use Oxycodone IR 5 mg four tabs q 6 p.r.n. breakthrough pain. Explained potential risks and side effects of long-acting analgesics such as methadone including sleepiness, constipation, nausea, vomiting, risk of profound sedation and respiratory depression resulting in death. It would take three to four days to achieve an adequate serum level to appreciate any analgesia and at that time would titrate off short-acting medications." As a result of late dictation, pertinent information related to the status and care of Patient #3 was unavailable to other physicians and medical staff.
2. On 9/27/11 at 3:29 PM, the family practice physician documented a consultation note about Patient #3. The first line of documentation said, "This is a late entry as the chart was unavailable when I returned to round on the patient. This is dated September 23, 2011." The delay in dictation prevented other physicians and medical staff from being aware of information that may have been pertinent to the on-going care of Patient #3. An example of pertinent information was, "OBJECTIVE: Vitals are stable, but patient is quite drowsy, he has pinpoint pupils, answers questions appropriately with mild slurred speech." Another example was, "ASSESSMENT: Side effect of Methadone (over-sedation), and constipation, acute right forearm from a fracture, end stage degenerative joint disease, right elbow, ongoing pressure points left thumb."
3. An "OVERFLOW NURSING NARRATIVE" note dated 9/24/11 at 6:47 AM included documentation by RN A, who stated, "Began CPR with Charge Nurse after Pt found unresponsive at 0645. Attached AED which advised no shock required. No pulse felt, no breathing observed, no response noted, continue CPR." There was no progress note found in Patient #3's record describing the events surrounding Patient #3's death completed by RN C, the Charge Nurse who directed resuscitation efforts.
The CNO was interviewed on 2/29/12 at 10:40 AM. He reviewed Patient #3's record and stated he was unable to locate a nursing progress note describing the code blue and CPR completed by RN C who directed the code.
A policy, "Clinical Services Documentation in Pt. Record," last revised on 3/09 documented as follows: "The RN will make an additional entry in the event of an unusual event or incident for both medical conditions and psychiatric changes. This note will include a description of the event, staff intervention, and patient response to the intervention." This was not done.
The facility failed to ensure Patient #3's change in condition, response to drugs and services and provided interventions were thoroughly documented in a timely manner.