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.

BROOKWOOD BAPTIST MEDICAL CENTER 2010 BROOKWOOD MEDICAL CENTER DRIVE BIRMINGHAM, AL 35209 July 12, 2018
VIOLATION: GOVERNING BODY Tag No: A0043
Based on the complaint survey the facility failed to assure the Governing Body was responsible for the operation of the hospital. In addition, the Governing Body failed to assure that all hospital policy and procedures were approved on an annual basis. This had the potential to affect all patients served by the facility.

1. Notify patient nurse of changes in patient's vital signs including alerts on the telemetry strips by the Central Monitoring Unit.

2. Provide an environment free from falls by following agency Falls Protocol.

3. Provided a safe enviromnent by documenting constant observation checks every 15 minutes.

4. Provided a safe environment by performing hourly rounds.

5. Ensure staff followed their own policy for elopement in the Partial hospitalization program and completed the Biopsychosocial Assessment intake form.

6. Assure Physicians were notified of changes in patient's conditions and needs.

Findings include:

Refer to A 057, A 115, A 144, A 385, A 392, and A 449 for findings.
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on the complaint survey the facility failed to assure the Governing Body was responsible for the operation of the hospital. In addition, the Governing Body failed to assure that all hospital policy and procedures were approved on an annual basis. This had the potential to affect all patients served by the facility.

1. Notify patient nurse of changes in patient's vital signs including alerts on the telemetry strips by the Central Monitoring Unit.

2. Provide an environment free from falls by following agency Falls Protocol.

3. Provided a safe enviromnent by documenting constant observation checks every 15 minutes.

4. Provided a safe environment by performing hourly rounds.

5. Ensure staff followed their own policy for elopement in the Partial hospitalization program and completed the Biopsychosocial Assessment intake form.

6. Assure Physicians were notified of changes in patient's conditions and needs.

Findings include:

Refer to A 057, A 115, A 144, A 385, A 392, and A 449 for findings.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on a review of medical records (MR), Unit Activity Report, Qantros Safety Event Manager Reports, RL Solutions Complaint Reports, Constant Observer Flow Sheet, facility policies and procedure, observations, and interviews, it was determined the facility failed to:

1. Notify patient nurse of changes in patient's vital signs including alerts on the telemetry strips by the Central Monitoring Unit. This deficient practice resulted in 1 patient's death.

2. Provide an environment free from falls by following agency Falls Protocol and performing hourly rounds.

5. Ensure staff followed their own policy for elopement in the Partial hospitalization program. This deficient practice resulted in 1 patient's death.

Findings include:

Refer to A- 0144 - Patient's Rights for findings.
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 medical records (MR), Unit Activity Report, Qantros Safety Event Manager Reports, RL Solutions Complaint Reports, Constant Observer Flow Sheet, facility policies and procedure, observations, and interviews, it was determined the facility failed to:

1. Notify patient nurse of changes in patient's vital signs including alerts on the telemetry strips by the Central Monitoring Unit.

2. Provide an environment free from falls by following agency Falls Protocol.

3. Provided a safe enviromnent by documenting constant observation checks every 15 minutes.

4. Provided a safe environment by performing hourly rounds.

5. Ensure staff followed their own policy for elopement in the Partial hospitalization program.

This affected 13 of 30 MRs reviewed and 4 unsampled patients, including Patient Identifier (PI) # 1, # 3, # 20, # 16, 3 unsampled patients, # 14, # 15, # 5, unsampled patient, # 12 and # 10, and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Falls Prevention and Resources
Policy Number: P_GN_PC_24-0318
Dated: 03/18

II. Purpose: "The purpose of this policy is to:

...B. Establish a framework for assessing risk factors for patient falls, implementing intervention for reducing the risk for falling and protecting patients from injury if a fall should occccur....

IV. Policy: ....The ultimate goal of a falls program is prevention of injury...
V. Procedure
A. Initial Falls Risk Assessment

1. Upon entry into the hospital system or through emergency services, a Registered Nurse (RN) should first complete the Morse Fall Scale Risk Screening Tool in Cerner as part of the patient's admission assessment....

B. Falls Risk Assessment

1. Morse Scale Assessment:
a) Patients who score 0-24 are considered at "Low Risk" for falls.
b) Patients who score 25-44...are considered "Moderate Risk" for falls.
c) Patients who score 45 and above are considered "High Risk" for falls....

E. Mandatory Fall Alert Intervention:

1. All patients identified as at risk for falls should have interventions implemented to alert other healthcare workers, family and visitor of the fall potential.
2. Minimally, all of the following measures will be implemented at all times:
a) For high risk, a yellow armband must be placed on the wrist and yellow no-slip/skid socks be applied....
c) A sign (star) identifying the patient is at risk for falls is placed outside the patient's door frame....
e) Make sure the bed is secured locked, locked in low position and bed alarm on...."


Policy: Constant Observer Assessment, Implementation, and Discontinuation
Policy Number: SYS_NRS 20
Dated: 5/18/18

Policy: "The Hospital recognizes the Constant Observers may be utilized in order to provide continuous observation of a patient to support safety....

A. If an assessment reveals that a patient is a danger to self and/or others a Constant Observer will be implemented immediately....
C....Definitions of levels of constant observation:
1. One on one observation - one competent Constant Observer to one patient within line of sight, in close proximity with no physical barriers in the same room/area....
2. Close observation - one competent Constant Observer to one or more patients in the same room/area.
3. Line of sight observation - one competent Constant Observer in direct line of sight with one or more patients....
D. Implementation of Constant Observer...
5. The Constant Observer will document patient observations at intervals not to exceed 15 minutes on the designated flow sheet as indicated...."

Policy: Central Nurse Call System
Policy Number: N_GN_NC_01_0716
Dated: 09/82

III. Policy: "The RN, Licenced Practical Nurse (LPN), and Patient Care Assistants (PCAs) with the assistance of the Central Nurse Call System (CNCS) operator, will respond to patient needs and requests by utilizing the CNCS. This system identifies proper staff members based on patient needs and location and enhances efficient use of nursing staff time."

Policy: Management of Medical/ Surgical Patients on Telemetry Monitoring
Policy Number: N_GN_PC_31
Dated: 11/2017

II. Purpose:

The purpose of this policy is to provide guideliens for the management of patients requiring telemetry monitoring.

III. Policy:

B. Communication:

1. The monitor tech will promptly comunicate non-life thratening rhythm problems/ changes to the nurse who is in charge of the patient within 5 minutes of alarm.

2. When patients are monitored from the central station outside of their home unit, the monitor tech will:

b) The monitor tech will communicate rhythm problems/ changes and questions by phoning the assigned nurse of the patient.

c) If non-threatening issue is not resloved at central station whin 5 minutes, the monitor tech will call the charge nurse . ....

3. b) The nurse will notify the physician of the following rhythm changes:
1. Asystole
2. Thrid degree heart block
3. V Tach
4. V tach - 6 beats
5. V Fib

C. Patient Care

1. The RN will review/ communicate rhythm strip data during shift report.

I. All Alarms will be set at default unless otherwise prescribed by a [hysician.

The standing alarms are aa follows, unless specified by the physician:
a) Heart Rate (HR) less than (<) 40; pause 3 seconds.
b) HR greater than (>) 150
c) SA02 < 90%
d) ST Segment Elevation or Depression (+/- 2 mm)
e) Complex ventricular ectipy > 6 beats VT; sustained V- Tach > 15seconds, sustained bigeminy, sustained treigiminy.
f) New supraventricular arrhythmia
g) Absence of signal
h) Any ither sunstantial changes in rhythm

4. All rhythm interpretations will be verified by an RN and physician notified before treatment is initiated.

Policy: Elopement
Policy Number: D-PS-PG-11.069
Date Reviewed: 09/09

"Policy:

While the independence of the Partial hospitalization patient is recognized, when a patient has left without notifying staff, this procedure will be followed.

Procedure:

1. When a patient fails to appear to the next scheduled group, staff will attempt to locate the patient and/or immediate grounds.

2. If the patient cannot be found, the attending physician, Medical Director, Operations Leader, or designee and the patient's family will be notified..."

1. PI # 1 was admitted to the facility on [DATE] with the diagnoses including Altered Mental Status and Rule Out Sepsis.

Review of the MR 7/5/18 at 11:00 AM revealed patient was admitted on [DATE] at 3:31 PM to Room 379 3 West/ Medical Cardiac Unit) with the chief complaint of Altered Mental Status, Rule Out Sepsis.

Review of the Nursing/ Clinical Information Note dated 6/10/18 at 3:47 AM had the documentation "the patient complained of indigestion and was given as needed (PRN) medication with no relief. Patient also complained of pain and was given PRN Norco x 2 doses with no relief. Patient was also given Restoril to help his/ her relax, but none of these mediations seemed to help the patient. Hospitalist was notified, no further orders given

Review of the Nursing/ Clinical Information Note 6/10/18 at 8:15 AM had the documentation the family requested that patient not be awaken. At 9:00 AM the patient's daughter was walking in the hallway stating that patient was not breathing. The nurse went into the patient's room and found patient unresponsive and not breathing, Code Blue was called @ 9:02 AM

Review of the Emergency/ Urgent Care emergency room (ER) Physician (MD) Summary dated 6/10/18 at 7:34 PM revealed documentation that he/ she responded to a Code Blue called to Room .... When the ER MD arrived full cardiopulmonary resuscitation was in progress. The Registered Nurse (RN) informed the ER MD that the patient was pulseless and apneic when he/ she found the patient. The RN further stated that he/ she called the Telemetry Room and was informed by a monitor technician that the patient has not had a rhythm for 15 minutes.
After stabilizing the patient and his/ her attending physician was notified and came in to the patient's room. The patient was then transferred to Coronary Care Unit on a ventilator with full support.

Review of the 24 Hour Telemetry strips revealed the last cardiac strip was printed on 6/10/18 at 7:09 AM (09 seconds (sec) , the cardiac strips showed heart rate (HR) at 64 beats per minutes (bpm) There were no printed cardiac strips until 8: 44 (14 seconds) when the HR dropped the he 46 beats per minutes (bpm); at 8:44 (34 sec) HR was 32 bpm; and at 8:44 (54 sec) HR was 28 bpm. .

Review of the Progress Note by the Physician Hospitalist dated 6/10/18 at 8:50 PM revealed the patient was pronounced dead at 7:58 PM .

An interview was conducted with Employee Identifier (EI) # 4, Director of 3 West and Central Monitoring who conducted on 7/6/18 at 11:00 AM, EI # 4 showed the surveyor a copy of Performance Management Program Record Conference done 6/13/18. at It was documented the reason for the conference was " EI # 5, Monitor Technician failed to notice the decrease in PI # 1 Heart Rate for over a 15 minute period. EI # 4 further documented " The patient subsequently coded and was transferred to the Intensive Care Unit." The Action Plan For Improvement section which was completed by EI # 4 and had this documentation, " Notify patients RN for any sudden or gradual rhythm/ rate change. The surveyor asked if there were any further action taken such as education, etc. EI # 4 answered "no".

2. PI # 3 was discharged from the facility's inpatient psychiatric care on 1/15/18 and admitted to the Partial hospitalization Program (PHP) on 1/22/18, with diagnoses including Bipolar Disorder, and Depression.

Review of the synopsis received on 7/10/18 at 8:25 AM from EI # 3, Vice President, Quality, included the following order of events:

"PI # 3 discharged [DATE] from inpatient psych (psychiatric) admission for depression/ anxiety. (She/he) completed (her/his) intake assessment for Partial Psych hospitalization day program on 1/19/18 and attended sessions on 1/22/18 and 1/23/18. (Husband/wife) dropped (her/him) off for the 1/24/18 sessions. PI # 3 registered at approximately 0840 (8:40 AM). At approximately 0919 (9:19 AM), Brookwood Security was notified by Homewood Police Department (HPD) that they had received a call from someone stating a body was seen at the base of the parking span on the hospital campus. ...We reconciled the Partial Psych hospitalization (day program) census and were unable to locate (PI # 3). Staff reported that (she/he) had checked in but did not come to the first group session at 0900 (9:00 AM). At this time, we informed the HPD that we may have identified a person of interest. (He/she) was able to pull up (her/his) AL (Alabama) driver's license which the coroner used for initial identification when he/she arrived..."

Review of the MR revealed a progress note dated 1/22/18 at 4:00 PM, written by EI # 12, Clinical Therapist, which stated, "Informed that patient's spouse called several times throughout day to check on pt (patient), as (she/he) may be an elopement risk. ...Will add concerns to tx (treatment) plan and discuss w/ (with) pt..."

Review of the PHP Interdisciplinary Care Plan dated 1/19/18, the date of the patient's intake appointment, revealed Safety, under category of Areas of Need, had been marked through with a line, and initialed by the Clinical Therapist. Further review of the Therapy Progress Notes, dated 1/22/18 and 1/23/18, revealed no update to the Care Plan, and "Areas of need addressed" did not change to include Safety/ Elopement Risk.

A tour of the facility and interview was conducted on 7/10/18 at 9:00 AM with EI # 6, Administrative Director, Psychiatric Services. EI # 6 stated PI # 3 was escorted by the spouse up to the third floor, to the PHP's waiting room on the morning of 1/24/18. The spouse kissed the patient and then left the premises.

Review of the documents provided to the surveyor on 7/10/18 revealed a patient sign in sheet for the PHP dated 1/24/18. PI # 3 was listed on the form, and 8:40 (AM) was written in the column labeled "Arrival Time."

EI # 6 stated PI # 3's purse and other belongings were discovered after the event in the casual gathering room, an area located beyond the waiting room of the office.

The staff failed to recognize PI # 3 had left without notifying staff, and failed to follow the procedure outlined in their elopement policy to attempt to locate the patient.

During an interview conducted on 7/10/18 at 11:00 AM with EI # 6, the above findings were confirmed.

3 . PI # 20 was admitted to the facility on [DATE] with an admitting diagnosis of New Onset of Atrial Fibrillation.

PI # 20 experienced a fall on 5/20/18 at 20:10 which resulted in a fracture of the superior part of the L1(Lumbar one) vertebral body.

Review of the Quantros Safety Event Manager event summary revealed the following:
a. The patient was determined to be at risk for a fall prior to the fall.
b. The Morse Fall Risk score was 75 (High risk)
c. Interventions in place prior to the fall included: assistive device, call light in reach, bed/chair alarm, non-slip footware and siderails.

Further review of the Quantros Safety event summary revealed the patient did not have on the non-slip footware as per the agency Falls protocol.The staff failed to implement all of the required falls interventions as per facility policy for PI # 20.

A telephone interview was conducted on 7/6/18 at 9:58 AM with Employee Identifier (EI) # 4, Director, 3 West and Central Monitoring, who stated all patients identified as falls risk must have the following: A star sign placed on their door, bed/Posey chair alarm, yellow non-skid socks and call light and personal items in reach. If a patient refuses any of the precautions, such as non-skid socks, it is to be documented on a "Refusal of Care " form. No Refusal of Care from was in the MR for PI # 20.

An interview was conducted on 7/9/18 at 10:40 AM with EI # 4, Director, 3 West and Central Monitoring, who confirmed the above findings.

4. PI # 16 was admitted to the facility on [DATE] with an admitting diagnosis of Pneumonia.

On 7/5/18 the surveyor asked EI # 8, 5 Main Nurse Manager, to identify a patient that was a high falls risk. EI # 8 identified PI # 16 due to the Morse Falls score was greater than 45.

Upon entering into room 527, room of PI # 16, the surveyor noted a star sign on the door, indicating the patient is a falls risk. The surveyor observed the PI # 16 lying in the middle the bed with his/her feet dangling on the floor, attempting to lie down. He/she was attempting to pull off some multi-colored socks as the surveyor and EI # 8 approached the bed.

The surveyor asked EI # 8 if the PI # 16 was wearing non-skid socks? EI # 8 responded "no". There were no yellow non-skid socks in the room. The surveyor asked EI # 8 to whether the bed alarm was on? EI # 8 responded "no it is not". The surveyor asked EI # 8 if PI # 16 had on a yellow falls bracelet? EI # 8 responded "no". The staff failed to implement all of the required falls interventions as per facility policy for PI # 16.

Upon further touring of the 5 main unit with EI # 8, the surveyor noted the star signs, which indicate the patient is a falls risk, on the doors of rooms 538, 539 541 and 543 but there were no patients currently assigned to these rooms. The surveyor asked EI # 8 why there were star signs on those doors. EI # 8 responded " I guess no one ever took them down".

An interview was conducted on 7/5/18 at 1:00 PM with EI # 8, who confimed the above findings.

5. Unsampled patient # 1 was located in room 357. The surveyor asked EI # 4 to identify patients on the 3 West unit that were at risk for falls. Unsampled patient # 1 had a Morse Falls risk score of 80.

Upon entering room 357 the surveyor noted a star sign on the door indicating the patient is a falls risk. The surveyor asked EI # 4 whether the bed alarm was on? EI # 4 stated "no". The staff failed to implement all of the required falls interventions as per facility policy for Unsampled patient # 1.

An interview was conducted on 7/9/18 at 10:40 AM with EI # 4, who confirmed the above findings.

6. Unsampled patient # 2 was located in room 359. EI # 4 identified Unsampled patient # 2 as a high falls risk. Unsampled patient # 2 had a Morse Falls risk score of 70.

Upon entering room 359 the surveyor noted a star sign on the door indicating the patient is a falls risk. The surveyor asked EI # 4 whether the Unsampled patient # 2 was wearing a yellow falls bacelet? EI # 4 stated "no". The staff failed to implement all of the required falls interventions as per facility policy for Unsampled patient # 2.

An interview was conducted on 7/9/18 at 10:40 AM with EI # 4, who confirmed the above findings.

7. Unsampled patient # 3 was an [AGE] year old patient admitted to 3 West who had a documented fall incident on 2/5/18 at 3:50 AM.

Review of the Safety Event entry revealed the "nurse heard a loud noise" and found the patient on the floor.

Review of the Safety Event Classification section revealed the question: "Prior to the fall, was this patient determined to be at risk for a fall?" with the documented reply as "unknown".

Further review of the Safety Event Classification section revealed the question: "Prior to the fall, was a formal fall risk assessment performed?" with the documented reply as "No". The facility failed to document the Morse Falls Risk assessment and implement interventions to prevent falls as per facility policy for Unsampled patient # 3.

An interview was conducted on 7/9/18 at 10:40 AM with EI # 4, who confirmed the above findings.

8. PI # 14 was admitted to room 540 on 6/25/18 with an admitting diagnosis of a Right Stump Infection.

Review of the MR revealed an order on 7/2/18 and 7/3/18 for Constant Observer, One to One Observation.

Review of the Constant Observer flow sheet for 7/2/18 revealed no documentation of Patient Activity/Behavior/Location or Staff initial on 7/2/18 for the 2:00 AM, 2:15 AM and 2:30 AM time slots.

Review of the Constant Observer flow sheet for 7/3/18 revealed no documentation of the Patient Location on 7/3/18 for the 5:15 AM, 5:30 AM, 5:45 AM, 6:00 AM, 6:30 AM and 6:45 AM time slots.

An interview was conducted on 7/5/18 at 1:00 PM with EI # 8, who confirmed the above findings.

9. PI # 15 was admitted to room 541 on 6/27/18 with an admitting diagnosis of Near Syncope, Urinary Tract Infection.

Review of the MR revealed an order on 7/4/18 for Constant Observer, Line of Sight.

Review of the Constant Observer flow sheet for 7/4/18 revealed no documentation of Patient Activity/Behavior/Location or Staff initial on 7/4/18 for the 6:45 AM time slot.

An interview was conducted on 7/5/18 at 1:00 PM with EI # 8, who confirmed the above findings.

10. PI # 5 was admiited to the facility from 5/6/18. A patient grievance was entered into the RL Solutions Patient Tracking System on 5/16/18 after a phone call interview by the Patient Experience Supervisor.

In the grievance, the PI # 5 alleged the staff "told her she had seven patients and that responding in four hours was good".

Review of the response letter sent to PI # 5, dated 5/23/18, from the Patient Experience Supervisor, revealed the following: "Based on your shared comments and the review of the nurse call response report, the specific staff members did not consistently meet our expectations for providing timely patient care and communicating with our patients. The Nursing Director has followed up with all staff involved in your care to share a learning moment on the importance of purposeful hourly rounding."

The surveyor requested of EI # 1, Accreditation Manager, Safety Officer, the Unit Activity Report for the room that PI # 5 was admitted to during the admission of the grievance and was provided a Unit Activity Report for Room 522.

Review of the Unit Activity Report for room 522 from 5/6/18 to 5/9/18 revealed the following:

Page 2 of 16: "(LPN, PCT (Patient Care Technician), RN) entered room on 5/6/18 at 11:41 PM
Page 3 of 16: "(LPN, PCT, RN) entered room on 5/7/18 at 2:59 AM
There was no documented staff presence in the room between 11:41 PM ro 2:59 AM.

Page 13 of 16: RN entered room on 5/8/18 at 2:36 PM
Page 14 of 16: a summary of Totals By Date
Page 15 of 16: RN entered room on 5/9/18 at 12:36 AM
There was no documented staff presence in the room between 2:36 PM to 12:36 AM to show hourly rounds.

An interview was conducted on 7/5/18 at 1:00 PM with EI # 8, who stated hourly rounds were the expectation of administration for patient safety.
The above concerns were communciated to EI # 2, Cheif Nursing Officer, on 7/12/18.

11. Unsampled Patient # 4 was admitted to 5 Main on 10/27/18. A patient grievance was entered into the RL Solutions Patient Tracking System on 3/15/18 related to an incident that occurred during the admission.

In the grievance, Unsampled Patient # 4 alleged " an enema was ordered on [DATE] at 4:00 AM and was given that morning....when my daughter arrived, she found me lying in my own feces and there wasn't a nurse or assistant to be found. When my daughter finally saw a nurse, she was told someone would be in after report".

Review of the response letter sent to the Unsampled Patient # 4, dated 3/20/18, from the Patient Experience Supervisor, revealed the following: "Our expectation is that team members respond timely to our patient's needs and Nurse Call activations. Based on the review of the nurse call response report, we did not meet our goal of responding to your needs".

An interview was conducted on 7/5/18 at 1:00 PM with EI # 8, who stated hourly rounds were the expectation of administration for patient safety.





13. PI # 10 was transferred from MICU (Medical Intensive Care Unit) to inpatient psychiatric care on 7/3/18 with diagnoses including Major Depressive Disorder without Psychosis, Substance Abuse Disorder, and Suicidal Ideations.

Review of the MR revealed the Psychiatry History and Physical dated 7/4/18 with the following documentation by the physician: "...And in the ICU he tried to elope and was found in the woods nearby."

Review of the orders dated 7/1/18 and in effect at the time of the elopement revealed an order for Precautions: Continuous, Suicide.

Review of the nursing documentation on 7/3/18 revealed the following order of events:

"0735 (7:35 AM) Patient sitting on side of bed ripped IV (Intravenous) tubing apart... Patient agitated.

0740 (7:40 AM) Patient at room door attempting to leave. Psych (Psychiatric) rapid response team called to obtain suicide risk assessment. Patient with continued agitation...

0745 (7:45 AM) Psych rapid response at bedside. ...Dr. Bell called related to patient behavior: left message.

0845 (8:45 AM) Patient pacing refusing care, removed monitoring device. Patient ran past CO (Constant Observer) out unit doors..."

Review of the statement of the CO, dated 7/3/18, revealed, "...the patient asked the nurse the best way out of the hospital. The patient was located in MICU bed 1, next to the doors to the ICU. The doors were opening and closing. He asked the nurse where the doors led. The CO reported to other nurses that (she/he) felt like the patient was going to try and leave..."

According to a narrative statement dated 7/3/18 by EI # 13, RN, Administrative Director, the patient was located by a Homewood Police officer. An involuntary commitment was obtained, and the patient was brought back to the hospital at 10:06 AM and admitted to psychiatry.

According to the Nursing Note dated 7/3/18 at 1:00 PM, PI # 10 hung himself/ herself on 6/28/18 with a belt, on the porch of his/her home and lost consciousness. He/she was rescued by the spouse.

During an interview conducted on 7/10/18 at 3:55 PM with EI # 1, Accreditation Manager/ Safety Officer the above findings were confirmed. The surveyor asked if a patient on suicide precautions exhibited increasing agitation over one hour and ten minutes, pulled out IV, asked where the doors led, and no orders received back from physician, would justify initiating a Code Brown (Pyschiatric emergency code)? EI # 1 answered "Yes."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on hospital policy, record review and interview the hospital failed to:

1). Ensure nurses were alerted/ informed of changes in the patients medical condition and vital signs.

2). Assure Physicians were notified of changes in patient's conditions and needs. This resulted in a death of the 1 medical patient.

3). Ensure the Clinical Therapist accurately completed the Partial hospitalization Program, Biopsychosocial Assessment intake form . This resulted in the death of 1 psychiatry patient.

This had the potential to affect all patients served.

Findings include:

Refer to A 0392 for findings.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on reviews of medical records (MR), policies and procedures and interviews, it was determined the staff in failed to ensure:

1). Nurses were alerted/ informed of changes in the patients medical condition and vital signs.

2). Physicians were notified of changes in patient's conditions and needs

This deficient practice affected 4 of 5 patient records that were monitored by the Central Monitoring Unit including Patient Indentifier (PI) # 1, # 2, # 29 and # 30 and have a potential to negatively affect all patients served by the facility.

Finding includes:

Policy: Management of Medical/ surgical Patients on Telemetry Monitoring
Policy Number: N_GN_PC_31
Dated: 11/2017

II. Purpose:

The purpose of this policy is to provide guidelines for the management of patients requiring telemetry monitoring.

I. Purpose

The purpose of this policy is to provide guidelines for the management of patients requiring telemetry monitoring.

III. Policy:

B. Communication:

1. The monitor tech will promptly communicate non-life threatening rhythm problems/ changes to the nurse who is in charge of the patient within 5 minutes of alarm.

2. When patients are monitored from the central station outside of their home unit, the monitor tech will:

b) The monitor tech will communicate rhythm problems/ changes and questions by phoning the assigned nurse of the patient.

c) If non-threatening issue is not resolved at central station within 5 minutes, the monitor tech will call the charge nurse . ....

3. b) The nurse will notify the physician of the following rhythm changes:
1. Asystole
2. Third degree heart block
3. V Tach
4. V tach - 6 beats
5. V Fib

C. Patient Care

1. The RN will review/ communicate rhythm strip data during shift report.

I. All Alarms will be set at default unless otherwise prescribed by a [physician.

The standing alarms are aa follows, unless specified by the physician:
a) Heart Rate (HR) less than (<) 40; pause 3 seconds.
b) HR greater than (>) 150
c) SA02 < 90%
d) ST Segment Elevation or Depression (+/- 2 mm)
e) Complex ventricular ectopy > 6 beats VT; sustained V- Tach > 15 seconds, sustained bigeminy, sustained treigiminy.
f) New supraventricular arrhythmia
g) Absence of signal
h) Any other substantial changes in rhythm

4. All rhythm interpretations will be verified by an RN and physician notified before treatment is initiated.

Subject: Medical Surgical Nursing Documentation - Routine Shift Assessment
Revised Date: 11/17

III. Policy:

" ... B. Nursing Documentation:

Assessment:

1. An assessment at the beginning of the shift, at transfer to another unit by the transferring unit and receiving unit is required, and throughout shift when changes are identified...

2. Blocks left blank in sections other than the assessment section denote treatment activity, or other interventions are not ordered and/ pr appropriate or this patient or it is charted in another place in the patient's record. ..
*****

Subject: Management of Medical/Surgical Patients on Telemetry Monitoring
Revised Date: 11/17

" ... III. Policy:

A. Telemetry Initiation Guidelines:

1. Decision for telemetry is ordered by the primary care provider...

C. Patient Care:

1. The RN will review/communicate rhythm strip data during shift report ..."


1. PI # 1 was admitted to the facility on [DATE] with the diagnoses including Altered Mental Status and Rule Out Sepsis.

Review of the MR 7/5/18 at 11:00 AM revealed patient was admitted on [DATE] at 3:31 PM to Room 379, 3 West/ Medical Cardiac Unit) with the chief complaint of Altered Mental Status, Rule Out Sepsis.

Review of the Nursing/ Clinical Information Note dated 6/10/18 at 3:47 AM had the documentation "the patient complained of indigestion and was given as needed (PRN) medication with no relief. Patient also complained of pain and was given PRN Norco x 2 doses with no relief. Patient was also given Restoril to help his/ her relax, but none of these mediations seemed to help the patient. Hospitalist was notified, no further orders given. "

Review of the Nursing/ Clinical Information Note 6/10/18 at 8:15 AM had the documentation the family requested that patient not be awaken. At 9:00 AM the patient's daughter/ son was walking in the hallway stating that patient was not breathing. The nurse went into the patient's room and found patient unresponsive and not breathing, Code Blue was called @ 9:02 AM.

Review of the Emergency/ Urgent Care emergency room (ER) Physician (MD) Summary dated 6/10/18 at 7:34 PM revealed documentation that he/she responded to a Code Blue called to Room 379. When the ER MD arrived full cardiopulmonary resuscitation was in progress. The Registered Nurse (RN) informed the ER MD that the patient was pulseless and apneic when he/ she found the patient. The RN further stated that he/she called the Telemetry Room and was informed by a monitor technician that the patient has not had a rhythm for 15 minutes.
After stabilizing the patient and his/her attending physician was notified and came in to the patient's room. The patient was then transferred to Coronary Care Unit on a ventilator with full support.

Review of the 24 Hour Telemetry strips revealed the last cardiac strip was printed on 6/10/18 at 7:09 AM (09 seconds) (sec) , the cardiac strips showed heart rate (HR) at 64 beats per minutes (bpm) There were no printed cardiac strips until 8:44 AM (14 seconds) when the HR dropped the he 46 beats per minutes (bpm); at 8:44 (34 sec) HR was 32 bpm; and at 8:44 (54 sec) HR was 28 bpm. .

Review of the Progress Note by the Physician Hospitalist dated 6/10/18 at 8:50 PM revealed the patient was pronounced dead at 7:58 PM .

An interview was conducted with Employee Identifier (EI) # 4, Director of 3 West and Central Monitoring who conducted on 7/6/18 at 11:00 AM, EI # 4 showed the surveyor a copy of Performance Management Program Record Conference done 6/13/18 which revealed documentation on the reason for the conference was " EI # 5, Monitor Technician failed to notice the decrease in PI # 1 Heart Rate for over a 15 minute period ". EI # 4 further documented " The patient subsequently coded and was transferred to the Intensive Care Unit." The Action Plan For Improvement section which was completed by EI # 4 and had this documentation, Notify patients RN for any sudden or gradual rhythm/ rate change." The surveyor asked if there were any further action taken such as education, etc. EI # 4 answered "no".

2. PI # 2 was admitted to the facility on [DATE] with the primary diagnoses of [DIAGNOSES REDACTED]

Review of the medical records on 7//918 at 2:15 PM revealed patient was admitted on [DATE] on 3 West/ Medical Cardiac Unit) with the chief complaint of Acute Myocardial Infarction.

Review of the Cardiovascular/ Cardiology Admission History and Physical dated 5/15/18 revealed patient was transfer from another hospital due to progressive shortness of breath since the "age of 35". Patient did complain of chest pains "but not bad".

Review of the patient's Vital Signs report revealed BP on 5/15/18 was in the range of 120/63 to 136/76 with runs of low BP ranging from 84/55. There was no documentation the physician was notified.

Review of the Vital Signs report dated 5/27/18 revealed blood pressure (BP) at 6:10 AM was 97/60; 12:00 PM was 70/44. There was no documentation the patient's nurse notified the physician of the low blood pressure.

Review of the Consultation Notes 5/27/18 revealed documentation at 3:00 PM, a Code Stroke was called due to the patient being unresponsive. Further review of the notes revealed the documentation" the patient had been hypotensive and hypoxic for a long period of time."

Review of the Nursing/ Clinical Information dated 5/27/18 at 3:15 PM had the following documentation Code Stroke called. "Upon arrival, patient found unresponsive, unable to assess for National Institute of Health Stroke Scale (NIHSS). Last known well time: 05/27/18 at 1:)) AM.". ... "Patient was transported per Advanced cardiovascular Life Support (ACLS) support to Computerized Tomography (CT) then transported to Intensive Care Unit (ICU/ Coronary Care Unit (CCU).

Review of the neurology/neurosurgery consultation revealed due to Hypoxemia and unstable condition, patient was intubated and placed on a ventilator. Patient was in ICU/CCU from 5/27/18 to 6/4/18. On 6/4/18 patient was transferred out of ICU/ CCU to 3 West (Cardiac Floor) where he/ she rehabilitation services.

Review of the Discharge Summary date 7/6/18 revealed the patient was discharged to home in stable condition with home health agency referral and will over the home care service at the patient's residence.

In an interview conducted on 7/8/18 at 5:15 PM with EI # 4 who confirmed the above mentioned findings.

3. PI # 30 was admitted on 2 General Surgery (Gastro Intestinal (GI)/ Genito-Urinary (GU) Unit on 7/1/18 at 3:40 PM to Room GS 277 with the chief complaints of Right Leg Cellulitis

On 7/10/18 at 3:15 PM, the surveyor surveyed the Central Monitoring Unit and found 3 monitor technician's on duty. The surveyor noted that 2 patients heart rate parameters were decreased from low of 50 to 40 bpm with the high range of 150 bpm. The surveyor asked EI # 16, Monitor Technician who was responsible for changing the patient's cardiac parameters, EI # 16 responded " I don't know who changed the parameters, it was that way when I got here this morning". The surveyor

The surveyors reviewed the records of PI # 29 and # 30 to Station 2 Gastro Intestinal (GI)/ Genito-Urinary) GU Unit and reveiwed the 2 telemetry patients.

Review of the Physician Orders dated 7/2/10 at 3:45 PM revealed there was no order to decrease the heart rate parameters to 40 bpm.

An interview was conducted on 7/10/18 at 4:00 PM with EI # 4. The surveyor with EI # 4 went back to the Central Monitoring Unit and clarify as to who gave the order to change the heart rate low level to 40 bpm. The surveyors noted the patient telemetry monitor was adjusted back to 50 bpm, when the surveyor asked who adjusted the heart rate back to 50 bpm, EI # 16, Monitor Technician stated that he/ she did. The surveyor asked if EI # 16 received an order from the patient's nurse or for the physician, he/ she answered "no."

***
A tour of the Central Telemetry Unit conducted on 7/5/18 at 10: 45 AM with a staff of (2) Monitor Technicians (MT) with 1 Patient Care Assistant (PCA) whose duty was to log in returned telemetry boxes, issue telemetry boxes and pulse oximetry. The surveyor notes that 1 MT had 42 patients and the other had 34 patients. When asked how many patients are each MT should monitor, the surveyor was told that their manager told them that they are to monitor 35 patients per MT.

An interview was conducted with Employee Identifier (EI) # 14, Monitor Techncian (MT) and EI # 17, MT. The surveyor asked EI # 14 what are the parameters set for the heart rate, EI # 14 stated the HR parameters were on defaulted at low range of 50 beats per minunte (bpm) and high range of 150 bpm. The surveyor further asked who can change the ranges of the HR parameters both stated they receive a call from the patient's registered nurse (RN) to change the HR parameters. When the MT receives the call to adjust, they are to call the Biomedical Support to unlock the temetry monitor so the MT can change the parameters. The surveyor then asked the MTs if the get any documents example copy of the physician's order, both MTs answered no.

The surveyor further asked EI # 14, MT who verbalized that the monitor technician on duty prints out the patient's cardiac strips every 4 hours unless there is noted Dysrhythmias or irregularities. EI # 14 further stated that when any irregularities and when patient is "off the monitor such as dislodged leads or in the bathroom, they are call the patient's nurse and informed of findings. The surveyor noted that each monitor has a note indicating when and how to call a code blue in the event patient is on Third Degree Heart Block, Asystole, [DIAGNOSES REDACTED], Ventricular Fibrillation and [DIAGNOSES REDACTED] - 6 beats.





4. PI # 29 was admitted to the 2nd floor GI/GU unit from the Emergency Department on 7/6/18 with diagnoses including Abdominal Pain with history of Irritable Bowel Syndrome.

An tour of the Central Monitor Station was conducted on 7/10/18 at 8:55 AM. All the HR (heart rate) alarms were set at 50 - 150 with the exception of 2 patients which were being monitored EI # 16, Monitor Tech (Technician).

The HR alarm for PI # 29 was set at 40 - 150. The surveyor asked EI # 16 why PI # 29's alarm was set at 40 and not 50. The answer was PI # 29 was alarming at 50 because he/she runs a low heart rate.

Review of all the physician's orders from 7/6/18 to 7/10/18 revealed no order for telemetry monitoring and no specific alarm parameters.

Review of telemetry monitor strips in PI # 29's chart from 7/6/18 to 7/9/18 revealed a HR range of 90 for the high documented on 7/8/18 at 6:00 PM to a low of 40 documented on 7/7/18 at 8:00 AM. There was no documentation on the strips that the nurse had reviewed the rhythm strips.

On 7/10/18 at 9:11 AM a medical record review was completed with EI # 11, 2 GI/GU Unit Manager, using the Workstation on Wheels.

Review of the nursing shift assessments revealed no documentation of PI # 29's heart rhythm in the cardiac assessment section.

EI # 11 was asked what the expectation was for the nursing assessment of patients on telemetry. EI # 11 stated there should be documentation of the heart rhythm with each shift assessment.

On 7/10/18 at 9:30 AM EI # 11 confirmed the nursing staff failed to assess and document the heart rhythm for patients on cardiac telemetry monitoring.
VIOLATION: CONTENT OF RECORD Tag No: A0449
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the medical record (MR), PHP (Partial hospitalization Program) Chart Audit Form and interview with staff, it was determined the facility failed to ensure the Clinical Therapist completed the PHP Biopsychosocial Assessment intake form, and accurately completed the PHP Interdisciplinary Care Plan, for 1 of 1 record reviewed with elopement and suicide. This had the potential to affect all patients served by the facility, and did affect Patient Identifier (PI) # 3.

Findings include:

PHP Chart Audit
Date Approved: None Listed

"...Treatment Plan:
Completed by physician: Date/Initials
Completed by therapist: Date/Initials...

Therapist:
Assessment Completed: Date/Initials
SRA (Suicide Risk Assessment) at admission: Date/Initials
Initial Certification: Date/Initials
Therapy Notes Dated and Signed: Date/Initials..."

*****

1. PI # 3 was admitted on [DATE] with diagnoses including Bipolar Disorder, and most recent episode Depressed.

Review of the MR revealed an intake appointment on 1/19/18.

Review of the PHP Biopsychosocial assessment dated [DATE] was completed by Employee Identifier (EI) # 15, Clinical Therapist. Demographic Information included: "60 yr (year) old seeking tx (treatment) for Depression, SI (Suicidal Ideations), and Anxiety."

Review of the assessment revealed no documented work history listed under category of Educational, Vocational, and Occupational History. Additional instructions listed on form: "Include highest education level completed, work history." PI # 3 is listed as retired on the Hospital Information page.

Further review of Page 2 of the assessment revealed the Mental Status Examination is left blank. Included in this section was Affect (Blunted, Flat, Labile, Restricted, Appropriate), Orientation (Person, Place, Time), Demeanor (Cooperative, Uncooperative, Optimistic, Pessimistic, Suspicious, Fearful, Other: ), Hallucinations ( None, Auditory, Visual, Olfactory, Somatic, Tactile), and Delusions (None, Grandiose, Of Reference, Somatic, Tactile, Thought Broadcasting, Thought Insertion).

Under the category of "Capacity for Self-Harm," EI # 15 documented "Yes. Pt (patient) verbally contracts for safety."

Under the category of "Deficits in Activities of Daily Living," EI # 15 documented "Pt not able to function due to worry (Anxiety, Depression, SI)."

Review of the PHP Interdisciplinary Care Plan dated 1/19/18, revealed EI # 15 drew a line threw "Safety: ...Thoughts of harm to self or suicidal ideation..." and did not include Safety in the Plan of Care. This contradicts above documentation by EI # 15.

An interview conducted on 7/10/18 at 9:30 AM with EI # 18, PHP Patient Relations Manager, confirmed the above findings.