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.


Based on record review and interviews the facility failed to ensure 1 patient (#2) out of 10 patients reviewed, received necessary services while a patient in the facility in conjunction with the Condition of Participation: CFR 482.23 Nursing Services. Findings:

Specifically,the facility failed to:

Ensure patient #2, with known respiratory conditions was monitored during sleep, while a patient in the Psychiatric Emergency Department. In addition the facility failed to: 1) assess a patient with multiple known respiratory conditions; 2) provide medical equipment this patient needed while asleep and 3) properly document the patient's respiratory efforts. This failure caused the patient harm and potentially contributed to the patient's demise. Reference at tag A 395.



Based on record review and interview the facility failed to ensure a process was in place for the assessment, monitoring and documentation of the respiratory condition for 1 patient (#2), out of 10 patients whose records were reviewed. Specifically, the facility failed to: 1) assess respiratory equipment needs; and 2) monitor and document respiratory status in accordance to standards of practice. These failed processes placed patient #2 at risk for harm and were potentially causative factors towards the development of respiratory distress which ultimately contributed to patient #2's demise. In addition, these failed practices had the potential to harm all patients that received care at the facility. Findings:

During a complaint investigation electronic medical record (EMR) review at the facility on 2/19-20/19 revealed Patient #2 died in the Psychiatric Emergency Department (PED) on 11/2/18 at 3:38 am.

Review of the "Code Blue [a term used to indicate that a patient is experiencing cardiopulmonary arrest and needs immediate resuscitation] Note" dated 11/2/18 3:56 am, dictated by MD #2 revealed "...Of note, psych ED nursing staff report that the patient had been having some "raspy" breathing earlier ..." Further review of this document revealed, "...Shortly after conclusion of the code, two of the patients daughters arrived in the emergency department. I spoke with (the) in the family room in the presence of the house supervisor, [name], and chaplain [name]. They are understandably very emotional, stating that 'you guys must have messed up somehow,' ..."

Review on 2/19-20/19 of Patient #2's EMR document titled "Suicide/Violence Risk Assessment" dated 11/1/18 at 7:48 am, from Psychiatry Medical Social Worker (PMSW) #1, revealed Patient #2 was admitted to the facility's PED for on 11/1/18 with the complaint of "Suicidal Ideation" and Past Medical history that included 1) chronic lung disease; 2) Sleep Apnea - severe, supposed to be on CPAP (Continuous Positive Airway Pressure - air pressure machine delivered by mask to treat Sleep Apnea [a disorder when a person's breathing is interrupted during sleep]); 3) hypercapnic respiratory failure [a group of symptoms which cause the respiratory system to fail in its two main functions, intake of oxygen into the body and release of carbon dioxide outside the lungs]; and 4) obesity hyperventilatio[DIAGNOSES REDACTED] [a breathing disorder that causes too much carbon dioxide and too little oxygen in your blood-without treatment it can lead to serious even life threatening health problem]. Further review of the document stated, "Plan: Patient to be placed into psychiatric observation, Patient to be monitored for her sleep and safety..."

Review of the "ED (Emergency Department) Provider Notes" from Physician (MD) #1 dated 11/1/18 at 8:30 am, revealed "Past Medical History diagnosis chronic lung disease, sleep apnea-severe supposed to be on CPAP, hypercapnic respiratory failure, Obesity hyperventilatio[DIAGNOSES REDACTED] ... Course & Medical Decision Making ...The pulse oximeter was 97%on room air which is normal for the patient ...The patient was admitted to psychiatric observation for further care and evaluation ..." Further review of the provider note revealed no request for a respiratory evaluation or CPAP machine for patient #2.

Review of the Patient Care Timeline dated (11/1/2018 06:54 to 11/2/2018 03:38) revealed:

" 11/1/18 21:15 Vital Signs "Resp (respiration): 18; SpO2 (an estimate of oxygen in the blood) 98%; O2 Device: room air" by Certified Nurse Assistant (CNA) #1;
" 11/1/18 23:15 ED Notes "Pt has a slightly swollen tongue, pt able to breath[e], pt snoring in her room. RR [respiratory rate] at 18." by LN #1;
" 11/2/18 00:00 ED Quick Note "Note: patient is resting comfortably" by Licensed Nurse (LN) #1;
" 11/2/18 00:30 Continuous Visual Observ "Patient Observation: Asleep" by Mental Health Specialist (MHS) #1;
" 11/2/18 01:00 Continuous Visual Observ "Patient Observation: Asleep" by CNA #1;
" 11/2/18 01:30 Continuous Visual Observ "Patient Observation: Asleep" by MHS #1;
" 11/2/18 02:00 Ed Quick Note "Note: patient is resting comfortably" by LN #1;
" 11/2/18 02:00 Continuous Visual Observ "Patient Observation: Asleep" by MHS #1;
" 11/2/18 03:16 ED Notes "This Registered Nurse (RN) went to round on the pt. Pt. found in room, not breathing, no pulse, attempted to rouse pt, tapping, sternal rub done, code called on pt, ED staff responded. CPR started. See code sheet for further events." By LN #1;
" 11/2/18 03:38 Code Outcome "Survival: NO Code Termination Due to: Medical Futility." By LN #2.

Further record review revealed no documentation of any assessments regarding the need for a CPAP machine for severe sleep apnea. In addition, there were no documentation entries of SpO2 checks during sleep or documentation of the rate or description of respirations while the Patient #2 was asleep.

During an interview on 2/20/19 at 12:20 pm, with the Psychiatric Emergency Department Assistant Manager (PEDAM) was asked about the documentation in Patient #2's medical record stating "asleep" and/or "patient is resting comfortably". The PEDAM said he/she would expect in the details to see the nurse describing the respirations (breathing), showing the patient was observed to be breathing at a certain rate and description (i.e. unlabored, labored, or sonorous). When asked if the staff observe the patient from outside the room through the window or go into the room, the PEDAM stated that can't be known by the documentation in the EMR.

During an interview on 2/20/19 at 4 pm, with emergency room Nurse (ERN) #1 was asked what he/she would expect with documentation of patients respirations. The ERN stated he/she would expect a description of the patients breathing, (what it looked like).

On 3/6/19 at 12:30 pm, a return call was received from Patient #2's family member. When asked if Patient #2 used any special equipment when sleeping, the family member replied his/her parent (Patient #2) used a CPAP when sleeping at home. The family member further disclosed when at (another facility name) the family was asked to bring the machine to the facility for Patient #2 to use.

Review of the facility's policy, titled "Assessment/Re-Assessment of Patients," revised 12/2017, revealed "...This assessment begins at the time of admission and continues throughout the patient's contact with PAMC ... Assessment includes the collection and analysis of relevant physiological, social/environmental data regarding each patient. This process is utilized to determine the need for additional information; the patient's care needs, priorities and the plan of care required for diagnosis and treatment of the patient."