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.

REHOBOTH MCKINLEY CHRISTIAN HEALTH CARE SERVICES 1901 RED ROCK DRIVE GALLUP, NM 87301 Sept. 3, 2020
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review and interview, the facility failed to ensure that patients are free from all forms of abuse in 1 (P#1) of 11 patients reviewed by not having adequate staff in the ICU (Intensive Care Unit). This deficient practice is likely to expose patients to serious physical harm including death. Findings are:

A. On 8/28/20 at 10:30am during interview with S#3 (ICU Director), she confirmed that the ICU on 8/23/20 had 2 RN's (Registered Nurses), 1 tech, and 1 monitor tech (tech that monitor patients on cardiac monitoring on all unit of the hospital) assigned to work the unit.

B. On 8/28/20 at 10:30am during interview with S#3 (ICU Director), she confirmed that on 8/23/20 the ICU had 6 patients on the unit, 2 of the 6-patient's acuity (level of care required) required one on one nursing care, the other 4 patients acuity required two to one nursing care.

C. Record review of "Status List for Location: Intensive Care Unit" dated 8/23/20 revealed 6 patients assigned to the ICU with 2 of the 6 patients acuity requiring one to one nursing care and 4 of the 6 patients acuity requiring two to one nursing care.

D. On 8/28/20 at 9:30am during interview with S#8 (Monitor Tech), confirmed that she noted that P#1's cardiac monitor showed no rhythm at about 2:17pm. S#8 (Monitor Tech) stated, "There was no one on the floor and I cannot leave the monitor station."

E. On 9/3/20 at 11:00am during interview with S#9 (Registered Nurse), she confirmed that at around 2:15pm on 8/23/20 she was in room #7 with the other RN assisting a patient until about 2:55pm.

F. On 8/31/20 at 9:19am during interview with S#10 (House Supervisor), she confirmed that on 8/23/20 at about 2:17pm she was assisting staff in the ICU and was in a patients' room until about 2:55pm.

G. On 8/28/20 at 9:30am during interview with S#8 (Monitor Tech), confirmed that the primary RN (Registered Nurse) for P#1 was in another patients' room assisting the patient with the other RN on duty, the house supervisor was on the unit in another patients' room and the tech assigned to the unit was in another patients' room.

H. Record review of "Resuscitation Flow Sheet" date 8/23/20 at 3:00pm, revealed that P#1 had a cardiac rhythm of Asystole (No electrical impulses) at 2:57pm, chest compressions started at 3:00pm, Intubation (tube place down the throat of patient to assist with breathing) attempted at 3:04pm. Recorded no pulse at 3:09pm, provided electrical shock at 3:10pm continued chest compressions, checked pulse at 3:12pm with no pulse, checked pulse at 3:15 with no pulse, at 3:18pm check pulse with no pulse and stopped chest compressions and patient was pronounced dead.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on record review and interview, the facility failed to ensure there was adequate staffing for 6 of 6 patients in the ICU (Intensive Care Unit) on 08/23/20. This deficient practice is likely to not provide the immediate availability of a registered nurse to care for the patients on the unit. Findings are:

A. On 8/28/20 at 9:00am during interview with S#1 (Quality Director), she confirmed that the time line on the report of the incident on 8/23/20 to the State of New Mexico indicated that the time between the monitor tech noting P#1's cardiac monitor not identifying a cardiac rhythm (electrical impulses in the heart) and the time staff entered P#1's room was 38 minutes.

B. Record review of an email from S#1 (Quality Director) to S#5 (Medical Director), S#6 (Chief Executive Officer) and S#7 (Governing Board Member) dated 8/23/20 at 10:08pm, revealed at 2:17pm on 8/23/20 P#1's monitor alarms sounded and at 2:55pm the tech entered P#1's room and found the patient with no pulse and no respirations.

C. On 8/28/20 at 10:30am during interview with S#3 (ICU Director), she confirmed that the ICU on 8/23/20 had 2 RN's (Registered Nurses), 1 tech, and 1 monitor tech (tech that monitor patients on cardiac monitoring on all unit of the hospital) assigned to work the unit.

D. On 8/28/20 at 10:30am during interview with S#3 (ICU Director), she confirmed that on 8/23/20 the ICU had 6 patients on the unit, 2 of the 6 patient's acuity (level of care require) required one on one nursing care, the other 4 patients acuity required two to one nursing care.

E. On 8/28/20 at 9:30am during interview with S#8 (Monitor Tech), confirmed that she noted that P#1's cardiac monitor showed no rhythm at about 2:17pm and that the primary RN (Registered Nurse) for P#1 was in another patients' room assisting the patient with the other RN on duty, the house supervisor was on the unit in another patients' room and the tech assigned to the unit was in another patients' room. "There was no one on the floor and I cannot leave the monitor station."

F. On 8/31/20 at 9:19am during interview with S#10 (House Supervisor), she confirmed that on 8/23/20 at about 2:17pm she was assisting staff in the ICU and was in a patients' room until about 2:55pm. S#10 stated that she noted that P#1 was sitting up but did not go into the room, then the tech went into P#1's room and short after that called out for help and a code blue was called overhead.

G. On 9/3/20 at 11:00am during interview with S#9 (Registered Nurse), she confirmed at about 2:15pm on 8/23/20 she was in room #7 with the other RN assisting a patient that arrived on the unit and was being combative with the staff. S#9 stated that she placed P#1 in the prone position (laying on his stomach) at about 2:00 pm, then she was called to room #7.

H. Record review of "Resuscitation Flow Sheet" date 8/23/20 at 3:00pm, revealed that P#1 had a cardiac rhythm of Asystole (No electrical impulses) at 2:57pm, chest compressions started at 3:00pm, Intubation (tube place down the throat of patient to assist with breathing) attempted at 3:04pm, Recorded no pulse at 3:09pm, provided electrical shock at 3:10pm continued chest compressions, checked pulse at 3:12pm with no pulse, checked pulse at 3:15 with no pulse, at 3:18pm check pulse with no pulse and stopped chest compressions and patient was pronounced dead.