HospitalInspections.org

Based on record review and interview, facility failed to supervise and evaluate the nursing care for patient ID# 1.

Findings:

1. Review of Patient ID# 1 medical record revealed that patient was on suicide precaution. Facility ' s policy and procedure titled " Suicide/Safety Precaution " dated 10/02/12 requires that patients on suicide precautionary rounds or every 15 minutes observation checks are monitored at least every 15 minutes with notations documented on the Nursing Observation Record.

Review of Patient Observation Sheet showed that the patient was last checked at 5:15am. The Mental Health Technician (MHT) noted on the form " Observed patient sleeping comfortably with unlabored respiration " every 15 minute from 12:01am-5:15am.

Review of video recordings on 3/119/13 showed that patient was visible and active on the unit, between 6:26pm and 9:47pm, patient was seen moving around on the unit in his wheelchair, talking with peers and frequently at the nursing station talking with staff. At 9:50pm, patient went to his room and Staff ID# 2 made observation round on all patients at 9:55pm. Observational checks were made by MHT at 12:00am, 1:30am, and 2:15am. At 6:10am, patient was found unresponsive. Video recording reviewed with the Operations Manager.

Interview with the CEO in the conference room, he stated that the facility investigated the incident; the MHT who failed to make observational rounds as required was terminated. He also added that nurses are required to do rounds at the beginning of the shift and the task is then delegated to MHTs. During the interview with Staff ID# 2 in the conference room, she was asked how she ensured that MHTs made observational rounds, she stated " I expect that they know what they do and they will do it. "

2. Review of Patient ID# 1 vital signs record revealed that patient showed frequent drop in blood pressure requiring withholding his medications but the physician was not notified.

Medication Administration Record (MAR) revealed medications were held on the following dates:

? On 3/14/13, patient ' s bedtime medications: Lyrica 75mg, Ambien 10mg, Xanax 0.5mg, Elavil 300mg, Carvedilol 6.25mg, Clonazepam 0.5mg, and Atripla 1 tablet were held for sedation and BP (91/62). There was no parameter to hold medications, and physician was not notified.
? 3/15/13: Ambien 10mg at 9pm, and Carvedilol 6.25mg at 9pm, BP was 83/62.
? 3/16/13: Restoril 30mg at bedtime. Ambien 10mg at bedtime.
? 3/17/13: Restoril 30mg at bedtime.
? 3/18/13: Restoril 30mg at bedtime.
? On 3/19/13, Oxycodone 15mg at 6:00am was held, BP 90/55. Xanax 0.5mg at 6:00pm, Clonazepam 0.5mg at 6:00pm, Carvedilol 6.25mg at 9:00pm, and Restoril 30mg at 9:00pm were held. Patient ' s BP at 7:00pm was 74/55.

Interview with Staff ID #s 2 & 14 in the conference room, both stated that nurses held the patient ID# 1 ' s medications due to low BP and/or sedation, but the information was not communicated to the physician. Staff ID #s 8 & 9 also stated during interview that they were not notified of patient ' s repeated low BP.

Interview with the Nurse Manager on 3/27/13 at 2:30pm in the conference room, he stated that the doctor should have been notified that patient had low BP and his medications were held