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Based on review of Governing Body Bylaws, review of facility policy and procedures, review of facility documents and interviews with staff, it was determined the Governing Body failed to have policies and procedures in place that ensured staff responded in a timely manner to medical emergencies (MR1) and provided medical interventions in accordance with applicable Federal, State, and local laws and regulations.

Findings include:

The review of "LifeCare Hospitals of Mechanicsburg, LLC Governing Board Bylaws revealed "...4.3 Duties and Responsibilities The Governing Board shall have the following duties and responsibilities:...B. Assure that the Medical Staff is organized and able to carry out all regulatory and Joint Commission on Accreditation of Healthcare Organizations("JCAHO) required functions...V. Take all reasonable steps to confirm to all applicable federal, state, and local laws and regulations..."

A review of the "Medical-Surgical/CPU Admission Orders" for MR1 revealed "...Cardiac Monitoring/Pulse Oximetry: Telemetry - Cardiac Monitoring (had an x in the box)...
The review of the "Physician Order Form _Resuscitation/Do Not Resuscitate" revealed "... A. Full Code Unless other wise stated, all patients admitted to the hospital are considered as Full Code status, and will receive CPR and ALL appropriate life sustaining therapies including ventilator support... The form was signed by the physician and dated and timed; June 2, 2018 6 PM.

A review of the "Nurses Notes" revealed the following: "June 08, 2018, 0130 Pt resting in bed...No distress noted. " "@0228 Pt found by tech lying sideways on bed with legs hanging off the side-tech alerted this nurse, pt was pale, no pulse and no response. Code Blue called.
"@ 0231 CPR was started on pt, Pt was hooked up to defibrillator. @0233 we pushed epi 1 mg and continued CPR, shock was given @ 0237, CPR resumed, @ 0238 epi 1 mg was given CPR 2 0243 1 mg Epi given and shock was given @ 0244. Blood sugar was checked and 166. 911 called, family was called Dr was called, pt family agreed to intubation of pt. Pt was intubated at 0255 by EMT, pt went into Torresdale heart rhythm and 1 gm mag given @0300. Pt left via ambulance @ 0303..."
An interview conducted on June 12, 2018, with EMP1 revealed after reviewing the monitor system and pulling the data from that night, the patient was off (the monitor leads were not sending a signal to the monitor) the monitor for approximately 45 minutes. Further interview revealed that staff whose responsibility it was to monitor the alarms told 2 nurses that MR1's telemetry unit needed to be checked. Neither nurse went to check the patient and 45 minutes after the alarm began to sound, another staff found the patient unresponsive. The patient died that evening less than 1 hour after being taken to the hospital.

A review of facility policy revealed that the facility did not have nursing policy that addressed patient rounding.

A review of policy revealed that nursing staff was not following facility policy related to administration of medications. Review of the medical records revealed that medications were adminstered without providers orders.

An interview conducted on June 13, 2018 at 2:00PM with EMP2 confirmed that the patients received medication adminstered by the nursing staff and that the medical records did not contain physician's orders for the medications.



Cross reference:

482.12(a)A(5) Medical Staff -Accountability
482.12(f)(2)Emergency Services
482.23(c)(1),(c)(1)(i)&(c)(2)Administration of Drugs

Based on review of facility documents, medical records, and staff interview, it was determined the facility failed to ensure medical services were available for patients in need of emergency services for 4 out of 15 medical records reviewed (MR1, MR7, MR13, and MR14).

Findings include:

A review of MR1 revealed that on June 8, 2018, the patient stopped breathing and required resuscitation. The patient received Epinephrine (a hormone, neurotransmitter, and medication) and Mag 1 gm. (magnesium sulfate 1 gram used in the treatment of Torsades de pointes) as part of the resuscitation. Further review revealed that there were no physician orders for the medications and a physician was not present for the code.

A review of MR7 revealed the patient had a cardiopulmonary event on May 16, 2017, and received 1 amp (Ampule) of Epinephrine 1 mg. Further review of the medical record revealed there were no physician's orders for the medication and a physician was not present during the event.

A review of MR13 revealed the patient had a cardiopulmonary event on June 26, 2017, at 5:17 PM. The review of the documentation revealed the patient received 3 amps of Epinephrine 1 mg. Further review of the medical record revealed there were no physician's orders for the medication and a physician was not present during the event.

A review of MR14 revealed the patient had a cardiopulmonary event on January 14, 2017 and received 1 amp of Epinephrine 1 mg. Further review of the medical record revealed there were no physician's orders for the medication and a provider was not present during the event.

An interview conducted on June 13, 2018 at 2:00PM with EMP2 confirmed that the patients received medication adminstered by the Nursing Staff and that there was no physician's orders for the medications.

Based on review of facility documentation and interview with staff revealed the facility was not in compliance with 482.13(e)(2) which indicated that Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective and to protect the patient, a staff member, or others from harm (MR3).

A review of facility policy "Restraints" revised June 2016, revealed "...Purpose:...To provide guidelines for the safe use of restraints...D. Guidelines 1. Alternatives to Restraints: a. Preventative strategies and alternatives to restraints must be implemented prior to utilizing restraints unless an immediate safety risk is present for the patient, staff, or others..7. Appropriate Documentation and Reporting a. Each episode of restraint usage will be documented in the patient's medical record and include the following...3. Alternative methods attempted prior to restraints...

A review of medical records revealed staff used a restraint on MR3 on June 6, 2018. The review of the medical record did not reveal documentation of the alternatives attempted prior to the initiation of the restraints

An interview conducted on June 12, 2018, at 4:10 PM with EMP6 confirmed that the medical record did not contain documentation of alternatives being attempted prior to the initiation of restraints.

Based on review of facility policy and procedures and interview with staff (EMP), it was determined the facility failed to ensure adopted policies and procedures were followed for administration of medications for four of 15 medical records reviewed (MR 1, MR7, MR13 and MR14).

Findings include:

A review of facility policy "Orders for Medication or Treatment", revised January 2018, revealed "...Policy: Orders for patient treatment and medication may be carried out only when given by a qualified person duly authorized to prescribe by the State where the hospital is located, and who has been approved to perform this function by the medical staff of this Hospital...E. Medication Orders: Definition: Medication , as defined by the Joint Commission on Accreditation of Healthcare Organizations, is any"prescription medications, sample medications, herbal remedies, nutraceuticals, over-the-counter drugs, vaccines, diagnostic and contrast agents used on or administered to persons...1. All orders for the administration of drugs and biologicals must include at least the following:...i. Signature of the prescriber and/or name if verbal or telephone order..."

A review of MR1 revealed that on June 8, 2018, the patient had stopped breathing and required resuscitation. The patient received Epinephrine (a hormone, neurotransmitter, and medication) and Mag 1 gm. (magnesium sulfate 1 gram used in the treatment of Torsades de pointes) as part of the resuscitation. Further review did not reveal there were physician orders for the medications nor was the physician present.

A review of MR7 revealed the patient had a cardiopulmonary event on May 16, 2017 and received 1 amp (Ampule) of Epinephrine 1 mg. Further review of the medical record did not reveal any physician's orders for the medication, who administered the medications, nor was the physician present.

A review of MR13 revealed the patient had a cardiopulmonary event on June 26, 2017, at 5:17 PM. A review of the documentation revealed the patient received 3 amps of Epinephrine 1 mg. Further review of the medical record did not reveal there were physician's orders for the medication, who administered the medications, or that a provider was present during the event.

A review of MR14 revealed the patient had a cardiopulmonary event on January 14, 2017, and received 1 amp of Epinephrine 1 mg. Further review of the medical record did not reveal there were physician's orders for the medication, who administered the medications, or that a provider was present during the event.

An interview conducted on June 13, 2018, at 2:00PM with EMP2 confirmed that the patients received medication adminstered by the nursing staff and that the medical records did not contain physician's orders for the medications. The medical record would not have physicians' orders as all the Nursing Staff have ACLS (Advanced cardiac life support) and use ACLS protocols. The staff would not need physician orders. When asked for a copy of the ACLS protocol, EMP2 provided the ACLS book and said that the staff could look in the book to find information that would help them with the code.