HospitalInspections.org

Based on medical record review, review of the physician orientation manual, Hospital Policy and interview, the Hospital failed to have an effective governing body legally responsible for the conduct of the hospital.
Findings include:

The governing body failed to assure the quality of care for 1 (Patient #1) in a sample of ten patients.(Please refer to A131)

Based on medical record review, review of the physician orientation manual and Hospital Policy and interview, the governing body failed to assure the quality of care for 1 (Patient #1) in a sample of ten patients.

Patient #1 was determined to be a Full Code (in the event of a respiratory or cardiac arrest every possible measure will be used for resuscitation). Patient #1 was found without vital signs on 4/30/14 and no further resuscitation was provided.

1.) The Surveyor reviewed the Physician Progress Notes on 5/15/14. The Physician Progress Note, dated 4/29/14, indicated Patient #1 was a full code.

The Change of Condition Note, dated 4/30/14 at 2:56 A.M., indicated Patient #1 was extremely anxious and seen by the House Officer (Physician on-call). The Change of Condition Note indicated Patient #1 was alert and oriented and makes his/her own decisions.

The Change of Condition Note, dated 4/30/14 at 3:01 A.M., indicated Patient #1 was medicated with morphine (pain medication) and ativan (anti-anxiety medication).

The Nurses Notes, dated 4/30/14 at 8:07 A.M., indicated Patient #1's central line dressing was checked.

The Medication Administration Record, dated 4/30/14 at 10:34 A.M., indicated Patient #1 was medicated with his/her routine daily medications and administered a protein supplement using the feeding tube.

The Change of Condition Note, dated 4/30/14 at 11:37 A.M., indicated Patient #1 was pronounced [dead].

The Primary RN caring for Patient #1 was an agency nurse who no longer works at the hospital. The initial interview conducted by the Hospital, dated 5/1/14, indicated the Primary Nurse said during the medication administration, Patient #1 was alive. The Primary Nurse said he saw Patient #1 quite regularly because the pulse oximeters (a non-invasive method for monitoring a patient's O2 saturation) was alarming. The Primary Nurse said on the last occasion Patient #1 appeared dead and he called Staff Nurse #2 into Patient #1's room.

The Surveyor interviewed Staff Nurse #2 at 1:30 P.M. on 5/19/14. Staff Nurse #2 said he went into Patient #1's room at approximately 11:20 A.M. and attempted to get vital signs. Staff Nurse #2 said there were no vital signs, no heart sounds, and Patient #1's eyes were fixed. Staff Nurse #2 said he was not the primary nurse for Patient #1 and was not certain about Patient #1's current code status. Staff Nurse #2 said the Attending Physician entered Patient #1's room and gave no direction to code Patient #1.

The Surveyor interviewed the Attending Physician at 2:15 P.M. on 5/15/14. The Attending Physician said she had ordered full code status on Patient #1. The Attending Physician said Patient #1 was debilitated and experiencing a slow decline. The Attending Physician said Patient #1's full code status remained unchanged. The Attending Physician said she was stopped in the hallway and went to Patient #1's room where she had no doubt that Patient #1 was dead and she felt she would be resuscitating a dead person.

The Surveyor reviewed the Physician Orientation Manual on 5/19/14. The Orientation Manual indicated a Full Code (Category 1) patient would receive CPR (cardio-pulmonary resuscitation) and all life saving therapies.

The Surveyor reviewed the hospital policy titled Code Status Classification on 5/19/14. The policy indicated a Full Code patient would receive CPR in the event a patient's breathing or heart stopped.

Based on medical record review, review of the hospital policy and interviews, the hospital failed to ensure that a non-licensed nurse adhered to the hospital policy.

Patient #1 was ordered on 3/11/14 by the Attending Physician to be a Full Code (in the event of a respiratory or cardiac arrest every possible measure will be used for resuscitation). Patient #1 was found without vital signs on 4/30/14 and no further resuscitation was provided.

The Surveyor interview the Chief Clinical Officer (CCO) at 8:45 A.M. on 5/15/14. The CCO said Patient #1's primary nurse on 4/30/14 was an agency nurse.

The Primary RN caring for Patient #1 was an agency nurse who no longer works at the hospital. The initial interview conducted by the Hospital, dated 5/1/14, indicated the Primary Nurse said during the medication administration, Patient #1 was alive. The Primary Nurse said he saw Patient #1 quite regularly because the pulse oximeters (a non-invasive method for monitoring a patient's O2 saturation) was alarming. The Primary Nurse said on the last occasion Patient #1 appeared dead and he called Staff Nurse #2 into Patient #1's room.

The Surveyor interviewed Staff Nurse #2 at 1:30 P.M. on 5/19/14. Staff Nurse #2 said he went into Patient #1's room at approximately 11:20 A.M. and attempted to get vital signs. Staff Nurse #2 said there were no vital signs, no heart sounds, and Patient #1's eyes were fixed. Staff Nurse #2 could not remember if the pulse oximetry monitor was alarming. Staff Nurse #2 said he was not the primary nurse for Patient #1 and was not certain about Patient #1's current code status. Staff Nurse #2 said the primary nurse was at the bedside and did not call a code or a rapid response.

The Surveyor reviewed the hospital policy titled Code Status Classification on 5/19/14. The policy indicated a Full Code patient would receive CPR in the event a patient's breathing or heart stopped.