HospitalInspections.org

Based on policy review, document review and interview, the facility failed to follow its policy and report to the appropriate state agency an incident of neglect.

The findings included:

1. Review of the facility's "Allegations of Abuse/Neglect" policy revealed, "...RESPONSIBILITY...Hospital staff will take all necessary steps to ensure that patients are kept safe from abuse/neglect and that allegations of abuse/neglect by employees or visitors are investigated promptly, thoroughly, and reported to the proper authorities as necessary...The appropriate state and licensure agencies should be notified..."

2. Review of the facility's investigation and action plan for an incident that occurred on 10/11/2020, revealed Registered Nurse (RN) #1 did not provide interventions or recheck a critically low blood pressure (91/34) for Patient #1 at 1:17 AM on the morning of 10/11/2020. Patient #1 was found unresponsive at 4:10 AM and Cardiopulmonary Resuscitation (CPR) was initiated. Patient #1 was pronounced deceased at 5:15 AM on 10/11/2020. The facility found RN #1 to be negligent due to not addressing Patient #1's low blood pressure at 1:17 AM on 10/11/2020.

3. In an interview with the Quality Director (QD) on 5/27/2021 at 1:45 PM, the QD verified the incident was not reported to the office of Healthcare Facilities. The QD stated they reported the incident to "the Board" (Office of Board Investigations) but did not know they needed to report it to the office of Healthcare Facilities.