HospitalInspections.org

Based on document review and interviews, the hospital identified the cause of Patient #1's adverse event and subsequent death. However, the hospital failed to analyze that cause, and thus failed to implement corrective actions to prevent the possibility of a like event from re-occurrence.

See tag 0286.

Based on document review and interviews, the hospital failed to ensure that all nurses are adhering to the policies and procedures of the hospital.

See tag 0398.

Based on document review and interviews, the hospital identified the cause of Patient #1's adverse event and subsequent death. However, the hospital failed to analyze that cause, and thus failed to implement corrective actions to prevent the possibility of a like event from re-occurrence.

Findings include:

The PK (pulmonary) progress note of Patient #1, dated 02/19/2021, stated "ensure restraints at all times. has experienced multiple cardiac arrest from self-extubation." (self-extubation is a process where the patient removes their own endotracheal/tracheostomy tube (a tracheostomy tube is a device that allows air to travel from a ventilator (machine that mechanically pumps oxygen into your lungs) directly to the person's trachea (windpipe))).

The restraint order document of Patient #1, dated 02/19/2021 indicated that Patient #1 was under two-point soft limb right and left arm restraint and reasons for restraint use included "pulling at tubing/dressing," "unable to follow safety instructions," and "preventing disruption of life sustaining interventions."

The patient care note of Nurse #1, dated 02/20/2021 at 6:45 A.M. stated that at 6:02 A.M., Patient #1's ventilator alarm was going off. As Nurse #1 entered the room, Nurse #1 noted that Patient #1 was disconnected from the ventilator. Nurse #1 was unable to obtain a pulse. At 6:04 A.M., an RRT (rapid response team) was called. Pulse re-checked, no pulse and asystole (cardiac arrest). Chest compressions started at 6:06 A.M. until Do Not Resuscitate (DNR) code status was confirmed. Provider verified code status with health care proxy (agent who can make health care decisions on behalf of Patient #1) and Patient #1 subsequently passed at 6:14 A.M.

The surveyor interviewed the respiratory therapist on 04/29/2021 at 1:00 P.M. The respiratory therapist said that Nurse #1 told the respiratory therapist that Nurse #1 found Patient #1 disconnected from the ventilator at the tracheostomy area.

The surveyor interviewed the quality director and chief clinical officer on 04/27/2021 at 12:55 P.M. The chief clinical officer stated that staff verified that the restraints on Patient #1 were intact, and that the hospital did not identify any issues with the restraint process regarding Patient #1.

The Root Cause Analysis did not identify that the hospital's process for preventing Patient #1's self-disconnection of the ventilator from Patient #1's tracheostomy tube through the use of restraints (as indicated as the intention for restraints ordered on 02/19) failed.

The Root Cause Analysis, under Question 9, reviewing whether staff were properly qualified and currently competent for their responsibilities? The hospital organization response was that "registered nurses and respiratory therapist current with licenses and competencies."

The document titled Competency/Demonstration: Restraints, for Nurse #1 was blank. Nurse #1 failed to have the restraint competency/demonstration signed off by a manager/director who would identify in the comments section of the document "that this employee has been verified as competent as indicated in this checklist."

The document titled Fast Track Orientation Checklist (a list of topics to be reviewed and for employees to have been in-serviced for) for Nurse #1, also identifies a missing checkmark along the topic, Restraint Competency. The entire Fast Track Orientation Checklist for Nurse #1 is also missing a signature/sign-off from the orientation leader.

Based on document review and interviews, the hospital failed to ensure that all nurses are adhering to the policies and procedures of the hospital.

Findings include:

The policy titled Restraint Use - Nursing, last reviewed 01/2021, states that clinical staff will receive orientation and ongoing training related to the use of restraints. Training will take place during orientation and annually as indicated in the Vibra Education Plan.

The surveyor reviewed restraint training using a sample of eight nurses. Three of the eight nurses did not receive restraint training within the past year, with all three nurses having had their last restraint training/competency on file conducted greater than two years ago.

The surveyor reviewed the personnel file of Nurse #1 who was overseeing the care of Patient #1 who was in restraints at the time of death. The document titled Competency/Demonstration: Restraints for Nurse #1 was blank. Nurse #1 failed to have the restraint competency/demonstration signed off by a manager/director which identifies in the comments section of the document that "this employee has been verified as competent as indicated in this checklist."

The document titled Fast Track Orientation Checklist (a list of topics to be reviewed and for employees to have been in-serviced for) for Nurse #1, also identifies a missing checkmark along the topic, Restraint Competency. The entire Fast Track Orientation Checklist for Nurse #1 is also missing a signature/sign-off from the orientation leader.

The patient care notes of Patient #2, documented by Nurse #2 on 01/12/21 at 1:21 A.M., indicated that Patient #2's pulse rapidly declined until Patient #2 became pulseless and unresponsive.

The document titled Rapid Response Team Care Record, dated 01/12/2021, stated that at 01/12/21 at 1:21 A.M. Patient #2 became unresponsive, heart rate declining from 62 to 43 to no pulse. CPR (cardiopulmonary resuscitation) initiated and RRT (rapid response team) called.

The patient care notes of Patient #2, documented by the respiratory therapist on 01/12/21 at 6:32 A.M. indicated that Patient #2 had return of spontaneous circulation (ROSC) after 9 minutes of CPR and that Patient #2 was transferred out to an outside facility for further evaluation.

The policy titled Plan for Provision of Care - Nursing indicates that on page 17, "All RNs, RTs and Registered Pharmacists maintain BLS and ACLS certification." (Basic Life Support and Advanced Cardiovascular Life Support). On page 21 it further states, "Within the department of nursing, registered nurses, licensed practical nurses, and nursing assitants deliver care. All are certified in BLS."

The document titled 90-day introductory period performance evaluation for Nurse #2, under supervisor's comments indicated that Nurse #2 does not have a current BLS or ACLS on file (evaluation date 02/10/2021).

Nurse #2's file indicated that the previous BLS certificate was issued on 07/29/2018 with a recommended renewal date on 07/2020. The subsequent BLS on file was a BLS certificate issued on 03/25/2021.

The meeting minutes titled Critical Care Meeting, dated 04/20/2021 page 3, indicated BLS/ACLS compliance, states that 77.2% on file for BLS.

The surveyor interviewed the nursing director on 05/03/2021 at 1:15 P.M. The nursing director stated that ideally, the BLS training should be at 100%.