The Centers for Medicare and Medicaid Services (CMS) determined Old Vineyard Behavioral Health posed immediate jeopardy to patients’ health and safety when nursing staff failed to supervise and assess a patient with a medical emergency. A 47-year-old patient had a seizure, began vomiting, and complained his head felt like it was going to explode. A mental health worker repeatedly approached the nurses’ station for assistance, but help did not arrive until 14 minutes later. Additionally, there was no documentation of an assessment of the patient during or after the seizure, and patient was not placed on seizure precautions following the event. A mental health worker had complained to the CEO and director of clinical services about the care provided, yet there was no investigation into the incident. The director “didn’t see a cause for concern with the care that she observed … .”
The facility’s nursing staff was also found to be incompetent in the use of the hospital’s emergency equipment. When instructed to administer oxygen, a nurse fumbled with the tank for 9 minutes. She remarked, “I can’t give oxygen from this.” The nurse had connected the oxygen tubing to a port on the side of the tank, rather than the port at the back where oxygen flows.