The Centers for Medicare and Medicaid Services (CMS) found that Glen Oaks Hospital placed patients in immediate jeopardy. CMS found deficiencies with the facility’s governing body and nursing services, as well as its ability to promote and protect patient rights. CMS determined that these deficiencies “pose[d] an immediate jeopardy to patient’s health and safety and placed all patients at risk of potential harm, serious injury, and subsequent death.”
In one incident, a patient was admitted on 11/15/2012 and was noted as “a high risk for fall.” A few weeks later, the patient was found on the bathroom floor after an unobserved fall. There was no record of the patient being assessed for injuries after the fall, no evidence that a physician was notified of the fall, or any evidence that the patient was assessed after she complained of “feeling bad.” After more than 7 hours with no documentation, nurse notes indicate 7 pills suspected of being Norco, a narcotic painkiller, were found in the patient’s room. Following the discovery of these pills, patient’s vitals were taken and staff “failed to recognize the gravity of 80/43” blood pressure. There was no evidence of physician notification. Six hours later, the patient was unresponsive, had difficulty breathing and her skin was cold to touch — 911 was called. Patient was admitted to the acute care hospital for pneumonia and sepsis; physician notes indicate her condition improved after receiving medication to reverse sedation. She died 5 days later, the final diagnosis included multiorgan failure and sepsis.
Another patient, admitted on 12/13/2012, was noted to be suffering from sleep apnea. Four days after admission, records indicate that the family was notified that they would need to provide a Continuous Positive Airway Pressure (CPAP) machine to aid the patient’s sleep. There was no documentation of assessment of the patient’s sleep apnea or respiratory status while hospitalized. On 12/17/2012, nursing documentation reveals patient reported suffering a fall; he was helped into bed and notes indicate he was snoring at 11PM. Less than four hours later, patient was found unresponsive and not breathing in his room; 911 was called. CPR was started. EMTs arrived and recommended stopping CPR; patient was declared dead. CMS found no documentation that nursing staff notified the on-call physician or that a physician participated in the resuscitation attempts. When asked by CMS whether there was physician awareness or participation by a physician, the facility Director of Nursing did not provide a response.
In another incident, physician written orders on 09/20/2012 direct “fall precautions” to be taken for a patient. On 09/22/2012, the patient chart indicates the patient had suffered a fall in the shower; nursing notes from 09/19 through 09/22 were blank for “Risk of Fall” precautions. In an interview by CMS, the patient reported the shower safety chair had slipped because there were no rubber grips and the shower was missing non-slip strips. She was forced to scream for help and when help arrived no one covered her, “she was left nude laying [on] the floor and very embarrassed” while a male employee was asked to provide assistance. She was not sent for x-ray evaluation for 2 days.