In November, CMS placed a Penn Medicine hospital in immediate jeopardy for five hours after a possible preventable death. The corrections were published in late February.
Footage from the Philadelphia-based system’s Cedar Avenue location shows a behavioral health patient falling and delayed chest compressions on Nov. 3, according to a CMS report. Upon admission, the patient refused vital signs and “would not engage with staff when they encouraged her to sit down in [the] kitchen or dayroom,” the report said.
Upon arrival at the hospital, the patient was leaning between the wall and a walker, and at about 9 p.m., she fell to the ground and did not move. Two nurses straightened her out, but a pulse could not be found. A crash cart, vital sign machine and nurse supervisor then arrived.
About seven minutes after she fell, a rapid response nurse began compressions. A defibrillator pad and ambu bag were used. Resuscitation ended at about 9:26 p.m., and the patient was transferred to the morgue by 10 p.m.
A CMS assessment revealed the facility did not have policies for post-fall assessments and assessment of patient’s vital signs during admission. One of the nurses on the scene was also unsure how to call a code and left the patient to grab a computer.
“Failure to immediately assess the patient and provide rapid emergency response may [have] contributed to the patient’s death,” CMS’ report said.
Cedar Avenue — a campus about 2 miles away from the system’s flagship hospital — was cited for deficiencies in patient rights, care in a safe setting, nursing services, organization of nursing services and supervision of contract staff. Cedar Avenue offers emergency, inpatient and behavioral health services, according to its website.
The hospital submitted its correction plan less than five hours after the immediate jeopardy was issued, and CMS and the state’s health department approved the plan. On Feb. 26, CMS published the correction plans for the nursing services and contract staff supervision citations.
“Patient safety is an essential cornerstone of care across Penn Medicine,” a spokesperson for the Philadelphia-based system told Becker’s. “Our plan of correction demonstrates how seriously we take this commitment. We are saddened by the loss of this patient and are fully cooperating with the Centers for Medicare and Medicaid Services and the Pennsylvania Department of Health in connection with this matter.”