DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
390111 A. BUILDING __________
B. WING ______________ 		11/15/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HOSPITAL OF UNIV OF PENNSYLVANIA 34TH & SPRUCE STS, PHILADELPHIA, PA, 19104
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A0385 Nursing Services
482.23
Corrected On: 02/26/2024
45721 Based on observations, review of medical records (MR), review of facility policy and procedures and interview with staff (EMP), it was determined that the facility failed to identify, respond timely and appropriately to a medical emergency for one patient (MR1), and failed to ensure that all staff were adequately trained and competent in emergency response protocols (A398). On November 14, 2023, at 3:05 PM, Immediate Jeopardy (IJ) was identified, and the facility was notified, regarding its failure to identify and respond timely to a patient having a medical emergency, and failed to ensure that all staff were adequately trained on emergency response protocols. At 7:40 PM, IJ was removed after the State Survey Agency verified implementation of corrective actions to remove the immediate risk to patients. Cross Reference: 482.23(b)(6) Nursing Services
A0398 Supervision Of Contract Staff
482.23(b)(6)
Corrected On: 02/26/2024
45721 Based on observations, review of medical records (MR), review of facility policies and procedures and interviews with staff (EMP), it was determined that the facility failed to identify, respond timely and appropriately to a medical emergency for one patient (MR1) and failed to ensure that all staff were adequately trained and competent in emergency response protocols. Findings include: Review on November 15, 2023, of facility document "Clinical Emergencies Nursing Orientation," revised June 20, 2023, revealed a number to call for a rapid response code. The document listed the Primary Nurse's duties to stay with the patient, complete a Situation, Background Assessment Recommendation (SBAR), and notify the patient's physician or Provider. Further review revealed "Nursing Responsibilities The First 3 Minutes PRIOR TO RRT [Rapid Response Team] OR CODE TEAM ARRIVAL: 01 Assess patient - if not breathing and or no pulse, begin CPR. 02 Call For Help Activate local and global response teams. 03 Obtain Emergency Equipment Defibrillator/AED, code cart, backboard, bag-valve mask. 04 Turn Defibrillator On. 05 Continue CPR & Ventilate Patient Ensure connection to O2 deliver source. ..." Review of facility policy "Clinical Emergency Response System for Cardiopulmonary Arrest and Other Clinical Emergencies" effective October 4, 2023, revealed "Resuscitation efforts will be undertaken in accordance with the procedure set forth below and will be generally consistent with guidelines set forth by the American Heart Association. Specific clinical details of the resuscitation will be at the discretion of the coordinating provider present on the scene. PURPOSE: The purpose of this policy is to facilitate a timely response with trained personnel and adequate equipment to the activation of a Clinical Emergency System, cardiopulmonary arrest (Code Call), acute respiratory compromise (Anesthesia STAT or Airway Rapid Response), or other clinical emergency (Rapid Response, OB Rapid Response, CT Surgery STAT/ECMO Alert, Pediatric Emergency) ..." Review of MR1 nursing documentation, dated November 3, 2023, indicated that the patient was ambulating slowly, with a walker, towards the door between the units. Staff approached the patient and attempted to take the patient's vitals, but the patient refused and refused to go to the dayroom or kitchen area to sit down. Further review of the nurse's documentation indicated that nursing became concerned that the patient might fall so they went to obtain a wheelchair. However, while attempting to get the wheelchair, the patient "lowered" themself to the floor. When staff returned, they attempted again to take vitals for a second time. When they were unable to find a pulse, they called for the Rapid Response Team ["RRT" a team of nurses and other clinical personnel designated to respond to medical emergencies]. However, a "Code Blue" [an alert to indicate that a patient is having an unexpected cardiac event or is in respiratory arrest requiring resuscitation efforts and assistance is needed] was eventually initiated at 2055 [8:55 PM] due to the patient's unresponsiveness. Further review of documentation indicated that resuscitation ended at 2126 [9:26 PM] and the patient was pronounced deceased and subsequently transferred to the morgue. Observation of video footage, dated November 3, 2023, revealed that the patient was ambulating but then is observed slumped over their walker. Staff is viewed approaching the patient and appears to be talking to the patient, but the patient remains slumped over the walker, head down towards the floor. Staff leave the patient, and two mental health technicians approach the patient. One is observed tapping on the patient's walker. The patient becomes unsteady but assisted by the mental health technician. Shortly, thereafter the one technician leaves the patient, and the other technician follows, leaving the patient alone- still slumped over their walker. About two minutes later (video counter time 0:08:46), two Registered Nurses (RN) approach the patient and appear to be looking at the patient. They leave the patient. Another two minutes later (0:10:48), the patient is observed falling to the floor. However, in the medical record it is documented that the patient "lowers" themself to the floor. Seconds later the patient is observed lying on the floor, without movement. A registered nurse approaches the patient, about a minute later (0:11:50). With the help of a second nurse, the two nurses are observed straightening out the patient. For several minutes, the patient appears to be motionless and there is no visual evidence of vitals or emergency response being initiated until almost five minutes after nursing observed the patient on the floor. At 0:15:30 a nurse is observed arriving with a "crash cart" [ a cart that contains medications and supplies to aid in medical emergency situations]. At 0:17:09 a Rapid Response Nurse arrives and the nurse initiates chest compressions at 0:17:36. At 0:21:27 the Emergency Department physician is observed arriving on scene. Interview on November 14, 2023, at 4:15 pm with EMP4 (RN Supervisor) stated they received a phone call on November 3, 2023, asking for assistance with a patient that fell. EMP4 asked the nurse if there were any injuries and was told no, they just needed help getting the patient off the floor. EMP4 reported that when they got to the unit and looked at the patient, they noticed the patient appeared gray in color. EMP4 asked if anyone checked for responsiveness, and no one answered. EMP4 checked the carotid and femoral pulses and could not feel a pulse, and then instructed staff to call a code blue. Interview conducted on November 14, 2023, with EMP7 (RN) confirmed they were the charge nurse that evening and the patients primary care nurse. EMP7 stated they were unsure on how to call a code and left the patient to get a computer. Interview conducted on November 14, 2023, with EMP3 confirmed the patient was on the floor and that staff had left the area. Further interview confirmed the patient was not assessed, vital signs were not completed, and chest compression were not started timely.