HospitalInspections.org

Based on policy review, record review and interview, the facility failed to ensure a death of a patient in seclusion was reported for 1 of 1 (Patient #1) secluded patients reviewed.

The findings included:

1. Review of the facility's "Restraints and Seclusion" policy (effective 12/2021) revealed, "...Death Associated with the Use of Restraints/Seclusion...The nursing supervisor will report the following to the Compliance Office...Any death occurring while the patient is in restraints or seclusion...Any death that occurs within 24 hours after the patient has been removed from restraints or seclusion...The Compliance Officer will be responsible for notifying Centers for Medicare/Medicaid (CMS) no later than the close of the next CMS business day following knowledge of the patient's death. The Compliance Officer will place a written verification in the patient's medical record of the date and time of report to CMS..."

2. Record review for Patient #1 revealed arrival to the hospital's Emergency Department (ED) on 2/24/2023 at 2:05 AM with chief complaint of violent behavior. Patient #1 was brought to the ED by his Mother, who informed staff that he had not been taking his psychiatric medications and had not slept for 3 days. Patient #1 was documented as having violent behavior toward staff upon arrival to the ED. Patient #1 remained in the ED until his death on 3/2/2023.

Review of nursing assessments beginning 2/24/2023 at 7:15 AM revealed "...Seclusion Order Received and Implemented..."

Review of "PHYSICIAN ORDERS Behavioral Restraint/Seclusion" orders revealed Patient #1 was placed on Seclusion beginning 2/24/2023 and remained in Seclusion through 3/2/2023.

Further review of nursing assessments beginning 3/2/2023 at 2:00 AM documented, "...Pt [patient] was sitting in what looked like Feces was able to get Pt dressed put him on a shirt but unable to get his pants on pt stood up and was walking to bathroom as he we escorted him to the bathroom the pt colasped [collapsed] and started to have what looked like seizure activity...CPR [cardiopulmonary resuscitation] started..."

Review of a 3/2/2023 "DEATH NOTIFICATION FORM" revealed time of death as 2:42 AM.

There was no documentation in the medical record of CMS being notified of Patient #1's death while in seclusion.

In an interview on 6/25/2024 at 11:00 AM, the facility's Interim Quality Director verified there was no documentation of CMS being notified of Patient #1's death.