HospitalInspections.org

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Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 1 of 1 patient (Patient 1), review of 4 of 4 AD staff training records (RNs 1, 2, 3, and 4), review of OSH internal investigation documentation, review of medical emergency supplies and equipment documentation, review of medical emergency response documentation, review of training documentation, and review of P&Ps and procedural manuals, it was determined that the governing body failed to ensure the provision of safe and appropriate care to patients in the hospital in a manner that complied with all Conditions of Participation.

The cumulative effect of these systemic failures resulted in this Condition-level deficiency that represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited under this Condition at Tag A-093, CFR 482.12(f)(2) - Standard: Emergency Services. This Standard applies to hospitals that do not have a dedicated, organized emergency services department and therefore must develop and maintain written P&Ps for evaluation of emergencies, initial treatment, and referral when appropriate. The findings cited reflect that the hospital failed to fully develop and implement P&Ps and systems to ensure timely and appropriate assessment and response to individuals anywhere on campus who exhibited signs of a potential medical emergency (Tag A-093.)

2. Refer to the findings cited at Tag A-115, CFR 482.13 - CoP: Patient's Rights, that reflects the hospital failed to fully develop and implement P&Ps that ensured each patient's right to receive care in a safe setting. The hospital's failures to ensure appropriate patient assessment and provisions for response to medical emergencies created an unsafe EOC that potentially contributed to harm and death of one patient and created the likelihood of harm to other patients (Tag A-144).

3. Refer to the findings cited at Tag A-385, CFR 482.23 - CoP: Nursing Services, that reflects the hospital failed to fully develop and implement P&Ps that ensured that patient needs were met by ongoing RN assessment and response to the nursing and emergency care needs of the patient population of each department (Tag A-392).

4. Refer to the findings cited at Tag A-1600, CFR 482.60 - CoP: Special Provisions for Psychiatric Hospitals, that reflects the hospital failed to comply with all CoPs specified in CFRs 482.1 through 482.23 and CFRs 482.25 through 482.57 as the following CoPs were determined to be out of compliance (Tag A-1605):
* CFR 482.12 - CoP: Governing Body
* CFR 482.13 - CoP: Patient's Rights
* CFR 482.23 - CoP: Nursing Services
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29708

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Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 1 of 1 patient (Patient 1), review of 4 of 4 AD staff training records (RNs 1, 2, 3, and 4), review of OSH internal investigation documentation, review of medical emergency supplies and equipment documentation, review of medical emergency response documentation, review of training documentation, and review of P&Ps, it was determined that the hospital's failures to fully develop and implement P&Ps that ensured appropriate and timely provisions for response to medical emergencies anywhere on campus, at this hospital that did not have a dedicated Emergency Department, included:
* Failure to ensure AD and inpatient RN staff were determined to be qualified to conduct appropriate and timely assessment of patient condition and identification of the need for medical emergency response.
* Failure to ensure RN staff requested the immediate presence of a physician when the patient's unresponsive physical condition was believed to be behavioral versus medical.
* Failure to provide safe and adequate initial treatment of a person who experienced a medical emergency in an organized and coordinated manner.
* Failure to ensure that medical emergency supplies and equipment were organized and managed to ensure availability of necessary items during a medical emergency response.

Findings include:

1. The findings that follow reflect that the hospital failed to ensure that RN staff promptly assessed Patient 1's condition and initiated medical emergency response based on the patient's unresponsive condition that was immediately evident upon arrival to the hospital. When AD RN first observed the patient in the law enforcement transport vehicle they stated they saw the patient's eyes open briefly. That was the only detectable movement the patient made between the time they were transferred from the back of the transport vehicle until another RN who had accompanied the patient for transport from the AD to the inpatient unit checked for a pulse after the transport and entry into the patient's assigned inpatient room. RNs and other hospital staff failed to respond timely to the patient's unresponsive and motionless condition in the manner in which a reasonable or prudent layperson, or a person with BLS CPR training, would do should an individual who exhibited the same signs and condition be observed elsewhere in the hospital or in the community. The RNs responsible for the patient in the AD and en route to the inpatient unit failed to request the presence of a physician to determine whether the patient's unresponsive condition was behavioral, as law enforcement transporters claimed, versus medical. Once the medical emergency response had been initiated in the inpatient unit, the response was not conducted in an organized and coordinated manner. Further, survey findings revealed that medical emergency supplies in the AD where Patient 1 was initially observed were not organized or managed to ensure timely response. Refer to Tag A-144 for additional information regarding Patient 1's encounter, and the findings that resulted in identification of an IJ situation.

2.a. A document titled "OSH Office of Quality Management" was reviewed. It included the following information:
* "Incident Nature: Sentinel Event - Unexpected Patient Death"
* "Date/Time of Incident: 04/18/2024 1115hrs"
* "At approx. 1047 hrs. access control informed admissions Douglas County jail transport were waiting with [Patient 1] for admission to OSH. Staff arrived and the country [sic] transport vehicle entered a Sally Port, at approximately 1054 hrs. Deputies told [RN 4] [that Patient 1] would need a wheelchair because [they were] 'catatonic' and at times 'flops around like a fish'. This was reported to have been described to nursing staff as normal behavior by [Patient 1]. As [Patient 1] was transferred from the transport van to the wheelchair, at approximately 1101 hrs, the admission [RN 4] reported [they] observed [Patient 1's] eyes open and close, possibly in response to light hitting [Patient 1's] eyes. [Patient 1] was wheeled into OSH admissions at approximately 1102 hrs. Additional staff were called to the admissions area and assisted in photographing [Patient 1] for identification. Douglas County transport restraints were removed from [Patient 1] and [they were] taken, via wheelchair, to Lighthouse 1 by OSH Staff. During this process [Patient 1] was noted as not moving on [their] own accord and staff held the patients [sic] legs up with a blanket so [their] feet would not drag on the floor. Staff and the patient arrived on the unit at approx. 1107hrs. where the patient was taken directly to a patient room. As [Patient 1] was being transferred to the bed an RN decided to check the patient for a pulse and found none. Sternal rubs were done with no response and additional checks found no pulse. A Code Blue was initiated and additional staff arrived and life saving procedures were performed including the use of CPR and an AED. Narcan and epinephrine were administered and were ineffective. Paramedics arrived at approx. 1121hrs and took over life saving efforts. [Patient 1] was pronounced dead at 1156 hrs."

2.b. In regard to Narcan and epinephrine administration, Patient 1's medical record included a Psychiatry General Note written by psychiatrist MD 30 and dated and timed 04/18/2024 at 1451. It reflected that the Narcan was administered by OSH staff, and in regard to epinephrine administration the note reflected that "EMS arrived at approximately 1125-1126 and took over the management of the code. They continued CPR for approximately 30 more minutes and per their report, gave 5 rounds of epinephrine. Patient did not achieve return of spontaneous circulation at any point following the start of the code, and patient was eventually pronounced dead by EMS at 1156 on 4/18/24."

3.a. During interview on 04/24/2024 at 1105 with RN 4, they stated they had worked in AD since August 2023. RN 4 provided the following information regarding Patient 1:
* A "Douglas County" transport van pulled into Sally Port 8 drive-in garage. The deputies said the patient would need a wheelchair because they had not been able to get into the van themselves and had been "flopping around like a fish." The deputies stated that was the patient's baseline.
* RN 4 stated they got a wheelchair for the patient and went to the back of the van with a security staff. The patient, who was in the back of the van, "opened their eyes and moved a little". RN 4 introduced themselves to the patient. The deputies told the patient, "We'll get you out [of the van]" and the patient closed their eyes. RN 4 stated "I thought [the patient was] not being cooperative" and asked for more security staff. RN 4 stated 5-6 security staff came. The deputies gave the patient a few minutes to get out of the van and when they did not, the deputies lifted the patient to the wheelchair. RN 4 stated the deputies held the patient's legs up while they wheeled the patient backwards from the van into the AR.
* RN 4 stated in the AR "we got a photo of the patient for [their] ID" and the deputies said it would be OK to remove the patient's cuffs because they had never been aggressive. The deputies removed the cuffs. The patient was not able to hold their head up and "kept [their] eyes closed." RN 4 stated the patient was slouched with their head to one side, and "not holding it up like a normal person holds their head."
* RN 4 stated "typically we take a temperature and ask about a cough" in the AR. RN 4 stated they did not check the patient's temperature or any other vital signs and did not ask the patient if they had a cough. When RN 4 was asked if the patient was breathing, they stated, "I didn't observe any chest rise and fall." In response to the surveyor's follow-up question in regard to indications of oxygenation such as the patient's skin color and appearance, RN 4 additionally stated that the patient "was African American, had dry skin, and I didn't notice anything abnormal."
* RN 4, a unit nurse, and security staff pushed the patient in the wheelchair from the AR to LH1. One of the security staff lifted the patient's legs with a blanket so their legs wouldn't drag. When they got to the patient's room on the unit, the unit RN and 2 security staff laid the patient supine on the bed. RN 4 stated, "At that point, I knew something was off because there was no response from the patient, so I checked for a pulse. Nothing. I checked a sternal rub and nothing." The patient had no pulse and was not breathing, and they called a code blue.

3.b. Incident documentation recorded by AD RN 4, dated 04/18/2024 and untimed, reflected that "Access control called the main admissions office phone at around 10:47 to report that Douglas County was waiting to get into Sally Port 8 for an admission. Douglas County was scheduled to drop off two admits to OSH today on 4/18. [Patient 26] who was scheduled to admit to FW1, and [Patient 1] was scheduled to admit to LH1. The Douglas county transport van was waiting in the circle outside of OSH for roughly 5-10 minutes, due to there being a secure transport van in Sally Port 8. [RN 3] admissions RN, went outside Sally Port 9 to talk to the Douglas county officers to find out how the pts were doing. When [RN 3] came back through Sally Port 9, [they] reported to me ([RN 4] Admissions RN) that the officers said [Patient 1] will need a 'wheelchair' because [the patient] 'flops around like a fish' and is 'catatonic'. After secure transport left Sally Port 8. Douglas county pulled into Sally Port 8. FW3 unit staff showed up first, and [RN 3] who was assigned to admit [Patient 26] brought in [Patient 26] and introduced them to the FW3 staff and that pt was taken to FW3. [Patient 1's] unit staff from LH1 ([RN 13] along with unit MHT) showed up next. I was assigned to admit [Patient 1] as I had done [their] pre-admit note in avatar as well as a nurse to nurse with the jail RN. The deputy standing in the admissions area adjacent to Sally Port 8 then reported to me, '[Patient 1] won't stand up, [they're] catatonic. [They'll] need a wheelchair'. RN asked the deputy '[They] won't stand at all?', and deputy responded 'No'. Wheelchair and a blanket was obtained by this RN. [MHST 18] was the security assigned to help with admissions for 4/18. As Sally Port 8 doors were opened by access control, [MHST 18] held open the doors while this RN followed deputies to the back of the van with the wheelchair. The deputies opened up both doors to the back of the van. [Patient 1] was seen sitting in a slumped position with [their] back against van partition. As soon as the van doors opened, there was sunlight that came streaming into the back of the van, and this RN could see [Patient 1's] eye open and close. Deputies said to [Patient 1] that they needed [them] to get into the wheelchair and gave [the patient] a few seconds but pt did not make any movements or indication that [they were] going to get up. Deputies then assisted pt on either side and lifted the pt into the wheelchair. RN introduced [themselves] to [Patient 1] and explained [they were] at the hospital but pt did not respond. RN asked for pt to lift [their] legs, so [they] could be wheeled, but [Patient 1] did not lift [their] legs. Both deputies each lifted one of the pt's legs by the pant leg so [the patient's] heels would not be dragging, and this RN wheeled [Patient 1] backwards into the adjacent admitting room connected to Sally Port 8. [MHST 18] had called for additional security at the request of this RN, who were also present in the admitting area. A photo was obtained of [the patient] for [their] ID badge for security, but [they] did not open [their] eyes. This RN was assessing whether or not the cuffs should be removed in the admitting area, or on the unit for safety, when officers reported that they did not see [the patient] as a threat, and [they] had 'never been physically violent'. This RN gave the directive for officers to remove the cuffs as pt was not exhibiting any signs of aggressive behaviors. Cuffs were removed by officers. Pt was wheeled by security to LH1, with one security wrapping a blanket underneath pt's legs and lifting them up so they did not drag on the floor. Admissions RN and unit staff followed as well. Pt was taken onto LH1 unit, and down one of the first hallways on the right hand side as you enter the unit, where the pt's assigned bedroom was. Pt was wheeled into [their] room, and staff informed [the patient] that it was [their] bedroom and [they] could get up. One staff member said '[Patient] won't get up, [they're] catatonic'. Security and unit RN and another staff lifted the pt onto the bed. Pt was now in a supine position on the bed. Unit RN, [RN 13], then began doing [their] assessment. [RN 13] tried verbal stimuli, yelling pt's name, checking radial and pedal pulse, checked for breathing. This RN checked for radial pulse on the right side, and there was no pulse felt. This RN confirmed with [RN 13] there was no pulse. Compressions were started, and a code blue was called on the radio by security. Crash cart was obtained with AED. Pt was moved to the floor in supine position for compressions and ambu bag was used for breath. 911 was called. Two OSH medical doctors arrived. AED advised no shock. EMS arrived and took over care."

4. Incident documentation recorded by LH1 RN 13, dated 04/18/2024 and untimed, reflected that "I was the RN assigned to [Patient 1's] admission along with [MHT2 8]. We were called to the admission Sally Port around 1100 and waited in line as the county had two patients and the first was going to a different unit. [MHT2 8] and I remained outside the Sally Port per protocol, waiting for report from the [AD RN 4]. It was reported that the pt was not cooperating, would not walk, and [AD RN 4] retrieved a wheelchair. Security arrived at the Sally Port, evidently having been paged by admissions. The pt was retrieved from the transport vehicle utilizing the wheelchair and brought into the Sally Port; I was not able to observe the pt from my vantage point outside the Sally Port. It was reported to us that the pt was continuing to be uncooperative and not responding. Two security staff wheeled the pt out of the Sally Port, one pushing [TMHA 19], the other holding the pt's legs up with a blanket draped under [the patient's] ankles ([MHST 20], switched with [MHST 17] at some point). We quickly made our way to LH1; I walked alongside the wheelchair, attempting to engage the pt, explain the plan. We passed the bubble on LH1 at 1111. We had decided to take [Patient 1] directly to [their] room and transfer [them] to [their] bed. On arrival to [patient's] room, security [TMHA 19] and I immediately lifted the pt out of the wheelchair and onto the bed. During that transfer, I noted the pt was more limp than would have been expected from a simply unresponsive pt. I immediately began checking for a pulse on [their] R wrist and began calling [their] name loudly. I performed sternal rubs when I could not elicit a response verbally. When there continued to be no response I requested staff call a code blue (code was called @ 1114). I then attempted to find a pulse under [the patient's] upper arm, carotid, pedal while continuing to attempt to rouse [them] verbally and with sternal rubs and watch for chest rise (this was difficult to assess as [the patient] was in loose fitting jail clothing). I pulled open [the patient's] eye lid and noted a dilated pupil; I used my flashlight to test reactivity and no reactivity was seen. Staff arrived quickly and we began chest compressions (@ 1115). Staff arrived with the AED and crash cart. After applying the AED pads, we transferred the pt to the floor to have a more firm surface and continued compressions alternating with AMBU bag respirations following CPR protocol. Narcan was requested and administered by [PMHNP 23]. Various staff and medical personnel rotated through administering compressions and AMBU respirations. CPR was continued per protocol, following prompts from AED (no shock ever advised) until paramedics arrived and took over the situation."

5. On 04/24/2024 beginning at 1155, survey team review of multiple camera views of video-recordings, without audio capability, revealed the following timeline of events that occurred on 04/18/2024 when the vehicle Patient 1 was transported in from Douglas County Jail arrived to the OSH Sally Port 8. Regarding the video review there was no camera view provided in Sally Port 8 that showed directly into the back of the transport van used to transport Patient 1 so that the entirety of the inside of the van could be visualized. The camera that showed the view at the back of the van was mounted off to the side of the Sally Port so that a side view of the right rear of the van could be visualized. With both rear van doors opened only a small portion of the inside of the back compartment could be seen. In addition, the quality and clarity of some of the video footage was poor and details of some images were not clear. Further, there were occasions during video review where video skipped several seconds when there was activity occurring. Commonly video may skip seconds or minutes when there is no activity occurring.

* Between ~ 1054:52 and 1056:23 two camera views inside Sally Port 8 showed: A DC Jail transport van drove into Sally Port 8 with two DC deputies seated in the front seats. The garage door closed after the van had fully entered the Sally Port. A DC deputy walked to the back of the van, opened one of the back doors, removed two bundles of items, and walked away towards the door to the admitting room. At ~ 1056:07 Patient 26 exited the van through the passenger right side doors and walked in front of the second DC deputy towards the door to the admitting room.

* Between ~ 1058:18 and 1100:20 one camera view inside Sally Port 8 showed: A DC deputy walked back to the back of the van, opened one of the back doors and looked inside momentarily, then started to close the door, then reopened it and looked inside and left it open. They stood at the back of the van and periodically looked inside through the open door.

* Between ~ 1100:21 and 1102:20 two camera views inside Sally Port 8 showed: The second DC deputy approached the back of the van and joined the first deputy, immediately followed by RN 4 who pushed a w/c towards the back of the van. The deputies opened the other door so that both back van doors were open. At ~ 1100:28 only a portion of Patient 1's lower body was visualized up against the rear left side of the van. They were positioned on the floor so that their body was facing the interior of the left rear corner side panel of the van, their left buttocks could be seen on the van floor, the left side of their body was at the very end of the floor where the door closure was, their left leg was observed to be bent at the knee and had partially fallen outside of the van. The two deputies picked Patient 1 up off the van floor and in awkward and uncoordinated movements took the patient out of the van and rotated them to place them in the w/c. There was no indication that Patient 1 was assisting or resisting. The parts of their body that could be visualized were limp. Patient 1, who was Black, was positioned in the w/c with their shoulders at the level of the top of the w/c seat back, their head slumped fully forward towards their chest, and their eyes closed. RN 4 folded a blue blanket and place it around Patient 1's chest and shoulders and wrapped the ends around the w/c handles. At 1101:38 as the RN began to pull the w/c backward towards the admitting room Patient 1's upper body was observed to be positioned lower in the w/c and slumped toward the left. As their head was slumped forward, the lower part of their face, including mouth and nose, was covered by the blue blanket. At ~ 1102:01 as RN 4 pulled the w/c backwards along the side of the van towards the admitting room door, both deputies bent over the patient and made movements consistent with each having picked up one of the patient's pants legs to lift the patient's feet off the ground.

* At ~ 1102:24 one camera view inside the admitting room attached to Sally Port 8 showed: RN 4 pulled the w/c with Patient 1 backward into the admitting room. One deputy had hold of the patient's right pant leg near the hem with their right hand. The other deputy had hold of the patient's left pant leg near the middle of the pant leg with their left hand. Both of the patient's bare feet were dangling slightly above the floor. The patient's hands were cuffed in their lap. Their head was slumped forward, their eyes were closed, and their face was covered by the blue blanket that was held in place by RN 4 around their chest and shoulders and the w/c handles.

* Between ~ 1102:30 and 1105:50 one camera view inside the admitting room showed: RN 4 parked Patient 1 in the w/c near the middle of the room. The deputies' positions around the patient's body periodically block the camera view. At this time four other staff (not including RN 4 and the two deputies) arrived into the room. The RN can be seen to lean over towards the patient on the left side of the w/c and arms are extended toward the patient although the patient cannot be seen behind one of the deputies. At ~ 1103:02 the deputies stepped away and the patient was observed to be slumped further down in the w/c, however, the patient's face was no longer covered by the blue blanket that remained around their chest and shoulders. It looked as though RN 4 had their right hand on or near the blanket below the patient's face as if they moved the blanket to uncover the patient's face. The patient was motionless and their eyes were closed. At that time there were at least six other staff in the room. RN 4 stepped away and back from the w/c and was observed to address the deputies and staff that had gathered in the room who all stood and faced the patient within a few feet of the patient. Two of those staff stepped towards and leaned towards the patient and took photographs of the patient with cell phones. Then there were eight other staff in the room. The 11 people in the room (excluding the patient) were observed to talk amongst themselves and to the group while Patient 1 remained motionless in the w/c with their wrists in law enforcement transport restraints, their chin laid on their chest, and their eyes closed. Patient 1 showed no signs of movement. At ~ 1104:18 RN 4 slightly leaned toward the patient, extended their arm, and may have touched the blue blanket, the patient's clothing near their shoulder, or the w/c. It was not clear. At ~ 1104:24 one of the staff persons approached the patient, leaned toward them, and extended their arm towards the patient. There was no visible response or movement from Patient 1. At ~ 1104:29 a DC deputy removed the law enforcement transport restraints from the patient's wrists. At ~ 1105:08 when their right hand was free from those restraints their right forearm, wrist, and hand slid down and across their right thigh. At that time the patient was observed to have slid further down in the w/c, the blue blanket was removed, their head remained slumped fully forward with their chin on their chest, their eyes were closed, and their legs were extended straight in front of them with their bare feet on the ground. At ~ 1105:27 a staff person took the blue blanket and with assistance from another staff person positioned it under and around both the patient's legs at the knees and formed a handle of sorts to lift the patient's legs up off the ground. At that time the patient's buttocks were near to sliding off of the w/c and their arms had fallen off their thighs onto the w/c seat on either side of their body. At ~ 1105:44 one staff person pushed the w/c forward and another staff person held the blanket that was around the patient's legs to keep them off the ground and the group moved towards the door out of the admitting room into a hallway towards the inpatient unit. At no time while in the admitting room did the patient assist or resist, nor did they open their eyes or demonstrate any observable movement. At no time was there any meaningful touch or other activity by any staff that could be construed as a patient assessment component.

* Between ~ 1105:50 and 1108:30 four camera views showed: The two staff who pushed the w/c and held the patient's legs up were joined by RN 13 and six other staff as they transported Patient 1 through hospital hallways to the inpatient unit. Patient 1 remained motionless with their eyes closed and slumped to the left with their arms laid limply on the w/c seat on either side of their body and their chin laid on their chest. Overhead camera views during the transport showed that the blanket around the patient's knees used to hold the patient's legs up during transport had been tied and knotted or twisted. At ~ 1108:30 staff pushed the patient in the w/c into the assigned patient room on the inpatient unit and that was last video observation of Patient 1.

* Video recording beginning at 1108:30 captured staff activities in the hallway outside the room after Patient 1 entered the room, and after the Code Blue response had been initiated. Those video observations are described below under Finding 8 in this Tag.
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6. The findings that follow reflect the hospital's failure to ensure an organized and coordinated medical emergency response.

7. Incident documentation recorded by LH1 NM, dated 04/18/2024 and untimed, reflected that "Staff came to my office inside the nurses station to advise me that a code blue (medical emergency) was needed for this patient as the code blue was being called over the radio. I responded, running down the south hall to the patient's room at 1115 as the code blue was being called via overhead page. When I entered the patient bedroom the patient was non-responsive, eyes closed, without respirations, without pulse (as assessed by another RN present). I advised that staff begin chest compressions and then I ran to obtain the crash cart/code blue cart. When I returned to the patient bedroom I opened the code cart, gave the code blue sheet and clipboard to unit [OS2 24] and assigned [them] to the recorder role. I then entered the patient bedroom and advised that staff move the patient from the patient bed onto the floor after the current set of chest compressions were complete. Staff used the patient's blanket to lower this patient from [their] bed onto the floor and resumed chest compressions. More staff entered the scene and the automatic external defibrillator was brought to the scene. A nurse took a position at the patient's head and administered 2 rescue breaths using the ambu-bag between each set of 30 compressions. I took the role of code lead and asked staff to switch out with the person administering chest compressions to prevent physical exhaustion while counting chest compressions out loud. Staff continued to administer chest compressions and rescue breaths and the AED was attached to the patient. The AED analyzed and advised no shock, chest compressions and rescue breaths continued. Medical doctors and other staff continued to arrive and rescue attempts continued. This patient was pronounced deceased by our physicians at 1156 and at that time EMTs were present. It was later reported to me that the unit nurse assigned to the admission called for the code blue as this patient was being moved from the wheelchair to the patient bed by security and admissions office staff. Per staff report, the patient was slumped down in the wheelchair unable to maintain an upright posture while [they were] being transported to the unit."

8. Video recordings of the Code Blue medical emergency response for Patient 1 on 04/18/2024 revealed a disorganized and uncoordinated response as follows:

~ 1108:29 - Patient 1 was transported into the inpatient room in a w/c. RN 13 and other staff entered the room. Multiple staff entered and exited the room and others milled around outside the room with no demonstration of urgency. Another patient exited the patient room across the hall from Patient 1's room.
~ 1110:34 - MHST 14 walked at a leisurely pace and without urgency down the hall from the NS toward the patient room, pushed a mobile vital signs machine on wheels, and entered the patient room ~ 14 seconds later at ~ 1110:48.
~ 1111:56 - LH1 NM and Agency LPN 21 walked down the hallway from the NS towards the patient room at a quicker pace than previous staff, however, with minimal urgency. (The video observation is contrary to the incident documentation under Finding 7 above that described the response of LH1 NM as "I responded, running down the south hall to the patient's room ...")
~ 1112:14 - LH1 NM ran down the hall away from the patient room toward the NS. More staff, some at a quicker pace, began to arrive and gather in the hallway outside of the patient room while some entered the room.
~ 1112:33 - Staff were observed to push a Red Emergency Cart down the hall from the NS toward the patient room. It arrived at the patient room at 1112:45 and was positioned outside the doorway of that room where it remained until it was pushed further down the hall away from the room after EMS arrived.

~ 1112:45 until the arrival of EMS at ~ 1124:01 video recording showed: More staff arrived and continued to enter the patient's room and gather in the hall. The number of staff gathered in the hallway between the patient's room and the NS, particularly in the vicinity of the patient's room, created increased congestion that presented an obstacle for navigation through the hall, including for other patients whose rooms were between Patient 1's room and the NS. At times there were 20 or more staff, and may have included patients, in the space outside the room and there was no way to determine how many were in the room as staff continued to enter and exit. The crowd that had gathered did not leave a clear pathway for EMS who arrived at ~ 1124:01 with ~ eight EMT and Fire responders, a gurney, and EMS equipment.

Additionally, during the scene described above, multiple staff in the hallway were observed to do nothing, staff lined up against the hallway walls, some staff stood on their tiptoes or crowded the doorway of the room to try to see in the room, others engaged in various discussions and activities. Agency RN 26 and Agency LPN 25 were observed to open and look in, or retrieve items from drawers on the Red Emergency Cart, and then they would leave the drawers partially open. (There was no incident or medical record documentation by either Agency RN 26 or Agency LPN 25 regarding their activities and tasks during the Code Blue.)

~ 1112:46 - OS2 24 was observed to stand immediately next to the Red Emergency Cart at the patient room doorway with a clipboard to which a form was attached, looked at their left wrist, and recorded something on the form. During the video the form was discerned to be the Code Blue Flow Sheet. During the duration of this code activity captured on the video recordings until ~ 1125:17 OS2 24 never entered Patient 1's room, and they were not positioned during much of that time to be able to observe the code activities that were being carried out in the room. For example: They were observed to wander in the hallway outside the room, they stood to the left of the doorway without a view into the room, they stood in the hallway approaching the opposite wall, they sometimes leaned forward to look into the room and sometimes that was through a number of other staff that crowded the doorway, they crouched down on their knees in the hallway to the left of the door, they sat down on the floor on their knees and lower legs in the hallway, they talked with other staff. Up until ~ 1124:39 OS2 24 had the clipboard in their possession. The video skipped ~ 10 seconds at that time. The next time recorded was ~ 1124:51 and OS2 24 was observed to walk down the hall away from the patient's room and further from the NS without the clipboard in their possession. (On 05/09/2024 at ~ 1500 staff that included the DNS, LH1 NM, CBC, PD, DQM, and DSC confirmed that the form OS2 24 could be seen writing on in the video was a Code Blue Flow Sheet, and that it was the same Code Blue Flow Sheet provided during the survey for Patient 1.)

~ 1124:33 - Staff present

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Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 1 of 1 patient (Patient 1), review of 4 of 4 AD staff training records (RNs 1, 2, 3, and 4), review of OSH internal investigation documentation, review of medical emergency supplies and equipment documentation, review of medical emergency response documentation, review of training documentation, and review of P&Ps and procedural manuals, it was determined that the hospital failed to fully develop and implement P&Ps that ensured each patient's right to receive care in a safe setting. The hospital's failures to ensure appropriate patient assessment and organized response to medical emergencies created an unsafe EOC that potentially contributed to harm and death of one patient and created the likelihood of harm to other patients.

As stated in Tag A-0000 of this report, based on findings that medical emergency supplies and equipment were not organized to ensure timely and efficient medical emergency response as described under Tag A-144 of this report at Findings 18 through 21.c., on 04/26/2024 the hospital was notified that an IJ situation had been determined to exist. An IJ Removal Plan was approved on 05/01/2024 and the IJ was subsequently removed on 05/02/2024 after onsite verification that the IJ Removal Plan had been implemented.

The cumulative effect of these systemic failures resulted in this Condition-level deficiency that represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited under this Condition at Tag A-144, CFR 482.13(c)(2) - Standard: Privacy and Safety, that reflects that P&Ps and systems for the provision of safe care were not fully developed or implemented and failures included (Tag A-144):
* Failure to ensure AD and inpatient RN staff carried out assigned duties to provide appropriate and timely assessment of patient condition and identification of the need for medical emergency response.
* Failure to ensure RN staff requested the immediate presence of a physician when the patient's unresponsive physical condition was believed to be behavioral versus medical.
* Failure to ensure other staff demonstrated appropriate response to a patient whose condition indicated the need for medical emergency response.
* Failure to ensure that medical emergency supplies and equipment were organized and managed to ensure availability of necessary items during a medical emergency response.
* Failure to ensure an organized and coordinated medical emergency response during which:
- The roles of staff who responded were not clear and demonstrated;
- The tasks performed were not clearly identified and thoroughly documented, including orders for and administration of emergency medication;
- Situational awareness was not maintained.
* Failure to ensure AD staff practices for patient care were in accordance with, and supported by, written and approved P&Ps.
* Failure to ensure AD staff completed organized and documented AD orientation and onboarding that ensured clinical and procedural competency for patient care operations in that department.
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29708

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Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 1 of 1 patient (Patient 1), review of 4 of 4 AD staff training records (RNs 1, 2, 3, and 4), review of OSH internal investigation documentation, review of medical emergency supplies and equipment documentation, review of medical emergency response documentation, review of training documentation, and review of P&Ps and procedural manuals, it was determined that the hospital failed to fully develop and implement P&Ps that ensured each patient's right to receive care in a safe setting. The hospital's failures to ensure appropriate patient assessment and organized response to medical emergencies created an unsafe EOC that potentially contibuted to harm and death of one patient and created the likelihood of harm to other patients and included:
* Failure to ensure AD and inpatient RN staff carried out assigned duties to provide appropriate and timely assessment of patient condition and identification of the need for medical emergency response.
* Failure to ensure RN staff requested the immediate presence of a physician when the patient's unresponsive physical condition was believed to be behavioral versus medical.
* Failure to ensure other staff demonstrated appropriate response to a patient whose condition indicated the need for medical emergency response.
* Failure to ensure that medical emergency supplies and equipment were organized and managed to ensure availability of necessary items during a medical emergency response.
* Failure to ensure an organized and coordinated medical emergency response during which:
- The roles of staff who responded were not clear and demonstrated;
- The tasks performed were not clearly identified and thoroughly documented, including orders for and administration of emergency medication;
- Situational awareness was not maintained.
* Failure to ensure AD staff practices for patient care were in accordance with, and supported by, written and approved P&Ps.
* Failure to ensure AD staff completed organized and documented AD orientation and onboarding that ensured clinical and procedural competency for patient care operations in that department.

As stated in Tag A-0000 of this report, based on findings that medical emergency supplies and equipment were not organized to ensure timely and efficient medical emergency response as described below in this Tag at Findings 18 through 21.c., on 04/26/2024 the hospital was notified that an IJ situation had been determined to exist. An IJ Removal Plan was approved on 05/01/2024 and the IJ was subsequently removed on 05/02/2024 after onsite verification that the IJ Removal Plan had been implemented.

Findings include:

1. The findings that follow for Patient 1 reflect the hospital's failure to ensure the provision of care and services in a safe and appropriate manner. For example:
* RN staff failed to conduct appropriate and timely assessment and vital signs for Patient 1 who arrived at the hospital from jail. When AD RN first observed the patient in the transport vehicle they stated they saw the patient's eyes open briefly. That was the only detectable movement the patient made between the time they were transferred from the back of the transport vehicle until another RN who had accompanied the patient for transport from the AD to the inpatient unit checked for a pulse after the transport and entry into the patient's assigned inpatient room ~ eight minutes later.
* AD and inpatient RN staff failed to make independent decisions using their own nursing judgement that would call for an immediate assessment and emergency response to an unresponsive and motionless person.
* Other hospital staff failed to respond to the patient's unresponsive and motionless condition in the manner in which a reasonable or prudent layperson, or a person with BLS CPR training, would do should an individual who exhibited the same signs and condition be observed elsewhere in the hospital or in the community.
* RN and other staff inappropriately deferred to, believed without reasoning or questioning, and acted upon DC deputies' characterizations of the patient's unresponsive condition as being purposeful as in "choosing not to walk," "won't stand up," and "refusal to respond," "normal" and "usual," and "catatonic."
* RN staff who were responsible for the patient in the AD and en route to the inpatient unit failed to requested the immediate presence of a physician when the patient's unresponsive physical condition was believed to be behavioral versus medical.

2.a. During the entrance conference on 04/24/2024 beginning at 1035, hospital staff that included the Interim OSHS/CMO, Interim DS, COP, COM, CNO, DQM, and AAG confirmed the hospital's 04/19/2024 self-report of an incident that occurred on 04/18/2024 that involved Patient 1.

2.b. During review of incident documentation and hospital response with staff that included the Interim DS, DQM, DSC, COP, COM, DOS, PD, BOM1, and AAG on 04/24/2024 beginning at 1440 staff described the hospital's investigation and actions taken to date. A document titled "Investigative Memo," dated 04/24/2024 provided a summary of the information given by staff during the incident and response review on 04/24/2024 and included the following:
* "Date of incident: 4/18/2024"
* "Incident Nature: Unexpected patient death"
* "The purpose of this memo is to document the investigative process and immediate actions associated with the unexpected patient death on 4/18/2024, [Patient 1]."
* "The following is a timeline of events, and all times are approximate:
- Patient arrival, 1047 hrs.
- Patient entry into sallyport in County Transport Vehicle, 1057 hrs.
- Patient wheeled into Admissions area in wheelchair, 1102 hrs.
- Patient on unit (1107 hrs.) and was taken to [their] room (off camera location) where [they were] transferred to [a] bed and staff took vitals. Staff called a code blue at 1114 hrs. due to no pulse found.
- EMS arrived at OSH at 1118 hrs.
- EMS arrived on the Unit at 1123 hrs.
- Time of death called at 1156 hrs.
- EMS Departed OSH at 1200 hrs.
- Oregon State Police (OSP Case number: SP24-121397) was notified (1123 hrs.) and arrives at 1222 hrs.
- Security and OSH Incident Report and Systems Investigation (IRSI) staff reviewed video independent of each other.
- County Medical Examiner arrived 1246 hrs. (departed at 1536 hrs.)
- OSH Director of Quality Management ... consulted with OSH Interim Superintendent ... and was directed to initiate Joint Commission Reporting of a Sentinel Event.
- [DQM] sent email notification of the Sentinel event to OSH Legal Representation, Department of Justice - Oregon (DOJ) on 4/18/24.
- IRSI Review of video and screening document was sent to DOJ and Standards and Compliance for Joint Commission Reporting."
* "Actions in response to preliminary investigative findings: Video review and policy evaluation identified no policy requirement for vitals check on new admissions. On 4/19/2024 OSH Interim Superintendent [and CMO] memorialized 'CMO Directive - Admission vitals 4-19-24' based on initial investigative findings that vitals were not taken of the patient upon admission."
* "At the time of this memo this event is still under investigation by Oregon State Police and is scheduled for a Root Cause Analysis by OSH Standards and Compliance."

2.c. Review of the document on OSH letterhead, signed by the CMO/Interim OSHS and dated 04/19/2024, reflected the following:
"To all OSH staff, This CMO Directive modifies and adds to OSH policy 6.058, 'Admissions.' To ensure that patients who may be medically unstable on arrival are promptly assessed and receive necessary medical care as soon as possible, it is my directive, effective April 19, 2024, that:
* An Admissions RN must perform a brief assessment for every patient admitted to OSH, including - at minimum - vital signs and visual observation to identify any medical needs requiring immediate attention, before the patient leaves the Admissions area. This assessment must be documented in the patient's medical record.
* If a patient is not responsive to staff in the Admissions area, the possibility of a medical emergency must be immediately assessed.
* If a patient is too combative to safely obtain vital signs, this must be communicated to the unit RN and documented in the medical record, along with the nature of the patient's behavior.
This directive will remain in effect until policy 6.058 is updated."

2.d. A document titled "OSH Office of Quality Management" was reviewed. It included the following information:
* "Incident Nature: Sentinel Event - Unexpected Patient Death"
* "Date/Time of Incident: 04/18/2024 1115hrs"
* "At approx. 1047 hrs. access control informed admissions Douglas County jail transport were waiting with [Patient 1] for admission to OSH. Staff arrived and the country [sic] transport vehicle entered a Sally Port, at approximately 1054 hrs. Deputies told [RN 4] [that Patient 1] would need a wheelchair because [they were] 'catatonic' and at times 'flops around like a fish'. This was reported to have been described to nursing staff as normal behavior by [Patient 1]. As [Patient 1] was transferred from the transport van to the wheelchair, at approximately 1101 hrs, the admission [RN 4] reported [they] observed [Patient 1's] eyes open and close, possibly in response to light hitting [Patient 1's] eyes. [Patient 1] was wheeled into OSH admissions at approximately 1102 hrs. Additional staff were called to the admissions area and assisted in photographing [Patient 1] for identification. Douglas County transport restraints were removed from [Patient 1] and [they were] taken, via wheelchair, to Lighthouse 1 by OSH Staff. During this process [Patient 1] was noted as not moving on [their] own accord and staff held the patients [sic] legs up with a blanket so [their] feet would not drag on the floor. Staff and the patient arrived on the unit at approx. 1107hrs. where the patient was taken directly to a patient room. As [Patient 1] was being transferred to the bed an RN decided to check the patient for a pulse and found none. Sternal rubs were done with no response and additional checks found no pulse. A Code Blue was initiated and additional staff arrived and life saving procedures were performed including the use of CPR and an AED. Narcan and epinephrine were administered and were ineffective. Paramedics arrived at approx. 1121hrs and took over life saving efforts. [Patient 1] was pronounced dead at 1156 hrs."

2.e. In regard to Narcan and epinephrine administration, Patient 1's medical record included a Psychiatry General Note written by psychiatrist MD 30 and dated and timed 04/18/2024 at 1451. It reflected that the Narcan was administered by OSH staff, and in regard to epinephrine administration the note reflected that "EMS arrived at approximately 1125-1126 and took over the management of the code. They continued CPR for approximately 30 more minutes and per their report, gave 5 rounds of epinephrine. Patient did not achieve return of spontaneous circulation at any point following the start of the code, and patient was eventually pronounced dead by EMS at 1156 on 4/18/24."

3. During interview on 04/24/2024 at 1030 with ADM the following information was provided:
* AD normally has 4 AD RNs at all times.
* Most admissions come in through Sally Ports 8 and 9.
* When a transport vehicle arrives in Sally Port 8 drive-in garage, the deputy from the vehicle will check in with an AD nurse at the window between the garage and AD office. The AD nurse will talk to the deputy to find out "how the transport was" and any issues they need to know. The AD nurse tells the deputy to leave the patient in the vehicle and an AD nurse and a security staff will meet the patient at the vehicle before they get out. The AD nurse starts their assessment before the patient gets out of the vehicle by checking their behavior "to make sure they will be safe" and if needed, get a wheelchair for the patient.
* After the patient is brought inside the AR, restraints are removed and and AD nurse will ask the patient if they have a cough or any illnesses, and take their temperature. ADM stated a full set of vital signs were sometimes taken in AR "[depending on] how cooperative the patient is."
* When done in AR, a minimum of an AD nurse, unit nurse, and a MHT escort the patient to the unit the patient is being admitted to. The AD nurse gives report to the unit staff as they are "walking through the hall to the unit." When they get to the unit, staff "do vitals, weight, admissions process and shower."
* Regarding Patient 1, ADM stated 2 patients were in the transport vehicle upon arrival, Patient 1 and another patient. The deputies said Patient 1 was not being compliant so they brought the other patient in first and went through the process of checking them in before bringing Patient 1 in. After that, an AD nurse and security staff went out to the vehicle and met Patient 1 who was inside the vehicle. ADM asked the surveyor if they wanted to talk to RN 4, the AD nurse who went out to the vehicle.

4. During interview on 04/24/2024 at ~ 1205 regarding Patient 1, DQM stated the DC deputies had stopped at another location before arriving at Sally Port 8. When they arrived there were two patients in their transport vehicle, Patient 1 and another patient.

5.a. During interview on 04/24/2024 at 1105 with RN 4, they stated they had worked in AD since August 2023. RN 4 provided the following information regarding Patient 1:
* A "Douglas County" transport van pulled into Sally Port 8 drive-in garage. The deputies said the patient would need a wheelchair because they had not been able to get into the van themselves and had been "flopping around like a fish." The deputies stated that was the patient's baseline.
* RN 4 stated they got a wheelchair for the patient and went to the back of the van with a security staff. The patient, who was in the back of the van, "opened their eyes and moved a little". RN 4 introduced themselves to the patient. The deputies told the patient, "We'll get you out [of the van]" and the patient closed their eyes. RN 4 stated "I thought [the patient was] not being cooperative" and asked for more security staff. RN 4 stated 5-6 security staff came. The deputies gave the patient a few minutes to get out of the van and when they did not, the deputies lifted the patient to the wheelchair. RN 4 stated the deputies held the patient's legs up while they wheeled the patient backwards from the van into the AR.
* RN 4 stated in the AR "we got a photo of the patient for [their] ID" and the deputies said it would be OK to remove the patient's cuffs because they had never been aggressive. The deputies removed the cuffs. The patient was not able to hold their head up and "kept [their] eyes closed." RN 4 stated the patient was slouched with their head to one side, and "not holding it up like a normal person holds their head."
* RN 4 stated "typically we take a temperature and ask about a cough" in the AR. RN 4 stated they did not check the patient's temperature or any other vital signs and did not ask the patient if they had a cough. When RN 4 was asked if the patient was breathing, they stated, "I didn't observe any chest rise and fall." In response to the surveyor's follow-up question in regard to indications of oxygenation such as the patient's skin color and appearance, RN 4 additionally stated that the patient "was African American, had dry skin, and I didn't notice anything abnormal."
* RN 4, a unit nurse, and security staff pushed the patient in the wheelchair from the AR to LH1. One of the security staff lifted the patient's legs with a blanket so their legs wouldn't drag. When they got to the patient's room on the unit, the unit RN and two security staff laid the patient supine on the bed because the patient would not get on the bed themselves. RN 4 stated, "At that point, I knew something was off because there was no response from the patient, so I checked for a pulse. Nothing. I checked a sternal rub and nothing." The patient had no pulse and was not breathing, and they called a code blue.

5.b. Incident documentation recorded by AD RN 4, dated 04/18/2024 and untimed, reflected that "Access control called the main admissions office phone at around 10:47 to report that Douglas County was waiting to get into Sally Port 8 for an admission. Douglas County was scheduled to drop off two admits to OSH today on 4/18. [Patient 26] who was scheduled to admit to FW1, and [Patient 1] was scheduled to admit to LH1. The Douglas county transport van was waiting in the circle outside of OSH for roughly 5-10 minutes, due to there being a secure transport van in Sally Port 8. [RN 3] admissions RN, went outside Sally Port 9 to talk to the Douglas county officers to find out how the pts were doing. When [RN 3] came back through Sally Port 9, [they] reported to me ([RN 4] Admissions RN) that the officers said [Patient 1] will need a 'wheelchair' because [the patient] 'flops around like a fish' and is 'catatonic'. After secure transport left Sally Port 8. Douglas county pulled into Sally Port 8. FW3 unit staff showed up first, and [RN 3] who was assigned to admit [Patient 26] brought in [Patient 26] and introduced them to the FW3 staff and that pt was taken to FW3. [Patient 1's] unit staff from LH1 ([RN 13] along with unit MHT) showed up next. I was assigned to admit [Patient 1] as I had done [their] pre-admit note in avatar as well as a nurse to nurse with the jail RN. The deputy standing in the admissions area adjacent to Sally Port 8 then reported to me, '[Patient 1] won't stand up, [they're] catatonic. [They'll] need a wheelchair'. RN asked the deputy '[They] won't stand at all?', and deputy responded 'No'. Wheelchair and a blanket was obtained by this RN. [MHST 18] was the security assigned to help with admissions for 4/18. As Sally Port 8 doors were opened by access control, [MHST 18] held open the doors while this RN followed deputies to the back of the van with the wheelchair. The deputies opened up both doors to the back of the van. [Patient 1] was seen sitting in a slumped position with [their] back against van partition. As soon as the van doors opened, there was sunlight that came streaming into the back of the van, and this RN could see [Patient 1's] eye open and close. Deputies said to [Patient 1] that they needed [them] to get into the wheelchair and gave [the patient] a few seconds but pt did not make any movements or indication that [they were] going to get up. Deputies then assisted pt on either side and lifted the pt into the wheelchair. RN introduced [themselves] to [Patient 1] and explained [they were] at the hospital but pt did not respond. RN asked for pt to lift [their] legs, so [they] could be wheeled, but [Patient 1] did not lift [their] legs. Both deputies each lifted one of the pt's legs by the pant leg so [the patient's] heels would not be dragging, and this RN wheeled [Patient 1] backwards into the adjacent admitting room connected to Sally Port 8. [MHST 18] had called for additional security at the request of this RN, who were also present in the admitting area. A photo was obtained of [the patient] for [their] ID badge for security, but [they] did not open [their] eyes. This RN was assessing whether or not the cuffs should be removed in the admitting area, or on the unit for safety, when officers reported that they did not see [the patient] as a threat, and [they] had 'never been physically violent'. This RN gave the directive for officers to remove the cuffs as pt was not exhibiting any signs of aggressive behaviors. Cuffs were removed by officers. Pt was wheeled by security to LH1, with one security wrapping a blanket underneath pt's legs and lifting them up so they did not drag on the floor. Admissions RN and unit staff followed as well. Pt was taken onto LH1 unit, and down one of the first hallways on the right hand side as you enter the unit, where the pt's assigned bedroom was. Pt was wheeled into [their] room, and staff informed [the patient] that it was [their] bedroom and [they] could get up. One staff member said '[Patient] won't get up, [they're] catatonic'. Security and unit RN and another staff lifted the pt onto the bed. Pt was now in a supine position on the bed. Unit RN, [RN 13], then began doing [their] assessment. [RN 13] tried verbal stimuli, yelling pt's name, checking radial and pedal pulse, checked for breathing. This RN checked for radial pulse on the right side, and there was no pulse felt. This RN confirmed with [RN 13] there was no pulse. Compressions were started, and a code blue was called on the radio by security. Crash cart was obtained with AED. Pt was moved to the floor in supine position for compressions and ambu bag was used for breath. 911 was called. Two OSH medical doctors arrived. AED advised no shock. EMS arrived and took over care."

6. Incident documentation recorded by MHST 18, dated 04/18/2024 and untimed, reflected that "I, [MHST 18], was the admissions security staff to assist during the admit with the new patient [Patient 1]. There were two patients from Douglas County admitting today and [Patient 1] was the second one to come in at approximately 1105. When the Deputies arrived, they had let us know that this patient was not talking or moving but that this was usual for [them]. They recommended that we bring a wheelchair due to [the patient] choosing not to walk but that it was "[their] normal" per the deputy. They mentioned that they had to help place [Patient 1] into the vehicle to bring [them] here to OSH. [AD RN 4] took a wheelchair to the van where the patient was sitting. The officers asked the patient to exit the vehicle a couple times to which the patient did not move. I am unsure as to who helped the patient exit the vehicle and place [them] into the wheelchair. I stood holding the door at sallyport 8 open and called for additional security. Additional security responded. [AD RN 4] introduced [themselves] when [they] entered the building, then I introduced myself and let [the patient] know I would be taking [their] photo for [their] OSH ID badge. I took [the patient's] photo. [AD RN 4] asked [the patient] to contract for safety and there was no response. The deputies assured us that the patient would be safe and that this is just how [they were]. So [AD RN 4] gave them the go ahead to remove the cuffs. Another security staff asked, "is [the patient] catatonic?" and the deputies responded saying "pretty much."

7. Incident documentation recorded by MHST 16, dated 04/18/2024 and untimed, reflected that "... a call came over the radio for additional security assistance at Sallyport 8 with a new admit at 11:03. As I got closer to Sallyport 8 I could see security staff and two sheriff deputies standing in a semicircle around [Patient 1], who was still out of view to me in the admissions room attached to sallyport 8. There were two unit staff, [RN 13] and [MHT2 8], standing outside the room waiting for the admit per protocol, as I tried to quietly enter the room to not disrupt anything. I could see the admissions [RN 4], standing next to [Patient 1] attempting to get [them] to respond and open [their] eyes, but [they] just sat slumped in the wheelchair, in full cuffs, and unresponsive. Someone leaned over to me to let me know that this was a behavior, and I took that to mean that this situation was going to be unpredictable due to this being a new admission with no prior hospitalization. It is protocol to hear the patient agree to safety before we can release [them] from [their] cuffs. The deputies mentioned that [the patient] hadn't been violent, that all their assistance was because [they were] 'catatonic' and refused to respond. I saw that the unit staff had propped open the door to listen, so I stepped out to fill them in on what the deputies had said. When I came back into the room, they started to remove the cuffs, so I left the room again to open doors ahead of them to ease the transportation process. [TMHA 19] was pushing the wheelchair while [MHST 20] was holding [the patient's] legs up with a blanket, so [their] feet didn't drag on the ground. Halfway there, [MHST 17] swapped out with [MHST 20] and carried the patient's legs in a blanket. Once we got to the patient's new unit, LH1, [RN 13] wanted to assess the patient in [their] room (Room# G02-143) so [RN 13] and security staff lifted the patient from the chair to the bed. [RN 13] sent someone to grab the vitals machine while [they] continued to rub on the patient's chest, tap [their] shoulders, and shout [their] name. I stood out in the hallway due to patients walking by the room, redirecting them as they came near."

8. Incident documentation recorded by MHST 17, dated 04/18/2024 and untimed, reflected that "When I arrived at Sally Port 8, I saw the admission, [Patient 1] slouched down in a wheelchair unresponsive with closed eyes. Admission [RN 4] asked the two deputies from Douglas County how [Patient 1] has [sic] been on the way over from Douglas County? One of the deputies stated, 'This is how [the patient] always, [sic] is unresponsive and is catatonic.' [RN 4] was attempting to get a response from [the patient]. One of the deputies stated, '[the patient] is not violent we just needed to get [them] out of the truck by force because [they were] not cooperating with us.' [RN 4] stated [they] did not want to transport [Patient 1] in the wheelchair with [their] feet being dragged. [TMHA 19] stated we can use a blanket to hold [the patient's] feet up and have someone hold the blanket while escorting the patient. [MHST 20] began to assist with holding the blanket while [TMHA 19] was pushing the wheelchair to Lighthouse 1. I relived [sic] [MHST 20] due to [them] needing a break. Once we arrived on Lighthouse 1 in the main entry hall, [the patient] continued to slide down in the wheelchair I asked security to assist me in helping move up [Patient 1] in the wheelchair. Staff then entered the south hall and went into room G02-143. [RN 13] and [TMHA 19] and I assisted [the patient] to [their] bed. [RN 13] began to do an assessment on [the patient] and began to check [their] pulse on [their] right wrist, [RN 13] stated [they were] not feeling any pulse."

9. Incident documentation recorded by SOS 31, dated 04/18/2024 and untimed, reflected they were "Sending this incident report on the behalf of [MHST 14]. sometime early this morning before 11 o'clock security was called over the radio to assist with an admission at Sallyport 8. Myself and [MHST 32] responded. We walked into the foyer area. To the left of me, I saw [Patient 1] sitting in a wheelchair, patient was slightly slumped or slouched in the wheelchair. Eyes closed with a blanket placed around the cuff [sic] area/torso. Patient had jail clothes on with no shoes or socks. Patient had belly chain and wrist restraints, but no ankle restraints from what I saw. The deputies from Douglas County jail stated that the patient was unresponsive. I heard someone unknown to me reference the unresponsiveness to being catatonic, at which the deputies responded yes but that is normal for [the patient]. They proceeded to state that the patient is not assaultive hasn't been since being there in the jail but that [they] just [don't] respond. The admission nurse [RN 4] requested the deputies remove the cuffs. The cuffs were removed. [MHST 20] put a blanket underneath the patients legs, lifting them in the air to not drag on the ground. [TMHA 19] pushing the wheelchair. We got Halfway to the bubble, we stopped so that [MHST 20] could be swapped out for somebody else and repositioned the patient's body on wheelchair. [TMHA 19] and I then lifted the patient bringing [them] back fully on the chair and proceeded to the patients [sic] room. Unit nurse [RN 13], [TMHA 19] and I lifted the patient out of the wheelchair assisting [them] to the bed. [RN 13] began checking for responsiveness. [RN 13] then requested for the vital machine and code blue to be called. Throughout the remainder of the code blue, I assisted in updating Access Control and Dispatch for on [sic] information from Salem Police and Fire Emts. Patients time of death was 1156."

10. Incident documentation recorded by MHST 20, dated 04/18/2024 and untimed, reflected that "I responded to a call for security assistance at Sally Port 8. When I arrived, I saw Douglas County Deputies and OSH staff were standing around a patient, later identified as [Patient 1], that was in a wheelchair. The Deputies described [the patient] as being catatonic. I asked the Deputies if [the patient] had been responsive at all during the trip, they said that [the patient] was moving up and down in the back of the van. I then turned towards [the patient] and addressed [them] loudly and there was no response. I observed that there was abnormally thick but clear saliva around [their] mouth, I addressed [the patient] again and there was no response. [MHST 18], who was assigned new admissions processing then took a picture of [Patient 1], as part of the admissions process. It was then decided that since [the patient] appeared not to be cooperative with us that we would use a blanket to lift [their] legs so that we could easily transport [them] to Lighthouse 1 via the use of a wheelchair."

11. Incident documentation recorded by TMHA 19, dated 04/18/2024 and untimed, reflected that "The admissions [RN 4] made the decision to have the deputies remove the restraints before we moved the patient to Lighthouse 1, after the restraints where removed I grabbed the wheelchair handles while [MHST 20] held up the patients' legs with the assistance of a blanket while we moved the patient to Lighthouse 1. On arrival to the unit, we moved [the patient] into [their] assigned room (unknown number), the unit nurse who accompanied us from admission to the unit [RN 13] asked that we move [the patient] on the bed. [MHST 14] grabbed the patients left shoulder while I grabbed the right shoulder and [RN 13] grabbed [the patient's] legs and we move [sic] the patient from the wheelchair on to the bed. The patient was still [sic] appeared to be in [sic] catatonic at that time. After assisting with the movement, I left as I was already late for my assigned lunch period."

12. Incident documentation recorded by LH1 NM, dated 04/18/2024 and untimed, reflected that "[LH1 NM] is writing this incident report on behalf of [MHT 33]: I was doing the RCM/SSM checks - I saw [Patient 1] being taken to [their] room via wheelchair and [they] looked lifeless - security pushing [them] in a wheelchair - [the patient's] hands were hanging out to the sides and staff were holding [their] legs to keep [them] in the wheelchair."

13. Incident documentation recorded by LH1 RN 13, dated 04/18/2024 and untimed, reflected that "I was the RN assigned to [Patient 1's] admission along with [MHT2 8]. We were called to the admission Sally Port around 1100 and waited in line as the county had two patients and the first was going to a different unit. [MHT2 8] and I remained outside the Sally Port per protocol, waiting for report from the [AD RN 4]. It was reported that the pt was not cooperating, would not walk, and [AD RN 4] retrieved a wheelchair. Security arrived at the Sally Port, evidently having been paged by admissions. The pt was retrieved from the transport vehicle utilizing the wheelchair and brought into the Sally Port; I was not able to observe the pt from my vantage point outside the Sally Port. It was reported to us that the pt was continuing to be uncooperative and not responding. Two security staff wheeled the pt out of the Sally Port, one pushing [TMHA 19], the other holding the pt's legs up with a blanket draped under [the patient's] ankles ([MHST 20], switched with [MHST 17] at some point). We quickly made our way to LH1; I walked alongside the wheelchair, attempting to engage the pt, explain the plan. We passed the bubble on LH1 at 1111. We had decided to take [Patient 1] directly to [their] room and transfer [them] to [their] bed. On arrival to [patient's] room, security [TMHA 19] and I immediately lifted the pt out of the wheelchair and onto the bed. During that transfer, I noted the pt was more limp than would have been expected from a simply unresponsive pt. I immediately began checking for a pulse on [their] R wrist and began calling [their] name loudly. I performed sternal rubs when I could not elicit a response verbally. When there continued to be n

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Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 1 of 1 patient (Patient 1), review of 4 of 4 AD staff training records (RNs 1, 2, 3, and 4), review of OSH internal investigation documentation, review of medical emergency supplies and equipment documentation, review of medical emergency response documentation, review of training documentation, and review of P&Ps and procedural manuals, it was determined that the hospital failed to fully develop and implement P&Ps that ensured that the nursing services provided were under the supervision of an RN, that patient needs were met by ongoing nursing assessment, and that nursing personnel responded to the nursing and emergency care needs of the patient population of each department.

The cumulative effect of these systemic failures resulted in this Condition-level deficiency that represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited under this Condition at Tag A-392, CFR 482.23(b) - Standard: Staffing and Delivery of Care, that reflects the hospital failed to ensure that the nursing services provided were under the supervision of an RN, and that nursing personnel were knowledgeable regarding patient assessment to ensure appropriate and timely response to the nursing and emergency care needs of the patient population of each department (A392).

2. Refer to the findings cited at Tag A-115, CFR 482.13 - CoP: Patient's Rights, that reflects the hospital failed to fully develop and implement P&Ps that ensured each patient's right to receive care in a safe setting. The hospital's failures to ensure appropriate patient assessment and provisions for response to medical emergencies created an unsafe EOC that potentially contributed to harm and death of one patient and created the likelihood of harm to other patients (Tag A-144).
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29708

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Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 1 of 1 patient (Patient 1), review of 4 of 4 AD staff training records (RNs 1, 2, 3, and 4), review of OSH internal investigation documentation, review of medical emergency supplies and equipment documentation, review of medical emergency response documentation, review of training documentation, and review of P&Ps and procedural manuals, it was determined that the hospital's failures to fully develop and implement P&Ps that ensured nursing services were under the supervision of an RN, and that nursing personnel were knowledgeable and competent to provide appropriate and timely patient assessment and response to the nursing and emergency care needs of the patient population of each department included:
* Failure to ensure AD RN and inpatient RN staff relied upon independent nursing judgement to provide appropriate and timely assessment of patient condition and identification of the need for medical emergency response.
* Failure to ensure RN staff requested the immediate presence of a physician when the patient's unresponsive physical condition was believed to be behavioral versus medical.
* Failure to ensure that an RN supervised the nursing services in the AD and that AD RN practices for patient care were in accordance with, and supported by, written and approved P&Ps, and that they completed organized and documented AD orientation and onboarding that ensured clinical and procedural competency for patient care operations in that department.

Findings include:

1. The findings that follow reflect that RN staff failed to conduct appropriate and timely assessment and vital signs for Patient 1 who arrived at the hospital from jail. When AD RN first observed the patient in the transport vehicle they stated they saw the patient's eyes open briefly. That was the only detectable movement the patient made between the time they were transferred from the back of the transport vehicle until another RN who had accompanied the patient for transport from the AD through the hospital to the inpatient unit checked for a pulse after the transport and entry into the patient's assigned inpatient room. Neither of those RNs made independent decisions using their own nursing judgement that would call for an immediate assessment and emergency response to an unresponsive and motionless person. Instead those RNs inappropriately deferred to, believed without reasoning or questioning, and acted upon DC deputies' characterizations of the patient's unresponsive condition as being purposeful as in "choosing not to walk," "won't stand up," and "refusal to respond," "normal" and "usual," and "catatonic." Those RNs failed to request the immediate presence of a physician to evaluate whether the patient's unresponsive physical condition was behavioral versus medical. Refer to Tag A-144 for additional information regarding Patient 1's encounter.

2. A document titled "OSH Office of Quality Management" was reviewed. It included the following information:
* "Incident Nature: Sentinel Event - Unexpected Patient Death"
* "Date/Time of Incident: 04/18/2024 1115hrs"
* "At approx. 1047 hrs. access control informed admissions Douglas County jail transport were waiting with [Patient 1] for admission to OSH. Staff arrived and the country [sic] transport vehicle entered a Sally Port, at approximately 1054 hrs. Deputies told [RN 4] [that Patient 1] would need a wheelchair because [they were] 'catatonic' and at times 'flops around like a fish'. This was reported to have been described to nursing staff as normal behavior by [Patient 1]. As [Patient 1] was transferred from the transport van to the wheelchair, at approximately 1101 hrs, the admission [RN 4] reported [they] observed [Patient 1's] eyes open and close, possibly in response to light hitting [Patient 1's] eyes. [Patient 1] was wheeled into OSH admissions at approximately 1102 hrs. Additional staff were called to the admissions area and assisted in photographing [Patient 1] for identification. Douglas County transport restraints were removed from [Patient 1] and [they were] taken, via wheelchair, to Lighthouse 1 by OSH Staff. During this process [Patient 1] was noted as not moving on [their] own accord and staff held the patients [sic] legs up with a blanket so [their] feet would not drag on the floor. Staff and the patient arrived on the unit at approx. 1107hrs. where the patient was taken directly to a patient room. As [Patient 1] was being transferred to the bed an RN decided to check the patient for a pulse and found none. Sternal rubs were done with no response and additional checks found no pulse. A Code Blue was initiated and additional staff arrived and life saving procedures were performed including the use of CPR and an AED. Narcan and epinephrine were administered and were ineffective. Paramedics arrived at approx. 1121hrs and took over life saving efforts. [Patient 1] was pronounced dead at 1156 hrs."

3.a. During review of incident documentation and hospital response with staff that included the Interim DS, DQM, DSC, COP, COM, DOS, PD, BOM1, and AAG on 04/24/2024 beginning at 1440 staff described the hospital's investigation and actions taken to date. A document titled "Investigative Memo," dated 04/24/2024 provided a summary of the information given by staff during the incident and response review on 04/24/2024 and included the following:
* "Date of incident: 4/18/2024"
* "Incident Nature: Unexpected patient death"
* "The purpose of this memo is to document the investigative process and immediate actions associated with the unexpected patient death on 4/18/2024, [Patient 1]."
* "Actions in response to preliminary investigative findings: Video review and policy evaluation identified no policy requirement for vitals check on new admissions. On 4/19/2024 OSH Interim Superintendent [and CMO] memorialized 'CMO Directive - Admission vitals 4-19-24' based on initial investigative findings that vitals were not taken of the patient upon admission."

3.b. Review of the document on OSH letterhead, signed by the CMO/Interim OSHS and dated 04/19/2024, reflected the following:
"To all OSH staff, This CMO Directive modifies and adds to OSH policy 6.058, 'Admissions.' To ensure that patients who may be medically unstable on arrival are promptly assessed and receive necessary medical care as soon as possible, it is my directive, effective April 19, 2024, that:
* An Admissions RN must perform a brief assessment for every patient admitted to OSH, including - at minimum - vital signs and visual observation to identify any medical needs requiring immediate attention, before the patient leaves the Admissions area. This assessment must be documented in the patient's medical record.
* If a patient is not responsive to staff in the Admissions area, the possibility of a medical emergency must be immediately assessed.
* If a patient is too combative to safely obtain vital signs, this must be communicated to the unit RN and documented in the medical record, along with the nature of the patient's behavior.
This directive will remain in effect until policy 6.058 is updated."

4.a. During interview on 04/24/2024 at 1105 with RN 4, they stated they had worked in AD since August 2023. RN 4 provided the following information regarding Patient 1:
* A "Douglas County" transport van pulled into Sally Port 8 drive-in garage. The deputies said the patient would need a wheelchair because they had not been able to get into the van themselves and had been "flopping around like a fish." The deputies stated that was the patient's baseline.
* RN 4 stated they got a wheelchair for the patient and went to the back of the van with a security staff. The patient, who was in the back of the van, "opened their eyes and moved a little". RN 4 introduced themselves to the patient. The deputies told the patient, "We'll get you out [of the van]" and the patient closed their eyes. RN 4 stated "I thought [the patient was] not being cooperative" and asked for more security staff. RN 4 stated 5-6 security staff came. The deputies gave the patient a few minutes to get out of the van and when they did not, the deputies lifted the patient to the wheelchair. RN 4 stated the deputies held the patient's legs up while they wheeled the patient backwards from the van into the AR.
* RN 4 stated in the AR "we got a photo of the patient for [their] ID" and the deputies said it would be OK to remove the patient's cuffs because they had never been aggressive. The deputies removed the cuffs. The patient was not able to hold their head up and "kept [their] eyes closed." RN 4 stated the patient was slouched with their head to one side, and "not holding it up like a normal person holds their head."
* RN 4 stated "typically we take a temperature and ask about a cough" in the AR. RN 4 stated they did not check the patient's temperature or any other vital signs and did not ask the patient if they had a cough. When RN 4 was asked if the patient was breathing, they stated, "I didn't observe any chest rise and fall." In response to the surveyor's follow-up question in regard to indications of oxygenation such as the patient's skin color and appearance, RN 4 additionally stated that the patient "was African American, had dry skin, and I didn't notice anything abnormal."
* RN 4, a unit nurse, and security staff pushed the patient in the wheelchair from the AR to LH1. One of the security staff lifted the patient's legs with a blanket so their legs wouldn't drag. When they got to the patient's room on the unit, the unit RN and 2 security staff laid the patient supine on the bed. RN 4 stated, "At that point, I knew something was off because there was no response from the patient, so I checked for a pulse. Nothing. I checked a sternal rub and nothing." The patient had no pulse and was not breathing, and they called a code blue.

4.b. Incident documentation recorded by AD RN 4, dated 04/18/2024 and untimed, reflected that "Access control called the main admissions office phone at around 10:47 to report that Douglas County was waiting to get into Sally port 8 for an admission. Douglas County was scheduled to drop off two admits to OSH today on 4/18. [Patient 26] who was scheduled to admit to FW1, and [Patient 1] was scheduled to admit to LH1. The Douglas county transport van was waiting in the circle outside of OSH for roughly 5-10 minutes, due to there being a secure transport van in Sally Port 8. [RN 3] admissions RN, went outside Sally port 9 to talk to the Douglas county officers to find out how the pts were doing. When [RN 3] came back through Sally port 9, [they] reported to me ([RN 4] Admissions RN) that the officers said [Patient 1] will need a 'wheelchair' because [the patient] 'flops around like a fish' and is 'catatonic'. After secure transport left Sally port 8. Douglas county pulled into Sally port 8. FW3 unit staff showed up first, and [RN 3] who was assigned to admit [Patient 26] brought in [Patient 26] and introduced them to the FW3 staff and that pt was taken to FW3. [Patient 1's] unit staff from LH1 ([RN 13] along with unit MHT) showed up next. I was assigned to admit [Patient 1] as I had done [their] pre-admit note in avatar as well as a nurse to nurse with the jail RN. The deputy standing in the admissions area adjacent to Sally port 8 then reported to me, '[Patient 1] won't stand up, [they're] catatonic. [They'll] need a wheelchair'. RN asked the deputy '[They] won't stand at all?', and deputy responded 'No'. Wheelchair and a blanket was obtained by this RN. [MHST 18] was the security assigned to help with admissions for 4/18. As Sally port 8 doors were opened by access control, [MHST 18] held open the doors while this RN followed deputies to the back of the van with the wheelchair. The deputies opened up both doors to the back of the van. [Patient 1] was seen sitting in a slumped position with [their] back against van partition. As soon as the van doors opened, there was sunlight that came streaming into the back of the van, and this RN could see [Patient 1's] eye open and close. Deputies said to [Patient 1] that they needed [them] to get into the wheelchair and gave [the patient] a few seconds but pt did not make any movements or indication that [they were] going to get up. Deputies then assisted pt on either side and lifted the pt into the wheelchair. RN introduced [themselves] to [Patient 1] and explained [they were] at the hospital but pt did not respond. RN asked for pt to lift [their] legs, so [they] could be wheeled, but [Patient 1] did not lift [their] legs. Both deputies each lifted one of the pt's legs by the pant leg so [the patient's] heels would not be dragging, and this RN wheeled [Patient 1] backwards into the adjacent admitting room connected to Sally port 8. [MHST 18] had called for additional security at the request of this RN, who were also present in the admitting area. A photo was obtained of [the patient] for [their] ID badge for security, but [they] did not open [their] eyes. This RN was assessing whether or not the cuffs should be removed in the admitting area, or on the unit for safety, when officers reported that they did not see [the patient] as a threat, and [they] had 'never been physically violent'. This RN gave the directive for officers to remove the cuffs as pt was not exhibiting any signs of aggressive behaviors. Cuffs were removed by officers. Pt was wheeled by security to LH1, with one security wrapping a blanket underneath pt's legs and lifting them up so they did not drag on the floor. Admissions RN and unit staff followed as well. Pt was taken onto LH1 unit, and down one of the first hallways on the right hand side as you enter the unit, where the pt's assigned bedroom was. Pt was wheeled into [their] room, and staff informed [the patient] that it was [their] bedroom and [they] could get up. One staff member said '[Patient] won't get up, [they're] catatonic'. Security and unit RN and another staff lifted the pt onto the bed. Pt was now in a supine position on the bed. Unit RN, [RN 13], then began doing [their] assessment. [RN 13] tried verbal stimuli, yelling pt's name, checking radial and pedal pulse, checked for breathing. This RN checked for radial pulse on the right side, and there was no pulse felt. This RN confirmed with [RN 13] there was no pulse. Compressions were started, and a code blue was called on the radio by security. Crash cart was obtained with AED. Pt was moved to the floor in supine position for compressions and ambu bag was used for breath. 911 was called. Two OSH medical doctors arrived. AED advised no shock. EMS arrived and took over care."

5. Incident documentation recorded by LH1 RN 13, dated 04/18/2024 and untimed, reflected that "I was the RN assigned to [Patient 1's] admission along with [MHT2 8]. We were called to the admission Sally Port around 1100 and waited in line as the county had two patients and the first was going to a different unit. [MHT2 8] and I remained outside the Sally Port per protocol, waiting for report from [AD RN 4]. It was reported that the pt was not cooperating, would not walk, and [AD RN 4] retrieved a wheelchair. Security arrived at the Sally Port, evidently having been paged by admissions. The pt was retrieved from the transport vehicle utilizing the wheelchair and brought into the Sally Port; I was not able to observe the pt from my vantage point outside the Sally Port. It was reported to us that the pt was continuing to be uncooperative and not responding. Two security staff wheeled the pt out of the Sally Port, one pushing [TMHA 19], the other holding the pt's legs up with a blanket draped under [the patient's] ankles ([MHST 20], switched with [MHST 17] at some point). We quickly made our way to LH1; I walked alongside the wheelchair, attempting to engage the pt, explain the plan. We passed the bubble on LH1 at 1111. We had decided to take [Patient 1] directly to [their] room and transfer [them] to [their] bed. On arrival to [patient's] room, security [TMHA 19] and I immediately lifted the pt out of the wheelchair and onto the bed. During that transfer, I noted the pt was more limp than would have been expected from a simply unresponsive pt. I immediately began checking for a pulse on [their] R wrist and began calling [their] name loudly. I performed sternal rubs when I could not elicit a response verbally. When there continued to be no response I requested staff call a code blue (code was called @ 1114). I then attempted to find a pulse under [the patient's] upper arm, carotid, pedal while continuing to attempt to rouse [them] verbally and with sternal rubs and watch for chest rise (this was difficult to assess as [the patient] was in loose fitting jail clothing). I pulled open [the patient's] eye lid and noted a dilated pupil; I used my flashlight to test reactivity and no reactivity was seen. Staff arrived quickly and we began chest compressions (@ 1115). Staff arrived with the AED and crash cart. After applying the AED pads, we transferred the pt to the floor to have a more firm surface and continued compressions alternating with AMBU bag respirations following CPR protocol. Narcan was requested and administered by [PMHNP 23]. Various staff and medical personnel rotated through administering compressions and AMBU respirations. CPR was continued per protocol, following prompts from AED (no shock ever advised) until paramedics arrived and took over the situation."

6.a. The incident documentation described under Findings 6.b. through 6.g. below include further indications that Patient 1's unresponsive and concerning condition was evident yet RN 4 failed to assess and respond and allowed staff to remove the patient's motionless body from the AD and transport them throughout the hospital, and RN 13 failed to assess and respond at the time they assumed care of the patient outside of the AD.

6.b. Incident documentation recorded by MHST 18, dated 04/18/2024 and untimed, reflected that "I, [MHST 18], was the admissions security staff to assist during the admit with the new patient [Patient 1]. There were two patients from Douglas County admitting today and [Patient 1] was the second one to come in at approximately 1105. When the Deputies arrived, they had let us know that this patient was not talking or moving but that this was usual for [them]. They recommended that we bring a wheelchair due to [the patient] choosing not to walk but that it was "[their] normal" per the deputy. They mentioned that they had to help place [Patient 1] into the vehicle to bring [them] here to OSH. [AD RN 4] took a wheelchair to the van where the patient was sitting. The officers asked the patient to exit the vehicle a couple times to which the patient did not move. I am unsure as to who helped the patient exit the vehicle and place [them] into the wheelchair. I stood holding the door at sallyport 8 open and called for additional security. Additional security responded. [AD RN 4] introduced [themself] when [they] entered the building, then I introduced myself and let [the patient] know I would be taking [their] photo for [their] OSH ID badge. I took [the patient's] photo. [AD RN 4] asked [the patient] to contract for safety and there was no response. The deputies assured us that the patient would be safe and that this is just how [they were]. So [AD RN 4] gave them the go ahead to remove the cuffs. Another security staff asked, "is [the patient] catatonic?" and the deputies responded saying "pretty much."

6.c. Incident documentation recorded by TMHA 19, dated 04/18/2024 and untimed, reflected that "The admissions [RN 4] made the decision to have the deputies remove the restraints before we moved the patient to Lighthouse 1, after the restraints where removed I grabbed the wheelchair handles while [MHST 20] held up the patients' legs with the assistance of a blanket while we moved the patient to Lighthouse 1. On arrival to the unit, we moved [the patient] into [their] assigned room (unknown number), the unit nurse who accompanied us from admission to the unit [RN 13] asked that we move [the patient] on the bed. [MHST 14] grabbed the patients left shoulder while I grabbed the right shoulder and [RN 13] grabbed [the patient's] legs and we move [sic] the patient from the wheelchair on to the bed. The patient was still [sic] appeared to be in [sic] catatonic at that time. After assisting with the movement, I left as I was already late for my assigned lunch period."

6.d. Incident documentation recorded by MHST 16, dated 04/18/2024 and untimed, reflected that "... a call came over the radio for additional security assistance at Sallyport 8 with a new admit at 11:03. As I got closer to Sallyport 8 I could see security staff and two sheriff deputies standing in a semicircle around [Patient 1], who was still out of view to me in the admissions room attached to sallyport 8. There were two unit staff, [RN 13] and [MHT2 8], standing outside the room waiting for the admit per protocol, as I tried to quietly enter the room to not disrupt anything. I could see the admissions [RN 4], standing next to [Patient 1] attempting to get [them] to respond and open [their] eyes, but [they] just sat slumped in the wheelchair, in full cuffs, and unresponsive. Someone leaned over to me to let me know that this was a behavior, and I took that to mean that this situation was going to be unpredictable due to this being a new admission with no prior hospitalization. It is protocol to hear the patient agree to safety before we can release [them] from [their] cuffs. The deputies mentioned that [the patient] hadn't been violent, that all their assistance was because [they were] 'catatonic' and refused to respond. I saw that the unit staff had propped open the door to listen, so I stepped out to fill them in on what the deputies had said. When I came back into the room, they started to remove the cuffs, so I left the room again to open doors ahead of them to ease the transportation process. [TMHA 19] was pushing the wheelchair while [MHST 20] was holding [the patient's] legs up with a blanket, so [their] feet didn't drag on the ground. Halfway there, [MHST 17] swapped out with [MHST 20] and carried the patient's legs in a blanket. Once we got to the patient's new unit, LH1, [RN 13] wanted to assess the patient in [their] room (Room# G02-143) so [RN 13] and security staff lifted the patient from the chair to the bed. [RN 13] sent someone to grab the vitals machine while [they] continued to rub on the patient's chest, tap [their] shoulders, and shout [their] name. I stood out in the hallway due to patients walking by the room, redirecting them as they came near."

6.e. Incident documentation recorded by MHST 17, dated 04/18/2024 and untimed, reflected that "When I arrived at Sally Port 8, I saw the admission, [Patient 1] slouched down in a wheelchair unresponsive with closed eyes. Admission [RN 4] asked the two deputies from Douglas County how [Patient 1] has [sic] been on the way over from Douglas County? One of the deputies stated, 'This is how [the patient] always, [sic] is unresponsive and is catatonic.' [RN 4] was attempting to get a response from [the patient]. One of the deputies stated, '[the patient] is not violent we just needed to get [them] out of the truck by force because [they were] not cooperating with us.' [RN 4] stated [they] did not want to transport [Patient 1] in the wheelchair with [their] feet being dragged. [TMHA 19] stated we can use a blanket to hold [the patient's] feet up and have someone hold the blanket while escorting the patient. [MHST 20] began to assist with holding the blanket while [TMHA 19] was pushing the wheelchair to Lighthouse 1. I relived [sic] [MHST 20] due to [them] needing a break. Once we arrived on Lighthouse 1 in the main entry hall, [the patient] continued to slide down in the wheelchair I asked security to assist me in helping move up [Patient 1] in the wheelchair. Staff then entered the south hall and went into room G02-143. [RN 13] and [TMHA 19] and I assisted [the patient] to [their] bed. [RN 13] began to do an assessment on [the patient] and began to check [their] pulse on [their] right wrist, [RN 13] stated [they were] not feeling any pulse."

6.f. Incident documentation recorded by MHST 20, dated 04/18/2024 and untimed, reflected that "I responded to a call for security assistance at Sally Port 8. When I arrived, I saw Douglas County Deputies and OSH staff were standing around a patient, later identified as [Patient 1], that was in a wheelchair. The Deputies described [the patient] as being catatonic. I asked the Deputies if [the patient] had been responsive at all during the trip, they said that [the patient] was moving up and down in the back of the van. I then turned towards [the patient] and addressed [them] loudly and there was no response. I observed that there was abnormally thick but clear saliva around [their] mouth, I addressed [the patient] again and there was no response. [MHST 18], who was assigned new admissions processing then took a picture of [Patient 1], as part of the admissions process. It was then decided that since [the patient] appeared not to be cooperative with us that we would use a blanket to lift [their] legs so that we could easily transport [them] to Lighthouse 1 via the use of a wheelchair."

6.g. Incident documentation recorded by LH1 NM, dated 04/18/2024 and untimed, reflected that "[LH1 NM] is writing this incident report on behalf of [MHT 33]: I was doing the RCM/SSM checks - I saw [Patient 1] being taken to [their] room via wheelchair and [they] looked lifeless - security pushing [them] in a wheelchair - [the patient's] hands were hanging out to the sides and staff were holding [their] legs to keep [them] in the wheelchair."

7. On 04/24/2024 beginning at 1155, survey team review of multiple camera views of video-recordings, without audio capability, revealed the following timeline of events that occurred on 04/18/2024 when the vehicle Patient 1 was transported in from Douglas County Jail arrived to the OSH Sally Port 8. Regarding the video review there was no camera view provided in Sally Port 8 that showed directly into the back of the transport van used to transport Patient 1 so that the entirety of the inside of the van could be visualized. The camera that showed the view at the back of the van was mounted off to the side of the Sally Port so that a side view of the right rear of the van could be visualized. With both rear van doors opened only a small portion of the inside of the back compartment could be seen. In addition, the quality and clarity of some of the video footage was poor and details of some images were not clear. Further, there were occasions during video review where video skipped several seconds when there was activity occurring. Commonly video may skip seconds or minutes when there is no activity occurring.

* Between ~ 1054:52 and 1056:23 two camera views inside Sally Port 8 showed: A DC Jail transport van drove into Sally Port 8 with two DC deputies seated in the front seats. The garage door closed after the van had fully entered the Sally Port. A DC deputy walked to the back of the van, opened one of the back doors, removed two bundles of items, and walked away towards the door to the admitting room. At ~ 1056:07 Patient 26 exited the van through the passenger right side doors and walked in front of the second DC deputy towards the door to the admitting room.

* Between ~ 1058:18 and 1100:20 one camera view inside Sally Port 8 showed: A DC deputy walked back to the back of the van, opened one of the back doors and looked inside momentarily, then started to close the door, then reopened it and looked inside and left it open. They stood at the back of the van and periodically looked inside through the open door.

* Between ~ 1100:21 and 1102:20 two camera views inside Sally Port 8 showed: The second DC deputy approached the back of the van and joined the first deputy, immediately followed by RN 4 who pushed a w/c towards the back of the van. The deputies opened the other door so that both back van doors were open. At ~ 1100:28 only a portion of Patient 1's lower body was visualized up against the rear left side of the van. They were positioned on the floor so that their body was facing the interior of the left rear corner side panel of the van, their left buttocks could be seen on the van floor, the left side of their body was at the very end of the floor where the door closure was, their left leg was observed to be bent at the knee and had partially fallen outside of the van. The two deputies picked Patient 1 up off the van floor and in awkward and uncoordinated movements took the patient out of the van and rotated them to place them in the w/c. There was no indication that Patient 1 was assisting or resisting. The parts of their body that could be visualized were limp. Patient 1, who was Black, was positioned in the w/c with their shoulders at the level of the top of the w/c seat back, their head slumped fully forward towards their chest, and their eyes closed. RN 4 folded a blue blanket and place it around Patient 1's chest and shoulders and wrapped the ends around the w/c handles. At 1101:38 as the RN began to pull the w/c backward towards the admitting room Patient 1's upper body was observed to be positioned lower in the w/c and slumped toward the left. As their head was slumped forward, the lower part of their face, including mouth and nose, was covered by the blue blanket. At ~ 1102:01 as RN 4 pulled the w/c backwards along the side of the van towards the admitting room door, both deputies bent over the patient and made movements consistent with each having picked up one of the patient's pants legs to lift the patient's feet off the ground.

* At ~ 1102:24 one camera view inside the admitting room attached to Sally Port 8 showed: RN 4 pulled the w/c with Patient 1 backward into the admitting room. One deputy had hold of the patient's right pant leg near the hem with their right hand. The other deputy had hold of the patient's left pant leg near the middle of the pant leg with their left hand. Both of the patient's bare feet were dangling slightly above the floor. The patient's hands were cuffed in their lap. Their head was slumped forward, their eyes were closed, and their face was covered by the blue blanket that was held in place by RN 4 around their chest and shoulders and the w/c handles.

* Between ~ 1102:30 and 1105:50 one camera view inside the admitting room showed: RN 4 parked Patient 1 in the w/c near the middle of the room. The deputies' positions around the patient's body periodically block the camera view. At this time four other staff (not including RN 4 and the two deputies) arrived into the room. The RN can be seen to lean over towards the patient on the left side of the w/c and arms are extended toward the patient although the patient cannot be seen behind one of the deputies. At ~ 1103:02 the deputies stepped away and the patient was observed to be slumped further down in the w/c, however, the patient's face was no longer covered by the blue blanket that remained around their chest and shoulders. It looked as though RN 4 had their right hand on or near the blanket below the patient's face as if they moved the blanket to uncover the patient's face. The patient was motionless and their eyes were closed. At that time there were at least six other staff in the room. RN 4 stepped away and back from the w/c and was observed to address the deputies and staff that had gathered in the room who all stood and faced the patient within a few feet of the patient. Two of those staff stepped towards and leaned towards the patient and took photographs of the patient with cell phones. Then there were eight other staff in the room. The 11 people in the room (excluding the patient) were observed to talk amongst themselves and to the group while Patient 1 remained motionless in the w/c with their wrists in law enforcement transport restraints, their chin laid on their chest, and their eyes closed. Patient 1 showed no signs of movement. At ~ 1104:18 RN 4 slightly leaned toward the patient, extended their arm, and may have touched the blue blanket, the patient's clothing near their shoulder, or the w/c. It was not clear. At ~ 1104:24 one of the staff persons approached the patient, leaned toward them, and extended their arm towards the patient. There was no visible response or movement from Patient 1. At ~ 1104:29 a DC d

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Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 1 of 1 patient (Patient 1), review of 4 of 4 AD staff training records (RNs 1, 2, 3, and 4), review of OSH internal investigation documentation, review of medical emergency supplies and equipment documentation, review of medical emergency response documentation, review of training documentation, and review of P&Ps and procedural manuals it was determined that the hospital failed to comply with the CFR 482.60(b), Meet Hospital CoPs, under the "Special Provisions Applying to Psychiatric Hospitals," that required the hospital meet all CoPs specified in CFRs 482.1 through 482.23 and CFRs 482.25 through 482.57

The cumulative effect of these systemic failures resulted in this Condition-level deficiency that represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer the findings cited under this Condition at Tag A-1605, CFR 482.60(b) - Standard: Meet Hospital CoPs, that reflects the hospital failed to comply with the following CoPs (Tag A-1605):
* CFR 482.12 - CoP: Governing Body
* CFR 482.13 - CoP: Patient's Rights
* CFR 482.23 - CoP: Nursing Services

2. Refer to the findings cited at Tag A-043, CFR 482.12 - CoP: Governing Body, that reflects the governing body failed to ensure the provision of safe and appropriate care to patients in the hospital in a manner that complied with all CoPs. Those findings included for this hospital that did not have a dedicated Emergency Department, failure to ensure appropriate assessment and initial treatment of individuals anywhere on the hospital's campus who exhibited a need for a medical emergency response (Tag A-093).

3. Refer to the findings cited at Tag A-115, CFR 482.13 - CoP: Patient's Rights, that reflects the hospital failed to fully develop and implement P&Ps that ensured each patient's right to receive care in a safe setting. The hospital's failures to ensure appropriate patient assessment and provisions for response to medical emergencies created an unsafe EOC that potentially contributed to harm and death of one patient and created the likelihood of harm to other patients (Tag A-144).

4. Refer to the findings cited at Tag A-385, CFR 482.23 - CoP: Nursing Services, that reflects the hospital failed to fully develop and implement P&Ps that ensured that the nursing services were under the supervision of an RN, that patient needs were met by ongoing nursing assessment, and that nursing personnel responded to the nursing and emergency care needs of the patient population of each department (Tag A-392).
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29708

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Based on observations, review of video recordings, interviews, review of incident and medical record documentation for 1 of 1 patient (Patient 1), review of 4 of 4 AD staff training records (RNs 1, 2, 3, and 4), review of OSH internal investigation documentation, review of medical emergency supplies and equipment documentation, review of medical emergency response documentation, review of training documentation, and review of P&Ps and procedural manuals it was determined that the hospital failed to comply with all CoPs specified in CFRs 482.1 through 482.23 and CFRs 482.25 through 482.57 as the following CoPs were determined to be out of compliance:
* CFR 482.12 - CoP: Governing Body
* CFR 482.13 - CoP: Patient's Rights
* CFR 482.23 - CoP: Nursing Services

The cumulative effect of these systemic failures resulted in this Condition-level deficiency that represents a limited capacity on the part of the hospital to provide safe and adequate care.

Findings include:

1. Refer to the findings cited at Tag A-043, CFR 482.12 - CoP: Governing Body, that reflects the governing body failed to ensure the provision of safe and appropriate care to patients in the hospital in a manner that complied with all CoPs. Those findings included for this hospital that did not have a dedicated Emergency Department, failure to ensure appropriate assessment and initial treatment of individuals anywhere on the hospital's campus who exhibited a need for a medical emergency response (Tag A-093).

2. Refer to the findings cited at Tag A-115, CFR 482.13 - CoP: Patient's Rights, that reflects the hospital failed to fully develop and implement P&Ps that ensured each patient's right to receive care in a safe setting. The hospital's failures to ensure appropriate patient assessment and provisions for response to medical emergencies created an unsafe EOC that potentially contributed to harm and death of one patient and created the likelihood of harm to other patients (Tag A-144).

3. Refer to the findings cited at Tag A-385, CFR 482.23 - CoP: Nursing Services, that reflects the hospital failed to fully develop and implement P&Ps that ensured that the nursing services were under the supervision of an RN, that patient needs were met by ongoing nursing assessment, and that nursing personnel responded to the nursing and emergency care needs of the patient population of each department (Tag A-392).
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29708