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Based on medical record reviews, interviews with staff, a review of policies and procedures, an Emergency Department (ED) staff grid, an ED assignment sheet, and observations made during the investigation, it was determined the facility failed to ensure that nursing staff properly assessed and reassessed two patients (P) (P#1 and P#3) out of five sampled patients (P#2, P#4, and P#5) while receiving care at the facility.


Cross refer to A-0392 as it relates to the facility's failure to ensure nursing staff appropriately reassessed two patients (P#1 and P#3) of five sampled patients while receiving care at the facility.

Based on medical record reviews, interviews with staff, a review of policies and procedures, an Emergency Department (ED) staff grid, an ED assignment sheet, and observations made during the investigation, it was determined the facility failed to ensure that nursing staff properly assessed and reassessed two patients (P) (P#1 and P#3) out of five sampled patients (P#2, P#4, and P#5) while receiving care at the facility.

Findings:

A medical record (MR) review revealed that P#1 was a 30-year-old male who presented to the ED on 12/9/22 at 11:01 p.m. via emergency medical services (EMS) for a psychiatric evaluation. P#1 was roomed in the psychiatric unit at 11:49 p.m.

On 12/10/22 at 11:46 a.m., P#1's physician progress note revealed that P#1 was in no acute distress, ready to go home, and awaiting psychiatry evaluation.

On 12/10/22 at 11:56 a.m., a psychiatry consult note by Physician Assistant (PA) FF revealed that P#1 had a history of a traumatic brain injury and had a metal plate in his head. P#1 had no history of psychiatric illness. P#1 denied suicidal ideation and was not recommended for acute inpatient psychiatric hospitalization. PA FF noted that case management was consulted to provide safe disposition and outpatient resources.

On 12/12/22 at 1:40 p.m., Social Worker (SW) KK documented that P#1 had been homeless for 16 years; SW KK contacted P#1's family member and the State case worker. Additionally, SW KK documented that P#1's placement was pending State approval.

On 12/25/22 at 9:27 p.m., Registered Nurse (RN) CC noted that P#1 was visible on the unit. P#1 was awake and alert, and P#1's airway, breathing, and circulations were intact. P#1 was compliant with medication.

On 12/25/22 at 9:29 p.m., a review of P#1's flow sheet for neurological assessment revealed that P#1 was within normal limits.

On 12/25/22 at 11:31 p.m., P#1's vital signs were as follows: temperature 97.8 degrees (normal 97.5 to 99.0) Fahrenheit, heart rate- 69 beats per minute (normal 60 to 100 beats per minute), respiratory rate-18 breaths per minute (normal-12 to 20) blood pressure 123/69 (normal 120/80), pulse oximetry was not recorded (the amount of oxygen in the blood).

A review of the ED note dated 12/26/22 at 11:52 a.m. by Medical Doctor (MD) AA revealed that P#1 had no events overnight and was awaiting placement by social work. Further review of P#1's MR failed to reveal vital signs or neurological assessment were completed on 12/26/22.

On 12/27/22 at 3:51 a.m., RN EE documented that P#1 was found unresponsive on the mental health unit, and cardiopulmonary resuscitation (CPR) (emergency lifesaving procedure) was started. Additionally, RN EE noted that chest compression and medications were administered.

A review of the ED provider's note by MD JJ revealed that P#1 was found to be unresponsive in the psychiatric area at an unknown downtime. P #1 was unresponsive, pale, cold, and clenched. P#1 expired at 4:08 a.m.

A review of the facility's Behavioral and Monitoring Record revealed that RN BB documented observing and monitoring P#1 every 15 minutes from 12/26/22 at 7:00 p.m. to 12/27/22 at 3:00 a.m .Continued review revealed there were no observations after 3:00 a.m.

A review of P#3's MR revealed that P#1 was admitted to the facility on 12/16/22 at 3:12 p.m. for psychiatric evaluation. A further review of P#3's flow sheet revealed that a shift assessment was completed on 12/16/22 and 12/17/22. Detailed review failed to reveal a shift assessment for P#3 on 12/18/22. P#3 was discharged from the facility on 12/19/22.

An interview took place with Nurse Technician (NT) DD on 2/15/23 at 2:17 p.m. NT DD stated the last time she saw P#1 was on 12/26/22 at 7:00 p.m. at the end of her shift. NT DD said P#1 was lying down; she offered him juice, which he refused, and gave P#1 soap so he could shower. NT DD said P#1 was very quiet in the main room of the behavioral health unit. P#1 did not look ill. NT DD said P#1 was not in restraint or seclusion. NT DD said she did not want to answer questions regarding whether or not the facility was short-staffed due to fear of retaliation.

An interview took place with RN EE on 2/16/23 at 9:30 a.m. RN EE stated she worked mainly in triage and ED rooms but not the behavioral unit. RN EE said she recalled the code that involved P#1. RN EE said RN BB yelled for help, so she ran to offer assistance. RN EE acknowledged RN BB was the only RN working on the behavioral unit when the incident occurred. RN EE said she was unaware of how long P#1 was unconscious before RN BB found him.

An interview with RN II took place on 2/16/23 at 11:00 a.m. RN II stated she could not recall anything specific about P#1 when she cared for him during the day shift on 12/26/22. RN II said all the patients were okay; she completed their vital signs in the morning and gave them food. RN II said the doctor (MD AA) also examined P#1, and a technician (NT DD) was sitting on the unit the entire time. RN II said she was shocked when she heard that P#1 had expired because he had no medical concerns. RN II acknowledged staffing concerns on the unit. RN II said there were occasions when she worked as the charge nurse, was assigned to some ED rooms, and was responsible for the ED behavioral unit.

An interview took place with the ED Director (Dir) HH on 2/16/22 at 11:42 a.m. Dir HH acknowledged concerns with staffing. Dir HH said she sometimes had to work on the floor seven days a week in addition to being the ED director. Dir HH said she was constantly trying to hire more nurses but also experienced people calling out on Family Medical Leave and bereavement. Dir HH said many nurses called out on December 24 through December 26 because it was a holiday. Dir HH said she had made many changes and educated the staff that at least one staff should be assigned to patients on the behavioral health unit constantly. Dir HH said the facility staff provided appropriate care for patients; however, there may be missing documentation at times. Dir HH stated she had not been able to question RN BB, who worked on the unit the night of the incident, because RN BB had been on family leave.

An interview took place with Risk Manager (RM) GG on 2/16/23 at 12:13 p.m. RM GG stated she became aware of the incident with P#1 on 1/3/23 after resuming vacation. RM GG said she reviewed P#1's MR during a preliminary investigation. RM GG said on 1/6/23, the facility made arrangements with P#1's family to view P#1's body at the facility's morgue. RM GG said the facility started a root cause analysis (RCA) on 1/12/23. During the RCA, they identified documentation omissions. Staffing was also a concern the night the incident occurred. RM GG said they reviewed all the medications P#1 received throughout his stay, but there were no concerns with the medication he received at the facility. RM GG said one other thing recognized from the RCA was concerns about home medications. RM GG said when P#1 was at the facility, the staff couldn't tell which home medications P#1 was taking; however, when RM GG met with P#1's family member, RM GG asked if P#1 was on any medication at home. P#1's family member said P#1 had a seizure disorder and was on medication for it. RM GG said the facility was unaware because P#1 was homeless, found by the police, and brought to the hospital. RM GG said the facility would ensure a nurse attempted to call the patient's family, if possible, to confirm what medications they may be receiving at home. RM GG said from a staffing standpoint; the facility was trying to increase staffing.

A review of the facility policy titled "Assessment and Reassessment -Patient," revised 3/11/21, revealed that the goal was to identify patient-specific problems for the development and implementation of a plan of care, incorporating assessment, and continuing reassessment findings in order to adjust the plan of care accordingly to the needs of the patient. Reassessment occurred at regular intervals and would be defined by each discipline based on the patient's diagnosis, care setting, significant changes in condition, and response to any previous care in order to determine the patient's response to intervention. Specific patient populations, such as emotional-behavioral needs, alcoholism/drug dependencies, and possible abuse or neglect, had special assessment needs.

A review of the facility policy titled "Patient Rights and Responsibilities," revised 8/9/22, revealed that the patient had the right to receive care in a safe setting.

A review of the facility policy titled "Staffing Policy Plan," revised 1/11/23, revealed the goal of staffing each nursing unit was to ensure patient safety in healthcare delivery. Nurses were scheduled to provide quality/safe care. Further review of the policy revealed that staffing levels were assessed, and adjustments were made for staff assignments based on the needs of the patient. Patient care workload fluctuated and, therefore, required ongoing assessment and planning to ensure that adequate and qualified staff was available to meet patient care needs.

A review of the ED assignment sheet from 12/26/2022 at 7:00 p.m. to 12/27/2022 at 7:00 a.m. revealed that RN BB was assigned to ED rooms 17, 18,19, and 20 as well as the ED's behavioral health unit. In addition, RN BB was assigned as the charge nurse.

A review of the ED staff grid for 12/27/22 revealed a daily census of 136 patients, eight RNs, and five RNs on the day and night shifts, respectively.

A tour of the ED behavioral health unit was conducted on 2/15/23 at 11:15 a.m. with ED director (Dir) HH. The ED behavioral health unit consisted of two rooms with four beds each, a main area with six beds, two seclusion rooms, and a nursing station. There were no bathrooms attached to the seclusion rooms. Dir HH explained that patients in seclusion would be provided a urinal or accompanied to the bathroom by the staff with security assistance. Dir HH said the patient-to-nurse ratio at the behavioral health unit was eight patients to one nurse. Dir HH explained that she tried to have at least one staff member on the unit. Dir HH further explained that patients that required one-to-one observation were monitored from the nursing station through the video monitoring system. Dir HH said every room had a surveillance camera. Dir HH said if the staff on the unit needed assistance, they would call the charge nurse. Dir HH further explained that if the charge nurse was busy, they had to prioritize and respond to the most urgent needs.