HospitalInspections.org

Based on policy review, medical record review, document review, video recording review and interview, the facility failed to ensure patients' rights were promoted to receive care in a safe setting for one of one (Patient #1) patients who was placed in the Needs Assessment and Referral Center (NARC) Intake area for assessment and observation and was left unattended for 32 minutes, found non-responsive and later died in another acute care hospital (Hospital #2) due to anoxic brain injury.

The findings included:

1. Review of the "Admission Procedure" policy dated "06/2022" revealed, "...PROCEDURE... A safety search will be conducted in NARC prior to patient being escorted to the unit...Admitted patient to interview room and situate comfortable and conduct safety search..."

2. Review of the "Patient Observation Guidelines" policy dated "06/2021" revealed, "... PROCEDURE... The physician shall order one of five (5) levels of observation at the time of admission and may change the level of observation if the patients condition warrants a change..."

3. Review of the "Risk Reduction Guidelines" policy dated "03/2022" revealed, "... POLICY...It is the policy of [Named Hospital] that patients who exhibit high risk behaviors (...exhibiting medically compromised conditions) will be placed on appropriate precautions to minimize the threat of injury or harm... PROCEDURE...Patients are assessed upon admission and reassessed throughout hospitalization...for any...medical history that demonstrates a need for high risk precautions. Patients who require increased levels of supervision are placed on precautions through the following process...Early Identifiers...Medically Compromised...High Risk Opiate - patients at risk of opioid use disorder, especially those with past history of overdose, history of substance use disorder, high opioid dosages and concurrent benzodiazepine use...The interdisciplinary team will implement specific behavioral interventions based on the high-risk behaviors identified...1. A comprehensive evaluation will be performed and documented on all individuals assessed by the Needs Assessment and Referral Center (NARC) Staff...3. NARC staff will notify the nursing unit via the High Risk Alert Form of all high risk precautions...Opioid use...4. During the admission process, the patient and their belongings will be checked for items that could be used for self-injury...6. NARC staff will contact the physician for individuals assessed to be at risk for harm to self/others..."

4. Review of the "Registration Process" policy dated "03/2022" revealed, "... PROCEDURE...1. Upon entering the facility, prior to the assessment process, all individuals will be provided with a Registration Form to complete...2. The information provided will be used to assist the Needs Assessment and Referral [NARC] Staff in providing the most appropriate recommendations to individuals seeking services..."

5. Review of the "Portable Metal Detector" policy dated "03/2022" revealed, "... POLICY...At the time of admission, all patients will be scanned with the wand for metallic contraband...PROCEDURE...1. Prior to wanding a patient...The patient's belongings (bags, suitcases, purses, briefcases, etc.) will be secured in the locked area in the needs assessments...Any patient brought to the unit [admitted as an inpatient] will receive a further physical search conducted by nursing staff. Nursing staff will confiscate any contraband found on the patient or in their belongings..."

6. Review of the "...Medical Screening Examination and Stabilization" policy dated "07/2021" revealed, "... POLICY...It is the policy of [Named Hospital] to assess, stabilize and/or appropriately transfer individuals who come to [Named Hospital] with an emergency condition. Qualified Medical Professionals (QMP's) will provide an appropriate medical screening examination for any individual who comes to [Named Hospital] and requests an examination to determine whether the person has an emergency medical condition...PROCEDURE...Definition..."Comes to [Named Hospital] means with respect to an individual requesting examination or treatment that the individual is on the hospital property..."property" means the entire hospital campus..."

7. Medical record review revealed Patient #1, a 42-year-old Caucasian female presented to Hospital #1 for admission on 7/26/22 as an inpatient due to drug abuse. Patient #1 was diagnosed with Major Depressive Disorder with Severe Psychotic features.

During video recording review on 7/26/22 from 3:49 PM to 4:21 PM, Patient #1 was left unattended for 32 minutes in the NARC intake area. Patient #1 was lethargic and visibly wobbling her head.

Patient #1 was found unresponsive with no pulse, and no respiratory effort. Cardiopulmonary Resuscitation (CPR) was initiated, 911 was called, with paramedics/Emergency Medical Technicians (EMT's) arriving within 10 minutes. Respirations were recovered and Patient #1 was transported to Hospital #2. Patient #1 was admitted to the Intensive Care Unit (ICU) on life support. On 7/30/22 life support was removed after tests revealed no brain activity.

Patient #1 expired on 7/30/2022 due to anoxic brain injury.

The facility failed to implement interventions to ensure the safety of all patients in the admissions area and resulted in the subsequent death of a patient.

Refer to A-144

Based on policy review, document review, medical record review, video recording review, and interview, the facility failed to ensure patients' rights were promoted to receive care in a safe setting for one of one (Patient #1) patients who was left unattended in the Needs Assessment Referral Center (NARC) Intake area for a period of 32 minutes, was subsequently found non-responsive, and transferred to Hospital #2 and later died due to anoxic brain injury.

The findings included:

1. Review of the "Admission Procedure" policy dated "06/2022" revealed, "...PROCEDURE... A safety search will be conducted in NARC [Needs Assessment and Referral Center] prior to patient being escorted to the unit...Admitted patient to interview room and situate comfortable and conduct safety search..."

2. Review of the "Patient Observation Guidelines" policy dated "06/2021" revealed, "... PROCEDURE... The physician shall order one of five (5) levels of observation at the time of admission and may change the level of observation if the patients condition warrants a change..."
(This policy was for admitted inpatients. At the time of this incident, the hospital did not have an observation policy for patients being assessed and observed in the NARC prior to actual admission to this hospital as an inpatient.)

3. Review of the "Risk Reduction Guidelines" policy dated "03/2022" revealed, "... POLICY...It is the policy of [Named Hospital] that patients who exhibit high risk behaviors (...exhibiting medically compromised conditions) will be placed on appropriate precautions to minimize the threat of injury or harm... PROCEDURE...Patients are assessed upon admission and reassessed throughout hospitalization...for any...medical history that demonstrates a need for high risk precautions. Patients who require increased levels of supervision are placed on precautions through the following process...Early Identifiers...Medically Compromised...High Risk Opiate - patients at risk of opioid use disorder, especially those with past history of overdose, history of substance use disorder, high opioid dosages and concurrent benzodiazepine use...The interdisciplinary team will implement specific behavioral interventions based on the high-risk behaviors identified...1. A comprehensive evaluation will be performed and documented on all individuals assessed by the Needs Assessment and Referral Center (NARC) Staff...3. NARC staff will notify the nursing unit via the High Risk Alert Form of all high risk precautions...Opioid use...4. During the admission process, the patient and their belongings will be checked for items that could be used for self-injury...6. NARC staff will contact the physician for individuals assessed to be at risk for harm to self/others...."

4. Review of the "Registration Process" policy dated "03/2022" revealed, "... PROCEDURE...1. Upon entering the facility, prior to the assessment process, all individuals will be provided with a Registration Form to complete...2. The information provided will be used to assist the Needs Assessment and Referral [NARC] Staff in providing the most appropriate recommendations to individuals seeking services..."

5. Review of the "Portable Metal Detector" policy dated "03/2022" revealed, "... POLICY...At the time of admission, all patients will be scanned with the wand for metallic contraband...PROCEDURE...1. Prior to wanding a patient...The patient's belongings (bags, suitcases, purses, briefcases, etc.) will be secured in the locked area in the needs assessments...Any patient brought to the unit will receive a further physical search conducted by nursing staff. Nursing staff will confiscate any contraband found on the patient or in their belongings..."
(Metal contraband would include, knives, guns, anything metal. This metal detector does not detect drugs or alcohol hidden on any person.)

6. Review of the "...Medical Screening Examination and Stabilization" policy dated "07/2021" revealed, "... POLICY...It is the policy of [Named Hospital] to assess, stabilize and/or appropriately transfer individuals who come to [Named Hospital] with an emergency condition. Qualified Medical Professionals (QMP's) will provide an appropriate medical screening examination for any individual who comes to [Named Hospital] and requests an examination to determine whether the person has an emergency medical condition...PROCEDURE...Definition..."Comes to [Named Hospital] means with respect to an individual requesting examination or treatment that the individual is on the hospital property..."property" means the entire hospital campus..."

7. Patient #1 was admitted to a Cocaine and Alcohol Program (CAAP) o 7/7/22 and discharged 7/20/22.

Review of the CAAP Addiction Severity Index Narrative with an interview date of 7/7/22 revealed Patient #1 did not have any chronic medical problems at that time. Patient #1 used heroin regularly (three or more days per week) for a period of 14 years. She has used other opiates habitually for a period of 25 years. Patient #1 admitted to using amphetamines regularly for a period of 25 years. She admitted to overdosing 14 times in her life. Patient #1 admitted to using heroin once in the past 30 days. Patient #1 was arrested and charged with drug crimes 5 times. Patient #1 has a history of being incarcerated for 52 months. Patient #1 was incarcerated in the past 30 days. She was currently on probation or parole. Patient #1 had a serious problem with depression and anxiety in the past 30 days and was clearly depressed and anxious at the time of this interview. Obtaining psychological or emotional treatment is of profound importance to her.

Review of a CAAP History and Physical Examination signed by the Physician on 7/7/22 at 4:00 PM revealed, "...PLAN: Admit - Routine orders...begin Suboxone 8g [grams] / d [day] on Saturday 6/9/22 [appears to be an incorrect date- Saturday was 7/9/22]...continue Zoloft, Risperdol..."

Review of a CAAP Medication Log dated July, 2022 revealed Patient #1 received a 50 mg tablet of Zoloft on July 15, 16, 18, 19, and 20.

Review of CAAP Discharge Summary revealed Patient #1 was legally referred and admitted to CAAP on 7/2/22 and was discharged on 7/20/22. Patient #1 was admitted with a diagnosis of Opoid Use Disorder. The reason for dishcarge revealed, "...Therapeutically discharged: Non-compliance..."

Review of an email from CAAP Clinical Supervisor dated 8/24/22 revealed, "...Those are the meds that she reported that she was taking prior to admission, and he advised her to continue to take her meds. She never received Suboxone or Risperdal from us..."

8. Patient #1 was admitted to Hospital #1 on 7/26/22.

Medical record review revealed Patient #1, a 42-year-old female, presented to Hospital #1 for admission on 7/26/22 at approximately 1:30 AM. Patient #1 was placed in the NARC Intake area in Room #2 for further assessment. Patient #1 was diagnosed with Major Depressive Disorder with Severe psychotic features.

Review of the Inquiry Call Data Collection form dated 7/26/22 at 1:30 AM revealed, "...Presenting Problem/Reason for Call Depression, psychosis, SI [Suicide Ideation] thoughts, no plan...Suicidal [marked Yes with an X]...Homicidal [marked No with an X]..."

Review of a Medical Screening Exam dated 7/26/22 and signed at 2:53 AM revealed vital signs were obtained: blood pressure 133/83, temperature 98.2, pulse 99, respirations 16, Oxygen saturation 97%, height 5'3", weight 150 pounds. Patient #1 had no documented allergies. Patient #1 was cooperative, alert and oriented. Current medical symptoms revealed Patient #1 requested medications, and admitted to heroin addiction and denied any other medical symptoms. Significant medical history revealed GERD (Gastroesophageal Reflux Disease), Chronic Hepatitis C, PTSD (Post Traumatic Stress Disorder), manic, depression, and has overdosed 14 times. The screening exam also revealed Patient #1 admitted to taking heroin on 7/25/22, had auditory hallucinations (heard her sister's voice), denies alcohol and smoked 1/2 pack of cigarettes per day.

Review of the "STANDARDIZED INTAKE ASSESSMENT" form dated 7/26/22 beginning at 5:11 AM and ending at 5:23 AM, revealed patient #1 was single and lived with a friend. Presenting problems revealed psychosis, hearing the sister's voice and wanting to get on medication. Patient #1 denied suicidal and homicidal thoughts (although suicidal thoughts was marked as "yes" on Inquiry Call Data Collection form which was completed at 1:30 AM). The Level of Risk for Suicide Severity Scale was "No Identified Risk." Patient #1 admitted to difficulty staying asleep in the past 30 days, waking up several times during the night and difficulty staying asleep. Patient #1 admits to sleeping 4 hours and has been 2 or more days without sleep. Family history was unable to be assessed due to Patient #1 "was very lethargic". Patient #1 admitted to sexual abuse at 6 years old and physical abuse at 19 years old. Patient #1 admitted to alcohol and drug use with no current withdrawal symptoms present. Patient #1's current mental status revealed an unkempt appearance, lethargic, very sleepy, poor visual contact, appropriate mood and appropriate affect, short attention span -due to sleepiness, intact/organized thought process, auditory hallucinations -hearing voices, denies delusions, denies memory impairment, fair insight, fair judgment and no evidence or concern that Patient #1 may be concealing or denying current or past suicidal ideation or behaviors. Patient #1 was willing to engage in treatment. Risk factors identified were impulsive/aggressive tendencies, and non-compliance with medications but no protective factors were identified. There were no recommendations regarding the level of care for Patient #1. The Provisional Primary DSM 5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) Diagnosis for Patient #1 was F 32.3 Major Depressive Disorder, single episode, severe with psychotic features.

Review of the "STANDARDIZED INTAKE ASSESSMENT..." Collateral Information in the Narrative Summary dated 7/26/22 written at 11:15 AM revealed, "Court ordered to complete a program - to get off drugs. suboxone and heroin use started in 2016 on suboxone, stayed clean 3 yrs [years] used heroin yesterday (last night), used about a tenth [1/10 of a gram], snorts the heroin. on heroin 26 yrs. Charges as a habitual offender. will have to do 16 yrs. hx [history] at CAAP [Cocaine and Alcohol Awareness Program] but was kicked out for another pt [patient] sharing her [Suboxone] strips w/ [with] her." (Suboxone strips or pill forms are used to treat the symptoms of opioid withdrawal. This medication is meant to be placed under the tongue or in the cheek until fully dissolved.)

Review of the "Inquiry Call Data Collection Follow-Up and Notes" dated 7/26/22 at 12:00 PM revealed, "...Pt [Patient] stated she is not suicidal and someone told her to say she was...Change of plans due to psychosis -A. [Auditory] hallucinations - continue w/ [with] MCT [Mental Crisis Team]. Per MCT, pt has been assigned an assessor...Seeing MCT [Named Assessor] @ [at] 1508 [3:08 PM]...Per [Named Assessor] @ MCT she will refer pt [Patient #1] to CSU [Crisis Stabilization Unit] for inpatient tx, [treatment] pt is not committable/want be referred to [Named Mental Health Facility]...[Named Assessor] requested pts[patient's] assessment/MSE [Medical Screening Exam] to further assist in assessment process."

Review of the Urine Drug Screen Results dated 7/26/22 at 3:47 PM revealed Patient #1 tested positive for THC (Tetrahydrocannabinol-the main psychoactive compound in marijuana), mAMP (methamphetamine) and AMP (amphetamine).
There was no documentation why the urine drug screen was done approximately 14 hours after Patient #1 arrived at Hospital #1.


Review of the CODE BLUE FORM dated 7/26/22 revealed, "...Time Event Recognized: 1615 [4:15 PM], Time Code Blue Called: 1620 [4:20 PM]...Patient found unresponsive during observation checks...BP 16:28 [4:28 PM] 71/35...AED [applied and shocked] 1622 [4:22 PM]...Narcan 0.4mg IM [intramuscular]...1630 [4:30 PM] 1633 [4:33 PM]...911 called 1624 [4:24 PM]. Some of the times revealed on the CODE BLUE FORM do not coincide with the times on the video footage.

Review of the PATIENT OBSERVATION RECORD revealed Patient #1 was observed in the bathroom at 3:30 PM. Patient #1 was observed sitting in Room #2 at 3:45 PM and 4:00 PM. Patient was unresponsive at 4:15 PM. This documentation does not match with the video footage reviewed. The video footage revealed Patient #1 was left unattended in the NARC Intake area for 32 minutes without anyone checking on her as follows:

Review of the Video Footage for Patient #1 on 7/26/22:
12:52 AM Patient #1 enters main lobby with another male accompanying her.
1:54 AM Patient #1 goes through metal detector and gives her belongings to staff. Patient #1 was allowed to keep her shoes, eyeglasses, cigarettes and a metal drinking cup with a straw. Patient #1 was sitting in a lobby area with the male accompanying her.
2:36 AM Patient #1 walked into a small room to be assessed.
2:43 AM Patient #1 came back into the lobby and sat down with a white blanket given to her by staff.
2:45 AM Patient #1 walked into another room with a Nurse Practitioner for the MSE.
2:54 AM Patient #1 walked back into the lobby and sat down in chair.
5:10 AM Patient #1 walked with the blanket around her to an assessment room with a Master Social Worker assessor.
5:20 AM Patient #1 walked back into the lobby and sat in a chair.
6:49 AM Patient #1 walked into assessment room #2 where she will remain the remainder of the visit and sits in a chair behind a table. The male accompanying her also goes into the room and lays on a mat on the floor.
6:52 AM Patient #1 leaves the room, walks down the hall to the bathroom.
6:55 AM Patient #1 goes into the bathroom when a staff member unlocks the bathroom door. Patient #1 goes in and shuts the door.
7:00 AM Patient #1 comes out of the bathroom and walks back to Room #2. She lays her glasses on the table.
8:26 AM Male accompanying Patient #1 begins filling out paperwork given to him by a staff member.
8:49 AM Male accompanying Patient #1 leaves the room and does not return.
9:07 AM Patient #1 walks out of Room #2 and goes to the lobby door with a staff member and it appears she is talking through the doorway to the Male that accompanied her. He brought in a blue duffle bag and handed it to the staff member. The staff member locked the bag up with patient belongings.
9:08 AM Patient #1 is accompanied back to Room #2 with a staff member.
9:13 AM Patient #1 walks out of room down the hall and buzzes to get into the bathroom.
9:14 AM Patient #1 goes into the bathroom and shuts the door.
9:21 AM Patient #1 goes back into Room #2 and sits down in the chair.
10:42 AM Patient #1 goes into the bathroom.
10:50 AM Patient #1 comes out of the bathroom and walks through a door with a staff member towards the smoking area.
10:53 AM Patient #1 comes back in hallway with a staff member and walks back into Room #2.
11:21 AM A Staff member goes into Room #2, sits down and begins to talk while writing notes.
11:36 AM The Staff member leaves Room #2.
1:27 PM Lunch is brought in for Patient #1.
3:05 PM A Staff member brings in a Mobile Crisis iPad for an assessment with an assessor with the MCT.
3:24 PM Patient #1 walks to the doorway of Room #2 and hands the iPad to a Staff member.
3:25 PM Patient #1 walks down the hall to the bathroom. Someone else in in the bathroom.
3:26 PM Patient #1 quickly walks back to Room #2 and picks up a white object from the table (appears to be a plastic fork or spoon that was next to the styrofoam box of food) and walks back down the hallway to the bathroom and pushes the buzzer to be let in to the bathroom. She leans against the wall rocking side to side while waiting.
3:28 PM A Staff member opens the bathroom door, hands Patient #1 a urine specimen cup. Patient #1 goes into the bathroom and shuts the door.
3:34 PM Patient #1 opens the door and hands the Staff member a urine sample in the cup. Patient #1 stays in the bathroom and closes the door.
3:35 PM Patient #1 walks out of the bathroom. Patient #1 appears to have something in her left hand not recognizable on the video. Patient #1 arrives back in Room #2. Patient #1 wraps the blanket around her, and sits in the chair.
3:47 PM Community Coordinator (CC) #1 entered Room #1 to check and observe Patient #1. Patient #1 was asleep but was aroused by CC #1. CC #1 stayed in the room and talked to Patient #1 for approximately 2 minutes. Patient #1 was sitting in the chair and was visibly wobbly and her head and upper torso kept falling forward. Patient #1 was visibly lethargic and not in complete control of her upper body on the video. Patient #1's right leg began to shake. CC#1 leans in closer to Patient #1.
3:49 PM CC #1 leaves Room #1. The door remained open.
3:50 PM Patient #1 leans over, bending at the waist, her head resting on her knees. The blanket was over her shoulders, arms and top of head. The chair was behind the table and as Patient #1 was folded over in her own lap, she was not visible from the doorway.
3:52 PM Patient #1 never moved again.
There are no observations or checks on Patient #1 until 4:21 PM, 32 minutes after CC #1 had left Patient #1 and the patient was observed lethargic and visibly wobbling.
4:21 PM CC #1 comes into Room #2, begins to shake Patient #1, unable to arouse her, CC #1 leaves the room to get assistance.
4:22 PM Nurse Practitioner #1 and RN House Supervisor enter the room. They push her body up into a sitting position. Patient #1 is limp and her head flops backward. Patient #1 is visibly dark gray and her mouth is open. They put her on the floor and begin doing chest compressions. Additional staff members are arriving on scene.
4:23 PM Staff are pushing the crash cart down the hall to Room #2.
4:29 PM A Staff member appears to give Patient #1 an injection. (Narcan)
4:33 PM A Staff member appears to give Patient #1 another injection. (Narcan)
4:34 PM Paramedics and Emergency Medical Technicians (EMT) arrive on scene.
4:35 PM Patient #1 is pulled out into the hallway. CPR continues in the hallway.
4:40 PM RN #1 bent over in Room #2 and picked up a plastic bag from the floor area where Patient #1 was laying. She held it up and appeared to be showing it to the people in the hallway just outside the doorway. She then opened it and pulled out something white, held that item up to show someone in the hallway. She pulled each item out of the bag and appeared to count them, then returned the items into the zippered baggie. (A photograph taken by Hospital #1 was not clear enough to see the contents. A handwritten list was with the photograph revealed, "Qt [quart] size zip lock bag w/ [with] name on it, 4 crushed powder, 1 suboxone packet, 1 film strip (suboxone)?" ) There was no signature on this note.
4:44 PM The Bartlett Police arrived on scene.
4:53 PM Patient #1 was on a stretcher and is wheeled out to the ambulance for transport to Hospital #2.
5:00 PM The Bartlett Police left the scene.
5:08 PM Video footage stopped.

Review of the Bartlett Fire Department Patient Care Record dated 7/26/22 revealed Patient #1 was unresponsive at 4:34 PM with a pulse of 0. A 4-lead ECG revealed asystole at 4:34 PM. At 4:42 PM Patient #1 had a pulse of 100, respiratory rate of 11. At 4:43 PM a 2 milligram dose of Narcan was given IV with no change in patient response. At 4:48 PM, a 12-Lead ECG revealed Sinus Tocharian (heart rate greater than 100 beats per minute) of 157. Patient #1 remained unresponsive. The Narrative revealed, "...RESPONDED TO A FULL ARREST. PT PRESENTED SUPINE IN FLOOR...STAFF PERFORMING CPR...AED [Automated External Defibrillator] IN PLACE...TOOK OVER...PT IN ASYSTOLE...PT GIVEN EPI [Epinephrine]...NARCAN...SODIUM BICARB...PT HAD PULSE AND ORGANIZED EKG [Electrocardiogram]...PT PLACED ON 12 LEAD EKG...TRANSMITTED TO HOSP...ARRIVED UNLOADED LIFTED PT TO BED...PT CONDITIONS UNCHANGED @ [at] DESTINATION...PER [Named Hospital #1] STAFF PT CAME IN FOR INPATIENT TREATMENT FOR NARCOTICS. PT WAS BEING EVALUATED AND SIGNING PAPERWORK HAD STABLE VITAL SIGNS. PT WAS LEFT IN THE INTAKE ROOM ALONE FOR 15 MIN [minutes] WHEN STAFF RETURNED THEY FOUND PT UNRESPONSIVE, APNEIC, & PULSELESS. [Named Hospital #1] STAFF STATED THEY FOUND SANDWICH BAG WITH 2 SMALLER BAGS INSIDE IT LOOKED LIKE POSSIBLE ILLEGAL DRUGS. [Named Hospital #1] STAFF CALL FOR BPD [Bartlett Police Department] AND TURNED CONTRABAND TO THE BPD. [Named Hospital #1] STAFF DID NOT KNOW IF PT HAD TAKEN ANY OF THE DRUGS FOUND NEXT TO HER [Patient #1] BUT SUSPECT SHE DID..." Patient #1 was transported to Hospital #2.

Review of a Bartlett Police Department Incident Report dated 7/26/22 revealed, "...Report Narrative...responded to an assist agency call...for a full arrest on suspect...On scene, Unit 5 was performing life saving measures...A small baggie with 4 individually packaged narcotics was found...The package containing 2 individual plastic tear offs with an unknown white powdering substance, a foil packet with an unknown blue powdery substance, a dose of suboxone, and a small zip lock baggie was brought to [named Police Department] HQ [Headquarters] for testing. the white powdery substances tested negative for cocaine and Methamphetamine..."

Review of Hospital #2 Urine Drug Screen dated 7/26/22 at 5:35 PM revealed Patient #1 was positive for Amphetamines. Patient #1 was negative for Barbiturates, Benzodiazepines, THC, Cocaine, Opiates, PCP (Phencyclidine also known as angel dust) and Ethanol.

Review of Hospital #2 Depart Summary dated 7/26/22 at 8:05 PM revealed Patient #1 was discharged to ICU at 8:06 PM. The summary revealed patient diagnoses of cardiac arrest and anoxic brain injury.

Review of Hospital #2 History and Physical Notes dated 7/27/22 at 8:52 AM revealed, "...She has a history of some kind of amphetamine abuse, not very clear, came in, unresponsive, was intubated by the ER [Emergency Room] physician...The patient has been seizing, posturing. A CT [Computerized Tomography] scan showed effacement [fade or disappear] of the gray-white matter...IMPRESSION...Cardiopulmonary arrest...Probable anoxic brain injury with effacement f gray-white matter...Seizures...History of drug abuse...PLAN...Overall prognosis is futile [incapable of producing any useful result]..."

Patient #1 expired on 7/30/2022 at 12:38 PM due to anoxic brain injury.

9. During a telephone interview on 8/9/22 at 3:25 PM, Detective #1 with the Bartlett Police Department confirmed Patient #1 was officially declared deceased on Saturday 7/30/22 at 12:38 PM. Detective #1 also confirmed the Medical Examiner would not be doing an autopsy and would be doing a coroner's review which is a chart review.

During a telephone interview on 8/16/22 at 4:05 PM, the Director of Regulatory Compliance officer for Hospital #1 stated the observation policy doesn't really address the admissions department. She confirmed that since this incident occurred and through their investigation they had realized that and are addressing that now. She also confirmed they were in the process of training staff more on recognizing changes in condition in admissions. The Chief Executive Officer (CEO) stated that all employees go through the exact same training in regards to observations, but the form does not lend itself to the admissions area as we are seeing, for example there are no beds in intake but the form lists in bed, and they are not in groups, not going to the cafeteria. The CEO further stated that the things that apply at the unit level are not applicable down there (NARC area). The CEO and Director of Regulatory Compliance confirmed the staff were utilizing the 15 minute checks in every area of the hospital which included intake assessment areas and the inpatient units. The Director of Regulatory Compliance stated the doctor gives the order for the level of observation, but in the assessment area, there were no doctor's orders, they were not patients. That is part of the problem that we are addressing.

During a telephone interview on 8/22/22 at 8:26 AM, Community Coordinator (CC) #1 at Hospital #1 stated Patient #1 looked "sad all day" and her posture was "a little limp". She
CC#1 was asked if she noticed any changes in Patient #1 during the last time she had checked on the patient before she was found unresponsive. CC #1 stated she did not see any changes in her.
CC #1 was asked if she had any training on recognizing signs and symptoms of overdose. CC #1 revealed she did not think there was any training on overdose but there was training on patients "sneaking drugs and stuff in" but not how to respond to an overdoses.
CC #1 stated she normally works weekends and she picked up some additional shifts that week. CC #1 stated she remembered going in and having an interaction with Patient #1 and talking with her. CC #1 stated the next time she checked on Patient #1 was when she found her unresponsive.
CC #1 was asked if she goes into the room during the checks or did she stand at the door. CC #1 stated when patients are asleep, she would go in and make her presence known, but if they are up and walking in their room or standing at the door, she probably would not go in. CC #1 stated she felt those 15 minute checks probably did save her. She was not sure if Patient #1 was still here or alive, but those 15 minute checks probably gave Patient #1 more time and CC #1 stated she was glad the facility does incorporate the 15 minute checks.

During a telephone interview on 8/22/22 at 11:58 AM, the male friend of Patient #1 revealed he brought Patient #1 to Hospital #1. He stated they sat in his truck for a long time in the parking lot of Hospital #1 before they entered Hospital #1. The male companion stated after the patient was in the room he went back outside and got her bags to bring them in for Patient #1 and someone met him and Patient #1 came out and talked to him through the doorway to let him know what she wanted. He stated he put her things into 1 bag and gave it to the staff worker. He stated he did not understand how this could have happened. He stated when he got to Hospital #2 someone told him Patient #1 was without Oxygen for a while. He stated it is upsetting that they didn't watch her better.
The male companion was asked was he aware if Patient #1 had brought any drugs into the hospital with her. He stated he was not aware of any drugs and if she had any he did not have any idea. The male companion further stated Patient #1 might have had some drugs hidden on her.

During an interview on 8/22/22 at 2:13 PM, CC #2 at Hospital #1 stated the male companion with Patient #1 asked to go outside and smoke a cigarette. CC #2 took him out to smoke. CC #2 confirmed the male companion was allowed to come back in to sit with Patient #1. CC #2 revealed later that morning the Telephone operator came and got him and stated the male companion was cussing and acting out. CC #2 stated the male companion wanted me to go through Patient #1's belongings. CC #2 stated all Patient #1's belongings were put into a blue duffle bag.

The hospital failed to assess a patient who had been diagnosed with Major Depressive Disorder and Severe Psychotic features every 15 minutes and ensure the patient and/or the patient's belongings were checked thoroughly for harmful contraband. The hospital failed to ensure the safety of all patients.