HospitalInspections.org

Based on staff interview and record review, the facility failed to report a death of a patient with in 24 hours of being in seclusion for 1 of 3 sampled patients. (#1).

The finds are:

Record review for patient #1 found he was Baker Acted (involuntary hospitalization) due to auditory hallucinations after screening on 10/7/15. After screening he was admitted to Behavioral Unit for treatment. His admitting diagnosis was Psychotic disorder, Schizoaffective psychosis and Hypothyroidism. During treatment he had abusive behavior towards staff and patients. During his stay he was placed in seclusion for this behavior. Staff documented every 15 minutes and visually observed the patient during seclusion. On 10/30/15 he was released from seclusion at 12 noon. He was given a peanut butter and jelly sandwich at approximately 4:00 PM and water, which he drank. He started disrobing and was walked to the seclusion room for quiet time. The door was open and staff sat at doorway during quiet time. Staff continued to monitor the patient every 15 minutes according to facility policy. At 4:15 and 4:30 nurse documents he is in quiet and preoccupied and then sleeping. Approximately 4:30 PM the tech finds patient unresponsive. A Code Blue is called. Cardio Pulmonary Resuscitation (CPR) is started, 911 is called and Emergency Medical Staff (EMS) arrives and takes over. The patient is transported to hospital where he expires from cardiac arrest from possible aspiration of food.

Interview with Risk Manager on 11/13/15 at approximately 3:15 PM indicated she did not notify the Center for Medicaid and Medicare Services (CMS) of the death. She indicated she did not realize CMS had to notified if the patient was not in seclusion at the time of the incident. Facility policy did not include notifying CMS.