HospitalInspections.org

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Based on medical record review, document review, and interview, in one (1) of ten (10) medical records reviewed, the facility failed to inform the patient's representatives of significant changes in the patient's medical condition (Patient #2).

Findings include:

Review of policy and procedure (P&P) titled "Patient Death and Management of - Nursing and Security" last revised 05/2024 indicates "Procedure, 1. Nursing will make the following contacts once the patient is pronounced dead: a-Center for Organ Donation and Transplant (CDT) within one hour of death; b-Switchboard; c-Facilities occupied by the deceased before hospitalization (e.g., nursing home, homes for those with developmental disabilities, etc.)."

Review of the medical record for Patient #2 revealed the patient presented to the Emergency Department on 07/13/2023 at 00:55 AM from a Nursing Facility in respiratory distress. The patient had low oxygen levels and an elevated body temperature. The patient had an intellectual disability.

The patient's medical condition deteriorated, requiring oral intubation and mechanical ventilation. On 07/13/2023 at 08:53 PM, the patient was pronounced dead after unsuccessful resuscitation attempts.

The medical record face sheet documented the patient's court-appointed guardian and their contact information.

There was no documented evidence that facility's staff informed the patient's guardian of changes in their medical condition and of the patient's death, or notified the patient's residece.

During an interview with the patient's guardian on 09/05/2025 at 01:45 PM, they reported that they learned of the patient's death 15 days later when they contacted the facility to inquire about the patient.

During an interview on 09/05/2025 at 12:13 PM via phone, Staff R (Nurse) reported they were not aware of the Death and Management policy and nursing staff responsibilities.

During an interview on 09/05/2025 at 12:04 PM, Staff S (Nurse Administrator) acknowledged that staff did not adhere to the policy.

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Based on medical record review, document review, and interview, in one (1) of three (3) medical records reviewed, the facility failed to ensure that a patient was monitored for safety in accordance with the physician order and the facility's policies and procedures on "Observation of Patients in Non-Behavioral Health Areas" (Patient #1).

Findings:

Review of the facility policy titled "Observation of Patients in Non-Behavioral Health Areas: Close Observation (non-suicidal patients), 1:1 Observation (suicidal, homicidal, or non -suicidal aggressive patient)," revised 11/2023 stated "All patients that make statements regarding suicidal or homicidal ideation or had an attempt or any patient whose behavior demonstrates the high likelihood of imminent harm to self or others must be placed on 1:1 until discontinued by the order of the consulting Licensed Independent Practitioner (LIP) from the psychiatric services."

Review of the policy titled "Levels of Observation for Patients Hospitalized in Behavioral Health Units," revised 11/2024, revealed that the policy applies to Behavioral Health inpatient units only and is not to be used in other areas of the hospital.

Review of the medical record for Patient #1 identified that the patient presented to the Emergency Department (ED) on 08/01/2025 at 05:25 PM, accompanied by police officers for a mental health evaluation due to emotional disturbance, suicidal ideations, and depression.

On 08/01/2025 at 05:49 PM, the patient was placed on continuous one-to-one observation for safety, as per the physician's order. At 06:20 PM, the patient was transferred to the Psychiatric ED for continued care.

Review of the observation records revealed that the patient was on one-to-one observation in the Medical ED but underwent every 15-minute visual checks in the Psychiatric ED.

The Behavioral Health Social Worker on 08/02/2025 at 05:49 PM documented that the patient endorses suicidal ideation, and that the on-call nurse practitioner determined that the patient meets criteria for inpatient hospitalization for safety and stabilization.

There was no documented evidence that the physician discontinued the patient's order for one-to-one observation before the nursing staff changed the level of observation for the patient, who remained a threat to self.

On 09/04/2025, at 02:00 PM, during an over-the-phone interview with Staff X (Psychiatric ED Technician), they reported that in the Psychiatric ED, patients are not placed on one-to-one monitoring unless they are restrained.

There was no documented evidence that the facility's observation policy for patients placed on one-to-one observation for safety purposes was consistently implemented.

During the interview on 09/05/2025 at 3:08 PM, Staff Y (Psychiatric ED Administrator) stated that the Psychiatric ED implements a combination of policies, including the "Observation of Patients in Non-Behavioral Health Areas" and the "Levels of Observation for Patients Hospitalized in Behavioral Health Units." Staff Y confirmed that a patient who is a threat to self or others would be placed on one-to-one observation.