HospitalInspections.org

Based on observation, interview, and document review, the facility failed to:

a. adequately monitor high risk patients with suicide precautions per doctor's orders (patient ID A). Refer A0144

b. ensure the right to privacy for patients involved in emergency situations and codes resulting in lack of privacy in 2 of 2 codes. Refer to A0143

The deficient practices identified under the following Condition of Participation, CFR 482. 13 Patient Rights, were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Based on observation, record review, and interview the facility failed to ensure privacy was protected for patients while he/she is being examined or treated for 2 of 2 (#A, Q) #patients observed with medical emergencies that required immediate care.
The findings include:

1. Review of the surveillance of film May 4, 2023, at 1:10 pm with staff #1 Chief Executive Officer (CEO) and #3 Director of Risk Management (DRM) showed the following:

On 04/30/2023, the assigned floor staff #18 Registered Nurse (RN) checked patient #A's room at 12:12 pm and left immediately. At 12:14 pm staff # 41 RN entered patient #A's room and showed staff 41 pulling the patient into the room doorway with the patient's legs partially in the hallway.

Staff #18 arrived and began cardiopulmonary resuscitation (CPR) from 12:16 pm to 12:23 pm multiple staff arrived to assist and observe the code.

The film revealed six patients watching the emergency throughout, from bedroom doors and within patient A's hallway. No staff assigned to the unit or responding took charge including providing a privacy barrier or moved the observing patients away.

During an interview 05/04/2023, at 2:00 pm staff, #1 confirmed the unit patients were watching the emergency and no staff had redirected them to provide privacy.

During a tour on 05/05/2023 at 11:30 am a medical emergency was observed in the facility main dining room with staff#1 Chief Executive Officer (CEO). Patient #Q was on the floor next to a table that was immediately across from the food line. Patients with off unit privileges from Units A1/A2 and A3 were in the cafeteria line for food and seated throughout the dining room eating.

Patient #Q was being assessed and then was lifted into a chair from the
floor. The patient was dazed, glassy eyed and had a swollen area on his
forehead the size of half an egg. Approximately twelve staff arrived at the
code. Additional staff were present in the dining room with patients who
were in line and at tables for lunch.

Patients in the cafeteria line for food and seated throughout the dining room eating were watching patient #Q on the floor, being assessed and later being taken by Emergency Medical Services (EMS) for hospital care. Staff #41 Registered Nurse (RN) was observed standing next to patient #Q with other staff. RN #41 had his hands in his pockets and was not assisting with patient Q. No staff were observed taking charge including providing a privacy barrier or moving the observing patients away from patient Q.

Review of facility policy # PC 4.03 Revised: 02/22/2023 "Medical Emergencies" lists required Cardiopulmonary (CPR) training, where emergency supplies are located, Basic CPR steps and notification of key entities. The policy failed to mention having someone in charge of the emergency and those responsibilities including maintaining the privacy and dignity of the patient receiving care or treatment.

During an interview 05/05/2023 at 4:40 pm patient #D stated that seeing another "Code" [medical emergency] was very disturbing. Patient #D stated "I just want to get out of this place. I don't want to see that."

The deficient practices identified under the following Condition of Participation, CFR 482. 13 Patient Rights, were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Based on record review, observation, and interview the facility failed do maintain a safe environment by doing timely rounds as ordered for one of one patient (#A) on suicide precautions who ultimately committed suicide in house.

The findings include:

1. Observation of film 05/04/2023, at 1:10 pm with staff #1 Chief Executive Officer (CEO) and #3 Director of Risk Management (DRM) showed the following:

On 04/30/2023, staff #40 Mental Health Technician (MHT) was assigned rounds for patient #A. Film revealed patient #A entered his room at 10:27 am and remained in his room until his death.

The film revealed that neither Staff #40 nor any other rounding staff checked on the patient while he was in his room between 10:28 am and 11:24 am, as well as between 11:28 am and 12:07 pm. There was no MHT or staff nurse on film entering patient A's room, where he had been, for rounds during these times.


The housekeeper entered patient #A's room at 12:12 pm and appeared to summon help. The assigned floor staff #18 Registered Nurse (RN) checked patient #A's room at 12:12 pm and left immediately. At 12:14 pm staff # 41 RN entered patient #A's room and showed staff 41 pulling the patient into the room doorway with the patient's legs partially in the hallway.

Staff #18 arrived and began cardiopulmonary resuscitation (CPR). From 12:16 pm to 12:27 pm multiple staff arrived to assist and observe the code.

Emergency Medical Services (EMS/ambulance arrived at 12:27 pm and took over the code. EMS pronounced the patient dead at 12:34 pm on the unit.

During an interview 05/04/2023, at 1:55 pm staff, #1 stated that the [suicide] of patient #A was a nursing error because the MHTs did not do timely rounds as assigned. He stated when he interviewed the MHT's on 04/30/2023 (no specific time indicated) they could not say exactly who was doing rounds on which patient that afternoon.

2. Observation of unit A3, 05/04/2023 at 4:24 pm with staff #1, and #43. Staff #37 MHT was observed in an adjoining fenced outdoor patio area with four patients. Review of the rounding sheet showed he had seven sheets. Three of the patients were not in the area and had not been observed for their every 15-minute checks at 16:15 pm.

During an interview conducted at 4:25 pm, Staff #37 confirmed that the rounds for three patients who were not in the fenced outdoor patio area had not been completed on time.


3. Record review on 05/05/2023 of Policy [#200.29], "Rounds for Patient Observation," Reviewed by facility 02/23/2022, "An accurate record of all patients will be maintained during each shift by each unit".

PROCEDURE:

"Every patient must be observed by a staff member at a minimum of every 15 minutes. Documentation of observation MUST be done in real-time/clipboard must accompany staff doing the rounds."

"MHT (Mental Health Tech)
Observe each patient, a minimum of every 15 minutes and/or according to precaution level and document observation on the patient observation form as observations are made."

Record of undated Job Description on 05/04/2023 of facility combined MHT Job Description/Performance Appraisal and Competency Evaluation Form:
stated the purpose of the position was to "Provide direct care to patients and to ensure the safety and well-being of these patients" ...

Record review of MHT Job Description showed the facility failed to include specific job tasks including doing rounds.

4. Review of patient A Psychiatric Evaluation dated 04/28/2023 Staff # 4 Psychiatrist showed that patient #A was "Admitted 04/27/2023 after attempting suicide by cutting his throat and bilateral wrists with a pocketknife. The patient was then life-flighted to a Houston hospital. Tearful, appears to be minimizing symptoms. Admits depression."

Diagnoses: "Major depressive disorder, single episode, severe, without psychosis.
Rule out alcohol abuse disorder
Rule out substance-induced psychosis."

Admission orders 04/27/2023 included suicide precautions and unit restriction. With every 10-minute rounds. On 04/29/2023 this was changed to every 15-minute rounds with off unit privileges.

Physician Progress Notes: 04/29/2023 and 04/30/2023 by Staff #42 Nurse Practitioner (NP) States "he feels he is a terrible person." When asked if still having suicidal ideation, he stated "There's' not going to be an opportunity."

When interviewed 5/3/23 at 12:45 Staff #1 stated the housekeeper was the first person to find patient #1 in his room because she had go in to clean. He stated, when questioned, after the incident 4/30/23, the MHTs did not have answers for which patients they were responsible for doing rounds on. Staff #1 stated "We suspended the MHT's that were involved."


When interviewed 05/04/2023 at 10:20 am Staff #4 stated the patient died on 04/30/2023 of suicide by self-inflicted wound disruption causing fatal blood loss.


When interviewed 05/04/2023 at 11:20 am staff #2 Chief Nursing Officer (CNO) stated the two MHTs involved in the 4/30/2023 death had been suspended. Then added, "Oh, I'm going to fire them." When asked about the responsibility of the floor nurses in ensuring the delegated duty of rounds was completed, staff #2 stated she had not thought about them.

The deficient practices identified under the following Condition of Participation, CFR 482. 13 Patient Rights, were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Based on Observation, record review and interview the facility failed to
ensure that patient needs were met by ongoing Registered Nurse (RN) assessments of patients' needs for 2 of 2 patients (#A and #P) observed.

The findings include:

1. A review of patient A's Preadmission Evaluation/ Medical Clearance from transferring day of admit 04/27/2023 by Physician #44 read "self-inflicted lacerations to anterior neck, 1X to right wrist, and 2X to left."

Nursing Admission Assessment 04/27/2023 at 4:45 pm by RN # 44 read Pt has no major problems on the skin, but marks of self-lacerations. No measurements or descriptions of wounds on entry. Daily Nursing Assessment Notes done every 12-hour shift from admission date to death by suicide from opening prior lacerations on 04/30/2023 did not describe skin/wounds or measure them.

During an interview on 05/04/2023 at 11:40 am staff #2 Chief Nursing Officer (CNO) stated the RNs should describe wounds when documenting.


2. During a facility tour on unit A3, at 05/04/2023 at 4:10 pm patient #P was observed with very large calf's bilaterally that swung with movement and swollen ankles and feet. The patient was barefoot. Staff RN # 25 was asked what the diameter of patient #P's calves were. Staff #25 responded she did not know. When asked if she could measure them, she looked surprised and after a pause answer she did not have any way to measure. When asked what assessment tools are available, RN #25 stated that there is a blood pressure machine, thermometer, and one stethoscope.

Review of patient #P's Admission History and Physical dated 05/03/2023 diagnoses included hypertension, congestive heart failure, neuropathy, HIV, Karposi's Sarcoma with metastasis to spine and hips. Significant bilateral lower extremity pitting edema from lymphedema. Daily Nursing Assessment Notes done every 12-hour shift from admission date to 05/05/2023 had no description or measurement of patient #P's lower extremities.


Review of the facility Nursing Assessment and Reassessment Policy # 200.46 Reviewed 02/23/2022 read: "The Registered Nurse will complete a head-to-toe assessment on each patient a minimum every 12-hours and more often as deemed necessary. Assessment will include their mental and physical status....Any abnormal findings are documented on the RN Narrative section of the Daily Nursing Assessment."

Review of the facility Registered Nurse Job Description/Performance Appraisal and Competency Form reads "Can quickly decide what is best for all concerned. Can handle crisis, Factors changing situations into decision making." The job description failed to list any specific job duties including patient assessments.

During an interview on 05/04/2023 at 11:35 am staff #2 stated the RNs have paper tape measures in the kits for emergencies they can use.