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Based on observation, interview, record review and policy review, the facility failed to provide adequate nurse supervision for two patients who were at high risk for self harm and the facility failed to follow hospital policy related to documentation of the patients' supervision by nursing staff. The facility census was 884.

These deficient practices and systemic failures had the potential to place all patients at risk for self harm in immediate jeopardy to the patients' health and safety.

The cumulative effect of these findings resulted in non compliance with the Condition of Participation: Nursing Services, and an Immediate Jeopardy situation. The facility was informed of the Immediate Jeopardy on 09/05/13. The facility was able to provide an acceptable plan of correction on 09/06/13 to implement corrective actions and abate the Immediate Jeopardy. Please see A0395 related to the Immediate Jeopardy.

Based on observation, interview, record review and policy review, the facility failed to ensure that:
- Two patients (#20 and #26) of two patients who were at high risk for self harm were continuously monitored by nursing staff for safety and that documentation of the monitoring was completed according to the facility's policy;
- One patient (#4) of two patients with a tracheostomy (artificial opening to the throat) received tracheostomy care as ordered; and
- Three patients (#18, #34, and #35) of eight patients observed with restraints were provided care related to range of motion exercise. These failures had the potential to affect all patient care and outcomes. The facility census was 884.

Findings included:
1. Record review of the facility's policy titled, "Patient Safety Assistants" dated 06/12, showed direction for facility staff to obtain a sitter for patients who were at risk for injury. The Patient Safety Assistant (PSA - also known as a sitter or staff assigned to one-to-one observation), is an employee who sits in the patient's room and observes the patient constantly, and documents the patient's behavior on the Patient Safety Observation Log every 15 minutes. The policy also showed that the registered nurse (RN) had ultimate responsibility for patients being observed by a PSA, that the RN must check in with the PSA hourly and initial the PSA Observation log.

2. Observation on 09/04/13 at 2:00 PM, showed Patient #26 in his hospital room. The patient's room was located at the end of the nursing hall, next to an exit, and the patient did not have a sitter in his room.

3. During an interview on 09/04/13 at 2:00 PM, Staff UU, Registered Nurse, stated that "about three days ago", Patient #26 had left the inpatient floor, drank alcohol foam from the hospital dispensers, became unresponsive on the elevator, collapsed and had to be intubated (artificial breathing). "He almost died." Staff UU stated that nursing removed the alcohol foam dispensers from his room, but physicians were worried that the patient drank the alcohol foam again because the patient had just been off of the inpatient floor.

4. During an interview on 09/04/13 at 2:35 PM, Staff VV, Physician, stated that Patient #26 was admitted to an inpatient unit, left his room on 09/01/13, and drank alcohol foam, was found down (unresponsive), intubated and admitted to ICU. Staff VV stated that the patient needed a sitter because he was a threat to himself, but "we can't have a sitter with him" because he doesn't have suicidal ideations. "I was told this by the doctor whose service he was assigned to yesterday."

5. During an interview on 09/04/13 at 2:37 PM, Staff SS, Nursing Director, stated that the facility doesn't use sitters for patients "like this", because the patient cannot be restricted to his room. "It would be a violation of his patient rights" if the patient was prevented from leaving his room.

6. During an interview on 09/06/13 at 12:05 PM, Staff RRR, Supervisor for the Department of Public Safety, who works as law enforcement on the hospital campus, stated that if a patient was found drinking hand sanitizer inside the hospital, it would be considered "self destructive behavior" and that Public Safety staff as well as hospital staff should prevent the patient from continuing the behavior, up to and including restraining the patient.

7. During an interview on 09/04/13 at 3:05 PM, Staff XX, Social Worker, stated that the patient had reported to hospital staff that he drank alcohol hand foam, and that the patient had a history (prior inpatient visits) of drinking alcohol foam. "The patient gets up and leaves the floor, and he has that right." Staff XX stated that the patient's local case manager with behavioral health was trying to get the patient involuntarily placed at a facility for alcohol rehabilitation, but Staff XX did not currently know the outcome of the placement.

8. Record review of Patient #26's current medical record showed that the patient had a long history of alcohol abuse with pancreatitis (inflammation of the pancreas - a body organ), seizures (uncontrolled movements of the body caused by abnormal brain activity) and anxiety and depression. Further review of the medical record showed the following documentation:
- The patient was discharged from the Emergency Department (ED) on 08/29/13 at 4:48 PM with a diagnosis of acute alcohol intoxication.
- On 08/29/13 at 6:25 PM, the patient was returned to the hospital ED as a "code" (emergency response) after the patient became unresponsive in a waiting area of the hospital. The patient's blood alcohol was 295.3 (expected range is 0-10.0) milligrams per deciliter (mg/dl - unit of measure). While still a patient in the ED, the patient eloped to an inpatient floor and was found by security "drinking alcohol hand foam", and was returned to the ED. After the patient was returned to the ED, the patient was reported to have visual hallucinations with imagery of ants crawling over his skin, began repeatedly banging his head on the wall, "denting the wall", and cursing loudly, so a physician recommended a psychiatric consult. The patient was placed in four-point restraints (both arms and both legs) and admitted to the hospital for alcohol intoxication, with an admit order of "needs sitter". The patient remained in four point restraints until 08/30/13 at 4:36 AM, when he was taken to a room on the inpatient floor.
- Between 08/30/13 and 09/01/13, the patient's blood alcohol level decreased to 18 mg/dl. During this time, the hospital was contacted by the patient's local behavioral health service who informed the hospital that they were attempting to obtain a 21 day involuntary hold because the patient had been placing himself at risk. The local behavioral health service asked if the patient could remain at the hospital until 09/05/13, when the hold could be obtained.
- On 09/01/13 at 5:55 PM, after the patient had left the inpatient floor and returned, he became unresponsive and was witnessed to have what appeared to be a three minute seizure. The patient's oxygen level dropped, the patient was intubated (artificial breathing) and he was admitted to the Intensive Care Unit (ICU) with an elevated blood alcohol level of 81 mg/dl (high). While in the ICU, the patient stabilized, was extubated (removal of artificial breathing) and was transferred from the ICU back to an inpatient floor on 09/02/13.
- Between 09/03/13 and 09/04/13, the patient's blood alcohol decreased to less than 10.0 mg/dl (normal), and three physicians documented that they would obtain a sitter for the patient. When a sitter was ordered for the patient, the charge nurse informed the physician that the patient was unable to have a sitter unless the patient was suicidal or disoriented (confused). So, the patient was instructed not to leave the inpatient floor, but he continued to leave, and the physician was notified. A psychiatric assessment was completed on 09/04/13 at 5:05 PM.
- On 09/05/13, shortly after midnight and after the patient had been off of the inpatient floor again, he admitted to a nurse that he drank a "few Styrofoam cups full of hand sanitizer from the main floor" of the hospital. Within less than two hours, the patient was found face down next to his bed with possible seizure activity, was unresponsive, and unable to follow verbal commands. The patient's alcohol level was 151 mg/dl (high).
- Between 08/30/13 and 09/04/13, nine physicians (including a psychiatrist) and one social worker documented they were aware of reports that the patient was drinking alcohol based hand sanitizer inside the hospital. During that time, there was no sitter or one-to-one nursing observation of the patient and no 15 minute documentation of the patient behavior on the Patient Safety Observation logs, all while the patient continued to drink the alcohol foam.

9. During an interview on 09/05/13 at 10:55 AM, Patient #26 stated that he drank alcohol hand sanitizer two or three different times during this inpatient admission and that he obtains the alcohol foam from "all over the hospital" when he leaves the inpatient floor without an escort. Patient #26 stated that staff informed him that he almost killed himself when he drank the hand sanitizer, and added that he didn't want to "die a drunk".

10. During an interview on 09/05/13 at 11:43 AM, Staff TT, Clinical Nurse Manager, stated that there was no 15 minute documentation of the patient's behavior on Patient Safety Observation logs because the Patient Safety Observation logs were only used for patients who were suicidal, and not to be used for general patient safety.

11. During an interview on 09/05/13 at 10:25 AM, Staff OOO, Director of Survey and Compliance, stated that the hospital did not provide a sitter for Patient #26 because the hospital was not able to restrict him from leaving his room, prevent him from wandering around, or prevent him from leaving the hospital grounds. Staff OOO stated, "He is making bad choices," but the hospital was not responsible for the choices he makes. Staff OOO stated that the hospital allows inpatients to leave the hospital grounds, "go across the street and get drugs", and then come back into the hospital. Staff OOO stated that if the hospital were to stop these patients, it would be a violation of their patient rights.

12. Record review of the facility's policy titled, "Suicide Precautions" dated 12/12, showed suicide precautions were to reduce the risk of suicide for patients who threaten self harm, who threaten to end their life or have made a self-destructive gesture, or the physician has evaluated as being suicidal. The policy gave direction that patients on suicide precautions must be attended with one-to-one observation 24 hours a day, within three feet of the patient, and that staff will document patient behaviors every 15 minutes on the Patient Safety Observation Log.

13. During an interview on 09/06/13 at 12:45 PM, Staff PPP, Clinical Nurse Manager, stated that anyone with an active suicide attempt should be placed with a one-to-one sitter for safety.

14. Record review of Patient #20's medical record showed that the patient was brought to the ED on 08/31/13, after she ingested bleach and 96 Tylenol tablets. The patient had a history of severe depression and psychosis and was admitted to the ICU with a diagnosis of Overdose - Tylenol. Further review of the medical record showed that there was no 15 minute Patient Safety Observation log documentation on 09/01/13 between 1:15 AM and 7:00 AM, between 5:15 PM and 11:45 PM, and no 15 minute Patient Safety Observation log documentation from 09/02/13 at 12:00 AM until 09/03/13 at 7:00 AM. Since the patient was admitted with an active suicide attempt, and because staff had the ability to initiate one-to-one observation for patient safety, the record should have shown that the patient was continuously monitored through documentation of the patient's behaviors every 15 minutes on the Patient Safety Observation log.

15. During an interview on 09/06/13 at 12:50 PM, Staff QQQ, Process Improvement Specialist, stated that 15 minute Patient Safety Observation documentation is not required for all patients that are on suicide watch. Staff QQQ stated that the frequency of documentation varies based on which department the patient is in and who is assigned to monitor the patient.

16. Record review of the facility's policy titled, "Documentation: Nursing" dated 06/12, showed direction for facility staff to document appropriate nursing interventions.

17. Record review of Patient #4's medical record showed a physician order dated 08/29/13 for cleaning of the patient's tracheostomy tube inner cannula (trach care) every eight hours. (The inner cannula is a plastic tube that fits inside the outer tube that keeps the tracheostomy open and must be periodically cleaned of mucous secretions.)

18. Record review of nursing notes in Patient #4's medical record showed trach care performed two times from the patient's admission on 08/29/13 to 09/03/13.

19. During an interview on 09/03/13 at 3:25 PM, Staff I, Charge Nurse, stated that there should have been nursing documentation in Patient #4's medical record that trach care was either performed every eight hours as ordered or why it was not performed (such as the patient refused).

20. Observation on 09/03/13 at approximately 3:45 PM on Medical Unit #11100, showed Patient #4 with the inner cannula of his tracheostomy removed and dried secretions on the flange of the outer cannula. (The flange is a neck plate that extends from the sides of the outer tube and has holes to attach cloth ties around the neck.)

21. During an interview on 09/03/13 at approximately 3:45 PM, Patient #4 stated that he has had his tracheostomy for many years and trach care should be done one or two times per day. He stated that trach care had been done only two or three times over the four days since he was admitted to the facility on 08/29/13.

22. Record review of the facility's policy titled, "Restraints: Management of Non-Violent and Non-Self Destructive Behaviors" dated 06/12, showed direction to facility staff for restraint use (any physical or mechanical device, material or equipment that reduces the patient's ability to move freely and not easily removed by the patient, such as limb restraints, abdominal belts and/or hand mitts) to evaluate basic needs such as the need for regular exercise and range of motion.

23. Observations on 09/03/13 at approximately 1:50 PM and through 2:50 PM in the Neuro Intensive Care Unit (Neuro ICU) showed Patient #34:
- Calm in bed with eyes closed;
- Bilateral (right and left) upper and lower extremity (wrists and ankles) limb restraints;
- Bilateral lower limb restraints tied to one another further limiting movement; and
- Bilateral hand mitts approximately six inches in diameter (very bulky) covering the hands and secured at the wrists.

Observations on 09/05/13 at approximately 11:25 AM through 12:30 PM in the Neuro ICU showed Patient #34:
- Resting calmly and quietly in bed with eyes closed;
- Right wrist in limb restraint and a bulky hand mitt covering the hand and secured at the wrist; and
- Left extremity was immobilized in a arm sling extending from the shoulder to the wrist with a bulky hand mitt secured at the wrist.

24. Record review of Patient #34's medical record on 09/03/13 showed:
- Admission date of 08/10/13 from a rehabilitation center for increased agitation;
- History of a surgical repair of left shoulder on 08/08/13, mental retardation, autism, aggressive behavior, seizures and was non-verbal; and
- Continuous physician orders for the use of restraints for the dates 08/10/13 through 09/03/13.

The review showed no range of motion exercises by staff for dates 08/24/13 through 09/03/13.

25. During an interview on 09/05/13 at approximately 11:50 AM in the Neuro ICU, Staff TTT, RN assigned to the care of Patient #34, stated that she had not provided range of motion exercises to Patient #34.

26. During an interview on 09/03/13 at 2:30 PM in the Neuro ICU, Patient #35 stated that his left arm had been put in a restraint the night before. He stated that he could not use his right hand or arm because of a stroke. He stated that staff had not removed the restraint on his left arm so he was unable to exercise his arm.

27. Observation on 09/03/13 beginning at 3:00 PM through 3:15 PM in the Neuro ICU, showed Patient #18 resting quietly in bed with a left upper limb restraint and not moving his upper or lower extremities.

28. During an interview on 09/03/13 at 3:00 PM in the Neuro ICU, Patient #18's wife stated that the patient was admitted on 08/18/13 due to a stroke (bleeding in the brain) and that she is at the patient's bedside everyday during the hours of 8:00 AM until approximately 6:00 PM. She stated that the only exercise provided to the patient was by the Physical Therapy staff two to three times a week and that her daughter who is a nurse is concerned about his arms and legs not being exercised. She stated that the patient can't move his own arms.

29. Review of the medical record for Patient #18 showed no range of motion exercises provided by the staff.


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Based on observation, interview, record review and policy review, the facility failed to ensure nursing staff developed care plans for five patients (#4, #18, #34, #35, and #36) of 27 care plans reviewed. The failure to develop care plans for patients' individual nursing needs had the potential to affect all patient outcomes. The facility census was 884.

Findings included:

1. Record review of the facility's policy titled, "Documentation: Nursing" dated 06/12, showed direction for facility staff to develop a plan of care based upon the patient's individualized needs identified through initial and ongoing assessment. Further review showed direction for staff to identify and document appropriate nursing interventions, intended patient outcomes and goals of the interventions in the care plan that is then reviewed, changed, and updated on a continual basis to reflect the patient's status and clinical needs of the patient.

Record review of the facility's policy titled, "Restraints: Management of Non-Violent and Non-Self Destructive Behaviors" dated 06/12, showed direction to facility staff for restraint use (any physical or mechanical device, material or equipment that reduces the patient's ability to move freely and not easily removed by the patient) to be used in accordance with the patient's care plan.

2. Observations on 9/03/13 at approximately 1:50 PM and through 2:50 PM in the Neuro Intensive Care Unit (Neuro ICU) showed Patient #34:
- Calm in bed with eyes closed;
- Restraints on bilateral (right and left) upper and lower extremities (wrists and ankles);
- Bilateral hand mitts approximately six inches in diameter (very bulky) covering the hands; and
- Bilateral lower limb restraints tied to one another further limiting movement.

Observations on 09/5/13 beginning at approximately 11:25 AM through 12:30 PM in the Neuro ICU showed Patient #34:
- Resting calmly and quietly in bed with eyes closed;
- Right wrist in limb restraint and a bulky hand mitt covering the hand and secured at the wrist;
- Left extremity was immobilized in a arm sling extending from the shoulder to the wrist with a bulky hand mitt secured at the wrist; and
- Abdominal belt in place.

3. Record review of Patient #34's medical record on 09/03/13 showed continuous physician orders for the use of restraints from 08/10/13 through 09/03/13. The record showed no care plan for the use of restraints from 08/24/13 through 09/03/13.

4. During an interview on 09/03/13 at approximately 1:50 PM, Staff O, Registered Nurse (RN), assigned to the care of Patient #34 stated that:
- All patients have hand mitts and limb restraints when they are on a breathing machine or have tubes they could pull out.
- Restraints were in place to prevent him from pulling out his tubes.
- When asked how she planned care and interventions, she stated that the staff just knows what to do.

5. During an interview on 09/03/13 at 2:35 PM in the Neuro ICU, Staff KKK, RN assigned to the care of Patient #35, stated that the patient had been in a left wrist restraint during the night shift of 09/02/13 due to having a tube placed in his nose.

6. During an interview on 09/03/13 at 2:30 PM in the Neuro ICU, Patient #35 stated that his left arm had been put in a restraint the night before.

7. Record review of the medical record for Patient #35 on 09/03/13 at 2:35 PM showed no care plan for the use of restraints.

8. Observation on 09/03/13 beginning at 3:00 PM through 3:15 PM in the Neuro ICU, showed Patient #18 resting quietly in bed with a left upper limb restraint and not moving his upper or lower extremities.

9. Review of the medical record for Patient #18 showed no care plan for the use of restraints.

10. During an interview on 09/04/13 at approximately 11:00 AM, Staff HH, Nurse Practice Specialist, stated that all nursing staff were expected to develop care plans for all patients, including patients with restraints, according to facility policies.

11. During an interview on 09/04/13 at approximately 1:50 PM, Staff NNN, RN Risk Manager, stated that the nurses had the ability to develop a care plan for patients in restraints if they so choose.

12. Observation on 09/03/13 at 3:50 PM on the Progressive Care Unit (PCU) showed Patient #36 awake and alert in bed with his wife at the bedside. The patient and his wife did not understand questions asked by the surveyor related to nursing care. Both responded verbally "no English".

13. During interview on 09/03/13 at 3:50 PM, Staff R, RN who was assigned care of Patient #36, stated that the patient and his wife did not speak English; they spoke Nepalese. Staff R stated that no care plan had been developed for the communication needs or use of an interpreter for Patient #36.

14. Review of the medical record for Patient #36 showed the patient was admitted on 08/27/13 for stroke, spoke Nepalese, did not speak English and no care plan for communication needs/use of an interpreter.

15. Record review of Patient #4's medical record showed a physician order dated 08/29/13 for cleaning of the patient's tracheostomy tube inner cannula (trach care) every eight hours. (The inner cannula is a plastic tube that fits inside the outer tube that keeps the tracheostomy open and must be periodically cleaned of mucous secretions.) The review showed trach care was not included in the patient's care plan implementation worksheet.


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