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Based on observation, interview and record review, the facility failed to ensure that the Condition of Participation for Patient's Rights was met as evidenced by:

1. Failure to ensure a patient was provide an informed consent for a non-emergency procedure and for anesthesia (a state of controlled, temporary loss of sensation or awareness that is induced for medical purposes), prior to the procedures according to facility policy and procedure for one (1) of thirty (30) sampled patients (Patient 29). Patient 29 had an esophago-gastro-duodenoscopy (EGD - a diagnostic endoscopic procedure used to visualize the oropharynx [the middle part of the throat/behind the mouth], esophagus [the hollow muscular tube that passes food and liquid from the throat to the stomach], and proximal duodenum [first part of the small bowel/intestine]) and for colonoscopy (a procedure that checks the inside of the entire colon [intestine]).

This deficient practice resulted in Patient 29 not being provided information regarding the risks and benefits of the procedure and anesthesia being administered, prior to the procedure. (Refer to A - 0131).

2. Failure to maintain a safe environment in the Behavioral Health Unit (BHU, where patients with mental health emergencies are stabilized) Unit, during a code blue (any patient with an unexpected cardiac [heart] or respiratory [lung] arrest [stop] requiring resuscitation [revive from unconsciousness or apparent death] and activation of a hospital-wide alert) for one (1) of thirty (30) sampled patients (Patient 1), when:

a. A rapid response (a system designed to identify and respond to patients with early signs of clinical deterioration with the goal of preventing respiratory or cardiac arrest [heart stops]) was not immediately initiated.

This deficient practice resulted in delay for Patient 1 in receiving Cardiopulmonary Resuscitation (CPR, chest compressions and breathing for a patient that is not breathing and does not have a pulse). (Refer to A - 0144).

b. No functioning suction machine (device used to remove fluids from the airways) was available during a code blue (any patient with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a hospital-wide alert) which had compromised the success of intubation (the insertion of a tube either through the mouth or nose and into the airway to aid with breathing).

This deficient practice resulted to the physician assistance (PA)'s inability to clear Patient 1's airway was not able to intubate (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their trachea (airway/windpipe) to provide air to assist with breathing. (Refer to A - 0144).

c. Emergency treatment according to the American Heart Association Advance Cardiac Life Support (ACLS) Guidelines 2023 (Guidelines all certified personnel use in response to heart problems) during a "Code Blue" (used to summon personnel and equipment to the scene of a cardiopulmonary arrest or a life-threatening medical emergency) was not provided to Patient 1.

This deficient practice resulted to Patient 1 receiving a shock of 200 Joules (electrical shock administered by electrode pads (chest pads) for ventricular fibrillation [type of irregular heart rhythm]) that was not indicated for Patient 1, who as asystole (flat line, no electrical activity). (Refer to A - 0144).

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on interview and record review, the facility failed to ensure a patient was provide an informed consent for a non-emergency procedure and for anesthesia (a state of controlled, temporary loss of sensation or awareness that is induced for medical purposes), prior to the procedures according to facility policy and procedure for one (1) of thirty (30) sampled patients (Patient 29). Patient 29 had an esophago-gastro-duodenoscopy (EGD - a diagnostic endoscopic procedure used to visualize the oropharynx (the middle part of the throat/behind the mouth), esophagus (the hollow muscular tube that passes food and liquid from the throat to the stomach)stomach, and proximal duodenum) and for colonoscopy (a procedure that checks the inside of the entire colon, including the large intestine).

This deficient practice resulted in Patient 29 not being provided information regarding the risks and benefits of the procedure and anesthesia being administered, prior to the procedure.

Findings:

On 1/12/2024, at 11:27 AM, during concurrent interview with Quality Improvement Advisor (QIA) and record review of Patient 29's entire medical records, dated 12/15/2023, QIA stated there was no informed consent for Patient 29's non-emergency procedure, performed on 12/15/2023, for EGD and for colonoscopy. QIA stated patient should have had a signed informed consent for EGD and colonoscopy to discuss the risks and benefits of the procedures, because the procedures were not emergency procedures for Patient 29.

On 1/12/2024, at 11:27 AM, during an interview, QAA stated there was no informed consent for the anesthesia delivered to Patient 29, on 12/15/2023, during the EGD and colonoscopy, performed on 12/15/2023. QAA stated Patient 29 should have had a signed informed consent for anesthesia provided during EGD and colonoscopy procedures to discuss the risks and benefits of anesthesia.

On 1/12/2024, at 11:27 AM, during a concurrent interview and record review of Patient 29's post-anesthesia care assessment/implementation record, dated 12/15/2023, QAA stated patient was administered monitored anesthesia care (MAC - type of anesthesia service in which an anesthesia clinician continually monitors and supports the patient's vital functions, treats problems that occur, administers sedative or analgesic medications as needed) during a non-emergent procedure (EGD and colonoscopy).

On 1/12/2024, at 11:27 AM, during a concurrent interview and record during review of Patient 29's Physician Note, dated 12/13/2023, QAA stated Patient 29 had severe anemia (a condition when the blood had a lower-than-normal amount of healthy red blood cells) but had no signs of active gastro (stomach) -intestinal bleeding.

A review of facility's Informed Consents policy, dated 12/2022, indicated the following:

1. The patient must be given the opportunity to give an informed consent prior to the performance of procedures that place the patient at risk.

2. The patient's physician provides patient with information regarding the high-risk procedures or treatments planned, including anesthesia or sedation, so that an informed decision by the patient is made.

3. The patient's consent was to validate the process of informing the patient and must be on the patient's chart prior to the initiation of the procedure.

4. Informed consent information includes a discussion with the patient about the risks, drawbacks, anticipated convalescence, complications, and expected benefits of the procedure and associated anesthesia.

5. Consent must be obtained at the time when the patient was fully capable of understand the procedure so that an informed decision can be made.

Based on observation, interview, and record review, the facility failed to maintain a safe environment in the Behavioral Health Unit (BHU, where patients with mental health emergencies are stabilized) Unit, during a code blue (any patient with an unexpected cardiac [heart] or respiratory [lung] arrest [stop] requiring resuscitation [revive from unconsciousness or apparent death] and activation of a hospital-wide alert) for one (1) of thirty (30) sampled patients (Patient 1). Patient 1 had a code blue and the facility failed to provide safe care by:

1. Failure to immediately initiate a rapid response (a system designed to identify and respond to patients with early signs of clinical deterioration with the goal of preventing respiratory or cardiac arrest [heart stops]) when Patient 1 was found unresponsive.

2. Not having a functioning suction machine (device used to remove fluids from the airways) available during a code blue (any patient with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a hospital-wide alert) which had compromised the success of intubation (the insertion of a tube either through the mouth or nose and into the airway to aid with breathing).

3. An emergency treatment according to the American Heart Association Advance Cardiac Life Support (ACLS) Guidelines 2023 (Guidelines all certified personnel use in response to heart problems) during a "Code Blue" (used to summon personnel and equipment to the scene of a cardiopulmonary arrest or a life-threatening medical emergency) was not provided to Patient 1.

This deficient practice resulted in delay for Patient 1 to receive Cardiopulmonary Resuscitation (CPR, chest compressions and breathing for a patient that is not breathing and does not have a pulse), the physician assistance (PA)'s was unable to clear Patient 1's airway was not able to intubate (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their trachea (airway/windpipe) to provide open airway to facilitate breathing, and Patient 1 received a shock of 200 Joules (electrical shock administered by electrode pads (chest pads) for ventricular fibrillation [ type of irregular heart rhythm]) that was not indicated for Patient 1. Patient 1 was asystole (flat line, no electrical activity) when 200 Joules shock was delivered. Patient 1 died 24 minutes after being found unresponsive after code blue was called on 9/18/20 at 4:55 p.m.

On 1/11/2024 at 2:43 p.m., the survey team called an immediate jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Director of Risk Management. The facility failed to ensure Patient 1 received safe care after becoming unresponsive and a code blue was called to resuscitate Patient 1.

On 12/29/2023, facility submitted IJ removal plan. IJ removal plan accepted, and onsite survey team validated implementation of the IJ removal plan at 6:30 p.m. IJ removed at 7:17 p.m. in the presence of the facility's Chief Nursing Officer and Chief Executive Officer. The IJ Removal Plan indicated the following actions:

A. The hospital's sitter form was revised to require RNs to sign off when 1:1 sitters' handoff during breaks and change of shift to ensure that information related to reason for the 1:1 and recent observation are communicated.

B. Re-education for all Behavioral Health Unit (BHU) staff on RN sign off for 1:1 sitter handoff requirement.

C. An additional crash cart was placed in the BHU unit.

D. Code response requirements for Respiratory Therapy were enhanced to require RTs to bring Glide scopes (a device that is used for difficult airway management) to all code blue codes.

E. Code blue mock drill was included on the skills day agenda for BHU November 2023.

F. Mock code blue drills scheduled to be conducted quarterly in BHU and other areas where code blues rarely occur.

G. A purchase order for battery operated suction machines was requested for approval.

H. Communication devices will be purchased/distributed to enhance communication on the Behavioral Health Unit.

I. If a medical emergency occurs and the Emergency Department (ED) or Urgent Care physician is unable to intubate the patient, the on-call panel will be utilized.

Findings:

A review of Patient 1's "History of Present Illness," dated 9/9/2023 indicated, Patient 1 was admitted to the Behavioral Health Unit (BHU, unit dedicated to increasing health related to different behavioral diagnosis) with a diagnosis of "Paranoid schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves with feelings of distrustful or suspicious of other people) with acute exacerbation. Patient 1 was at the psychiatric unit (BHU) over the previous 4 weeks. Patient 1 was transferred from BHU to the emergency room because of declining kidney function, aggressive behavior, and noncompliance with care. Patient 1 was restrained prior to transfer because he was physically threatening staff during medical care. Patient 1 was evaluated in the emergency room and magnesium (a mineral need in the body, normal range 1.82 milligram [mg, unit of measurement]/deciliter [dL, unit of measurement] to 2.1 mg/dL)was slightly low and phosphorus (a mineral need in the body to build strong bones and teeth, normal level 2.5 to 4.5 mg/dL) was slightly low and he was treated and medically cleared. Patient 1 was transferred back to the BHU to continue his psychiatric and medical management.

1. During an interview, with the Director of Behavioral Unit (DBHU) on 1/9/2024, at 3:43 p.m., DBHU stated, on 09/18/23, Patient 1 was in the seclusion room with Mental Health Technician 1 (MHT 1). MHT 1 observed Patient 1 lowering himself to the floor, then Patient laid down to the floor. MHT 1 check Patient 1 about 45 seconds to a minute later after Patient 1 laid down on the floor. MHT 1 found Patient 1 to be unresponsive and did not initiate and call rapid response. MHT 1 left Patient 1 and then MHT 1 went to the nurse station to asked for help from Licensed Vocational Nurse 2 (LVN 2). MHT did not indicate the situation was an emergency to LVN 2. LVN 2 went to checked on Patient 1. LVN 2 found Patient 1, Patient 1 was unresponsive, and not breathing. LVN 2 initiated the rapid response. DBHU stated MHT1 was the first responder and should have called a rapid response upon identifying the patient (Patient 1) to be unresponsive.

A review of the Patient's 1 "Nursing Narrative Note", by LVN 2, dated 9/18/2023 5:45 p.m., indicated on 09/18/2023 at 4:52 p.m., MHT 1 came and stated Patient 1 fell to the floor, LVN 2 ran into the room and observed Patient 1 on the floor. Patient 1'sface was blue, and chest was not raising and falling. LVN 2 informed Charge Nurse to call a rapid response.

A review of the facility's policy and procedure (P&P), titled, "Rapid Response Team", revised date 07/2022, indicated the purpose was (1) To quickly recognize the patient's clinical deterioration, (2) To respond quickly and appropriately to adverse changes in the patient's condition, and (3) To avert inpatient Code Blue situations through timely intervention. The policy also indicates that Rapid Response can be called by any hospital personnel, outside clinical contractor, clinical student, patient, or their family member.

2. A review of Patient 1's "Physician Code Blue," dated 9/18/2023, indicated, reason for code blue was Patient 1 was in full arrest (loss of all heart activity), respiratory arrest (breathing stops), and unresponsive. The note indicated, "Patient is lying on gurney and is unresponsive in full cardiac arrest. No heart sounds heard. CPR (Cardiopulmonary Resuscitation, chest compressions and breathing for a patient that is not breathing and does not have a pulse) in progress ..."

During an interview, on 1/10/2023 at 1:10 p.m. with the Director of Behavior Health Unit (DBHU), DBHU stated during the code blue in Patient 1's room, "The suction machine was not working because there was no extension cord long enough to plug the suction machine to the nearest electrical outlet."

During an observation, on 1/10/2024 at 2:00 PM, in Patient 1's room on the Behavioral Health Unit (BHU), Patient 1's room was an isolation room (single patient room). Patient 1's room was the location of the Code Blue. A bed was in the center of the room. The walls do not have electrical outlets. There are two doors in this room with locking abilities. Door 1 had a small window with the ability to view the hallway when looking from inside the room to the exterior. Door 2 was for a private bathroom.

During a concurrent observation and interview on 1/10/2023 at 2:03 p.m. with DBHU and the Charge Nurse 2 (CN 2) of BHU in the room where Patient 1 was found during code blue, there was no electrical outlet on all walls of the room. The DBHU confirmed that there was no outlet in the room during the code blue, which prevented the suction machine from being plugged in.

A review of Patient 1's "Code Blue Record (record kept during resuscitation of time for each intervention and Patient 1's's response to intervention)," dated 9/18/2023, the record indicated that the code blue first time of entry started at 4:55 p.m. The record indicated under "Intubated by" was the name of the physician assistance (PA), but the PA name had a line drawn through, and under "Time," indicated a time of 5:12 p.m., but also had a line drawn through (Patient 1 was not intubated).

During an interview on 1/10/2023 at 4:40 p.m., the House Supervisor (HS), HS stated he arrived in the Patient 1's room with the PA when the code blue was called. HS stated the patient (Patient 1) was never intubated. HS further stated, "(name of the PA) first attempt was not successful, but the second time (name of the PA) scream out that she got it but is not able to confirm placement (tube is in correct place). The PA was not able to intubate at the end." HS confirmed this was the reason that the Code Blue Record had a line drawn through the entries.

During a phone interview, on 1/11/2024 at 9:33 a.m. with the PA, the PA stated, "During intubation, it (intubation) was difficult because there was no suction. There was no plug. There was nowhere to plug in the suction machine." PA further stated, "After bagging (using an ambu bag, a medical device used to manually assist with breathing that forces air into the lungs) the patient for a long time, we will need to intubate (placement of a tube into the trachea (windpipe) to provide artificial respiration to the lungs). Now that the RT (Respiratory Therapist) is there and the two ER (emergency room) nurses are there, I tried very hard to visualize and walk through it (the intubation process)."PA stated that she only tried to intubate once. The PA stated, "I saw how difficult the lack of suction was and how dark it was. It (intubation) was not worth trying again, as it interrupted CPR. The MD (ED physician) called the time of death at 17:19 (5:19 p.m.)."

During a review of the facility's policy and procedure (P&P) titled, "Code Blue," dated, 9/2022 the P&P indicated, the purpose and objective were "To outline the duties and responsibilities of all personnel in maintaining vital functions during the cardiopulmonary arrest of any patient aged 14 and over. The Emergency Department (ED) maintains equipment and supplies needed for the resuscitation of the pediatric patient ... Responsibilities: The 1st responder stays with the patient and initiates CPR (cardiopulmonary resuscitation, an emergency lifesaving procedure performed when the heart stops beating). Assists in obtaining equipment and supplies as designated by the Code Blue Team Leader or M.D. after relieved of CPR ... Third responder: Sets up suction equipment and suctions airways as necessary ..."

3. During an observation of the nursing station at the BHU, on 1/10/2024 at 2:00 PM with Director of BHU, a crash cart (a cart on wheels with Advance Cardiac Life Support [ACLS] supplies) was observed equipped with a cardiac (heart) monitor with defibrillator (a device that apply an electric charge or current to the heart to restore a normal heartbeat).

During a telephone interview on 1/11/2024 at 8:41 AM, with Registered Nurse 1 (RN 1) about Patient 1's code blue incident stated, "The crash cart was there (in Patient 1's isolation room) when I entered the room. I charged the monitor and selected 200 joules. I interpreted the rhythm (heart rhythm, or heartbeat) and cleared the patient (from other people touching the patient). And shocked the patient at 200 joules with a rhythm of asystole (no heartbeat). A patient does not receive a shock at asystole rhythm."

During a telephone interview, on 1/11/2024 at 8:48 AM, with RN 1, RN 1 stated his ACLS certificate (certificate of competence to provide ACLS care) was expired. RN 1 stated his ACLS was expired due to ACLS was not required in the BHU.

During a telephone interview on 1/11/2024 at 9:27 AM, with the Emergency Department Physician Assistant (PA 1), PA 1 stated "Entering the room (Patient 1's room), RN 1 was delivering the shock." PA 1 stated "RN 1 was the only one leading prior to my arrival as the higher medical authority. PA 1 stated RN 1 said, "Everyone step away I am giving a shock." PA 1 stated, asking RN 1, "Why did you give a shock that was asystole?"

During an interview on 1/12/2024 at 10:50 AM with the Director of BHU, Director of BHU stated, "We adhere to American Heart Guidelines for BLS (Basic Life Support) and ACLS ... ACLS certified personnel has the ability (is trained) to interpret EKG (electrocardiogram, a line seen on paper or monitor showing electrical activity through the heart) rhythms ... The expectation is to start CPR (Cardiopulmonary Resuscitation, chest compressions and breathing for a patient that is not breathing and does not have a pulse) immediately. The expectation is to set up the BLS procedures (Basic Life Support, including apply electrode pads) and wait for qualified personnel to interpret the EKG rhythm."

A review of Patient 1's "Intake Information/Initial Assessment" (Code Blue Document) dated 9/18/2023 at 1651 (4:51 PM), indicated, at "1656 (4:56 PM), Rhythm asystole (no electrical activity to create the heart to mechanically pump), 1 shock delivered," at "1719 (5:19 PM), Code Stopped (stopped treatment per ACLS guidelines), Disposition (status of Patient 1) Following Code Expired (Dead)".

A review of the facility's policy and procedure (P&P) titled, "Code Blue" (Cardiopulmonary Resuscitation) dated 9/2022, the P&P indicated, "The term Code Blue will be used to summon personnel and equipment to the scene of a cardiopulmonary arrest or a life-threatening medical emergency ... American Heart Association guidelines will be followed."

A review of American Heart Association Advance Cardiac Life Support Services guidelines (AHA ACLS guidelines) titled, "Adult Cardiac Arrest Algorithm, Asystole/PEA (pulseless electrical activity, heart is not mechanically pumping)" dated 2020 (with 2023 updates), under 9. Asystole/PEA (Pulseless Electrical Activity) treatment intervention was to administer Epinephrine (medication used during emergency to stimulate the heart) response to ASAP (As Soon As Possible) 10. CPR (Cardiopulmonary Resuscitation) 2 minutes (provide CPR for 2 minutes prior to the next step [step 11])." No shock was indicated asystole. The guideline indicated shock was indicated for ventricular fibrillation (VF, a type of irregular heart rhythm)or ventricular tachycardia (VT, a type of abnormal heart rhythm).

Based on interview and record review, the facility failed to ensure that the Condition of Participation for Nursing Services was met as
evidenced by:

1. Failure to develop and implement a baseline care plan addressing the primary diagnosis for one (1) of thirty (30) sampled patients (Patient 7), who was admitted to the facility with a diagnosis of seizure (an uncontrolled, abnormal electrical activity of the brain that causes uncontrolled muscle twitching or jerking).

This deficient practice had the potential for delayed provision of necessary care and services related to seizures for Patient 7 and other patients. (Refer to A - 0396).

2. Failure to ensure four (4) of five (5) personnel nurse files reviewed had abuse training on file according to facility policy and procedure for Abuse, Neglect and Abandonment.

This deficient practice had the potential for patients at the facility not being provide with appropriate care for abuse. (Refer to A - 0397).

3. Failure to ensure one (1) of five (5) sampled employees Registered Nurse 2 (RN 2) had current training for restraints (devices used to limit a patient's movement).

This deficient practice had the potential for the unsafe environment for patients on restraints. (Refer to A - 0397).

4. Failure to ensure one (1) of five (5) sampled employees RN 1 was competent to provide treatment for an emergency treatment according to the American Heart Association Advance Cardiac Life Support (ACLS) Guidelines 2023 (Guidelines all certified personnel use in response to heart problems) during a "Code Blue" (used to summon personnel and equipment to the scene of a cardiopulmonary arrest or a life-threatening medical emergency) was not provided to Patient 1.

This deficient practice resulted to Patient 1 receiving a shock of 200 Joules (electrical shock administered by electrode pads (chest pads) for ventricular fibrillation [ type of irregular heart rhythm]) that was not indicated for Patient 1, who as asystole (flat line, no electrical activity). Refer to A - 0397).

5. Failure to update and accurately document on the medical record information regarding assessment and care provided for three (3) of the thirty (30) sampled patients' (Patient 11, Patient 12, and Patient 16) in accordance with the facility's policy and procedure (P&P).

a. Patient 11's fall risk assessment was not updated to reflect that Patient 11 had recently fallen according to facility P&P for fall.

b. Patient 12's fall history assessment was not updated to reflect that Patient 12 had recently fallen according to facility P&P for fall.

c. Patient 16's Code Blue Record (recording of the event during which any patient had an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a hospital-wide alert) was incomplete and contained inappropriate scratching out of writing according to facility P&P for code blue.

This deficient practice resulted Patient 11, Patient 12, and Patient 16's medical record information not accurate and complete. The deficient practice had the potential for the care and safety of patients not appropriately implemented after a fall or an emergency. (Refer to A - 0398).

6. Failure to immediately initiate a rapid response (a system designed to identify and respond to patients with early signs of clinical deterioration with the goal of preventing respiratory or cardiac arrest [heart stops]) according to facility's P&P for rapid response (a system designed to identify and respond to patients with early signs of clinical deterioration with the goal of preventing respiratory [lung] or cardiac [heart] arrest) for one (1) of 30 sampled patient (Patient 1), who was found unresponsive.

This deficient practice resulted in delay for Patient 1 in receiving Cardiopulmonary Resuscitation (CPR, chest compressions and breathing for a patient that is not breathing and does not have a pulse). Patient 1 eventually died. (Refer to A - 0398).

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care by the nursing staff.

Based on interview and record review, the facility failed to develop and implement a baseline care plan addressing the primary diagnosis for one (1) of thirty (30) sampled patients (Patient 7), who was admitted to the facility with a diagnosis of seizure (an uncontrolled, abnormal electrical activity of the brain that causes uncontrolled muscle twitching or jerking).

This deficient practice had the potential for delayed provision of necessary care and services related to seizures for Patient 7 and other patients.

Findings:

A review of Patient 7's "Admission Record" (undated), indicated Patient 7 was admitted on 9/19/2023, with a primary diagnosis of seizure. Other active diagnosis includes auditory hallucination (hearing voices or noises that don't exist in reality), aggressive behavior (behavior intending to cause physical or mental harm), and cholecystitis (inflammation of the gallbladder [a small organ on the right side of the belly]).

A review of Patient 7's "History and Physical Reports" (H&P), dated 9/18/2023 at 4:20 PM, indicated Patient 7 has history of repeated falls.

A review of Patient 7's "Care Plan" initiated on 9/20/2023, Patient 7's Care Plan addressed safety-fall risk, knowledge deficit, gait instability, limited mobility, and pain management. There was no care plan addressing the admitting diagnosis of seizures.

A review of Patient 7's "Medication Administration Record (MAR)", dated 9/19/2023 to 9/19/2023, Patient 7s MAR indicated administration of Keppra (medication that help treat and prevent seizures) 500 milligrams (mg, unit of measurement) given in the emergency room (page one of two).

A review of Patient 7's "Physician Progress Note", dated 9/24/2023 at 11:51 PM, indicated a recent onset seizure disorder presents after a witnessed episode on the psychiatric floor (page two of two). The Physician Progress Note indicated the patient is doing well on Keppra (page two of two) and seizure precautions (page two of two).

A review of Patient 7's "Nursing Narrative Note", dated 9/19/2023 at 9:58 AM, indicated Patient 7 was brought in by the Behavioral Health Unit (BHU, an area of the hospital designed to stabilize someone with mental health emergency) for complaints of a seizure episode at 2:00 AM.

A review of Patient 7's "Nursing Narrative Note", dated 9/19/2023 at 2:57 AM, indicated Patient 7 reports having a seizure at 12:10 AM. Patient 7's doctor was called and informed about the patient's seizure episode.

A review of Patient 7's "Discharge Instructions", dated 10/11/2023 at 12:09 PM, indicated Patient 7 was to be discharged with medication Keppra (levetiracetam) 500 mg two times per day. This medication was continued for the treatment and prevention of seizures.

During a concurrent interview with Staff Nurse 2 (SN 2) and record review of Patient 7's Admission Orders and Care Plan, on 1/11/2024 at 5:30 PM, with SN 2, SN 2 stated Patient 7 had no care plan addressing seizures. SN 2 stated Patient 7 should have a care plan addressing seizures to identify the risk associated with seizures like falls, hurting themselves, and the risk of a compromised airway. SN 2 stated it (a care plan) was important to have a care plan addressing seizures for the patient's safety.

During a concurrent interview with the Director of Risk Management (DRM) and record review of Patient 7's Admission Orders and Care Plan, on 1/12/2024 at 4:57 PM, with the DRM, DRM stated Patient 7 was admitted to the emergency room for seizures. DRM stated Patient 7 had no care plan addressing seizures. DRM stated if Patient 7 was being treated for seizures and had reports of having seizures a care plan should have been initiated. DRM stated the care plan was important to identify appropriate interventions (actions taken to improve a situation) and to identify appropriate safety precautions.

A review of facility policy and procedure (P&P), titled, "Interdisciplinary Plan of Care," dated 11/2022, indicated, "The Interdisciplinary Plan of Care shall be based upon the assessments performed by all disciplines, which describes the intentions, rationale, and interventions associated with identified issues." The P&P indicated the following:

1. The plan of care provides for the continuum of care in meeting the needs of the patient throughout their stay.

2. An individualized Plan of Care was to be developed for each patient that reflect the patient's unique needs.

3. Each discipline shall initiate and revise the Interdisciplinary Plan of Care based upon ongoing assessment of the patient's needs.

4. All disciplines review and the patient's plan of care each shift and update goals when there are changes in patient condition.

Based on interview and record review, the facility failed to ensure licensed nurses had current competence to provide necessary care for patient as evidence by:

1. Failure to ensure four (4) of five (5) nurse (Registered Nurses [RN 1, RN 8, RN 9, and RN 10] files reviewed had abuse training on file according to facility policy and procedure for Abuse, Neglect and Abandonment.

This deficient practice had the potential for patients at the facility not being provide with appropriate care for abuse.

2. Failure to ensure one (1) of five (5) sampled employees (RN 2) had current training for restraints (devices used to limit a patient's movement).

This deficient practice had the potential for the unsafe environment for patients on restraints.

3. Failure to ensure one (1) of five (5) sampled employees RN 1 was competent to provide treatment for an emergency treatment according to the American Heart Association Advance Cardiac Life Support (ACLS) Guidelines 2023 (Guidelines all certified personnel use in response to heart problems) during a "Code Blue" (used to summon personnel and equipment to the scene of a cardiopulmonary arrest or a life-threatening medical emergency) was not provided to Patient 1.

This deficient practice resulted to Patient 1 receiving a shock of 200 Joules (electrical shock administered by electrode pads (chest pads) for ventricular fibrillation [ type of irregular heart rhythm]) that was not indicated for Patient 1, who as asystole (flat line, no electrical activity).

Findings:

1. On 1/12/2024, at 3:27 PM, during interview with Human Resources Operation Manager (HR Mgr.) and Director of Human Resources (HR Dir.), HR director stated the following:

a. All employees were screened prior to being hired with background checks for criminal history.

b. Abuse training was required for all employees, was provided upon hire during orientation, and was done annually, through on-line training.

On 1/12/2024, at 6:30 PM, during concurrent interview with HR Dir. and HR Mgr., and record review of personnel files, HR Dir. stated four of five sampled employees (RN 1, RN 8, RN 9, & RN 10) did not have current abuse training.

A review of facility's Abuse, Neglect and Abandonment policy, dated 8/2022, indicated the following:

a. All employees will comply with abuse reporting requirements under state and local laws, as mandated reporters, to report witnessed or suspected abuse of a patient.

b. Mandated reporter was anyone in their professional capacity or within their scope of employment, who has observed or has knowledge of an incident that reasonably appears to be abuse of neglect must complete a form for each report of known or suspected instance of abuse involving an elder or dependent adult and report to their adult protective services (APS - agency to help elder adults and dependent adults when these adults are unable to meet their own needs, or are victims of abuse, neglect, or exploitation) or local law enforcement.

A review of facility's Competency Assessment policy, dated 3/2023, indicated included the following:

a. Competency was part of the performance appraisal system and is assessed upon hire, transfer to a new role, prior to assignment to a new unit, when there is a change in job performance or job requirements and thereafter, on an annual basis.

b. Skills selected for competency assessment are determined from organization-wide and department specific, job descriptions, performance evaluations, policies and procedures, additional standards of practice for specialty areas.

c. Competency requirements are updated as needed and reviewed annually by the managers, directors or designee, and the education department to reflect changes in performance improvement activities, developments in science and technology, and changing patient care needs.

d. Competency verification includes satisfactory annual performance appraisal, observation of required competency skills, verbal interviews demonstrating proficiency in specific knowledge/skills, continuing education and in-services, role and department specific competency/skills demonstration, medical record documentation review.

2. On 1/12/2024, at 4:06 PM, during a concurrent interview with HR Dir. and HR Mgr., and record review of RN 2's personnel file, HR Dir stated RN 2's last documentation for restraint training was done on 2/13/2021.

On 1/12/2024, at 4:06 PM, during an interview, HR Dir. stated training for restraints was done upon hire, during hospital orientation, and annually, through on-line training.

A review of facility's Competency Assessment policy, dated 3/2023, indicated the following:

a. Initial competency assessment begins when the Human Resources Department establishes the educational background, licensure, certification, and previous experiences and references to the job candidate.

b. Activities included: orientation, in-service education, equipment in-service, continuing education courses, competency assessment/skills validation, preceptor activities, 90-day, and annual performance review, and participation in performance/quality improvement teams.

c. Skills selected for competency assessment are determined from organization-wide and department specific, job descriptions, performance evaluations, policies and procedures, additional standards of practice for specialty areas.

d. Competency requirements are updated as needed and reviewed annually by the managers, directors or designee, and the education department to reflect changes in performance improvement activities, developments in science and technology, and changing patient care needs.

e. Competency verification includes satisfactory annual performance appraisal, observation of required competency skills, verbal interviews demonstrating proficiency in specific knowledge/skills, continuing education and in-services, role and department specific competency/skills demonstration, medical record documentation review.

f. All ongoing competencies must be 100% completed by the end of the designated year.

3. A review of Patient 1's "Physician Code Blue," dated 9/18/2023, indicated, reason for code blue was Patient 1 was in full arrest (loss of all heart activity), respiratory arrest (breathing stops), and unresponsive. The note indicated, "Patient is lying on gurney and is unresponsive in full cardiac arrest. No heart sounds heard. CPR (Cardiopulmonary Resuscitation, chest compressions and breathing for a patient that is not breathing and does not have a pulse) in progress ..."

During an observation of the nursing station at the BHU, on 1/10/2024 at 2:00 PM with Director of BHU, a crash cart (a cart on wheels with Advance Cardiac Life Support [ACLS] supplies) was observed equipped with a cardiac (heart) monitor with defibrillator (a device that apply an electric charge or current to the heart to restore a normal heartbeat).

During a telephone interview, on 1/11/2024 at 8:41 AM, with a Registered Nurse 1 (RN 1) about Patient 1's code blue incident stated, "The crash cart was there (in Patient 1's isolation room) when I entered the room. I charged the monitor and selected 200 joules. I interpreted the rhythm (heart rhythm, or heartbeat) and cleared the patient (from other people touching the patient). And shocked the patient at 200 joules with a rhythm of asystole. A patient does not receive a shock at asystole rhythm."

During a telephone interview, on 1/11/2024 at 8:48 a.m., with RN 1, RN 1 stated his ACLS certificate (certificate of competence to provide ACLS care was expired. RN stated his ACLS was expire due to ACLS was not required in the BHU.

During a telephone interview, on 1/11/2024 at 9:27 AM, with the Emergency Department Physician Assistant (PA 1), PA 1 stated "Entering the room (Patient 1's room), RN 1 was delivering the shock." PA 1 stated "RN 1 was the only one leading prior to my arrival as the higher medical authority. PA 1 stated RN 1 said, "Everyone step away I am giving a shock." PA 1 stated, asking RN 1, "Why did you give a shock that was asystole?"

During an interview, on 1/12/2024 at 10:50 AM with the Director of BHU, Director of BHU stated, "We adhere to American Heart Guidelines for BLS (Basic Life Support) and ACLS ... ACLS certified personnel has the ability (is trained) to interpret EKG (electrocardiogram, a line seen on paper or monitor showing electrical activity through the heart) rhythms ... The expectation is to start CPR (Cardiopulmonary Resuscitation, chest compressions and breathing for a patient that is not breathing and does not have a pulse) immediately. The expectation is to set up the BLS procedures (Basic Life Support, including apply electrode pads) and wait for qualified personnel to interpret the EKG rhythm."

A review of Patient 1's "Intake Information/Initial Assessment" (Code Blue Document), dated 9/18/2023 at 1651 (4:51 PM), indicated, at "1656 (4:56 PM), Rhythm asystole (no electrical activity to create the heart to mechanically pump), 1 shock delivered," at "1719 (5:19 PM), Code Stopped (stopped treatment per ACLS guidelines), Disposition (status of Patient 1) Following Code Expired (Dead)".

A review of the facility's policy and procedure (P&P) titled, "Code Blue" (Cardiopulmonary Resuscitation) dated 9/2022, the P&P indicated, "The term Code Blue will be used to summon personnel and equipment to the scene of a cardiopulmonary arrest or a life-threatening medical emergency ... American Heart Association guidelines will be followed."

A review of American Heart Association Advance Cardiac Life Support Services guidelines (AHA ACLS guidelines) titled, "Adult Cardiac Arrest Algorithm, Asystole/PEA (pulseless electrical activity, heart is not mechanically pumping)" dated 2020 (with 2023 updates), under 9. Asystole/PEA (Pulseless Electrical Activity) treatment intervention was to administer Epinephrine (medication used during emergency to stimulate the heart) response to ASAP (As Soon As Possible) 10. CPR (Cardiopulmonary Resuscitation) 2 minutes (provide CPR for 2 minutes prior to the next step [step 11])." No shock was indicated asystole. The guideline indicated shock was indicated for ventricular fibrillation (VF, a type of irregular heart rhythm)or ventricular tachycardia (VT, a type of abnormal heart rhythm).

A review of facility's Competency Assessment policy, dated 3/2023, indicated the following:

a. Skills selected for competency assessment are determined from organization-wide and department specific, job descriptions, performance evaluations, policies and procedures, additional standards of practice for specialty areas.

b. Competency requirements are updated as needed and reviewed annually by the managers, directors or designee, and the education department to reflect changes in performance improvement activities, developments in science and technology, and changing patient care needs.

c. Competency verification includes satisfactory annual performance appraisal, observation of required competency skills, verbal interviews demonstrating proficiency in specific knowledge/skills, continuing education and in-services, role and department specific competency/skills demonstration, medical record documentation review.

d. All ongoing competencies must be 100% completed by the end of the designated year.

Based on observation, interview, and record review, the facility staff failed provide adequate care according to facility policy and procedure as evidence by:

1. Failure to update and accurately document the medical record information regarding assessment and care provided for three (3) of the thirty (30) sampled patients' (Patient 11, Patient 12, and Patient 16) in accordance with the facility's policy and procedure (P&P).

a. Patient 11's fall risk assessment was not updated to reflect that Patient 11 had recently fallen according to facility P&P for fall.

b. Patient 12's fall history assessment was not updated to reflect that Patient 12 had recently fallen according to facility P&P for fall.

c. Patient 16's Code Blue Record (recording of the event during which any patient had an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a hospital-wide alert) was incomplete and contained inappropriate scratching out of writing according to facility P&P for code blue,

This deficient practice resulted Patient 11, Patient 12, and Patient 16's medical record information not accurate and complete. The deficient practice had the potential for the care and safety of patients not appropriately implemented after a fall or an emergency.

2. Failure to immediately initiate a rapid response (a system designed to identify and respond to patients with early signs of clinical deterioration with the goal of preventing respiratory or cardiac arrest [heart stops]) according to facility's P&P for rapid response (a system designed to identify and respond to patients with early signs of clinical deterioration with the goal of preventing respiratory [lung] or cardiac [heart] arrest) for one (1) of 30 sampled patient (Patient 1), who was found unresponsive.

This deficient practice resulted in delay for Patient 1 in receiving Cardiopulmonary Resuscitation (CPR, chest compressions and breathing for a patient that is not breathing and does not have a pulse). Patient 1 eventually died.

Findings:

1 a. During a review of Patient 11's "History and Physical (H&P, a physician's examination of a patient)," dated 11/10/2023, indicated, Patient 11 was admitted to the facility for psychiatric (mental) evaluation. Patient 11's medical history included diabetes mellitus (the body is unable regulate blood sugar causing blood sugar levels to be abnormally high), chronic (persisting for a long time) back pain, and urgency of urination (a sudden and strong need to urinate).

During a concurrent observation and interview, on 1/9/2024 at 1:49 p.m., with the Administrator (ADM) and the Assistance Chief Nursing Officer (ACNO) in Patient 11's room, Patient 11 was sitting on the bed. Patient 11 stated, "I fell in the patio while standing up. There were staff nearby and assisted me back onto the seat."

A review of Patient 11's "Nursing Narrative Note" dated 11/15/2023 at 6:59 a.m., the note indicated, "Patient (Patient 11) was in the Patio for a smoke break. MHW (mental health worker) witnessed the patient (Patient 11) fell on his right shoulder. Assisted patient (Patient 11) to his room and assessed patient for any pain, redness, or injury. No pain, redness or injury noted."

During a concurrent interview and record review of Patient 1's Morse Fall Scale (a rapid and simple method of assessing a patient's likelihood of falling), on 1/9/2024 at 3:00 p.m. with the ACNO. Patient 11's "Morse Fall Scale," dated 11/15/2023 was reviewed. The ACNO stated the Morse Fall Scale for the morning shift, on 11/15/2023, had a missing entry. ACNO stated, "There should be an update to the patient's (Patient 11) Morse Fall Risk assessment to indicate that the patient (Patient 11) has fallen." ACNO stated it (documentation) was important to update Patient 11's Morse Fall Risk to communicate that the patient (Patient 11) had an increased risk of falling and to increase monitoring to prevent the patient (Patient 11) from falling again. ACNO stated, "A yellow wrist band will be place on the patient's wrist."

1. b. A review of Patient 12's "History and Physical (H&P)," dated 12/14/2023, indicated, Patient 12 was admitted to psychiatric unit (a unit of a general hospital that provides inpatient services for individuals with serious mental illness or serious emotional disturbance) for suicidal ideation (having thoughts about the possibility of ending one's own life). The H&P indicated Patient 12 has existing edema (a condition characterized by an excess of watery fluid collecting in the tissue) to both lower extremities (the part of the body that includes the hip, thigh, knee, leg, ankle, and foot).

During a concurrent observation and interview on 1/9/2024 at 1:40 p.m. with the Administrator (ADM) and the Assistance Chief Nurse Officer (ACNO) in Patient 12's room, Patient 12 was observed exiting the restroom in a slow motion but was not limping. Patient 12 stated, "I fell in the restroom." Patient 12 stated he could not recall how he fell.

During a concurrent interview and record review on 1/9/2024 at 4:00 p.m. with the ACNO, Patient 12's "Nursing Narrative Note," dated 12/16/2023, was reviewed. The note indicated, on 12/15/2023 at 12:23 a.m. Patient 12 fell in the bathroom and hit his head and scrape his elbow.

During a concurrent interview and record review of Patient 12's Morse Fall Scale, on 1/9/2024 at 4:02 p.m. with the ACNO, Patient 12's "Morse Fall," ,dated 11/15/2023 was reviewed. The Morse Fall Scale indicated Patient 12 has "No" history of falls. The ACNO stated the Morse Fall Scale should have been updated to indicate "Yes" under "History of Fall," to indicate that Patient 12 had fallen. The ACNO stated, "It is important to identify that the patient had fallen to communicate to other staff and to individualized interventions to reduce risk and prevent future fall."

During a review of the facility's P&P titled, "Documentation." dated September 2022, indicated, "Admission Documentation: the minimum data set required but not limited to those identified below should be assessed and documented/updated in the admission/visit assessment. All entries made by assistive personnel must be validated by a Registered Nurse. The medical record system serves all members of the interdisciplinary team as a source of primary information about the patient, which was changed by further physical and psychosocial assessments and evaluations throughout the patient stay. All Initial assessments completed within 2 hours of admission (full systems [head to toe] including skin, suicide and fall risk), skin integrity, pain, venous thromboembolism (VTE, blot clot in the vein), suicide, potential violence to others, methicillin-resistant Staphylococcus aureus (MRSA, a type of bacteria), acuity, functional status, nutrition and hydration status and learning and communication needs."

A review of the facility's P&P titled, "Fall Prevention Policy," dated September 2019, indicated, the facility, "Believes all falls can be prevented by assessing the risk of patients and with the provision of individualized care. When a fall occurs, we are dedicated to reviewing the event and implementing corrective actions to prevent future falls from occurring. The purpose: To establish guidelines for assessing fall risk, implementing standard and individualized interventions to reduce risk, and guide staff on post-fall assessments, interventions, huddles, and follow-up care ...Responsibilities of Staff (Inpatient areas): A nurse assesses every patient for fall risk at every point of entry, every shift, and as needed when the patient's condition warrants ... Fall Risk Assessment shall be performed as follows: Patients are reassessed for fall risk every shift, with a change in status, upon transfer to another unit by the receiving unit nurse, post-fall, or as the patient's condition warrants ...Reassessment is performed and documented on the "Shift Assessment" at least once a shift and when patient's status or condition changes."

1. c. A review of Patient 16's "History and Physical (H&P)," dated 10/4/23, indicated Patient 16 was admitted due to a fever and abnormal labs. Patient 16 presented with difficulty breathing and cloudy urine (urine has a hazy or milky color that is not normal, clear, or light yellow and may indicate a urinary infection).

A review of Patient16's "Nursing Narrative Note," dated 10/6/2023 at 10:53 a.m. the note indicated, "At 1322 (1:22 p.m.), Patient (Patient16) noted with asystole (when the heart's electrical system fails entirely, which causes the heart to stop pumping) on the monitor. Code [blue was] called and CPR (Cardiopulmonary Resuscitation, an emergency lifesaving procedure) started. Code team (emergency response team) in the room ACLS (Advanced Cardiovascular Life support, a group of procedures and techniques that treat immediately life-threatening conditions) protocol guided by (name of the physician [MD3]) ..."

During a concurrent interview and record review of Patient 16's Code Blue Record, on 1/12/2024 at 4:45 p.m. with the House Supervisor (HS), Patient 16's Code Blue Record, undated, was reviewed. Patient 16's Code Blue Record was incompletely filled out. HS read the Code Blue Record and stated, "There is no date; looking at this document (Patient 16's Code Blue Record), we do not know when this (Patient 16's Code Blue) occurred; we can't tell which source of ventilation (the supply of air to the lungs, by means of a machine or device used to support or replace the breathing) the patient (Patient 16) has or has received. The patient (Patient 16) was shocked at 1337 (1:37 p.m.), but we cannot tell what rhythm (heart rhythm or heartbeat) the patient (Patient 16) was in when the shock was delivered. We don't know how much energy was delivered to the patient (Patient 16), and there is no documentation of the patient's (Patient 16) condition or response." HS also stated the document contained scratched-out entries. HS stated, "An incorrect entry should have a line drawn across the incorrect entry with the word "Error" written directly on top."

A review of the facility's P&P titled, "Code Blue," dated September 2022, the P&P indicated, "Purpose/ Objective: A patient's right to accept or refuse medical treatment is fundamental, particularly when faced with a terminal illness; the aim of this policy is to provide a guideline for cardiopulmonary resuscitation while promoting the patient's right to make decisions regarding his/her healthcare by requesting no resuscitation. To outline the duties and responsibilities of all personnel in maintaining vital functions during the cardiopulmonary arrest of any patient aged 14 and over ... Unit Nurse Manager/Director/Nursing Supervisor ... Receives and reviews the copy of Cardiopulmonary Resuscitation Report and Code Blue Evaluation Form following the code ... Documentation is done on the Cardiopulmonary Resuscitation Report by the designated recorder at the code. This report becomes a permanent part of the chart ..."

A review of the facility's policy and procedure (P&P) titled, "Documentation." dated September 2022, the P&P indicated, "Document Correction: When an error is made in a handwritten medical record entry, the information may NOT be obliterated or otherwise altered by blacking out the entry with a marker, using white out, writing over the entry, etc. If the error is made when making an entry, draw a single line through the error only, leaving the remainder of the entry documented and write the word error."

2. A review of Patient 1's "History of Present Illness," dated 9/9/2023 indicated, Patient 1 was admitted to the Behavioral Health Unit (BHU, unit dedicated to increasing health related to different behavioral diagnosis) with a diagnosis of "Paranoid schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves with feelings of distrustful or suspicious of other people) with acute exacerbation. Patient 1 was at the psychiatric unit (BHU) over the previous 4 weeks. Patient 1 was transferred from BHU to the emergency room because of declining kidney function, aggressive behavior, and noncompliance with care. Patient 1 was restrained prior to transfer because he was physically threatening staff during medical care. Patient 1 was evaluated in the emergency room and magnesium (a mineral need in the body, normal range 1.82 milligram [mg, unit of measurement]/deciliter [dL, unit of measurement] to 2.1 mg/dL)was slightly low and phosphorus (a mineral need in the body to build strong bones and teeth, normal level 2.5 to 4.5 mg/dL) was slightly low and he was treated and medically cleared. Patient 1 was transferred back to the BHU to continue his psychiatric and medical management.

During an interview, with the Director of Behavioral Unit (DBHU) on 1/9/2024, at 3:43 p.m., DBHU stated, on 09/18/23, Patient 1 was in the seclusion room with Mental Health Technician 1 (MHT 1). MHT 1 observed Patient 1 lowering himself to the floor, then Patient laid down to the floor. MHT 1 check Patient 1 about 45 seconds to a minute later after Patient 1 laid down on the floor. MHT 1 found Patient 1 to be unresponsive and did not initiate and call rapid response. DBHU stated MHT1 was the first responder and should have called a rapid response upon identifying the patient (Patient 1) to be unresponsive. MHT 1 left Patient 1 and then MHT 1 went to the nurse station to asked for help from Licensed Vocational Nurse 2 (LVN 2). MHT did not indicate the situation was an emergency to LVN 2. LVN 2 went to checked on Patient 1. LVN 2 found Patient 1, Patient 1 was unresponsive, and not breathing. LVN 2 initiated the rapid response. DBHU stated MHT1 was the first responder and should have called a rapid response upon identifying the patient (Patient 1) to be unresponsive.

A review of the Patient 1's, "Nursing Narrative Note," by LVN 2, dated 9/18/2023 5:45 p.m., indicated on 09/18/2023 at 4:52 p.m., MHT 1 came and stated Patient 1 fell to the floor, LVN 2 ran into the room and observed Patient 1 on the floor. Patient 1's face was blue, and chest was not raising and falling. LVN 2 informed Charge Nurse to call a rapid response.

A review of the facility's policy and procedure (P&P), titled, "Rapid Response Team," revised date 07/2022, indicated the purpose was (1) To quickly recognize the patient's clinical deterioration, (2) To respond quickly and appropriately to adverse changes in the patient's condition, and (3) To avert inpatient Code Blue situations through timely intervention. The policy also indicates that Rapid Response can be called by any hospital personnel, outside clinical contractor, clinical student, patient, or their family member.