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Based on observation, documentation review, and interviews the hospital failed ensure all employees received current education on Code Green policy which addressed employees response related to the patient's unsafe, aggressive, and/or unpredictable behaviors to meet the needs and safety of the patient population for 3 of 12 patients reviewed with behavioral symptoms.

The failure to ensure all staff receive this training resulted in the hospital's inability to ensure patient safety.

Therefore the hospital was unable to meet the Condition of Participation of Patient Rights at 42 CFR 482.13. These deficient practices had the potential to effect all patients receiving services in the hospital.

See A-0200.

Based on observation, documentation review, and interviews the hospital failed to ensure a safe patient environment by failing to provide adequate staff training and interventions based on individual assessments of patients behavioral status or condition for 3 of 12 patients (P6, P7, P8) who exhibited behavioral symptoms.
Findings include:

Review of the hospital policy and procedure for Nursing Service Administration Code Green: Response and Staff Training Requirements, last reviewed 10/12, defines roles and documentation that needs to be followed during and after Code Greens. All responding team members will stay and participate in the code debriefing. Identified opportunities for improvement are noted on the form ....Training Requirements: (Initial and Ongoing) Staff preparation and training to effectively manage disruptive behaviors in the care environment will occur at each site orientation. Each site will provide core system content in addition to site specific content ....Core system content will include: Warning signs of impending crisis, Steps to take to prevent the situation from escalating, Interventions that can be used to manage situations, Site specific information must include core system content: Specific focus on safe team interventions, Site specific information ....Ongoing Training: (Required for all Code Green Responders team members every two years coordinated at each site) Additional education/training maybe initiated by sites, units, services as deemed necessary. "

Review of the Healtheast Code Green Responder Course, undated, noted: "Goal/learning objectives of session: 1. Warning signs of impending crisis 2. Behaviors to de-escalate impending crisis....Escalation Continuum of Anxiety to Agitation to Acting Out to Adaptation". The course describes levels of patient behavior escalation and provides information to the employee what they may see with each level, what will make it worse, and how to respond.

Observation of the P1 nursing unit on 11/6/14 at 10:50 a.m. revealed the patient population is medical-surgical, neurology, overflow obstetrics and infants, and pediatric patients. The doors to the unit are kept closed and automatically secured when there are obstetric patients, infants or pediatric patients on the unit. The doors to P1 were closed and secured when entering the unit due to a pediatric patient on the unit.

Observation of the P2 nursing unit on 11/10/14 revealed door to the unit were open and patients were primarily oncology patients, although non-oncology patients and overflow obstetric patients with infants may be admitted to this floor when a bed is needed.

P6's medical record review of Emergency Department (ED) physician notes, dated 10/29/14, revealed P6 presented to the emergency department with a chief complaint of confusion and a change in personality. The family indicated he was confused, was excited, talking more and not sleeping the last couple of days.

P6's history and physical, dated 10/29/14, noted the patient had confusion. P6 was admitted to the hospital with diagnoses including mood disorder, encephalopathy with psychomotor excitement, psychotic disorder with delusions, and hypotension. P6 was found to have a calcified brain mass not thought to be causing his symptoms. The physician consult orders, dated 10/29/14, noted the physician referred P6 for a neurology consult and a psychiatry consult.

Neurology consult notes, dated 10/30/14, noted CT and MRI of P6's head showed no acute event, no significant thromboses and no evidence of significant edema. P6 had delirium with paranoid ideation and increased vigilance and agitation. Review of progress notes by the neurologist, dated 11/1/14 at 10:24 a.m. noted P6 had delirium with paranoid ideation and increased vigilance and agitation.

Psychiatry consult notes, dated 10/30/14, noted P6 had possible sleep deprivation psychosis, leading to personality changes. P6 exhibited disorganized, excessive and confused speech. P6 also had grossly depressed judgment insight, memory, attention and comprehension. P6 could not provide much reliable information. The psychiatric nurse practitioner ordered Seroquel 12.5 milligrams at bedtime, Remeron 15 milligrams at bedtime as needed, and Melatonin 3 milligrams at bedtime.

Review of progress notes by the psychiatric nurse practitioner, dated 11/1/14 at 10:52 a.m., noted P6 did not feel safe around his family but could not elaborate. P6 was preoccupied with being dead, refused medications intermittently and family was inconsistent in their agreement with the plan to increase Seroquel to 25 milligrams four times a day. The notes indicated transfer P6 to psychiatric inpatient when medically stable and orders were written for care management/social work due to paranoid ideation, mania, and delusional. P6 was noted to have increased irritability when family was around. P6 had paranoia and was alert to self and some family.

Physician progress notes from 10/31/14 noted P6 appeared quite depressed, stating he was running out of gas and would not last. P6 denied suicidal ideation but thought he was dying. The primary physician noted she would talk with the psychiatric consult to see if P6 was a candidate for inpatient psych.

Progress note by a nurse, dated 10/31/14 at 4:08 a.m., noted P6 complained of thinking he was dying after having a bad dream. The nurse was able to calm P6. There is no further progress note entry by nursing.

Review of P6's Patient Education Flowsheets on 11/1/14 at 12:30 a.m. noted P6 was upset and wanting to leave, getting dressed and not redirectable. The nurse provided emotional support.

Documentation flowsheets on 11/1/14 noted P6 was assessed at 9:00 a.m., was reassessed at 11:00 a.m. when P6 was asleep, and 12:20 p.m. noted P6 was more cooperative, refused cares, and slept one hour.

Progress notes, dated 11/1/14 at 2:39 p.m., revealed the primary physician noted P6 was anxious, irritated, refused to take medications, refused to be touched and had an high blood pressure. Documentation did not address recommendation for inpatient psychiatric transfer consistent with the psychiatric nurse practitioner consultation three and a half hours earlier that day.

Patient Education Flowsheets, dated 11/1/14 at 4:30 p.m. noted P6 was apprehensive, paranoid and anxious and his family member was verbally aggressive, tearful, angry, hostile and upset regarding the presence of two visitors. Nursing Assistant( NA)-O documentation noted she checked P6's vital signs and revealed an elevated blood pressure with no notation the nurse was notified. There is no further nursing documentation regarding P6's mood or behavior until after P6 assaulted staff, eloped from the hospital, and later died.

Review of P6's medical record revealed no behavior documentation or behavior assessment after 4:30 p.m.

Review of P6 ' s documentation flowsheet and progress noted after 4:30 p.m. on 11/1/14 through 2:00 a.m. revealed no behavior documentation.

A form titled Security Assistance, dated 11/1/14 from 5:13 p.m. - 5:46 p.m., was provided by hospital security and reviewed. It noted hospital security was called to the nursing unit as P6's primary contact family members wanted another family member and her friend to be removed from the hospital as they were causing problems in the patient's room.

Review of P6's Significant Event-Flowsheet Notes, dated 11/2/14 at 3:39 a.m., noted " At approximately 1:30 a.m.(P6) came running out of his room" with the metal bar for the SCD (Sequential Compression Device) pump from the end of his bed. (This metal bar was approximately two feet long by 2 1/2 inches high by 1 inch wide with a covered hook on each end of the bar. This hung over the foot board of the bed and was easily removable from the bed.)P6 yelled at staff and swung the metal bar. P6 struck one staff member multiple times in the leg and back. He continued to chase staff members down the hall where he struck another staff member in the head midway down the hall between (the nursing station) and the cafeteria. At some point during the chase, the patient struck two other staff members with the metal bar. P6 then turned down the hall and ran towards the maternity center and then turned right towards the exit. Staff followed in pursuit, but lost the patient when he exited the building. After the incident it was reported to the RN-P, charge nurse, by Nursing Assistant (NA)- O that P6 was very agitated from the beginning of the shift. P6 did not want the first aide that was assigned to him because she was white and he was stating 'the white nurses are not helping me and are trying to kill me.' P6 stated he was hungry and was not being fed, once the newly assigned aide brought pt graham crackers he accused this aide of trying to kill him."

An interview with NA-O on 11/5/14 at 3:55 p.m. revealed NA-O was the nursing assistant assigned to care for P6 from 11/1/14 at 3:00 p.m.-11:00 p.m. and 11/1/14 at 11:00 p.m. through 11/2/14 at 7:00 a.m. NA-O said P6 had behaviors including anger and was accusatory toward staff. P6 told NA-O that he felt staff was trying to kill him. NA-O stated she did not report P6 ' s behaviors and verbalizations to the primary nurse or charge nurse on the night shift beginning 11:00 p.m. on 11/1/14 until after P6's assaultive behavior towards staff and elopement from the hospital. NA-O stated she was informed of no behavior interventions for P6 except to leave him alone if he was sleeping. When NA-O came back from her dinner break the doors to the unit were closed, secured. NA-O stated she thought since the doors were closed there was an obstetrics or pediatric patient admitted to the unit. She stated she never heard why except the doors were locked for P6' s safety and not sure why she did not report P6's behaviors or mood to the nurse.

Review of the medical record for P7 revealed he presented to the ED on 10/30/14 at 5:41 p.m. He had diagnoses including pancreatitis, alcohol liver disease, mild confusion, upper abdominal pain, gout flareup and abnormal labs related to heavy alcohol use. In the ED notes at 7:05 p.m., the physician noted P7 had mild alcohol withdrawal with an increased heart rate and elevated blood pressure and Magnesium Sulfate intravenous was started due to P7's elevated blood pressure. The ED notes reveal P7's blood pressures were 181/113, 172/113, 155/102, and 165/109. P7 was transferred to the unit on 10/31/14 at 12:05 a.m. P7 was admitted to P2 nursing unit. Review of the assessment documentation flowsheet and progress notes for the night shift revealed no documentation by the nursing staff. Progress notes of 10/31/14 at 10:33 a.m. noted P7 was examined by the physician who ordered clinical indicators from withdrawal from alcohol (CIWA). Progress notes of 10/31/14 at 2:29 p.m. noted the resident physician evaluated P7 and he noted P7 had a history of hallucinations with detox, no history of seizures and to continue to monitor P7 closely.

Code Green documentation form, dated 10/31/14 at 5:11 p.m., indicated a Code Green was called due to P7 removed his intravenous (IV) lines, was found drenched in blood had written in blood on the wall of his room. A Code Green Evaluation form was initiated but incomplete. There was no specific documentation noting who was the code green team facilitator.

Review of P7's progress notes was conducted and revealed no assessment or note regarding P7's condition following the Code Green of 5:00 p.m. on 10/31/14.

Review of a second Code Green documentation form, dated 10/31/14 noted a Code Green was called again at 9:09 p.m. due to P7 threatened to kill himself, swung his fists at staff, threw water at staff, and tore his IV tubing in half. P7 then ran into a patient room across the hall and closed himself in that bathroom. P7 agreed to return to his own room and talk with sister and after 15 minutes P7 agreed to take his medications. The Code Green Evaluation was incomplete. There was no notation of who the team facilitator was during the code green. Review of assessment documentation revealed no follow up assessment after this code green.

A third Code Green Documentation form for a code green called on P7 again on 10/31/14 at 10:11 p.m. was reviewed. The Code Green Evaluation was incomplete and noted the team leader was not the only person communicating with the patient. Staff documented behaviors of acting out, belligerent, combative, hallucinates, angry, hostile. Interventions included setting limits, notify family, psychiatric referral and medicate. Staff post intervention discussion noted a male nurse stayed with the patient.
Review of the psychiatric consult of 11/1/14 at 12:31 p.m. noted P7 required Haldol on 10/31/14 due to his behavioral agitation and aggression in the context of alcohol intoxication and withdrawal.

Medical record review for P8 revealed P8 presented to the ED on 7/30/14 with diagnoses including altered mental status, history of cirrhosis, and hepatic encephalopathy-end stage. P8 was admitted to the intensive care unit at 7:03 a.m. and then transferred to the P1 nursing unit at 6:59 p.m. Review of assessments noted on 7/31/14 P8 had 1:1 staff supervision due to confusion and unpredictable behavior, was changed to 15-30 minute checks sometime that same day. On 8/3/14 a Code Green was called at 10:46 a.m. as P8 attempted to leave the hospital in her gown and purse and struck staff with her phone when she threw it. The Code Green Documentation form noted P8 was on a 72 hour hold. P8 was placed on 1:1 supervision all the time and continued on a 72 hour hold, and a psychiatric consult was ordered. The psychiatric consultation was completed on 8/3/14 at 12:28 p.m. P8 had a long standing history of alcohol abuse, was confused, disoriented, and often irritated. Additional diagnoses included presently acute encephalopathy with cognitive disorder, major depressive disorder, alcohol abuse. The consult notes also noted P8 was a flight risk with extremely poor insight and judgement and P8 needed to be monitored closely. Review of P8's care plan revealed no problems or interventions addressed P8's behaviors and altered mental status.

An interview was conducted with RN-F on 11/6/14 at 7:50 a.m. who stated code green documentation is reviewed by the unit director and the mental health group director. There was no code green documentation completed by the administrative house supervisor regarding the incident with P6 on 11/2/14 until after the state agency investigators requested the documentation.

An interview with RN -Q was conducted on 11/6/14 at 8:00 a.m. and she stated as an administrative nursing supervisor she was unaware when patients had behavior concerns and she was not aware who would respond to a Code Green when one was called. She also stated she thought all unit staff had Code Green training.

An interview was conducted with Employee C/director of nursing on 11/7/14 at 1:20 p.m. and she stated charge nurses, select Code Green responders, and new employees are trained regarding Code Green. Not all staff were trained regarding Code Green. The unit staff schedule does not indicate who was trained as a Code Green responder or who would respond to a Code Green.

An interview was conducted with Registered Nurse (RN)-S on 11/6/14 at 11:00 a.m. She stated the nursing unit has additional overflow obstetrics and infant patients and pediatric patients along with the medical surgical and neurology patients on the unit. RN-S stated there has been no staff behavior training on how to respond to patients with psychiatric issues and it is difficult to keep patients safe.

An interview was conducted with NA-T on 11/06/14 at 11:40 a.m. and she stated she had received no behavior management training at the hospital during her seven year employment at the hospital.

An interview was conducted with RN-U on 11/6/14 at 11:54 a.m. and she stated all charge nurses had code green training with no follow up training since the initial training. RN-U's code green training was 2-3 years ago. All new hires receive code green training on hire. There are more mental health patients being admitted due to less beds available and it is difficult at times to keep everyone safe. If a patient would have increased behaviors or verbalizations the expectation is the nursing assistant or staff would tell the nurse. The nurse would assess the patient and notify the physician regarding the patient's behavior.

An interview was conducted with RN-V on 11/6/14 at 3:28 p.m. and he stated as a charge nurse he received initial training at orientation three years ago but had no follow up training since classes were canceled due to low enrollment. When checking the schedule he would not know who would be a code green responder. Nursing assistants are responsible to report patient changes to the nurse right away.

An interview was conducted with Employee L/group director of mental health on 11/6/14 at 3:05 p.m. and he stated the committee which reviews Code Green and documentation meets the last Tuesday of each month. He indicated the purpose of the meeting is to review the current policy and focus on the number of Code Greens called the previous month. The committee also reviews the number of debriefing tools turned in. Education regarding Code Green still needs to be done for this hospital including assessing current staff for training.

Review of Code Green Documentation and Evaluation forms from August and September, 2014, revealed inconsistent and incomplete documentation. One of 3 codes in August were documented and 2 of 4 codes in September were documented. Code Green documentation were incomplete or missing. Three November Code Green Documentation forms and Code Green Evaluation forms were reviewed and noted to be incomplete. No facilitator was noted on the forms and debriefing and reviews were incomplete.

A review of the hospital minutes from the committee which meets monthly to review Code Greens, "System for Code Green Minutes", dated 9/23/14, revealed 3 Code Green calls for August 2014 were submitted and only 2 had debriefing submitted. The minutes also noted Mock Code Greens needed to be conducted to focus on staff roles, placement of restraints, and location of the restraint kit.

Review of the hospital policy and procedure for Nursing Service Administration St. John' s Addendum Code Green, dated 11/29/11, revealed " St. John' s Site Specific Code Green Education: Initial Training: All newly hired staff in direct patient care will receive 2 hours of Code Green training during the St. John' s Site Orientation. The goal of the training is to prepare staff for early de-escalation and personal safety when managing patient or family with escalating behavior. Upon completion, the participant will be able to do the following: ....Identify the warning signs of impending crisis and escalating behavior ....Code Green Responder Training for Identified Team Members: All staff identified as St. John' s Code Green Response Tam will receive Code Green Responder training. This training will be offered, monthly in 3-4 hour sessions, at St. Johns. This training will be required every two years. "

Review of personnel files revealed 5 of 15 staff who were a new hire, security officer, or worked in a charge nurse role had code green training last that exceeded two years ago. Review of personnel files are as follows:
Security Officer(SO) last Code Green training was on 4/11
SO-Y last Code Green training was on 7/10
RN-V employed for three years with no documentation of training, responds to Code Green
RN-U last Code Green training was on 4/11
RN-S last Code Green training was on 10/11


The immediate jeopardy was removed on 11/10/14 at 3:40 p.m. related to implementation of an acceptable immediate jeopardy removal plan including: 1. All employees notified regarding education to be completed by the evening of 11/10/14. "Just in Time" huddle information to be presented to staff on duty for education including 11 things never to say to a patient-to prevent escalation of behaviors, documents regarding calling a Code Green, Code Green Responder, Code Green Leader. These will be presented by the charge nurse and read by staff. Nursing supervisor to ensure completion. 2. 60 % of staff have completed online training by the morning of 11/10/14. 3. Communication of patient behaviors to change nurse and nursing supervisor. 4. Three times a day huddle regarding behaviors, including alcohol related, family issues, etc. 5. Care plans to be individualized and modified based on interventions. 6. Epic clinical software being modified 11/10/14 with more specific care plan information and use words to trigger specific interventions. 7. Care plan information specific for patients with mental health concerns. 8. Root cause analysis, part 1, to look for contributing factors or event leading to outburst of patient and, part 2, of root cause analysis related to follow up after the event. Report of adverse event to state not done yet, is pending the conclusion of the completion of the root cause analysis. Add: metal bar as potential for use as a weapon.

Based on documentation review and interviews the hospital failed to ensure staff developed, implemented, and revised care plans based on assessments of individual patient needs, specifically those with behavioral symptoms.

The severity and cumulative effect of these system failures resulted in the hospital's inability to ensure patient cares were developed and implemented based on individual patient needs.

Therefore, the hospital was unable to meet the Condition of Participation of Nursing Services at 42 CFR 482.23. These deficient practices had the potential to impact all patients, especially those with behavioral symptoms, mood symptoms and or mental health diagnoses. Findings include:

See A-0396 -

Based on documentation review and interviews the hospital failed to develop, implement, and revise a nursing care plan based on ongoing assessments of patient needs for 3 of 10 patients (P6, P7, P8) reviewed. Findings include:

P6's medical record review of Emergency Department (ED) physician notes, dated 10/29/14, revealed P6 presented to the emergency department with a chief complaint of confusion and a change in personality. P6's family indicated he was confused, excited, talking more, and not sleeping the last couple of days.

P6's history and physical, dated 10/29/14, noted the patient had confusion. P6 was admitted to the hospital with diagnoses including mood disorder, encephalopathy with psychomotor excitement, psychotic disorder with delusions, and hypotension. P6 was found to have a calcified brain mass not thought to be causing his symptoms. On 10/29/14 the primary physician referred the patient for a neurology consult and a psychiatry consult.

Neurology consult notes, dated 10/30/14, noted CT and MRI of P6's head showed no acute event, no significant thromboses and no evidence of significant edema. P6 had delirium with paranoid ideation and increased vigilance and agitation. Review of progress notes by the neurologist, dated 11/1/14 at 10:24 a.m. noted P6 had delirium with paranoid ideation and increased vigilance and agitation.

Psychiatry consult notes, dated 10/30/14, noted P6 had possible sleep deprivation psychosis, leading to personality changes. P6 exhibited disorganized, excessive and confused speech. P6 also had grossly depressed judgment insight, memory, attention and comprehension. P6 could not provide much reliable information. The psychiatric nurse practitioner ordered Seroquel 12.5 milligrams at bedtime, Remeron 15 milligrams at bedtime as needed, and Melatonin 3 milligrams at bedtime.

Review of progress notes by the psychiatric nurse practitioner, dated 11/1/14 at 10:52 a.m., noted P6 did not feel safe around his family but could not elaborate, P6 was preoccupied with being dead, refused medications intermittently, and family was inconsistent in their agreement with the plan to increase Seroquel to 25 milligrams four times a day. The notes indicated to transfer P6 to psychiatric inpatient when medically stable and orders were written for care management/social work due to paranoid ideation, mania, and delusional. P6 was noted to have increased irritability when family was around. P6 had paranoia and was alert to self and some family.

Physician progress notes from 10/31/14 noted P6 appeared quite depressed, stating he was running out of gas and would not last. P6 denied suicidal ideation but thought he was dying. The primary physician noted she would talk with the psychiatric consult to see if P6 was a candidate for inpatient psych.

A nurse progress note, dated 10/31/14 at 4:08 a.m., noted P6 complained of thinking he was dying after having a bad dream. The nurse was able to calm P6. There is no further progress note entry by nursing.

Review of P6's Patient Education Flowsheets on 11/1/14 at 12:30 a.m. noted P6 was upset and wanting to leave, getting dressed and not redirectable. The nurse provided emotional support.

Documentation flowsheets on 11/1/14 noted P6 was assessed at 9:00 a.m., was reassessed at 11:00 a.m. when P6 was asleep, and 12:20 p.m. noted P6 was more cooperative, refused cares, and slept one hour.

Progress notes, dated 11/1/14 at 2:39 p.m., revealed the primary physician noted P6 was anxious, irritated, refused to take medications, refused to be touched and had an high blood pressure. Documentation did not address recommendation for inpatient psychiatric transfer consistent with the psychiatric nurse practitioner consultation three and a half hours earlier that day.

Patient Education Flowsheets, dated 11/1/14 at 4:30 p.m. noted P6 was apprehensive, paranoid and anxious and his family member was verbally aggressive, tearful, angry, hostile and upset regarding the presence of two visitors. Nursing Assistant( NA)-O documentation noted she checked P6's vital signs and revealed an elevated blood pressure with no notation the nurse was notified. There is no further nursing documentation regarding P6's mood or behavior until after P6 assaulted staff, eloped from the hospital, and later died.

Review of P6's medical record revealed no behavior documentation or behavior assessment after 4:30 p.m.

Review of P6 ' s documentation flowsheet and progress noted after 4:30 p.m. on 11/1/14 through 2:00 a.m. revealed no behavior documentation.

A form titled, Security Assistance, dated 11/1/14, was provided by hospital security and reviewed. It noted that from 5:13 p.m. - 5:46 p.m. hospital security was called to the nursing unit as P6's primary contact family members wanted another family member and her friend to be removed from the hospital as they were causing problems in the patient's room.

Review of P6's care plan revealed no behavior problem or interventions despite diagnoses including encephalopathy, paranoia with delusions and consults to neurology and psychiatry due to inappropriate behaviors, confusion and paranoia.

Review of P6's Significant Event-Flowsheet Notes, dated 11/2/14 at 3:39 a.m., noted " At approximately 1:30 a.m.(P6) came running out of his room" with the metal bar for the SCD (Sequential Compression Device) pump from the end of his bed. (This metal bar was approximately two feet long by 2 1/2 inches high by 1 inch wide with a covered hook on each end of the bar. This hung over the foot board of the bed and was easily removable from the bed. P6 yelled at staff and swung the metal bar. P6 struck one staff member multiple times in the leg and back. He continued to chase staff members down the hall where he struck another staff member in the head midway down the hall between the nursing station and the cafeteria. At some point during the chase, the patient struck two other staff members with the metal bar. P6 turned down the hall and ran towards the maternity center and then turned right towards the exit. Staff followed in pursuit, but lost the patient when he exited the building. After the incident it was reported to registered nurse (RN)-P, charge nurse by NA-O that P6 was very agitated from the beginning of the shift. P6 did not want the first aide that was assigned to him because she was white and he was stating 'the white nurses are not helping me and are trying to kill me.' P6 stated he was hungry and was not being fed, once the newly assigned aide brought pt graham crackers he accused this aide of trying to kill him.

An interview with NA-O on 11/5/14 at 3:55 p.m. revealed NA-O was the nursing assistant assigned to care for P6 from 11/1/14 at 3:00 p.m. - 11:00 p.m. and 11/1/14 at 11:00 p.m. through 11/2/14 at 7:00 a.m. NA-O said P6 had behaviors including anger and was accusatory toward staff. P6 told NA-O that he felt staff was trying to kill him. NA-O stated she did not report P6' s behaviors and verbalizations to the primary nurse or charge nurse on the night shift beginning 11:00 p.m. on 11/1/14 until after P6' s assaultive behavior towards staff and elopement from the hospital. NA-O stated she was informed of no behavior interventions for P6 except to leave him alone if he was sleeping. When NA-O came back from her dinner break the doors to the unit were closed, secured. NA-O stated she thought since the doors were closed there was an obstetrics or pediatric patient admitted to the unit. She stated she never heard why except the doors were locked for P6' s safety and not sure why she did not report P6's behaviors or mood to the nurse.

An interview was conducted with RN-P on 11/5/14 at 4:52 p.m. and she stated NA-O did not report P6's verbalizations to her earlier in the shift prior to when P6 attacked staff and eloped. RN-P also stated it would have been information important to know.

An interview with RN-N on 11/6/14 at 6:12 p.m. was conducted and RN-N stated NA-O did not report P6's verbalizations to RN-N the night P6's verbalizations. RN-N stated she was not aware of any increased agitation and confusion that night.

Review of the medical record for P7 revealed P7 presented to the ED on 10/30/14 at 5:41 p.m. He had diagnoses including pancreatitis, alcohol liver disease, mild confusion, upper abdominal pain, gout flareup and abnormal labs related to heavy alcohol use. In the ED notes at 7:05 p.m., the physician noted P7 had mild alcohol withdrawal with an increased heart rate and elevated blood pressure and Magnesium Sulfate intravenous was started due to P7's elevated blood pressure. The ED notes reveal P7's blood pressures were 181/113, 172/113, 155/102, and 165/109. P7 was transferred to the P2 nursing unit on 10/31/14 at 12:05 a.m. Review of the assessment documentation flowsheet and progress notes for the night shift revealed no documentation by the nursing staff. Progress notes of 10/31/14 at 10:33 a.m. noted P7 was examined by the physician who ordered clinical indicators from withdrawal from alcohol (CIWA). Progress notes of 10/31/14 at 2:29 p.m. noted the resident physician evaluated P7 and he noted P7 had a history of hallucinations with detox, no history of seizures and to continue to monitor P7 closely. Progress notes and documentation flowsheets review revealed no CIWA was completed for P7. No assessment was completed for P7.

Code Green documentation form, dated 10/31/14, noted that at approximately 5:11 p.m. a Code Green was called due to P7 removed his intravenous lines, was found drenched in blood and had written in blood on the wall of his room. Review of progress notes was conducted and revealed no assessment or note regarding P7's condition following the Code Green of 5:00 p.m. on 10/31/14. Patient Education flowsheet notes revealed staff placed a peripheral IV line in P7's right antecubital 10/31/14 at 5:40 p.m. Staff administered Ativan 2 milligrams by mouth at 6:00 p.m. and Ativan 1 milligram by mouth at 8:00 p.m.

Review of a second Code Green documentation form, dated 10/31/14, noted a Code Green was called again on P7 at 9:09 p.m. due to P7 threatened to kill himself, swung his fists at staff, threw water at staff, tore his IV tubing in half. P7 then ran into a patient room across the hall and closed himself in that bathroom. P7 agreed to return to his own room and talk with sister and after 15 minutes P7 agreed to take his medications. Medication record review noted staff administered Haldol 2 milligrams injectable at 9:09 p.m., and Benadryl 50 milligrams injectable and Ativan 1 milligram injectable at 10:00 p.m. Review of assessment documentation revealed no follow up assessment after this code green.

A third Code Green Documentation form for a code green called again on P7 on 10/31/14 at 10:11 p.m. was reviewed. Review of P7's Patient Education flowsheet documentation noted on 10/31/14 at 10:37 p.m. P7 removed his left forearm and right antecubital IV lines. At 10:38 p.m. staff placed a peripheral IV line in P7's left hand. Staff documented behaviors of acting out, belligerent, combative, hallucinates, angry, hostile. Interventions included setting limits, notify family, psychiatric referral and medicate. Staff post intervention discussion noted a male nurse stayed with the patient.

Review of the psychiatric consult of 11/1/14 at 12:31 p.m. noted P7 required Haldol the previous night due to his behavioral agitation and aggression in the context of alcohol intoxication and withdrawal.

Review of P7's care plan revealed no problems or interventions related to behavior or mood concerns or alcohol withdrawal monitoring as ordered by the physician.

Medical record review for P8 revealed P8 presented to the ED on 7/30/14 with diagnoses including altered mental status, history of cirrhosis, and hepatic encephalopathy-end stage. P8 was admitted to the intensive care unit at 7:03 a.m. and then transferred to the P1 nursing unit at 6:59 p.m.

Review of assessments noted on 7/31/14 P8 had 1:1 staff supervision due to confusion and unpredictable behavior, was changed to 15-30 minute checks sometime that same day but the documentation does not stated when this was initiated or when it was discontinued.

On 8/3/14 a Code Green was called at 10:46 a.m. as P8 attempted to leave the hospital in her gown and purse and struck staff with her phone when she threw it. The Code Green Documentation form noted P8 was on a 72 hour hold. P8 was placed on 1:1 supervision all the time and continued on a 72 hour hold, and a psychiatric consult was ordered.

The psychiatric consultation was completed on 8/3/14 at 12:28 p.m. P8 had a long standing history of alcohol abuse, was confused, disoriented, and often irritated. Additional diagnoses included presently acute encephalopathy with cognitive disorder, major depressive disorder, alcohol abuse. The consult notes also noted P8 was a flight risk with extremely poor insight and judgement and P8 needed to be monitored closely.

Review of P8's care plan revealed no problems or interventions addressed P8's behaviors and altered mental status.

An interview with RN -Q was conducted on 11/6/14 at 8:00 a.m. and she stated as an administrative nursing supervisor she was unaware when patients had behavior concerns.

An interview was conducted with Employee C/director of nursing on 11/7/14 at 1:20 p.m. and she verified care plans were not specific or individualized for patients with behavioral symptoms or diagnoses. Patient behavioral and mood symptoms should be reported to the nurse right away.

An interview was conducted with RN-V on 11/6/14 at 3:28 p.m. and he stated as a charge nurse he would expect nursing assistants are responsible to report patient changes to the nurse right away.

Review of the hospital policy and procedure, Nursing Assessment/Reassessment of the Patient, last reviewed 5/14, noted: C. i. Plan of Care-include: Identification of current and ongoing needs; Individualized patient care outcomes with established time frames and goals; Interventions addressing identified physiological, psychological, spiritual, cultural, education, or environmental patient/family needs D. To be completed within 24 hours of admission to the nursing unit....Safety screening-psychosocial and behavioral assessment....2. Ongoing assessment A. ii. Physical assessment-General head to toe assessment or Focused assessment to medical/surgical, or behavioral diagnosis and/or abnormal findings....viii. Psychosocial and behavioral assessment-safety and risks.

Review of the hospital policy and procedure, Plan of Care, last reviewed 8/13, noted: POLICY: Each inpatient will have an individualized, goal directed plan of care documented in the medical record. PROCESS: A. The plan of care will be initiated by an RN upon admission based on the patient's specific assessed needs. C. The patient's assigned nurse will be responsible for delegating, supervising, revising, and updating the plan of care as needed based on the patient condition, response to interventions, progress towards goals, new and ongoing needs.

The immediate jeopardy was removed on 11/10/14 at 3:40 p.m. related to implementation of an acceptable immediate jeopardy removal plan including: 1. All employees notified regarding education to be completed by the evening of 11/10/14. "Just in Time" huddle information to be presented to staff on duty for education including 11 things never to day to a patient-to prevent escalation of behaviors, documents regarding calling a Code Green, Code Green Responder, Code Green Leader. These will be presented by the charge nurse and read by staff. Nursing supervisor to ensure completion. 2. 60 % of staff have completed online training by the morning of 11/10/14. 3. Communication of patient behaviors to change nurse and nursing supervisor. 4. three times a day huddle regarding behaviors, including alcohol related, family issues, etc. 5. Care plans to be individualized and modified based on interventions. 6. Epic clinical software being modified 11/10/14 with more specific care plan information and use words to trigger specific interventions. 7. Care plan information specific for patients with mental health concerns. 8. Root cause analysis, part 1, to look for contributing factors or event leading to outburst of patient and, part 2, of root cause analysis related to follow up after the event. Report of adverse event to state not done yet, is pending the conclusion of the completion of the root cause analysis. Add: metal bar as potential for use as a weapon.