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Based on record reviews, police death investigation report, policy and procedures, interviews, and observation of the video surveillance recording, the facility failed to be in compliance with 42 CFR 489.24 as evidenced by the facility's failure to provide stabilizing treatment to Sample Patient #1 (SP), one out of 20 sampled patients.

Findings include:

The facility failed to provide stabilizing treatment for one (1) out of 20 sampled patients, (SP #1).

Refer to A 2407

Based on record reviews, police death investigation report, policy and procedures, interviews, and observation of the video surveillance recording, the facility failed to provide stabilizing treatment for one (1) out of 20 Sampled Patients, (SP #1).

Findings include:

Record review of the clinical record for SP #1 showed the patient was walking and talking on 10/04/2021 at 1504 hours; and declared deceased at 1954 hours.


Record review of SP # 1's clinical record revealed, the patient was brought into the Jackson Behavioral Health Hospital Emergency Department (ED) Crisis Unit after being Baker Acted (BA) by the local police on 10/04/2021 at 1504 hours. The patient was severely intoxicated and was exhibiting self-harm and had combative behavior. He was given an ETO (Emergency Treatment Order) of Benadryl 50 milligrams (mg) and Olanzapine 10 mg intramuscular (IM) one time at 1523 hours by Nurse A.

SP #1 was found in observation room #1761 of the Emergency Department (ED) Crisis unit unresponsive by the night shift (incoming shift) Mental Health Specialist(MHS)/Tech - B at around 1915 hours. A Code Blue was activated, but the patient expired.

On 10/13/2021 at 11:05 AM, during a phone interview MHS - B stated: "I went in the Observation room with another coworker on the 7 PM to 7 AM shift. I asked him to come with me so he could help me bring the patient out to sit in the recliner. The patient was found lying on his back, head up. His lips were blue. I checked his neck for a pulse check; there was no pulse and the patient was not breathing."

Review of the preliminary police death investigation report, the form was not dated, had a time of 2:10AM from the Medical Examiner showed that MHS - B found SP #1, the V (victim) unresponsive inside the observation room. 911 was contacted and the City Fire Rescue responded and declared the victim deceased at 7:54 PM.

The Medical Emergency Code record review showed the code was initiated on 10/04/2021 at 1915 and ended on 1958. A description of event showed: the patient was found unresponsive during rounds - CPR (Cardio Pulmonary Resuscitation) was started. EMS (Emergency Medical Services) was called.

During interview with Nurse - A on 10/13/2021 at 10:20 AM it was reported, "It was best to put him (SP #1) in the observation room for less stimulation. We tried to de-escalate him. The patient was given an ETO one time."

Review of the medication administration record showed on 10/04/2021 at 1523 hours SP#1 was medicated by Nurse - A with the ETO (Emergency Treatment Order) ordered by the Psychiatrist.

During a Zoom interview on 10/13/2021 at 9:30AM with the ED Crisis Unit physician who ordered the ETO (Emergency Treatment Order) for (SP #1) revealed, the patient came in with handcuffs accompanied by three (3) police officers. "The patient was shouting. Obviously intoxicated. We took him in the observation room, #1761. I ordered the ETO to diffuse the situation. Finally he calmed down."

Review of the Q (Every) 15 minute patient observation documentation completed by MHS - B for SP # 1 on 10/04/2021 from 1645 to 1900 hours showed the patient activity documented the patient was sleeping, but there was no noted respiration documented.

An observation on 10/14/2021 of the video recording labeled 100421 Homicide BHI ED (Behavioral Health) Rear Door, the video recording was taken from the ceiling inside the observation room and provided by the ED Crisis Unit Director of Risk Management, was completed. Observation of the video showed that the last staff who went in the observation room was a male staff wearing a burgundy colored uniform who placed a white sheet over the patient and after that no other staff went into the room until a male and female staff wearing burgundy colored uniforms went into the room. Then, after a few seconds the female staff started to place her fingers on the patient's neck. A few seconds later, more staff came in and a male staff member started compressing the patient's chest and performing CPR.

Review of the facility's policy and procedure, Policy No. 208 dated revised on 9/13/2021, supersedes 7/24/2020, Subject: patient observation, reads on page two (2) item A. 6: while the patient appears to be sleeping, staff will have adequate proximity to the patient, this includes ensuring that patient is breathing normally. Documentation of the q 15 minute patient observation on 10/04/2021 from 1645 to 1900 did not have respirations documented. The policy was not followed.

Review of the q 15 minute patient observation from 1645 to 1900 showed the initials of MHS - C, a female staff member. Observation of the video recording labeled 100421 Homicide BHI ED Rear Door video recording showed that the last staff member to go into the observation room was a male staff member; there was no female staff who went into the room to assess the patient.

Interview with the ED Nursing Director on 10/14/2021 at 9:44 AM revealed, she reviewed the video surveillance on 10/04/2021 and she stated, "I observed that what we trained the staff on observation, was not done. The Patient was not being observed."