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Based on document review and interview, the facility failed to ensure care in a safe setting in 1 of 1 patient death records reviewed (P23). See tag 0144.

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review and interview the facility failed to ensure patient received care in a safe setting by failing to establish patient well-being during 15-minute interval observation checks and in identifying environmental safety risks in 1 of 1 patient death records reviewed (P23).

Findings include:
1. Facility policy/procedure titled, Seclusion, Restraint, and Emergency Intervention Procedures, Policy Number: RM1140, in effect June 2022, indicated as part of the initial nursing assessment, the R.N. will assess the patient for any special physical or medical consideration or previous trauma that may influence use of specific behavior management techniques, including emergency interventions. A notation of any special consideration to be taken will be noted on the nursing assessment and communicated with the treatment team. Emergency intervention measurers shall be used for all patients.

2. MR's indicated P23 was in imminent danger to self/others and admitted to facility for suicidal ideation and substance abuse under Service Code 120 - Emergency Crisis Intervention, on 6/20/22 at approximately 2:46 pm. Nursing Admission Assessment at approximately 4:22 pm indicated inpatient admission reason as Suicidal and Gravely Disabled with a recent history of suicidal behavior within the last 30 days. Patient's personal valuables/belongings were inventoried and returned on admission, including 3 pairs of pants.
Inpatient Nursing DARP Progress Note evaluated P23's level as Suicidal 0/10. Problem Statement and Action plan as patient states he/she has had suicidal ideation in the past two days, facility to provide 1:1 discussion with patient and 15-minute checks regarding patient safety status.
Patient's Individual Treatment Plan (ITP) indicated a diagnosis of suicidal ideation (SI) with barriers and limitations related to depression. Facility to monitor patient's vital signs and symptoms of opioid withdrawal and provide medication for withdrawal relief. Strategic Interventions included assessing/prescribing medication for depression and medication effectiveness. Updated comments on ITP at approximately 9:25 pm indicated patient transferred to other facility by EMS for medical treatment.
MR's lacked documentation to address patient SI's or how patient would remain safe. MR's lacked patient transfer documentation.

3. Psychiatric Close Observation Record indicated security checks for patient P23's safety at 15-minute intervals.
a. 8:30 pm : I9 - patient in group room, watching TV
b. 8:45 pm: F5 - patient in room (Room #205), quiet
c. 9:00 pm: F5 - patient in room (Room #205), quiet
d. 9:15 pm: P3 - patient in bathroom (Room 205), unresponsive

4. Inpatient Progress Note indicated medication given in the milieu and patient then went to his/her room at approximately 8:28 pm on 6/20/22. Daily Notes indicated patient found in bathroom at approximately 9:05 pm with pants wrapped around neck, 911 called, patient with faint pulse, CPR initiated and continued until EMS arrived.

5. Incident Reports reviewed indicated the following:
a. N7 (Registered Nurse [RN]) indicated patient found on bathroom floor in patient room with pants wrapped around neck at approximately 9:05 pm. N7 removed pants, initiated/continued CPR until EMS arrived.
b. N50 (RN) indicated he/she called 911 and then went to assist other staff in patient room with CPR until EMS arrived.
c. N52 (Mental Health Technician [MHT]) indicated security doing 15 minutes checks on patient and patient was in bathroom. Fifteen minutes later, security did another patient check, and he/she was still in bathroom. Security notified N52 to perform patient check. N52 called patient name twice without response. N52 then went to get the charge nurse who returned with N52 to patient room. Charge Nurse called out to patient twice without response and then the door was opened as patient fell over backwards onto bathroom floor with pants wrapped tightly around his/her neck. An arrow sign is indicated for further documentation on this incident report, but no further documentation was provided regarding N52's notes.
d. N53 (Security Officer [SO]) indicated at approximately 9:00 pm he/she went to check on patient without any response. N53 reported this to N52 who returned to patient room #205, calling out to patient without a response. N53 and N52 went to get N7, and all returned to patient room, flipped the lights on and N53 noticed a knot above the bathroom door. When bathroom door was opened, patient's face was blue and after CPR initiated, patient's color began to return to his/her face.
e. Facility failed to provide page 2 of 3 of the findings from N50, N7, N52 or N53. Page 3 of the Incident Reports lacked documentation of Conclusion/Follow-Up Actions/Debriefings or Comments.

6. Facility initiated/provided Root Cause Analysis (RCA) of Sentinel Event from 6/20/22. RCA did not indicate what preventative measures facility put into place to prevent future reoccurrences.

7. Critical Incident Report to Family And Social Services Administration Division Of Mental Health And Addiction indicated patient injury on 6/20/22. Critical Incident Report lacked documentation of patient death.

8. In entrance conference on 11/28/23 at approximately 9:35 am to 9:50 am, A1 (RN, Inpatient Director) indicated one facility death occurred June 20, 2022.

9. In interview on 11/29/23 at approximately 3:20 pm, A3 (Quality Improvement [QI] Coordinator) confirmed P23's MR's presented on scan disk at approximately 3:00 pm on 11/29/23, were complete records regarding the incident on 6/20/22. A3 confirmed P23 was not placed in an observation room but was provided 15-minute safety checks. A3 indicated procedures were changed/implemented to prevent future reoccurrences but did not articulate what specific procedures changed.

Based on document review and interview, the facility failed to ensure the use of restraint was authorized by the order of a physician or LIP (licensed independent practitioner) for two (2) of three (3) patients reviewed (P5 and P6).

Findings:

1. Review of the policy titled Seclusion, Restraint, and Emergency Intervention Procedures, Policy Number RM1140, last revised February 27, 2023, indicated the following:
a. All consumers have the right to be free from unnecessary restraint and seclusion of any form. Restraints are utilized only in emergent or crisis situations...
b. Definitions - Restraint: Any manual method, physical device, mechanical device or pharmaceutical agent that prevents freedom of movement or normal access to the patients own body that the consumer cannot remove.
c. A physician or Licensed Independent Practitioner (LIP) can authorize (order) the use of Seclusion and/or restraint.
d. An RN can initiate the emergent use of Seclusion and/or Restraint until a physician or LIP order is obtained.

2. A Review of patient #5 medical record indicated the following:
(A) Restrain/Seclude note dated 03/02/2023 at 1640 hours indicated that P5 was placed in a physical hold due to he/she was threatening staff, attempting to elope the building, and manic behaviors.
(B) The medical record lacked a physician order for the physical hold.

3. A Review of patient #6 medical record indicated the following:
(A) Restrain/Seclude note dated 08/14/2023 at 1424 hours indicated that P6 was placed in a four (4) point physical restraint due to he/she was yelling, tossing chairs, and banging on the nurses station.
(B) The medical record lacked a physician order for the 4 point restraint.

4. On 11/29/2023 at 1:30 PM, AH3, Case Manager/Activity Specialist, indicated that the MR lacked an order for P5 and P6 restraint episodes listed above.

Based on document review and interview, the hospital failed to ensure staff ability to demonstrate competency in the application of restraints for 7 (seven) of 7 (seven) credentialed staff members (MD1, MD2, MD3, AH1, AH2, AH4, and AH5) and 5 (five) of 9 (nine) staff members personnel files. (N2, N3, N4, N7, and N9)

Findings:

1. Review of the policy titled Seclusion, Restraint, and Emergency Intervention Procedures, Policy Number RM1140, last revised February 27, 2023, indicated the following: All direct care staff will be trained in patient assessment, recognition, and treatment of the problems causing the need for restraint, seclusion, and emergency intervention. Training will include alternative as well as the proper application of restraints, seclusion and emergency intervention through the use of Crisis Prevention Institute (CPI) training on the Personal Safety Plan.

2. Review of credential files of MD1, MD2, MD3, AH1, AH2, AH4, and AH5 lacked current Crisis Prevention Intervention (CPI), training.

3. Review of personnel files of N2, N3, N4, N7, and N9 lacked current Crisis Prevention Intervention (CPI), training.

4. On 11/29/2023 at 1000 hours, A5, Human Resource Director, indicated that the above staff listed are required to have current training in CPI and they all lacked current training.

Based on document review and interview, facility failed to provide adequate personnel to ensure medical records compliance per policy.

Findings include:

1. Facility policy/procedure titled, Content, Supervision and Control of the Client Record, Policy Number: CR8110, last revised 7/01/19, a licensed Medical Records porfessional shall be employed at least on a consultative basis to assure that clinical record procedures and Clinical Records Department procedures are adequate to meet the Center's needs.

2. Facility failed to provide documentation of MR reviews for the previous 4 quarters.

3. In interview on 11/29/23 at approximately 2:05 pm, A3 (Quality Improvement Coordinator) confirmed MR reviews/audits have not been conducted for facility patient records the last 4 quarters. A3 indicated facility does not have qualified staff that meets policy critera.

Based on document review and interview, the infection control committee failed to ensure compliance for personnel immunizations upon hire for two (2) of nine (9) personnel files reviewed. (P6 and P9)

Findings include:

1. Policy/procedure, Policy Number: FA0448, Immunization Record, last revised July 1, 2021, indicated on page 1: All inpatient staff that provides direct care must provide documentation of immunizations for or antibodies to MMR and Varicella (Chicken Pox), or by submitting a copy of an official State Immunization Form which indicates immunization. This form will be given to all direct care inpatient staff at orientation by the Nurse Manager or designee.

2. Review of personnel file indicated that P6 lacked immunization for or antibodies to Measles Mumps Rubella Vaccine (MMR) and Varicella completed upon hire.

3. A review of personnel file indicated that P9 lacked immunization for or antibodies to Measles Mumps Rubella Vaccine (MMR), Varicella, and (TB) Tuberculosis screening completed upon hire.

4. Staff A7 Human Resources Director was interviewed on 11//29/2023 at approximately 1015 hours and confirmed the above-mentioned personnel files lacked documentation of immunizations for or antibodies to upon hire.

Based on document review and interview the facility failed to ensure an appropriate transfer in 1 of 1 patient death records reviewed (P23).

Findings include:
1. Facility policy/procedure titled, Patient Transfer To/From Another Facility, Policy Number PD1190, last revised 7/01/06, facility will collaborate with other facilities for the appropriate admission/transfer to and from Inpatient Services.

1. Review of P23's ITP (Individual Treatment Plan) indicated patient transferred by EMS to other facility for medical treatment at 9:25 pm on 6/20/22. Patient's MR's lacked documentation of any communication/documents sent to receiving facility.

2. In interview at approximately 3:20 pm on 11/29/23, A1 (RN, Inpatient Director) indicated when an inpatient is transferred to another facility for medical needs, he/she does not document in the MR as a transfer, but considers it a discharge if the patient does not return. A1 confirmed there is no documentation in the patient medical record if the patient is transferred to another facility for medical reasons and then returns to their inpatient facility. A1 indicated verbal communication is provided to receiving facility, but no documents are sent.