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The Condition of Participation for Patient Rights has not been met. Based on clinical record review, interviews with staff, review of hospital policies and procedures, and review of video surveillance, the hospital failed to provide a safe environment for 1 of 10 patients (Patient #1) when staff failed to recognize that the patient had an obstructed airway, failed to conduct observations in accordance with hospital policy, and failed to provide life-saving measures in accordance with hospital policy and/or current standards of practice and failed to communicate knowledge of the patient's unsafe eating behaviors which resulted in a finding of Immediate Jeopardy.


Please see A144

Based on clinical record review, interviews with staff, review of hospital policies and procedures, and review of video surveillance, the hospital failed to provide a safe environment for 1 of 10 patients (Patient #1) when staff failed to recognize that the patient had an obstructed airway, failed to conduct observations in accordance with hospital policy, and failed to provide life-saving measures in accordance with hospital policy and/or current standards of practice and failed to communicate knowledge of the patient's unsafe eating behaviors which resulted in a finding of Immediate Jeopardy. The findings include:


A. Patient #1 was admitted on 7/7/16 with diagnoses of schizophrenia and Obsessive Compulsive Disorder (OCD). An admission nursing assessment nutritional screen dated 07/07/16 identified that the patient was a fast eater but did not have chewing or swallowing difficulties. A quarterly Integrated Treatment Plan (ITP) dated 11/29/16 identified that Patient #1 experienced compulsions, intrusive thoughts, anxiety, psychosis, irrational delusional thoughts and disorganized behaviors. The ITP identified that on 11/23/16, Patient #1 was determined to be not competent. In addition, Patient #1 had periods of agitation and threatening with aggressive and unprovoked assaultive behaviors. The ITP, MD orders and/or integrated progress notes identified that between 11/11/16 and 12/1/16, Patient #1 was on constant 2-to-1 observational status (2 staff members observe 1 patient) due to assaultive behaviors.

A physician order dated 12/1/16 at 9:00 AM directed Patient #1 be on a 2-to-1 observational status (special observations) between 7:00 AM and 11:00 PM for being highly agitated and a high risk for assault (to others). The order further directed a 2-to-1 status "from a distance" from 11:00 PM to 7:00 AM.

The hospital policy for special observations identified that a 1-to-1 or greater observation is considered the highest level of observation that requires the staff member(s) to be within arm's length of the patient at all times. If the patient is sleeping, staff may sit inside the doorway. The patient is never left unattended and must be watched at all times. The patient's hands, face and neck must be in clear view at all times.

A progress note by MD #2 dated 12/1/16 at 8:30 PM identified that the patient was eating a fig bar, began choking, aspirated food, stopped breathing, had a low pulse oxygenation of 44 to 64 (percent), and a pulse of 235 (per minute). The patient was unconscious, suctioned, Heimlich performed, cardiopulmonary resuscitation (CPR) done, 911 called, EMS arrived and continued CPR, suctioning and cardiac monitoring. Patient #1 was transferred to the emergency department at 8:20 PM and pronounced expired at 8:46 PM with the cause of death being respiratory arrest.

A nursing note dated 12/1/16 at 9:30 PM (for the evening shift) identified that Patient #1 remained on a 2-to-1 status and was "highly agitated" and "oppositional" towards staff. Patient #1 displayed compulsive behaviors such as a desire to be in the bathroom and was agitated about ongoing supervision in the bathroom (as outlined in Patient #1's individualized bathroom guidelines). Supplemental medications were initially refused however, Patient #1 ultimately took scheduled evening medications but continued with oppositional and agitated behaviors.

Interview with FTS #2 on 12/20/16 at 2:00 PM and again on 12/21/16 at 10:30 AM identified Patient #1 was known to him/her, had a history of aggressive and assaultive behaviors directed towards staff and patients, comes out of the room and attacks "sitters", and had had an aggressive episode earlier that day. FTS #2 and #3 were providing 2-to-1 observation on 12/1/16 during snack time. The patient was provided his/her routine snack of fig bars and was directed to eat them in the lounge, dining room, or patient bedroom. Patient #1 began eating his/her fig bar in the hallway and was instructed to go to his/her room and not eat in the hallway. FTS #2 stated that Patient #1 had finished the first package (of the bars), then FTS #2 observed Patient #1 put the remainder of the fig bars in his/her mouth without benefit of chewing, enter his her/room and begin pacing. Within approximately 10 seconds, Patient #1 came back out of the room, swinging his/her arms appearing physically aggressive and threatening but did not speak (as he/she had been able to talk prior to this time). He/she was banging the dresser and FTS #2 identified that he/she was concerned that the patient was going to come out of the room and physically attack both FTSs. The patient, once again, slammed the door and after 10-15 seconds, the patient began to run out of the room, towards the FTSs who were in the hallway. The FTS's, entered the room, placed the patient in a Secure Guided Escort hold, and called a psychiatric emergency code. The patient was on his/her knees by the side of the bed when FTS #2 observed that the patient was struggling to breathe. He/she did not initiate back blows or abdominal thrusts. RN #1 responded to the emergency code, noticed the patient struggling to breathe and initiated back blows and abdominal thrusts.

The hospital policy for special observations (including 2-to-1 observations) requires staff member(s) to be within arm's length of the patient at all times. However, on interview with FTS #2, he/she thought that constant 2-to-1 observation included that staff were to be within arms-reach when the patient is out of the room and at the door when the patient was in the room. In addition, FTS #2 stated that Patient #1 was never restrained in the bed face down in this timeframe.

Interview with FTS #3 on 12/21/16 at 3:30 PM identified that Patient #1 often swung his/her arms and was on a 2-to-1 observation due to impulsive and assaultive behaviors which progressively worsened throughout the shift. When Patient #1 left the snack area, he/she stopped in the hallway to eat the fig bar. The patient was making threatening gestures and was angry. Patient #1 was observed putting more than one fig bar in his/her mouth and running back inside the bedroom, slamming the door, the patient emerged and made loud chewing noises as if to mock the FTSs, then went back in the room and started banging on the dresser repeatedly with both hands, but did not speak (as he/she had been able to talk prior to this time). It appeared that the patient was preparing for an act of aggression. Patient #1 began to run towards the FTS's with "arms flailing wildly like a wild man". FTS #3 identified that he/she was concerned for their safety and needed to get control off the situation. FTS #2 and FTS #3 each held one of the patient's arms and the patient began to physically struggle, silently, in what FTS #3 described as an attempt to attack them. While struggling, Patient #1 fell to his/her knees. FTS's #2 and #3 were calling out for assistance and RN #1 was the first staff to arrive on the scene. Initially, RN #1 attempted to gain control of the patient's lower body, and within seconds, RN #1 had identified that the patient was in distress. FTS #2 identified that Patient #1 had choked and vomited what appeared to be chewed up fig bar, saliva, and vomit. As RN #1 administered the abdominal thrusts, more material came out of the patient's mouth and he/she gasped. The patient continued to make some deep gasping sounds. RN #3 arrived to assist RN #1 and performed finger sweeps and suctioning. FTS #3 identified that he/she assisted to transfer the patient from the floor to the bed and then back to the floor where the patient remained until the EMT's arrived. FTS #3 identified that when he observed Patient #1 stuff the fig bar into his/her mouth he/she considered the act to be part of the patient's behavior and had not observed him/her rush with food or eat in an unsafe manner in the past.

According to RN #1's progress note dated 12/1/16 at 7:45 PM and interview on 12/20/16 at 3:00 PM and again on 12/21/16 at 2:20 PM, 2 Forensic Treatment Specialists (FTS equivalent to Psychiatric Technician), FTS #2 and FTS #3 were providing constant 2-to-1 observation for Patient #1. For the evening snack, Patient #1 received 2 packages of fig-type bars for a total of 4 bars. RN #1 was in the medication room when he/she heard the psychiatric emergency code. When RN #1 arrived in Patient #1's room, he/she observed the patient, kneeling on the floor kicking. The patient was alert, with projectile vomiting, and, initially, did not appear in respiratory distress, however, when RN #1 moved the patient's hair away from his/her face he/she identified that the patient appeared to be struggling to breathe and was in respiratory distress secondary to an obstructed airway. A medical emergency code was called at that time. RN #1 directed FTS ' s #2 & #3 to release the Secure Guide Escort hold and abdominal thrusts were started with the patient in a standing position. The patient went down on his/her knees and continued to vomit. RN #1 identified that he/she was unable to dislodge the airway obstruction. At that time, the patient was transferred back to bed from the floor. RN #1 placed the backboard from the emergency cart under Patient #1's mattress (instead of under the patient) and chest compressions were continued. RN #1 observed what appeared to be, chunks of the fig bar in the vomitus. RN #1 identified further, that the patient never spoke during the attempt to clear the airway and/or resuscitate the patient. Patient #1 was suctioned several times, oxygenated (ambu-bag), chest compressions were initiated, and emergency services were called. The Patient responded on 2 occasions via eye contact and/or hand squeezing. However, he/she became unresponsive, emergency medical personnel arrived, and assumed treatment including intubation and chest compressions.

Hospital security video surveillance of the unit 4 hallway was reviewed with the Chief of Patient Care Services and the Chief of Hospital Police. The Chief of Hospital Police identified that the time stamp on the video was off by 18 minutes and the following time references account for that difference. Review of the video for the time period of 12/01/16 at 7:47 PM through 12/01/16 at 8:21 PM identified the following:
At 7:47 PM FTS's #2 and #3 were walking down the hallway with chairs towards Patient #1 who was standing in the doorway of his/her room (not within arm's length).
At 7:48:59 PM Patient #1 was in the hallway standing in front FTS ' s #2 & #3 and appeared to have something in his/her hand. The Patient returned to his her room, however, the FTS's remained outside of the room, not at arm's length.
At 7:49:16 Patient #1 was observed in the hallway, making hand gestures, consistent with putting something in his/her mouth in front of FTS #2 & #3, then returned to the room. FTS #2 and #3 remained in the hallway, not within arm's length.
At 7:50:34 PM, Patient #1 came out of his/her room again and was observed interacting with the FTS's in the hallway and at 7:50:51 returned to his/her room.
At 7:51 PM, one of the FTS's approached the patient's door, then backed away, as the second FTS was observed talking with another patient (Patient #2) in the hallway. No light was visible coming from underneath Patient #1's bedroom door consistent with the door being closed at that time.
At 7:51:23 PM FTS's #2 & #3 both moved quickly into Patient #1's room.
At 7:51:34 RN #1 was observed quickly entering the room followed by other staff at 7:51:38 PM and 7:51:46 PM.
At 7:53 PM officers escorted the Emergency Medical Technicians (EMT) into the hospital building. MD #2 was observed outside the patient room at 8:01:28 PM. A crash cart was removed from the patient room at 8:06:16 PM.
Paramedics arrived at 8:07:24 PM and left the building with Patient #1 at 8:21 PM.

Based on a review of the hospital security video surveillance and interviews with staff, there was a delay of 2 minutes and 28 seconds where staff did not identify and respond to Patient #1's obstructed airway from 7:49:16 to 7:51:34.

The Hospital's policy/guideline for conscious choking identified that staff should perform 5 back blows between the shoulder blades then give 5 abdominal thrusts and repeat this sequence until the object is forced out or until the victim becomes unconscious.
Hospital guidelines and/or American Red Cross guide lines identifies that when performing cardiopulmonary resuscitation, place a cardiac board (back board) beneath the patient to provide a hard surface for performing chest compressions.

Review of the American Red Cross First Aid/CPR/AED Participant's Manual copyrighted 2014 and used as training material for all hospital staff identified the causing of choking in adults included trying to swallow large pieces of poorly chewed foods, eating while talking excitedly or eating too fast, and walking with food in the mouth. Signs of choking in adults includes inability to cough, speak, cry, or breathe, panic, bluish skin color and losing consciousness. Additionally, in a breathing emergency, seconds count, so it is important to act at once.



B. An admission nursing assessment nutritional screen dated 07/07/16 identified that the patient was a fast eater but did not have chewing or swallowing difficulties. Patient #1's Integrated Treatment Plan (ITP) dated 11/29/16 identified that the patient's eating habits were erratic and he/she often refused meals and requested supplement drink instead. Problems related to rapid eating or "shoveling" of food were not addressed.
Interview with FTS #1 on 12/20/15 at 3:45 PM identified that he/she had worked with Patient #1 on the 3:00 PM to 11:00 PM shift since the patient's admission and was frequently assigned to perform the 2-to-1 constant observation. FTS #1 had observed the patient "shovel" food, rapidly into his/her mouth on more than one occasion and had to cue him/her to slow down during meals. FTS #1 identified that he/she did not inform anyone of Patient #1's unsafe eating behavior.

Interviews with FTS's #2 & #3 and with RN #1 identified that they were not aware of Patient #1's unsafe eating behavior.

Interview with Patient #1's primary psychiatrist, MD #1 on 12/21/16 at 2:00 PM identified that he/she was not aware that Patient #1 had a history of "shoveling food" or rushing with meals.


Although the hospital obtained staff statements regarding the event on 12/1/16 and assessed all patient's for unsafe eating practices and/or risk for choking, the hospital failed to address staff competency in the identification of choking and/or airway obstruction, failed to address staff response to an airway obstruction, and failed to address staff performance of and/or implementation of special observations in accordance with hospital policy prior to the Departments inititaion of an investigation.


The Department requested and received an action plan from the hospital. The plan included education to ensure that all nursing staff were knowledgeable in recognizing unsafe eating behaviors, signs of choking, and ensure the appropriate response and treatment of a patient who is choking. The hospital's plan included education to all staff as they report to duty, competency check lists, and demonstration. A plan was developed to ensure that physician's assessed all patient's on special observations for appropriateness, and to reinforce the requirements for special observations.

An on-site review of the action plan on 12/23/16 identified that the hospital implemented the action plan as stated and therefore, Immediate Jeopardy was removed as of 12/23/16.

Based on review of clinical records, hospital policies and procedures and interviews for 1 of 6 patients reviewed for physical restraints for management of violent or self-destructive behavior (Patient #1), the hospital failed to ensure documentation of a physical restraint episode in accordance with hospital policy. The findings include:

Patient #1 was admitted on 7/7/16 with diagnoses of schizophrenia and Obsessive Compulsive Disorder (OCD). A quarterly Integrated Treatment Plan (ITP) dated 11/29/16 identified that Patient #1 experienced compulsions, intrusive thoughts, anxiety, and psychosis. In addition, Patient #1 had periods of agitation and threatening with aggressive and unprovoked assaultive behaviors. The ITP, MD orders and/or integrated progress notes identified that between 11/11/16 and 12/1/16, Patient #1 was on constant 2-to-1 observational status following assaultive behaviors.
A nursing note dated 12/1/16 at 9:30 PM (for the evening shift) identified that Patient #1 remained on a 2-to-1 status and was "highly agitated" and "oppositional" towards all staff. Medications were initially refused however, Patient #1 ultimately took scheduled evening medications with ongoing oppositional and agitated behaviors.

Interview with FTS #2 on 12/20/16 at 2:00 PM and again on 12/21/16 at 10:30 AM identified that Patient #1 was known to him/her, had a history of aggressive behaviors and comes out of the room and attacks "sitters". Patient #1 had had an aggressive episode earlier in the day on 12/01/16. Later on 12/01/16, FTS ' s #2 and #3 thought that Patient #1 was going to attack them when the patient slammed a door then came running out of the door. FTS ' s #2 and #3 held the patient's arms in a Secure Guide Escort hold (identified as a restraint) for about 7 seconds as they escorted him/her into the bedroom, and called out for staff to call a behavioral code. Once in the room, Patient #1 continued to be held in Secure Guide Escort on his/her knees next to the bed. RN #1 responded to the room and attempted to stabilize the patient ' s legs as he/she attempted to kick the staff.
The hospital reported Patient #1 ' s death that occurred within 24 hours of removal of a restraint to the Federal Regulating Agency (CMS) after conducting a review of the event on 12/13/16. However, review of the clinical record, lacked documentation of a physician ' s order for a Secure Guide Escort and/or documentation in the clinical ecord of the restraint episode on 12/01/16.
Review of the hospital policy for restraint use for the management of violent or self-destructive behavior identified that the medical record contains documentation of each restraint and includes a description of the therapeutic intervention and the patient's response to the intervention.

The Condition of Participation for Nursing Services has not been met. Based on clinical record review, interviews with staff, review of hospital policies and procedures, review of staff education, and review of video surveillance for 1 of 10 patients (Patient #1) the hospital failed to ensure that nursing staff assigned to provide patient oversight and care demonstrated competency when nursing staff failed to recognize that the patient had an obstructed airway, failed to provide life-saving measures in accordance with hospital policy and/or current standards of practice, failed to conduct observations in accordance with hospital policy, and failed to communicate knowledge of the patient's unsafe eating behaviors.


Please see A397

Based on clinical record review, interviews with staff, review of hospital policies and procedures, review of staff education, and review of video surveillance for 1 of 10 patients (Patient #1) the hospital failed to ensure that nursing staff assigned to provide patient oversight and care demonstrated competency when nursing staff failed to recognize that the patient had an obstructed airway, failed to provide life-saving measures in accordance with hospital policy and/or current standards of practice, failed to conduct observations in accordance with hospital policy, and failed to communicate knowledge of the patient's unsafe eating behaviors. The findings include:



A. Patient #1 was admitted on 7/7/16 with diagnoses of schizophrenia and Obsessive Compulsive Disorder (OCD). An admission nursing assessment nutritional screen dated 07/07/16 identified that the patient was a fast eater but did not have chewing or swallowing difficulties. A quarterly Integrated Treatment Plan (ITP) dated 11/29/16 identified that Patient #1 experienced compulsions, intrusive thoughts, anxiety, psychosis, irrational delusional thoughts and disorganized behaviors. The ITP identified that on 11/23/16, Patient #1 was determined to be not competent. In addition, Patient #1 had periods of agitation and threatening with aggressive and unprovoked assaultive behaviors. The ITP, MD orders and/or integrated progress notes identified that between 11/11/16 and 12/1/16, Patient #1 was on constant 2-to-1 observational status (2 staff members observe 1 patient) due to assaultive behaviors.

A physician order dated 12/1/16 at 9:00 AM directed Patient #1 be on a 2-to-1 observational status (special observations) between 7:00 AM and 11:00 PM for being highly agitated and a high risk for assault (to others). The order further directed a 2-to-1 status "from a distance" from 11:00 PM to 7:00 AM.

The hospital policy for special observations identified that a 1-to-1 or greater observation is considered the highest level of observation that requires the staff member(s) to be within arm's length of the patient at all times. If the patient is sleeping, staff may sit inside the doorway. The patient is never left unattended and must be watched at all times. The patient's hands, face and neck must be in clear view at all times.

A progress note by MD #2 dated 12/1/16 at 8:30 PM identified that the patient was eating a fig bar, began choking, aspirated food, stopped breathing, had a low pulse oxygenation of 44 to 64 (percent), and a pulse of 235 (per minute). The patient was unconscious, suctioned, Heimlich performed, cardiopulmonary resuscitation (CPR) done, 911 called, EMS arrived and continued CPR, suctioning and cardiac monitoring. Patient #1 was transferred to the emergency department at 8:20 PM and pronounced expired at 8:46 PM with the cause of death being respiratory arrest.

A nursing note dated 12/1/16 at 9:30 PM (for the evening shift) identified that Patient #1 remained on a 2-to-1 status and was "highly agitated" and "oppositional" towards staff. Patient #1 displayed compulsive behaviors such as a desire to be in the bathroom and was agitated about ongoing supervision in the bathroom (as outlined in Patient #1's individualized bathroom guidelines). Supplemental medications were initially refused however, Patient #1 ultimately took scheduled evening medications but continued with oppositional and agitated behaviors.

Interview with FTS #2 on 12/20/16 at 2:00 PM and again on 12/21/16 at 10:30 AM identified Patient #1 was known to him/her, had a history of aggressive and assaultive behaviors directed towards staff and patients, comes out of the room and attacks "sitters", and had had an aggressive episode earlier that day. FTS #2 and #3 were providing 2-to-1 observation on 12/1/16 during snack time. The patient was provided his/her routine snack of fig bars and was directed to eat them in the lounge, dining room, or patient bedroom. Patient #1 began eating his/her fig bar in the hallway and was instructed to go to his/her room and not eat in the hallway. FTS #2 stated that Patient #1 had finished the first package (of the bars), then FTS #2 observed Patient #1 put the remainder of the fig bars in his/her mouth without benefit of chewing, enter his her/room and begin pacing. Within approximately 10 seconds, Patient #1 came back out of the room, swinging his/her arms appearing physically aggressive and threatening but did not speak (as he/she had been able to talk prior to this time). He/she was banging the dresser and FTS #2 identified that he/she was concerned that the patient was going to come out of the room and physically attack both FTSs. The patient, once again, slammed the door and after 10-15 seconds, the patient began to run out of the room, towards the FTSs who were in the hallway. The FTS's, entered the room, placed the patient in a Secure Guided Escort hold, and called a psychiatric emergency code. The patient was on his/her knees by the side of the bed when FTS #2 observed that the patient was struggling to breathe. He/she did not initiate back blows or abdominal thrusts. RN #1 responded to the emergency code, noticed the patient struggling to breathe and initiated back blows and abdominal thrusts.

The hospital policy for special observations (including 2-to-1 observations) requires staff member(s) to be within arm's length of the patient at all times. However, on interview with FTS #2, he/she thought that constant 2-to-1 observation included that staff were to be within arms-reach when the patient is out of the room and at the door when the patient was in the room. In addition, FTS #2 stated that Patient #1 was never restrained in the bed face down in this timeframe.

Interview with FTS #3 on 12/21/16 at 3:30 PM identified that Patient #1 often swung his/her arms and was on a 2-to-1 observation due to impulsive and assaultive behaviors which progressively worsened throughout the shift. When Patient #1 left the snack area, he/she stopped in the hallway to eat the fig bar. The patient was making threatening gestures and was angry. Patient #1 was observed putting more than one fig bar in his/her mouth and running back inside the bedroom, slamming the door, the patient emerged and made loud chewing noises as if to mock the FTSs, then went back in the room and started banging on the dresser repeatedly with both hands, but did not speak (as he/she had been able to talk prior to this time). It appeared that the patient was preparing for an act of aggression. Patient #1 began to run towards the FTS's with "arms flailing wildly like a wild man". FTS #3 identified that he/she was concerned for their safety and needed to get control off the situation. FTS #2 and FTS #3 each held one of the patient's arms and the patient began to physically struggle, silently, in what FTS #3 described as an attempt to attack them. While struggling, Patient #1 fell to his/her knees. FTS's #2 and #3 were calling out for assistance and RN #1 was the first staff to arrive on the scene. Initially, RN #1 attempted to gain control of the patient's lower body, and within seconds, RN #1 had identified that the patient was in distress. FTS #2 identified that Patient #1 had choked and vomited what appeared to be chewed up fig bar, saliva, and vomit. As RN #1 administered the abdominal thrusts, more material came out of the patient's mouth and he/she gasped. The patient continued to make some deep gasping sounds. RN #3 arrived to assist RN #1 and performed finger sweeps and suctioning. FTS #3 identified that he/she assisted to transfer the patient from the floor to the bed and then back to the floor where the patient remained until the EMT's arrived. FTS #3 identified that when he observed Patient #1 stuff the fig bar into his/her mouth he/she considered the act to be part of the patient's behavior and had not observed him/her rush with food or eat in an unsafe manner in the past.

According to RN #1's progress note dated 12/1/16 at 7:45 PM and interview on 12/20/16 at 3:00 PM and again on 12/21/16 at 2:20 PM, 2 Forensic Treatment Specialists (FTS equivalent to Psychiatric Technician), FTS #2 and FTS #3 were providing constant 2-to-1 observation for Patient #1. For the evening snack, Patient #1 received 2 packages of fig-type bars for a total of 4 bars. RN #1 was in the medication room when he/she heard the psychiatric emergency code. When RN #1 arrived in Patient #1's room, he/she observed the patient, kneeling on the floor kicking. The patient was alert, with projectile vomiting, and, initially, did not appear in respiratory distress, however, when RN #1 moved the patient's hair away from his/her face he/she identified that the patient appeared to be struggling to breathe and was in respiratory distress secondary to an obstructed airway. A medical emergency code was called at that time. RN #1 directed FTS ' s #2 & #3 to release the Secure Guide Escort hold and abdominal thrusts were started with the patient in a standing position. The patient went down on his/her knees and continued to vomit. RN #1 identified that he/she was unable to dislodge the airway obstruction. At that time, the patient was transferred back to bed from the floor. RN #1 placed the backboard from the emergency cart under Patient #1's mattress (instead of under the patient) and chest compressions were continued. RN #1 observed what appeared to be, chunks of the fig bar in the vomitus. RN #1 identified further, that the patient never spoke during the attempt to clear the airway and/or resuscitate the patient. Patient #1 was suctioned several times, oxygenated (ambu-bag), chest compressions were initiated, and emergency services were called. The Patient responded on 2 occasions via eye contact and/or hand squeezing. However, he/she became unresponsive, emergency medical personnel arrived, and assumed treatment including intubation and chest compressions.

Hospital security video surveillance of the unit 4 hallway was reviewed with the Chief of Patient Care Services and the Chief of Hospital Police. The Chief of Hospital Police identified that the time stamp on the video was off by 18 minutes and the following time references account for that difference. Review of the video for the time period of 12/01/16 at 7:47 PM through 12/01/16 at 8:21 PM identified the following:
At 7:47 PM FTS's #2 and #3 were walking down the hallway with chairs towards Patient #1 who was standing in the doorway of his/her room (not within arm's length).
At 7:48:59 PM Patient #1 was in the hallway standing in front FTS ' s #2 & #3 and appeared to have something in his/her hand. The Patient returned to his her room, however, the FTS's remained outside of the room, not at arm's length.
At 7:49:16 Patient #1 was observed in the hallway, making hand gestures, consistent with putting something in his/her mouth in front of FTS #2 & #3, then returned to the room. FTS #2 and #3 remained in the hallway, not within arm's length.
At 7:50:34 PM, Patient #1 came out of his/her room again and was observed interacting with the FTS's in the hallway and at 7:50:51 returned to his/her room.
At 7:51 PM, one of the FTS's approached the patient's door, then backed away, as the second FTS was observed talking with another patient (Patient #2) in the hallway. No light was visible coming from underneath Patient #1's bedroom door consistent with the door being closed at that time.
At 7:51:23 PM FTS's #2 & #3 both moved quickly into Patient #1's room.
At 7:51:34 RN #1 was observed quickly entering the room followed by other staff at 7:51:38 PM and 7:51:46 PM.
At 7:53 PM officers escorted the Emergency Medical Technicians (EMT) into the hospital building. MD #2 was observed outside the patient room at 8:01:28 PM. A crash cart was removed from the patient room at 8:06:16 PM.
Paramedics arrived at 8:07:24 PM and left the building with Patient #1 at 8:21 PM.

Based on a review of the hospital security video surveillance and interviews with staff, there was a delay of 2 minutes and 28 seconds where staff did not identify and respond to Patient #1's obstructed airway from 7:49:16 to 7:51:34.

The Hospital's policy/guideline for conscious choking identified that staff should perform 5 back blows between the shoulder blades then give 5 abdominal thrusts and repeat this sequence until the object is forced out or until the victim becomes unconscious.
Hospital guidelines and/or American Red Cross guide lines identifies that when performing cardiopulmonary resuscitation, place a cardiac board (back board) beneath the patient to provide a hard surface for performing chest compressions.

Review of the American Red Cross First Aid/CPR/AED Participant's Manual copyrighted 2014 and used as training material for all hospital staff identified the causing of choking in adults included trying to swallow large pieces of poorly chewed foods, eating while talking excitedly or eating too fast, and walking with food in the mouth. Signs of choking in adults includes inability to cough, speak, cry, or breathe, panic, bluish skin color and losing consciousness. Additionally, in a breathing emergency, seconds count, so it is important to act at once.

Tour of the hospital on 12/22/16 at 2:00 PM identified educational posters on patient care units that identified universal aspiration precautions and emergency care for a patient who is choking. The posters had been in place prior to Patient #1's obstructed airway event.

Review of staff education files identified that staff received annual training on emergency cart competency, medical emergency response competency, and standard first aid. Despite this training and education, on 12/1/16, nursing staff failed to recognize that Patient #1 had an obstructed airway which caused a delay in life-saving emergency treatment.


B. An admission nursing assessment nutritional screen dated 07/07/16 identified that the patient was a fast eater but did not have chewing or swallowing difficulties. Patient #1's Integrated Treatment Plan (ITP) dated 11/29/16 identified that the patient's eating habits were erratic and he/she often refused meals and requested supplement drink instead. Problems related to rapid eating or "shoveling" of food were not addressed.
Interview with FTS #1 on 12/20/15 at 3:45 PM identified that he/she had worked with Patient #1 on the 3:00 PM to 11:00 PM shift since the patient's admission and was frequently assigned to perform the 2-to-1 constant observation. FTS #1 had observed the patient "shovel" food, rapidly into his/her mouth on more than one occasion and had to cue him/her to slow down during meals. FTS #1 identified that he/she did not inform anyone of Patient #1's unsafe eating behavior.

Interviews with FTS's #2 & #3 and with RN #1 identified that they were not aware of Patient #1's unsafe eating behavior.

Interview with Patient #1's primary psychiatrist, MD #1 on 12/21/16 at 2:00 PM identified that he/she was not aware that Patient #1 had a history of "shoveling food" or rushing with meals.

Although the hospital obtained staff statements regarding the event on 12/1/16 and assessed all patient's for unsafe eating practices and/or risk for choking, the hospital failed to address staff competency in the identification of choking and/or airway obstruction, failed to address staff response to an airway obstruction, and failed to address staff performance of and/or implementation of special observations in accordance with hospital policy prior to the Departments inititaion of an investigation.

The Department requested and received an action plan from the hospital. The plan included education to ensure that all nursing staff were knowledgeable in recognizing unsafe eating behaviors, signs of choking, and ensure the appropriate response and treatment of a patient who is choking. The hospital's plan included education to all staff as they report to duty, competency check lists, and demonstration. A plan was developed to ensure that physician's assessed all patient's on special observations for appropriateness, and to reinforce the requirements for special observations.

An on-site review of the action plan on 12/23/16 identified that the hospital implemented the action plan as stated and therefore, Immediate Jeopardy was removed as of 12/23/16.

Based on clinical record review, interviews with staff, review of hospital policies and procedures, and review of video surveillance, the hospital failed to provide a safe environment for 1 of 10 patients (Patient #1) when staff failed to recognize that the patient had an obstructed airway, failed to conduct observations in accordance with hospital policy, and failed to provide life-saving measures in accordance with hospital policy and/or current standards of practice and failed to communicate knowledge of the patient's unsafe eating behaviors which resulted in a finding of Immediate Jeopardy. The findings include:


A. Patient #1 was admitted on 7/7/16 with diagnoses of schizophrenia and Obsessive Compulsive Disorder (OCD). An admission nursing assessment nutritional screen dated 07/07/16 identified that the patient was a fast eater but did not have chewing or swallowing difficulties. A quarterly Integrated Treatment Plan (ITP) dated 11/29/16 identified that Patient #1 experienced compulsions, intrusive thoughts, anxiety, psychosis, irrational delusional thoughts and disorganized behaviors. The ITP identified that on 11/23/16, Patient #1 was determined to be not competent. In addition, Patient #1 had periods of agitation and threatening with aggressive and unprovoked assaultive behaviors. The ITP, MD orders and/or integrated progress notes identified that between 11/11/16 and 12/1/16, Patient #1 was on constant 2-to-1 observational status (2 staff members observe 1 patient) due to assaultive behaviors.

A physician order dated 12/1/16 at 9:00 AM directed Patient #1 be on a 2-to-1 observational status (special observations) between 7:00 AM and 11:00 PM for being highly agitated and a high risk for assault (to others). The order further directed a 2-to-1 status "from a distance" from 11:00 PM to 7:00 AM.

The hospital policy for special observations identified that a 1-to-1 or greater observation is considered the highest level of observation that requires the staff member(s) to be within arm's length of the patient at all times. If the patient is sleeping, staff may sit inside the doorway. The patient is never left unattended and must be watched at all times. The patient's hands, face and neck must be in clear view at all times.

A progress note by MD #2 dated 12/1/16 at 8:30 PM identified that the patient was eating a fig bar, began choking, aspirated food, stopped breathing, had a low pulse oxygenation of 44 to 64 (percent), and a pulse of 235 (per minute). The patient was unconscious, suctioned, Heimlich performed, cardiopulmonary resuscitation (CPR) done, 911 called, EMS arrived and continued CPR, suctioning and cardiac monitoring. Patient #1 was transferred to the emergency department at 8:20 PM and pronounced expired at 8:46 PM with the cause of death being respiratory arrest.

A nursing note dated 12/1/16 at 9:30 PM (for the evening shift) identified that Patient #1 remained on a 2-to-1 status and was "highly agitated" and "oppositional" towards staff. Patient #1 displayed compulsive behaviors such as a desire to be in the bathroom and was agitated about ongoing supervision in the bathroom (as outlined in Patient #1's individualized bathroom guidelines). Supplemental medications were initially refused however, Patient #1 ultimately took scheduled evening medications but continued with oppositional and agitated behaviors.

Interview with FTS #2 on 12/20/16 at 2:00 PM and again on 12/21/16 at 10:30 AM identified Patient #1 was known to him/her, had a history of aggressive and assaultive behaviors directed towards staff and patients, comes out of the room and attacks "sitters", and had had an aggressive episode earlier that day. FTS #2 and #3 were providing 2-to-1 observation on 12/1/16 during snack time. The patient was provided his/her routine snack of fig bars and was directed to eat them in the lounge, dining room, or patient bedroom. Patient #1 began eating his/her fig bar in the hallway and was instructed to go to his/her room and not eat in the hallway. FTS #2 stated that Patient #1 had finished the first package (of the bars), then FTS #2 observed Patient #1 put the remainder of the fig bars in his/her mouth without benefit of chewing, enter his her/room and begin pacing. Within approximately 10 seconds, Patient #1 came back out of the room, swinging his/her arms appearing physically aggressive and threatening but did not speak (as he/she had been able to talk prior to this time). He/she was banging the dresser and FTS #2 identified that he/she was concerned that the patient was going to come out of the room and physically attack both FTSs. The patient, once again, slammed the door and after 10-15 seconds, the patient began to run out of the room, towards the FTSs who were in the hallway. The FTS's, entered the room, placed the patient in a Secure Guided Escort hold, and called a psychiatric emergency code. The patient was on his/her knees by the side of the bed when FTS #2 observed that the patient was struggling to breathe. He/she did not initiate back blows or abdominal thrusts. RN #1 responded to the emergency code, noticed the patient struggling to breathe and initiated back blows and abdominal thrusts.

The hospital policy for special observations (including 2-to-1 observations) requires staff member(s) to be within arm's length of the patient at all times. However, on interview with FTS #2, he/she thought that constant 2-to-1 observation included that staff were to be within arms-reach when the patient is out of the room and at the door when the patient was in the room. In addition, FTS #2 stated that Patient #1 was never restrained in the bed face down in this timeframe.

Interview with FTS #3 on 12/21/16 at 3:30 PM identified that Patient #1 often swung his/her arms and was on a 2-to-1 observation due to impulsive and assaultive behaviors which progressively worsened throughout the shift. When Patient #1 left the snack area, he/she stopped in the hallway to eat the fig bar. The patient was making threatening gestures and was angry. Patient #1 was observed putting more than one fig bar in his/her mouth and running back inside the bedroom, slamming the door, the patient emerged and made loud chewing noises as if to mock the FTSs, then went back in the room and started banging on the dresser repeatedly with both hands, but did not speak (as he/she had been able to talk prior to this time). It appeared that the patient was preparing for an act of aggression. Patient #1 began to run towards the FTS's with "arms flailing wildly like a wild man". FTS #3 identified that he/she was concerned for their safety and needed to get control off the situation. FTS #2 and FTS #3 each held one of the patient's arms and the patient began to physically struggle, silently, in what FTS #3 described as an attempt to attack them. While struggling, Patient #1 fell to his/her knees. FTS's #2 and #3 were calling out for assistance and RN #1 was the first staff to arrive on the scene. Initially, RN #1 attempted to gain control of the patient's lower body, and within seconds, RN #1 had identified that the patient was in distress. FTS #2 identified that Patient #1 had choked and vomited what appeared to be chewed up fig bar, saliva, and vomit. As RN #1 administered the abdominal thrusts, more material came out of the patient's mouth and he/she gasped. The patient continued to make some deep gasping sounds. RN #3 arrived to assist RN #1 and performed finger sweeps and suctioning. FTS #3 identified that he/she assisted to transfer the patient from the floor to the bed and then back to the floor where the patient remained until the EMT's arrived. FTS #3 identified that when he observed Patient #1 stuff the fig bar into his/her mouth he/she considered the act to be part of the patient's behavior and had not observed him/her rush with food or eat in an unsafe manner in the past.

According to RN #1's progress note dated 12/1/16 at 7:45 PM and interview on 12/20/16 at 3:00 PM and again on 12/21/16 at 2:20 PM, 2 Forensic Treatment Specialists (FTS equivalent to Psychiatric Technician), FTS #2 and FTS #3 were provid

Based on clinical record review, interviews with staff, review of hospital policies and procedures, review of staff education, and review of video surveillance for 1 of 10 patients (Patient #1) the hospital failed to ensure that nursing staff assigned to provide patient oversight and care demonstrated competency when nursing staff failed to recognize that the patient had an obstructed airway, failed to provide life-saving measures in accordance with hospital policy and/or current standards of practice, failed to conduct observations in accordance with hospital policy, and failed to communicate knowledge of the patient's unsafe eating behaviors. The findings include:



A. Patient #1 was admitted on 7/7/16 with diagnoses of schizophrenia and Obsessive Compulsive Disorder (OCD). An admission nursing assessment nutritional screen dated 07/07/16 identified that the patient was a fast eater but did not have chewing or swallowing difficulties. A quarterly Integrated Treatment Plan (ITP) dated 11/29/16 identified that Patient #1 experienced compulsions, intrusive thoughts, anxiety, psychosis, irrational delusional thoughts and disorganized behaviors. The ITP identified that on 11/23/16, Patient #1 was determined to be not competent. In addition, Patient #1 had periods of agitation and threatening with aggressive and unprovoked assaultive behaviors. The ITP, MD orders and/or integrated progress notes identified that between 11/11/16 and 12/1/16, Patient #1 was on constant 2-to-1 observational status (2 staff members observe 1 patient) due to assaultive behaviors.

A physician order dated 12/1/16 at 9:00 AM directed Patient #1 be on a 2-to-1 observational status (special observations) between 7:00 AM and 11:00 PM for being highly agitated and a high risk for assault (to others). The order further directed a 2-to-1 status "from a distance" from 11:00 PM to 7:00 AM.

The hospital policy for special observations identified that a 1-to-1 or greater observation is considered the highest level of observation that requires the staff member(s) to be within arm's length of the patient at all times. If the patient is sleeping, staff may sit inside the doorway. The patient is never left unattended and must be watched at all times. The patient's hands, face and neck must be in clear view at all times.

A progress note by MD #2 dated 12/1/16 at 8:30 PM identified that the patient was eating a fig bar, began choking, aspirated food, stopped breathing, had a low pulse oxygenation of 44 to 64 (percent), and a pulse of 235 (per minute). The patient was unconscious, suctioned, Heimlich performed, cardiopulmonary resuscitation (CPR) done, 911 called, EMS arrived and continued CPR, suctioning and cardiac monitoring. Patient #1 was transferred to the emergency department at 8:20 PM and pronounced expired at 8:46 PM with the cause of death being respiratory arrest.

A nursing note dated 12/1/16 at 9:30 PM (for the evening shift) identified that Patient #1 remained on a 2-to-1 status and was "highly agitated" and "oppositional" towards staff. Patient #1 displayed compulsive behaviors such as a desire to be in the bathroom and was agitated about ongoing supervision in the bathroom (as outlined in Patient #1's individualized bathroom guidelines). Supplemental medications were initially refused however, Patient #1 ultimately took scheduled evening medications but continued with oppositional and agitated behaviors.

Interview with FTS #2 on 12/20/16 at 2:00 PM and again on 12/21/16 at 10:30 AM identified Patient #1 was known to him/her, had a history of aggressive and assaultive behaviors directed towards staff and patients, comes out of the room and attacks "sitters", and had had an aggressive episode earlier that day. FTS #2 and #3 were providing 2-to-1 observation on 12/1/16 during snack time. The patient was provided his/her routine snack of fig bars and was directed to eat them in the lounge, dining room, or patient bedroom. Patient #1 began eating his/her fig bar in the hallway and was instructed to go to his/her room and not eat in the hallway. FTS #2 stated that Patient #1 had finished the first package (of the bars), then FTS #2 observed Patient #1 put the remainder of the fig bars in his/her mouth without benefit of chewing, enter his her/room and begin pacing. Within approximately 10 seconds, Patient #1 came back out of the room, swinging his/her arms appearing physically aggressive and threatening but did not speak (as he/she had been able to talk prior to this time). He/she was banging the dresser and FTS #2 identified that he/she was concerned that the patient was going to come out of the room and physically attack both FTSs. The patient, once again, slammed the door and after 10-15 seconds, the patient began to run out of the room, towards the FTSs who were in the hallway. The FTS's, entered the room, placed the patient in a Secure Guided Escort hold, and called a psychiatric emergency code. The patient was on his/her knees by the side of the bed when FTS #2 observed that the patient was struggling to breathe. He/she did not initiate back blows or abdominal thrusts. RN #1 responded to the emergency code, noticed the patient struggling to breathe and initiated back blows and abdominal thrusts.

The hospital policy for special observations (including 2-to-1 observations) requires staff member(s) to be within arm's length of the patient at all times. However, on interview with FTS #2, he/she thought that constant 2-to-1 observation included that staff were to be within arms-reach when the patient is out of the room and at the door when the patient was in the room. In addition, FTS #2 stated that Patient #1 was never restrained in the bed face down in this timeframe.

Interview with FTS #3 on 12/21/16 at 3:30 PM identified that Patient #1 often swung his/her arms and was on a 2-to-1 observation due to impulsive and assaultive behaviors which progressively worsened throughout the shift. When Patient #1 left the snack area, he/she stopped in the hallway to eat the fig bar. The patient was making threatening gestures and was angry. Patient #1 was observed putting more than one fig bar in his/her mouth and running back inside the bedroom, slamming the door, the patient emerged and made loud chewing noises as if to mock the FTSs, then went back in the room and started banging on the dresser repeatedly with both hands, but did not speak (as he/she had been able to talk prior to this time). It appeared that the patient was preparing for an act of aggression. Patient #1 began to run towards the FTS's with "arms flailing wildly like a wild man". FTS #3 identified that he/she was concerned for their safety and needed to get control off the situation. FTS #2 and FTS #3 each held one of the patient's arms and the patient began to physically struggle, silently, in what FTS #3 described as an attempt to attack them. While struggling, Patient #1 fell to his/her knees. FTS's #2 and #3 were calling out for assistance and RN #1 was the first staff to arrive on the scene. Initially, RN #1 attempted to gain control of the patient's lower body, and within seconds, RN #1 had identified that the patient was in distress. FTS #2 identified that Patient #1 had choked and vomited what appeared to be chewed up fig bar, saliva, and vomit. As RN #1 administered the abdominal thrusts, more material came out of the patient's mouth and he/she gasped. The patient continued to make some deep gasping sounds. RN #3 arrived to assist RN #1 and performed finger sweeps and suctioning. FTS #3 identified that he/she assisted to transfer the patient from the floor to the bed and then back to the floor where the patient remained until the EMT's arrived. FTS #3 identified that when he observed Patient #1 stuff the fig bar into his/her mouth he/she considered the act to be part of the patient's behavior and had not observed him/her rush with food or eat in an unsafe manner in the past.

According to RN #1's progress note dated 12/1/16 at 7:45 PM and interview on 12/20/16 at 3:00 PM and again on 12/21/16 at 2:20 PM, 2 Forensic Treatment Specialists (FTS equivalent to Ps