HospitalInspections.org

Based on interview and record review, the facility's Governing Body failed to assume full legal responsibility for implementing, and monitoring policies governing the facility's process of suicide screen by use of the Columbia Suicide Severity Rating Scale screener tool. The facility's Governing Body failed to provide oversight for quality health care in a safe environment. The facility did not meet the condition for coverage in governing body and management by failing to:

1. Ensure staff adhere to the process on assessing patients for suicide and implement safety measures in accordance with the facility's policy and procedure. This deficient practice resulted in Patient 1 not being properly assessed and no safety measures in-place. Patient 1 eloped from the Emergency Department (ED) and was found dead 1 mile away from the facility by the police department. (Refer to A-144)

2. Ensure that QAPI (Quality Assessment & Performance Improvement) Committee implemented an effective plan of correction that ensured staff adherence to the facility's policy and procedure (P&P) titled "Suicide Risk Assessment and Prevention" after the incident of Patient 1's elopement on 6/15/22. This deficient practice can lead to the reoccurrence of failing to implement suicide safety measures on patient who are unable to participate in the CSSRS screening process or is providing any answer other than "yes" or "no". (Refer to A-273 and A-286)

The cumulative effect of these systemic practices resulted in the facility's inability to ensure the governing body had oversight and accountability for all the facility's activities and total operations.

Based on interview and record review, the facility's Governing Body failed to ensure nursing services provide a safety and guiding standard of care for nurses to screen and assess patients risk of self harm or suicide and implementing steps to protect the patient in accordance with the facility's policy and procedure (P&P).
These deficient practices resulted in nursing staff failing to establish a safe process to screen and properly assessed Patient 1, who eloped from the Emergency Department (ED) and was found dead 1 mile away from the facility by the police department. In addition, these deficient practices had the potential for other patients who come in the ED with risk of suicidal ideation to not be assessed appropriately and for appropriate safety intervention to not be implemented.
Findings:
During a concurrent record review of Patient 1 electronic medical record (EMR) and interview with the Quality RN (QRN) on 5/6/24 at 2:05 p.m., the QRN stated that patient arrive to the ED on 6/15/2022 at 15:03 p.m. by ambulance. Patient with chief complaint of overdose with an unknown substance. Patient noted to refuse to answer suicide ideation question. there was no documentation of Patient 1 being on a 5150 hold, medical hold or a sitter during this ED admission.

During a concurrent record review of Patient 1 electronic medical record (EMR) and interview with Social Worker 1 (SW1) on 5/6/2024 at 2:41 p.m., the SW 1 stated she was made aware of Patient 1 who came in the ED on 6/15/2022 with a chief complaint of accidental overdose. Patient eloped before a SW 1 assessment was completed.

During a concurrent record review of Patient 1 electronic medical record (EMR) and interview with the Director of Emergency Department (DED) on 5/7/24 at 11:00 a.m., the DED stated Patient 1's Columbia Suicide Severity Rating Scale (C-SSRS) screening on 6/15/22 at 1508, by the Triage Nurse, the C-SSRS question, "In the past month, have you wished you were dead or wished you could go to sleep and not wake up?" Patient 1's answer was "no (unsure)." The DED stated the answer "unsure" of Patient 1 should be considered as a "yes" and Patient 1 should be positive for C-SSRS. The DED stated if a patient was screened positive for C-SSRS, the triage nurse will admit the patient in the ED and the assigned ED nurse should do a C-SSRS reassessment, behavior health assessment of the patient and the patient will have a 1:1 sitter for safety monitoring.

During a concurrent record review of the facility's course outline titled, "Suicide Prevention and Mitigation Plan - Suicide Risk Assessment" and interview with Emergency Department Educator (EDE) on 5/7/24 at 11:40 a.m., EDE concurred the course outline for nursing on suicide risk assessment does not include scenario if a patient is unable to participate in the screening process, or a nurse cannot get an answer of Yes or No from the patient when completing the C-SSRS Screener Tool (a reliable and valid risk assessment tool for determining risk level for suicide).

During an interview on 5/9/24 at 4:50 p.m., with the Executive Director of Quality (EDQ). EDQ stated there was no Root Cause Analysis (RCA - is a structured facilitated team process to identify root causes of an event that resulted in an undesired outcome and develop corrective actions) done involving Patient 1's elopement. There was a critical event review led by the previous EDQ, but that review did not identify any gaps in suicide screening process. Patient 1's elopement incident deemed to not meet criteria for it to be escalated for an RCA review, there was no concern identified on its initial review; therefore, no action plan was implemented. There was a focus by the facility on reviewing with the security team about elopement, the facility's P&P and its expectation, but the Facility did not identify there was a gap in the nursing suicide screening process sooner.

Based on interview and record review, the facility to:

Ensure staff adhere to the process on assessing patients for suicide and implement safety measures in accordance with the facility's policy and procedure. This deficient practice resulted in Patient 1 not being properly assessed and no safety measures in-place. Patient 1 eloped from the Emergency Department (ED) and was found dead 1 mile away from the facility by the police department. (Refer to A-144)

Based on observation, interview, and record review, the facility failed to ensure for one of three sampled patients (Patient 30), the Important Message from Medicare (IMM - a notice given to the patient with Medicare benefits indicating the patient's rights to a hospital discharge appeal) letter was provided to Patient 30 upon admission to the facility.

This deficient practice resulted in Patient 30 to not be informed of his (Patient 30) rights as a patient, which may also result in Patient 30's inability to effectively make decisions regarding his care or treatment.

Findings:

During a record review of Patient 30's record, the "Speech and Language Pathologist Initial Evaluation," dated 5/7/24, the evaluation indicated Patient 30 was admitted to the facility on 5/6/2024, status post laryngectomy (surgical removal of the larynx [voice box]) right neck dissection left anterolateral thigh free flap (reconstructive surgery technique that involves transfer of skin from one body area to another).

During an interview on 5/8/24 at 11:20 a.m., with the Director of Case Manager (DCM), the DCM stated the patient with Medicare (health insurance program) would be issued the IMM letter upon admission and 48-hours prior to the patient discharge from the facility. The DCM stated the initial IMM letter will be issued by the Admitting Department when the patient was admitted, and the IMM letter would be provided to the patient again within 48 hours prior to the patient's discharge by the case manager.

In the same interview, the DCM stated Patient 30's record did not indicate Patient 30 was given the IMM letter since admission (5/6/24).

During an interview on 5/8/24 at 11:29 a.m., with the Patient Access Manager (PAM), the PAM stated the Admitting Department would be responsible in providing the IMM letter to the patient upon admission. The PAM stated Patient 30's record did not indicate Patient 30 was given the IMM letter on admission.

During a review of the facility's policy and procedure (P&P) titled, "Important Message from Medicare," revised in 1/2023, the P&P indicated, "The Important message must be provided to all inpatients within two days of their hospital admission."

Based on interview and record review, the facility failed to ensure for one of six sampled patients (Patients 29), Patient 29 and/or Patient 29's family member (FM) was provided and signed a consent form for blood transfusion and a consent form for right external ventricular catheter placement (EVD - a temporary method of draining cerebrospinal fluid from the ventricles in the brain) in the preferred written language as indicated in Patient 29's record.

This deficient practice resulted in Patient 29 and Patient 29's FM to not able to exercise the right to make informed decisions regarding her (Patients 29) care.

Findings:

During a record review of Patient 29's record, the "Intensive Care Unit Consultation Note," dated 5/5/24, the note indicated Patient 29 was admitted to the facility for subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain).

A review of Patient 29's document titled, "Condition of Admission, " the document was written in Spanish and was signed by Patient 29's FM on 5/5/24.

A review of Patient 29's "Blood Transfusion Consent," the consent was written in English and was signed by Patient 29's FM on 5/5/24.

A review of Patient 29's "Authorization For And Consent to Surgery Special Diagnostic or Therapeutic Procedures," the consent, for right EVD placement, was written in English and was signed by Patient 29's FM on 5/5/24.

During a concurrent interview and record review on 5/8/24 at 11:29 a.m., with the Patient Access Manager (PAM), the PAM verified Patient 29's record indicated, "Language: English (spoken), Spanish (written)." The PAM stated the preferred language for spoken and written language in Patient 29's record should be followed.

During an interview on 5/8/24 at 11:35 a.m., with Registered Nurse (RN) 2 and Registered Nurse (RN) 3, RN 2 stated she was the assigned RN for Patient 29. RN 2 stated she speaks English to Patient 29 and Patient 29's FM. RN 2 and RN 3 stated they were not aware Patient 29's record had a different preferred language for spoken and written.

In the same interview, RN 2 and RN 3 verified in Patient 29's record that the preferred written language was in Spanish. RN 3 stated the preferred written language in Patient 29 should have been followed. Patient 29 should have been provided documents written in Spanish.

During a review of the facility's policy and procedure (P&P) titled, "Consents," revised in 7/2018, the P&P indicated, "The consent form must either be in a language the patient can read and understand or be translated into the patient's preferred language for the patient by an approved translator..."

Based on interview and record review, the facility's failed to ensure nursing services provide a safety and guiding standard of care for nurses to screen and assess patients risk of self harm or suicide and implementing steps to protect the patient in accordance with the facility's policy and procedure (P&P).
These deficient practices resulted in nursing staff failing to establish a safe process to screen and properly assessed Patient 1, who eloped from the Emergency Department (ED) and was found dead 1 mile away from the facility by the police department. In addition, these deficient practices had the potential for other patients who come in the ED with risk of suicidal ideation to not be assessed appropriately and for appropriate safety intervention to not be implemented.

Findings:

During a concurrent interview and record review on 5/6/24 at 2:05 p.m. with Quality RN (QRN), the QRN statedPatient 1 arrived to the ED on 6/15/2022 at 15:03 p.m. by ambulance. Patient 1 with chief complaint of overdose with an unknown substance. Patient 1 noted to refuse to answer suicide ideation question, and there was no documentation of Patient 1 being on a 5150 hold, medical hold or a sitter during this ED admission.

During a record review of Patient 1 electronic medical record (EMR) and interview with Social Worker 1 (SW1) on 5/6/2024 at 2:41 p.m., the SW 1 stated she was made aware of Patient 1 who came in the ED on 6/15/2022 with a chief complaint of accidental overdose. Patient eloped before a SW 1 assessment was completed.

During a concurrent interview and record review on 5/7/24 at 11 a.m. with the Director of Emergency Department (DED). Patient 1's Columbia Suicide Severity Rating Scale (C-SSRS) screening on 6/15/22 at 1508, by the Triage Nurse, the C-SSRS question, "In the past month, have you wished you were dead or wished you could go to sleep and not wake up?" Patient 1's answer was "no (unsure)." The DED stated that the answer "unsure" of Patient 1 should be consider as a "yes" and Patient 1 should be positive for C-SSRS. The DED stated if a patient was screened positive for C-SSRS, the triage nurse will admit the patient in the ED and the assigned ED nurse should do a C-SSRS reassessment, behavior health assessment of the patient and the patient will have a 1:1 sitter for safety monitoring.

During a concurrent record review of the facility's course outline titled, "Suicide Prevention and Mitigation Plan - Suicide Risk Assessment" and interview with Emergency Department Educator (EDE) on 5/7/24 at 11:40 a.m., EDE concur that the course outline for nursing on suicide risk assessment does not include scenario if a patient is unable to participate in the screening process, or a nurse cannot get an answer of Yes or No from the patient when completing the C-SSRS Screener Tool (a reliable and valid risk assessment tool for determining risk level for suicide).

Based on interview and record review the facility failed to ensure the Condition of Participation for Quality Assurance Performance Improvement (QAPI) was met as evidenced by:

1. The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI, a process used to ensure services are meeting quality standards and assuring care reaches a certain level) department analyze and provide measurable data to track emergency department nursing staffs perform accuracy of answering Columbia Suicide Severity Rating Scales [(C-SSRS) screener tool for suicidal assessment] upon admission at Emergency Department (ED).

This deficient practice resulted in the facility's inability to assess and monitor its staff performance including accuracy of answering C-SSRS for a patient with suicidal ideation which led to Patient 1's elopement and found dead outside the facility (Refer to A- 0273).
2. The facility failed to perform a root cause analysis (RCA, a structured, facilitated team process to identify the root cause of an event that resulted in an undesired outcome) for accuracy of answering C-SSRS by staff and led to Patient 1's e elopement from the ED and death outside of the facility.

This deficient practice resulted in the facility's inability to identify potential system or process changes that could improve performance or patient safety and prevent any undesired outcome such as Patient 1's death or prevent harm and/or death to other patients who are admitted to the ED. (Refer to A- 0286)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment and potentially placing patients at risk of unable to identify patient has risk for suicide, thus compromising patient safety.

1. The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI, a process used to ensure services are meeting quality standards and assuring care reaches a certain level) department analyze and provide measurable data to track emergency department nursing staffs perform accuracy of answering Columbia Suicide Severity Rating Scales [(C-SSRS) screener tool for suicidal assessment] upon admission at the ED.
This deficient practice resulted in the facility's inability to assess and monitor its staff performance including accuracy of answering C-SSRS for patient with suicidal ideation, which led to Patient 1's elopement and death outside of the facility (Refer to A- 0273).

Findings:
During a review of Patient 1's History of Present illness (HPI) in ED provider note dated 6/15/22 at 3:07 p.m., the note indicated Patient 1 was brought in by medics from Patient 1's home, with chief complaint of overdose (accidental). There were several psychiatric medications found at Patient 1's home. Initially, Patient 1 was given intranasal Narcan, and then medics gave Patient 1 additional doses of IV Narcan in order to regain Patient 1's mental status and respiration. The medics reported Patient 1 made some statements concerning for possible intentional intent for overdose (OD). Patient 1 denies any drug use, but is evasive in his answering of questions.

During a review of Patient's 1 ED Triage note dated 6/15/22 at 3:06 p.m., Registered Nurse (RN 4) indicated the following: Patient 1 was brought in by Santa Monica Engine 5 for overdose (OD) on unknown substance. Patient 1 refusing to answer suicidal ideation questions. Unknown if ingested or injected. Patient 1 was given Narcan x 3 doses (one intranasal and two IV). Patient 1 was awake and responsive but still denies question.

During a review of Patient 1's Patient Care timeline in ED; dated 6/15/22 at 3:08 p.m., indicated that C-SSRS screening tool was performed by RN 4; C-SSRS number 1 question, " In the past month, have you wished you were dead or wished you could go to sleep and not wake up?". RN 4 answered "No (unsure)".

During an interview on 5/7/2024 at 10:00 a.m., with Director of Emergency Department (DED); stated that if patient did not answer C-SSRS or answer (unsure) or answer is not a definitely "No"; staff should treat the patient as positive for suicide ideation. Staff should immediately establish continuous visual observation with a contact observer per facility policy, observe patient for suicidal/self-harm behaviors and complete screening once patient is able to participate.

During a review of Patient 1's social worker (SW) note dated 6/15/22 at 5:53 p.m., indicated there is concern that Patient 1 did intentionally try to OD even though he stated otherwise. Patient 1 kept requiring Narcan while in the ED. Patient 1 would not communicate with staff. Patient 1 bolted from the ED smashing through the doors in the ambulatory bay and was seen running down 22nd street towards Wilshire. Santa Monica Police Department (PD) were called. SW spoke with the Patient 1's mother by phone. Patient 1's mother said she will try to convince the patient to return to the ED, but does not want to do anything that will hurt their relationship. SW expressed concern that Patient 1 may be suicidal and he needs to return to the ED.
During a review of Patient 1's Patient Care timeline in ED; dated 6/15/22 at 5:44 p.m., indicated Patient 1 was absent without leave (AWOL) around 5:40 p.m. with IV still in Patient's body. PD was notified.

During an interview on 5/9/2024 at 3:30 p.m. with the Director of Quality (DQ), stated she did not know Patient 1's eloped and death case until Patient 1's mother lawyer contact Providence attorney regarding the lawsuit. Patient 1's case was not escalated to perform a RCA. Suicidal screening is never brought up to QAPI meeting by ED manager.

During an interview on 5/9/2024 at 3:50 p.m. with Risk Management (RM), RM stated a verbal debrief about Patient 1's case; was reported everything was done correctly and no action plan required. RM clarified with security regarding the elopement, and there was no fall out in the process. Patient 1's death was presented in a leadership meeting hospital consult meeting. The risk management revisited the case in 2023 due to the hospital management received an intent to sue; however, no second RCA was performed to determine Patient 1's C- SSRS was not screened correctly by ED staff and no further safety precaution was implemented. Patient 1 eloped and died a mile away from the hospital.

During an interview on 5/9/2024 at 5:55 p.m., with DED, stated she was not aware there was any issue with ED staff conducting suicidal screenings until an onsite complaint validation survey. The ED staff suicidal screening topic was never brought to QAPI for discussion.

During an interview on 5/7/24 at 11:57 a.m., with Emergency Room Nurse (ERN); surveyor asked ERN if a patient is not able to answer the C- SSRS screening, what intervention should be done prior to patient being able to answer the question. ERN stated he did not know the answer to the question.

During a record review, there were 6 out of 24 patients (6, 7, 14, 15, 22 & 23) did not have C-SSRS completed during the ED visit.

During a concurrent review with sepsis coordinator (SC) of Patient 6's Patient Care timeline in ED on 5/8/24 1:50 p.m., indicated Patient 6 brought in by ambulance at 1:18 pm; found in car unresponsive by police; given Narcan intranasal 1 time; patient awoke. ED provider saw patient 6 at 1:22 p.m. ED provider indicated patient was eloped from emergency room prior to re-evaluation at 2:38 p.m. No C-RRSR screening tool was performed by ED nurse during the visit.

During a concurrent review with sepsis coordinator (SC) of Patient 7's Patient Care timeline in ED on 5/8/24 1:50 p.m, indicated Patient 7 brought in by ambulance at 1:18 pm; sent in for evaluation after mechanical fall on sidewalk, no loss of conscious or trauma; patient awoke. ED provider saw patient 7 at 4:03 p.m. ED provider indicated patient refused all treatment and declined x-ray for his lower back, patient 7 eloped ED at 5:11 p.m. No C-RRSR screening tool was performed by ED nurse during the visit.

During a concurrent record review of Patient 14's EMR (Electronic Medical Record) and interview with the Emergency Department Educator (EDE) on 5/8/24 at 10:30 a.m., the EDE stated Patient 14 was seen in the ED (Emergency Department) on 2/4/24 for Overdose (OD - is the ingestion or application of a drug or other substance in quantities much greater than are recommended) Accidental. There are no records that a C-SSRS Screener Tool (a reliable and valid risk assessment tool for determining risk level for suicide) was completed for patient 14. EDE stated that all patient with a chief complaint or diagnosis of OD should have a C-SSRS Screener Tool completed by a nurse.

During a concurrent record review of Patient 15's EMR (Electronic Medical Record) and interview with the Emergency Department Educator (EDE) on 5/8/24 at 10:30 a.m., the EDE stated Patient 15 was seen in the ED (Emergency Department) on 2/2/24 for Overdose (OD - is the ingestion or application of a drug or other substance in quantities much greater than are recommended) Accidental. There are no records that a C-SSRS Screener Tool (a reliable and valid risk assessment tool for determining risk level for suicide) was completed for Patient 15.

During a concurrent record review of Patient 22's EMR (Electronic Medical Record) and interview with the Emergency Department Educator (EDE) on 5/8/24 at 1:54 p.m., the EDE stated Patient 22 was seen in the ED (Emergency Department) on 3/11/24 for Overdose (OD - is the ingestion or application of a drug or other substance in quantities much greater than are recommended) Accidental. There are no records that a C-SSRS Screener Tool (a reliable and valid risk assessment tool for determining risk level for suicide) was completed for Patient 22.

During a concurrent record review of Patient 22's EMR (Electronic Medical Record) and interview with the Emergency Department Educator (EDE) on 5/8/24 at 1:54 p.m., the EDE stated that Patient 23 was seen in the ED (Emergency Department) on 4/12/24 for Overdose (OD - is the ingestion or application of a drug or other substance in quantities much greater than are recommended) Accidental. There are no records that a C-SSRS Screener Tool (a reliable and valid risk assessment tool for determining risk level for suicide) was completed for Patient 23.

During a record review of the facility's policy and procedure (P&P) titled, "Suicide Risk Assessment and Prevention," approved 10/2020; indicated C-SSRS Risk assessment tool is completed by ministry designated personnel. If the patient is unable to participate in the screening process, observe patient for suicidal/self-harm behaviors and complete screening once patient is able to participate. If the C-SSRS Screener tool is positive or the patient tis expressing suicidal thoughts or exhibits self-harm behaviors, take the following initial steps: a) Immediately establish continuous visual observation with a constant observer per Constance Observer ...d) Ministry designated caregiver completes he C-SSRS risk assessment tool. Interventions maybe modified/implemented based on risk stratification level .....

During a record review of the facility's Quality Assurance & Performance Improvement (QAPI) and Patient Safety Plan 2021 - 2026, indicated, "An important aspect of improving organization performance and patient safety is to effectively implement evidence-based practice and reducing variation and non-value-added processes that contribute to unanticipated adverse patient safety events and/or outcomes. To accomplish this, Providence has committed to becoming a High Reliability Organization (HRO) through the adoption of its Our Caring Way program's evidence-based practices, behaviors, and utilization of the continuous process improvement model to ensure processes are designed for safety.

The facility failed to perform a root cause analysis (RCA, a structured, facilitated team process to identify the root cause of an event that resulted in an undesired outcome) that accuracy of answering C-SSRS by staff and led to Patient 1's elopement from the ED and f death outside of the facility.

This deficient practice resulted in the facility's inability to identify potential system or process changes that could improve performance or patient safety and prevent any undesired outcome such as Patient 1's death or prevent harm and/or death to other patients who are admitted to the ED. (Refer to A- 0286)

Findings:

During a review of Patient 1's History of Present illness (HPI) in ED provider note dated 6/15/22 at 3:07 p.m., the note indicated Patient 1 was brought in by medics from Patient 1's home, with chief complaint of overdose (accidental). There were several psychiatric medications found at Patient 1's home. Initially, Patient 1 was given intranasal Narcan, and then medics gave Patient 1 additional doses of IV Narcan in order to regain Patient 1's mental status and respiration. The medics reported Patient 1 made some statements concerning for possible intentional intent for overdose (OD). Patient 1 denies any drug use, but is evasive in his answering of questions.

During a review of Patient's 1 ED Triage note dated 6/15/22 at 3:06 p.m., Registered Nurse (RN 4) indicated the following: Patient 1 was brought in by Santa Monica Engine 5 for overdose (OD) on unknown substance. Patient 1 refusing to answer suicidal ideation questions. Unknown if ingested or injected. Patient 1 was given Narcan x 3 doses (one intranasal and two IV). Patient 1 was awake and responsive but still denies question.

During a review of Patient 1's Patient Care timeline in ED; dated 6/15/22 at 3:08 p.m., indicated that C-SSRS screening tool was performed by RN 4; C-SSRS number 1 question, " In the past month, have you wished you were dead or wished you could go to sleep and not wake up?". RN 4 answered "No (unsure)".

During an interview on 5/7/2024 at 10:00 a.m., with Director of Emergency Department (DED); stated that if patient did not answer C-SSRS or answer (unsure) or answer is not a definitely "No"; staff should treat the patient as positive for suicide ideation. Staff should immediately establish continuous visual observation with a contact observer per facility policy, observe patient for suicidal/self-harm behaviors and complete screening once patient is able to participate.

During a review of Patient 1's social worker (SW) note dated 6/15/22 at 5:53 p.m., indicated there is concern that Patient 1 did intentionally try to OD even though he stated otherwise. Patient 1 kept requiring Narcan while in the ED. Patient 1 would not communicate with staff. Patient 1 bolted from the ED smashing through the doors in the ambulatory bay and was seen running down 22nd street towards Wilshire. Santa Monica Police Department (PD) were called. SW spoke with the Patient 1's mother by phone. Patient 1's mother said she will try to convince the patient to return to the ED, but does not want to do anything that will hurt their relationship. SW expressed concern that Patient 1 may be suicidal and he needs to return to the ED.
During a review of Patient 1's Patient Care timeline in ED; dated 6/15/22 at 5:44 p.m., indicated Patient 1 was absent without leave (AWOL) around 5:40 p.m. with IV still in Patient's body. PD was notified.

During an interview on 5/9/2024 at 3:30 p.m. with the Director of Quality (DQ), stated she did not know Patient 1's eloped and death case until Patient 1's mother lawyer contact Providence attorney regarding the lawsuit. Patient 1's case was not escalated to perform a RCA. Suicidal screening is never brought up to QAPI meeting by ED manager.

During an interview on 5/9/2024 at 3:50 p.m. with Risk Management (RM), RM stated a verbal debrief about Patient 1's case; was reported everything was done correctly and no action plan required. RM clarified with security regarding the elopement, and there was no fall out in the process. Patient 1's death was presented in a leadership meeting hospital consult meeting. The risk management revisited the case in 2023 due to the hospital management received an intent to sue; however, no second RCA was performed to determine Patient 1's C- SSRS was not screened correctly by ED staff and no further safety precaution was implemented. Patient 1 eloped and died a mile away from the hospital.

During an interview on 5/9/2024 at 5:55 p.m., with DED, stated she was not aware there was any issue with ED staff conducting suicidal screenings until an onsite complaint validation survey. The ED staff suicidal screening topic was never brought to QAPI for discussion.

During an interview on 5/7/24 at 11:57 a.m., with Emergency Room Nurse (ERN); surveyor asked ERN if a patient is not able to answer the C- SSRS screening, what intervention should be done prior to patient being able to answer the question. ERN stated he did not know the answer to the question.

During a record review, there were 6 out of 24 patients (6, 7, 14, 15, 22 & 23) did not have C-SSRS completed during the ED visit.

During a concurrent review with sepsis coordinator (SC) of Patient 6's Patient Care timeline in ED on 5/8/24 1:50 p.m., indicated Patient 6 brought in by ambulance at 1:18 pm; found in car unresponsive by police; given Narcan intranasal 1 time; patient awoke. ED provider saw patient 6 at 1:22 p.m. ED provider indicated patient was eloped from emergency room prior to re-evaluation at 2:38 p.m. No C-RRSR screening tool was performed by ED nurse during the visit.

During a concurrent review with sepsis coordinator (SC) of Patient 7's Patient Care timeline in ED on 5/8/24 1:50 p.m, indicated Patient 7 brought in by ambulance at 1:18 pm; sent in for evaluation after mechanical fall on sidewalk, no loss of conscious or trauma; patient awoke. ED provider saw patient 7 at 4:03 p.m. ED provider indicated patient refused all treatment and declined x-ray for his lower back, patient 7 eloped ED at 5:11 p.m. No C-RRSR screening tool was performed by ED nurse during the visit.

During a concurrent record review of Patient 14's EMR (Electronic Medical Record) and interview with the Emergency Department Educator (EDE) on 5/8/24 at 10:30 a.m., the EDE stated Patient 14 was seen in the ED (Emergency Department) on 2/4/24 for Overdose (OD - is the ingestion or application of a drug or other substance in quantities much greater than are recommended) Accidental. There are no records that a C-SSRS Screener Tool (a reliable and valid risk assessment tool for determining risk level for suicide) was completed for patient 14. EDE stated that all patient with a chief complaint or diagnosis of OD should have a C-SSRS Screener Tool completed by a nurse.

During a concurrent record review of Patient 15's EMR (Electronic Medical Record) and interview with the Emergency Department Educator (EDE) on 5/8/24 at 10:30 a.m., the EDE stated Patient 15 was seen in the ED (Emergency Department) on 2/2/24 for Overdose (OD - is the ingestion or application of a drug or other substance in quantities much greater than are recommended) Accidental. There are no records that a C-SSRS Screener Tool (a reliable and valid risk assessment tool for determining risk level for suicide) was completed for Patient 15.

During a concurrent record review of Patient 22's EMR (Electronic Medical Record) and interview with the Emergency Department Educator (EDE) on 5/8/24 at 1:54 p.m., the EDE stated Patient 22 was seen in the ED (Emergency Department) on 3/11/24 for Overdose (OD - is the ingestion or application of a drug or other substance in quantities much greater than are recommended) Accidental. There are no records that a C-SSRS Screener Tool (a reliable and valid risk assessment tool for determining risk level for suicide) was completed for Patient 22.

During a concurrent record review of Patient 22's EMR (Electronic Medical Record) and interview with the Emergency Department Educator (EDE) on 5/8/24 at 1:54 p.m., the EDE stated that Patient 23 was seen in the ED (Emergency Department) on 4/12/24 for Overdose (OD - is the ingestion or application of a drug or other substance in quantities much greater than are recommended) Accidental. There are no records that a C-SSRS Screener Tool (a reliable and valid risk assessment tool for determining risk level for suicide) was completed for Patient 23.

During a record review of the facility's policy and procedure (P&P) titled, "Suicide Risk Assessment and Prevention," approved 10/2020; indicated C-SSRS Risk assessment tool is completed by ministry designated personnel. If the patient is unable to participate in the screening process, observe patient for suicidal/self-harm behaviors and complete screening once patient is able to participate. If the C-SSRS Screener tool is positive or the patient tis expressing suicidal thoughts or exhibits self-harm behaviors, take the following initial steps: a) Immediately establish continuous visual observation with a constant observer per Constance Observer ...d) Ministry designated caregiver completes he C-SSRS risk assessment tool. Interventions maybe modified/implemented based on risk stratification level ....

During a record review of the facility's Quality Assurance & Performance Improvement (QAPI) and Patient Safety Plan 2021 - 2026, indicated, "An important aspect of improving organization performance and patient safety is to effectively implement evidence-based practice and reducing variation and non-value-added processes that contribute to unanticipated adverse patient safety events and/or outcomes. To accomplish this, Providence has committed to becoming a High Reliability Organization (HRO) through the adoption of its Our Caring Way program's evidence-based practices, behaviors, and utilization of the continuous process improvement model to ensure processes are designed for safety.

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

1. One of four sampled patients (Patient 30), Patient 30's Pasero Opiod-Induced Sedation Scale (POSS - a tool use to assess the sedation level of patients receiving opiod medications) was completed with each dose of Dilaudid (an opiod, pain medication) as ordered by the physician. This deficient practice had the potential to cause adverse health outcomes which could negatively affect Patient 30's health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death of the patient. (Refer to A-0395)

2. One of four sampled patients (Patient 30) had a comprehensive care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) developed upon admission to address Patient 30's speech deficit as a result from his (Patient 30) surgery. This deficient practice had the potential to result in the delayed provision of care to the patient (Patient 30) by not identifying Patient 30's needs and risks. (Refer to A-0396)

3. One of six sampled patients (Patient 28), the facility's policy and procedure (P&P) for Transmission-based Precautions (are additional precaution used for patients with suspected or known transmissible infection to help prevent the spread of infection) was implemented when, Certified Nursing Assistant (CNA) 1 was observed inside Patient 28's room, who was on contact isolation, not wearing proper personal protective equipment (PPE, equipment worn to minimize exposure to illness, includes gown, gloves, mask, face shield) while taking care of Patient 28. This deficient practice had the potential for the introduction of pathogens (a microorganisms such as bacteria or virus that can cause a disease process) from CNA 1 not wearing proper PPE and the potential for risk of transmission of microorganism to other patients in the same unit or hospital setting. (Refer to A-0398)

4. One of 30 sampled patients (Patients 28), Zosyn (antibiotic medication) was administered as ordered by the physician. This deficient practice resulted in delay of treatment and had the potential to cause adverse health outcomes which could negatively affect Patients 28 and 30's health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death. (Refer to A-405)

5. One of 30 sampled patients (Patient 30), Dilaudid (narcotic pain medication) was administered as ordered by the physician. This deficient practice resulted in delay of treatment and had the potential to cause adverse health outcomes which could negatively affect Patients 28 and 30's health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death. (Refer to A-405)

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

Based on interview and record review, the facility failed to ensure for one of four sampled patients (Patient 30), Patient 30's Pasero Opiod-Induced Sedation Scale (POSS - a tool use to assess the sedation level of patients receiving opiod medications) was completed with each dose of Dilaudid (an opiod, pain medication) as ordered by the physician.

This deficient practice had the potential to cause adverse health outcomes which could negatively affect Patient 30's health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death of the patient.

Findings:

During a record review of Patient 30's record, the "Speech and Language Pathologist Initial Evaluation," dated 5/7/24, the evaluation indicated Patient 30 was admitted to the facility on 5/6/2024, status post laryngectomy (surgical removal of the larynx [voice box]) right neck dissection left anterolateral thigh free flap (reconstructive surgery technique that involves transfer of skin from one body area to another).

During a review of Patient 30's "Medication Order," dated 5/6/24, the order indicated to administer Dilaudid 0.2 to 0.4 milligram (mg) intravenous (IV - through the vein) every 2 hours as needed (PRN) for pain. The order further indicated, "If dose range is ordered, then first dose must be the lowest dose. Titrate to effective dose by repeat of lowest dose every 30 minutes PRN pain...Use Pasero Sedation Scale (POSS)..."

During a review of Patient 1's "Medication Administration Record (MAR)" the MAR indicated Patient 1 was administered Dilaudid IV on the following dates and times:

- On 5/6/24 at 10:59 p.m., Dilaudid 0.2 mg IV was given;

- On 5/6/24 at 11:47 p.m., Dilaudid 0.2 mg IV was given;

- On 5/7/24 at 2:24 a.m., Dilaudid 0.2 mg IV was given;

- On 5/7/24 at 6:27 a.m., Dilaudid 0.2 mg IV was given;

- On 5/7/24 at 7:31 a.m., Dilaudid 0.2 mg IV was given;

- On 5/7/24 at 10:12 a.m., Dilaudid 0.4 mg IV was given;

- On 5/7/24 at 12:56 p.m., Dilaudid 0.4 mg IV was given;

- On 5/7/24 at 5:46 p.m., Dilaudid 0.4 mg IV was given;

- On 5/7/24 at 10:48 p.m., Dilaudid 0.4 mg IV was given;

- On 5/8/24 at 2:57 a.m., Dilaudid 0.4 mg IV was given;

- On 5/8/24 at 6:53 a.m., Dilaudid 0.4 mg IV was given;

- On 5/8/24 at 1:20 p.m., Dilaudid 0.4 mg IV was given; and,

- On 5/8/24 at 7:14 p.m., Dilaudid 0.4 mg IV was given.

There was no documented evidence Patient 1's POSS was completed with each dose of Dilaudid. These lack of documentation was verified by the Medication Safety Officer (MSO).

During an interview on 5/9/24 at 11:43 a.m., with the MSO, the MSO stated when a patient received opiod medication, it is important to do the POSS with each dose to assess the patient's sedation level. The MSO stated the patient's POSS assessment would help ensure medication safety on the effect of the opiod to the patient and if dose adjustment or discontinuation of the opiod medication is needed.

In the same interview, the MSO stated Patient 1 should have a POSS completed with each dose of Dilaudid, as indicated in the physician's order, to monitor Patient 1's sedation level from the use of the opiod medication.

During a review of the facility's policy and procedure (P&P) titled, "Pasero Opiod-induced Sedation Scale," revised in 4/2021, the P&P indicated the following:

- The Pasero Opiod-induced Sedation Scale (POSS) may be used to assess opiod related sedation and guide care.

- The nurse interacts with the patient and determines the level of sedation based on the scale's descriptions of patient arousal.

- Associated with each level are suggested nursing measures for the ongoing care of the patient.

- Document the POSS score and any interventions required in the electronic medical record.

Based on observation, interview, and record review, the facility failed to ensure for one of four sampled patients (Patient 30) had a comprehensive care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) developed upon admission to address Patient 30's speech deficit as a result from his (Patient 30) surgery.

This deficient practice had the potential to result in the delayed provision of care to the patient (Patient 30) by not identifying Patient 30's needs and risks.

Findings:

During an observation on 5/8/24 at 11 a.m., Patient 30 was observed in his room, lying in bed, alert and awake. Patient 30 had a tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea from the outside of the neck). The Registered Nurse (RN) at the bedside stated Patient 30 was not able to speak and communicate through writing on the white board or by gesture. Patient 30 made a sign with his hand indicating he did not want to participate and subsequently left the patient's room. From outside Patient 30's room, Patient 30 was observed to be gesturing a sign to the RN while the RN was trying to guess what Patient 30 wanted.

During a record review of Patient 30's record, the "Speech and Language Pathologist (SLP) Initial Evaluation," dated 5/7/24, the SLP evaluation indicated Patient 30 was admitted to the facility on 5/6/2024, status post laryngectomy (surgical removal of the larynx [voice box]) right neck dissection left anterolateral thigh free flap (reconstructive surgery technique that involves transfer of skin from one body area to another).

The SLP evaluation further indicated Patient 30's current communication was via writing and gestures.

There was no documented evidence a care plan for Patient 30's speech deficit and communication needs were developed. This lack of documentation was verified by Quality Registered Nurse (QRN) 2.

During an interview on 5/9/24 at 11:24 a.m., with QRN 2, QRN 2 stated it is important to developed a care plan for Patient 30 addressing the patient's speech deficit and communication needs. The care plan would ensure continuation of quality care and the staff would be consistent in addressing Patient 30's needs.

During a review of the facility's policy and procedure (P&P) titled, "Plan of Care," revised in 7/2021, the P&P indicated the following:

- The Registered Nurse (RN) is accountable to assure the development of a patient-centric, interprofessional individualized plan of care.

- Developing the Patient's Plan of Care...Determine specific patient goals, preferences and care needs that require intervention (including, but not limited to language, communication, cultural practices, health beliefs and/or spiritual practices).

Based on observation, interview, and record review, the facility failed to ensure for one of six sampled patients (Patient 28), the facility's policy and procedure (P&P) for Transmission-based Precautions (are additional precaution used for patients with suspected or known transmissible infection to help prevent the spread of infection) was implemented when, Certified Nursing Assistant (CNA) 1 was observed inside Patient 28's room, who was on contact isolation, not wearing proper personal protective equipment (PPE, equipment worn to minimize exposure to illness, includes gown, gloves, mask, face shield) while taking care of Patient 28.

This deficient practice had the potential for the introduction of pathogens (a microorganisms such as bacteria or virus that can cause a disease process) from CNA 1 not wearing proper PPE and the potential for risk of transmission of microorganism to other patients in the same unit or hospital setting.

Findings:

During a concurrent observation and interview on 5/6/2 at 1:37 p.m., with Nurse Manager (NM) 1, Patient 28's room was observed to have an isolation sign at the patient's (Patient 28) door and an isolation cart outside the patient's room. NM 1 stated Patient 28 was on contact isolation. Subsequently, CNA 1 was observed to entered Patient 28's room, wearing a face mask and closed the patient's door. CNA 1 was not observed donning (putting on) proper PPE before entering Patient 28's room.

In the same observation and interview, NM 1 asked CNA 1 to step out of Patient 28's room. CNA 1 stated she was aware Patient 28 was on contact isolation. CNA 1 stated she was aware that she needed to don proper PPE (gown and gloves) before entering Patient 28's room. CNA 1 stated she rushed going inside the patient's room to assist Patient 28 and she did not have time to wear her PPE.

During an interview on 5/6/24 at 1:40 p.m., with Registered Nurse (RN) 1, RN 1 stated she was the assigned RN for Patient 28. RN 1 stated Patient 28 was on contact isolation for Methicillin-resistant Staphylococcus aureus (MRSA - a type of bacterial infection) of the sputum. RN 1 stated it is important to wear proper PPE before entering the patient's room, on isolation, to help protect from the infection and prevent the spread of infection to the other patients in the unit.

In the same interview, RN 1 stated part of PPE when entering Patient 28's room was to wear a face shield because Patient 28 was confused and had an incident of spitting on the staff.

During a follow-up observation on 5/6/24 at 1:42 p.m., NM 1 asked CNA 1, who was inside Patient 28's room, where was her (CNA 1) face shield. CNA 1 told NM 1 that it was hanging at the isolation cart outside Patient 28's room. NM 1 observed to picked up a face shield with CNA 1's name written on it and hand it to CNA 1, CNA 1 wore the face shield.

During a review of Patient 28's "Hospitalist History and Physical (H&P)," dated 4/24/24, the H&P indicated Patient 28 was admitted to the facility with a chief complaint of weakness. .

During a review of physician's order, dated 5/4/24, the order indicated Patient 28 was on contact isolation for Acinetobacter calcoacaticus-baumannii (type of infection) in the sputum.

During a review of Patient 28's "Progress Notes," dated 5/2/24 at 5:12 p.m., authored by the chaplain, the note indicated the sitter reported that Patient 28 spit on her (sitter).

During a review of Patient 28's nursing notes, dated 5/2/24 at 6:48 p.m., the note indicated Patient 28 was uncooperative with care, refusing medication and spit on the sitter.

During a review of the facility's P&P titled, "Standard Precautions & (and) Transmission-Based Precautions," revised in 12/2022, the P&P indicated the following:

- Use Contact Precaution...For patients known or suspected to be infected or colonized with epidemiologically important/significant microorganisms that can be transmitted by direct/indirect contact with the patient or with environmental surfaces or patient care items in the patient's environment.

- Caregiver Protection and Personal Protective Equipment (PPE). In addition to Standard Precautions, wear gloves and gown with 360-degree coverage when there is a risk of self or clothing having direct contact with the patient, potentially contaminated environmental surfaces or items.

- Don PPE when entering a patient's room based on the anticipated interaction with the patient or their environment.

Based on interview and record review, the facility failed to ensure for two of 30 sampled patients (Patients 28 and 30) the following:

1. Patient 28's Zosyn (antibiotic medication) was administered as ordered by the physician; and

2. Patient 30's Dilaudid (narcotic pain medication) was administered as ordered by the physician.

These deficient practices resulted in delay of treatment and had the potential to cause adverse health outcomes which could negatively affect Patients 28 and 30's health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death.

Findings:

1. During a review of Patient 28's "Hospitalist History and Physical (H&P)," dated 4/24/24, the H&P indicated Patient 28 was admitted to the facility with a chief complaint of weakness and was assessed to have severe sepsis (a life threatening complication of an infection) and suspected pneumonia (infection of the lungs).

During a review of Patient 28's "Medication Order," dated 4/24/24, the order indicated Zosyn 3.375 gram (g) to be given intravenous (IV - through the veins) every 8 hours at the rate of 25 milliliter / hour (ml/hr) over 4 hours.

The Zosyn order further indicated Patient 28 was administered Zosyn 3.375 g IV on the following dates and times:

- On 4/24/24 at 5:53 p.m., the next dose was on 4/25/24 at 3:26 a.m. (9 hours and 30 minutes from the last dose);

- On 4/28/24 at 12:04 a.m., the next dose was on 4/28/24 at 10:17 a.m. (10 hours from the last dose);

- On 4/29/24 at 11:59 p.m., the next dose was on 4/30/29 at 9:29 a.m. (9 hours and 30 minutes from the last dose);

- On 4/30/24 at 11:30 p.m., the next dose was on 5/1/24 at 9 a.m. (9 hours and 30 minutes from the last dose);

- On 5/4/24 at 8:07 a.m., the next dose was on 5/4/24 at 6:04 p.m. (10 hours from the last dose).

During an interview on 5/8/24 at 2:30 p.m., with the Quality Registered Nurse (QRN) 2, QRN 2 stated Patient 28's record review was accurate.

In the same interview, QRN 2 stated Patient 28's Zosyn 3.375 g IV every 8 hours was not given as ordered by the physician. QRN 2 stated antibiotics should be given on time for effective treatment of the patient's infection.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," revised in 7/2023, the P&P indicated, "Time Critical - Medications are to be administered within 30 minutes before or after the scheduled time: antibiotics..."

2. During a record review of Patient 30's record, the "Speech and Language Pathologist Initial Evaluation," dated 5/7/24, the evaluation indicated Patient 30 was admitted to the facility on 5/6/2024, status post laryngectomy (surgical removal of the larynx [voice box]) right neck dissection left anterolateral thigh free flap (reconstructive surgery technique that involves transfer of skin from one body area to another).

During a review of Patient 30's "Medication Order," dated 5/6/24, the order indicated to administer Dilaudid 0.2 to 0.4 milligram (mg) intravenous (IV - through the vein) every 2 hours as needed (PRN) for pain. The order further indicated, "If dose range is ordered, then first dose must be the lowest dose. Titrate to effective dose by repeat of lowest dose every 30 minutes PRN pain...Use Pasero Sedation Scale (POSS)..."

During a review of Patient 1's "Medication Administration Record (MAR)" the MAR indicated Patient 1 was administered Dilaudid IV on the following dates and times:

- On 5/7/24 at 2:24 a.m., Dilaudid 0.2 mg IV was given.

Patient 30's corresponding pain assessment on 5/7/24 at 2 a.m., indicated a pain score of 0 (0, means no pain) and on 5/7/24 at 2:54 a.m., indicated Patient 30 was "sleeping;" and,

- On 5/7/24 at 6:27 a.m., Dilaudid 0.2 mg IV was given.

There was no documented evidence Patient 30's pain was assessed when Dilaudid was given on 5/7/24 at 6:27 a.m.

This lack of documentation was verified by the Medication Safety Officer (MSO).

During an interview on 5/9/24 at 2 p.m., with the MSO, the MSO stated Patient 30's record review was accurate. The MSO stated Patient 30 should have not given Dilaudid on 5/7/24 at 2 a.m., since the patient's (Patient 30) pain score was 0 and does not warrant a Dilaudid dose.

During an interview on 5/9/24 at 2 p.m., with QRN 2, QRN 2 stated Patient 30 did not have a pain assessment when Dilaudid was given on 5/7/24 at 6:27 a.m. QRN 2 stated the patient pain should be assessed prior to administering pain medication to ensure the patient received the correct dose of pain medication.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," revised in 7/2023, the P&P indicated, "Medication Administration Requirements - General...Verifying patient identification and medication to be administered is accomplished by the following...Administer the medication as directed..."