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A. Based on record review, video monitoring review, policy review and staff interview it was determined the hospital failed to ensure that all patients were given care in a safe setting and that patients remained free from death as evidenced by a Unit 2 West Behavior Health Technician and Charge Nurse who failed to follow physician orders and hospital policy for conducting ten (10) minute patient safety checks on nine (9) patients of ten (10) patients (patients #1, 2, 4, 5, 6, 7, 8, 9 and 10) (See A-0144).

B. Based on record review, video monitoring review, policy review, and staff interview it was determined the hospital failed to ensure all patients were given care in a safe setting by ensuring all Registered Nurses involved in a cardiopulmonary resuscitation (CPR) event was competent to use life saving medical equipment needed during a code blue in one (1) of one (1) patients that required CPR as required by policy (patient #1) (See A-0144).

A. Based on record review, video monitoring review, policy review, and staff interview it was determined the 2 West, Registered Nurse (RN) #1 and Behavior Health Technician (BHT) #1 failed to follow physician orders and hospital expectations on every ten (10) minute patient safety checks to be completed on nine (9) of ten (10) patients (patients #1, 2, 4, 5, 6, 7, 8, 9 and 10). This failure has the potential for all patients to have the ability to stop breathing and not receive immediate emergency care.

1. Review of the medical record for patient #1, revealed on 01/06/18 at 1:30 a.m. an order was written for every ten (10) minute observations by Doctor #1.

2. Review of the medical record, the checksheet titled "BHT 10 Observation Record" for patients #1, #2, #4, #5, #6, #7, #8, #9, #10, revealed all ten (10) minute safety checks had been completed on 01/07/18, from 9:00 p.m. to 11:30 p.m.

3. Review of video monitoring on 01/15/18 at 9:27 a.m. and on 01/17/18 at 8:45 a.m. in the presence of the Director of Quality of the 2 West hallway revealed no ten (10) minute safety checks had been completed on patients #1, 2, 4, 5, 6, 7, 8, 9 and 10 from 9:00 p.m. to 11:30 p.m. with the exception of patient #1. At 8:58 p.m. patient #1 went to a hallway bathroom and then returned to his room at 9:02:30 p.m. and at the 10:02 p.m. check patient #1 was found by RN #1 not breathing.

4. Review of the policy titled "Levels of Observation" with a last review date of 01/18/16, states in part, "An order for the appropriate level of observation and precautions should be documented in the medical record and the rounds sheets should be initiated...A physician's order is required to decrease or increase observation levels."

5. An interview was conducted on 01/15/18 at 2:20 p.m. with BHT #1. When asked to explain the frequency of safety checks on patients on 2 West she stated in part, "Checks are every 10 minutes." When asked who completed safety checks on 01/07/18, before, during, and after the code blue on patient #1, she stated in part, "I did, I helped in the code by cleaning the boy's mouth and nose with his sheet and then I left when the code team arrived and did my hallway checks." When asked when completing a safety check if it was considered adequate to view the patient from the hallway by looking through the patient's window she stated in part, "Yes, I look to see if the covers are moving up and down."

6. An interview was conducted on 01/15/18 at 10:00 a.m. with the Director of Quality during review of the hallway video monitoring. When asked if she saw any safety checks completed on the patients and what the expectation of a safety check is she stated in part, "The expectation is they wouldn't look from the window, they would go into the room to ensure the patient was breathing, color was good and the patient was all right." She concurred with the above findings.

B. Based on record review, video monitoring, policy review and staff interview it was determined registered nurses (RN) #1, 2, 3 and 4 and Licensed Practical Nurse (LPN) #1 failed to provide competent use of medical equipment needed for cardio-pulmonary resuscitation (CPR) in one (1) of one (1) patient who required CPR (patient #1). This failure has the potential for all patients who require CPR to result in a poor outcome.

1. Review of the medical record for patient #1 revealed there was no code sheet in the medical record.

2. Review of the video monitoring on 01/15/18 at 9:27 a.m. and on 01/17/18 at 8:45 a.m. in the presence of the Director of Quality of the 2 West hallway revealed on 10:01 p.m. RN #1, entered patient #1's room, 260 A, and then came into the hallway. Behavior Health Technician (BHT) #1 entered the room with RN #1. BHT #4 was sitting on close constant observation in room 252-A and ran to the nurse's station, made a phone call and went back to her close constant observation. At 10:05:24 p.m. BHT #2, arrived from another unit and went into room 260-A and immediately ran to the nursing station and returned to the room at 10:06:27 p.m. with a suction machine and an Automated External Defibrillator (AED). At 10:07:33 p.m. the BHT can be seen moving her arms in the hallway and the code team started to run. LPN #1, RN #2 and #3 went into room 260. The rest of the code team remained in the hallway. At 10:08:38, RN #4 entered room 260 and LPN #1 left the room and returned at 10:09:07 p.m. with an oxygen tank which was taken into the room. At 10:13:37 p.m. the emergency squad entered the patient's room. At 10:13:50 p.m. one member of the emergency squad left the unit and returned at 10:15:27 p.m. with a backboard. At 10:17:17 p.m. the emergency squad left with the patient while continuing chest compressions.

3. Review of the county com log sheet revealed that 911 was notified of emergency assistance at 10:08 p.m.

4. Review of the policy titled "CPR" with a last revised date of 09/01/16 states in part, "If patient is unresponsive, 1st responder calls for help noting the time and initiating CPR using pocket mask/barrier device. Instruct staff member to announce code blue, telephone 911 for emergency medical services. Instruct staff to bring ABC boc and obtain a disposable mouth barrier and/or ambu bag...All additional staff will take and record vital signs...time code called...Nursing staff members not involved in the code blue will have the responsibility for assisting in keeping area clear and attending the needs of other patients."

5. Review of the policy titled "Code Blue Response" with a last revised date of 05/02/16 states in part, "Equipment for basic airway restoration and support and an AED which is located on each unit."

6. Review of the policy titled "Provision of Emergency Services" states in part, "Call 911 for all medical emergencies needed...CPR is initiated as appropriate...Obtain emergency cart with available supplies."

7. Review of the policy titled "AED" with a last review date of 11-08-14, states in part, "The AED in conjunction with cardio-pulmonary resuscitation (CPR), is to be used...when a cardiac emergency occurs...Nurse will bring the AED to the emergency site...When a cardiac emergency occurs, the doctor on call, assistant NE, House Supervisor, and Registered Nurses who have been trained and certified AED/CPR instructor will utilize the AED and begin CPR."

8. Review of personal files for RN's #1, 2 and 3 and LPN #1 revealed all CPR cards are up to date and all annual hospital training on CPR and Codes were up-to-date."

9. An interview was conducted with BHT #2 on 01/15/18 at 11:30 a.m. When asked to explain how she came to be involved in the code blue and to explain what occurred during the code she states in part, "Well I was working 1C and a code blue was called so I ran up the back stairs and went into the room. The nurse had the patient on the floor and was doing chest compressions. Stuff was coming out of his nose and mouth and he was gray all over except his feet, they looked a pink color. No one was coming so we called a code blue assist and I brought the suction, ambu bag and AED into the room. When I was walking into the room people were walking down the hall and I asked them to hurry up and they ran. Someone yelled has anyone called 911 and no one had so someone else ran and called 911. The suction wouldn't work and the little boy kept vomiting up red and brown stuff and it kept coming out his nose. No one could get it to work. So we went to get another one from another unit. That one wouldn't work either. They couldn't get the mask to work either, they couldn't get a good fit. It wouldn't give him a breath. The nurses kept trading off with chest compressions. They tried the ambu bag, a pocket mask and we carry throw away masks and they wouldn't work either. One nurse from another unit came in and even tried to use plastic she found on the floor to provide mouth-to mouth. The supervisor finally wiped his mouth and did mouth to mouth and he got a breath and then the emergency squad came." When asked if the patient ever had vital signs taken, AED connected, oxygen used or if the suction machine ever worked she stated in part, "No one did vital signs, no the AED never was used, I don't know about the oxygen but neither suction machine worked."

10. An interview was conducted with RN #2 on 01/15/18 at 12:15 p.m. When asked if she remembered the night of 01/07/18 and a code blue being called and if so to explain what happened during the code. She states in part, "A code blue was called to 2 West the child/adolescent unit and we thought it was a mistake and that it was a code gray so I was on my way and they called for a code blue assist and we still thought they meant a code gray. I went in to the room and the nurse had the patient on the floor doing compressions and I asked if she needed a break and I tried to clear his airway with my fingers because the suction wasn't working he had thick mucus, dark brown that smelled like stool. He was a grayish, purplish blue and had no pulse or respirations. The nurses kept relieving each other with chest compressions." When asked why suction wouldn't work she stated, "We heard later the cap wasn't removed."

11. An interview was conducted on 01/15/18 at 12:30 p.m. with LPN #1. When asked if she could explain the code blue for patient #1 she stated in part, "I was in the room with the patient and did chest compressions. I came from my unit when the code was called. The patient was on the floor by the bed. Someone yelled they needed oxygen and the little mask. I gave them a plastic mask a BHT had. The suction wasn't working and we had someone run and get a BHT to go to another unit to get another suction machine. The baby kept throwing up and we rolled him to his side and cleaned his mouth. A nurse from another unit (RN #4) came in and told us to stop because he was already gone and we were wasting our time and we didn't stop. Another BHT told me I said "screw you." When asked if she knows why the suction machine did not work she stated, "We found out later no one had removed the cap."

12. An interview was conducted with BHT #2 on 01/15/18 at 2:20 p.m. and when asked to explain what occurred during the code she stated in part, "I stayed in the room with the nurse and helped clear the airway with a sheet, he had drainage from his nose and mouth with a foul smell. The nurse was doing CPR. I didn't do mouth to mouth but I know they did. The RN yelled for equipment and code and then I left to do hallway checks on the other patients."

13. An interview was conducted on 01/15/18 at 4:59 p.m. with RN #1. When asked to explain the events leading up to finding patient #1 and all events once she found him not breathing she stated in part, "He had been up earlier playing with the other kids and I understand the doctor saw him earlier because he had a little temperature and they gave him Tylenol. He had a low-grade fever for me and I gave him Tylenol at 9:18 p.m. Nurses do the safety checks at 10, 2, 6, and I was going in his room to do his recheck for Tylenol and his 10:00 p.m. check. I was trying to gently touch him because I didn't want to wake him up and I couldn't see him breathing because he was laying on his belly. I went to the door to get the BHT and we both attempted to arouse him and he had no response. I checked his pulse and didn't feel one. We placed him on the floor and I started chest compressions and yelled for a code to be called. With every compression he had a bloody mucus then brown vomit. People came to help and the suction wasn't working. Someone did mouth to mouth because none of the masks worked. They couldn't get a seal. I couldn't believe this was happening he was just up playing earlier."

14. An interview was conducted on 01/16/18 at 7:53 a.m. with RN #3 (nursing supervisor). When asked to explain patient #1's code blue once she arrived she stated in part, "At 10:06 p.m. the code was called. We took off and went up the steps and that's when a code blue assist was called at 10:09 p.m. The elevators were down and we had to use the steps. I walked into the room and saw the nurse with the child on the floor and the patient was not breathing. I tried to clear his airway of mucus and vomit. I asked if anyone called 911 and if not to do so now. I asked for an ambu bag. Myself and another nurse relieved the nurse with CPR. People brought stuff in to work with. I tried to seal the mask and it wouldn't seal. I was told it was a child's mask. I asked for a pocket mask and it wouldn't work either. I finally gave him mouth to mouth. The LPN helped me with clearing his mouth. The suction wouldn't work and we got another suction machine and it wouldn't work. Another nurse switched out with me and another nurse (RN#4) tried to do mouth to mouth with a piece of plastic off the floor. He vomited and she stopped and began compressions after the paramedic asked her to leave the room. The nurse who tried to use the plastic (RN#4) yelled for us to stop the code but we refused. The police had arrived with the emergency squad and they came to the unit. After the squad left I notified the physician, the nurse manager, the director of nursing, DHHR and the administrator." When asked if she herself ever checked the suction machine she stated in part, "No I don't think so I was busy with the code." When asked if the AED was used she stated, "No, I don't think so."

15. A telephone interview was conducted on 01/16/18 at 12:22 p.m. with RN #4. When asked to explain what happened during the code she stated in part, "The child was on the floor, it was chaotic not a controlled code. There was no vital machine, suction didn't work and the mask wasn't working. They need emergency medicine, trained for pediatrics and ACLS."

16. Review of still pictures of patient #1's room after the patient was taken to another hospital from 01/15/18 to 01/17/18 revealed in part, a suction machine laying at the head of bed A, no contents can be seen in the suction machine. An oxygen machine is at the foot of bed A and no oxygen tubing is connected and no packaging can be seen for oxygen tubing in the room. An AED can be seen on the bedside table of bed A in the carrying case with unopened AED pads. An Ambu bag is not seen in the picture (emergency squad took bag) and a small plastic bag in the area where the patient was given CPR.

17. Review of still picture on 01/17/18 from 9:30 a.m. through 3:30 p.m. taken from video monitoring on patient #1 exiting the unit with emergency squad shows an emergency worker carrying an ambu-bag with an adult face mask. The Director of Quality had made the still picture as requested during 01/17/18, at 8:45 a.m. reviewing of video monitoring.

18. An interview was conducted on 01/17/18 at 9:30 a.m. with the Director of Quality she concurs with all of the above findings.

19. An interview was conducted on 01/17/18 at 3:15 p.m. with the Interim Director of Nursing she concurs with all of the above findings.

Based on record review and staff interview it was determined the hospital failed to follow their policies during a sentinel event in one (1) of one (1) sentinel events in the last six (6) months. This failure has the potential to cause harm to all patients who have a sentinel event in the care of the hospital.

1. Review of the policy titled "Sentinel Events" with a last revision date of 01/13/18, states in part, "If the decision is to report the event to Joint Commission, this is to be done within five (5) business days..." Joint Commission defines sentinel event as: "An unexpected occurrence involving death or serious physical or psychological injury, or risk thereof."

2. Upon request of the policy of sentinel events at 01/17/18 at 10:00 a.m. the Director of Quality stated in part, "I haven't notified the joint commission of the event and I know it had to be done within five days but, I will do it."

A. Based on record review, video monitoring review, policy review and staff interview it was determined the Registered Nurse (RN) #1 failed to ensure that all patients were supervised by following a physician's order on ten (10) minute patient safety checks were completed on nine (9) of ten (10) patients. Unit 2 West Charge Nurse did not follow hospital policy to ensure ten (10) minute patient safety checks were completed on nine (9) patients (patients #1, 2, 4, 5, 6, 7, 8, 9 and 10) (See A-0392 and A-0393).

B. Based on record review, video monitoring review, policy review and staff interview it was determined the Nursing Supervisor failed to ensure one (1) RN was in charge of a pediatric code blue {cardiopulmonary resuscitation (CPR)}, and that the RN was competent to use life saving medical equipment needed during a code blue in one (1) of one (1) patients that required CPR as required by the policy(patient #1) (See A-0392 and A-0393).

C. Based on video monitoring, policy review and staff interview it was determined the Nursing Supervisor failed to ensure all units of the hospital (Unit 5 North) were supervised by an RN at all times (See A-0392 and A-0393).

A. Based on record review, video monitoring review, policy review, and staff interview it was determined the 2 West, Registered Nurse (RN) #1 failed to supervise the delegation of physician orders delegated to a Behavior Health Technician (BHT) for every ten (10) minute patient safety checks to be completed on nine (9) of ten (10) patients (patients #1, 2, 4, 5, 6, 7, 8, 9 and 10). This failure has the potential for all patients to have the ability to not be supervised by a RN and physician orders not being followed as written.

1. Review of the medical record for patient #1 revealed on 01/06/18 at 1:30 a.m. an order was written for every ten (10) minute observation by Doctor #1.

2. Review of the medical record, the checksheet titled "BHT 10 Observation Record" for patients #1, 2, 4, 5, 6, 7, 8, 9, and 10 revealed all ten (10) minute safety checks had been completed on 01/07/18, from 9:00 p.m. through 11:30 p.m.

3. Review of video monitoring on 01/15/18 at 9:27 a.m. and on 01/17/18 at 8:45 a.m. in the presence of the Director of Quality of the 2 West hallway revealed no ten (10) minute safety checks had been completed on patients #1, 2, 4, 5, 6, 7, 8, 9 and 10 from 9:00 p.m. through 11:30 p.m. with the exception of patient #1. At 8:58 p.m. patient #1 went to a hallway bathroom and then returned to his room at 9:02:30 p.m. and then 10:02 p.m. when patient #1 was found by RN #1 not breathing.

4. Review of the policy titled "Levels of Observation" with a last review date of 01/18/16, states in part, "An order for the appropriate level of observation and precautions should be documented in the medical record and the rounds sheets should be initiated...A physician's order is required to decrease or increase observation levels.

5. An interview was conducted on 01/15/18 at 2:20 p.m. with BHT #1. When asked to explain the frequency of safety checks on patients on 2 West she stated in part, "Checks are every 10 minutes." When asked who completed safety checks on 01/07/18, before, during, and after the code blue on patient #1, she stated in part, "I did, I helped in the code by cleaning the boy's mouth and nose with his sheet and then I left when the code team arrived and did my hallway checks." When asked if when completing a safety check if it was considered adequate to complete from the hallway by looking through the patient's window she stated in part, "Yes, I look to see if the covers are moving up and down."

6. An interview was conducted on 01/15/18 at 10:00 a.m. with the Director of Quality during review of the hallway video monitoring. When asked if she saw any safety checks completed on the patients and what the expectation of a safety check is she stated in part, " The expectation is they wouldn't look from the window, they would go into the room to ensure the patient was breathing, color was good and the patient was all right. She concurred with the above findings.

B. Based on record review, video monitoring, policy review and staff interview it was determined the Nursing Supervisor failed to ensure one RN was in Charge of a Code Blue (cardiopulmonary resuscitation {CPR}) and failed to ensure RN's #1, 2, 3 and 4 and Licensed Practical Nurse (LPN) #1 provided competent use of medical equipment needed for CPR, in one (1) of one (1) patients who required CPR (patient #1). This failure has the potential for all patients who require CPR to have the end result of death.

1. Review of the medical record for patient #1 revealed no code sheet in the medical record.

2. Review of the video monitoring on 01/15/18 at 9:27 a.m. and on 01/17/18 at 8:45 a.m. in the presence of the Director of Quality of the 2 West hallway revealed on 10:01 p.m. RN #1, entered patient #1's room (260-A) then came into the hallway. The BHT #1 entered the room with RN #1. BHT #4 who was sitting on close constant observation in room 252-A ran to the nurse's station, made a phone call and went back to her close constant observation. At 10:05:24 p.m. BHT #2, arrived from another unit and went into room 260-A and immediately ran to the nursing station and returned to the room at 10:06:27 p.m. with a suction machine and an Automated External Defibrillators (AED). At 10:07:33 p.m. the BHT can be seen moving her arms in the hallway and the code team started to run. LPN #1, RN #2 and 3 went into room 260. The rest of the code team remained in the hallway. At 10:08:38, RN #4 entered room 260 and LPN #1 left the room and returned at 10:09:07 p.m. with an oxygen tank which was taken into the room. At 10:13:37 p.m. the emergency squad entered the patient's room. At 10:13:50 p.m. one member of the emergency squad left the unit and returned at 10:15:27 p.m. with a backboard. At 10:17:17 p.m. the emergency squad left with the patient while continuing chest compressions.

3. Review of the county com log sheet revealed that 911 was notified of emergency assistance at 10:08 p.m.

4. Review of the policy titled "CPR" with a last revised date of 09/01/16 states in part, "If patient is unresponsive, 1st responder calls for help noting the time and initiating CPR using pocket mask/barrier device. Instruct staff member to announce code blue, telephone 911 for emergency medical services. Instruct staff to bring ABC boc and obtain a disposable mouth barrier and/or ambu bag...All additional staff will take and record vital signs...time code called...Nursing staff members not involved in the code blue will have the responsibility for assisting in keeping area clear and attending the needs of other patients."

5. Review of the policy titled "Code Blue Response" with a last revised date of 05/02/16 states in part, "Equipment for basic airway restoration and support and an AED which is located on each unit."

6. Review of the policy titled "Provision of Emergency Services" states in part, "Call 911 for all medical emergencies needed...CPR is initiated as appropriate...Obtain emergency cart with available supplies."

7. Review of the policy titled "AED" with a last review date of 11-08-14, states in part, "The AED in conjunction with cardio-pulmonary resuscitation (CPR), is to be used...when a cardiac emergency occurs...Nurse will bring the AED to the emergency site...When a cardiac emergency occurs, the doctor on call, assistant NE, House Supervisor, and Registered Nurses who have been trained and certified AED/CPR instructor will utilize the AED and Begin CPR."

8. Review of personal files for RN #1, #2, and #3 and LPN #1 revealed all CPR cards are up to date and all annual hospital training on CPR and Codes were up-to-date."

9. An interview was conducted with BHT #2 on 01/15/18 at 11:30 a.m. When asked to explain how she came to be involved in the code blue and to explain what occurred during the code she states in part, "Well I was working 1C and a code blue was called so I ran up the back stairs and went into the room. The nurse had the patient on the floor and was doing chest compressions. Stuff was coming out of his nose and mouth and he was gray all over except his feet they looked a pink color. No one was coming so we called a code blue assist and I brought the suction, ambu bag and AED into the room. When I was walking into the room people were walking down the hall and I asked them to hurry up and they ran. Someone yelled has anyone called 911 and no one had so someone else ran and called 911. The suction wouldn't work and the little boy kept vomiting up red and brown stuff and it kept coming out his nose. No one could get it to work. So we went to get another one from another unit. That one wouldn't work either. They couldn't get the mask to work either, they couldn't get a good fit and it wouldn't give him a breath. The nurses kept trading off with chest compressions. They tried the ambu bag, a pocket mask and we carry throw away masks and that wouldn't work either. One nurse from another unit came in and even tried to use plastic she found on the floor to provide mouth-to mouth. The supervisor finally wiped his mouth and did mouth to mouth and he got a breath and then the emergency squad came." When asked if the patient ever had vital signs taken, AED connected, oxygen used or if the suction machine ever worked she stated in part, "No one did vital signs, no the AED never was used, I don't know about the oxygen but neither suction machine worked."

10. An interview was conducted with RN #2 on 01/15/18 at 12:15 p.m. When asked if she remembered the night of 01/07/18 and a code blue being called and if so to explain what happened during the code. She states in part, "A code blue was called to 2 West the child/adolescent unit and we thought it was a mistake and that it was a code gray so I was on my way and they called for a code blue assist and we still thought they meant a code gray. I went in to the room and the nurse had the patient in the floor doing compressions and I asked if she needed a break and I tried to clear his airway with my fingers because the suction wasn't working he had thick mucus, dark brown that smelled like stool. He was a grayish, purplish blue and had no pulse or respirations. The nurses kept relieving each other with chest compressions." When asked why suction wouldn't work she stated, "We heard later the cap wasn't removed".

11. An interview was conducted on 01/15/18 at 12:30 p.m. with LPN #1. When asked if she could explain the code blue for patient #1 she stated in part, "I was in the room with the patient and did chest compressions. I came from my unit when the code was called. The patient was on the floor by the bed next to the floor. Someone yelled they needed oxygen and the little mask. I gave them a plastic mask a BHT had. The suction wasn't working and we had someone run and get a BHT to go to another unit to get another suction machine. The baby kept throwing up and we rolled him to his side and cleaned his mouth. A nurse from another unit (RN #4) came in and told us to stop because he was already gone and we were wasting our time and we didn't stop. Another BHT told me I said, "screw you." When asked if she knows why the suction machine did not work she stated, "We found out later no one had removed the cap."

12. An interview was conducted with BHT #2 on 01/15/18 at 2:20 p.m. and asked to explain what occurred during the code. She stated in part, "I stayed in the room with the nurse and helped clear the airway with a sheet, he had drainage from his nose and mouth with a foul smell. The nurse was doing CPR. I didn't do mouth to mouth but, I know they did. The RN yelled for equipment and code and then I left to do hallway checks on the other patients."

13. An interview was conducted on 01/15/18 at 4:59 p.m. with RN #1. When asked to explain the events leading up to finding patient #1 and all events once she found him not breathing she stated in part, "He had been up earlier playing with the other kids and I understand the doctor saw him earlier because he had a little temperature and they gave him Tylenol. He had a low-grade fever for me and I gave him Tylenol at 9:18 p.m. Nurses do the safety checks at 10, 2, 6, and I was going in his room to do his recheck for Tylenol and his 10:00 p.m. check. I was trying to gently touch him because I didn't want to wake him up and I couldn't see him breathing because he was laying on his belly. I went to the door to get the BHT and we both attempted to arouse him and he had no response. I checked his pulse and didn't feel one. We placed him on the floor and I started chest compressions and yelled for a code to be called. With every compression he had a bloody mucus then brown vomit. People came to help and the suction wasn't working. Someone did mouth to mouth because none of the masks worked. They couldn't get a seal. I couldn't believe this was happening he was just up playing earlier."

14. An interview was conducted on 01/16/18 at 7:53 a.m. with RN #3 (nursing supervisor). When asked to explain patient #1's code blue once she arrived she stated in part, "At 10:06 p.m. the code was called. We took off and went up the steps and that's when a code blue assist was called at 10:09 p.m. The elevators were down and we had to use the steps. I walked into the room and saw the nurse with the child on the floor and the patient was not breathing. I tried to clear his airway of mucus and vomit. I asked if anyone called 911 and if not to do so now. I asked for an ambu bag. Myself and another nurse relieved the nurse with CPR. People brought stuff in to work with. I tried to seal the mask and it wouldn't seal. I was told it was a child's mask. I asked for a pocket mask and it wouldn't work either. I finally gave him mouth to mouth. The LPN helped me with clearing his mouth. The suction wouldn't work and we got another suction machine and it wouldn't work. Another nurse switched out with me and another nurse (RN#4) tried to do mouth to mouth with a piece of plastic off the floor, he vomited and she stopped and began compressions after the paramedic asked her to leave the room. The nurse who tried to use the plastic (RN#4) yelled for us to stop the code but we refused. The police had arrived with the emergency squad and they came to the unit. After the squad left I notified the physician, the nurse manager, the director of nursing, DHHR and the administrator." When asked if she herself ever checked the suction machine she stated in part, "No, I don't think so. I was busy with the code." When asked if the AED was used she stated, "No, I don't think so.

15. A telephone interview was conducted on 01/16/18 at 12:22 p.m. with RN #4. When asked to explain what happened during the code she stated in part, "The child was on the floor, it was chaotic not a controlled code. There was no vital machine, suction didn't work, the mask wasn't working. They need emergency medicine, trained for pediatrics and ACLS."

16. Review of still pictures of patient #1's room after the patient was taken to another hospital from 01/15/18 through 01/17/18 revealed in part, a suction machine laying at the head of the bed A, no contents can be seen in the suction machine. An oxygen machine is at the foot of bed A and no oxygen tubing is connected and no packaging can be seen for oxygen tubing in the room. An AED can be seen on the bedside table of bed A in the carrying case with unopened AED pads. An Ambu bag is not seen in the picture (emergency squad took bag) and a small plastic bag was in the area where the patient was given CPR.

17. Review of still picture on 01/17/18 from 9:30 a.m. through 3:30 p.m. taken from video monitoring on patient #1 exiting the unit with emergency squad shows an emergency worker carrying an ambu-bag with an adult face mask. The Director of Quality had made the still picture as requested during 01/17/18, at 8:45 a.m. reviewing of video monitoring.

18. An interview was conducted on 01/17/18 at 9:30 a.m. with the Director of Quality she concurs with all of the above findings.

19. An interview was conducted on 01/17/18 at 3:15 p.m. with the Interim Director of Nursing she concurs with all of the above findings.

C. Based on video monitoring, staff interview and hospital expectations it was determined the Director of Nursing failed to ensure all patients were supervised by a Registered Nurse (RN). On 01/07/18 from approximately 10:02 p.m. through 10:35 p.m. an RN was not present on the 5 North patient unit to supervise care for fourteen (14) of fourteen (14) patients admitted on the unit (patients #11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23 and 24). This failure has the potential for all patients left without the supervision of an RN to receive substandard care.

1. Review of video monitoring on 01/15/18 at 9:27 a.m. and on 01/17/18 at 8:45 a.m. in the presence of the Director of Quality of the 2 West hallway revealed RN #4 arrived on the 2 West at 10:07 p.m. and left the unit at 10:25 p.m.

2. A telephone interview was conducted on 01/16/18 at 12:15 p.m. with RN #4. When asked if she was on the code team on 01/07/18 and if another RN was on 5 North to supervise the patients in her care during the code on 01/07/18, she stated in part, "I don't know if I was on the code team, I felt I should go and I was the only RN and an LPN was on the unit."

3. An interview was conducted on 01/17/18 at 10:15 a.m. with Behavior Health Technician #3. When asked if he remembered the night of the code on 2 West and if so if he could remember who went with him? He stated in part, Yes, RN#4 was with me. She wasn't sure if she was supposed to go but she went with me." When asked if she was the only RN on the unit he stated, "Yes, there was an LPN but RN #4 came with me and I don't really know why she wasn't on the code team, I was."

4. An interview was conducted on 01/15/18 with the Director of Quality during the review of the video. When asked the expectations of all units being left in the care of an RN she stated, "The expectation is that an RN is to remain on the unit at all times and RN #4, was not on the code team and should not have left her unit." She concurred with the above findings.

Based on staff interview and hospital expectations the Director of Nursing failed to ensure all patients were supervised by a Registered Nurse (RN) #4. On 01/07/18 from approximately 10:02 p.m. through 10:35 p.m. an RN was not present on the 5 North patient unit to supervise care for fourteen (14) of fourteen (14) patients admitted on the unit (patients #11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23 and 24). This failure has the potential for all patients left without the supervision of an RN to receive substandard care.

1. Review of video monitoring on 01/15/18 at 9:27 a.m. and on 01/17/18 at 8:45 a.m. in the presence of the Director of Quality of the 2 West hallway revealed RN #4 arrived on the 2 West at 10:07 p.m. and left the unit at 10:25 p.m.

2. A telephone interview was conducted on 01/16/18 at 12:22 p.m. with RN #4. When asked if she was on the code team on 01/07/18 and if another RN was on 5 North to supervise the patients in her care during the code on 01/07/18, she stated in part, "I don't know if I was on the code team, I felt I should go and I was the only RN and an Licensed Practical Nurse (LPN) was on the unit."

3. An interview was conducted on 01/17/18 at 10:15 a.m. with Behavior Health Technician (BHT) #3. When asked if he remembered the night of the code on 2 West and if so if he could remember who went with him? He stated in part, "Yes, RN#4 was with me. She wasn't sure if she was supposed to go but she went with me." When asked if she was the only RN on the unit he stated, "Yes, there was an LPN but RN #4 came with me and I don't really know why she wasn't on the code team, I was."

4. An interview was conducted on 01/15/18 with the Director of Quality during the review of the video. When asked the expectations of all units being left in the care of an RN she stated, "The expectation is that an RN is to remain on the unit at all times and RN #4, was not on the code team and should not have left her unit." She concurred with the above findings.

A. Based on record review, video monitoring review, policy review, and staff interview it was determined the 2 West, Registered Nurse (RN) #1 failed to supervise the delegation of physician orders delegated to a Behavior Health Technician (BHT) for every ten (10) minute patient safety checks to be completed on nine (9) of ten (10) patients (patients #1, 2, 4, 5, 6, 7, 8, 9 and 10). This failure has the potential for all patients to have the ability to not be supervised by a registered nurse and physician orders not being followed as written.

1. Review of the medical record for patient #1, revealed on 01/06/18 at 1:30 a.m. an order was written for every ten (10) minute observation by Doctor #1.

2. Review of the medical records and checksheet titled "BHT 10 Observation Record" for patients #1, 2, 4, 5, 6, 7, 8, 9 and 10 revealed all ten (10) minute safety checks had been completed on 01/07/18, from 9:00 p.m. through 11:30 p.m.

3. Review of video monitoring on 01/15/18 at 9:27 a.m. and on 01/17/18 at 8:45 a.m. in the presence of the Director of Quality of the 2 West hallway revealed no ten (10) minute safety checks had been completed on patients #1, 2, 4, 5, 6, 7, 8, 9 and 10 from 9:00 p.m. through 11:30 p.m., with the exception of patient #1. At 8:58 p.m. patient #1 went to a hallway bathroom and then returned to his room at 9:02:30 p.m. and then 10:02 p.m. when patient #1 was found by RN #1 not breathing.

4. Review of the policy titled "Levels of Observation" with a last review date of 01/18/16, states in part, "An order for the appropriate level of observation and precautions should be documented in the medical record and the rounds sheets should be initiated...A physician's order is required to decrease or increase observation levels."

5. An interview was conducted on 01/15/18 at 2:20 p.m. with BHT #1. When asked to explain the frequency of safety checks on patients on 2 West she stated in part, "Checks are every 10 minutes." When asked who completed safety checks on 01/07/18, before, during, and after the code blue on patient #1, she stated in part, "I did, I helped in the code by cleaning the boy's mouth and nose with his sheet and then I left when the code team arrived and did my hallway checks." When asked if when completing a safety check it was considered adequate to complete from the hallway by looking through the patients window she stated in part, "Yes, I look to see if the covers are moving up and down."

6. An interview was conducted on 01/15/18 at 10:00 a.m. with the Director of Quality during review of the hallway video monitoring. When asked if she saw any safety checks completed on the patients and what the expectation of a safety check is she stated in part, "The expectation is they wouldn't look from the window, they would go into the room to ensure the patient was breathing, color is good and the patient was all right." She concurred with the above findings.

B. Based on record review, video monitoring, policy review and staff interview it was determined the Nursing Supervisor failed to ensure one (1) Registered Nurse (RN) was in Charge of a Code Blue (cardiopulmonary resuscitation {CPR}) and failed to ensure RN's #1, 2, 3 and 4 and Licensed Practical Nurse (LPN) #1 provided competent use of medical equipment needed for CPR in one (1) of one (1) patients who required CPR (patient #1). This failure has the potential for all patients who require CPR to have the end result of a poor outcome.

1. Review of the medical record for patient #1 revealed no code sheet in the medical record.

2. Review of the video monitoring on 01/15/18 at 9:27 a.m. and on 01/17/18 at 8:45 a.m. in the presence of the Director of Quality of the 2 West hallway revealed on 10:01 p.m. RN #1, entered patient #1's room (260-A) and then came into the hallway. Behavior Health technician (BHT) #1 entered the room with RN #1. BHT #4 who was sitting on close constant observation in room 252-A ran to the nurse's station, made a phone call and went back to her close constant observation. At 10:05:24 p.m. BHT #2, arrived from another unit and went into room 260-A and immediately ran to the nursing station and returned to the room at 10:06:27 p.m. with a suction machine and a Automated External Defibrillator (AED). At 10:07:33 p.m. the BHT can be seen moving her arms in the hallway and the code team started to run. LPN #1, RN's #2 and 3 went into room 260. The rest of the code team remained in the hallway. At 10:08:38, RN #4 entered room 260 and LPN #1 left the room and returned at 10:09:07 p.m. with an oxygen tank which was taken into the room. At 10:13:37 p.m. the emergency squad entered the patient's room. At 10:13:50 p.m. one (1) member of the emergency squad left the unit and returned at 10:15:27 p.m. with a backboard. At 10:17:17 p.m. the emergency squad left with the patient while continuing chest compressions.

3. Review of the county com log sheet revealed that 911 was notified of emergency assistance at 10:08 p.m.

4. Review of the policy titled "CPR" with a last revised date of 09/01/16 states in part, "If patient is unresponsive, 1st responder calls for help noting the time and initiating CPR using pocket mask/barrier device. Instruct staff member to announce code blue, telephone 911 for emergency medical services. Instruct staff to bring ABC boc and obtain a disposable mouth barrier and/or ambu bag...All additional staff will take and record vital signs...time code called...Nursing staff members not involved in the code blue will have the responsibility for assisting in keeping area clear and attending the needs of other patients."

5. Review of the policy titled "Code Blue Response" with a last revised date of 05/02/16 states in part, "Equipment for basic airway restoration and support and an AED which is located on each unit."

6. Review of the policy titled "Provision of Emergency Services" states in part, "Call 911 for all medical emergencies needed...CPR is initiated as appropriate...Obtain emergency cart with available supplies."

7. Review of the policy titled "AED" with a last review date of 11-08-14, states in part, "The AED in conjunction with cardio-pulmonary resuscitation (CPR), is to be used...when a cardiac emergency occurs...Nurse will bring the AED to the emergency site...When a cardiac emergency occurs, the doctor on call, assistant NE, House Supervisor, and Registered Nurses who have been trained and certified AED/CPR instructor will utilize the AED and begin CPR."

8. Review of personnel files for RN's #1, 2 and 3 and LPN #1 revealed all CPR cards were up to date and all annual hospital training on CPR and Codes were up-to-date.

9. An interview was conducted with BHT #2 on 01/15/18 at 11:30 a.m. When asked to explain how she came to be involved in the code blue and to explain what occurred during the code she states in part, "Well, I was working 1C and a code blue was called so I ran up the back stairs and went into the room. The nurse had the patient on the floor and was doing chest compressions. Stuff was coming out of his nose and mouth and he was gray all over except his feet they looked a pink color. No one was coming so we called a code blue assist and I brought the suction, ambu bag and AED into the room. When I was walking into the room people were walking down the hall and I asked them to hurry up and they ran. Someone yelled has anyone called 911 and no one had so someone else ran and called 911. The suction wouldn't work and the little boy kept vomiting up red and brown stuff and it kept coming out his nose. No one could get it to work. So we went to get another one from another unit. That one wouldn't work either. They couldn't get the mask to work either, they couldn't get a good fit, it wouldn't give him a breath. The nurses kept trading off with chest compressions. They tried the ambu bag, a pocket mask and we carry throw away masks and that wouldn't work either. One nurse from another unit came in and even tried to use plastic she found on the floor to provide mouth-to mouth. The supervisor finally wiped his mouth and did mouth to mouth and he got a breath and then the emergency squad came." When asked if the patient ever had vital signs taken, AED connected, oxygen used or if the suction machine ever worked she stated in part, "No one did vital signs, no the AED never was used, I don't know about the oxygen but neither suction machine worked."

10. An interview was conducted with RN #2 on 01/15/18 at 12:15 p.m. When asked if she remembered the night of 01/07/18 and a code blue being called and if so to explain what happened during the code. She states in part, "A code blue was called to 2 West the child/adolescent unit and we thought it was a mistake and that it was a code gray so I was on my way and they called for a code blue assist and we still thought they meant a code gray. I went in to the room and the nurse had the patient on the floor doing compressions and I asked if she needed a break and I tried to clear his airway with my fingers because the suction wasn't working. He had thick mucus, dark brown that smelled like stool. He was a grayish, purplish blue and had no pulse or respirations. The nurses kept relieving each other with chest compressions." When asked why suction wouldn't work she stated, "We heard later the cap wasn't removed. "

11. An interview was conducted on 01/15/18 at 12:30 p.m. with LPN #1. When asked if she could explain the code blue for patient #1 she stated in part, "I was in the room with the patient and did chest compressions. I came from my unit when the code was called. The patient was on the floor by the bed. Someone yelled they needed oxygen and the little mask. I gave them a plastic mask a BHT had. The suction wasn't working and we had someone run and get a BHT to go to another unit to get another suction machine. The baby kept throwing up and we rolled him to his side and cleaned his mouth. A nurse from another unit (RN #4) came in and told us to stop because he was already gone and we were wasting our time and we didn't stop, another BHT told me I said "screw you." When asked if she knows why the suction machine did not work she stated, "We found out later no one had removed the cap."

12. An interview was conducted with BHT #2 on 01/15/18 at 2:20 p.m. asked to explain what occurred during the code she stated in part, "I stayed in the room with the nurse and helped clear the airway with a sheet, he had drainage from his nose and mouth with a foul smell. The nurse was doing CPR. I didn't do mouth to mouth but, I know they did. The RN yelled for equipment and code and then I left to do hallway checks on the other patients."

13. An interview was conducted on 01/15/18 at 4:59 p.m. with RN #1. When asked to explain the events leading up to finding patient #1 and all events once she found him not breathing she stated in part, "He had been up earlier playing with the other kids and I understand the doctor saw him earlier because he had a little temperature and they gave him Tylenol. He had a low-grade fever for me and I gave him Tylenol at 9:18 p.m. Nurses do the safety checks at 10, 2, 6, and I was going in his room to do his recheck for Tylenol and his 10 o'clock check. I was trying to gently touch him because I didn't want to wake him up and I couldn't see him breathing because he was laying on his belly. I went to the door to get the BHT and we both attempted to arouse him and he had no response. I checked his pulse and didn't feel one. We placed him on the floor and I started chest compressions and yelled for a code to be called. With every compression he had a bloody mucus then brown vomit. People came to help and the suction wasn't working. Someone did mouth to mouth because none of the masks worked. They couldn't get a seal. I couldn't believe this was happening he was just up playing earlier."

14. An interview was conducted on 01/16/18 at 7:53 a.m. with RN #3 (nursing supervisor). When asked to explain patient #1's code blue once she arrived she stated in part, "At 10:06 p.m. the code was called. We took off and went up the steps and that's when a code blue assist was called at 10:09 p.m. The elevators were down and we had to use the steps. I walked into the room and saw the nurse with the child on the floor and the patient was not breathing. I tried to clear his airway of mucus and vomit. I asked if anyone called 911 and if not to do so now. I asked for an ambu bag. Myself and another nurse relieved the nurse with CPR. People brought stuff in to work with. I tried to seal the mask and it wouldn't seal. I was told it was a child's mask. I asked for a pocket mask and it wouldn't work either. I finally gave him mouth to mouth. The LPN helped me with clearing his mouth. The suction wouldn't work we got another suction machine and it wouldn't work. Another nurse switched out with me and another nurse (RN#4) tried to do mouth to mouth with a piece of plastic off the floor. He vomited and she stopped and began compressions after the paramedic asked her to leave the room. The nurse who tried to use the plastic (RN#4) yelled for us to stop the code but, we refused. The police had arrived with the emergency squad and they came to the unit. After the squad left I notified the physician, the nurse manager, the director of nursing, DHHR and the administrator." When asked if she herself ever checked the suction machine she stated in part, "No, I don't think so I was busy with the code." When asked if the AED was used she stated, "No, I don't think so."

15. A telephone interview was conducted on 01/16/18 at 12:22 p.m. with RN #4. When asked to explain what happened during the code she stated in part, "The child was on the floor, it was chaotic not a controlled code. There was no vital machine, suction didn't work, the mask wasn't working. They need emergency medicine, trained for pediatrics and ACLS."

16. Review of still pictures of patient #1's room after the patient was taken to another hospital from 01/15/18 to 01/17/18 revealed in part, a suction machine laying at the head of bed A. No contents can be seen in the suction machine. An oxygen machine is at the foot of bed A and no oxygen tubing is connected and no packaging can be seen for oxygen tubing in the room. An AED can be seen on the bedside table of bed A in the carrying case with unopened AED pads. An Ambu bag is not seen in the picture (emergency squad took bag) and a small plastic bag in the area where the patient was given CPR.

17. Review of still picture on 01/17/18 from 9:30 a.m. through 3:30 p.m. taken from video monitoring on patient #1 exiting the unit with emergency squad shows an emergency worker carrying an ambu-bag with an adult face mask. The director of quality had made the still picture as requested during 01/17/18, at 8:45 a.m. reviewing of video monitoring.

18. An interview was conducted on 01/17/18 at 9:30 a.m. with the Director of Quality she concurs with all of the above findings.

19. An interview was conducted on 01/17/18 at 3:15 p.m. with the Interim Director of Nursing she concurs with all of the above findings.

A. Based on record review, policy review and staff interview it was determined the hospital failed to maintain a complete and accurate medical record on one (1) of ten (10) medical records reviewed (patient #1). This failure has the potential for all medical records to be incomplete and inaccurate for future treatment of all patients.

1. Review of the medical record for patient #1 revealed the patient's chart did not contain a code sheet, or a discharge summary.

2. Review of the policy titled "CPR" with a last revised date of 09/01/16 states in part, "If patient is unresponsive, 1st responder calls for help noting the time and initiating CPR using pocket mask/barrier device. Instruct staff member to announce code blue, telephone 911 for emergency medical services. Instruct staff to bring ABC boc and obtain a disposable mouth barrier and/or ambu bag...All additional staff will take and record vital signs...time code called...start documentation...Nursing staff members not involved in the code blue will have the responsibility for assisting in keeping area clear and attending the needs of other patients."

3. Review of the policy titled "Sentinel Events" with a last revision date of 01/13/16 states in part, "The attending physician or on-call medical staff should request consent for an autopsy from responsible party when death is unexpected or a result of a sentinel event within twenty-four (24) hours...The final note will describe the reason for admission, the findings and course of treatment in the hospital, and the events leading to death.

4. Upon entrance to the hospital on 01/15/18 at 8:35 a.m. when the Director of Quality was given the request for information and was requested a copy of the Code sheet she stated in part, "There won't be any. They didn't complete one.

5. During entrance on 01/15/18 at 8:35 a.m. the Director of Nursing concurred.

6. An interview was conducted with Doctor #1 on 01/17/18 at 2:50 p.m. at her request to explain why the discharge summary was not in the medical record. She stated in part, "I just dictated the discharge summary and it will be available tomorrow and I will make sure you get it but, I was waiting to complete it until I had a cause of death."

B. Based on record review, video monitoring review, policy review, and staff interview it was determined the 2 West, Behavior Health Technician (BHT) #1 falsified documentation of every ten (10) minute safety checks to be completed on nine (9) of ten (10) patients (patients #1, 2, 4, 5, 6, 7, 8, 9 and 10). This failure has the potential for all patients to have falsified medical records.

1. Review of the medical record for patient #1 revealed on 01/06/18 at 1:30 a.m. an order was written for every ten (10) minute observation by Doctor #1.

2. Review of the medical records and the checksheet titled "BHT 10 Observation Record" for patients #1, 2, 4, 5, 6, 7, 8, 9 and 10 revealed all ten (10) minute safety checks had been completed on 01/07/18, from 9:00 p.m. through 11:30 p.m.

3. Review of video monitoring on 01/15/18 at 9:27 a.m. and on 01/17/18 at 8:45 a.m. in the presence of the Director of Quality of the 2 West hallway revealed no ten (10) minute safety checks had been completed on patients #1, 2, 4, 5, 6, 7, 8, 9 and 10 from 9:00 p.m. through 11:30 p.m. with the exception of patient #1. At 8:58 p.m. patient #1 went to a hallway bathroom and then returned to his room at 9:02:30 p.m. and then 10:02 p.m. when patient #1 was found by Registered Nurse #1 not breathing.

4. Review of the policy titled "Levels of Observation" with a last review date of 01/18/16, states in part, "An order for the appropriate level of observation and precautions should be documented in the medical record and the rounds sheets should be initiated...A physician's order is required to decrease or increase observation levels.

5. An interview was conducted on 01/15/18 at 2:20 p.m. with Behavior Health Technician #1. When asked to explain the frequency of safety checks on patients on 2 West she stated in part, "Checks are every ten (10) minutes." When asked who completed safety checks on 01/07/18, before, during, and after the code blue on patient #1, she stated in part, "I did, I helped in the code by cleaning the boy's mouth and nose with his sheet and then I left when the code team arrived and did my hallway checks." When asked if when completing a safety check it was considered adequate to complete from the hallway by looking through the patients window she stated in part, "Yes, I look to see if the covers are moving up and down."

6. An interview was conducted on 01/15/18 at 10:00 a.m. with the Director of Quality during review of the hallway video monitoring. When asked if she saw any safety checks completed on the patient's and what the expectation of a safety check is she stated in part, " The expectation is they wouldn't look from the window, they would go into the room to ensure the patient was breathing, color was good and the patient was all right." She concurred with the above findings.

A. Based on record review, policy review and staff interview it was determined the hospital failed to maintain a complete medical record on one (1) of ten (10) medical records reviewed (patient #1). This has the potential for all medical records to be incomplete for future treatment of all patients.

1. Review of the medical record for patient #1 revealed the patient's chart did not contain a code sheet, or a discharge summary.

2. Review of the policy titled "CPR" with a last revised date of 09/01/16 states in part, "If patient is unresponsive, 1st responder calls for help noting the time and initiating CPR using pocket mask/barrier device. Instruct staff member to announce code blue, telephone 911 for emergency medical services. Instruct staff to bring ABC boc and obtain a disposable mouth barrier and/or ambu bag...All additional staff will take and record vital signs...time code called...start documentation...Nursing staff members not involved in the code blue will have the responsibility for assisting in keeping area clear and attending the needs of other patients."

3. Review of the policy titled "Sentinel Events" with a last revision date of 01/13/16 states in part, "The attending physician or on-call medical staff should request consent for an autopsy from responsible party when death is unexpected or a result of a sentinel event within twenty-four (24) hours...The final note will describe the reason for admission, the findings and course of treatment in the hospital, and the events leading to death.

4. Upon entrance to the hospital on 01/15/18 at 8:35 a.m. when the Director of Quality was given the request for information and was requested a copy of the Code sheet she stated in part, "There won't be any. They didn't complete one."

5. During entrance on 01/15/18 at 8:35 a.m. the Director of Nursing concurred.

6. An interview was conducted with Doctor #1 on 01/17/18 at 2:50 p.m. at her request to explain why the discharge summary was not in the medical record. She stated in part, "I just dictated the discharge summary and it will be available tomorrow and I will make sure you get it but, I was waiting to complete it until I had a cause of death."

B. Based on record review, video monitoring review, policy review, and staff interview it was determined the 2 West, Behavior Health Technician (BHT) #1, falsified documentation of every ten (10) minute safety checks to be completed on nine (9) of ten (10) patients, (patients #1, 2, 4, 5, 6, 7, 8, 9 and 10). This failure has the potential for all patients to have falsified medical records.

1. Review of the medical record for patient #1, revealed on 01/06/18 at 1:30 a.m. an order was written for every ten (10) minute observation by Doctor #1.

2. Review of the medical records and the checksheet titled "BHT 10 Observation Record" for patients #1, 2, 4, 5, 6, 7, 8, 9 and 10 revealed all ten (10) minute safety checks had been completed on 01/07/18 from 9:00 p.m. through 11:30 p.m.

3. Review of video monitoring on 01/15/18 at 9:27 a.m. and on 01/17/18 at 8:45 a.m. in the presence of the Director of Quality of the 2 West hallway revealed no ten (10) minute safety checks had been completed on patients #1, 2, 4, 5, 6, 7, 8, 9 and 10 from 9:00 p.m. through 11:30 p.m., with the exception of patient #1. At 8:58 p.m. patient #1 went to a hallway bathroom and then returned to his room at 9:02:30 p.m. and then 10:02 p.m. when patient #1 was found by Registered Nurse #1 not breathing.

4. Review of the policy titled "Levels of Observation" with a last review date of 01/18/16, states in part, "An order for the appropriate level of observation and precautions should be documented in the medical record and the rounds sheets should be initiated...A physician's order is required to decrease or increase observation levels.

5. An interview was conducted on 01/15/18 at 2:20 p.m. with Behavior Health Technician (BHT) #1. When asked to explain the frequency of safety checks on patients on 2 West she stated in part, "Checks are every ten (10) minutes." When asked who completed safety checks on 01/07/18, before, during, and after the code blue on patient #1, she stated in part, "I did, I helped in the code by cleaning the boy's mouth and nose with his sheet and then I left when the code team arrived and did my hallway checks." When asked if when completing a safety check if it was considered adequate to complete from the hallway by looking through the patient's window she stated in part, "Yes, I look to see if the covers are moving up and down."

6. An interview was conducted on 01/15/18 at 10:00 a.m. with the Director of Quality during review of the hallway video monitoring. When asked if she saw any safety checks completed on the patients and what the expectation of a safety check is she stated in part, "The expectation is they wouldn't look from the window, they would go into the room to ensure the patient was breathing, color was good and the patient was all right." She concurred with the above findings.

Based on tour, record review and staff interview it was determined the facility failed to provide life saving medications in one (1) of one (1) patients who required emergency medication during cardiopulmonary resuscitation (CPR)(patient #1). This failure has the potential for all patients who require life saving medications to not receive the highest quality of care.

1. A tour of the Unit 2 West on 01/15/18 at 09:50 a.m. with Director of Nursing and the Nurse Manager of 2 West, showed no crash cart, no intravenous fluids (IV) and IV start kits.

2. An interview with Registered Nurse #5, during the tour of the unit revealed the unit does not have a crash cart and does not keep medications to use during a code blue (CPR).

3. An interview with the Nurse Manager of 2 West during the tour revealed the unit keeps an ambu-bag, AED, Suction and oxygen for CPR but no medications to be given during the code.

4. An interview was conducted on 01/15/18 at 3:30 p.m. with the medical director, pharmacist, and the Chief Operating Officer (CEO). When asked if the hospital has any life saving medication on the units to be used during codes the medical director stated in part, "No, we don't keep them here we send them to the emergency department. We start CPR and continue until the EMS shows up. We don't have a doctor in the hospital twenty-four (24) hours a day to give medications during the code. The pharmacist and the CEO concurred with the findings.

Based on tour, record review and staff interview it was determined the facility failed to provide life saving medications in one (1) of one (1) patients who required emergency medication during cardiopulmonary resuscitation (CPR)(patient #1). This failure has the potential for all patients who require life saving medications to not receive the highest quality of care.

1. During a tour of the Unit 2 West on 01/15/18 at 09:50 a.m. with Director of Nursing and the Nurse Manager of 2 West, there were no crash carts, no intravenous fluids (IV), and no IV start kits.

2. An interview with Registered Nurse #5, during the tour of the unit revealed the unit does not have a crash cart and does not keep medications to use during a code blue (CPR).

3. An interview with the Nurse Manager of 2 West during the tour revealed the unit keeps an ambu-bag, AED, Suction and oxygen for CPR but no medications to be given during the code.

4. An interview was conducted on 01/15/18 at 3:30 p.m. with the Medical director, Pharmacist, and the Chief Operating Officer (CEO). When asked if the hospital had any life saving medication on the units to be used during codes the Medical Director stated in part, "No, we don't keep them here we send them to the emergency department. We start CPR and continue until the EMS shows up. We don't have a doctor in the hospital twenty-four (24) hours a day to give medications during the code. The pharmacist and the CEO concurred with the findings.

A. Based on record review, video monitoring, policy review and staff interview it was determined the Medical Director failed to ensure one (1) registered nurse (RN) was in Charge of a Code Blue (cardiopulmonary resuscitation {CPR}), and failed to ensure RN's #1, 2, 3 and 4 and Licensed Practical Nurse (LPN) #1 provided competent use of medical equipment needed for CPR, in one (1) of one (1) patients who required CPR (patient #1). This failure has the potential for all patients who require CPR to have the end result of a poor outcome.

1. Review of the medical record for patient #1 revealed there was no code sheet in the medical record.

2. Review of the video monitoring on 01/15/18 at 9:27 a.m. and on 01/17/18 at 8:45 a.m., in the presence of the Director of Quality of the 2 West hallway, revealed on 10:01 p.m. RN #1 entered patient #1's room (260-A) then came into the hallway. Behavior Health Technician (BHT) #1 entered the room with RN #1. BHT #4, who was sitting on close constant observation in room 252-A, ran to the nurse's station, made a phone call and went back to her close constant observation. At 10:05:24 p.m., BHT #2 arrived from another unit and went into room 260-A and immediately ran to the nursing station and returned to the room at 10:06:27 p.m. with a suction machine and an Automated External Defibrillators (AED). At 10:07:33 p.m., the BHT can be seen moving her arms in the hallway and the code team started to run. Licensed Practical Nurse (LPN) #1 and RN's #2 and 3 went into room 260. The rest of the code team remained in the hallway. At 10:08:38, RN #4 entered room 260 and LPN #1 left the room and returned at 10:09:07 p.m. with an oxygen tank which was taken into the room. At 10:13:37 p.m. the emergency squad entered the patient's room. At 10:13:50 p.m., one (1) member of the emergency squad left the unit and returned at 10:15:27 p.m. with a backboard. At 10:17:17 p.m., the emergency squad left with the patient while continuing chest compressions.

3. Review of the county com log sheet revealed that 911 was notified of emergency assistance at 10:08 p.m.

4. Review of the policy titled "CPR", last revised 09/01/16, revealed it states, in part: "If patient is unresponsive, 1st responder calls for help noting the time and initiating CPR using pocket mask/barrier device. Instruct staff member to announce code blue, telephone 911 for emergency medical services. Instruct staff to bring ABC bag and obtain a disposable mouth barrier and/or ambu bag...All additional staff will take and record vital signs...time code called...Nursing staff members not involved in the code blue will have the responsibility for assisting in keeping area clear and attending the needs of other patients."

5. Review of the policy titled "Code Blue Response", last revised 05/02/16, revealed it states, in part: "Equipment for basic airway restoration and support and an AED which is located on each unit."

6. Review of the policy titled "Provision of Emergency Services" revealed it states, in part: "Call 911 for all medical emergencies needed...CPR is initiated as appropriate...Obtain emergency cart with available supplies."

7. Review of the policy titled "AED", last reviewed 11/08/14, revealed it states, in part: "The AED in conjunction with cardio-pulmonary resuscitation (CPR), is to be used...when a cardiac emergency occurs...Nurse will bring the AED to the emergency site...When a cardiac emergency occurs, the doctor on call, assistant NE, House Supervisor, and Registered Nurses who have been trained and certified AED/CPR instructor will utilize the AED and Begin CPR."

8. Review of the personnel files for RN #1, 2 and 3 and LPN #1 revealed all CPR cards were up to date and all annual hospital training on CPR and Codes were up-to-date."

9. An interview was conducted with BHT #2 on 01/15/18 at 11:30 a.m. When asked to explain how she came to be involved in the code blue and to explain what occurred during the code, she stated, in part: "Well, I was working 1C and a code blue was called so I ran up the back stairs and went into the room. The nurse had the patient on the floor and was doing chest compressions. Stuff was coming out of his nose and mouth and he was gray all over, except his feet, they looked a pink color. No one was coming so we called a code blue assist and I brought the suction, ambu bag and AED into the room. When I was walking into the room people were walking down the hall and I asked them to hurry up and they ran. Someone yelled 'has anyone called 911' and no one had so someone else ran and called 911. The suction wouldn't work and the little boy kept vomiting up red and brown stuff and it kept coming out his nose. No one could get it to work. So we went to get another one from another unit. That one wouldn't work either. They couldn't get the mask to work either; they couldn't get a good fit and it wouldn't give him a breath. The nurses kept trading off with chest compressions. They tried the ambu bag and a pocket mask and we carry throw away masks but that wouldn't work either. One (1) nurse from another unit came in and even tried to use plastic she found on the floor to provide mouth-to mouth. The supervisor finally wiped his mouth and did mouth to mouth and he got a breath and then the emergency squad came." When asked if the patient ever had vital signs taken, AED connected, oxygen used or if the suction machine ever worked, she stated, in part: "No one did vital signs and the AED never was used. I don't know about the oxygen but neither suction machine worked."

10. An interview was conducted with RN #2 on 01/15/18 at 12:15 p.m. When asked if she remembered the night of 01/07/18 and a code blue being called and if so to explain what happened during the code, she stated, in part: "A code blue was called to 2 West, the child/adolescent unit, and we thought it was a mistake and that it was a code gray so I was on my way and they called for a code blue assist and we still thought they meant a code gray. I went in to the room and the nurse had the patient in the floor doing compressions and I asked if she needed a break and I tried to clear his airway with my fingers because the suction wasn't working, he had dark brown thick mucus that smelled like stool. He was a grayish, purplish blue and had no pulse or respirations. The nurses kept relieving each other with chest compressions." When asked why suction wouldn't work, she stated, "We heard later the cap wasn't removed."

11. An interview was conducted on 01/15/18 at 12:30 p.m. with LPN #1. When asked if she could explain the code blue for patient #1, she stated, in part: "I was in the room with the patient and did chest compressions. I came from my unit when the code was called. The patient was on the floor by the bed next to the floor. Someone yelled they needed oxygen and the little mask. I gave them a plastic mask that a BHT had. The suction wasn't working and we had someone run and get a BHT to go to another unit to get another suction machine. The baby kept throwing up and we rolled him to his side and cleaned his mouth. A nurse from another unit (RN #4) came in and told us to stop because he was already gone and we were wasting our time and we didn't stop. Another BHT told me and I said, "screw you." When asked if she knew why the suction machine did not work, she stated, "We found out later no one had removed the cap."

12. An interview was conducted with BHT #2 on 01/15/18 at 2:20 p.m. and asked to explain what occurred during the code. She stated, in part: "I stayed in the room with the nurse and helped clear the airway with a sheet. He had drainage from his nose and mouth with a foul smell. The nurse was doing CPR. I didn't do mouth to mouth but I know they did. The RN yelled for equipment and code and then I left to do hallway checks on the other patients."

13. An interview was conducted on 01/15/18 at 4:59 p.m. with RN #1. When asked to explain the events leading up to finding patient #1 and all events once she found him not breathing, she stated, in part: "He had been up earlier playing with the other kids and I understand the doctor saw him earlier because he had a little temperature and they gave him Tylenol. He had a low-grade fever for me and I gave him Tylenol at 9:18 p.m. Nurses do the safety checks at 10, 2 and 6 and I was going in his room to do his recheck for Tylenol and his 10:00 p.m. check. I was trying to gently touch him because I didn't want to wake him up and I couldn't see him breathing because he was laying on his belly. I went to the door to get the BHT and we both attempted to arouse him and he had no response. I checked his pulse and didn't feel one. We placed him on the floor and I started chest compressions and yelled for a code to be called. With every compression he had a bloody mucus then brown vomit. People came to help and the suction wasn't working. Someone did mouth to mouth because none of the masks worked. They couldn't get a seal. I couldn't believe this was happening he was just up playing earlier."

14. An interview was conducted on 01/16/18 at 7:53 a.m. with RN #3 (nursing supervisor). When asked to explain patient #1's code blue once she arrived, she stated, in part: "At 10:06 p.m. the code was called. We took off and went up the steps and that's when a code blue assist was called at 10:09 p.m. The elevators were down and we had to use the steps. I walked into the room and saw the nurse with the child on the floor and the patient was not breathing. I tried to clear his airway of mucus and vomit. I asked if anyone called 911 and if not to do so now. I asked for an ambu bag. Myself and another nurse relieved the nurse with CPR. People brought stuff in to work with. I tried to seal the mask and it wouldn't seal. I was told it was a child's mask. I asked for a pocket mask and it wouldn't work either. I finally gave him mouth to mouth. The LPN helped me with clearing his mouth. The suction wouldn't work and we got another suction machine and it wouldn't work. Another nurse switched out with me and another nurse (RN#4) tried to do mouth to mouth with a piece of plastic off the floor, he vomited and she stopped and began compressions after the paramedic asked her to leave the room. The nurse who tried to use the plastic (RN#4) yelled for us to stop the code but we refused. The police had arrived with the emergency squad and they came to the unit. After the squad left I notified the physician, the nurse manager, the director of nursing, DHHR and the administrator." When asked if she herself ever checked the suction machine, she stated, in part: "No, I don't think so. I was busy with the code." When asked if the AED was used, she stated, "No, I don't think so."

15. A telephone interview was conducted on 01/16/18 at 12:22 p.m. with RN #4. When asked to explain what happened during the code, she stated, in part: "The child was on the floor, it was chaotic, not a controlled code. There was no vital machine, suction didn't work, the mask wasn't working. They need emergency medicine, trained for pediatrics and ACLS."

16. From 01/15/18 through 01/17/18, a review of still pictures of patient #1's room after the patient was taken to another hospital revealed, in part: a suction machine laying at the head of the bed A (no contents can be seen in the suction machine); an oxygen machine is at the foot of bed A and no oxygen tubing is connected and no packaging can be seen for oxygen tubing in the room; an AED can be seen on the bedside table of bed A in the carrying case with unopened AED pads; an Ambu bag is not seen in the picture (emergency squad took bag); and, a small plastic bag was in the area where the patient was given CPR.

17. Review of a still picture on 01/17/18 from 9:30 a.m. through 3:30 p.m. taken from video monitoring on patient #1 exiting the unit with emergency squad shows an emergency worker carrying an ambu-bag with an adult face mask. The Director of Quality had made the still picture as requested during 01/17/18 at 8:45 a.m. while reviewing the video monitoring.

18. An interview was conducted with the Medical Director on 01/15/18 at approximately 2:00 p.m. When asked if Doctor #1 notified her of the patient's change of condition, she stated, in part: "No, I was notified of the patient's death and I called her to let her know." When asked if she had watched the hallway video monitoring of the code and if she thought the code was ran according to policy, she stated, in part: "No, it obviously wasn't." At the time of the interview she concurred with the above findings.

19. An interview was conducted with Doctor #1 on 01/17/18 at 2:50 p.m. When asked if she was informed by RN #1 of the change of condition with patient #1, she stated, in part: "No, after he was transferred to United Hospital Center the Medical Director contacted me to tell me the patient died."

20. An interview was conducted on 01/17/18 at 9:30 a.m. with the Director of Quality. When asked if the hospital ensures their staff is properly educated with cardiopulmonary resuscitation and if mock codes were in place to ensure competency, she stated, in part: "We ensure all of our staff has CPR cards but we do not do mock codes." She concurred with all of the above findings.

21. An interview was conducted on 01/17/18 at 3:15 p.m. with the Interim Director of Nursing and she concurred with all of the above findings.

B. Based on record review, policy review and staff interview it was determined the facility failed to ensure one (1) RN was in Charge of a Code Blue (cardiopulmonary resuscitation {CPR}) and failed to ensure registered nurse (RN) #1, 2, 3 and 4 and Licensed Practical Nurse (LPN) #1 notified physician #1 of a emergent change of condition in one (1) of one (1) patients who had an emergent change of condition (patient #1). This failure has the potential for all patients with an emergent change of condition to not receive appropriate care by a physician.

1. Review of the medical record for patient #1 revealed on 01/07/18 from 9:00 p.m. through 10:35 p.m. there was no documentation of physician notification in the change of condition for a fever of 100.6 or that the patient had stopped breathing and a cardiopulmonary resuscitation had begun or the patient was transferred to United Hospital Center.

2. Review of the policy titled "Change of Condition and Provision of Emergency Services", last revised 10/19/16, revealed it states, in part: "To monitor and report changes in patient condition to appropriate staff (i.e. physician or therapist) changes to be reported would be any move from baseline...Physical changes: Difficulty breathing...Any method of treatment i.e., inducing vomiting shall be dependent on the condition of the patient. If the patient is comatose, supportive therapy to maintain adequate, cardiac and respiratory function shall be instituted...The appropriate notification procedures and documentation shall be completed."

3. An interview was conducted with the Medical Director on 01/15/18 at approximately 2:00 p.m. When asked if Doctor #1 notified her of the patient's change of condition, she stated, in part: "No, I was notified of the patient's death and I called her to let her know." At the time of the interview she concurred with the above findings.

4. An interview was conducted with Doctor #1 on 01/17/18 at 2:50 p.m. When asked if she was informed by RN #1 of the change of condition with patient #1, she stated, in part: "No, after he was transferred to United Hospital Center the Medical Director contacted me to tell me the patient died."