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Based on review of the Clinical Decision Unit Scope of Services, policy review, observations, medical record review, staff interviews, review of police reports, staffing assignments, patient census, personnel files and training material, the hospital failed to have an effective Governing Body to ensure the protection of patients' rights and an organized nursing service to ensure the safety of patients.

The findings include:

1. Hospital staff failed to protect and promote patients' rights for a safe environment for patients on 6D (Clinical Decision Unit) as evidenced by failing to monitor, evaluate and assess environmental safety and care delivery to behavioral health patients.

~cross refer to 482.13 Patients' Rights, Condition Tag A0115

2. Nursing staff failed to demonstrate an organized nursing service as evidenced by failing to ensure a safe environment for the delivery of care to patients on 6D (Clinical Decision Unit) during a psychiatric emergency.

~cross refer to 482.23 Nursing Services, Condition Tag A0385

Based on review of the Clinical Decision Unit Scope of Services, policy review, observations, medical record review, staff interviews, review of police reports, staffing assignments, patient census, personnel files and training material, hospital staff failed to protect and promote patients' rights for a safe environment for patients on 6D (Clinical Decision Unit) as evidenced by failing to monitor, evaluate and assess environmental safety and care delivery to behavioral health patients.

The findings include:

Hospital staff failed to provide a safe setting for the delivery of patient care on 6D (Clinical Decision Unit) as evidenced by failing to assess and eliminate environmental hazards and failing to ensure trained and qualified staff were assigned and available to direct response during a behavioral emergency for 1 of 1 sampled patients (#5).

~cross refer to 482.13(c)(2) Patients' Rights Standard: Tag A0144

Based on review of the hospital's "Clinical Decision Unit Scope of Services", policy review, observations, medical record review, staff interviews, review of police reports, staffing assignments, patient census, personnel files and training material, the hospital failed to provide a safe setting for the delivery of patient care on 6D (Clinical Decision Unit) as evidenced by failing to assess and eliminate environmental hazards and failing to ensure trained and qualified staff were assigned and available for direct response during a behavioral emergency for 1 of 1 sampled patients (#5).

The findings include:

Review of the "Scope of Service/Care Clinical Decision Unit (CDU)" revised November 2010 revealed "... The Clinical Decision Unit (CDU), a unit within a unit, exists for patients who have been directed by a Primary Care Physician, Emergency Department Physician, or PICS (hospitalist) physician who determined that the patient requires an inpatient care admission or observation status.... Patient population is adult (age 18-65) and geriatric patients (age 65 and over). The patient initial history assessment along with a full systems assessment is used initially to assess patients' needs.... Care of the patient may include the following diagnostic modalities or therapies: cardiac telemetry monitoring available, oxygen therapy, safety management.... Inclusion criteria: Patients who require admission to a Medical/Surgical unit and/or telemetry, Patients age 18 to geriatric. Exclusionary Criteria: ...Behavioral Health primary diagnosis patients.... Registered nurses care for patients. Support staff includes secretaries and care technicians who are supervised by a registered nurse.... Patient safety is given the highest priority in annual education and includes restraint, medication, and risk topics. Updates in procedure care, changes in technology, and/or patient populations are provided...."

Review of "Suicide Precautions" policy revised June 15, 2010 revealed "Patients on suicide precautions will be monitored by a Safety Attendant on a 1:1 basis (one staff to one patient).... Stay with the patient under suicide precautions on non-behavioral health units and patients on 1:1 monitoring within an inpatient behavioral health unit at all times until relieved by appropriate personnel, including times when the patient must travel off the unit.... Inform the RN (registered nurse) - by using the call bell - of changes in the patient's condition, patient needs/requests, or when assistance is needed.... The safety attendant will keep the patient within sight at all times and will keep his/her focus on the patient."

Observations during tour of 6D (CDU) on 06/07/2011 at 1600 revealed an unlocked 14 bed unit with 11 patients assigned to beds on the unit. Review of the patient census and staff interview at the time of observation revealed 4 medical patients and 7 behavioral health patients were assigned to the unit.
Review of patient information provided during tour revealed 3 of the 7 behavioral health patients located on 6D were petitioned for involuntary commitment (determined to be a danger to self or others). Interview with a staff nurse during the tour revealed the unit accepts medical patients and behavioral health patients. Interview revealed the patients could be observation status, admitted pending room placement or emergency department patients (outpatients) pending placement (behavioral health patients). Interview revealed that the unit 6D (CDU) started admitting behavioral health patients around October 2010. Interview revealed safety measures for patients included all behavior health patients assigned to the unit have 1:1 (1 staff to 1 patient) Safety Attendants (sitters) assigned. Observation confirmed 1:1 staff were present with the behavioral health patients during tour. Observation revealed no seclusion room or isolated area was available on 6D. Interview with the staff nurse during tour revealed 6D staff do not use restraints or seclusion on this unit. The staff member stated "If they act out, we send them to the emergency department." Interview revealed there was no video or audio surveillance available on the unit. Observation during tour of 6D (CDU) revealed patient room (#687) with two windows approximately 6 foot tall by 3 1/2 foot wide on two walls of the room. Observation revealed a rooftop three floors below the windows with shattered glass present below each window. Observation revealed all patient rooms on 6D had the same windows and also had pictures hanging on the walls. Interview with staff during the tour revealed patient room #687 was currently out of service because the windows had to be replaced after a patient broke the glass out of the windows the prior week. Interview revealed the room could not be used until the blinds were replaced.

Review on 06/08/2011 of Patient #5's closed medical record revealed a 30 year-old male that presented to the hospital's emergency department (ED) on 05/26/2011 at 1424 with a chief complaint of "depression and suicidal thoughts." Review of the triage note recorded at 1438 revealed "The patient has had suicidal thoughts (Pt says 'I ran through a sliding glass door.') Has no obvious injury noted in triage. The patient describes serious intent." Record review revealed suicide precautions were initiated at 1430. Review of the ED physician's examination revealed the patient was seen on 05/26/2011 at 1623. Review of the notes revealed the patient had a prior admission to the hospital's behavioral unit on 05/09/2011 through 05/19/2011 for suicide thoughts, depression and hallucinations. Notes recorded the patient reported he was having panic attacks and medications were not helping. Physician notes recorded "Patient states after the anxiety attacks he gets very angry, rages out and thinks about hurting himself and others. Patient states a couple of nights ago he ran through a glass door and broke it when he raged out after an anxiety attack. Patient states he has suicidal thoughts of overdose, but would not act out on this because he does not want to leave his mother and sister." Further review of the physician's notes revealed "seen and admitted for depression. Patient feels he's not controlling his anger and may be at risk for self harm.... Access (behavioral health consultant) feels as if too impulsive and unable to contract for safety, will commit. Protective custody form completed. Clinical Impression: Mood disorder, Suicidal ideation, Depression." Review of a behavioral health consult note dated 05/26/2011 at 2004 revealed "Patient reports that he has been having suicidal ideation with thoughts of overdose, unable to contract for safety, mood swings and anxiety, where he becomes anxious then rages, and ran through a glass door at his fathers house last evening. Denies psychosis. Spoke with (psychiatrist on call) who recommends inpatient admission. (Hospital behavioral unit) at capacity." Review revealed phone calls for inpatient admission placement were initiated with disposition pending. Further review revealed a petition for Involuntary Commitment (IVC) signed by the physician on 05/26/2011 at 2345 that recorded that the patient was a danger to himself with suicidal and homicidal ideations with a plan to overdose. Review of nursing notes revealed the patient was transferred to 6D (CDU) room #687 on 05/26/2011 at 2104. Review of nursing notes at 2232 revealed the patient was calm and cooperative upon arrival. Review of behavioral health consult notes dated 05/27/2011 at 1010 revealed the patient reported having fits of rage and stated "I've been getting set off by panic and have a rage," especially in the evenings. Review of a psychiatric consult notes dated as dictated 05/27/2011 at 1556 revealed the patient had continued to experience panic attacks with increased levels of rage following discharge from the inpatient behavioral unit on 05/19/2011. Review of the note recorded that the patient expressed that these panic attacks were directed at "anything" and are triggered by miscommunications with other individuals as well as negative comments. The notes recorded the patient acknowledged anger issues and violence. Review of the notes revealed that people as well as situations can often trigger these panic attacks, which included symptoms of shortness of breath, paranoia, claustrophobia and racing heart. Notes recorded that "so far, he has been able to take his rage out on objects and has not resulted in physical altercations with other individuals.... Our recommendations include: 1. The patient is an IVC admission for behavioral health unit. Secondary to the patient getting in an altercation with a patient on the unit in the past, he is unable to be transferred up to the behavior unit at this time. We will continue to look for placement in another psychiatric facility for further evaluation, diagnostic clarification, and medication management. 2. Continue 1:1 supervision until the patient is either transferred to another facility or he is released from the hospital...." Review of behavioral health consult notes dated 05/28/2011 at 1936 recorded that the "Patient reported he is very impulsive and becomes angry and will get suicidal very easily...." Review of behavioral health consult notes dated 06/02/2011 at 1055 revealed "... Patient reported he has had a very difficult time understanding his feelings and stated the most prevalent feeling is anger. Patient reports he has impulse control and anger issues that have made it difficult to control his actions and have led to problems with significant consequences..." Review of nursing notes revealed the patient remained on suicide precautions and had a 1:1 Safety Attendant (sitter) present from arrival on 6D on 05/26/2011 at 2104 through 6/2/2011 at 2305. Review of 6D nursing notes (late entry) dated 06/03/2011 at 0122 recorded "(06/02/2011) 2305. Security precautions maintained: one to one supervision. pt (patient) sitting on side of bed. pt becoming flushed and began to rock back and forth then leaned forward and down between legs. Not responding to any questions asked by the nurse. Pt exhaled loudly, got up and broke picture glass on wall then began banging windows with fist and chair, all windows in room broke. Security called for assistance. Patient appears agitated: writhing hands. appears anxious, restless, agitated, frustrated, angry and hostile and patient is uncommunicative. 2322 security in to see pt. pt taken to ED. Review of an ED charge nurse note dated 06/02/2011 at 2356 revealed "charge note: this pt was escorted here by several public safety officers. I was informed by officers that he "broke all the windows upstairs." Call placed to 6D for report, RN will call back with report." Review of ED nursing notes dated 06/03/2011 at 0011 recorded "Suicide precautions maintained. Pt. in Room 18 (seclusion room), states he does not remember what happened from his "Panic attack" upstairs but the events are slowly coming back to him. Knows he was breaking everything in the room. ... single medium-sized subcutaneous laceration to left arm." Review of physician's note dated 06/03/2011 at 0019 revealed "Pt apparently had episode of rage in 6D and broke glass in room despite having a sitter resulting in LUE (left upper extremity) laceration. On exam, patient has a 10 cm (centimeter) laceration to left arm, medially to SQ (subcutaneous) tissue. Distal NVI (neurovascular intact).... Closed with 7 staples." Review of behavior health consult notes dated 06/03/2011 at 0147 recorded "Upon hearing patient was transferred to room 18 from 6D, I first spoke/listened to the 6D staff, then went down to talk with patient. He had told me during my reassessment of him just a few minutes before that he has these incidents, where he gets upset, panicky, can't breath, and feels like something horrible is going to happen. Once he gets that way, he said, he wants to go after glass - to break glass. Indeed he did exactly that after I left the room, and broke out both windows, ripping a large gash in his upper left arm.... I asked him about the voices he mentioned he was hearing to his 6D nurse. He said words were not discernable. It was like whisperings...." Further record review revealed the patient remained in the emergency department with 1:1 staff present until time of transfer on 06/03/2011 at 1945. The review revealed the patient was transferred to an acute inpatient psychiatric hospital.

Review of a hospital dispatch report revealed a "Code Gray (security alert)" call was placed on 06/02/2011 at 2343 from unit 6D requesting assistance. Review of the report revealed a Public Safety Officer (PSO) arrived on the scene (6D) at 2347 (four minutes after the call for assistance). (NOTE: times on dispatch report are not consistent with times on Public Safety Department report)

Review of Public Safety Department Incident report revealed a response to Unit 6D, room #687 on 06/02/2011 at 2335. Review of the officers statement recorded six PSO (hospital security) responded to a Code Gray on Unit 6D Room 687. PSO #1 and #2 "arrived on the scene first to witness the patient crowded in the corner of (see reference photos) Wall A and Wall B. The patient was crouching low to the ground with a large piece of glass in his right hand. The patient was alert and not reacting to PSO's presence. Room 687 was littered with glass from the very apparent broken windows and picture frame. The patient responded to verbal commands to drop the piece of glass and lay in a prone position along Wall B. PSO's secured the patient with soft hand techniques and cleared the patient of any additional dangerous objects. The patient was responsive to verbal commands and was guided, on each side, to a wheelchair for transport to the Emergency Department. The patient received basic first aid from PSOs with a clean towel wrapping a severe laceration on the left arm, above the elbow. The patient was cooperative and was able to place pressure on the wound with his body. The patient was transferred to the Emergency Department by PSOs (6 named PSOs). (1 named PSO) remained on 6D to assist staff. Information was gathered pertaining to the events prior to the Code Gray. The 6D Charge Nurse was (RN #2) and the patient's nurse was (RN #1). The patient was agitated and hearing voices prior to the incident and (RN #1) and Safety Attendant (#3) were in 687 when the patient was described as "exploded" and began banging on the windows and destroying the glass. Staff evaded the scene to safe locations on the unit and notified Public Safety...."

Interview on 06/08/2011 at 1000 with PSO #1 revealed he was the primary responder to the Code Gray call to 6D Room 687 on 06/02/2011. The officer stated he was in the front lobby of the hospital when he received the call from the dispatcher at 2335 and could tell by the sound in the voice that it was urgent. The officer stated he got off the elevator and observed a Unit Secretary "peeking around the corner into Room 687. The Unit Secretary told me to go to 687. She turned away from the room and left the area. There were no other staff present. I arrived at 687. The door was open, lights off. I see the patient in the corner, crouched down in a stance, shoulders against the wall with a very long piece of glass that would make your kitchen butcher knife look small. There was a lot of glass, a lot of damage. The patient stayed in the corner. I gave him a verbal command to stay down. Another officer arrived. The patient didn't respond. Lights were turned on. We told him to put down the glass in his hand. He tossed it onto Wall A (away from himself). He had no verbal response. I told him to lay down and keep his hands on the ground. He followed, laid on the floor on his stomach with his hands flat to the ground. I and (other PSO) went into the room further and walked to the patient. We secured his arms, cupping his shoulder and searched his hands for weapons/glass. The patient was compliant." Interview revealed other officers arrived and the patient was picked up out of the glass and placed in a wheelchair. PSO #1 stated he saw the blood immediately and saw the injury to the patient's left arm while searching him. The officer stated a clean towel was obtained from a linen closet located in the patient's room and he wrapped the patient's arm. Interview revealed the patient applied pressure to control the bleeding while he was transported to the emergency department. The officer stated five PSOs escorted the patient to the ED and four PSOs remained in the ED with the patient. The officer stated the next time (after the unit secretary) he saw medical staff members was after he had hands on the patient and was calling for a wheelchair. The officer stated "6D staff never administered care to the patient after I arrived. First aid was provided by us (PSOs)." Interview further revealed PSO #1 took pictures of the room around 10 minutes after leaving the ED. The officer presented the pictures and described the scene. PSO #1 revealed that he had received Non-Violent Crisis Intervention (CPI) training upon hire and completes a refresher course annually.

Interview on 06/08/2011 at 1110 with RN #1 revealed the nurse arrived around 2130 to 2200 on 06/02/2011 and was the primary nurse for Patient #5. Interview revealed Patient #5 came to the desk and wanted medication. The nurse stated the patient said he was "seeing things." The nurse stated "I told him to go back to his room and I would be in with some medication. I went to his room and offered the medication. He didn't have ice water. I went to get ice water and returned and gave him the medication. He was calm and talking. He was sitting on the side of the bed and suddenly lowered his body (bent over at the waist). His demeanor changed, red face and eyes, flat affect. I asked him if he wanted Benadryl (as needed medication for anxiety). He knew his meds. He didn't respond to me. I stepped out of the room and returned 30 seconds later. I thought he was mad with me. The Safety Attendant was standing by the door. He jolted up. His aura changed. He was not talking. I said 'We might need to get out of here.' He jumped up and hit the picture with his hands/fists. He jerked the picture off the wall. I grabbed (Safety Attendant) and we left. He threw the picture across the room. We heard noise. The door was open. I went to the nursing station and told the unit secretary to call security. My co-workers were at the nursing station. We could hear glass shattering. It sounded like a bowling ball hitting. I and (another nurse) went into the break room (locked area) to protect ourselves. All staff were going to the medication room (locked area). The CNA was down in Room 693 with a medical patient (away from Room #687). The three RNs (named) went to the medication room. There was a housekeeper on the unit that moved toward room 693. The Safety Attendants with the behavioral patients closed their doors and remained with their patients. (Safety Attendant #3 assigned to Patient #5) went to the medication room. I called the operator (from the break room) and she said they (PSOs) are up there. (Another nurse) and I came out of the room." Interview revealed there were 6 PSOs with the patient when she went to the room. The nurse stated she saw that the patient was bloody. Interview revealed PSO asked for a towel and wheelchair. The nurse revealed that she did not get close to the patient and did not assess his injury. Interview revealed Patient #5 never threatened her, but he had threatened another patient in Room #690 two days before this incident. The nurse stated the patient had a history of violence and should not have been on 6D. Interview revealed the patient was "banned from admission here (behavioral unit) due to a prior history of attacking a patient in the behavioral unit here." Interview revealed Unit 6D started getting behavioral patients around a year ago. Interview revealed RN #1 has not been trained in Non-Violent Crisis Intervention (CPI). Interview revealed the Safety Attendants were left to care for patients on 6D during the incident and that no licensed nursing staff were supervising or directing the behavioral emergency. The staff member stated "It was like a terrorist situation. I felt threatened based on his demeanor. He never verbally threatened me." Interview revealed the patient was transported by PSOs to ED room #18 which is a padded seclusion room. The staff member stated "My concern was patient safety and our safety. I did not think he was going to jump (out the window). He could have jumped. I thought he was going to hurt us. I was worried about the other patients. I don't think anybody was directing the situation. All nursing were in locked areas. I never saw a doctor."

Interview on 06/08/2011 at 1205 with Safety Attendant #3 revealed she has worked all units of the hospital as a sitter. Interview revealed her job as a Safety Attendant is to keep the patient safe from harm. Interview revealed she was assigned to Patient #5 on 06/02/2011 from 1900 through 0700. The staff member stated "He had a visitor. Everything was fine. He wanted his meds and I walked him to the nursing station and he told the nurse he wanted his meds. We returned to the room and he laid in the bed. Around 30 minutes later, the tech took his vital signs. He laid back down and suddenly jumped up and left the room. He was going back to the nursing station. He told (RN #1) he needed his medication. He told her they stopped his Prozac (depression medication) that day and he was hearing voices. Earlier that night he thought he saw a cat jump up on the table. I passed it off. The nurse was going to bring his meds to the room. He returned to his room and I followed him. The nurse came with his meds, then left to get water. I could tell he was upset. He was holding his head down, face was dark red. He is angry. I stood over by the wall toward the door. He shook his head and threw his hands up. I am by myself in the room. The nurse returned with water and he took his meds. She asked if he wanted Benadryl. He would not respond. She left the room, outside the door and came back in and touched my arm. He immediately jumped up from bed to the window and was beating it with both fists. The blinds were down. We could hear glass shattering. The nurse held my arm pulling me toward the doorway. She let it go and told the staff at the nursing station to call PSO. I stood in the hall. I didn't know what to do. We went into the medication room. (RN #1) went into the break room. All nurses were in the locked areas. Another nurse came from 6C (she heard the noise) and she went into the med room. I stayed in there until I heard PSO arrived. After arrival, I returned to the patient's room. I saw the patient in the corner with glass in his hand. We went to the locked rooms for safety. The other Safety Attendants with behavioral patients closed their doors." Interview revealed the staff member had not received Non-Violent Crisis Intervention training or restraint training.

Interview was attempted with CNA #4 who worked on 6D on 06/02/2011 during the incident with Patient #5. The staff member declined to interview.

Interview on 06/08/2011 at 1600 with the Nurse Manager on Unit 6D revealed the unit opened in October 2004 as an observation unit and transitioned within a year to a Clinical Decision Unit. The staff member stated around June 2010 the emergency department had an increase in behavioral health patients and no beds available. Interview revealed Unit 6D (CDU) started getting the behavioral health patients that were waiting placement to assist with the ED flow. Interview revealed safety measures were taken that included removing trash can liners, gloves, telephone and telephone cord, having a 1:1 Safety Attendant with all behavioral health patients and having a security presence (PSOs made rounds on the unit and were available when called). Interview revealed Non-Violent Crisis Intervention (CPI) training is required for nursing staff and that 80% of the nursing staff on 6D were trained. Interview revealed Non-Violent Crisis Intervention training is not required for Safety Attendants. Interview revealed the Safety Attendants were taught not to touch patients. Interview further revealed that Unit 6D had admitted adolescent patients "early on" but had not taken pediatrics/adolescents since 6 to 9 months ago. Interview revealed Environment of Care Rounds are conducted annually to identify safety hazards. Interview revealed there had been no concerns identified with non-laminated windows on 6D when the patient population included behavioral patients. Interview revealed no concerns were identified with the unit not being a locked unit and having patients that were petitioned for IVC. Interview revealed staff did not have body alarms or have a panic button to utilize in case of behavioral emergencies. Interview revealed nursing staff had no prior warning of Patient #5's behavior on 06/02/2011 and the staff were fearful. Interview revealed staff were following Non-Violent Crisis Intervention procedures and waiting for ample backup to maintain safety.

Review of staff assignments for Unit 6D on 06/02/2011 from 2300 to 0700 revealed 4 registered nurses (RNs), 1 RN orientee, 1 Certified Nursing Assistant (CNA), 1 Unit Secretary and 5 Safety Attendants (sitters). Review of patient census and assignments revealed there were 10 patients on 6D during this shift with 5 medical patients and 5 behavioral health patients. Review of the assignment revealed RN #1 was assigned to provide care to Patient #5. Review Safety Attendant #3 was assigned as a sitter with Patient #5 during this shift.

Review of personnel file for RN #1 (assigned to Patient #5 during incident on 06/02/2011) revealed the nurse was hired on 07/31/2006. Review of the file revealed RN #1 had not received Non-Violence Crisis Intervention (CPI, behavioral health emergency response) training. Interview on 06/09/2011 at 1645 with a nurse educator confirmed that RN #1 had not received Non-Violence Crisis Intervention training.

Review of personnel file for Safety Attendant #3 (assigned to Patient #5 during incident on 06/02/2011) revealed the staff member was hired on 11/29/2010. Review of the file revealed Safety Attendant #3 had not received Non-Violence Crisis Intervention (CPI, behavioral health emergency response) training. Interview on 06/09/2011 at 1645 with a nurse educator confirmed that Safety Attendant #3 had not received Non-Violence Crisis Intervention training.

Interview on 06/09/2011 at 1700 with with the Nurse Manager on Unit 6D revealed the Charge Nurse usually determines patient care assignments. Interview revealed there was no process in place to determine competency with Non-Violent Crisis Intervention (CPI) prior to assignment of behavioral health patients. Interview revealed there were nurses working on 06/02/2011 during the incident with Patient #5 that had completed Non-Violent Crisis Intervention training. Interview confirmed RN staff with Non-Violent Crisis Intervention training were assigned to medical patients and RN staff with no Non-Violent Crisis Intervention training were assigned to behavioral patients.

Review of Non-Violent Crisis Intervention (CPI) training material revealed "The Non-Violent Crisis Intervention program is a safe, nonharmful behavior management system designed to help human service professionals provide for the best possible Care, Welfare, Safety and Security of disruptive, assaultive, and out-of-control individuals - even during their most violent moments." Review of the training material revealed program objectives included preventive techniques (de-escalation) and non-violent physical crisis intervention (physical control and restraint positions). Review of the training material does not direct staff to leave a patient unattended during escalating behaviors.

Interview on 06/09/2011 at 1130 with a Non-Violent crisis Intervention (CPI) trainer revealed CPI training teaches techniques for de-escalation and safe physical restraints when necessary. Interview revealed CPI does not train staff to leave a patient during a behavioral emergency. The staff member stated that staff are taught to observe the patient from a safe distance until enough help arrives to safely restrain the patient. Interview revealed it would never be appropriate or safe to leave the patient in a crisis situation.

Consequently, Patient #5 presented to the emergency department on 05/26/2011 at 1424 and was petitioned for IVC due to being a danger to self and others. The patient was identified by staff as having panic attacks followed by fits of rage that could be violent. The patient verbalized that when he became upset he wanted to "break glass." The patient was placed in room #687 on unit 6D pending admission placement. Unit 6D had environmental hazards including pictures with non-laminated glass hanging on the walls and windows with non-laminated glass. Staff assigned to the patient on 06/02/2011 did not have training in Non-Violent Crisis Intervention (response to a behavioral emergency). Patient #5's behaviors escalated and the patient broke the glass in the picture and windows. Nursing staff and the patient's assigned 1:1 sitter retreated to locked areas for safety leaving other patients and their 1:1 sitters without licensed staff available for assistance and direction. Patient #5 was left alone in an unsafe setting without nursing supervision during a psychiatric emergency.

Based on policy review, Clinical Decision Unit Scope of Services review, observations, medical record review, staff interviews, review of police reports, staffing assignments, patient census, personnel files and training material, the hospital's nursing staff failed to demonstrate an organized nursing service as evidenced by failing to ensure a safe environment for the delivery of care to patients on 6D (Clinical Decision Unit) during a psychiatric emergency.

The findings include:

1. Nursing staff failed to provide a safe setting for the delivery of patient care on 6D (Clinical Decision Unit) by failing to assess, supervise and monitor care during a psychiatric emergency for 1 of 1 sampled patients (#5); and nursing staff failed to assess an injury after a fall for 1 of 1 sampled patients with a fall (#6).

~cross refer to 482.23 (b)(3) Nursing Services Standard: Tag A0395

2. Nursing staff failed to assure qualified and competent staff were assigned to provide safe delivery of care to a behavioral health patient for 1 of 1 sampled patients (#5).

~cross refer to 482.23 (b)(5) Nursing Services Standard: Tag A0397

Based on policy review, Clinical Decision Unit Scope of Services review, observations, medical record review, staff interviews, review of police reports, staffing assignments, patient census, personnel files and training material, nursing staff failed to provide a safe setting for the delivery of patient care on 6D (Clinical Decision Unit) by failing to assess, supervise and monitor care during a psychiatric emergency for 1 of 1 sampled patients (#5); and nursing staff failed to assess an injury after a fall for 1 of 1 sampled patients with a fall (#6).

The findings include:

Review of "Suicide Precautions" policy revised June 15, 2010 revealed "Patients on suicide precautions will be monitored by a Safety Attendant on a 1:1 basis (one staff to one patient).... Stay with the patient under suicide precautions on non-behavioral health units and patients on 1:1 monitoring within an inpatient behavioral health unit at all times until relieved by appropriate personnel, including times when the patient must travel off the unit.... Inform the RN (registered nurse) - by using the call bell - of changes in the patient's condition, patient needs/requests, or when assistance is needed.... The safety attendant will keep the patient within sight at all times and will keep his/her focus on the patient."

Review of the "Scope of Service/Care Clinical Decision Unit (CDU)" revised November 2010 revealed "... The Clinical Decision Unit (CDU), a unit within a unit, exists for patients who have been directed by a Primary Care Physician, Emergency Department Physician, or PICS (hospitalist) physician who determined that the patient requires an inpatient care admission or observation status.... Patient population is adult (age 18-65) and geriatric patients (age 65 and over). The patient initial history assessment along with a full systems assessment is used initially to assess patients' needs.... Care of the patient may include the following diagnostic modalities or therapies: cardiac telemetry monitoring available, oxygen therapy, safety management.... Inclusion criteria: Patients who require admission to a Medical/Surgical unit and/or telemetry, Patients age 18 to geriatric. Exclusionary Criteria: ...Behavioral Health primary diagnosis patients.... Registered nurses care for patients. Support staff includes secretaries and care technicians who are supervised by a registered nurse.... Patient safety is given the highest priority in annual education and includes restraint, medication, and risk topics. Updates in procedure care, changes in technology, and/or patient populations are provided...."

Observations during tour of 6D (CDU) on 06/07/2011 at 1600 revealed an unlocked 14 bed unit with 11 patients assigned to beds on the unit. Review of the patient census and staff interview at the time of observation revealed 4 medical patients and 7 behavioral health patients were assigned to the unit.
Review of patient information provided during tour revealed 3 of the 7 behavioral health patients located on 6D were petitioned for involuntary commitment (determined to be a danger to self or others). Interview with a staff nurse during the tour revealed the unit accepts medical patients and behavioral health patients. Interview revealed the patients could be observation status, admitted pending room placement or emergency department patients (outpatients) pending placement (behavioral health patients). Interview revealed 6D (CDU) started admitting behavioral health patients around October 2010. Interview revealed safety measures for patients included all behavior health patients assigned to the unit have 1:1 (1 staff to 1 patient) Safety Attendants (sitters) assigned. Observation confirmed 1:1 staff were present with the behavioral health patients during tour. Observation revealed no seclusion room present on 6D. Interview with the staff nurse during tour revealed 6D staff do not use restraints or seclusion on this unit. The staff member stated "If they act out, we send them to the emergency department." Interview revealed there was no video or audio surveillance available on the unit. Observation during tour of 6D (CDU) revealed patient room (#687) with two windows approximately 6 foot tall by 3 1/2 foot wide on two walls of the room. Observation revealed a rooftop three floors below the windows with shattered glass present below each window. Observation revealed all patient rooms on 6D had the same windows and also had pictures hanging on the walls. Interview with staff during the tour revealed patient room #687 was currently out of service because the windows had to be replaced after a patient broke the glass out of the windows the prior week. Interview revealed the room could not be used until the blinds were replaced.

Review on 06/08/2011 of Patient #5's closed medical record revealed a 30 year-old male that presented to the hospital's emergency department (ED) on 05/26/2011 at 1424 with a chief complaint of "depression and suicidal thoughts." Review of the triage note recorded at 1438 revealed "The patient has had suicidal thoughts (Pt says 'I ran through a sliding glass door.') Has no obvious injury noted in triage. The patient describes serious intent." Record review revealed suicide precautions were initiated at 1430. Review of the ED physician's examination revealed the patient was seen on 05/26/2011 at 1623. Review of the notes revealed the patient had a prior admission to the hospital's behavioral unit on 05/09/2011 through 05/19/2011 for suicide thoughts, depression and hallucinations. Notes recorded the patient reported he was having panic attacks and medications were not helping. Physician notes recorded "Patient states after the anxiety attacks he gets very angry, rages out and thinks about hurting himself and others. Patient states a couple of nights ago he ran through a glass door and broke it when he raged out after an anxiety attack. Patient states he has suicidal thoughts of overdose, but would not act out on this because he does not want to leave his mother and sister." Further review of the physician's notes revealed "seen and admitted for depression. Patient feels he's not controlling his anger and may be at risk for self harm.... Access (behavioral health consultant) feels as if too impulsive and unable to contract for safety, will commit. Protective custody form completed. Clinical Impression: Mood disorder, Suicidal ideation, Depression." Review of a behavioral health consult note dated 05/26/2011 at 2004 revealed "Patient reports that he has been having suicidal ideation with thoughts of overdose, unable to contract for safety, mood swings and anxiety, where he becomes anxious then rages, and ran through a glass door at his fathers house last evening. Denies psychosis. Spoke with (psychiatrist on call) who recommends inpatient admission. (Hospital behavioral unit) at capacity." Review revealed phone calls for inpatient admission placement were initiated with disposition pending. Further review revealed a petition for Involuntary Commitment (IVC) signed by the physician on 05/26/2011 at 2345 that recorded that the patient was a danger to himself with suicidal and homicidal ideations with a plan to overdose. Review of nursing notes revealed the patient was transferred to 6D (CDU) room #687 on 05/26/2011 at 2104. Review of nursing notes at 2232 revealed the patient was calm and cooperative upon arrival. Review of behavioral health consult notes dated 05/27/2011 at 1010 revealed the patient reported having fits of rage and stated "I've been getting set off by panic and have a rage," especially in the evenings. Review of a psychiatric consult notes dated as dictated 05/27/2011 at 1556 revealed the patient had continued to experience panic attacks with increased levels of rage following discharge from the inpatient behavioral unit on 05/19/2011. Review of the note recorded that the patient expressed that these panic attacks were directed at "anything" and are triggered by miscommunications with other individuals as well as negative comments. The notes recorded the patient acknowledged anger issues and violence. Review of the notes revealed that people as well as situations can often trigger these panic attacks, which included symptoms of shortness of breath, paranoia, claustrophobia and racing heart. Notes recorded that "so far, he has been able to take his rage out on objects and has not resulted in physical altercations with other individuals.... Our recommendations include: 1. The patient is an IVC admission for behavioral health unit. Secondary to the patient getting in an altercation with a patient on the unit in the past, he is unable to be transferred up to the behavior unit at this time. We will continue to look for placement in another psychiatric facility for further evaluation, diagnostic clarification, and medication management. 2. Continue 1:1 supervision until the patient is either transferred to another facility or he is released from the hospital...." Review of behavioral health consult notes dated 05/28/2011 at 1936 recorded that the "Patient reported he is very impulsive and becomes angry and will get suicidal very easily...." Review of behavioral health consult notes dated 06/02/2011 at 1055 revealed "... Patient reported he has had a very difficult time understanding his feelings and stated the most prevalent feeling is anger. Patient reports he has impulse control and anger issues that have made it difficult to control his actions and have led to problems with significant consequences..." Review of nursing notes revealed the patient remained on suicide precautions and had a 1:1 Safety Attendant (sitter) present from arrival on 6D on 05/26/2011 at 2104 through 6/2/2011 at 2305. Review of 6D nursing notes (late entry) dated 06/03/2011 at 0122 recorded "(06/02/2011) 2305. Security precautions maintained: one to one supervision. pt (patient) sitting on side of bed. pt becoming flushed and began to rock back and forth then leaned forward and down between legs. Not responding to any questions asked by the nurse. Pt exhaled loudly, got up and broke picture glass on wall then began banging windows with fist and chair, all windows in room broke. Security called for assistance. Patient appears agitated: writhing hands. appears anxious, restless, agitated, frustrated, angry and hostile and patient is uncommunicative. 2322 security in to see pt. pt taken to ED. Review of an ED charge nurse note dated 06/02/2011 at 2356 revealed "charge note: this pt was escorted here by several public safety officers. I was informed by officers that he "broke all the windows upstairs." Call placed to 6D for report, RN will call back with report." Review of ED nursing notes dated 06/03/2011 at 0011 recorded "Suicide precautions maintained. Pt. in Room 18 (seclusion room), states he does not remember what happened from his "Panic attack" upstairs but the events are slowly coming back to him. Knows he was breaking everything in the room. ... single medium-sized subcutaneous laceration to left arm." Review of physician's note dated 06/03/2011 at 0019 revealed "Pt apparently had episode of rage in 6D and broke glass in room despite having a sitter resulting in LUE (left upper extremity) laceration. On exam, patient has a 10 cm (centimeter) laceration to left arm, medially to SQ (subcutaneous) tissue. Distal NVI (neurovascular intact).... Closed with 7 staples." Review of behavior health consult notes dated 06/03/2011 at 0147 recorded "Upon hearing patient was transferred to room 18 from 6D, I first spoke/listened to the 6D staff, then went down to talk with patient. He had told me during my reassessment of him just a few minutes before that he has these incidents, where he gets upset, panicky, can't breath, and feels like something horrible is going to happen. Once he gets that way, he said, he want to go after glass - to break glass. Indeed he did exactly that after I left the room, and broke out both windows, ripping a large gash in his upper left arm.... I asked him about the voices he mentioned he was hearing to his 6D nurse. He said words were not discernable. It was like whisperings...." Further record review revealed the patient remained in the emergency department with 1:1 staff present until time of transfer on 06/03/2011 at 1945. The review revealed the patient was transferred to an acute inpatient psychiatric hospital.

Review of a hospital dispatch report revealed a "Code Gray (security alert)" call was placed on 06/02/2011 at 2343 from unit 6D requesting assistance. Review of the report revealed a Public Safety Officer (PSO) arrived on the scene (6D) at 2347 (four minutes after the call for assistance). (NOTE: times on dispatch report are not consistent with times on Public Safety Department report)

Review of Public Safety Department Incident report revealed a response to Unit 6D, room #687 on 06/02/2011 at 2335. Review of the officers statement recorded six PSO (hospital security) responded to a Code Gray on Unit 6D Room 687. PSO #1 and #2 "arrived on the scene first to witness the patient crowded in the corner of (see reference photos) Wall A and Wall B. The patient was crouching low to the ground with a large piece of glass in his right hand. The patient was alert and not reacting to PSO's presence. Room 687 was littered with glass from the very apparent broken windows and picture frame. The patient responded to verbal commands to drop the piece of glass and lay in a prone position along Wall B. PSO's secured the patient with soft hand techniques and cleared the patient of any additional dangerous objects. The patient was responsive to verbal commands and was guided, on each side, to a wheelchair for transport to the Emergency Department. The patient received basic first aid from PSOs with a clean towel wrapping a severe laceration on the left arm, above the elbow. The patient was cooperative and was able to place pressure on the wound with his body. The patient was transferred to the Emergency Department by PSOs (6 named PSOs). (1 named PSO) remained on 6D to assist staff. Information was gathered pertaining to the events prior to the Code Gray. The 6D Charge Nurse was (RN #2) and the patient's nurse was (RN #1). The patient was agitated and hearing voices prior to the incident and (RN #1) and Safety Attendant (#3) were in 687 when the patient was described as "exploded" and began banging on the windows and destroying the glass. Staff evaded the scene to safe locations on the unit and notified Public Safety...."

Interview on 06/08/2011 at 1000 with PSO #1 revealed he was the primary responder to the Code Gray call to 6D Room 687 on 06/02/2011. The officer stated he was in the front lobby of the hospital when he received the call from the dispatcher at 2335 and could tell by the sound in the voice that it was urgent. The officer stated he got off the elevator and observed a Unit Secretary "peeking around the corner into Room 687. The Unit Secretary told me to go to 687. She turned away from the room and left the area. There were no other staff present. I arrived at 687. The door was open, lights off. I see the patient in the corner, crouched down in a stance, shoulders against the wall with a very long piece of glass that would make your kitchen butcher knife look small. There was a lot of glass, a lot of damage. The patient stayed in the corner. I gave him a verbal command to stay down. Another officer arrived. The patient didn't respond. Lights were turned on. We told him to put down the glass in his hand. He tossed it onto Wall A (away from himself). He had no verbal response. I told him to lay down and keep his hands on the ground. He followed, laid on the floor on his stomach with his hands flat to the ground. I and (other PSO) went into the room further and walked to the patient. We secured his arms, cupping his shoulder and searched his hands for weapons/glass. The patient was compliant." Interview revealed other officers arrived and the patient was picked up out of the glass and placed in a wheelchair. PSO #1 stated he saw the blood immediately and saw the injury to the patient's left arm while searching him. The officer stated a clean towel was obtained from a linen closet located in the patient's room and he wrapped the patient's arm. Interview revealed the patient applied pressure to control the bleeding while he was transported to the emergency department. The officer stated five PSOs escorted the patient to the ED and four PSOs remained in the ED with the patient. The officer stated the next time (after the unit secretary) he saw medical staff members was after he had hands on the patient and was calling for a wheelchair. The officer stated "6D staff never administered care to the patient after I arrived. First aid was provided by us (PSOs)." Interview further revealed PSO #1 took pictures of the room around 10 minutes after leaving the ED. The officer presented the pictures and described the scene. PSO #1 revealed that he had received Non-Violent Crisis Intervention (CPI) training upon hire and completes a refresher course annually.

Interview on 06/08/2011 at 1110 with RN #1 revealed the nurse arrived around 2130 to 2200 on 06/02/2011 and was the primary nurse for Patient #5. Interview revealed Patient #5 came to the desk and wanted medication. The nurse stated the patient said he was "seeing things." The nurse stated "I told him to go back to his room and I would be in with some medication. I went to his room and offered the medication. He didn't have ice water. I went to get ice water and returned and gave him the medication. He was calm and talking. He was sitting on the side of the bed and suddenly lowered his body (bent over at the waist). His demeanor changed, red face and eyes, flat affect. I asked him if he wanted Benadryl (as needed medication for anxiety). He knew his meds. He didn't respond to me. I stepped out of the room and returned 30 seconds later. I thought he was mad with me. The Safety Attendant was standing by the door. He jolted up. His aura changed. He was not talking. I said 'We might need to get out of here.' He jumped up and hit the picture with his hands/fists. He jerked the picture off the wall. I grabbed (Safety Attendant) and we left. He threw the picture across the room. We heard noise. The door was open. I went to the nursing station and told the unit secretary to call security. My co-workers were at the nursing station. We could hear glass shattering. It sounded like a bowling ball hitting. I and (another nurse) went into the break room (locked area) to protect ourselves. All staff were going to the medication room (locked area). The CNA was down in Room 693 with a medical patient (away from Room #687). The three RNs (named) went to the medication room. There was a housekeeper on the unit that moved toward room 693. The Safety Attendants with the behavioral patients closed their doors and remained with their patients. (Safety Attendant #3 assigned to Patient #5) went to the medication room. I called the operator (from the break room) and she said they (PSOs) are up there. (Another nurse) and I came out of the room." Interview revealed there were 6 PSOs with the patient when she went to the room. The nurse stated she saw that the patient was bloody. Interview revealed PSO asked for a towel and wheelchair. The nurse revealed that she did not get close to the patient and did not assess his injury. Interview revealed Patient #5 never threatened her, but he had threatened another patient in Room #690 two days before this incident. The nurse stated the patient had a history of violence and should not have been on 6D. Interview revealed the patient was "banned from admission here (behavioral unit) due to a prior history of attacking a patient in the behavioral unit here." Interview revealed Unit 6D started getting behavioral patients around a year ago. Interview revealed RN #1 has not been trained in Non-Violent Crisis Intervention (CPI). Interview revealed the Safety Attendants were left to care for patients on 6D during the incident and that no licensed nursing staff were supervising or directing the behavioral emergency. The staff member stated "It was like a terrorist situation. I felt threatened based on his demeanor. He never verbally threatened me." Interview revealed the patient was transported by PSOs to ED room #18 which is a padded seclusion room. The staff member stated "My concern was patient safety and our safety. I did not think he was going to jump (out the window). He could have jumped. I thought he was going to hurt us. I was worried about the other patients. I don't think anybody was directing the situation. All nursing were in locked areas. I never saw a doctor."

Interview on 06/08/2011 at 1205 with Safety Attendant #3 revealed she has worked all units of the hospital as a sitter. Interview revealed her job as a Safety Attendant is to keep the patient safe from harm. Interview revealed she was assigned to Patient #5 on 06/02/2011 from 1900 through 0700. The staff member stated "He had a visitor. Everything was fine. He wanted his meds and I walked him to the nursing station and he told the nurse he wanted his meds. We returned to the room and he laid in the bed. Around 30 minutes later, the tech took his vital signs. He laid back down and suddenly jumped up and left the room. He was going back to the nursing station. He told (RN #1) he needed his medication. He told her they stopped his Prozac (depression medication) that day and he was hearing voices. Earlier that night he thought he saw a cat jump up on the table. I passed it off. The nurse was going to bring his meds to the room. He returned to his room and I followed him. The nurse came with his meds, then left to get water. I could tell he was upset. He was holding his head down, face was dark red. He is angry. I stood over by the wall toward the door. He shook his head and threw his hands up. I am by myself in the room. The nurse returned with water and he took his meds. She asked if he wanted Benadryl. He would not respond. She left the room, outside the door and came back in and touched my arm. He immediately jumped up from bed to the window and was beating it with both fists. The blinds were down. We could hear glass shattering. The nurse held my arm pulling me toward the doorway. She let it go and told the staff at the nursing station to call PSO. I stood in the hall. I didn't know what to do. We went into the medication room. (RN #1) went into the break room. All nurses were in the locked areas. Another nurse came from 6C (she heard the noise) and she went into the med room. I stayed in there until I heard PSO arrived. After arrival, I returned to the patient's room. I saw the patient in the corner with glass in his hand. We went to the locked rooms for safety. The other Safety Attendants with behavioral patients closed their doors." Interview revealed the staff member had not received Non-Violent Crisis Intervention training or restraint training.

Interview was attempted with CNA #4 who worked on 6D on 06/02/2011 during the incident with Patient #5. The staff member declined to interview.

Interview on 06/08/2011 at 1600 with the Nurse Manager on Unit 6D revealed the unit opened in October 2004 as an observation unit and transitioned within a year to a Clinical Decision Unit. The staff member stated around June 2010 the emergency department had an increase in behavioral health patients and no beds available. Interview revealed Unit 6D (CDU) started getting the behavioral health patients that were waiting placement to assist with the ED flow. Interview revealed safety measures were taken that included removing trash can liners, gloves, telephone and telephone cord, having a 1:1 Safety Attendant with all behavioral health patients and having a security presence (PSOs made rounds on the unit and were available when called). Interview revealed Non-Violent Crisis Intervention (CPI) training is required for nursing staff and that 80% of the nursing staff on 6D were trained. Interview revealed Non-Violent Crisis Intervention training is not required for Safety Attendants. Interview revealed the Safety Attendants were taught not to touch patients. Interview further revealed that Unit 6D had admitted adolescent patients "early on" but had not taken pediatrics/adolescents since 6 to 9 months ago. Interview revealed Environment of Care Rounds are conducted annually to identify safety hazards. Interview revealed there had been no concerns identified with non-laminated windows on 6D when the patient population included behavioral patients. Interview revealed no concerns were identified with the unit not being a locked unit and having patients that were petitioned for IVC. Interview revealed staff did not have body alarms or have a panic button to utilize in case of behavioral emergencies. Interview revealed nursing staff had no prior warning of Patient #5's behavior on 06/02/2011 and the staff were fearful. Interview revealed staff were following Non-Violent Crisis Intervention procedures and waiting for ample backup to maintain safety.

Review of staff assignments for Unit 6D on 06/02/2011 from 2300 to 0700 revealed 4 registered nurses (RNs), 1 RN orientee, 1 Certified Nursing Assistant (CNA), 1 Unit Secretary and 5 Safety Attendants (sitters). Review of patient census and assignments revealed there were 10 patients on 6D during this shift with 5 medical patients and 5 behavioral health patients. Review of the assignment revealed RN #1 was assigned to provide care to Patient #5. Review Safety Attendant #3 was assigned as a sitter with Patient #5 during this shift.

Review of personnel file for RN #1 (assigned to Patient #5 during incident on 06/02/2011) revealed the nurse was hired on 07/31/2006. Review of the file revealed RN #1 had not received Non-Violence Crisis Intervention (CPI, behavioral health emergency response) training. Interview on 06/09/2011 at 1645 with a nurse educator confirmed that RN #1 had not received Non-Violence Crisis Intervention training.

Review of personnel file for Safety Attendant #3 (assigned to Patient #5 during incident on 06/02/2011) revealed the staff member was hired on 11/29/2010. Review of the file revealed Safety Attendant #3 had not received Non-Violence Crisis Intervention (CPI, behavioral health emergency response) training. Interview on 06/09/2011 at 1645 with a nurse educator confirmed that Safety Attendant #3 had not received Non-Violence Crisis Intervention training.

Interview on 06/09/2011 at 1700 with with the Nurse Manager on Unit 6D revealed the Charge Nurse usually determines patient care assignments. Interview revealed there was no process in place to determine competency with Non-Violent Crisis Intervention (CPI) prior to assignment of behavioral health patients. Interview revealed there were nurses working on 06/02/2011 during the incident with Patient #5 that had completed Non-Violent Crisis Intervention training. Interview confirmed RN staff with Non-Violent Crisis Intervention training were assigned to medical patients and RN staff with no Non-Violent Crisis Intervention training were assigned to behavioral patients.

Review of Non-Violent Crisis Intervention (CPI) training material revealed "The Non-Violent Crisis Intervention program is a safe, nonharmful behavior management system designed to help human service professionals provide for the best possible Care, Welfare, Safety and Security of disruptive, assaultive, and out-of-control individuals - even during their most violent moments." Review of the training material revealed program objectives included preventive techniques (de-escalation) and non-violent physical crisis intervention (physical control and restraint positions). Review of the training material does not direct staff to leave a patient unattended during escalating behaviors.

Interview on 06/09/2011 at 1130 with a Non-Violent crisis Intervention (CPI) trainer revealed CPI training teaches techniques for de-escalation and safe physical restraints when necessary. Interview revealed CPI does not train staff to leave a patient during a behavioral emergency. The staff member stated that staff are taught to observe the patient from a safe distance until enough help arrives to safely restrain the patient. Interview revealed it would never be appropriate or safe to leave the patient in a crisis situation.

Consequently, Patient #5 presented to the emergency department on 05/26/2011 at 1424 and was petitioned for IVC due to being a danger to self and others. The patient was identified by staff as having panic attacks followed by fits of rage that could be violent. The patient verbalized that when he became upset he wanted to "break glass." The patient was placed in room #687 on unit 6D pending admission placement. Unit 6D had environmental hazards including pictures with non-laminated glass hanging on the walls and windows with non-laminated glass. Staff assigned to the patient on 06/02/2011 did not have training in Non-Violent Crisis Intervention (response to a behavioral emergency). Patient #5's behaviors escalated and the patient broke the glass in the picture and windows. Nursing staff and the patient's assigned 1:1 sitter retreated to locked areas for safety leaving other patients and their 1:1 sitters without licensed staff available for assistance and direction. Patient #5 was left alone in an unsafe setting without nursing supervision during a psychiatric emergency.



14819

2. Closed record review of patient #6 revealed an 85 year old female admitted to the hospital on 02/16/2011 at 0953 with diagnosis of right sided weakness, malignant hypertension and stroke symptoms.

Review of an incident report showed on 02/17/2011 at approximately 1600 the patient needed assistance to use the bedside potty chair. The nurse left her on the potty , BSC (bedside commode) alone. The patient was given the call bell and was told not to get up by herself. She was told that someone would be back in a few minutes but to use the call bell if needed. The patient did not use the call bell and tried to get up alone. The patient then fell sustaining a laceration on the back of her head. Further note in the incident report stated "I (nurse manger) visited the patient and the patient stated that the nurse did tell her not to get up by herself. She stated that the nurse did not leave her alone for more than a couple of minutes. The patient apologized for not following the nurse's instructions". Further review of the incident report revealed, "Patient instructed to call for assistance when finished on the bedside commode. Patient stated that she knew that the care tech told her to ask for assistance but she thought that she was able to get up herself." The patient stated in an interview by the nurse "My nurse just left me for a minute to have privacy on the commode. He told me not to get up. He gave me the call bell and told me to call him. I knew not to get up but I thought I could do it myself. I'm sorry."

Review of patient's medical record showed the patient did sustain a laceration on the back of her head. The physician wrote orders for a CT of Head without contrast, which was done and read on 02/17/2011 at 1827. Review of the head CT revealed "Conclusion 1. superficial injury as above. No evidence of acute Intracranial hemorrhage." Continued review of the medical record did not show that the wound had been assessed following the fall, in regards to the size of the laceration, how deep the laceration was. Review revealed no documentation to indicate the wound had been cleaned and appropriately dressed. Review of Interdisciplinary Documentation forms revealed a nursing note on 02/17/2011 at 2000 (four hours after the fall) that the patient had a laceration to the back of the head with pressure dressing intact. Review of the "Interdisciplinary Patient Plan of Care Outcomes Evaluation" for the date of 02/17/2011 showed only one entry on 02/17/2011 1900 - 0700 "...Pt had moderate bleeding from fall laceration." There was no 0700 - 1900 shift documentation regarding the fall or laceration by the nurse. Review of Interdisciplinary Documentation forms showed on 02/18/2011 occipital laceration from fall o

Based on policy review, staffing assignment review, personnel file review, closed medical record review and staff interview, the hospital's nursing staff failed to assure qualified and competent staff were assigned to provide safe delivery of care to a behavioral health patient for 1 of 1 sampled patients (#5).

The findings include:

Review of "Staffing and Scheduling" policy revised January 2011 revealed "Patient units will be staffed by competent nursing members who will assess and meet individualized nursing care needs of the patients. Patients will have their care planned, supervised and evaluated by registered nurses. ... 4. Assignments and Daily Staffing: a) Patient care is administered under the direction of the Registered Nurse who retains ultimate responsibility for all patient care activities. b) when making decisions regarding work assignments, the following are considered: (1) The individual's ability to provide care is based on education, clinical experience, and specialized training. (2) The patients' needs and the level of care required. (3) The availability of employees with experience in the area to be utilized as a resource...."

Review of staff assignments for Unit 6D (Clinical Decision Unit) on 06/02/2011 from 2300 to 0700 revealed 4 registered nurses (RNs), 1 RN orientee, 1 Certified Nursing Assistant (CNA), 1 Unit Secretary and 5 Safety Attendants (sitters). Review of patient census and assignments revealed there were 10 patients on 6D during this shift with 5 medical patients and 5 behavioral health patients. Review of the assignment revealed RN #1 was assigned to provide care to Patient #5. Review revealed Safety Attendant #3 was assigned as a sitter with Patient #5 during this shift.

Review of personnel file for RN #1 (assigned to Patient #5 during incident on 06/02/2011) revealed the nurse was hired on 07/31/2006. Review of the file revealed RN #1 had not received Non-Violence Crisis Intervention (CPI, behavioral health emergency response) training. Interview on 06/09/2011 at 1645 with a nurse educator confirmed that RN #1 had not received Non-Violence Crisis Intervention training.

Review of personnel file for Safety Attendant #3 (assigned to Patient #5 during incident on 06/02/2011) revealed the staff member was hired on 11/29/2010. Review of the file revealed Safety Attendant #3 had not received Non-Violence Crisis Intervention (CPI, behavioral health emergency response) training. Interview on 06/09/2011 at 1645 with a nurse educator confirmed that Safety Attendant #3 had not received Non-Violence Crisis Intervention training.

Review on 06/08/2011 of Patient #5's closed medical record revealed a 30 year-old male that presented to the hospital's emergency department (ED) on 05/26/2011 at 1424 with a chief complaint of "depression and suicidal thoughts." Review of the triage note recorded at 1438 revealed the patient was having suicidal thoughts. Record review revealed suicide precautions were initiated at 1430. Review of the ED physician's examination revealed the patient was seen on 05/26/2011 at 1623. Review of the notes revealed the patient had a prior admission to the hospital behavioral unit on 05/09/2011 through 05/19/2011 for suicide thoughts, depression and hallucinations. Notes recorded the patient reported he was having panic attacks and medications were not helping. Physician notes recorded "Patient states after the anxiety attacks he gets very angry, rages out and thinks about hurting himself and others. Patient states a couple of nights ago he ran through a glass door and broke it when he raged out after an anxiety attack. Patient states he has suicidal thoughts of overdose, but would not act out on this because he does not want to leave his mother and sister." Further review of the physician's notes revealed "seen and admitted for depression. Patient feels he's not controlling his anger and may be at risk for self harm.... Access (behavioral health consultant) feels as if too impulsive and unable to contract for safety, will commit. Protective custody form completed. Clinical Impression: Mood disorder, Suicidal ideation, Depression." Review of a behavioral health consult note dated 05/26/2011 at 2004 revealed the hospital's behavioral unit was at capacity. Review revealed phone calls for inpatient admission placement were initiated with disposition pending. Further review revealed a petition for Involuntary Commitment (IVC) signed by the physician on 05/26/2011 at 2345 that recorded that the patient was a danger to himself with suicidal and homicidal ideations with a plan to overdose. Review of nursing notes revealed the patient was transferred to 6D (Clinical Decision Unit) room #687 on 05/26/2011 at 2104. Review of nursing notes revealed the patient remained on suicide precautions and had a 1:1 safety attendant (sitter) present from arrival on 6D on 05/26/2011 at 2104 through 6/2/2011 at 2305. Review of 6D nursing notes (late entry) dated 06/03/2011 at 0122 recorded the patient became angry and hostile, got out of bed and broke the glass out of the picture on the wall and then began breaking the windows with his fists and a chair. The notes recorded that all windows in the room were broke and security was called for assistance. Review revealed Public Safety Officers (PSO) arrived and took the patient to the emergency department. Review of physician's note dated 06/03/2011 at 0019 revealed "Pt apparently had episode of rage in 6D and broke glass in room despite having a sitter resulting in LUE (left upper extremity) laceration. On exam, patient has a 10 cm (centimeter) laceration to left arm, medially to SQ (subcutaneous) tissue. Distal NVI (neurovascular intact).... Closed with 7 staples."

Interview on 06/09/2011 at 1700 with the Nurse Manager on Unit 6D revealed the Charge Nurse usually determines patient care assignments. Interview revealed there was no process in place to determine competency with Non-Violent Crisis Intervention (CPI) prior to assignment of behavioral patients. Interview revealed there were nurses working on 06/02/2011 during the incident with Patient #5 that had completed Non-Violent Crisis Intervention training. Interview confirmed RN staff with Non-Violent Crisis Intervention training were assigned to medical patients and RN staff with no Non-Violent Crisis Intervention training were assigned to behavioral patients.

NC00073403, NC00072367, NC00071179