HospitalInspections.org

Based on record review and interview the facility failed to meet the Condition of Participation on Patient Rights as evidenced by the facility failed to ensure the policies were followed to monitor behavioral health patients every 15 minutes, and to provide safe care and treatment to sampled patients (SP#2) to prevent abuse and death in 1 of 10 sampled patients, and to provide level 3 (1:1) monitoring for 1 of 10 sampled patients (SP) #1 who admitted to committing a violent act against SP #2.

(Refer to A-145 and A-396)

Based on interview and record review, the facility failed to ensure policies were followed to monitor behavioral health patients every 15 minutes, and provide safe care and treatment to sampled patient (SP#2) to prevent abuse (death) in 1 of 10 sampled patients, and to provide level 3 (1:1) monitoring for 1 of 10 sampled patients (SP) #1 who admitted to committing a violent act against SP #2.


Findings include:

1. Sampled Patient #2 medical record showed he was Baker Acted on 06/05/2014 with bizarre behavior. According to the discharge summary dated 07/01/2014, the patient was seen and evaluated, was grossly psychotic, and internally preoccupied. There was no interactions with peers. The summary further stated that on 06/23/2014, the patient reported feeling better, psychosis was less intrusive, more interactive, no depressive symptoms and no side effects to medications.

According to the "Behavioral Health Services 24 hour Intensive Monitoring Log," the patient was on Q (every) 15 minutes observation rounding as ordered since admission on 06/05/2014. On 06/26/2014 there was no documentation to show that SP#2 was observed from 2:45pm to 3:35pm (approximately 50 minutes during the time of the emergency incident).

On June 26, 2014 the physician note documented that SP# 2 was found on the floor by the RN (Registered Nurse). A Code Blue was called (at 3:38 PM), and SP #2 was in cardio-pulmonary arrest. Initial rhythm was asystole (no rhythm, no pulse). The RN found the patient (SP#2) on the floor with the bed sheet around his neck. The patient's face and upper neck were swollen and cyanotic. Epistaxis (nose bleed) was evident. Patient was unresponsive, cold, and pulseless. CPR (Cardio Pulmonary Resuscitation) was initiated. All attempts at resuscitation were unsuccessful.

On July 2, 2014 at 10:30 AM during interview, the ACNO (Assistant Chief Nursing Officer) and the Director of BHU (Behavioral Health Unit) it was stated that SP#1 was admitted around 10:00 AM on June 26, 2014 and was placed in the same room with SP#2 who was later found on the floor next to his bed by the housekeeper around 3:35 PM, while making a final round prior to the end of the shift. The nurse (NS#7) on duty was notified and found SP#2 unresponsive. A Code Blue was called with prompt response and ACLS (Advanced Cardiac Life Support) protocol was followed but was unsuccessful. SP#1 was found in the bathroom taking a shower and was escorted out to the next room. The staff originally thought SP #2 injuries were self-inflicted due to the sheet around SP #2's neck and was not tied to anything. Everyone was interviewed but management couldn't determine how the incident could have happened. Police assistance was eventually requested after an hour and they responded promptly. The area was secured and nothing was removed. Police took over the investigation and started to conduct their own interviews. No one initially suspected that SP#1 could have something to do with the death of SP#2. No one noticed anything unusual with SP#1.
The ACNO and Director of BHU further reported, that sometime close to dinner time SP#1 confided to SP#3 that he had done something really bad and that he killed somebody. SP#3 then told the MHT (Mental Health Technician (NS#9) and the Director of BHU what SP#1 had told her, that he had did something wrong and that he killed somebody.


Interview via phone on 7/3/2014 at 11:05 am, (Nurse Sample) NS#7 stated that she was sitting at the corner of the nurse's station and behind her was the room for SP#2. The distance could not have been more than 10 feet. The room door was open. NS#7 stated that she could have easily heard something if they were fighting or struggling inside the room, but she did not hear anything. NS#7 further stated that she knew SP#2 was in the room but I didn't actually check at 3:15 PM.

On 7/3/2014 at 12 noon the Mental Health Technician (MHT) (NS#9) who was on duty on 6/26/2014 stated that it was a busy day and she took a late lunch break around 3PM. She was giving care to a patient in the adjacent room and SP#2 was visible from where she was, and that she even spoke with SP #2 right before she clocked out for lunch break around 3 PM. She reports, SP#2 was in the room lying in bed talking to himself. NS#9 stated that she failed to record the rounding at 3:00 pm since she was leaving already. NS#9 also stated that there was nothing suspicious about the actions of SP#1.

2. Clinical record review showed that SP #1 arrived at the (Emergency Department) ED at 04:46 am on 06/26/2014 after being baker acted by the police department. The local police Baker Act report titled "Report of Law Enforcement Officer Initiating Involuntary Examination" noted that there is substantial likelihood that without care and treatment the person will cause serious bodily harm to self and others in the near future, as evidenced by recent behavior. The Police noted that they were dispatched to an apartment building who reported an unwanted person wandering around. When the police tried to talk to SP#1, he started walking into traffic but they were able to stop the patient. SP#1 stated to police that he was seeing and hearing things and he had a date on the 13th floor of the apartment. Security at the apartment advised police that there was no 13th floor and that SP#1 was also asked to leave the premises the previous day as well.

At 05:30 am on 06/26/2014, an emergency department assessment was completed on SP #1, and a suicide screening was done. His presenting signs included hallucinations. The patient was placed near security, with a sitter, and in a psychiatric safe room while in the ED.
He was medically cleared on 06/26/2014 to go to the facility's psychiatric unit for a psychiatric evaluation.
The emergency admission orders on 06/26/2014 at 07:30 am, document SP #1 condition as guarded. He was admitted to the general psychiatric floor (room 412-1) with a diagnosis of psychosis.

On 06/26/2014 at 10:38 am, the nursing admission note document, SP #1 was admitted to the floor at 10:15 am under Baker Act with delusional thoughts, bizarre behavior, and suicide gesture. The patient was admitted in the same room as SP #2.

On 06/26/2014 at 13:12 PM, Sampled Patient #1's Behavioral Health Assessment showed: SP#1 was dirty, and had a disheveled appearance. The patient was easily distractible, suspicious and grandiose. Patient was Baker Acted by police. Patient is delusional, guarded, and suspicious. Alerts: Self Harm Potential.

SP #1's complaint/arrest affidavit dated June 27, 2014, documented that the witness (named stated that the def. (defendant) told her that he had done something wrong. She noticed that he was trying to clean what appeared to be blood off of his fingers with napkins. The report further stated that on Thursday, June 26, 2014, the above named def. (defendant) committed the following violation of law on the 26th day of June 2014 at 3:00 pm.

The police report also documented that SP#1 was interviewed by the police and he (SP#1) admitted to killing SP#2 by strangling SP#2 with his hands and a bed sheet.
On 06/27/2014 at 5:03 pm the discharge instruction showed that the patient is being transferred to another facility (police department).
The Discharge summary dated 07/03/2014 further noted that SP#1 had prior psychiatric admissions, and that he was baker acted due to bizarre behaviors.

Review of the policy, "Psychiatric Patient Neglect and Abuse," (revised 2/2010 and reviewed on 06/2012) showed that abuse is mistreatment, physical, psychological or civil. The policy does not address procedures for prevention of abuse.

Based on interview and record review the facility failed to meet the Condition of Participation of Nursing Services as evidenced by the failure to ensure that the patient was monitored and supervised in 2 ( SP#1 and SP#2) of 10 Sampled Patients.

(Refer to A-395, and A-145)

Based on facility and medical record review, and interview, the facility failed to ensure that the patient was adequately supervised and nursing care was adequately evaluated for 2 (SP#1 and SP#2) of 10 Sampled Patients.

Findings Include:

1. Sampled Patient #2 medical record showed he was Baker Acted on 06/05/2014 with bizarre behavior. According to the discharge summary dated 07/01/2014, the patient was seen and evaluated, was grossly psychotic, and internally preoccupied. There was no interactions with peers. The summary further stated that on 06/23/2014, the patient reported feeling better, psychosis was less intrusive, more interactive, no depressive symptoms and no side effects to medications.

According to the "Behavioral Health Services 24 hour Intensive Monitoring Log," the patient was on Q (every) 15 minutes observation rounding as ordered since admission on 06/05/2014. On 06/26/2014 there was no documentation to show that SP#2 was observed from 2:45pm to 3:35pm (approximately 50 minutes during the time of the emergency incident).

On June 26, 2014 the physician note documented that SP# 2 was found on the floor by the RN (Registered Nurse). A Code Blue was called (at 3:38 PM), and SP #2 was in cardio-pulmonary arrest. Initial rhythm was asystole (no rhythm, no pulse). The RN found the patient (SP#2) on the floor with the bed sheet around his neck. The patient's face and upper neck were swollen and cyanotic. Epistaxis (nose bleed) was evident. Patient was unresponsive, cold, and pulseless. CPR (Cardio Pulmonary Resuscitation) was initiated. All attempts at resuscitation were unsuccessful.

On July 2, 2014 at 10:30 AM during interview, the ACNO (Assistant Chief Nursing Officer) and the Director of BHU (Behavioral Health Unit) it was stated that SP#1 was admitted around 10:00 AM on June 26, 2014 and was placed in the same room with SP#2 who was later found on the floor next to his bed by the housekeeper around 3:35 PM, while making a final round prior to the end of the shift. The nurse (NS#7) on duty was notified and found SP#2 unresponsive. A Code Blue was called with prompt response and ACLS (Advanced Cardiac Life Support) protocol was followed but was unsuccessful. SP#1 was found in the bathroom taking a shower and was escorted out to the next room. The staff originally thought SP #2 injuries were self-inflicted due to the sheet around SP #2's neck and was not tied to anything. Everyone was interviewed but management couldn't determine how the incident could have happened. Police assistance was eventually requested after an hour and they responded promptly. The area was secured and nothing was removed. Police took over the investigation and started to conduct their own interviews. No one initially suspected that SP#1 could have something to do with the death of SP#2. No one noticed anything unusual with SP#1.
The ACNO and Director of BHU further reported, that sometime close to dinner time SP#1 confided to SP#3 that he had done something really bad and that he killed somebody. SP#3 then told the MHT (Mental Health Technician (NS#9) and the Director of BHU what SP#1 had told her, that he had did something wrong and that he killed somebody.


Interview via phone on 7/3/2014 at 11:05 am, (Nurse Sample) NS#7 stated that she was sitting at the corner of the nurse's station and behind her was the room for SP#2. The distance could not have been more than 10 feet. The room door was open. NS#7 stated that she could have easily heard something if they were fighting or struggling inside the room, but she did not hear anything. NS#7 further stated that she knew SP#2 was in the room but I didn't actually check at 3:15 PM.

On 7/3/2014 at 12 noon the Mental Health Technician (MHT) (NS#9) who was on duty on 6/26/2014 stated that it was a busy day and she took a late lunch break around 3PM. She was giving care to a patient in the adjacent room and SP#2 was visible from where she was, and that she even spoke with SP #2 right before she clocked out for lunch break around 3 PM. She reports, SP#2 was in the room lying in bed talking to himself. NS#9 stated that she failed to record the rounding at 3:00 pm since she was leaving already. NS#9 also stated that there was nothing suspicious about the actions of SP#1.

2. Clinical record review showed that SP #1 arrived at the (Emergency Department) ED at 04:46 am on 06/26/2014 after being baker acted by the police department. The local police Baker Act report titled "Report of Law Enforcement Officer Initiating Involuntary Examination" noted that there is substantial likelihood that without care and treatment the person will cause serious bodily harm to self and others in the near future, as evidenced by recent behavior. The Police noted that they were dispatched to an apartment building who reported an unwanted person wandering around. When the police tried to talk to SP#1, he started walking into traffic but they were able to stop the patient. SP#1 stated to police that he was seeing and hearing things and he had a date on the 13th floor of the apartment. Security at the apartment advised police that there was no 13th floor and that SP#1 was also asked to leave the premises the previous day as well.

At 05:30 am on 06/26/2014, an emergency department assessment was completed on SP #1, and a suicide screening was done. His presenting signs included hallucinations. The patient was placed near security, with a sitter, and in a psychiatric safe room while in the ED.
He was medically cleared on 06/26/2014 to go to the facility's psychiatric unit for a psychiatric evaluation.
The emergency admission orders on 06/26/2014 at 07:30 am, document SP #1 condition as guarded. He was admitted to the general psychiatric floor (room 412-1) with a diagnosis of psychosis.

On 06/26/2014 at 10:38 am, the nursing admission note document, SP #1 was admitted to the floor at 10:15 am under Baker Act with delusional thoughts, bizarre behavior, and suicide gesture. The patient was admitted in the same room as SP #2.

On 06/26/2014 at 13:12 PM, Sampled Patient #1's Behavioral Health Assessment showed: SP#1 was dirty, and had a disheveled appearance. The patient was easily distractible, suspicious and grandiose. Patient was Baker Acted by police. Patient is delusional, guarded, and suspicious. Alerts: Self Harm Potential.

SP #1's complaint/arrest affidavit dated June 27, 2014, documented that the witness (named stated that the def. (defendant) told her that he had done something wrong. She noticed that he was trying to clean what appeared to be blood off of his fingers with napkins. The report further stated that on Thursday, June 26, 2014, the above named def. (defendant) committed the following violation of law on the 26th day of June 2014 at 3:00 pm.

The police report also documented that SP#1 was interviewed by the police and he (SP#1) admitted to killing SP#2 by strangling SP#2 with his hands and a bed sheet.
On 06/27/2014 at 5:03 pm the discharge instruction showed that the patient is being transferred to another facility (police department).
The Discharge summary dated 07/03/2014 further noted that SP#1 had prior psychiatric admissions, and that he was baker acted due to bizarre behaviors.

3. Review of the policy,"Suicide, Elopement and Assaultive Precaution," (last review date of 06/12) showed that all patients will be evaluated for the level of observation required to insure patient safety. This will be done each shift and if the patient behavior indicates a change in observation level the nursing staff will contact the attending physician or their designee to discuss recommended changes. The policy further noted that when a patient verbalizes increased feelings or threats of wanting to harm themselves or others, staff will notify physician to discuss any increased levels of observation, such as Line of Sight or a 1:1 sitter. The policy further noted that Q (every) 15 minutes checks are required as a minimal level of observation for all patients. A patient's whereabouts through direct visual contact is documented every 15 minutes on the 24 hour Intensive monitoring log.
Review of the " Suicide Prevention Plan " policy (last reviewed 05/2014) revealed that all patients presenting with any behaviors that may place the patient at risk for suicide will be screened. Examples of screening include: psychotic episode, and injury consistent with attempt to harm one ' s self. The patients who are screened/ assessed to be at risk for suicidality will be placed on patient observation and monitoring as assigned by the RN or assigned LIP assessment is completed. Level one (every 15 minutes monitoring (standard precautions): staff visually observes the patient at least every 15 minutes, verifies their well-being, and ensures that they are safe both physically and mentally. Patients who have displayed any self-injurious behaviors in the last 12 hours are noted under Level 3 = 1:1 (one to one) monitoring and observation. The patient is never to be out of arms reach of the assigned and dedicated staff member.

These policies/procedures were not followed when SP #1 was admitted to the general psychiatric unit, when less than 12 hours earlier, on June 26, 2014 at 4:10 am, the "Report of Law Enforcement Officer Initiating Involuntary Examination," noted that there is substantial likelihood that without care and treatment the person will cause serious bodily harm to self and others in the near future, as evidenced by recent behavior. When police tried to talk to SP#1 he started walking into traffic but they were able to stop the patient.

These policies/procedures were not followed immediately after SP#1 verbalized that he had done something wrong. Review of sampled patient # 1 Behavioral Health Services: 24 hours Intensive Monitoring Log dated 06/26/2014 at 4:00 pm after the incident was reported, revealed that the patient continued on every 15 minute precaution checks until 06/27/2014. The patient was noted in the in the hall and in the patient dining room during the evening of 06/26/2014. The patient was not placed on 1:1 observation until 06/27/2014. This allowed the potential for other patients to be harmed by SP #1.