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The hospital failed to ensure the Condition of Participation: CFR 482.12 Governing Body was met by failing to ensure:

1. The facility implemented their policy titled "Levels of Observation and Special Precautions..." when they failed to do observation rounds every fifteen minutes for one (1) of 31 sampled patients (Patient 1). This failure resulted in the cause of death for Patient 1.((Refer to A-0392)

2. The minimum nurse to patient ratios in the Labor and Delivery Units (The specialized care for pregnant patients that are going to deliver their babies). (Refer to A-0392)

3. Documented evidence that patient attempted to injured self by using a sharp toothpaste cap was completed for one (1) of 31 sampled patients (Patient 1). (Refer to A-0395)

4. There was an accurate documented evidence for one (1) of 31 sampled patients (Patient 1), when Patient 1 made a phone call. (Refer to A-0438)

5. The observation rounds every 15 minutes time of the video surveillance tape recording for one (1) of 31 sampled patients (Patient 1) did not correlate with the actual time. (Refer to A-0438)

6. Documented evidence that the Telepsychiatric services (the delivery of psychiatric assessment and care through videoconferencing) were completed for one (1) of 31 sampled patients (Patient 13). (Refer to A-0438)

7. Behavioral health (BH) patients in the Emergency Department (ED), awaiting admission to the Behavior Health Unit (BHU) were provided with ADL's (activities of daily living) which included hot meals, baths/showers, a change of clothes and the opportunity to brush their teeth. These failures created the potential for decreases self esteem and an increase in possible infectious disease opportunities. (Refer to A-0395)

8. The RN (Registered Nurse) documented the behavior notes every two (2) hours demonstrating the need for continued 1:1 observation. (Refer to A-0395)

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation: Governing Body.

The Condition is not met as evidenced by: The facility failed to ensure the Condition of Participation: CFR 482.21 Quality Assessment and Performance Improvement was met by failing to ensure:

1. The facility implemented their policy titled "Levels of Observation and Special Precautions..." when they failed to do observation rounds every fifteen minutes for one (1) of 31 sampled patients (Patient 1). This failure resulted in the cause of death for Patient 1. (Refer to A-0392)

2. The minimum nurse to patient ratios in the Labor and Delivery Units (The specialized care for pregnant patients that are going to deliver their babies). (Refer to A-0392)

3. Documented evidence that patient attempted to injured self by using a sharp toothpaste cap was completed for one (1) of 31 sampled patients (Patient 1). (Refer to A-0395)

4. There was an accurate documented evidence for one (1) of 31 sampled patients (Patient 1), when Patient 1 made a phone call. (Refer to A-0438)

5. The observation rounds every 15 minutes time of the video surveillance for one (1) of 31 sampled patients (Patient 1) did not correlate with the actual time. (Refer to A-0438)

6. Documented evidence that the Telepsychiatric services (the delivery of psychiatric assessment and care through videoconferencing) were completed for one (1) of 31 sampled patients (Patient 13). (Refer to A-0438)

7. Behavioral health (BH) patients in the Emergency Department (ED), awaiting admission to the Behavior Health Unit (BHU) were provided with ADL's (activities of daily living) which included hot meals, baths/showers, a change of clothes and the opportunity to brush their teeth. These failures created the potential for decreases self esteem and an increase in possible infectious disease opportunities. (Refer to A-0395)

8. The RN (Registered Nurse) documented the behavior notes every two (2) hours demonstrating the need for continued 1:1 observation. (Refer to A-0395)

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation: Quality Assessment and Performance Improvement.

This Condition is not met as evidenced by: The facility failed to ensure the Condition of Participation: CFR 482.23 Nursing Services was met by failing to ensure:

1. The facility implemented their policy titled "Levels of Observation and Special Precautions..." when they failed to do observation rounds every fifteen minutes for one (1) of 31 sampled patients (Patient 1). This failure resulted in the cause of death for Patient 1. (Refer to A-0392)

2. The minimum nurse to patient ratios in the Labor and Delivery Units (The specialized care for pregnant patients that are going to deliver their babies). (Refer to A-0392)

3. Documented evidence that patient attempted to injured self by using a sharp toothpaste cap was completed for one (1) of 31 sampled patients (Patient 1). (Refer to A-0395)

4. There was an accurate documented evidence for one (1) of 31 sampled patients (Patient 1), when Patient 1 made a phone call. (Refer to A-0438)

5. The observation rounds every 15 minutes time of the video surveillance for one (1) of 31 sampled patients (Patient 1) did not correlate with the actual time. (Refer to A-0438)

6. Documented evidence that the Telepsychiatric services (the delivery of psychiatric assessment and care through videoconferencing) were completed for one (1) of 31 sampled patients (Patient 13). (Refer to A-0438)

7. Behavioral health (BH) patients in the Emergency Department (ED), awaiting admission to the Behavior Health Unit (BHU) were provided with ADL's (activities of daily living) which included hot meals, baths/showers, a change of clothes and the opportunity to brush their teeth. These failures created the potential for decreases self esteem and an increase in possible infectious disease opportunities. ( Refer to A-0395)

8. The RN (Registered Nurse) documents behavior notes every two (2) hours demonstrating the need for continued 1:1 observation. (Refer to A-0395)

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation: Nursing Services.

Based on observation, interview, and record review the facility failed to ensure:

1. The facility implemented their policy titled "Levels of Observation and Special Precautions..." when they failed to do observation rounds every fifteen minutes for Patient (1). This failure resulted in Patient's 1's death by hanging himself with a bedsheet from the bathroom door.


2. The minimum nurse to patient ratios in the Labor and Delivery Units (The specialized care for pregnant patients that are going to deliver their babies). This failure had the potential for patients that received care and services in the Labor and Delivery Units, not to have their assessed needs met in a safe environment, a potential risk of safety in the delivery of care in a universe of thirteen patients.

Findings:

1. During a review of the medical record for Patient 1, the admission record indicated Patient One was admitted on May 30, 2017 at 4:45 PM and passed away on June 9, 2017 and weight 76.2 kilograms, with a diagnoses of Bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day to day tasks), Asphyxia from hanging anoxic ( the state or process of being deprived of oxygen, which can result in unconsciousness, death, and suffocation), and Encephalopathy Acute Respiratory Failure (the loss of brain function due to low oxygen).

During an observation of the recorded surveillance video tape for the date of June 3, 2017, it was observed that the Mental Health Worker (MHW 1) did not do observation rounds every fifteen minutes for Patient One at 10:45 AM when Patient 1 continued to be inside his room.

During a concurrent interview with the Director of Behavioral Health (DBH), she confirmed that MHW 1 did not do observation rounds every fifteen minutes for Patient 1. The DBH also stated that the MHW 1 should've gone inside Patient Ones (1's) room to make sure he was safe. It was between 10:28 AM and 11:00 AM on June 3, 2017 that Patient 1 used a bedsheet to hang himself from the bathroom door and was found unresponsive. Patient 1 was transferred to the emergency room and then to the Intensive care unit. Patient One passed away on June 9, 2017.

During a review of Patient one's (1's) medical record (Nurses Notes) revealed on June 3, 2017 at 11:43 AM, "the patient was found in his room by Mental Health Worker 1 (MHN 1) at 11:00 AM hanging from the bathroom door with a ripped sheet tied around his neck. The Registered Nurse 3 (RN 3) also came to the room and found Patient one's (1's) skin was pale and lips were turning light blue color. RN 3 made one attempt to loosen the knot around his neck, but was unsuccessful due to the weight of the patient."

During a review of the facility's policy and procedure titled, "Levels of Observation and Special Precautions" dated November 2016 indicated,"Presumes that the patient meets criteria for danger to self, danger to others or gravely disabled. This is the minimum observation for all behavioral health services."

2. During an interview with the Registered Nurse 1 (RN 1) on July 11, 2017 at 2:09 PM, RN 1 stated that today she was out of ratio, four registered nurses to three (1:3) patients on morning shift that were out of ratio. She also stated that they usually don't have a charge nurse and no lunch breaks because it's busy and not safe. There were five Registerd Nurses on the unit.

During an interview with Registered Nurse 2 (RN 2) on July 11, 2017 at 2:23 PM, the RN 2 stated that today she was out of ratio, one registered nurse to three (1:3) patients for one hour in the morning shift. She also stated, that this has been happening at least once a week. They never get their lunch breaks

During an interview with Charge Nurse 1 (CN 1) on July 11, 2017 at 2:35 PM, CN 1 stated that today she had two Registered Nurses that were out of ratio (1:3) patients.

During an interview with the Manager of Labor and Deliver (MLD) on July 11, 2017 at 2:39 PM, the MLD stated that today they've been out of ratio for four hours. The census was thirteen patients

During a review of the Labor and Delivery units registered nurse assignments indicated they were out of ratio (1:3) on the following dates:

a. June 1, 2017
b. June 4, 2017
c. June 5, 2017
d. June 6, 2017
e. June 8, 2017
f. June 9, 2017
g. June 10, 2017
h. June 12, 2017
i. June 13, 2017
j. June 14, 2017
k. June 15, 2017
l. June 16, 2017
m. June 17, 2017
n. June 18, 2017
o. June 19, 2017
p. June 20, 2017
q. June 21, 2017
r. June 22, 2017
s. June 23, 2017
t. June 24, 2017
u. June 26, 2017
v. June 27, 2017
w. June 28, 2017
x. July 11, 2017

During a review of the facility's policy and procedure titled, "Patient Care Assignment and Patient Classification by Acuity (the measurement of the intensity of nursing care required by a patient)" dated September 2016 indicated,"Relief coverage during caregiver meals, breaks or other times caregiver may be absent from the unit will be assigned within the acuity system (regulates the number of nurses on a shift according to the patients needs) to ensure appropriate patient coverage and maintenance of staffing ratios. The charge nurse on each shift of the selected units will complete the patient assignment utilizing the outcomes driven acuity system, taking into consideration the patient's acuity and workload needs, nurse-patient ratios, and the individual nurse's experience, competency and skills as well as variables within the practice setting..."

Based on observation, interview, and record review the facility failed to ensure:

1. Documented evidence that Patient 1 attempted to injure self by using a sharp toothpaste cap was completed for one (1) of 31 sampled patients (Patient 1). This failure resulted in the cause of death for Patient 1.

2. Behavioral health (BH) patients in the Emergency Department (ED), awaiting admission to the Behavioral Health Unit (BHU) were provided with ADL's (activities of daily living) which included hot meals, baths/showers, a change of clothes and the opportunity to brush their teeth. These failures created the potential for decreases self esteem and an increase in possible infectious disease opportunities.

3. The RN (Registered Nurse) documented the behavior notes every two (2) hours demonstrating the need for continued 1:1 observation. This failure had the potential for patients that received care and services in the facility, not to have their assessed needs met in a safe environment and a potential risk of safety in the delivery of care.

Findings:

1. During a review of the medical record for Patient 1, the admission record indicated Patient One was admitted on May 30, 2017 at 4:45 PM and passed away on June 9, 2017, with a diagnoses of Bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, and activity levels), Aphyxia (the state or process of being deprived of oxygen, which can result in unconsciousness, death, and suffocation), and Encephalopathy Acute Respiratory Failure (the loss of brain function due to low oxygen).

During an interview with Registered Nurse 3 (RN 3) on July 12, 2017 at 2:35 PM, the RN 3 stated that on June 3, 2017 before Patient one (1) hung himself with a sheet, Mental Health Worker 1 (MHW 1) told her that Patient 1 tried to harm himself by scratching his bilateral wrists with a toothpaste tube cap. The RN 3 told the psychiatrist 1(psychiatrist 1) but the psychiatrist 1 did not place Patient 1 on a one to one observation for suicidal ideation's (refers to thinking about, considering, or planning suicide).

During an interview with the Psychiatrist 1 (Psychiatrist 1) on July 12, 2017 at 2:56 PM, the Psychiatrist 1 stated that Patient 1 did have superficial scratches on his bilateral wrists and he thought Patient 1 was playing the system instead of having suicidal ideation's.

During an interview with the Director of Behavioral Health (DBH) on July 14, 2017 at 7:55 AM, the DBH stated that the Psychiatrist did not tell her that Patient 1 had attempted to scratch his bilateral wrists by using a toothpaste tube cap.

During an interview with the Manager of Behavioral Health (MBH) on July 14, 2017 at 10:56 AM, the MBH confirmed there was no documentation in Patient one's (1's) medical record dated June 3, 2017 that Patient 1 attempted to scratch his bilateral wrists by using a toothpaste tube cap.

During a review of the facility's policy and procedure titled, "Documentation Requirements" 2016 indicated,"Nursing shift note which includes patient behavior, mental status, presence or absence of suicidal ideation, homicidal ideation (Having thoughts to harm others), aggression, signs/symptoms of disease process, behavior including frequency in which it occurs, and progress or lack of progress in achieving identified treatment objectives (goals) described in observable behavior..."

During a review of the facility's policy and procedure titled, "Documentation" dated August 2016 indicated, "Documentation must be accurate, brief, and concise..."


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2. During a tour of the Emergency Department (ED) conducted on July 11, 2017 at 10 AM, observations revealed multiple patients dressed in blue paper scrubs (top and pants) in various rooms and in the hallway.

On July 11, 2017 at 10:10 AM, an interview was conducted with the ED Charge Nurse (EDCN) who stated, the patients dressed in blue scrubs were awaiting admission to the Behavioral Health Unit (BHU-an area where patients with mental illness are provided care). As the interview with the EDCN continued, the EDCN stated, it's a good day if we have under four (4) BHU patients awaiting admission.

A review of the ED log dated July 11, 2017 at 3:31 PM, revealed 11 BH (behavioral health) patients were in the ED awaiting admission to the BHU. Further review of the ED log revealed the following:

a. Patient 28, had been in the ED awaiting admission to the BHU for 26 hours and 15 minutes.

b. Patient 27, had been in the ED awaiting admission to the BHU for 25 hours and seven (7) minutes.

On July 12, 2017 at 8:45 AM, an interview was conducted with the Director of the Emergency Department (DED). The DED stated, they currently had nine (9) BH patients awaiting admission to the BHU which included Patient 28, who had been in the ED for 43 hours and 27 minutes and Patient 27, who had been in the ED for 42 hours and 19 minutes.

On July 12, 2017 at 10:50 AM, a second interview was conducted with the DED. During the interview, the DED was asked to describe the care the BH patients receive while in the ED awaiting a bed in the BHU. The DED stated, "They get medications and are seen by a psychiatrist via Telepsych (the use of medical information exchanged from one site to another via electronic communication)." The DED was asked if the BH patients were provided with ADL's (activities of daily living) such as meals, baths/showers and the opportunity to brush their teeth, the DED stated they receive "Boxed meals," for breakfast, lunch and dinner. When questioned if the BH patients were provided with baths/showers the DED stated, "No they don't." When asked about being provided the opportunity to brush their teeth, the DED stated, "I'm not sure."

On July 14, 2017 at 1:50 PM, an interview was conducted with Patient 27. Patient 27 presented to the ED on July 10, 2017 at 2:24 PM via ambulance and was subsequently admitted to the BHU on July 12, 2017 at 4 PM, 50 hours after her initial arrival to the ED. During the interview, Patient 27 was asked what she did while she was in the ED, Patient 27 stated, "Just sat around." Patient 27 was asked if she was able to take a shower while she was in the ED, Patient 27 stated, "No." Patient 27 was asked if ED staff asked her if she wanted to brush her teeth or offered to change her blue paper scrubs, the patient stated, "No."

3. During observations in the Emergency Department (ED) revealed multiple patients dressed in blue paper scrubs (top and pants) in various rooms and in the hallway.

On July 11, 2017 at 10:10 AM, an interview was conducted with the ED Charge Nurse (EDCN) who stated, the patients dressed in blue paper scrubs were awaiting admission to the Behavioral Health Unit (BHU-an area where patients with mental illness are provided care). The EDCN further stated that the mixture of BH patients were there voluntarily and others were on a 5150 (the patient exhibits signs of danger to self, others, or is gravely disabled).

A review of the the facilities policy and procedure (P & P) #7010.067, titled "Observations and Special Precautions for Patients Requiring Emergent Psychiatric Evaluation in the Emergency Department," dated 11/2016, under the "Purpose" section documentation revealed the following:

"To provide guidelines for observation and the steps for special precautions to staff when caring for a patient presenting to the ED with a psychiatric emergency."

Further review of the P & P under the "Responsibility" section documentation revealed the following:

"All ED clinical staff shall follow the guidelines for observation of a patient presenting to the ED with a psychiatric emergency."

Continued review of the P & P under the "Procedure" section #3.0 "Behavioral One-To-One (1:1)" documentation revealed the following:

"3.8 The RN (Registered Nurse) documents behavior notes every two (2) hours demonstrating the need for continued 1:1 observation."

A review of Patient 28's medical record, revealed one (1) ED nursing note which made reference to a meal provided to the patient. No further documentation could be located which demonstrated the need for continued 1:1 observation. Patient 28 was in the ED over 43 hours prior to being admitted to the BHU.

Based on observation, interview, and record review the facility failed to ensure:

1. There was an accurate documented evidence for one (1) of 31 sampled patients (Patient 1), when Patient 1 made a phone call to his mother.

2. The observation rounds every 15 minutes time of the video surveillance tape for one (1) of 31 sampled patients (Patient 1) did not correlate with the actual time on the clock.

3. Documented evidence that the Telepsychiatric services (the delivery of psychiatric assessment and care through videoconferencing) were completed for one (1) of 31 sampled patients (Patient 13).

These failures had the potential for patients that received care and services in the facility, not to have their assessed needs met in a safe environment and a potential risk of safety in the delivery of care in a universe of 127 patients.

Findings:

1. During a review of the medical record for Patient 1, the admission record indicated Patient 1 was admitted on May 30, 2017 at 4:45 PM and passed away on June 9, 2017 and weight 76.2 kilograms, with a diagnoses of Bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day to day tasks), Asphyxia ( the state or process of being deprived of oxygen, which can result in unconsciousness, death, and suffocation), and Encephalopathy Acute Respiratory Failure (the loss of brain function due to low oxygen).

During a review of the "Fifteen Minute Observation Record" for Patient 1 dated June 3, 2017 at 10:30 indicated,"Patient was in the hall and used the phone."

During a review of the video surveillance tape for Patient 1 dated June 3, 2017 at 10:30 AM, Patient 1 was in his room. The patient used the phone at 9:38 AM.

During a concurrent interview with the Director of Behavioral Health (DBH), confirmed that the staff incorrectly documented at 10:30 AM that Patient 1 was in the hall and used the phone at that time.

During a review of the facility's policy and procedure titled, "Documentation" dated August 2016 indicated, "Documentation must be accurate, brief, and concise..."

2. . During a review of the medical record for Patient 1, the admission record indicated Patient 1 was admitted on May 30, 2017 at 4:45 PM and passed away on June 9, 2017 and weight 76.2 kilograms, with a diagnoses of Bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day to day tasks), Asphyxia from hanging anoxic ( the state or process of being deprived of oxygen, which can result in unconsciousness, death, and suffocation), and Encephalopathy Acute Respiratory Failure (the loss of brain function due to low oxygen).

During a review of the video surveillance time on the video for Patient 1 dated June 3, 2017 did not correlate with the actual time on the facility clock.

During a concurrent interview with the Director of Behavioral Health (DBH), confirmed that there was a six minute and forty-nine seconds delay between the video surveillance tape time with the actual time on the facility clock.

During an interview with the Security Manager (SM) confirmed that there was a six minute and forty-nine seconds delay between the video surveillance time with the actual time on the facility clock.

The facility did not provide a policy regarding the video surveillance time should correlate with the actual time on the facility clock.

3. During a review of the medical record for Patient 13, the admission record indicated Patient 13 was admitted on July 9, 2017 at 3:57 PM, with a diagnosis of recurrent major depression (loss of interest in activities, causing significant impairment in daily life).

During a review of the Behavioral Health Unit Psychiatric Emergency Services Assessment (the initial assessment made by the Registered Nurse in the emergency department) for Patient 13 dated July 9, 2017 indicated,"Has agreed to be evaluated by Telemed (the use of medical information exchanged from one site to another via electronic communication)."


During an interview with the Manager of Behavioral Health (MBH) on July 14, 2017 at 4:21 PM, the MBH confirmed that there was no documentation evidence in Patient 13's medical record indicating that Telepsychiatric services were done by a psychiatrist via television monitor.

During a review of the facility's policy and procedure titled, "Telepsychiatric Treatment" dated May 2016 indicated, "Physiological stability will be assessed and documented by both onsite and remote staff. Upon consultation and criteria being met, the telepsychiatrist must assess the patient's physiological stability and document the findings."