HospitalInspections.org

Based on observation, interview, and record review, the facility failed to protect the patients' rights to informed consent for 1 of 4 patients (P-2), failed to follow facility policy and nationally recognized standards of practice for emergency care for one of one patients (P-1), failed to protect all 9 of 9 patients on the Developmentally Delayed unit from accessing harmful items, failed to protect two of two patients (P-15 and P-16) reviewed for abuse free from abuse by staff, and failed to report the death of a patient in restraints in one of one patients (P-1) to CMS (Centers for Medicare and Medicaid) resulting in the potential for poor patient outcomes to all patients served by the facility. Findings include:

Please see tags:
A-0131 - Failure to obtain informed consent.
A-0144 - Failure to provide care in a safe setting.
A-0145 - Failure to protect patients from abuse.
A-0213 - Failure to recognize and report death in restraints.

Based on record review and interview, the facility failed to gain informed consent from the guardian of one of four patients (P-2) resulting in the potential of uniformed consent for all patients with a guardian. Findings include:

On 5/20/2024 a record review of P-2's medical record was conducted. A document in the medical record titled, "Guardian Verification," stated under subtitle "Guardianship Status, patient does not have a guardian." Review of the document titled, "Consent to share your health information," dated 5/1/2024 at 1400, listed two family members but failed to list a guardian. The document was noted to signed by the patient with the wrong last name. Additional documents signed by the patient included, "General Consent for treatment, the Important Message from Medicare, Primary Care Physician Notification, Notice of Privacy Practices Acknowledgement, Receipt of Adult Formal Voluntary Admission Application, Mental Health Codes Confidentiality and Privileges Communication, Patient Rights Booklet / Unit booklet, Unit Rules & Expectations, and Smoking Restriction."

On 5/9/2024 at 1650 a general consent by the guardian was taken over the phone. The guardian was not identified by name, but two witnesses signed that consent was obtained from the guardian. All documents signed by P-2 were resigned by consent obtained from the guardian on 5/9/2024 via a phone conversation with nursing.

On 5/20/2024 during an interview with staff D, the Director of Nursing, it was asked if a person with severe dementia could sign documents if they had cognitive issues that interfered with understanding what they were signing. Staff D stated, "No." Staff D was then queried how the facility would know if a patient had a guardian. Staff D stated two employees access a program on the county website to run a query if a patient has filed guardianship papers. Staff D stated, "Sometimes if the patient is coming from a care facility a phone call is placed to where they reside." Documentation failed to show that a query had been made for P-2 guardianship, and failed to include where contact had been made to the care facility where P-2 resides."

On 5/21/2024 record review occurred of the document titled, "Consent: Informed Consent for Treatment," policy number BMD-C-7, with a revision date of 6/14/2023. According to the document under the subtitle "Definitions" it stated under "5. Comprehension, An individual must be able to understand what the personal implications of providing consent will be based upon the information provided under subdivision (b) of this subrule...Definitions, 2. Competency: An individual shall be presumed to be legally competent. This presumption may be rebutted only by a court appointment of an guardian or exercise by a court of guardianship powers and only to the extent of the scope and duration of the guardianship. An individual shall be presumed legally competent regarding matters that are not within the scope and authority of the guardianship...Procedure: 4. Recipient or his/her Legal guardian shall be informed that consent can be withdrawn for participation or any activity at any time and that this can be done without any prejudice towards the Recipient."

Based on record review and interview, the facility failed to follow policy and nationally recognized standards of practice while providing CPR (Cardiopulmonary Resuscitation) for one of one patients (P-1), and failed to provide a secure environment, resulting in the potential for poor outcomes for all patients. Findings include:

A record review of P-1 medical record occurred on 5/20/2024 at 1600. According to the medical record P-1 was documented by staff K, registered nurse as, "Male, 41-years-old, brought in by law enforcement, no listed guardian, no advance directive, Vital Signs Height 75 in. (6'3"), Weight 394 lbs., Temperature 97.7 degrees Fahrenheit, Pulse 102, BP (blood pressure) 132/73, pain not addressed, BMI (body mass index) 49." The chief complaint stated, "Pt (patient) denies any pain, but appears very labile. Pt balled his fist up and jerked towards nurse during assessment. Pt presents altered mental status; Pt states he feels overwhelmed due to loss of employment. Pt has tangential speech."

Further nursing mental health assessment states, "consciousness: alert, confused, speech: garbled, rambling, patient medically stable: yes, ... Mental status exam, cooperation: poor, motor activity: normal, eye contact: fair, speech rate: hesitant, comfort style: guarded, mood: labile, impulsive, appearance/hygiene: disheveled, clothing: layered in clothes, affect: labile, oriented to: person, sensorium: alert, thought process: flight of ideas, hallucinations: denies, detail what patient sees, hears, feels, etc.: Pt denies seeing or hearing anything but rumbles random words / outburst." Information continued, "delusions: paranoid, detail delusions: blank, thought content: paranoia, detail: blank, homicidal: denies homicidal ideation, insight: poor, judgement: poor, impulse control: poor."

Physical assessment stated, "Nutritional risk screen appetite: good, EENT - assess eyes, ears, nose, and throat for abnormalities denies, respiration - assess chest configuration, respiration rate, rhythm, depth, pattern, breath sounds, comfort: Denies. (no documentation found for assessment of respiratory system). Cardiovascular - assess heart sounds, rate, rhythm, pulse, blood pressure, circulation, fluid retention, comfort. Denies (no documentation found for assessment of cardiovascular system).

P-1 did not have a psychiatric evaluation prior to the code event.

On 5/20/2024 at 1400 record review occurred of video documentation of 4/4/2024 at 0627 on the 5S all male unit. P-1 was viewed as coming out of his patient room. P-1 was observed rubbing his eyes. P-1 room door was shut from 062900 to 062920 by MHT, staff H. Staff H released the patient room door at 062921 at which time P-1 came out of the room and began swinging at staff H and staff E, MHT. Staff F, RN charge nurse, staff H, and staff E were observed struggling to physically restrain P-1 in order to gain control of P-1 at 063059. P-1 was observed falling prone to the floor at 063102. P-1 was observed to be maintained in a prone position by staff H straddling P-1 and using his right knee to keep P-1's left thigh to the ground and using his right elbow in the center of P-1 scapulae holding P-1 down. Staff H was then viewed at 063133 placing his chest on P-1 upper back as P-1 remained in a prone position. Staff P-1 continued to struggle until 063206 when P-1 stopped moving. At 063225 staff E was viewed providing a bath blanket to staff H to cover P-1 as his lower body and buttocks were in full view. P-1 remained in a prone position. Staff F remained to the right of P-1 upper body near P-1 head. Staff E was observed going into P-1 patient room at 063237. Staff K, RN was observed placing her right hand next to P-1 neck at 063247 to check P-1 pulse. At 063313 staff K rechecked P-1 pulse. At 063335 P-1 was rolled supine. Staff E was observed placing a pillow underneath P-1 head. Staff F remained at the right side of P-1. At 063336 Staff K was observed standing above P-1 doing compressions on P-1 chest. At 063350 staff K was observed stopping compressions to check pulse. Compressions were restarted at 063407 by staff F. The crash cart was observed being removed by staff at 063407 from the medication room but was not brought to the patient. Resident staff M was observed next to P-1 at 063407. Staff J, attending psychiatrist was noted to be present at 063416. Resident staff M took over compressions at 063424. Multiple staff were noted in the immediate area without participation in the code. Compression rate was approximately 60 per minute. Compression rate less than 100 per minute. Resident staff N was noted to be making a phone call at 063520 (Call by staff N was being placed to staff G, medical director - attending medical physician. As confirmed by staff G interview.) Compressions were changed over to staff F. Compression rate was 60 per minute. Oxygen administration began at 063616. At 063623 Staff L, LPN was noted to go to the crash cart. At 063623 Resident staff M took over compressions. 063729 Staff F was noted to be drawing medication. At 063805 compressions were taken over by staff N. During this time the defibrillator remained on the crash cart. At 063822 compressions were taken over by unknown resident. At 063911 compression were once again switched out (staff N). Staff L was noted at 063933 to have a syringe in his right hand to administer to P-1. At 063925 staff F resumed compressions. Compression rate remained at 60 per minute. Staff L performed IM (intramuscular) injection to P-1 at 063937 in lower extremity. At 064040 compressions were switched out again to unknown resident. Compression rate was 100 per minute. Compressions were taken over by staff F at 064123. Compression rate was 60 per minute. Compressions were taken over by staff N at 064208. A second crash cart arrived on scene at 064302. Staff F took over compressions at 064255. Staff L was noted drawing medication into a syringe at 064307. At 064316 staff L administered medication to P-1. At 064501 the defibrillator was taken off the second crash cart by staff N. The defibrillator was placed next to P-1 at 064542. Defibrillator pads were placed on P-1 at 064642. At 064648 staff L was noted drawing medication. At 064702 EMS personnel arrive on scene. At 064718 Police authorities arrive on scene. At 064730 compressions were stopped to place EMS blanket under P-1. At 064800 compressions by unknown resident were started again on P-1. Compressions were switched again at 064844. At 065048 Compressions and ambu-bag resuscitation were stopped to check the EMS defibrillator. Compressions were restarted at 065104 by resident staff N. EMS personnel were seen establishing an IO (Intraosseous access) at 065350. Compressions were stopped at 065400. Compressions resumed at 065500. P-1 was transferred to EMS stretcher at 065549 with a stop in compressions until 065603. Compressions ceased at 065618 and resumed again at 065622. P-1 was transported by EMS off the unit at 065657.

Employee files for staff involved in the Code blue event performed on P-1 on 4/4/2024 were reviewed. All staff were found to have current BLS certification. Review of staff F (registered nurse) file revealed a signed document dated 10/5/2023 that stated, "I, (staff F) by signing this acknowledgement, agree that I have been educated on the following elements of patient care ... I will never place a patient face down during restraints ..."

Record review of P-1 medical record from the receiving facility took place on 5/22/2024. Documentation by the Emergency Room physician stated the following, "Patient (P-1) is a 41-year-old male presenting to the ED for evaluation via EMS from (facility) as a CPR in progress. History was obtained from EMS. Per EMS report patient was being treated for excited delirium and became unresponsive. On arrival here, patient remained pulseless and appears cyanotic. Patient was placed on a cardiac monitor and CPR was continued. There was no airway established. Used bag mask for ventilation until 8-0 ETT (endotracheal tube) placed. Prior to arrival, EMS performed CPR and administered 2 doses of epinephrine. They were able to establish IO (Intraosseous) access. Here in the ED, with continued CPR, patient was administered 5 more doses of epinephrine through continued CPR. At pulse check, cardiac monitor showed V-fib (Ventricular fibrillation) and shocked at 200 J (Joules). CPR was then continued and a sixth dose of epinephrine was administered (8 doses of epinephrine in total). At subsequent pulse check, patient was found to be in asystole. Time of death was pronounced at 0722. Next of kin was notified. Attending physician, (name) at bedside during CPR. Medical examiner requests examination."

On 5/22/2024 a record review occurred of the policy titled, "Code Blue," with a revision date of 3/19/2024. The policy it states under the subtitle, "Scope of Application," The medical staff, patient care staff, and other direct/indirect healthcare professionals within the scope of his or her practice at (facility). The document stated the following,

"Policy:

The Code Blue alert will provide timely and effective assessments and interventions to patients ....who experience cardiopulmonary arrest within and outside the direct patient care units of (facility). The term "Code Blue" will be used to summon a team of trained medical personnel to undertake cardiopulmonary resuscitation. Cardiopulmonary resuscitation implies but is not limited to the use of approved techniques for:
1. Oxygenation, 2. Airway management, 3. Cardiac arrhythmia recognition, cardiac defibrillation, and pharmacological interventions of perfusion in an orderly attempt to achieve a return of spontaneous circulation, and 4. External cardiac massage.

Procedure
Initiation of a Code Blue
A. Any personnel that identify a person in suspected or actual cardiopulmonary arrest may initiate a Code Blue. This person will:
1. Stay with the patient, visitor, or hospital staff and begin Basic Life Support (BLS) interventions, if certified.
2. Simultaneously beginning the process of notification for assistance (yelling out to additional staff members.)
B. The first staff that receives notification of needed assistance with Code Blue will:
1. Activate Code blue by pressing the labeled speed dial button on the Charge Nurse phone.
2. Code and location will be automatically announced three times via the overhead public paging system.
3. If, for any reason, the overhead paging system does not operate appropriately, staff will use the two-way radio to activate code blue alert.
4. Retrieve the Crash Cart and bring it to the location.
C. CODE BLUE STAFF MEMBERS MAY INCLUDE:
* Attending physician and/or Resident doctor
* Anesthesiologist/CRNA if available
* Registered Nurses
* Licensed Practical Nurses
* Certified Nursing Assistants
* Mental Health Technicians
* Any other staff certified and deemed necessary to perform BLS.
Departmental and Hospital Staff Responsibilities
A. Each identified department is responsible for ensuring that competently trained staff will be designated to respond to all Code Blue events each shift.
Chain of Command During Code Blue
A. Management of the patient will be assumed by the first physician or Resident Doctor to arrive on scene of the Code Blue. This management will continue until a higher priority physician (Attending Physician / Physician on call) is contacted and advice received, as defined below, arrive to the scene.
B. In the event a physician or resident doctor is not present the first Registered Nurse to respond will assume responsibility for the Code Blue Management.
C. A registered nurse will be identified as Code Leader and is responsible for directing additional personnel during the Code Blue.
Responsibilities of Nursing Staff in Patient Care Areas
A. All Nursing Staff at (facility) are required to have BLS Health Care Provider certification. They are responsible for knowing the location of the Crash Cart and/or additional emergency equipment on their unit.
B. Upon hearing the page of a Code Blue announcement over the paging system, the unit nurse and other patient care staff assigned to the unit will proceed immediately to the Code Blue location. The first arriving qualified staff will initiate BLS interventions and perform automatic external defibrillation (if indicated).
C. The RN delegates responsibility to Code Blue responders to assist with resuscitation efforts including, but not limited to:
1. Monitoring the patient's vital signs
2. Attach electrodes and lead to the patient
3. Identify and document the patient's cardiac rhythm if able.
4. Securing necessary equipment/medications from the Crash Cart.
5. Establish or assist the resident doctor with the establishment of IV/IO access.
6. Administering emergency medications as ordered by the physician leader.
7. Continuously observing the patient and providing documentation for the medical record.
8. Ensuring security is notified if traffic control is needed.
9. Facilitating the notification of family, guardian, and/or patient advocate for support as necessary.
10. Providing a report to the receiving unit/facility if the patient is transferred.
D. The Crash Cart from the unit will remain with the coding patient until the final disposition of the patient. After the final disposition of the patient is complete, the Crash Cart (including all exposed equipment, e.g. defibrillator) will be cleaned, restocked, and appropriately documented in the Crash Cart Log by the Charge nurse and then returned to its origin.
E. The nurse will complete the Code Blue Debriefing with the clinical team.
Responsibilities of the Medical Resident or Attending Physician
A. Respond to all Code Blue pages.
B. Assume command of the Code Blue event upon arrival; Direct resuscitation efforts and dismiss staff not required for the resuscitation efforts ....
C. Promptly provide a narrative of the events and actions taken in the patient's progress note and notify the attending physician (if not present during the code).
D. Transfer the patient to ER if required.
Responsibilities of Security
A. Establish and maintains a perimeter around the patient and the staff responding to the code blue.
B. Re-direct non-essential persons/family away from the scene.
Responsibilities for Crash Cart monitoring and maintenance
A. Crash Carts are checked by designated staff on patient care units every 24 hours on the 7P - 7A shift to verify it is unopened. The designated staff will verify that the Crash Cart has not been opened by confirming the Crash Cart lock tag is intact with the unique lock tag numbers corresponding with those documented in the Crash Cart Log. All individual equipment and individual medications expiration dates will be documented on the Crash Cart Inventory on the first day of each month and each time the Crash Cart lock tag is broken. At this time, any expired equipment and/or medications will be removed and replaced following the process as indicated below. Any items replaced in the Crash Cart after a Code Blue or due to expiration will be documented on the Crash Cart Inventory.
B. If the lock is not intact or the expiration date is exceeded:
1. The nurse manager/supervisor on duty must be notified immediately.
2. Crash Cart medication trays are immediately returned and exchanged in the
Pharmacy.
C. Departments that are not open around-the-clock will have the Crash Cart Log and Equipment Logs completed daily during routine operational hours by designated staff. Departments will assign staff to complete logs in areas that are closed due to low census.
D. Defibrillators are and logged by the designated staff every 24 hours on the 7P - 7A shift (or during routine operational hours) for charging capability per manufacturer's guidelines through successful completion of self-test. Following the check, defibrillators should be plugged into red emergency outlets where available."

On 5/22/2024 an interview was conducted with staff D, the Director of Nursing. Staff D was queried if she had conducted a review of the events on 4/04/2024. Staff D stated, "Yes." Staff D was queried if a Code Sheet had been completed for the code event. Staff D stated, "No." Staff D was then asked if she had conducted a debriefing of staff that were involved in the code. Staff D stated that she had talked with everyone involved in the code event. Staff D was then asked if she had identified any opportunities for improvement for future codes. Staff D stated that she and staff R, Nurse Educator and BLS (Basic Life Safety) Instructor had identified that the defibrillator was not used. Staff D was queried why the defibrillator had not been used. Staff D stated that staff thought the defibrillator was inoperable. Staff D was asked to review the documentation on the Crash Cart checklist from the morning of 4/4/2024 at 0300. Staff D was then asked if the defibrillator was checked to assess operational status. Staff D stated that it was checked. Staff D was then asked if the oxygen tank was noted to be empty on 4/4/2024 at 0300. Staff D stated, "Yes ...but I think it was full." Staff D was then shown where the oxygen tank had been marked as not available until 4/5/2024 where it stated the oxygen tank had been replaced. Staff D was asked if a code sheet had been used to record the code event. Staff D stated, "No." Staff D was then queried if a list of all personnel involved in the code on 4/4/2024 was available. Staff D stated, "No but we can review the video and make a list." Staff D was queried if a debriefing had taken place with staff involved. Staff D stated, "not anything formal but we did ask staff what happened." Staff D was asked if staff not involved in the code should have been removed from the area. Staff D stated, "Yes." Staff D was then asked if the Code Blue on 4/4/2024 had followed policy. Staff D stated, "We have identified areas of opportunity."

On 5/22/2024 an interview was conducted with staff R, Nurse Educator and BLS Instructor. During the interview with staff R, it was asked what professional organization standards were used for BLS. Staff R responded, "American Heart Association." Staff R was queried if she had reviewed the video documentation of the code conducted with P-1. Staff R stated, "Yes." Staff R was then queried if she had identified any issues with the code. Staff R stated, "We (staff D and staff R) noticed the defibrillator was not used from the first cart as staff thought it was not working." Staff R was asked if compressions were done at an appropriate rate. Staff R stated, "They (compressions) were done on the lower side of acceptable." Staff R was then asked if she thought the compressions were done at a rate of 100 per minute. Staff R stated, "Yes ... I think so."

On 5/21/2024 a record review occurred of the document titled, "Highlights of the 2020 American Heart Association Guidelines for CPR and ECC,"p.8, published date 2020, electronic copy found at https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines. According to the document titled "Adult Cardiac Arrest Algorithm" it states the following:

CPR Quality -
*Push hard (at least 2 inches [5 cm]) and fast 100-120/min), *Minimize interruptions in compressions, *Avoid excessive ventilation, *Change compressor every 2 minutes or sooner if fatigued, *If no advanced airway, 30:2 compression - ventilation ratio, *Quantitative waveform capnography - If PETCO2 is low or decreasing reassess CPR quality,
Rhythm shockable?
Shock energy for Defibrillation -
*Biphasic: Manufacturer recommendation (e.g. Initial dose of 120 - 200 J (Joules); if unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses may be considered,
*Monophasic: 360 J (Joules)
Drug Therapy -
Epinephrine IV/IO dose: *First dose: 1 mg every 3-5 minutes
*Amiodarone IV/IO dose: First dose: 300 mg bolus, Second Dose: 150 mg or
Lidocaine IV/IO dose: First dose: 1-1.5 mg/kg, Second Dose: 0.5-0.75 mg/kg
Advanced Airway -
*Endotracheal intubation or supraglottic advanced airway,
*Waveform capnography or capnometry to confirm and monitor ET (endotracheal) tube placement,
*Once advanced airway in place, give 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions
Return of Spontaneous Circulation (ROSC)
* Pulse and blood pressure
*Abrupt sustained increase in PETCO2 (typically ?40 mm Hg)
*Spontaneous arterial pressure waves with intra-arterial monitoring
Reversible Causes
*Hypovolemia
*Hypoxia
*Hydrogen ion (acidosis)
*Hypo-/hyperkalemia
*Tension pneumothorax
*Tamponade, cardiac
*Toxins
*Thrombosis, pulmonary
*Thrombosis, coronary


1. Start CPR
*Give Oxygen
*Attach monitor/defibrillator
Rhythm Shockable?
#2 Ventricular Fibrillation/p Ventricular Tachycardia
#3 Shock
Epinephrine ASAP
(see above Drug Therapy)
#4 CPR 2 minutes
Rhythm Shockable?
#5 Shock
*IV/IO access
# 6 CPR 2 minutes
*Epinephrine every 3-5 minutes
*Consider advanced airway, capnography
Rhythm Shockable? If Yes proceed to #7
#7 Shock
#8 CPR 2 minutes
#9 Asystole/Pulseless Electrical Activity
Epinephrine ASAP
(see above Drug Therapy)
#10 CPR 2 minutes
*IV/IO access
*Epinephrine every 3-5 minutes
*consider advanced airway, capnography
Rhythm Shockable?
#11 CPR 2 minutes
*Treat reversible causes
#12
* If no signs of return of spontaneous circulation (ROSC), go to #10 or #11
*If ROSC, go to Post-Cardiac Arrest Care
*Consider appropriateness of continued resuscitation


50585

On May 20th, 2024, at 1040, during the initial tour of 4 South Unit for developmentally delayed patients with Staff D, the Director of Nursing, it was observed the janitor's closet was unlocked allowing access to patients who were freely roaming the unit. Within the janitor's closet the following was accessible, a spray container of germicidal disinfectant, a television remote unit, and a gallon of liquefying stripper solution. Staff D confirmed all three hazardous substances were accessible to all 9 patients on the unit. Staff D confirmed the door to the janitor's closet should remain locked and secured from all patients.

On May 20th, 2024, at 1057 the door to the laundry room was unlocked allowing access to an open box of powdered laundry detergent on the table next to the washer. Staff D confirmed that the door should remain locked and secured at all times to patients.

On May 20th, 2024, at 1103, during the initial tour of 5 South patient care area, with Staff D present, it was observed a cloth underneath the partially opened door to patient room 545 preventing the door from closing and opening. Staff D confirmed the finding and stated that doors were not to be propped open.

On May 20th, 2024, at 1140, during the initial tour of the 5 South patient care area, patients were observed walking the hallways. Room 553 designated for the storage of patient's belongings, was noted to be unlocked allowing access to patients' valuables. A bin located in the room was noted to include tubes of paint and other liquid art supplies on the lower back shelf.

Based on record review and interview, the facility failed to protect 2 of 2 patients (P-15 and P-16) from abuse by staff resulting in harm. Findings include:

On 5/21/2024 a record review occurred of an adverse event where P-16 reported being abused to multiple staff members including staff O, the Officer of Recipient Rights and staff MM, Nursing Supervisor. According to the adverse event P-16 was locked in the Quiet Room on the night of 4/17/2024 for an unknown extended period of time. P-16 reported that he had been thrown to the ground by staff NN, RN 4S Developmentally Delayed unit, on 4/18/2024.

Record review of the medical record for P-16 stated the following, "The patient is a 34-year-old Caucasian single male. The patient present from his group home due to aggression, delusional behavior, paranoia, and being internally preoccupied. Upon arrival, the patient was noted to be hyperglycemic, see medical note. The patient believes that people are out to harm him. The patient states that he has a fax machine that has been hacked and he needs to fix it ....The patient has an 8th grade education ...Orientation is to person ...Intelligence is below average ....Justification for admission: danger to self, danger to others, psychosis, and inability to function." According to an order for admission it states, "Patient acts like a child at times ...." P-16 was admitted to the Developmentally Delayed unit on 12/22/2023 with the diagnosis of schizophrenia and intellectual disability. There was no documentation related to seclusion in the patient's chart.

On 5/22/2024 at 1245 a record review of video documentation occurred of the incident on 4/18/2024 with P-16. According to the video documentation on 4/18/2024 at 070514 P-16 could be seen in the doorway of the activity room with staff NN, registered nurse of the 4 S. At 070516 Staff NN could be seen pushing P-16 through the doorway and continuing to push P-16 past tables and chairs. At 070519 Staff NN was viewed pushing P-16 to the floor and grabbing P-16 ballcap from him. Staff NN continued to point his finger in P-16's face. At 070533 Staff NN was viewed turning away from P-16 at which time he continued to walk out the room. P-16 was seen getting up from the floor and walking to follow Staff NN. P-16 was seen going to the nurse's station visibly upset. Additional staff are viewed guiding P-16 into the activity room. At 0707, staff MM was viewed engaged in interviewing P-16.

A psychiatry daily physician notes by staff OO, psychiatrist on 4/18/2024 at 0625 stated, "Chief Complaint: I was attacked ... Patient (P-16) interviewed and chart was reviewed. Patient presents anxious. Patient reports that allegedly a staff member attacked him and per staff, currently doing investigation with the patient and guardian and RR (Recipient Rights) are notified. Patient has reached his chronic baseline. Patient has marginal hygiene and grooming. Patient is seen engaged in conversation with the attending psychiatrist. Will continue to monitor for safety and follow up with social work regarding placement."

According to a progress note dated 4/18/2024 at 1700 it stated, "Pt (P-16) was seen due to the complaint of altercation with staff from nursing station. Pt reports that he was pushed by the nurse. Pt denies any fall, injuries, trauma, painfever [SIC], chills, nausea, vomiting and headache at this time."

According to P-16 statement taken by staff MM, Nursing supervisor the following was stated, "Patient was standing at the nurses station screaming and writer walked up to the patient and asked him what was wrong, and patient stated he is tired of being abused. Patient stated, "he attacked me". Writer asked "Who" patient was walked into the dining room and interviewed by nurse supervisor and nurse educator. Patient persisted to state he had got in trouble by night shift nurse for stealing his phone, "it was on the desk and I was jealous so I took it. So they locked me in the quiet room all night and would not let me out" Patient states "so when I did come out in the morning I was standing at the desk and he attacked me he threw me to the floor" Patient was asked if he would like to file a police report and patient states "No I don't want the police here" Patient was then asked if he would like to file a grievance and patient states no. (Physician) notified, medical notified and Guardian contacted. Guardian was asked if she would like to file a police report and or a grievance report and she stated that she would like to hold off for now." Staff NN was no longer employed by the facility. No other corrective actions occurred after this incident.



On 5/22/2024 at 1057 during survey, a "Team Strong" (Team Strong is a term used by the facility when a patient altercation is ensuing and available staff are to go to assist with the patient) was announced overhead throughout the hospital to assist with an agitated patient.

On 5/22/2024 at 1320 during an interview with staff A, Chief Operations Officer a request was made to conduct record review of video footage of the "Team Strong" incident.

On 5/22/2024 at 1425 a record review occurred of video footage of the "Team Strong" incident. On 5/22/2024 at 1055 P-15 was viewed at the 5 South Nurse's Station where P-15 was engaged in a verbal argument with Staff Q, Charge Nurse of 5 South. At 1055 Staff W, Mental Health Technician was seen approaching P-15. At 105517 Staff W was viewed in verbal exchange with P-15. At 105521 P-15 became aggressive and lunged at Staff W. Staff W and P-15 were viewed physically fighting. At 105526 a Mental Health Tech placed himself between staff W and P-15. At 105528 P-15, staff W, and the additional staff member fell to the floor. Staff W and the additional staff member were observed to be on top of P-15. Staff W was the first to stand up. While the additional staff member (MHT) and P-15 went to stand staff W drew back his right arm and punched P-15 at 105537. The force of staff W's punch propelled P-15 back to the ground causing P-15 to hit his head. At 105543 P-15 returned to standing and was redirected away from staff W. Staff W continued to follow P-15 and required restraint from additional staff.

On 5/22/2024 at 1450 an interview was conducted with staff Q. Staff Q was asked to explain the incident. Staff Q stated that P-15 had been monopolizing the phone and was asked to step away from the phone. Staff Q stated P-15 was becoming belligerent and was told that he needed to refrain from the use of foul language and being disrespectful. Staff Q stated that P-15 continued with profanity and staff W came up to the nurse's station. Staff Q stated P-15 looked at staff W and stated, "so you want to continue from this weekend?" Staff Q stated she did not know what was meant by that comment. Staff Q then stated that P-15 lunged at staff W and she called a "Team Strong" over the announcement system." Staff W was not available for interview prior to the exit of survey.

On 5/22/2024 at 1505 an interview occurred with P-15. P-15 was asked to explain the incident. P-15 stated that staff W had targeted him during the weekend and several times had pointed his finger at him in a threatening manner. P-15 was asked if he felt safe. P-15 stated he did feel safe except for the mental health tech (name)(staff W). P-15 was asked if he was physically harmed during the incident. P-15 stated that his right hand had skin missing in two places. P-15 bandage was noted to be loose and not adhered to his skin. P-15 pulled the bandage back and said, "this is what happened," exposing the palm of his right hand. Two areas were noted to have the top layer of skin (epidermis) missing. P-15 was asked if he had pain. P-15 stated his right shoulder and face "hurt a little bit." P-15 was asked if anyone had assessed him after the incident. P-15 stated that staff G had "checked on me." P-15 was asked if he hit his head during the incident. P-15 stated, "I don't know ... maybe because I have a headache."

On 5/22/2024 at 1600 an interview was conducted with staff G, the Medical Director. Staff G was asked if he had seen P-15. Staff G stated, "Yes...I just saw him...He was in an altercation." Staff G was queried if he had seen P-15 right hand. Staff G stated, "Yes... I ordered the staff to clean the wound with soap and water and to place antibiotic cream on the wounds then to apply a dressing." Staff G was then queried if he had ordered alcohol to be used to wipe the wound. Staff G stated, "No...that is not what I ordered." Staff G was then queried if he was aware that P-15 had hit his head in the altercation. Staff G stated, "No. No one told me that he had hit his head." Staff G stated that he was going to reassess P-15 with new knowledge that P-15 had struck his head during the altercation.

A record review of the medical record for P-15 occurred on 5/22/2024. P-15 was petitioned for mental health treatment on 5/10/2024 and was admitted to the facility on 5/14/2024. P-15 signed a "Formal Voluntary Admission," on 5/14/2024. According to the "Family Medicine History and Physical," by staff G, Medical Physician, P-15 is described as, "a 19-year-old male with PMH (past medical history) significant for Gonorrhea as per chart. Pt (patient) was admitted to (facility) with Psychosis, NOS (not otherwise specified). Pt at this time denies any chronic and acute complaints. Pt denies any history of HTN (hypertension), Asthma, T2DM (Diabetes Mellitus Type 2), Hypothyroidism, Seizure disorder, stroke, heart attacks, blood or clotting disorders. Patient denies cough, fever, chills, nausea, vomiting, chest pain, shortness of breath, abdominal pain, and changes in bowel and bladder movements and lower extremity swelling or calf tenderness at this time. All other pertinent ROI (release of information) are negative except mentioned above. Vital signs are WNL and pt is medically stable at this time. Patient was cleared medically by Sending Facility." P-15 vital signs at the time of admission were listed as: Height 67 in (5'7"), Weight 162.4 lbs, Temperature 97.7 degrees Fahrenheit, Pulse 69, Respirations 18, Blood Pressure 140/94, Pain not documented, BMI (Body Mass Index) 25.

According to the document "Psychiatric Evaluation" dated 5/14/2024 stated, "The patient (P-15) was transferred from (facility) per court order and petitioned by mother. As per intake records, the patient present on AOT (Assisted Outpatient Treatment), has history of outpatient treatment with auditory and visual hallucinations, medication and treatment refusal, tangential, disorganized thoughts and speech, aggression paranoia, lack of frustration tolerance, and limited insight and judgment. The patient has a prior inpatient hospitalization ..." P-15 admitting diagnoses were listed as, "1. Schizoaffective Disorder, Bipolar Type, 2. Nicotine Use Disorder, Moderate, 3. Cannabis Use Disorder, unknown severity, and 4. Rule Out Schizophrenia."

According to the policy titled "Abuse and Neglect," number BMD-A-1, revision date 12/14/2023 it states under subtitle "Abuse Class II, (b) 'Abuse class II' means any of the following: (i) A non-accidental act or provocation of another to act by an employee, volunteer, or agent of a provider that caused or contributed to non-serious physical harm to a recipient. (I) 'Non-serious physical harm' means physical damage or what could be reasonably be construed as pain suffered by a recipient that a physician or registered nurse determines could not have caused, or contributed to, the death of a recipient, the permanent disfigurement of a recipient, or an impairment of his or her bodily functions. (ii) the use of unreasonable force on a recipient by an employee, volunteer, or agent of a provider with or without apparent harm. (iii) Any action or provocation of another to act by an employee, volunteer, or agent of a provider that causes or contributes to emotional harm to a recipient. (iv) An action taken on behalf of a recipient by a provider who assumes the recipient is incompetent despite the fact that a guardian has not been appointed, that results in substantial economic, material, or emotional harm to the recipient. (m) 'Physical management' means a technique used by staff as an emergency intervention to restrict the movement of a recipient by direct physical contact to prevent the recipient from harming himself, herself, or others. (v) Exploitation of a recipient by an employee, volunteer, or agent of a provider. (z) 'Unreasonable force' means physical management or force that is applied by an employee, volunteer, or agent of a provider to a recipient in one or more of the following circumstances: (i) There is no imminent risk of serious or non-serious physical harem to the recipient, staff or others. (ii) The physical management used is not in compliance with techniques approved by the provider and the responsible mental health agency. (iii) The physical management used in not in compliance with the emergency interventions authorized in the recipient's individual plan of service. (iv) The physical management or force is used when other less restrictive measures were possible but not attempted immediately before the use of physical management or force."

The policy continues to define "Vulnerable Adults" as "Those individuals who are unable to protect themselves from Abuse, Neglect or exploitation because of a mental or physical impairment or because of advanced age."

Subtitle "Staff to Patient Allegations of Abuse or Neglect" states, "Attending physicians are contacted to provide evaluation of patient condition inclusive of Psychiatry and Medical."

Based on interview and record review, the facility failed to report the death of one of one patient's (P-1) reviewed for death in restraints after being physically restrained by manual hold on 4/4/2024 to the Regulatory Authority by the end of the next business day 4/5/2024. Findings include:

On 5/20/2024 at 1155 during the opening conference it was revealed that the facility had failed to report the death of P-1 after being physically restrained by manual hold to the Regulatory Authority. Staff A, the Chief Operating Officer was asked if there had been any patient deaths related to restraint. Staff C, the Director of Operations stated, "Yes and that was reported to your office." Staff C was asked to provide documentation that was provided to the Regulatory Authority. Staff A stated, "We received an email in response to a request from (name) in your office...I can show it to you."

At 1400 on 5/20/2024, staff A provided an email with instructions and a hyperlink to report death of a patient related to restraint use. The hyperlink was shown to navigate directly to the CMS site to provide information from the reporting facility. Staff A stated he had provided and forwarded the information to staff C for reporting purposes.

At 1420 on 5/20/2024, staff C was asked if she had used the information provided by staff A in order to report the death of P-1 to the Regulatory Authority. Staff C stated, "This doesn't look like the site I went to... I actually Googled the form and filled it out and sent it to ORR (Office of Recipient Rights) for the State of Michigan and to MDHHS (Michigan Department of Health and Human Services). Staff C was queried if she had followed up with the Regulatory Authority to confirm receipt of the submission. Staff C stated, "No... I didn't think it was necessary."

On 5/20/2024 at 1525 a record review occurred of the policy titled, "Restraint/Seclusion - Behavioral," Number BMD-R-5, last revised 06/15/2023. According to the policy under subtitle Procedure, it states, "22. Any death of a Recipient/patient that occurs while in restraints or seclusion or where it is reasonable to assume the death is a result of being in restraints or seclusion shall be reported to the department manager. The Recipient/patient's condition prior to death and the category of restraints used within the last 7 days will be reported to the CMS regional office by the next business day following the Recipient/patient's death. Staff must document in the Recipient/patient's medical record the date and time the death was reported to CMS."

On 5/21/2024 at 0945 a record review occurred of P-1 medical record. The medical record for P-1 failed to have documentation of reporting of the death to CMS. Staff D, the Director of Nursing confirmed the finding.

Based on interview and observation, the facility failed to follow standards of care for wound care, and failed to follow a physician's verbal orders for one of one patients (P-15) resulting in less than optimal patient outcomes. Findings include:

On 5/22/2024 at 1500 during an interview with P-15 it was revealed P-15 had two open wounds approximately one half inch by one quarter inch on the right palm of his hand. P-15 stated he obtained the wounds during an altercation with a staff member. P-15 dressing was not adhered to the skin and stated, "It really hurt after they cleaned it with alcohol." The wounds were visualized and appeared the epidermal layer (top layer of skin) was missing with the dermis (middle layer of skin) exposed. P-15 was queried how the wound was cleansed and he stated, "They had me rinse it with water because it was bleeding then they wiped it off with alcohol pads...It really stung and hurt."

On 5/22/2024 at 1520 an interview was conducted with staff Q, the charge nurse for the 5 South unit. Staff Q was queried if alcohol was appropriated to clean out a wound. Staff Q stated, "No." After the interview staff Q communicated to staff BB, RN that P-15 dressing needed to be changed. Staff BB went to the medication room and returned with gloves and alcohol wipes. Staff BB was queried what the alcohol wipes were needed for in a dressing change. Staff BB stated, "to clean the wound." Staff BB was then queried if alcohol wipes were used for wound care. Staff BB stated, "Yes."

On 5/22/2024 at 1525 an interview was conducted with staff D, the Director of Nursing. Staff D was asked if alcohol should be used for wound care. Staff D stated, "No."

On 5/22/2024 at 1600 an interview was conducted with staff G, the Medical Director. Staff G was asked if he had seen P-15. Staff G stated, "Yes...I just saw him...He was in an altercation." Staff G was queried if he had seen P-15 right hand. Staff G stated, "Yes... I ordered the staff to clean the wound with soap and water and to place antibiotic cream on the wounds then to apply a dressing." Staff G was then queried if he had ordered alcohol to be used to wipe the wound. Staff G stated, "No...that is not what I ordered."

Based on observation, interview, and record review, the facility failed to keep medication refrigerators clean, resulting in the potential of contamination of medications and poor patient outcomes for all patients requiring refrigerated medications. Findings include:

On 05/20/2024 at 1125, during at a tour of 5 South patient care area, in the medication room with Staff S, (pharmacy technician) present, the medication refrigerator contained brownish frozen substance on the top shelf and scattered throughout the refrigerator. On the refrigerator shelf, there was an unlabeled plastic container with a dark green substance inside. On the bottom and walls of the refrigerator, multiple brownish stains were present.

On 05/20/2024 during an interview with staff S at 1130, she stated the day before she took a picture of a soda can that exploded on the refrigerator door shelf, and she informed the nurse.

On 5/21/2024 a record review occurred of the policy titled, "Medication Storage," dated 10/2023. According to the policy it states, "Drug Supplies shall be stored under proper conditions of sanitation, temperature, light, and humidity to comply with the manufacturer's recommendations." During an interview with staff T, the Director of Pharmacy it was confirmed the facility failed to follow the policy.