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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance.

A-0168 The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. Based on document review and interviews the facility failed to ensure a physician's order was obtained when patients were placed in physical restraints for violent or non-violent behaviors. The failure was identified in 4 of 7 medical records reviewed for restraints (Patient #35, #38, #16, and #19).

A-0175 The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed independent practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. Based on document review and interviews, the facility failed to ensure patients placed in violent restraints were monitored according to the hospital's policy. Specifically, the facility failed to ensure patients placed in violent restraints were monitored every 15 minutes and documented per protocol. The failure was identified in 4 of 4 records reviewed where patients were placed in restraints for violent behavior (Patient #7, #35, #36, and #37) .

Based on document review and interviews the facility failed to ensure a physician's order was obtained when patients were placed in physical restraints for violent or non-violent behaviors. The failure was identified in 4 of 7 medical records reviewed for restraints (Patient #35, #38, #16, and #19).

Findings include:

Facility policy:

According to the Restraint policy, a restraint is any manual method, physical or mechanical, material, or equipment that immobilizes or reduces the ability of a patient to move his/her arms, legs, body or head freely. Restraints initiated for violent/destructive behaviors require a licensed practitioner's (LP) order no longer that one hour following the initiation of the restraint. For patients 18 years or older, written or verbal orders for violent behavior restraints are limited to 4 hours. Non-violent, nondestructive behavior restraints require a written or verbal LP order no longer than 12 hours following the initiation of the restraint. If a restraint needs to continue beyond the expiration of the time limited order, a new order for restraint is obtained from a licensed practitioner after a face to face evaluation.

1. The facility failed to ensure a physician's order was obtained when patients were placed in physical restraints for violent or non-violent behaviors.

a. A record review was conducted for Patient #35 who arrived at the emergency department (ED) on 10/4/19 due to altered mental status, aggressive behavior, and history of a psychiatric disorder. Due to non-compliant and violent/aggressive behaviors the patient was placed in four point limb restraints from 10/4/19 at 9:01 a.m. to 5:45 p.m., approximately nine hours according to the nursing note documentation. Violent restraints were then reapplied at 6:00 p.m. until 10:10 p.m. due to recurring violent behavior.

Review of the LP orders found restraint orders were not obtained on a frequency of every four hours as stated in the facility policy. According to facility policy, on 10/4/19 an LP order for Patient 35's violent restraints was required at approximately 1:00 p.m., 5:00 p.m. for the initial restraint episode and at 6:00 p.m. due to the reapplication of the restraints.

i. A record review was conducted for Patient #19 who was placed in non-violent restraints on 10/11/19 at 8:00 p.m. in order to prevent "pulling at tubes". However, further review of the record found no evidence the nurse obtained an LP order to initiate the restraints at that time, or obtained an order within 12 hours of initiation per policy.

ii. A record review was conducted for Patient #16 who was in non-violent bilateral wrist restraints while in the Intensive Care Unit (ICU) from 8/8/19 10:45 a.m. until 8/10/19 9:00 a.m., approximately 2 days in restraints. Review found a lack of LP restraint orders were obtained after the initial order for restraints.

According to the instructions of the LP restraint order obtained on 8/8/19 at 10:45 a.m., the patient was to be placed in bilateral soft wrist restraints for 24 hours to prevent removal of essential medical devices. Therefore, the order was set to expire on 8/9/19 at 10:45 a.m. However, review of the record had not identified that an LP restraint order was obtained once the physical restraints remained in place beyond the parameters of the initial order.

iii. A record review was conducted for Patient #38 who arrived to the ED on 1/9/20 with signs and symptoms of substance abuse, confusion, and agitation. Upon arrival to the ED the patient was in four point physical restraints (restraints for all four limbs) for non-violent behaviors. According to the Restraint Flowsheet documentation, non-violent restraints were on the patient from 1/9/20 7:31 a.m. to 8:05 a.m. There was no evidence in the patient's record which showed nursing staff obtained a restraint order from the patient's physician. Patient #38 was restrained for 30 minutes. Patient #38's nurse documented at 8:05 a.m., the restraints were removed after a Foley catheter was placed.

b. On 1/30/20 at 11:50 a.m., an interview was conducted with ICU nurse (RN #12) who was one of the nurses assigned to provide care to Patient #16 during his stay at the facility. According to the interview, patients placed in non-violent restraints must have an LP order within 12 hours of initiating the restraint. She also stated that non-violent restraint orders were only good for 24 hours, and must be renewed if the patient's restraints had not been removed.

RN #12 reviewed Patient #16's restraint documentation. She was unable to find a renewal order for the patient's restraints. RN #12 stated she was unaware of any recent restraint education conducted in her unit the last four months prior to the survey.

c. On 1/30/20 at 10:06 a.m., an interview was conducted with the emergency department (ED) medical director (Physician #20). According to the interview, obtaining an LP's order for restraints was important because placing a patient in restraints was depriving the patient of their rights. He stated only someone with a medical license had the authority to take away a patient's rights. Physician #20 stated, restraints should be used only when needed and procedures should be followed.

d. On 1/30/20 at 12:16 p.m., an interview was conducted with a hospitalist (Physician #17). He stated nonviolent restraint orders were to be obtained 12 hours after initiation and renewed every 24 hours. Physician #17 stated the importance of obtaining an order was to allow the physician to assess the need for restraints. He stated it was dignity issue and if the patient was cooperative and following commands then the patient should be released from the restraints.

Based on document review and interviews, the facility failed to ensure patients placed in violent restraints were monitored according to the hospital's policy. Specifically, the facility failed to ensure patients placed in violent restraints were monitored every 15 minutes and documented per protocol. The failure was identified in 4 of 4 records reviewed where patients were placed in restraints for violent behavior (Patient #7, #35, #36, and #37) .

Findings include:

Facility policy:

The Restraint policy read, a "Restraint for Violent or Destructive Behavior" may be utilized immediately when less restrictive methods were not effective in controlling violent, aggressive, destructive, or threatening patient behavior. The "Periodic Assessment, Monitoring and Assistance for the Patient" section of the policy read, a staff member trained and competent in the use of restraints must assess the patient at initiation of the restraint and every 15 minutes thereafter. The assessment is relative to the type of restraint, and included assessments for: signs of injury associated with restraint application, nutrition/hydration, circulation and range of motion in the extremities, vital signs, hygiene and elimination, physical and psychological status and comfort, readiness for discontinuation of restraint.

1. The facility failed to ensure patients placed in restraints for violent/destructive behaviors were monitored and reassessed every 15 minutes per hospital policy.

a. A record review was conducted for Patient #35 which identified gaps in 15 minute reassessments following the initiation of violent behavior restraints. Three different nurses were responsible for monitoring Patient #35 while she was restrained for 13 hours. All three nurses did not monitor and document every 15 minutes according to policy.

Patient #35 arrived to the emergency department (ED), on 10/4/19, due to altered mental status, aggressive behavior, and history of a psychiatric disorder. Due to non-compliant and violent/aggressive behaviors the patient was placed in four point limb restraints from 10/4/19 at 9:01 a.m. to 5:45 p.m., which was approximately nine hours according to the nursing note documentation. Violent restraints were then reapplied for another four hours from 6:00 p.m. until 10:10 p.m.

Review of the restraint assessments found nursing staff completed the assessments approximately every hour, versus every 15 minutes per policy.

Review of the nursing assessments during the nine hour restraint period found the patient's status while in four point restraints (restraints applied to all four limbs) were not reassessed every 15 minutes according to policy. The restraint was documented as initiated at 9:01 a.m., then the subsequent reassessments were documented at the following intervals during the nine hour restraint period: 9:36 a.m., 10:37 a.m., 11:23 a.m., 12:18 p.m., 12:46 p.m., 1:46 p.m., 2:45 p.m., 3:45 p.m., 4:45 p.m., and the patient was documented as out of restraints at 5:45 p.m. Additional missed assessments were found from 6:00 p.m. through 10:10 p.m.

i. A record review was conducted for Patient #7, who was transferred to the Intensive Care Unit (ICU) on 11/21/19, for treatment of alcohol withdrawals and management of medical comorbidities. Review of the ICU restraint log noted Patient #7 was in violent restraints. According to the restraint order documented on 11/23/19 at 10:00 a.m., the patient was placed in four point limb restraints for violent behavior including attempting to punch and elbow staff.

According to the nursing documentation, on 11/23/19 at 9:30 a.m. a nursing restraint assessment was documented as completed. The next reassessment, two hours later, was documented on 11/23/19 at 11:30 a.m. The next reassessment was documented on 11/23/19 at 12:00 p.m., 30 minutes after the previous assessment. The third reassessment was documented on 1/23/19 at 2:00 p.m., two hours after the previous reassessment. On 1/23/19 at 3:00 p.m., the patient was documented as "removed" from restraints after exhibiting safe behavior.

According to the restraint reassessments completed on 1/23/19 restraints the patient's nurse failed to reassess the patient every 15 minutes per policy for signs of injury associated with restraint application, nutrition/hydration, circulation and range of motion in the extremities, vital signs, hygiene and elimination, physical and psychological status and comfort, readiness for discontinuation of restraint.

ii. Similar gaps in 15 minute assessments for violent restraints were noted for Patient #36 and Patient #37. Both patients were placed in restraints for approximately 2-3 hours related to violent behavior. However, review of nursing documentation found the patients were not monitored every 15 minutes per the hospital policy.

b. On 1/30/20 at 10:55 a.m., an interview was conducted with an emergency room nurse (RN #7). RN #7 stated patients placed in violent restraints should be monitored for appropriate circulation in the restrained extremities, cardiac pulse checks, motor sensation, mental evaluation, need for restraints, review of systems, and general status of the restrained limbs.

c. On 1/30/2020 11:50 a.m., an interview was conducted with an ICU nurse (RN #12). RN #12 stated the nursing staff attended a skills lab annually which reviewed the restraint process. RN #12 stated patients in violent restraints required close monitoring, every 15 minutes, to check for comfort, assess for harm, offer toileting, and evaluate if the restraints needed to be continued.

d. On 1/30/20 at 10:06 a.m., the emergency department medical director (Physician #20) was interviewed. Physician #20 stated restraints were not ideal with patient care. He stated patients were at risk for safety concerns such as vomiting and airway issues while being restrained. Physician #20 stated restraining a patient not only had safety concerns, but also had moral and ethical issues, including taking away a patient's fundamental rights.

Based on interviews and document review, the facility's quality committee failed to implement preventive actions for internal safety event reports which showed lapses in required documentation and monitoring in one of one patient events reviewed for violent restraints (Patient #35). This resulted in continued staff non-compliance in the care and management of patients restrained for violent and self-destructive behavior.

Findings include:

Facility policies:

The Incident Reporting Procedure read, the purpose of the reports are to improve the management of patient care and treatment and to provide a safe environment. This is accomplished by assuring that appropriate and immediate intervention occurs and there is a subsequent prevention of recurrences.

The Restraint policy read, for violent/self-destructive behavior restraints, patients in restraints need to be assessed upon initiation of the restraints and every 15 minutes thereafter for signs of any injury associated with the restraint application, nutrition/hydration, circulation and range of motion in the extremities, vital signs, hygiene and elimination, physical and psychological status and comfort and readiness for discontinuation of restraint.

Additionally, documentation in the medical record should include: patient condition or symptoms warranting restraint/patient behavior, date time physician notified, time/date order/reordered, alternative or less restrictive interventions attempted, any modification made to plan of care, restraint device used and duration of use, patient assessment and reassessments, injuries to patient, patient care performed, education, patients response to intervention and actions taken upon reevaluation.

1. The quality committee failed to ensure action plans were implemented after staff non-compliance was identified during a quality review of a patient's restraint episode.

a. Review of Patient #35's safety event report revealed, on 10/4/19, the patient was kept in four point restraints (restraints applied to all four limbs) for over 13 hours. According to a comment entered on 10/10/19, the facility identified multiple concerns with the restraint episode. The documented concerns included lack of proper orders and staff failing to document the required 15 minutes assessments. Per the restraint policy, patients were to be assessed every 15 minutes thereafter for signs of any injury associated with the restraint application, nutrition/hydration, circulation and range of motion in the extremities, vital signs, hygiene and elimination, physical and psychological status and comfort and readiness for discontinuation of restraint.

The safety report event comments further read, on 10/30/19, the emergency department director and manager found several other restraint medical records lacking the required documentation. The plan noted both emergency department and intensive care unit (ICU) directors were to implement education to staff for restraint documentation.

i. Review of Patient #35's emergency department medical record, dated 10/4/19, was conducted. According to the restraint assessment documentation, three different RNs (RNs #7, #18 and #19) provided care to the patient during the 13 hours she was restrained.

ii. On 1/30/20 at 10:06 a.m., the emergency department medical director (Physician #20) was interviewed. Physician #20 said he did review Patient #35's restraint safety event report with the ED medical director. He said restraints were not ideal with patient care. He said patients were at risk for safety concerns such as vomiting and airway issues. Physician #20 stated restraining a patient had moral and ethical issues as well, including taking away a patient's fundamental rights.

Although, the facility provided evidence of education for the emergency department (ED) physicians and charge nurses, the quality committee was unable to provide evidence all nursing staff, including the ED and ICU, were educated about required restraint monitoring and documentation for patients who were restrained for violent and self-destructive behaviors. Three additional patient restraint episodes were reviewed which took placed after Patient #35's event. All three patient records were found with missing 15 minute assessments (Patients #7, #36 and #37).

b. Review of Patient #37's emergency department record, dated 1/2/20, showed RN #18 was responsible for Patient #37's care while the patient was restrained for violent behavior. Patient #37 was restrained from 8:25 a.m. until 11:08 a.m. Patient #37's restraint documentation showed no evidence RN #18 evaluated the patient every 15 minutes according to policy. The record lacked documentation of 15 minute restraint assessments at 10:15 a.m. and 10:45 a.m. This was the same failure identified by the quality committee three months prior to the patient's ED admission.

Similar findings were found in two other patient records reviewed for violent restraint monitoring (Patients #7 and 36). Patient #7 was placed in restraints for violent behavior while she admitted in the ICU.

Cross Reference V0175

c. On 1/30/20 at 12:23 p.m., ED Director (Director #21), ICU Director (Director) #22, Risk Manager (Manager #23) and Senior Director of Quality and Risk (Director #24) were interviewed.

Director #21 said she did educate the three nurses involved in Patient #35's restraint event. However, she was unable to provide documented evidence of the counseling.

Director #22 stated the ICU did review restraint records for documentation and was able to provide the completed audits. However, he stated there had been no formal education for his nursing staff for missed opportunities identified during the audits.

Based on the on-site validation survey completed on February 18th and 19th, 2020, the facility failed to comply with the regulations set forth for Life Safety and therefore, deficiencies were cited under Life Safety Code tags K211, K324, K343, K353, K363, K373, and K929. Please see survey event ID #BXDC21 for full details of the cited deficiencies.

Based on observations, interviews, and document review the facility failed to ensure staff completed hand hygiene per hospital policy and referenced infection control guidelines. The failure was identified during 1 of 1 surgical case tracer conducted (Patient #39).

Also based on observations, interviews, and document review the facility failed to ensure the mobile computer workstations were cleaned between patient use according to facility policy. This failure was identified in 4 of 4 medication administrations observations on the inpatient unit.

Findings include:

Facility policy:

The policy, Hand Hygiene Guidelines, read that hand hygiene is the single most important activity for preventing the spread of infection and that the policy extends to all hospital employees. The policy further read that healthcare workers (HCW) were expected to follow the World Health Organization "5 Moments of Hand Hygiene". The following situations require hand hygiene: before touching a patient, before clean/aseptic procedure, after body fluid exposure risk, after touching the patient, after touching the patient's surroundings. Other opportunities identified to perform hand hygiene included before/after medication administration, before/after procedure or treatment administration, or before handling /inserting indwelling urinary catheters.

The policy, Cleaning and Disinfection Guidelines, read Workstation on Wheels (WOW) should be disinfected with hospital-approved disinfectant wipes frequently during day, and as needed, if visibly soiled. The policy attachment Specific Low Level Disinfection Environment and Equipment Cleaning guideline read that the WOW keyboard, mouse, and bar scanner were to be cleaned between patient use with a germicidal wipe.

1. The facility failed to ensure staff completed hand hygiene per hospital policy and referenced infection control guidelines.

a. On 1/28/20 at approximately 10:54 a.m., a surgical case tracer observation was conducted for Patient #39 in operating room #3. At 11:06 a.m., the operating room (OR) nurse (RN #8) began to initiate the process for inserting a urinary catheter (a catheter inserted and secured aseptically into the bladder in order to mechanically collect urinary output) into the patient. However, the observation at that time found the nurse RN #8 had not completed hand hygiene prior to donning sterile gloves worn while inserting the urinary catheter.

At 11:09 a.m., RN #8 removed the sterile gloves and did not perform hand hygiene. RN #8 then touched Patient #39's leg with an ungloved hand to place the urine collecting tray of the urinary catheter between the patient's leg on the OR bed. Following the direct patient contact, RN #8 still had not completed hand hygiene.

At 11:12 a.m., RN #8 was preparing to aseptically apply surgical skin prep on the patient's abdomen. However, the observation found the nurse had not completed hand hygiene prior to donning the sterile gloves worn during the process.

The process findings were not compliant with the 5 Moments for Hand Hygiene referenced by the hospital's policy.

i. Further observations were conducted of Patient #39 receiving care in the Post Anesthesia Care Unit (PACU) following surgery, which identified two more hand hygiene breaches during intravenous (IV) medication administration by the PACU nurse (RN #9).

At 3:16 p.m., RN #9 was observed administering an IV dose of Fentanyl for pharmacological pain management. However, RN #9 did not complete hand hygiene prior to administering the medication via the patient's IV. At 3:20 p.m., the same nurse was observed providing an additional dose of IV pain medication without completing hand hygiene prior to administration.

b. On 1/30/20 at 12:05 p.m., an interview was conducted with a critical care registered nurse (RN #10). According to the interview, staff completed training involving hand hygiene on an annual basis. RN #10 stated hand hygiene was required when entering the direct patient care area, after patient care/contact, before/after donning gloves, and before/after sterile tasks. RN #10 stated hand hygiene was important to prevent cross contamination and decrease the risk of infections.

c. On 1/30/2020 at 2:32 p.m., an interview was conducted with the infection control officer (IC #11). IC #11 confirmed the facility's healthcare workers were expected to follow the 5 Moments of Hand Hygiene as referenced in the hospital's policy. IC#11 stated hand hygiene was important to prevent the spread of infection. She confirmed the hand hygiene breaches identified during the survey were not consistent with the facility's policy and expectations. IC #11 stated hand hygiene was a continuous performance improvement (PI) project in the infection control program. However, she stated hand hygiene audits were conducted mostly on the inpatient units, and did not include the surgical department.



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2. The facility failed to follow infection control policies for the disinfection of Workstation on Wheels ((WOW) mobile computer stations) between patient use.

a. On 1/27/20 at 3:33 p.m., an observation was conducted of registered nurse (RN #13) administer a blood transfusion. RN #13 touched the keyboard of the WOW, touched the blood transfusion tubing, and touched the patient several times. RN #13 then rolled the WOW out of the patient's room without cleaning it and left the WOW at the nurse's station.

i. On 1/27/20 at 4:00 p.m., during an observation of a medication pass, RN #14 rolled the WOW into a patient room. RN #14 touched the keyboard to enter information into the electronic health record (EHR), touched the patient's arm, removed and replaced the scanner on the WOW. RN #14 did not clean the WOW upon exiting the room, then returned the WOW to the nurse's station.

ii. On 1/28/20 at 9:00 a.m., an observation of a medication pass was conducted with RN #15. After rolling the WOW into a patient room, RN #15 touched the patient while scanning the armband with the handheld scanner, touched the keyboard, touched the patient to give an injection and touched the keyboard a second time. RN #15 then rolled the WOW out of the room. RN #15 then took the WOW into another patient room without cleaning it.

iii. On 1/28/20 at 10:00 a.m., RN #16 was observed leaving a patient room with a WOW. RN #16 did not clean the WOW prior to leaving it in the hallway.

b. An interview was conducted with RN #16, who reported the WOW's were routinely stored in the hallway or nurses station and were not cleaned. She reported no policy or guidelines were available regarding cleaning recommendations for the WOW's.

c. On 1/28/20 at 12:05 p.m., an observation of a medication pass was conducted with RN #13. During medication administration, RN #13 touched the patient's arm, scanned the arm band with the scanner, touched the keyboard, disconnected and reconnected the IV tubing, touched the patient's arm in the area of the IV site, and touched the keyboard several more times. RN #13 rolled the WOW out of the room without cleaning it and left the WOW in the hallway.

d. On 1/28/20 at 12:15 p.m., an interview was conducted with RN #13. She stated there was no policy or need for routine cleaning of the WOW's. She reported the WOW's were taken to multiple rooms by multiple nurses during a shift and were not assigned to a particular nurse. RN #13 stated there was no concern for cross contamination when a WOW had not fully entered a patient room. The 1/28/20 12:05 p.m. medication administration observations with RN #13 revealed she had fully entered the patient's room with the WOW, and had not disinfected the equipment upon exiting the patient room.

e. On 1/30/2020 an interview was conducted with the infection control officer (IC #11.) She stated the WOW should be cleaned between patient rooms to prevent cross contamination. She stated the policy regarding cleaning of equipment, including the WOW, was covered in department orientation but had no further training or active surveillance to ensure compliance.

Based on interviews and record review, the facility failed to reassess the appropriateness of the discharge plan in 1 of 1 patient who experienced a change in condition within 24 hours of discharge (Patient #10).

Findings include:

Facility policy:

The Discharge Planning policy read, each patient's needs for continuing care are assessed in an ongoing fashion by all members of the healthcare team. Any health care team member may identify a patient with discharge needs or concerns. Discharge planning identifies a patient's unique needs for continuing physical, emotional, transportation, social and other needs and to arrange services to meet those needs. Care, treatment and services are coordinated to ensure patient information is shared, scheduling conflicts are resolved, timely and accurate information reaches those needing it prior to discharge to avoid unnecessary delays. Case Managers will be primarily responsible for the development, documentation and implementation of the discharge plan. Case Managers are RN's/LPN's who have had the necessary training and meet the qualifications needed to conduct discharge planning activities. In the event that Case Management is unavailable such as after hours and/or weekends/holidays, discharge needs will be addressed by the primary nurse and/or the House Supervisor. The final discharge plan will be documented in discharge intervention and the progress notes as appropriate. Adjustments to this plan will be made as needed.

1. The facility failed to ensure the discharge plan was reassessed after a patient exhibited a change in condition prior to discharge.

a. A review was conducted of Patient #10's medical record. On 9/30/19 at 7:45 a.m., Registered Nurse (RN) #1 documented an End of Shift Note in which Patient #10 drank hand sanitizer and the patient stated he was afraid he would consume excessive amounts of alcohol if he was discharged. Review of both the History and Physical (H&P) and the Emergency Department Physician Clinical Report (ED notes) written on 9/27/19 revealed no documentation Patient #10 had a history of drinking hand sanitizer.

b. On 1/29/20 at 3:05 p.m., an interview with RN #2 was conducted. RN #2 stated she normally worked in the acute rehabilitation unit, but sometimes floated to the medical surgical unit. RN #2 stated she discharged Patient #10 on 1/30/20 around 10:30 a.m. She stated she remembered Patient #10 because he drank hand sanitizer which in her mind was not normal. She stated she was told in change of shift report Patient #10 drank hand sanitizer. RN #2 also stated she was told another RN looked up the hand sanitizer and determined it was not poisonous, but no one had called the poison control center to verify. She stated although drinking hand sanitizer was not normal, she did not ask for a psychological evaluation prior to discharge, nor did she know how to do so. RN #2 stated she was not sure if Patient #10 was safe to discharge. She stated Patient #10 signed his discharge papers, was escorted to the hospital exit and simply walked away alone.

c. On 1/30/20 at 10:54 a.m., case manager (RN #6) was interviewed. RN #6 stated her role was to ensure patients had a safe discharge plan. RN #6 stated it was disturbing to her Patient #10 drank hand sanitizer. RN #6 stated Patient #10 should have been evaluated to discharge to the crisis stabilization unit (CSU) because he drank hand sanitizer and stated he was going to continue to drink excessively. RN #6 stated case managers saw patients on the day of discharge. RN #6 reviewed the note RN #3 documented on 9/30/19. RN #6 stated there was no mention Patient #10 had been re-evaluated for a safe discharge plan after he drank hand sanitizer and prior to discharge. RN #6 reviewed RN #3's case management note on 9/29/19 which stated Patient #10 did not have a primary care provider and sent a referral to the CSU because Patient #10 had requested to be established with a mental health provider. RN #6 reviewed the Discharge Summary written on 9/30/19. She stated since there was no mention the patient drank hand sanitizer or plan to drink excessively, there was no way to determine if Provider #4 evaluated Patient #10 for a safe discharge plan. RN #6 stated Patient #10 had a change in condition and was not safe for discharge.

d. Patient #10's Discharge Instructions signed on 9/30/19 were reviewed. Patient #10 was instructed to follow up with his primary care physician even though RN #3's case management note on 9/29/19 stated Patient #10 did not have a primary care provider. There was no mention of follow up regarding a mental health provider or the crisis stabilization unit. Patient #10 was simply instructed to avoid further alcohol consumption.

e. Review of Patient #10's hospital admissions revealed he was readmitted on 10/11/19 for isopropyl alcohol intoxication and toxicity which required intubation (the placement of a flexible plastic tube into the trachea to maintain an open airway) and ventilation (placing oxygen into the lungs of people who have lost the ability to breathe on their own).