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Based on observations, interviews, record reviews and review of the hospital's video recording and policy and procedures, the Condition of Participation for Patient Rights was not met due to the hospital's nursing staff failure to ensure a safe environment by assessing the patient for possible changes in condition. The hospital failed to ensure monitoring was performed as required. The hospital's 15-minute check system failed to prevent one (Patient #1's) of 10 patients reviewed, suicide attempt on 11/4/14 and death on 11/5/14. The immediate jeopardy beginning on 11/4/14, was identified on 11/17/14.


The findings include:


The hospital nursing staff failed to ensure every 15 minutes checks where done on all patients who needed these checks to ensure a safe environment. There was no systematic way to ensure the checks were performed in an accurate and timely manner. The hospital nursing staff failed to ensure 15-minutes checks were completed in accordance with hospital procedures to monitor patient safety, prevent self-harm and the death for Patient #1. The mental health technicians (MHT) failure to implement the hospital's 15-minute check system, including the nursing staff pulling MHT from conducting the 15-minute checks, resulted in Patient #1's suicide attempt on 11/4/14 and death on 11/5/14.

The immediate jeopardy was removed on 11/18/14, based upon the implementation of corrective actions. (See A 144 for additional information regarding Patient #1)

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Based on interviews, record reviews and observation of the hospital's video recording from 11/4/14, the hospital failed to provide care and monitoring to ensure a safe environment sufficient to prevent harm and death for one (Patient #1) of 10 patients reviewed. The immediate jeopardy beginning on 11/4/14 was identified on 11/17/14, due to the hospital's 15-minute check system failed to prevent Patient #1's suicide attempt on 11/4/14 and death on 11/5/14. The immediate jeopardy was removed on 11/18/14, based upon the implementation of corrective actions.


The findings included:


Patient #1 was a 51 year old male, admitted to Park Royal Hospital under a Baker Act on 10/28/2014. (Note: The Florida Mental Health Act of 1971 [Florida Statute 394.451-394.47891], commonly known as the "Baker Act," allows the involuntary institutionalization and examination of an individual in a psychiatric facility.) Review of the admission assessment indicated for the past 5 weeks, the patient's suicidal ideations had increased. Prior to admission, he was very depressed and felt like people were following him. He had suicidal thoughts but had not acted on the thoughts. Patient #1 reported: 1) his depression started 5 weeks prior when he lost his job; 2) his sister-in-law had accused him of doing "something" to his niece; 3) about 20 years ago, he was in Russia on business and said he witnessed "frozen bodies"; 4) he was assaulted while in Russia; 5) feelings of paranoia and hopelessness but was on no medications; and 6) he drank 2-3 times per week. The record indicated his parents were his support system.

On 10/29/2014, the record indicated the medical doctor (MD) H, Patient #1's psychiatrist, discontinued the Baker Act, as the patient agreed to a contract that he would not attempt to harm himself.

During interviews on 11/13/2014 at 11:15 a.m., registered nurse (RN) F and who worked with patient #1, indicated the patient was very quiet and kept to himself, but when approached by staff he would talk. During interviews on 11/13/2014 A at 5:15 p.m., mental health technician (MHT) and who worked with patient #1, indicated the patient was very quiet and kept to himself, but when approached by staff he would talk. They said the patient would lie around in his bed and told them he did not want any further visitors.

On 11/1/2014, Patient #1 asked to be discharged from the hospital and signed his request to be released. The patient never withdrew his release request.

During an interview on 11/12/2014 at 2:45 p.m., the social worker said the patient never attended group therapy sessions. The social worker said Patient #1, on 11/2/2014, asked for a living will form. The social worker said he asked the unit secretary for the advance directive forms. Later in the day the patient told the social worker he had received the forms. The social worker said the patient told him in case he left the hospital and was not doing well, he wanted a living will in place. The social worker said he did not tell anyone about Patient #1's requesting a living will. He did not discuss with the patient why he wanted to complete a living will.

On 11/4/2014 at 3:05 p.m., the record indicated MD H ordered Patient #1 again be Baker Acted. MD H indicated the patient continued to be disorganized, confused, and preoccupied with discharge. He was compliant with medications and denied suicidal ideations. Patient #1 was not placed on suicide precautions, he was to be monitored 15-minutes.

Review of the Policy and Procedure for patients not placed on suicide precautions, indicated they will be monitored every 15 minutes on the 15-minute check sheet. Staff does not need to be within eyesight of the patient at all times, but need to monitor the patient every 15 minutes.

On 11/4/2014 at 8:45 p.m., review of the hospital's video recording taken by the camera placed on the 2 East Unit, positioned looking toward the nursing station. Review of the hospital's video recording revealed Patient #1 was seen walking down the hallway carrying a patient gown and went into his room. He was the only patient residing in the room at the time. At 9:00 p.m., 9:15 p.m., and 9:30 p.m. no staff were recorded going to the area to conduct a 15-minute check of Patient #1 in room #104. At 9:44 p.m., MHT J entered Patient #1's room and exited the room appearing to scream down the hall.
A review of the "Generic Nursing Progress Note" dated 11/4/14 and Park Royal Emergency Department Referral" undated, noted a call for help was made by MHT J because he had found Patient #1 hanging from the bathroom door with a patient gown tied around his neck. Staff responded and Patient #1 was given Cardiopulmonary Resuscitation (CPR), a code blue was initiated and 911 was called. Patient #1 was taken to an acute care hospital where he died on 11/5/14.

MD H voiced on 11/13/2014 at 2:50 p.m., being so upset about the unanticipated death of Patient #1 he insisted he provide a statement/disclaimer. Per MD H, "I was not aware or informed by staff that the patient was asking for living will paperwork and that he had written do not resuscitate on a piece of paper. If I had been made aware of the living will dated 11/3/2014, I would have placed the patient on suicide watch and 1:1 supervision immediately. I learned about the living will the patient had written while the patient was in intensive care at the medical hospital. I believe one of the nursing supervisors at Park Royal Hospital told me about the living will. I saw the living will at the time I was doing my discharge summary after the patient had expired. I was surprised to see the paper for the first time the day after my patient had expired. I never saw the living will /do not resuscitate paper inside the medical record."

During an interview on 11/14/2014 at 11:45 a.m., the chief medical officer said he was alarmed at the fact the social worker was approached by a patient who requested a living will and the staff member did not follow up by notifying other staff or the patient's physician of the incident. The chief operating officer said the social worker was a new hire. He said he would have the director of social services have the social worker monitored.


The hospital implemented correction actions to remove the immediate jeopardy: 1) revising the assignment of mental health technicians (MHT) every 15-minute check/round process; 2) educated the staff, including the MHT and nursing staff, about the expectation of what is to occur when doing the 15-minute checks/rounds and the nursing staff review process; 3) competency evaluation of the MHT conducting 15-minute check/round process and documentation completion; and 4) assigned minimally 1 staff no other responsibility than conducting 15-minute checks/rounds, without the nursing staff pulling to complete other tasks. As a result the immediate jeopardy was removed at the exit conference. The hospital has not completed the auditing of correction actions effectiveness.



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Based on a review of quality assurance documents and interviews with administrative staff, the hospital failed to ensure quality monitoring was analyzed. The hospital failed to modify the plan as necessary. The hospital system failures resulted in effective change in hospital practices to prevent injury and death to one (Patient #1) of 10 patients reviewed.


The findings included:


The hospital had an incident on 9/20/14 at 3:30 a.m., where a patient followed a staff member out a locked door and left the hospital. The patient was a voluntary patient and this was regarded by the hospital as leaving against medical advice (AMA) rather than an elopement. Investigation by the quality staff revealed the patient was gone for 2 hours and 20 minutes before it was discovered the patient was not on the unit. It was noted, in the investigation, 3 rounds of 15-minute check monitoring were documented as the patient was in bed sleeping after the patient had left the building.

An action plan was developed including: 1) staff education on 15-minute check monitoring of patients (standard for some of the patients); 2) legal documentation; 3) a mandatory meeting with the chief executive officer and administrative staff to review job expectations and patient safety; and 4) monitoring of the documentation of 15-minute check observations will be done.

During an interview on 11/18/14 at 4:30 p.m., the risk manager/quality manager indicated he had not received any monitoring on the every (q) 15-minute check monitoring sheets by the supervisors until 11/18/14. He had not analyzed the data, and he is not sure what the supervisors were monitoring.

The acting director of nursing provided a 15-minute check monitoring sheets going back about to September 2014. The form was titled "Supervisor Monitoring For Patient Safety: Q15 Minute Check Logs" On the log are columns for: 1) Date, with sub-rows for Time, Employee Name, and Unit; 2) Patient Observation Sheets Accurate? with sub-columns for Yes or No; and 3) If Not Accurate, Explanation. When asked about the use of the form, the acting director of nursing said when they started using it they were just looking at the forms to see if the mental health technicians (MHT) were documenting timely about the every 15 minute checks. There was no assessment to ensure the accuracy of the observation by the MHT. She said recently they have changed the focus of the monitoring to ensure the accuracy of the observation, but this had just been done within the last week or so. She said she was looking at these forms, but agreed there was no analysis and evaluation of the effectiveness of the auditing tool, and no evaluations of the quality of the MHT performance of the every 15-minute checks.

On 11/4/14 at 9:58 p.m., Patient #1 was found hanging in the bathroom. The patient was resuscitated and sent to the acute care hospital. Patient #1 subsequently expired at the acute care hospital. As a part of the analysis of this incident, there were issues identified based on a review of the hospital's video recording of the lack of 15-minute check observations for Patient #1 on 11/4/14. This was inconsistent with documentation on the form titled "Patient Observation" dated 11/4/14 for the 2 East Unit Room 104A noting 15-minute checks were completed from 0000 (12:00 a.m.) to 2130 (9:30 p.m.).



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Based on observations, interviews, record reviews and review of the hospital's video recording and policy and procedures, the Condition of Participation for Nursing Services was not met due to the hospital's nursing staff failure to ensure nursing and mental health technician ancillary services were provided in a manner to provide a safe environment for patients. The hospital's 15-minute check system failed to prevent one (Patient #1's) of 10 patients reviewed, suicide attempt on 11/4/14 and death on 11/5/14. The immediate jeopardy beginning on 11/4/14, was identified on 11/17/14.



The findings include:


The hospital nursing services failed to ensure 15-minute checks where done on all patients who needed these checks. There was no systematic way to ensure the checks were performed in an accurate and timely manner. The hospital nursing services failed to ensure 15-minute checks were completed in accordance with hospital procedures to monitor patient safety, prevent self-harm and the death for Patient #1. The hospital's 15-minute check system failures of the mental health technicians (MHT) conducting the 15-minute checks. The nursing staff pulled MHT from conducting the 15-minute checks. These hospital system failures resulted in the failure to prevent Patient #1's suicide attempt on 11/4/14 and death on 11/5/14. The immediate jeopardy was removed on 11/18/14, based upon the implementation of corrective actions. (See A 397 for additional information regarding Patient #1)



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Based on observation, record review, interviews of clinical and administrative staff, and review of the hospital's video recording, the hospital failed to ensure nursing care was provided by ancillary services in accordance with hospital procedures to prevent harm and death for one (Patient #1) of 10 patients reviewed. The immediate jeopardy beginning on 11/4/14 was identified on 11/17/14, due to the hospital's 15 minute check system failed to prevent Patient #1's suicide attempt on 11/4/14 and death on 11/5/14. The immediate jeopardy was removed on 11/18/14, based upon the implementation of corrective actions.


The findings included:


1. On 11/4/2014, Patient #1 was found hanging in his bathroom at Park Royal Hospital. Resuscitation measures were initiated and the patient was transferred to an acute care hospital. The patient expired on 11/5/14.

Review of the record indicated Patient #1 was admitted on 10/28/2014 under a Baker Act. (Note: The Florida Mental Health Act of 1971 [Florida Statute 394.451-394.47891], commonly known as the "Baker Act," allows the involuntary institutionalization and examination of an individual in a psychiatric facility.) Review of the admission assessment indicated for the past 5 weeks, the patient's suicidal ideations had increased. Prior to admission, he was very depressed and felt like people were following him. He had suicidal thoughts but had not acted on the thoughts. Patient #1 reported: 1) his depression started 5 weeks prior when he lost his job; 2) his sister-in-law had accused him of doing "something" to his niece; 3) about 20 years ago, he was in Russia on business and said he witnessed "frozen bodies"; 4) he was assaulted while in Russia; 5) feelings of paranoia and hopelessness but was on no medications; and 6) he drank 2-3 times per week. The record indicated his parents were his support system.

During an interview on 11/13/2014 at 5:15 p.m., mental health technician (MHT) A said on 11/04/2014, the night of the incident, there were 3 MHTs scheduled to work on the Baker Act Unit. He said MHT B was originally assigned to Patient #1. He said MHT B was called to work on another unit. MHT A said he and MHT J were left to divide up the assignment. He said they each took one of the two hallways with 10 patients split between them. He said that MHT J took the hallway where Patient #1 resided.

Patient #1 was not placed on suicide precautions but was to be monitored every 15 minutes.

Review of the Policy and Procedure for patients not placed on suicide precautions, indicated they will be monitored every 15 minutes on the 15 minute check sheet. Staff does not need to be within eyesight of the patient at all times, but need to monitor the patient every 15 minutes.

The hospital had video recording cameras in the hallways on each unit. Review of the hospital's video recording taken by the camera placed on the 2 East Unit, positioned looking toward the nursing station, on 11/4/2014 of the hallway where Patient #1 resided, revealed at 8:45 p.m., the patient was walking down the hallway carrying a patient gown and went into his room and closed the door. The MHT documented on the form titled "Patient Observation" dated 11/4/14, at 2045 (8:45 p.m.) for the 2 East Unit Room 104A, Patient #1 was in bed asleep.

Review of the hospital's video recording of the incident revealed the following:
? At 9:00 p.m., No 15-minute room check done in Patient #1's room 104. Review of the 15 minute check sheet for 9:00 p.m., documented MHT J had noted Patient #1 was in his room asleep with chest rising and falling and quiet.
? At 9:15 p.m., No 15-minute room check done in Patient #1's room 104. Review of the 15 minute check sheet for 9:00 p.m., documented MHT J had noted Patient #1 was in his room asleep with chest rising and falling and quiet.
? At 9:30 p.m., No 15-minute room check done in Patient #1's room 104. Review of the 15 minute check sheet for 9:00 p.m., documented MHT J had noted Patient #1 was in his room asleep with chest rising and falling and quiet.
? At 9:44 p.m., MHT J entered Patient #1's room 104. MHT J exited room 104 and appeared to scream down the hall.
? At 9:45 p.m., RN H entered room 104 and came out of the room and appeared to yell at another nurse. RN H reentered room 104.
? At 9:46 p.m., a crash cart was taken into room 104.
? At 9:55 p.m., Emergency Medical Service (EMS) entered room 104.
? At 10:14 p.m., Patient #1 was transported to the acute care hospital.

Review of the "Generic Nursing Progress Note" dated 11/4/14 at 11:50 p.m. documented at 10:00 p.m. MHT called for help. Review of the "Cardiopulmonary Arrest Record" dated 11/4/14, documented paramedic unit 10:11 (p.m.) and in hospital at 2232 (10:32 p.m.)

During an interview on 11/13/2014 at 5:15 p.m., MHT A said the MHTs divide their 15-minute checks up amongst each other.

Review of Park Royal Hospital Staff Education Program - Titled Patient Safety, dated September 2014, indicated "Nurses are ultimately responsible for the staff compliance with rounding. Usually it is the MHTs who are assigned to make the rounds; however, it is the nurse's responsibility to ensure someone is completing them."



2. Review of the Daily Nursing Assignment Sheet, dated 11/13/2014, for the 7:00 a.m. to 3:30 p.m. shift indicated it was prepared and signed by the registered nurse (RN). There were 3 mental health technicians (MHTs) assigned to patients. Those MHTs were assigned 15 minute checks, morning, closure groups and breaks. The assignment did not allow for effective every 15 minute monitoring of patients.

During an observation on 11/13/2014, at 1:00 p.m., 15 minute checks were being done by MHT C on 3 West/Geriatric unit. Observed the 12:45 p.m. slot on the 15-minute check form was blank. MHT C said that MHT D, who was responsible for the 15-minute check did not complete the 15-minute check because RN E had told MHT D to discharge a patient. While talking with MHT C, while she was performing her 15-minute checks, RN E interrupted MHT C to ask her about the blood pressure machine for another patient.

During an interview on 11/14/2014 at 1:30 p.m., MHT D said she did not complete the 15-minute check at 12:45 p.m. because she was instructed by RN E to take a discharged patient to the exit. She said RN E told her to give the board to someone else. MHT D said when she is in the middle of doing the 15-minute checks, the nurses are always interrupting and having her do other things such as vitals, toileting a patient, getting a snack for a patient, the patient needs a bath, find clothes for a patient, get a urine sample, or go downstairs and get inventory for intake. She said this is stressful for her because she knows how important it is to complete the 15-minute checks.


3. The hospital implemented correction actions to remove the immediate jeopardy: 1) revising the assignment of mental health technicians (MHT) every 15-minute check/round process; 2) educated the staff, including the MHT and nursing staff, about the expectation of what is to occur when doing the 15-minute checks/rounds and the nursing staff review process; 3) competency evaluation of the MHT conducting 15-minute check/round process and documentation completion; and 4) assigned minimally 1 staff no other responsibility than conducting 15-minute checks/rounds, without the nursing staff pulling to complete other tasks. As a result the immediate jeopardy was removed at the exit conference. The hospital has not completed the auditing of correction actions effectiveness.



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