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Based upon observation, record review, and interview, the Governing Body failed to:

A. prohibit the use of chemical restraint for staff convenience, document less restrictive interventions attempted, and assess 1 (#1) of 2 patients before and after the use of a chemical restraint to ensure patient safety. Unit wide seclusion was utilized on the adult unit for 7 of 8 patients when patient #1 was acting aggressively, and for staff convenience due to inadequate staffing.

B. ensure least restrictive interventions were attempted when 9 of 9 adolescent patients were secluded to their rooms without a physician's order for discipline of behaviors, and staff convenience due to inadequate staffing. One (1) of 9 patients was restrained, medicated, and secluded due to non-compliance with staff initiated seclusion. Patient #6 was placed in seclusion without a physician's order.

Refer to Tag A0154

C. have an adequate staffing plan and/or matrix that assisted in determining adequate staffing and ensure patient safety.

Refer to Tag A0392

D. follow their own policy and procedures for Nursing assessment and documentation by exception. Nursing failed to monitor to assist with identified patient needs, notify the physician when patients experienced a change in condition, failed to follow physician orders to obtain daily vital signs, assess and monitor patients receiving chemical restraints in 2 (1 and 2) of 3 (#1, 2, and 7) charts reviewed. These deficient practices resulted in the death of patient #1 and placed all other patients at risk for the likelihood of harm.

Refer to Tag A0395

These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.

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


Based upon record review and interview, the facility failed to:

A. Prohibit the use of chemical restraint for staff convenience, document less restrictive interventions attempted, and assess 1 (#1) of 2 patients before and after the use of a chemical restraint to ensure patient safety. Unit wide seclusion was utilized on the adult unit for 7 of 8 patients when patient #1 was acting aggressively and for staff convenience due to inadequate staffing.

B. Ensure least restrictive interventions were attempted when 9 of 9 adolescent patients were secluded to their rooms without a physician's order for discipline of behaviors and staff convenience due to inadequate staffing. One (1) of 9 patients was restrained, medicated, and secluded due to staff initiated seclusion. Patient #6 was placed in seclusion without a physician's order.

Refer to Tag A0154

These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.

Based upon record review and interview, the facility failed to:

A. Prohibit the use of chemical restraint for staff convenience, document less restrictive interventions attempted, and assess 1 (#1) of 2 patients before and after the use of a chemical restraint to ensure patient safety. Unit wide seclusion was utilized on the adult unit for 7 of 8 patients when patient #1 was acting aggressively and for staff convenience due to inadequate staffing.

B. Ensure least restrictive interventions were attempted when 9 of 9 adolescent patients were secluded to their rooms without a physician's order for discipline of behaviors and staff convenience due to inadequate staffing. One (1) of 9 patients was restrained, medicated, and secluded due to non-compliance with staff initiated seclusion. Patient #6 was placed in seclusion without a physician's order.


These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.



A. Review of patient#1's chart revealed patient #1 was admitted involuntary by Order of Protective Custody (OPC) to the facility for Schizophrenia, paranoid type, with acute exacerbation on 2/12/16, at 2:45PM.

Review of patient #1's medical record revealed the physician ordered the following psychotropic medications on admission, 2/12/16:

Seroquel 300mg by mouth at bedtime.
Risperdal 3mg by mouth twice a day.


Review of Patient #1's "Clinical Notes Report" revealed the following:
02/12/16, at 5:05PM, Staff #18 documented, "patient brought to unit and shown to his room, and now is sitting in the day area watching television, pt. is very guarded and seems paranoid at this time."


2/12/16, at 9:00PM, Staff #14 documented, "Awake in the day area watching tv. Quiet. Isolates. Paranoid. Preoccupied. Denies any thoughts of SH/HTO (Suicidal Homicidal/Harm to Others) or A/V (Audio/Visual) hallucinations. Eyes red. He states that he was crying. When asked why, he states that he just "feels sad." Clean appearance. Denies any physical complaints. Ate HS snack. Med compliant. Will continue to monitor every 15 minutes for safety per "C." No further nursing intervention documentation found.


2/13/16, at 12:41AM, Staff #14 documented, "Pt. keeps coming up to the nurse's station, standing at the desk and staring at staff. He refuses to leave the desk. He has to be told several times to leave the desk before he will finally leave. He does not show any signs of aggression he just stares at staff. Staff #15 notified. Will continue to monitor every 15 minutes for safety per "C" status protocol." There was no documentation found of nursing interventions to assess any needs of the patient.


2/14/16, at 8:47AM, Staff #11 documented, "Pt very paranoid and hallucinating. Jeans are down around his feet and he will not let staff pull his pants up so he won"t fall. Begins to smile inappropriately at female staff. Called male supervisor to assist male patient and he refused help and batted male staff hand away. Tried giving his am meds which contained Risperdal 3 mg po and pt. refused to take, when offered to take pills back pt. lunged at nurse. Pt threw water and pills across the room. No PRNs ordered. Texted Dr. Pogue and got Geodon (antipsychotic) 20mg. IM order for one time injection. Gathered male staff and gave IM RD (Intramuscular Right Deltoid - into a muscle in the arm) without incident. Pt grabbed female pt. by the arm and would not release. Peers keep walking up behind him and getting in his space and trying to talk to pt. sent all of the pts to their rooms for safety. Pt lying down on chairs in the day area." There was no documentation found of any nursing interventions to engage the patient in another activity, to assess the patient for discomfort, to redirect the patient in any manner. The only documentation found on effectiveness of medication was "patient sleeping."


Review of patient #1's physician orders revealed an order written 2/14/16, at 8:07AM, stated, "Ziprasidone (GEODON) 20mg = 1ML Intramuscular Q4H PRN (as needed) Agitation, 40mg/24 hour dosage limit." Further review of the patient #1's medical record revealed no documentation on medication effectiveness, or assessment of psychoactive medication administration that was given at 8:47 AM. Geodon (ziprasidone) is an antipsychotic medication.


Review of the pharmacy order summary for Patient #1 revealed the Geodon was ordered as a PRN but was stopped and discontinued on 2/14/16 (same day it was given). Staff #3 confirmed it was a one-time dose.


Review of the policy and procedure, "POLICY CODE: 1600.112 Revision
SUBJECT: BHC/RESTRAINT AND SECLUSION OF INDIVIDUALS IN A HOSPITAL-BASED PSYCHIATRIC UNIT


PROHIBITIVE PRACTICES FOR RESTRAINT OR SECLUSION IN A BEHAVIORAL EMERGENCY
Use of drugs or processes that fit the definition of a chemical restraint.


The definition of a Chemical Restraint-The use of any chemical, including pharmaceuticals, through topical application, oral administration, injection, or other means, for purposes of restraining an individual and which is not a standard treatment for the individual's medical or psychiatric condition."


Interview with Staff #3 on March 30, 2016, at 10:40 AM, was conducted in the conference room. Staff #3 stated that they do not provide chemical restraints. Staff #13 stated since patients at the hospital have psychiatric diagnosis, their behaviors are a result of their psychiatric condition. They are given psychiatric medications to control their symptoms. If they were given something like Diprivan (a medication used to sedate patients), that would be a chemical restraint. Staff #3 stated that they never give chemical restraints and have no policies to cover them.


An interview was conducted with staff #11 on 3/30/16, at 9:45AM., Staff #11 reported that patient #1 was being aggressive and was psychotic. Patient #1 didn't talk a lot and his pants were sagging. Staff #11 reported she had tried to pull up his pants and the patient seemed confused on why she was pulling on his pants. "I think he thought I was being sexual because he kept smiling at me and grabbing my arm." Staff #11 reported she requested a male RN that works in admitting to come pull up his pants so he would not fall. Staff #11 reported patient #1 became manic and didn't want anyone to touch him. There was no one available to do a 1:1( one staff member to one patient at arm's length.) so she had to cancel group and send all the patients to their rooms for safety. "The patients kept getting in patient #1's space and I felt he might hurt one of them. I texted the doctor and got an order for a shot. I was trying to keep him out of restraints. The physician ordered the shot and we gave it to him to calm him down. Staff #11 did not feel it was a chemical restraint "because it didn't put him to sleep. Maybe if we had given him a bigger dose to knock him out but he just sat on the couch and was quiet." The surveyor asked why no interventions with a 1:1 or seclusion was attempted first. Staff #11 reported that they didn't have anyone available to do a 1:1. "Sometimes we can get extra people. They are supposed to be on call but most of the time we are told they just won't come in." Staff #11 reported the patient was afraid of his room and she had opened the door to another room but he would not go in. Staff #11 reported that the injection was the best route.


Review of the Daily Staffing Sheet for 2/14/16 (Sunday) revealed on the 7:00AM-7:00PM shift, there were 8 patients on unit 300 and 2 staff members, both of them RN's, to monitor the patients. Review of the patient status revealed 4 patients were a class D and 4 were a class C observation status. Both C and D status patients are either unit restricted or require supervision and must be accompanied by staff at all times. All 8 patients were on psychosis precautions, 1 patient was on fall precautions, 1 patient on seizure precautions, 4 patients on suicide precautions, and 3 patients on assaultive precautions.

Record review and interview revealed patient #1 was given Geodon in an effort to control patient's aggressive behavior and for staff convenience due to inadequate staffing. Record review and interview also revealed 7 of 8 patients on the adult unit were secluded to their rooms due to the aggressive behavior of patient #1 and staff convenience due to inadequate staffing.


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B. Patient #6 was a 16 year old, female who had been admitted on 3-13-16 for Major Depressive Disorder, Recurrent, Severe.


Review of clinical nursing notes on 3/16/16, at 9:00 PM, revealed, "All patients were directed to their rooms R/T (related to) not folowing (SIC) direction to reduce excessive noise level. All pt. complied after promp(SIC). Pt. are advised "quiet time" would end when direction is complied with. (SIC)."


Review of orders showed an order dated 3/13/16, at 9:21 AM, for "Communication Telephone/Visitation limited to immediate family only until otherwise specified in the treatment plan or orders." Nothing in the orders or treatment plan limited her being able to call her mother.


Clinical notes documented on 3/16/16, at 9:45 PM, "Pt is advised to close her door (sic) as she is one of several pt. supporting disruptive loud behavior of pt. #1729. This pt. stated that she did not have to close her door. This writter varified (SIC) her choice and advised as long as the inapropriate (SIC) behavior cotinued (SIC) quiet time would remain in effect. Pt stated "You pissed me off I want to call my Mother. Pt is very loud at this point. I returned to nurse station."


At 9:50 PM, "Pt is at nurses station yelling, demands "I want to call my Fucking Mother!" Pt. then elevated herself over the counter and grabes (SIC) the telephone. Code M is called. Pt. is placed in Physical hold for safty(SIC). Pt. continues to violently resisting and yelling "Let me call My Fucking Mother!" Pt. is placed in restraint chair for safty(SIC). On call Dr. is notified, orders for restraint and Benadryl 25mg IM now are given."


At 10:35 PM, Patient #6 notified the nurse that she was now calm and ready to be released.


Review of "Restraint/Seclusion Monitoring Log" revealed on 3/16/16, at 9:40 PM, patient #6 had Physical hold applied, put in a Restraint Chair, and placed in seclusion.


Review of the Physician's order for Restraint/Seclusion dated 3/16/16, at 2200, revealed a telephone order for Physical Hold to Restraint Chair. There was no order for seclusion noted. The physician's order was not signed, dated or timed by the physician.


No physician documentation was found in the medical record of why the order was necessary; other generally accepted, less intrusive forms of treatment, if any, that the physician has evaluated but rejected; and the reasons those treatments were rejected.


Review of the Daily Staffing Sheet for 3/16/16, (Wednesday) revealed on the 7:00PM-7:00AM shift there were 9 patients on the adolescent unit and 2 staff members, both of them RN's, to monitor the patients. Review of the patient status revealed 7 patients were a class D and 2 patients were a class C observation status. Both C and D status patients are either unit restricted or require supervision and must be accompanied by staff at all times. All 9 patients were on suicide precautions, 1 patient was on assault precautions, and 4 patients on psychosis precautions. While 2 staff members would be adequate to care for 9 patients, the observation status and the # of patients on special precautions increased the acuity of the patients requiring additional staff to monitor the patients.

Review of policy as follows:

" POLICY CODE: 1600.112 Revision
SUBJECT: BHC/RESTRAINT AND SECLUSION OF INDIVIDUALS IN A HOSPITAL-BASED PSYCHIATRIC UNIT OBJECTIVE:


To set forth the conditions for restraint or seclusion of an individual (patient) who evidences a behavioral emergency ("imminent danger" to self or others) and for whom less restrictive interventions have been determined to be ineffective or when the prevention of dangerous behavior does not allow for the consideration or implementation of less restrictive measures.


Approved Practices and Devices for Responding To a Behavioral Emergency


Escort or brief physical prompt-individual may be assisted to move from one location to another when guidance is needed if the individual agrees verbally or with gestures, and cooperates with the staff member assisting the move.


Activities of Daily Living-a staff member may assist an individual who is willing and able to cooperate with toileting, bathing, dressing, eating, or other personal hygiene activities that normally involve the use of touch.


Removal from imminent danger-a staff member may escort, prompt, or move an individual who is unable to respond in the affirmative or negative or is unable to move due to his or her psychiatric or medical condition if there is imminent danger of harm to the individual because of a circumstance in the individual's immediate environment.


Immobilization during medical, dental, diagnostic, or surgical procedure-a positioning or securing device used to maintain the position, limit mobility, or temporarily immobilize an individual with the individual's consent during a procedure is not considered a restraint.


Quiet Time-an individual may request and be granted the use of quiet time unless clinically contraindicated


Clinical Timeout-an individual may not be forced to participate in a timeout that is suggested by the staff member; failure to comply with timeout request does not justify a restraint or seclusion


Voluntary use of protective and supportive devices-must be easily removable by the individual without staff assistance and requires a physician order. Involuntary use of protective devices or voluntary use of protective devices beyond medical necessity becomes subject to the requirements for restraint or seclusion. Individuals must be educated and agree to the use of protective devices. Use of protective and supportive devices requires the consent of the parent or LAR when the individual is a minor or when individual has a legally appointed guardian.


LESS RESTRICTIVE INTERVENTIONS FOR A BEHAVIORAL EMERGENCY


Restraint or seclusion may be used only after less restrictive interventions have been considered, or attempted and determined to be ineffective, or are judged to be unlikely to protect the individual or others from harm in an emergent situation
The rationale for failure to utilize less restrictive measures before initiation of restraint or seclusion must be documented


Examples of less restrictive measures may include, but are not limited to:
1. Making a verbal/written contract with the individual for the desired safe behavior
2. Redirecting an individual's aggression by providing a distracting activity
3. Providing a physical activity that helps individual release angry or violent emotions
4. Providing 1:1 counseling to help the individual identify the causes of the agitation
5. Asking the individual in a kind but firm tone to stop the dangerous behavior
6. Allowing the individual the opportunity to call an approved family member or friend
7. Offering medications to assist individual in regaining emotional control
2. Offering food or beverage to the individual
9. Allowing the individual an appropriate outlet to reduce tension (physical activity, music, deep breathing exercises, arts & crafts)
10. Removing the stimuli that precipitated the dangerous behavior
11. Reducing the noise or light level
12. Suggesting a clinical timeout or allowing a quiet time
13. Reviewing the treatment goals to accomplish desired outcomes
14. Show of Force


PROHIBITIVE PRACTICES FOR RESTRAINT OR SECLUSION IN A BEHAVIORAL EMERGENCY

Use of restraint or seclusion when used as:
A means of discipline, retaliation, punishment, or coercion
A means convenience for staff members
A part of a behavior therapy (management) plan
A substitution for treatment or habilitation


Use of any form of restraint in conjunction with seclusion or simultaneous use of multiple forms of mechanical restraint Use of drugs or processes that fit the definition of a chemical restraint



Record review revealed 9 of 9 adolescent patients were secluded to their rooms without a physician's order for discipline of behaviors and staff convenience due to inadequate staffing. One (#6) of 9 patients became angry and refused to comply with staff initiated seclusion and was denied the right to call her mother. Physician's order was obtained for physical hold to restraint chair and medicated for anxiety. Patient #6 was also placed in seclusion without a physician's order.

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

A. have an adequate staffing plan and/or matrix that assisted in determining adequate staffing and ensure patient safety.

Refer to Tag A0392
B. follow their own policy and procedures for Nursing assessment and documentation by exception. Nursing failed to monitor to assist with identified patient needs, notify the physician when patients experienced a change in condition, failed to follow physician orders to obtain daily vital signs, assess and monitor patients receiving chemical restraints in 2 (1 and 2) of 3 (#1, 2, and 7) charts reviewed. These deficient practices resulted in the death of patient #1 and placed all other patients at risk for the likelihood of harm.

Refer to Tag A0395

This deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.

Based upon record review and interview, the facility failed to have an adequate staffing plan and/or matrix that assisted in determining adequate staffing and ensure patient safety.

An interview with staff #19 was conducted on 3/31/16. Staff #19 reported that there was no policy or guideline that had a staffing grid or matrix to determine the minimum staff required related to the patient census. Staff #19 stated, "I walk around to each unit and ask if anybody feels they need help based on the acuity of the patients on that unit."

Review of a form titled "Classification Rating Work Sheet" provided by Staff # 19 revealed the worksheet would be completed for each unit. The worksheet would help to determine the following:
1. The unit
2. Patient names and room numbers
3. What patients were on special precautions, Code M's, Code 44's or "other."
4. Hospital census on each unit.
5. Comment section for the House Supervisors to communicate from shift to shift.

At the bottom of the sheet was a calculation section to add up all the patients with special precautions that would require and justify needed personnel. Staff #19 reported that this report is to be filled out each shift to assist in staffing. Staff #19 reported that she monitors the staffing along with the DON during the week. The RN House Supervisor fills out the form and monitors the staffing at night, weekends, and holidays. Staff #19 reported there was no policy or guidelines how to prepare and monitor this report. When asked how would it be determined how many staff members were needed for a certain staff/patient ratio, Staff #19 reported "we don't have anything in writing, we just know."

Review of the "Classification Rating Work Sheet" revealed the facility had 4 units to staff. The worksheets for each unit was not completed 13 times from 3/15/16-3/31/16 for the 7:00PM -7:00AM shift. Staff #19 confirmed that this was the responsibility of the RN House Supervisor.

An interview with staff #1, #2, and #3 confirmed there was no policy or guidelines to determine staff to patient ratios.

Based on chart review, policy and procedure review, and interviews, the facility failed to follow their own policy and procedures for Nursing assessment and documentation by exception. Nursing failed to monitor and to assist with identified patient needs, notify the physician when patients experienced a change in condition, failed to follow physician orders to obtain daily vital signs, assess and monitor patients receiving chemical restraints in 2 (#1 and #2) of 3 (#1, 2, and 7) charts reviewed. These deficient practices resulted in the death of patient #1 and placed all other patients at risk for the likelihood of harm.

These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.

Review of patient#1's chart revealed patient #1 was admitted involuntary by Order of Protective Custody (OPC) to the facility for Schizophrenia, paranoid type, with acute exacerbation on 2/12/16 at 2:45PM.

Patient #1's physician orders written on 2/12/16 at 3:56PM stated, "Vital Signs Daily." The first recorded vital signs for this patient was on 2/13/16 at 3:39AM; 12 hours and 54 minutes after admission. There were no further vital signs documented on this patient." The vital signs recorded were as follows:
Temperature 98.1 F
Respirations 20
Blood Pressure 112/71
Pulse 102 *H* (H stands for high)
O2 Saturation 100.

Interview with staff #14 on 3/29/16 confirmed vital signs are usually taken between 5:00AM and 6:30AM each day. Review of policy and procedure "Documentation -Charting by Exception" stated, "Physical assessment of body systems is documented daily. Assessment frequency should reflect patient need and good clinical judgment. Any change of condition should be documented in system review. Body systems assessments are charted by exception.
Adult Standards for Charting By Exception Vital Signs /Physical Assessment;
Respirations - 12 - 20 breaths per minute
Heart Rate - 60 - 100 beats per minute
Urine Output - Greater than, or equal to, 30 mI/hr."

Review of the policy and procedure, Documentation -Charting by Exception (CBE) stated, "Nursing assessments are documented in a Chart by Exception method. Exceptions may be documented when standards are defined.). Interventions and evaluations are documented as provided or assessed."

Interview with Staff #3 on 3/30/16 confirmed if a patient has a change in condition or behavior the nurse shall document those changes.

Review of Patient #1's chart revealed the patient had an elevated heart rate of 102 outside of the policy and procedure guidelines. There was no documentation found that the physician was notified or if any nursing interventions were done. There are no further vital signs documented on this patient during the course of treatment.

Review of the Investigation Summary conducted by staff #3 on 2/26/16 revealed patient #1 could not provide any reliable health information upon admission. The ER (Emergency Room) physician had indicated that he had a history of hypertension and psychiatric problems but did not indicate if he was being actively treated for those conditions. It was listed under previous history of Hydrochlorothiazide and Lisinopril but had not been active prescriptions for an undetermined amount of time. Upon admission 2/12/16 patient #1 was ordered the following medication:

a. Hydrochlorothiazide (to decrease or stabilize blood pressure) 25mg oral daily. Hydrochlorothiazide is a diuretic (water pill) used for treating high blood pressure (hypertension) and accumulation of fluid (edema).

b. Lisinopril (to decrease or stabilize blood pressure) 10mg oral daily. (Lisinopril is an angiotensin converting enzyme (ACE) inhibitor used for treating high blood pressure, heart failure and for preventing kidney failure due to high blood pressure and diabetes.)

Review of patient #1's chart revealed vital signs were not assessed before administering hypertensive medications daily. Failure to assess a patient's vital signs prior to administration of the hypertensive medication could result in hypotension (low blood pressure). Hypotension can result in dizziness, confusion, and possibly shock. In shock, not enough blood and oxygen flow are sent to the body's major organs, including the brain. The early signs and symptoms of reduced blood flow to the brain include light-headedness, sleepiness, confusion, and possible death.

Review of Patient #1's "Clinical Notes Report" revealed the following:

02/12/16 at 5:05PM Staff #18 documented, "patient brought to unit and shown to his room, and now is sitting in the day area watching television, pt. is very guarded and seems paranoid at this time."

2/12/16 at 9:00PM Staff #14 documented, "Awake in the day area watching tv. Quiet. Isolates. Paranoid. Preoccupied. Denies any thoughts of SH/HTO (Suicidal Homicidal/Harm to Others) or A/V (Audio/Visual) hallucinations. Eyes red. He states that he was crying. When asked why, he states that he just "feels sad." Clean appearance. Denies any physical complaints. Ate HS snack. Med compliant. Will continue to monitor every 15 minutes for safety per "C." No further nursing intervention documentation found.

2/13/16 at 12:41AM Staff #14 documented, "Pt. keeps coming up to the nurse's station, standing at the desk and staring at staff. He refuses to leave the desk. He has to be told several times to leave the desk before he will finally leave. He does not show any signs of aggression, he just stares at staff. Staff #15 notified. Will continue to monitor every 15 minutes for safety per "C" status protocol. "There was no documentation found of nursing interventions to assess any needs of the patient.

Patient #1 was a class "C" status. Review of policy and procedure "OBSERVATION STATUS C (Close Observation-Unit Restricted)

Definition: Close Observation-Unit Restricted This is designed for patients who are viewed as a high risk for impulsive acts and need closer observation by the staff. Procedures include:

A. Patients are unit restricted and must be supervised when on unit patio.

B. Sharp and electrical appliances may be used only with constant visual supervision by clinical staff. Sharps should be signed out and back in on the Sharps Log.

Used For:
Those patients who are at high risk for impulsive acts. Those patients who show minimal insight and continue to require close supervision.

Documentation:
Progress notes will be made in the patient 's chart every 12 hours by an RN or LVN with RN oversight and review. An entry will be made very 15 minutes on the Observation Rounds Sheet by the staff assigned to the patient.

Order:
Physician's Order is necessary with Clinical justification for unit restriction, but in an emergency an R.N. may initiate status change from D" to "A", "B" or "C" after consulting with a House Supervisor or D.O.N. Must be confirmed by a physician within 2 hours."

2/13/16 5:30AM Staff # 14 documented, "Did not sleep any last night. He stayed in the day area all night." There were no documented nursing interventions found to assist patient #1 to his room or offer other alternatives to rest. No found documentation on why the patient was awake all night or what the patient was doing other than sitting in the dayroom. There was no documentation of vital signs or if physician was notified.

2/13/16 at 9:00PM Staff #14 documented,"Watching tv in the day area. Slow to respond. Preoccupied. Denies any thoughts of SH/HTO or A/V hallucinations. Med compliant. Denies any physical complaints. Disheveled appearance. Ate HS snack. Will continue to monitor every 15 minutes for safety per "C" status protocol."

2/14/16 at 5:37AM Staff #14 documented, "Slept approx. 5 hours." No vital signs were documented. Review of the Mental Health Technicians (MHT) "Observation Rounds" report revealed documentation of patient #1 sleeping in the dayroom from 10:45PM-2:30AM a total of 4 hours and 15 minutes. Patient #1 was documented as sleeping in day room from 4:45AM- 7:00AM a total of 2 hours and 15 minutes. There was no documentation why patient was sleeping in dayroom or any nursing interventions for other alternatives.

2/14/16 at 8:47AM Staff #11 documented, "Pt very paranoid and hallucinating. Jeans are down around his feet and he will not let staff pull his pants up so he won't fall. Begins to smile inappropriately at female staff. Called male supervisor to assist male patient and he refused help and batted male staff hand away. Tried giving his am meds which contained Risperdal 3 mg po and pt. refused to take, when offered to take pills back pt. lunged at nurse. Pt threw water and pills across the room. No prns ordered. Texted Dr. Pogue and got Geodon (antipsychotic) 20mg. IM order for one time injection. Gathered male staff and gave IM RD (Right Deltoid) without incident. Pt grabbed female pt. by the arm and would not release. Peers keep walking up behind him and getting in his space and trying to talk to pt. Sent all of the pts to their rooms for safety. Pt lying down on chairs in the day area." There was no documentation found of any nursing interventions to engage the patient in another activity, to assess the patient for discomfort, to redirect the patient in any manner. There were no vital signs taken or physical assessment documented before or after a chemical restraint administration.

Review of patient #1's physician orders revealed an order written 2/14/16 at 8:07AM stated, "Ziprasidone (GEODON) 20mg = 1ML Intramuscular Q4H PRN (as needed) Agitation, 40mg/24 hour dosage limit." Further review of the patient #1's medical record revealed no documentation on medication effectiveness, or assessment of psychoactive medication administration that was given at 8:47 AM.

2/14/16 at 1:01PM staff #11 documented, "Patient still lying in day area. Refused breakfast and lunch. Pt stood up and said he needed to go to the bathroom and is holding the front of his jeans. Told him the bathroom is in his room but he refused to go down there and layed (SIC) back down. Got male staff to offer to take him out in the hallway to handicap shower/bathroom but when staff did he refused and layed (SIC) there and wet his pants. Has on wet shorts and jeans but refuses to change into a gown or shower." There was no documentation of a nursing assessment, vital signs, and any further nursing interventions to clean the patient up from soiled clothing. There was no documentation regarding patient offered fluids or meal alternatives. No documentation of nursing intervention to the refusal of breakfast, lunch or fluid intake. 2/14/16 at 1:07PM patient #1 had an ADL assessment performed and stated the patient had refused breakfast and lunch. The RN documented that patient #1 was independent in toileting, bathing and grooming.

2/14/16 at 7:16PM Staff #14 documented in the assessment report that patient #1 was alert and oriented, skin moisture dry, heart regularity was normal, capillary refill was less than 3 seconds, strong radial and pedal pulse, abdomen soft with bowel sounds present and independent with ADL's. There was no documentation found that the patient cleaned himself or that the nurse attempted to clean the patient up from urine soaked pants. There were no found vital signs.

2/14/16 at 9:20PM staff #14 documented, "pt. walked down the hall, took out his penis and urinated on the floor. Will not respond when asked by staff why he did that. Preoccupied. Staring into space. Will continue to monitor every 15 minutes for safety per "C" status protocol." There was no documentation found that a nursing assessment or neurological assessment was performed. There was no documentation found that nursing interventions were done to assist the patient to the bathroom at frequent intervals or monitoring to assist the patient's needs.

2/15/16 at 6:24AM revealed that Staff #14 documented, "slept approx. 7 hours." There were no vital signs documented or nursing interventions after 9:20PM. A revision correction was made in the medical record on 2/15/16 at 6:25AM stating patient #1 slept only 4 hours. Review of the MHT "every 15 minute observation status " revealed patient #1 was asleep in the dayroom from 2/14/16 at 11:00PM until he was found deceased on 2/15/16 at 6:45AM for a total of 7 hours and 45 minutes.

2/15/16 at 6:45AM staff #14 documented, "Pt. sitting in day area on couch. Unresponsive. CPR initiated @ 6:45AM. 911 notified. EMS arrived at 6:58AM. CPR stopped at 6:58AM. Pupils dilated. MD present on unit, also present was staff # 2, and #8." 6:58AM pt. pronounced deceased @ 6:58AM per staff #13. Tyler police here at 7:45AM. City police talked to staff # 2 and staff #3. Pt body removed from day area at 8:25AM. Staff is continuing to contact family.

There was no nursing documentation that patient #1 was assessed from 2/14/16 at 9:20PM until 2/15/16 at 6:45AM a total of 9 hours and 25 minutes.

Review of the Code 44 Flowsheet revealed documentation from the patient cardiac code arrest. The form was dated 2/15/16 at 6:45AM. The section for cardiac code was not checked. There was no RN signature, under AED section it stated patient was in Asystole (no heart beat) the event ended at 7:01AM. A list of staff first names were on the sheet in attendance but no last names or disciplines.

Review of the EMS report dated 2/15/16 at 7:01AM Narrative, "831 dispatched P1 for cardiac arrest. Arrived on scene to find patient laying on couch, unresponsive to our arrival with CPR being done. Patient was last seen around 2345 (11:45PM) last night, but appeared to have been sleeping all night on the couch in the dayroom. Patient was found to be apneic and cold when the nursing staff tried to wake him. Up to move him to his room this morning. They initiated CPR. Upon our initial assessment, patient appears to have been dead for a few hours so CPR was ceased and cardiac monitor showed asystole. Patient's pupils are fixed and dilated and patient has some rigor mortis starting in arms. PD was notified as there was not currently a doctor on scene. Patient's doctor showed up as well as PD and the scene was left in charge of PD. 831 clear with DAS."

Review of definition of rigor mortis on website titled "WebMD/deathreference.com " revealed: Rigor Mortis- Rigor mortis (Latin: rigor "stiffness", mortis "of death") is one of the recognizable signs of death, caused by chemical changes in the muscles after death, causing the limbs of the corpse to stiffen. Beginning approximately in the third hour after death, again depending upon numerous factors, chemical changes within the body's cells cause all of the muscles to begin stiffening. Known as rigor mortis, the first muscles affected include the eyelids, jaw and neck. Over the next several hours, rigor mortis spreads upward into the face and down through the chest, abdomen, arms and legs until it reaches the fingers and toes.

An interview was conducted with staff #3 on 3/29/16 at 1:00PM with Staff #1 and #2 present. Staff #3 reported that patient #1 had died on the adult unit 300 on 2/15/16. Staff #3 reported the patient was found unresponsive and CPR was initiated. Staff #3 reported the psychiatrist was on scene during the code. When EMS (Emergency Medical Service) arrived, they ended the code. Instead of the Justice of the Peace coming out to pronounce the death, Staff #13 offered to pronounce the death of patient #1. Surveyor questioned staff #3 as to why Patient #1 was not transferred to the ER. Staff #3 stated patient #1 was not viable and physician called the code. Surveyor requested that staff #3 provide a copy of the EMS report. Staff #3 reported they did not have that and did not think to look at that report. Staff #3 requested the report and it was faxed to her during this interview. Staff #1, #2 and #3 were shown the EMS report. The report stated, "Upon our initial assessment, patient appears to have been dead for a few hours so CPR was ceased and cardiac monitor showed Asystole (no heart beat). Patient's pupils are fixed and dilated and patient has some rigor mortis starting in arms. PD was notified as there was not currently a doctor on scene." Staff #1, #2, and #3 confirmed this was the first time they had heard that rigor mortis had set in. Staff #3 stated, "I never touched him. I just pulled the sheet back and looked at his face." Staff #3 reported a Root Cause Analysis (RCA) was initiated the morning of 2/16/16 by staff #6 and #17 from the Quality Assurance Department. Staff #3 reported there was not a completed root cause analysis due to the delay in receiving the patient autopsy. Staff #3 reported that there was no individual interviews with the staff concerning the incident. The only investigation was held during the initial RCA and confirmed there has been no follow up investigation of the RCA. Staff #3 reported that training had been developed and was to be initiated the following Monday, 4/4/16, with staff. However, RCA had not been completed with determination of training needs. To date of interview, staff #3 reported there had been no training or interventions initiated. Staff #1 and staff #2 confirmed these findings.

An interview was conducted on 3/30/16 with staff #6 concerning the RCA process. Staff #6 reported the initial RCA involving patient #1 was initiated on 2/16/16. Staff #6 reported he had reviewed the chart on 2/15/16 and felt it was appropriate to have the RCA started the following morning. Staff #6 reported that the facility follows the guidelines set forth from their accreditation entity. Staff #6 reported that he was the moderator and had everyone meet in one group setting. The physicians start, then we try to get nursing perspective. Staff #6 reported, "We try to limit it to one hour." Staff #6 reported the group comes up with a summary of findings, define the problem, then the project would go down to the unit management to conclude the report. Staff #6 reported he did not have a reason for why the RCA process had not been completed or initiated. Staff #6 was not aware that EMS reported patient #1 had signs of rigor mortis and that the medical record had minimal documentation for vital signs, nursing assessments, or chemical restraints.


An interview was conducted with staff #14 in the afternoon of 3/29/16. Staff #14 reported that she was on duty 2/15/16 at the time patient #1 was identified as being unresponsive. Staff #14 reported she was the only nurse working that night on unit 300 and had one MHT. The 300 unit is an acute adult unit that holds a capacity of 10 patients. Staff #14 reported that she had 8 patients on her unit when she came to work that night and received two more admissions before midnight leaving a total of 10 patients. Staff #14 reported that patient #1 had been difficult to deal with since his admission on 2/12/16. Staff #14 reported that patient #1 refused to go to his room to sleep. Patient #1 had told staff #14 that the devil was in that room. Patient #1 was refusing to go to his room and wanted to stay in the dayroom and sleep. Staff #14 reported that patient #1 was sleeping all night in an upright position but had done that since he was admitted. When staff #14 was asked by surveyor what time vital signs were normally taken staff #14 stated, "Between 5:00AM-6:30AM. Somewhere in that time frame. I tried to take his vital signs during the night but he wouldn't let me." Staff #14 could not remember what time that he had refused vital signs. Staff #14 reported the patient was sitting in the dayroom in front of her desk. She went to wake him to take vital signs at 6:45AM on 2/15/16 and the patient was unresponsive. Staff #14 stated, "I'm just gonna be honest, I panicked. I did not start CPR, the oncoming nurses did. I was just so upset." Staff #14 reported she did not remember who called the code 44 or who called 911. Staff #14 reported the paramedics stopped the code and called the police. Staff #13 was in the building and offered to pronounce the death of patient #1. Staff #14 reported when she was charting she forgot to document patient #1 refusing vital signs. Staff #14 reported that she wanted to make a late entry note and was advised by her supervisors, staff #2 and #3, that she could not document a late entry note because it would look suspicious.

An interview with staff #2 and #3 on 3/29/16 confirmed that they did advise staff #14 not to document a late entry note about the vital signs that it would look suspicious.

An interview was conducted with staff #8 on 3/30/16 at 8:40AM. Staff #8 was the RN House Supervisor on 2/14/16-2/15/16. Staff #8 reported that patient #1 had "been crashing out on the couch. I saw him at 11:30PM. The nurse said he went down the hall and urinated on the floor." Staff #8 reported he made a visit to the 300 unit around 5:00AM and saw patient #1 still sitting up with his head back. Staff #8 stated, "I thought to myself that had to be uncomfortable to sit with your head like that all night. I would have had a crick in mine." Staff #8 confirmed that he did not wake patient #1 because "he had been difficult before." Staff #8 reported no one had called a code 44 when staff #9 came to his office and told him patient #1 was unresponsive and they needed him to come to the unit. Staff #8 stated, "He was still sitting up when I got there. I laid him down on the couch and felt no pulse or respirations. Staff #10 started compressions and I put on the AED. We continued with CPR until EMS came. "Staff #8 reported that he spent most of his time that night doing admissions. Staff #8 reported he had 4 admissions that shift and was busy filtering calls for referrals. Surveyor asked House Supervisor if he had documented anything in a shift report concerning the code or patient #1's condition. Staff #8 reported that the house supervisor is to write daily shift reports on the staffing sheets. Review of staffing sheets for 2/14/16 revealed documentation of a patient transfer but no information of patient #1's behavior or any other patient. Review of staffing sheet for 2/15/16 revealed a comment with no documented time that stated, "Patient #1 urinated in hallway, attempts to grab people who walk by, paranoid." There was no further documentation found on the staffing sheets.

An interview was conducted with staff #9 on 3/30/16 at 8:57AM. Staff #9 reported that patient #1 was acting "ok" he sat in the dayroom and watched tv. Around 1:00AM-2:00AM patient #1 woke up and urinated in the floor. Staff #14 told patient #1 to clean it up but patient #1 went back to the couch in the day area and went to sleep. Staff #9 reported that he cleaned up the urine in the hall. Staff #9 reported that patient #1 was afraid of his room and never went down there. Staff #9 stated, 'I thought he was asleep, it was hard to see in the dayroom. The nurse cuts the lights off. The only lights on are under the counter lights at the nurses station." Staff #9 reported around 4:00AM on 2/15/16 that patient #1 had urinated on himself. Staff #9 went to staff #14 and was instructed not to wake patient #1, to just clean him up at shift change. Staff #9 reported at around 6:15AM that he shook patient #1 gently by the arm but he did not wake up. Staff #14 came over and tried to wake patient #1 and checked for a pulse. Patient #1 didn't have a pulse. Staff #9 stated, "I ran to go get staff #8 in his office. I didn't know what else to do." Staff #9 reported that he helped with the patient's airway. EMS arrived and took over.

An interview was conducted with staff #10 on 3/30/16 at 9:15AM. Staff #10 reported that she had been off all weekend and had come onto the unit that morning early. Staff #10 was not sure exactly what time but said she usually comes in about 30 minutes early. Staff #10 reported that she could see patient #1 sitting up and staff #14 and #9 standing next to him with a Dynamap. (A device to take vital signs). Staff #10 reported she heard staff #14 say something but was not sure what was said when staff #11 ran over to patient #1. Staff #11 and #14 were talking and I heard staff #11 stated, "he's gone." Staff #10 reported she called the code 44 and got the crash cart from the back. Staff #11 had already started chest compressions and started to bag the patient when staff #8 showed up to do compressions. Staff #8 had brought the AED and applied it to patient #1. Staff #10 reported that the patient was cold when she felt his feet and smelled of feces.

An interview was conducted with staff #11 on 3/30/16 at 9:45AM. Staff #11 reported that she and staff #10 had arrived early at 6:15AM and had not yet clocked in because they could not clock in until 6:38AM. She noticed that patient #1 was sitting on the couch in front of the nurse's station with his head back. Staff #11 stated, "I just thought that would hurt my neck to sleep like that. Staff #14 had said she was going over there about 6:30AM or so to clean him up. The lights were very dim and the only lights on were at the nurses station. I saw staff #14 shaking patient #1 and shouting. I went over to patient #1 and checked for a carotid pulse and he was cold. I knew he had died and had been dead because he was already stiff. Staff #14 kept yelling, "he's gone, he's gone" We laid him down and started CPR even though I knew he was gone. From the waist up he was rigid. I tried to do a chin lift but I couldn't, it was stiff." Staff #10 reported that she had asked staff #9 to assist in holding the mask for the ambu bag (a device used during emergency resuscitation to get oxygen into the lungs) tighter to patient #1's face but all the air was going into his stomach due to inability to open airway properly. Staff #10 stated, "9 minutes is a long time to do CPR. That's how long it took EMS to get here. I could smell feces from the patient. I could tell he had been dead for a while. EMS came and called the code. They were waiting for the Coroner to pronounce the patient but staff #13 was there and offered to pronounce."



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Review of patient #2's chart revealed she was taken to an Emergency Room (ER) due to suicidal ideation and depression on 2/15/16. Patient #2 had reported to the ER staff that she wanted to run out into traffic or overdose on Benadryl. Patient #2 was documented and verified to be 33 weeks pregnant in the ER. Patient #2 was homeless and had been living in a shelter.

Patient#2 was admitted with a diagnosis of bipolar disorder otherwise unspecified. Patient#2 was brought to the facility in the admission and receiving department as a voluntary patient. There was no documentation how the patient was transported or received. There was no warrant in the chart. Patient #2 signed a voluntary admission consent on the following day 2/16/16.

Review of the nursing "Clinical Notes Report" dated on 2-16-16 at 8:50PM stated, "Patient extremely combative and verbally abusive threatening MHT with physical violence" I'm gonna hit that bitch right in the nose, I'll punch her face in. Y'all come up here asking all these questions and get me started, I'll take him (MHT) down in a heartbeat over my unborn child." Staff #13 contacted and rec'd order for 2mg Haldol IM stat emergency. Will gather staff for show of force in order to administer medication."

The patient refused the Haldol, stating she had a seizure disorder and Haldol triggered her seizures. Staff #13 was called again at 9:15 PM and 1 mg Ativan was ordered to be administered with the 2 mg of Haldol.

Nurse documented 35 minutes after original Stat order at 9:25 PM, "2 mg Haldol/ 1 mg Ativan given IM Left deltoid per TORB (telephone order read back) Staff #13. Patient complied with medication administration and offered no resistance to medication administration." During the 35 minute delay in Stat order and administration of medication, no documentation of re-assessment of the continued need for medication was found. Follow-up assessment for effectiveness or adverse reaction to medication was not documented. There was no assessment documented of fetus or fetal movement after medication administration.

At 10:00 PM, the nurse charted "Upon arrival in unit, pt (patient) agitated and refused assessment. Necessary to have little interaction at this time due to nature of behavior in admission. "At 10:30 PM, the nurse charts the patient is "calmed and sleeping".

At 10:49 PM, an order was placed for vital signs to be assessed four times a day. Patient was 33 weeks into her pregnancy. Plan of care not initiated. As previously documented at 10:00 PM, the nurse charted it was "necessary to little interaction."

The next documented attempt to assess patient #2 did not occur until the next morning at 6:48 AM when the nurse charted "Pt refused VS (vital signs), pts slept soundly 8 hrs." No documentation was found to indicate attempt or interventions to reassess patient for vital signs or assess fetus movement.

Review of medications in chart "Orders Report" for Patient #2 showed that Haldol, 2mg oral to be given every 6 hours as needed for agitation was ordered on 2-16-16 at 9:14 PM. Ativan, 1mg intravenous (in a vein) was ordered to be given once Stat on 2-16-16 at 9:35 PM. No reason for giving the Ativan Stat was identified in the order. Neither order had an electronic signature in the Signed-By/Co-Signed By section of the orders. Both medications were given by routes not indicated on orders.

Review of patient #2's "Clinical Notes Report" on 2/17/16 at 7:53AM stated, "Patient refused to sign consents for Haldol and Ativan, says they put her at risk for seizures." There was no documentation of nursing intervention or education concerning medications or seizure disorder.

Review of patient #2's "Clinical Notes Report" on 2/17/16 at 7:53AM stated, "attempted to get pt. to come out of rm (SIC) for vitals and to see dr, refused, cont. to say she is dressing." 12:44PM, "pt in to see staff #5." There was no further documentation of an attempt to get vital signs or assess the fetus for fetal movement.

On 2-17-16 at 1:14 PM, the nurse charted, "pt getting very agitated and threating to punch nurse, after I asked in a very calm manner to given lamictal and im zyprexa signed med consents, but refused to take lamictal, says it is too late."(SIC) Documentation was not found in chart of alternatives tried to de-escalate the threatening behavior or address the agitation. There were no vital signs documented and no fetal assessment for movement.

On 2-17-16 at 1:27 PM, the nurse charted, "pt getting very agitated, cursing, threating to punch the nurse, me. refused to let me give her im zyprexa, argue with staff, did finally take im injection."(SIC) There was no documentation of a nursing assessment after the medication or fetal assessment. There were no vital signs documented.

On 2-17-16 at 1:32 PM, the nurse charted, "pt took im injection, still being combative saying he (sic) going to get my bitch ass, cont to threaten nurse says she will hit doctor if she finds out he out he (sic) ordered shot threw coloring markers on floor."(SIC) There was no documentation of nursing interventions.

On 2-17-16 at 1:36 PM, the nurse charted, "code m called, patient agreed to go back to room after talking to Staff #16."(SIC)

The next note was on 2-17-16 at 3:16 PM. The nurse charted that the patient was sleeping. At 4:58 PM the nurse charted again that the patient continued to sleep at this time. At 6:12 PM the nurse charted that the patient was awake and eating dinner in the day area. There was no documentation of vital signs, nursing assessment or fetal monitoring.

Review of group therapy notes showed that patient did not attend any groups on 2-17-16.

On 2/18/16 at 12:32 PM, patient #2 was given 5mg of Zyprexa IM for agitation. Follow-up assessment for effectiveness or adverse reaction to medication was not documented. Vital signs had not been taken since patient admission. No fetal assessment was documented. At 1:36 PM an entry was made, "Psychosocial assessment postponed based on nurse advisement."

On 2-19-16 at 10:44 PM, patient #2 was transported by ambulance to the main hospital campus ER to have "unrelenting" abdominal pain evaluated. Patient was 33 weeks pregnant. Patient #2 returned to unit on 2-20-16 at 01:08 AM stating, "I'm calling the complaint hotline on them tomorrow. They knew I was having contractions and they sent me back. They're discriminating against me because I'm a mental health patient." The nurse did not chart that she had received report or what the patient condition was following the ER evaluation. Patient care at main campus was not charted in this patient