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Based on interview and record review, the facility failed to protect the rights of patients for 4 (#1, #3, #6, and #11) of 13 patients reviewed requiring a safe environment, resulting in the potential for poor outcomes. Findings include:

See tags:

A0144: Failure to provide care in a safe setting.

A0145: Failure to provide goods and services necessary to avoid physical harm or mental anguish.

Based on interview and record review, the facility failed to provide adequate communication and documentation for 2 (#6, 13) of 2 patients reviewed for suicidal ideation resulting in elopement and potential for poor patient outcomes. Findings include:

On 8/19/2024 at 1450, review of the medical record for P-6 revealed he was a 22-year-old male who presented to the ED (emergency department) via EMS (emergency medical services) on 8/15/2024 at 0147. The chief complaint stated, "INGESTION (From home, ingested 70 DXM [dextromethorphan] pills over the course of 3 days (1000 mg [milligrams] total possible) called police and made SI [suicidal ideation] threats. Per EMS trying to self harm (sic), depressed. PD [police department] on scene, cooperative with EMS. Hx [history] anxiety and depression, and drug use. Aox4 [alert and oriented to person, place, time, and situation], diaphoretic, enlarged pupils, HTN [hypertension-high blood pressure] 161/114, HR [heart rate] -100, BG [blood glucose] 115..."

Review of the EMS run sheet dated 8/15/2024 revealed, "Pt stated that he was feeling depressed and anxious and called PD and made suicidal threats during the phone call..."

On 8/15/2024 at 0154, the triage nursed used the Columbia Suicide Severity Rating Scale to assess suicide risk. P-6 answered yes to having suicidal ideations in the past month with thoughts of method to use. Suicide intent without a specific plan, and suicidal behavior in the past 3 months and in his lifetime. The level of risk from the screening was listed as "High."

On 8/15/2024 at 0157, orders were placed by Internal Medicine Resident Staff II for "Safety Attendant at Bedside High risk (sic) suicide 1:1; Secured Environment Precautions; Consult to Social Work." The orders were acknowledged at the same time and the patient was placed in a "Behavioral Health Hold; Safety Attendant at Bedside High risk (sic) suicide 1:1; Secured Environment Precautions; Consult to Social Work."

P-6 was evaluated in the ED by Physician Staff X. She documented on 8/15/2024 at 0238 that P-6 had been taking "copious amounts of dextromethorphan" for the past 3 days and was taking it for "the 4th dimension." He denied he was trying to hurt himself. Staff X stated she was "Unable to perform ROS (review of systems)" due to mental status change. Physical exam revealed pupils dilated "at 5" (5 millimeters in size), normal thought processes, and P-6 was alert and oriented to person, place, and time. His affect was described as flat, but it is noted that he was answering questions appropriately. He denied being suicidal.

On 8/20/2024 at 0948, Staff X stated she remembered P-6 and described him as "calm, cooperative, definitely out there, and intoxicated on dextromethorphan. His pupils were huge, but he was cooperative." P-6 told her he was not trying to hurt himself. When asked why he took so much dextromethorphan, he replied he was trying to attain "the fourth dimension."

Staff X further stated she had a toxicology consult to see how long it would take P-6 to clear the dextromethorphan from his system and was told it would take longer than 24 hours. Staff X also explained the process in the ED with a patient that had overdosed was to wait until they were sober before having the social worker and/or psychiatric consult. The social work consult had not yet taken place yet because the P-6 was not yet sober.

ED Physician note from 8/15/2024 at 0238 also revealed lab work showed the urine drug screen was negative as well as the salicylate and acetaminophen levels. His CK levels were somewhat elevated. Blood pressure was elevated, and the patient was tachycardic. The patient was admitted to observation for dextromethorphan toxicity.

The history and physical (H&P) done on 8/15/2024 at 0303 had a plan of keeping the patient on a cardiac monitor; monitoring for altered mental status, seizures, autonomic instability, and muscular hypertonicity; monitoring for rhabdomyolysis (breakdown of muscle tissue), monitoring and medicating for high blood pressure, social work/behavioral health consult, and toxicology consult. Attending Physician Staff KK signed an attestation to the H&P on 8/19/2024 at 1451 which stated, "I have personally interviewed and examined the patient on the date of service of the attached note. Management was discussed with (Resident II). I agree with the documented findings and plan of care in their note..."

The toxicology consult from 8/15/2024 at 0714 stated "reported ingestion of approximately 1300 mg (milligrams) of dextromethorphan ... we do feel that he is likely still suffering from the effects of this ingestion and will likely have more apparent amnestic effects once he is more lucid, likely tomorrow."

On 8/20/2024 at 1323, Registered Nurse (RN) Staff Y stated prior to his arrival on shift on 8/15/2024 P-6 had been caught vaping in his room. They explained hospital policy did not permit vaping and the vape was taken away and secured in an orange box in the patient's room. At approximately 0730-0800, Staff Y entered P-6's room and found him trying to access the orange box in the room to get his vape. When told it was against hospital policy to vape, "His immediate response was 'I want to leave.'" Resident Staff DD and Resident Staff JJ went in to speak with the patient, stated medications could be administered to replace the vape, and encouraged P-6 to stay. The patient was agreeable. Shortly after, P-6 was found trying to access the orange box again and said he wanted to leave. Staff Y then opened the box, gave P-6 his belongings, reviewed the risks of leaving against medical advice (AMA), and had P-6 sign the AMA form. P-6 left the hospital on 8/15/2024 at 0840.

Further review of the medical record revealed a social work note from Social Worker (MSW) Staff EE dated 8/15/2024 at 0840 titled "Social Work Behavioral Health Assessment" and the reason for the consult was listed as "Behavioral Health/Suicide." In the consult note, Staff EE documented a county deputy had completed a petition for P-6 after he made multiple suicidal statements and said he wanted to kill himself. She wrote, "The petition was uploaded to Careport. It should be noted that Careport is visible to the care management department, however all other departments (nursing, providers, etc.) do not have access to Careport and therefore could not see petition. Patient transferred from emergency department to 7HC overnight. The petition was not brought up with patient. There was no documentation of a petition having been completed. There was no social work note indicating high risk suicide or recommended safety precautions. By the time unit MSW began shift at 0800, there was no safety attendant or secured environment precautions in place."

When interviewed on 8/20/2024 at 1134, Staff EE, stated social work had been consulted for a suicide assessment through the ED. When she went in to review the chart, she noticed there were no increased risk precautions in place, like sitters. She went to inform the charge nurse and was informed the patient had left AMA. She had also noticed within the system that another MSW had acknowledged the order, but nothing had been done from there. Staff EE contacted her manager for direction. They called security as well as city and county police departments and requested a welfare check was done. Staff EE stated she did receive word back from the county police that contact had been made with a family member and there were no concerns. The police informed her they would not be bringing the patient back to the hospital.

On 8/20/2024 at 1444, Manager of Clinical Care Management Staff FF stated the original petition usually originates from the ED. It is then carried to the inpatient unit on admission. Careport was an area that was only available to care management. She stated, "We are very well aware standard practice was not followed in this case. Gaps have been identified ... The social worker in the ED had the petition but was unable to see (P-6) because of altered mental status. Had she written a note into the medical record about the presence of the petition, this wouldn ' t have happened." When queried as to why the petition and/or clinical certification was not made a part of the medical record, Staff FF stated it was not part of their workflow process.

Review of the workflow process on 8/20/2024 at 1610 revealed in task description number 7, "When there is a concern that a patient is at risk for self-harm, a Behavioral Health hold should be ordered by the RN until a full assessment can be completed. The Behavioral Health hold allows the hospital to 'hold' the at-risk patient. This patient will not be able to leave the hospital Against Medical Advice (AMA) until the patient has been cleared by the social worker and physician and is no longer considered to be At-Risk." Information was present about hand-carrying the petition and/or clinical certification to the inpatient unit; however, nothing was present about making it part of the medical record.

Further review of the discharge summary dated 8/15/2024 at 0840 revealed there was an attestation present by Attending Physician KK which stated, "ED MSW (social worker) documented suicidal thought, and started petition and uploaded info to Careport. This information were not passed to RN at floor during call, nor to attending physician or admitting physician. Patient left AMA in am."

Review of the Incident Report Log for for the past six months revealed an entry for P-6 which indicated a safety attendant was present on admission; however, between the time of admission and prior to the arrival of first shift staff, "the safety attendant and monitoring were cancelled for unclear reason."

Review of facility policy "Care of The Suicidal/Potentially Suicidal Patient" effective 7/19/2024 states, "I. Purpose: To identify the process for maintaining the safety of patients who are expressing and/or demonstrating suicidal or potentially suicidal behavior. II. Responsibilities: Registered Nurse (RN) Physicians, Advanced Practice Provider (APP), Social Worker (SW), Safety Attendant (SA), Medical Assistant (MA), Any health care professional or care giver who may encounter a patient who expresses suicidal ideation and/or suicidal behaviors...Behavioral Health Hold: An order placed in the EHR [electronic health record] that identifies a patient as unsafe to leave the ED until clinical evaluation and discontinuation of the order by a provider; often done in collaboration with social work. The order is placed for patients experiencing a certain risk level for suicidal ideation...The order may also be placed for patients presenting with a completed petition, a court ordered metal [sic] health pick-up order, those presenting from a psychiatric hospital or crisis residential center, or those referred by a community agency or provider for medical clearance prior to transfer to a higher level of psych care... A patient at risk is identified by one or more of the following: 1. Completed risk screening 2. Presenting complaint/admitting diagnosis (i.e. intentional overdose, self-inflicted injury) 3. Patient actions that are concerning for patient safety. 4. Concerns or comments expressed by patient, family, friends, significant other(s), court order, law enforcement or community agencies. 5. SW and/or Provider assessment B. Suicide Risk screening: 1. The Columbia-Suicide Severity Rating Scale (C-SSRS)... will be completed on all patients, 10 years of age and older, who presents to the Emergency Department, Inpatient hospital, expresses suicidal thoughts, demonstrates suicidal behaviors and/or screens at risk... C. Caring for an at-risk patient: 1. Refer to the applicable appendixes to guide the screening, assessment, interventions, and care of a patient who has been identified at risk... Appendix C: Inpatient and Emergency Department... B. Social Work (SW) evaluation of at-risk patient: 1. SW receives consult and completes the suicide assessment utilizing an evidence-based tool including suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors and protective factors. 2. SW validates or assigns risk level. 3. SW then notifies bedside nurse and provider with outcome of assessment and assigned risk level. 4. SW facilitates collaboration with the Provider for initiation or adjustment of patient care orders as appropriate. Only the Provider may adjust or discontinue orders. 5. SW will collaborate as needed with psychiatry, especially with a high-risk patient and discharge disposition to an outpatient setting. 6. SW will collaborate with the interdisciplinary team to guide the plan of care for patient. Information such as individual patient triggers, approved items that are deemed safe to remain with the patient, and/or approved and/or restricted visitors will be included in the patient's plan of care. Routine RN assessments are conducted according to the applicable nursing assessment policy... SW will be promptly notified by the RN with any concerns for change in patient behaviors that may indicate change in risk level."

Review of the medical record for P-13 revealed she was a 30 year-old female that presented to the facility on 7/21/2024 with a suicide attempt. Review of documentation revealed a note present by the MSW there was a petition and clinical certification that had been done on the patient; however, it was not found in the medical record.

Manager of Clinical Case Management Staff FF stated on 8/20/2024 at 1444 the petition and clinical certifications were not scanned into the medical record, they are kept with CarePoint and if needed are printed and sent with the patient to the inpatient unit or in the transfer packet to another facility.

Based on interview and record review, the facility failed to provide services necessary to avoid physical harm or mental anguish for 3 (P-1, 3, 11) of 3 patients reviewed for tracheostomy assessments and care resulting in the potential for unmet patient needs and poor patient outcomes. Findings include:

On 8/16/2024 at 1400, review of the medical record for P-1 revealed she was a 35 year-old female who had a tracheostomy placed on 8/1/2024. Review of tracheostomy documentation revealed assessments and care were provided every six hours according to facility policy except for the following dates and times:

8/2/2024 0304 (gap of 7 hours, 22 minutes)
2059 (gap of 6 hours, 59 minutes)
8/3/2024 1030 (gap of 7 hours, 29 minutes)
8/4/2024 0259 (gap of 6 hours, 40 minutes)

8/5/2024 0303 (gap of 18 hours, 16 minutes)
1020 (gap of 7 hours, 17 minutes)
1655 (gap of 6 hours, 35 minutes)

8/7/2024 0301 (gap of 6 hours, 29 minutes)
0939 (gap of 6 hours, 38 minutes)
1641 (gap of 7 hours, 2 minutes)

8/8/2024 0343 (gap of 7 hours, 59 minutes)
1541 (gap of 6 hours, 48 minutes)

8/9/2024 0304 (gap of 11 hours, 23 minutes)
1745 (gap of 9 hours, 55 minutes)

8/10/2024 0020 (gap of 6 hours, 20 minutes)

On 8/16/2024 at 1259, review of the medical record for P-3 revealed he was a 21 year-old male who had a tracheostomy placed shortly after birth. Review of tracheostomy documentation revealed assessments and care were provided every six hours according to facility policy except for the following dates and times:

8/12/2024 1838 (gap of 7 hours, 23 minutes)

8/13/2024 0303 (gap of 7 hours, 30 minutes)

8/14/2024 0347 (gap of 7 hours, 7 minutes)

8/15/2024 1532 (gap of 6 hours, 46 minutes)

8/16/2024 0915 (gap of 10 hours, 45 minutes)

On 8/16/2024 at 1330, review of the medical record for P-11 revealed he was a 60 year-old male who had a tracheostomy placed 8/14/2024. Review of tracheostomy documentation revealed assessments and care were provided every six hours according to facility policy except for the following dates and times:

8/14/2024 1535 (initial after placement)

8/15/2024 0449 (gap of 7 hours, 27 minutes)

8/16/2024 0330 (gap of 7 hours, 30 minutes)

On 8/19/2024 at 1201, RT Staff P stated the RT is responsible for performing assessments on patients with an artificial airway.

Facility policy titled "Artificial Airway Assessment" effective 7/19/2024 states, "Purpose: To outline the process and steps for artificial airway assessments performed by the Licensed Respiratory Therapist... An artificial airway is a device inserted into the trachea via nare, mouth or stoma bypassing the upper airway anatomical structures, rendering them nonfunctional. Artificial airway is the generic term for endotracheal tubes (ETT), nasotracheal tubes, tracheostomy and LaryTubes... Required observations will be performed at least every six hours..."

Based on interview and record review, the facility failed to ensure that registered nurses supervised and evaluated the nursing care for one (P-12) of 13 patients reviewed, resuling in the lack of assessment and monitoring for P-12 and the potential for poor outcomes. Findings include:

Review of P-12's medical record on 08/20/2024 at 1350 revealed P-12 was a 44-year-old female with past medical history of coronary artery disease, hyperlipidemia, nonischemic cardiomyopathy who presented to the Emergency Department on 07/04/2024 with chest pain. Review of ED physician noted dated 07/04/2024 revealed P-12 had a heart attack on 05/30/2024, was subsequently admitted to the hospital where she had a coronary artery dissection and V-Fib arrest. P-12 did require placement of an Impella device (temporary heart pump implanted into the heart to improve blood flow) and ECMO. P-12 reported that she had been doing well until 02:30 on 07/04/2024 when she developed pain at the site, chest pain, shortness of breath, and a mild cough. P-12 was admitted to 7 Meijer Heart Critical Care Unit with diagnosis of hematoma and chest wall abscess. Review of nursing documentation indicated P-12 was admitted after right chest washout in the OR. Operative note indicated P-12 had incision and debridement of infection done on 07/04/2024 down to the muscle layer.

Review of physician's orders for P-12 revealed on order dated 07/07/2024 at 2318 for Leave of Absence (LOA) for Pivotal Life Event.

Review of nursing notes for P-12 revealed nursing note dated 07/08/2024 at 0445 "Pt (patient) left hospital at 0145 via cab per leave of absence order to bring her 13-year-old daughter back home. Pt plans to return back via cab." Nursing note dated 07/08/2024 at 0401 documented P-12 "arrived back on unit and is now in her room." Assessment on 07/08/2024 at 0420 indicated P-12 had right, upper moderate chest pain/discomfort with pain medication given.

Nursing note dated 07/08/2024 at 0533 indicated, "VSS (vital signs stable) on RA (room air). IV abx (antibiotics)continued. Pain controlled with oxy and Tylenol. Pts 13-year-old daughter was left here without a ride home. Hospital supervisors and provider made aware. Leave of absence order put in and pt left hospital at 0145 via cab with daughter per order to bring her home. Pt then arrived back in hospital at 0400." The note did not reveal any documented assessment of P-12's wound, or reason for admission. Review of entire medical record for P-12 for documented vital signs revealed the last vital signs completed on 07/08/2024 were at 2003. The next documented vital signs were 07/09/2024 at 0028. There were no vital signs documented prior to the LOA and upon return from the LOA for P-12.

Review of facility grievance for P-12 on 08/20/2024 at 1220 revealed a grievance was filed for P-12 on 07/08/2024 by a staff member on 7 Meijer Heart Critical Care Unit. The grievance description indicated P-12 was upset she had to leave the hospital to take her 13-year-old home in the middle of the night. Felt the facility should have let her child stay until morning. Follow-up document included "we cannot be overnight babysitters" and "I knew this was coming", "Yes we consulted with Risk who agreed options were that child present to ED so she could be cared for as a patient until morning (which would result in Peds having to contact CPS, per policy), patient could find a ride for her, or she could leave with her if doctor was willing to grant leave of absence". Comment from Risk on the Grievance form was that they don't like LOA's because there is a lot of risk, but nursing had done this before calling Risk. Interview with P-12 on grievance revealed brother was coming to get 13-year-old but got pulled over. Father had taken his sleeping medication, other family not available, P-12 tried and explained this to everyone who came into her room. At 2:00am Supervisor came in her room. P-12 stated she felt harassed. Pulled her IV out, put her in a cab. The cab driver was going to leave her at her house. P-12 stated she had to talk to someone on the driver's phone to get the driver to take her back to the hospital. The driver dropped her at the front door of the hospital which was locked. P-12 stated she had to walk around the entire hospital to get back into the hospital. She got 2 hours of sleep, was exhausted and cried all day the next day. P-12 stated there was zero reason for her to be treated this way.

Review of facility "Inpatient Leave of Absence (LOA) policy, dated 04/21/224 revealed Purpose: This policy should not be used for non-time sensitive matters..." Examples of LOA would be for funeral of a close family member or a pivotal life event. I. If the patient is medically stable to have a LOA, consider if discharge is a safe option. II. LOA for inpatients will be managed and approved on a case-by-case basis. Prior to obtaining leave, approvals will be obtained from: medical, financial and administrative. Documentation: An inpatient LOA requires a physician's order that is preferred to be written at least 24 hours in advance of the planned LOA that includes: date, duration of leave (no more than 4 hours), how patient may be transported, who must accompany the patient, equipment/medications to accompany patient and instructions for care. Physician's progress note should include reason the LOA is required, summary of the patient's current clinical status, discussion of the risks of the LOA. II. Nursing staff or physician: A. Date/time patient leaves the unit. B. Full patient assessment within 4 hours. C. Patient/family instructions were provided D. Notification of all approving bodies (medical, financial, and administrative representatives). III. Patient or legal representative should sign instructions as well as "Patient Convenience Leave Release without Discharge form". IV. Upon return to nursing unit, staff will document the return date/time, full patient assessment, and record medication/treatments completed while on LOA.

During the review of the medical record for P-12 on 08/20/2024 at 1350 with Staff A, a "Patient Convenience Leave Release without Discharge" form could not be located. Staff A reviewed the entire medical record, including scanned documents and stated the form was not in P-12's medical record.