HospitalInspections.org

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Based on medical record review, document review, and interview, in one (1) of eleven (11) medical records reviewed, the Behavioral Health Unit failed to provide care of a patient in accordance with acceptable standards of practice. Specifically, the facility failed to (a) monitor a patient sedated with antipsychotics medication and (b) timely identify and manage a patient in an acute respiratory distress.

A serious adverse outcome occurred due to the identified noncompliance and may place other patients at risk for adverse outcome or
death.

See Tag 0175.
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Based on medical record review, document review, staff interview and in one (1) of eleven (11) medical records reviewed, the facility did not ensure patients in Behavioral Health units received care in a safe setting. Specifically, the facility failed to:
(1) Monitor a patient who received antipsychotic medication for the management of acute agitation.
(2) Timely identify and manage a patient in acute respiratory distress.

Findings:

Review of the medical record for Patient #1 revealed; on 5/08/2023 at 06:26 PM, patient was brought to CPEP (Comprehensive Psychiatric Emergency Program) in handcuffs by the New York Police Department officers. Patient appeared to be extremely agitated.

At 06:40 PM, the patient received Haldol (a psychotropic drug used to treat mental illness) 10 mg intramuscularly (IM), and Ativan (drug used to treat anxiety disorder) 2 mg IM.

At 08:26 PM, Staff J, Post Graduate Year 2 (PGY 2), documented that Patient #1 presented "acutely agitated, and as per collateral [father], he is severely paranoid, reclusive .... making violent threats. Patient is a risk to self, others and will be admitted for safety/stabilization."

At 11:30 PM, CPEP nurse, documented: "Received patient on the unit ...as per previous shift RN, patient was 'IM'd' for agitation with Haldol 10 mg and Ativan 2mg. Patient admitted to EOB (Extended Observational Unit) for safety and further observation. Vital signs completed 11:15 PM - Blood Pressure (BP) 91/50, Pulse (P) 91, Respiration Rate (RR) 18, Temperature (T) 98.8 Fahrenheit (F). MD made aware of the BP. Instructed to monitor Q 4 hours. The patient was transferred to the EOB at 11:30 PM."

At 11:30 PM, Staff I, EOB nurse noted that while patient was being wheeled in from CPEP, he was making unusual sounds, similar to 'sleep apnea' sounds. At 11:40 PM, patient was transferred to bed from stretcher. "Patient all this time was being called by name and was not responding." Vital signs were P130, oxygen saturation 35%. Staff was immediately called, and rapid response was activated.

Rapid Response Code was called at 11:50 PM, Rapid Response team arrived at 11:55 PM. The patient was orally intubated, placed on mechanical ventilation, and was transferred to the Medical Intensive Care Unit on 05/09/23 at 1:00 AM.

On 05/11/23 at 12:30 PM, Neurology consultant noted, "CT scan showed absent brain stem function most likely brain-dead secondary to polysubstance abuse, probably overdose, anoxic brain injury."

On 05/11/23, Death Note signed by two providers stated, "Acute Metabolic Encephalopathy secondary to substance abuse."

Review of the policy titled, "Restraint " (Effective: 06/2023) stated: "..Chemical Restraint Or Drug Used As A Restraint " The use of any medication that is not a usual or customary part of a medical diagnostic or treatment procedures and that is used to restrict an individual's freedom of movement, such as medication used to calm a patient on a medical/surgical unit who becomes increasingly aggressive and agitated, trying to strike the roommate. Chemical Restraint Is Not Approved Method Within Richmond University Medical Center."

During interview on 08/02/2023, at 11:40 AM, Staff K, Attending Psychiatrist, reported that the facility does not use chemical restraints and has no policy for monitoring patients who have received Psychotropic medications including stat IM medications. Staff K stated that Haldol and Ativan were administered to "calm him down." The patient was placed in CPEP/EOB unit where he was observed and monitored 24/7.

Review of the facility's policy titled "Patient Observation in CPEP," revised January 2023, stated "A staff member to observe the patient every 15 minutes ...The staff member will document using the Close Observation sheet every 15 minutes, after observing the patient."

The facility policy failed to provide guidance to staff on what type of information to observe and document during
Q15 minutes rounding/observation.

Review of the document "Close Observation" sheet for CPEP, dated 05/08/23, revealed that Behavioral Health Technicians only document location of each patient on the unit every 15 minutes. There was no documentation of their activities [sleeping or awake] from 6:30 PM to the end of the observation period on the sheet at 11:45 PM.

During interview 08/02/2023, at approximately 1:27 PM, Staff C, MD, Behavioral Health Chairman, stated that technicians are looking also at the "chest rise of patients" but they are not documenting it in the Close Observation sheet. Staff C added that "Nurses can also use their judgment to monitor patients; and there are one or two physicians present at in CPEP/EOB at all times."

There was no documented evidence that Patient #1 was closely observed and monitored for the effects of the Haldol and Ativan medications that were given on 05/08/23 at 06:40 PM.

On 08/09/2023 at 2:17 PM, these findings were brought to the attention of facility's administrative personnel during IJ announcement.
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Based on medical record review, document review, and interview, in one (1) of eleven (11) medical records reviewed, the Emergency Department (ED) staff failed to:
(1) Monitor a patient who received antipsychotics for the management of acute agitation;
(2) Timely identify and manage a patient in acute respiratory distress.

These failures resulted in the death of Patient #1 and placed other patients at risk for harm.

Findings include:

The Emergency Department staff failed to monitor and respond timely to Patient #1 who presented on 5/08/2023 at 06:26 PM with severe agitation. The patient received Haldol (a psychotropic dug used to treat mental illness) 10 mg intramuscularly (IM), and Ativan (drug used to treat anxiety disorder) 2 mg IM. On 05/08/23 at 11:40 PM, the patient's oxygen saturation dropped to 35% requiring intubation and management in the Intensive Care Unit.

On 05/11/23 at 12:30 PM, Neurology consultant noted, "CT scan showed absent brain stem function most likely brain-dead secondary to polysubstance abuse, probably overdose, anoxic brain injury." The patient was pronounced dead on 05/11/23 at 4:00 PM.

See Tag A-1104.
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Based on medical record review, document review, and interview, in one (1) of eleven (11) medical records reviewed, the Emergency Department (ED) staff failed to:
(1) Monitor a patient who received antipsychotics for the management of acute agitation;
(2) Timely identify and manage a patient in acute respiratory distress.

These failures caused harm to Patient #1 and may result in harm to other patients.

Findings include:

Patient #1 was a 20-year-old male with a medical history of Schizophrenia, Anxiety, and noncompliance with his medication regimen.

Triage note on 05/08/23, at 01:54 AM, indicated the patient was brought from home by Emergency Medical Services (EMS) for possible drug overdose.
The patient used four (4) Ecstasy pills (Synthetic drug that alters mood and perception) and Marijuana. The Ambulance Pre-Hospital Report noted the patient received Narcan (drug used to treat narcotic overdose) 0.4 mg intranasally.

At 01:30 PM, the ED provider noted the patient was evaluated and glucose was 300 mg/dL.

At 04:50 PM, psychiatric consultation was obtained to determine patient's capacity to leave against medical advice (AMA). Psychiatrist documented the patient has full capacity to make decisions.

At 05:00 PM, patient signed AMA and exited the ED.

On 5/08/2023 at 06:26 PM, triage nurse documented that Patient #1 was brought to CPEP (Comprehensive Psychiatric Emergency Program) in handcuffs by the New York Police Department officers. They witnessed the patient arguing with his father on the facility's grounds and was extremely agitated.

At 06:40 PM, the patient received Haldol (a psychotropic dug used to treat mental illness) 10 mg intramuscularly (IM), and Ativan (drug used to treat anxiety disorder) 2 mg IM.

At 08:26 PM, Staff J (PGY2) documented that Patient #1 presented "acutely agitated, and as per collateral [father], he is severely paranoid, reclusive ....making violent threats. Patient is a risk to self, others and will be admitted for safety/stabilization."

At 11:30 PM, CPEP nurse, documented: "Received patient on the unit ...as per previous shift RN, patient was 'IM'd' for agitation with Haldol 10 mg and Ativan 2mg. Patient admitted to EOB (Extended Observational Unit) for safety and further observation. Vital signs completed 11:15 PM - Blood Pressure (BP) 91/50, Pulse (P) 91, Respiration Rate (RR) 18, Temperature (T) 98.8 Fahrenheit (F). MD made aware of the BP. Instructed to monitor Q 4 hours. The patient was transferred to the EOB at 11:30 PM."

At 11:30 PM, EOB nurse, Staff I noted that while patient was being wheeled in from CPEP, he was making unusual sounds, similar to 'sleep apnea' sounds. At 11:40 PM, patient was transferred to bed from stretcher. "Patient all this time was being called by name and was not responding." Vital signs were P 130, oxygen saturation 35%. Staff was immediately called, and rapid response was activated.

Rapid Response Code was called at 11:50 PM, Rapid Response team arrived at 11:55 PM. The patient was orally intubated, placed on mechanical ventilation, and was transferred to the Medical Intensive Care Unit on 05/09/23 at 1:00 AM.

On 05/11/23 at 12:30 PM, Neurology consultant noted, "CT scan showed absent brain stem function most likely brain-dead secondary to polysubstance abuse, probably overdose, anoxic brain injury."

On 05/11/23, Death Note signed by two providers stated, "Acute Metabolic Encephalopathy secondary to substance abuse."

On 08/02/2023, at 11:40 AM, Staff K (Attending Psychiatrist) reported that the facility has no policy for monitoring of patients who have received Psychotropic medications including stat IM medications. Staff K stated that Haldol and Ativan were administered to "calm him down." The patient was placed in CPEP/EOB unit where he was observed and monitored 24/7.

Review of the facility's policy titled Patient Observation in CPEP revised January 2023, stated "A staff member to observe the patient every 15 minutes ...The staff member will document using the Close Observation sheet every 15 minutes, after observing the patient.

The facility policy failed to provide guidance to staff on what type of information to observe and document during Q 15 minutes rounding/observation.

Review of the Close Observation sheet for CPEP dated 05/08/23, revealed that Behavioral Health Technicians only document location of each patient on the unit every 15 minutes. There was no documentation of their activities [sleeping or awake] from 6:30 PM to the end of the observation period on the sheet at 11:45 PM.

During interview with Staff C (MD, Behavioral Health Chairman) he stated that technicians are looking also at the "chest rise of patients" but they are not documenting it in the Close Observation sheet. Staff C added that "Nurses can also use their judgment to monitor patients; and there are one or two physicians present at in CPEP/EOB at all times."

There was no documented evidence that Patient #1 was closely observed for the effects of the Haldol 10 mg IM and Ativan 2 mg IM that were given on 05/08/23 at 06:40 PM.

2. The facility did not provide an organized response to the patient's emergency on 5/8/23 at 11:30 PM when Patient 1 was transferred from CPEP to EOB and was observed by EOB nurse in respiratory distress. There was no immediate treatment provided to the patient until the arrival of the Rapid Response team at 11:55 PM.

On 08/01/23, at 01:40 PM, during an interview with Staff H, Psychiatrist (currently a 3rd year Resident) she stated that during the code, she attempted to break the Emergency Cart seal and open the drawers but struggled with it. She stated, "I did not realize that each draw can only be open when others are closed." She reported that these are not physician's responsibilities to obtain equipment. "I just wanted the hand-pump to be available for the Rapid Response team."

On 08/04/23 at 10:05 AM, during an interview with Staff Q, Behavioral Health Charge Nurse, staff stated that she was unable to break the seal of the crash cart during the emergency. She was also unable to open crash cart draws. When the RRT asked for an IV starter kit and IV flush, there was none in the "Medication Box", so she ran to CPEP to get the item.

On 08/07/2023, at 03:40 PM, during an interview with Staff I (Behavioral Health In-Patient Nurse) she stated that she was not oriented to CPEP or EOB Units. Staff I said she works in the psychiatric inpatient unit but on 05/08/23, she was asked by the Manager to work in EOB unit since there was no nurse to cover the unit.

On 08/01/23, at approximately 10:00 AM, during the tour of CPEP, Staff M, Unit Nurse was unable to break the seal of the crash cart. The seal was broken with the assistance of Staff U, Unit Manager.

Staff M stated that for three years she has had no training on managing emergencies and operating the crash cart. Staff U stated that there was no Educator for Behavioral Health Units since 2020 but one was recently hired in June 2023.

On 08/08/23, at 10:40 AM, during an interview with Staff V, Behavioral Health Educator, she stated that the "training on the use of code cart, emergency procedures, and staff roles is being planned, but training had not begun."