HospitalInspections.org

Based on record review, observations and interviews, the Hospital failed to protect and promote the patients' rights for two (Patient #1, Patient #5) of ten patients sampled.

See tag 0144.

Based on record review, observations and interviews, the Hospital failed to provide care in a safe setting for two (Patient #1, Patient #5) of ten patients sampled.

Findings include:

The hospital report, dated 06/29/2022, stated that Patient #1 arrived to the hospital ED on 06/16/2022 complaining of new onset suicidal ideation. After approximately seven hours in the ED, Patient #1 was transferred to the hospital behavioral health unit (BHU) the evening of 06/16/2022. Patient #1 was placed on 15 minute checks. During a safety check on 06/17/2022 at approximately 10:27 A.M. Patient #1 was found unresponsive. Resuscitation attempts were unsuccessful and Patient #1 was pronounced (declared passed away) at 10:55 A.M.

Record review indicated that Patient #1 was triaged in the Hospital ED on 06/16/2022 at 12:49 P.M., with the "chief complaints updated" section stating, "suicidal."

The policy titled Patients at Risk for Suicide, effective 09/27/2021, states under definitions that: a) 1:1 direct observation requires that the staff member has an unobstructed view of the patient at all times, including during toileting. b) Constant Observation requires an unimpeded view of assigned patient(s) for up to three patients.

Record review of Patient #1 indicated that on 6/16/2022 at 2:13 P.M. an order was placed for 1:1 constant observation. An order was placed for Patient #1 to be in snap pajamas (a designated safer type of hospital gown geared for patients at risk for suicide). An order was placed for a clothing search and a belongings search.

Video observation, conducted on 07/25/2022 at 11:00 A.M., indicated that Patient #1 was seen walking alone out of an ED pod (a pod is a space in the ED waiting area where patients may be initially triaged prior to being moved into the main ED area) and towards an ED bathroom. Patient #1 walked out of the ED pod alone at 1:00 P.M. 56 seconds and is seen going to the bathroom. Patient #1 exits the bathroom at 1:04 P.M. and 46 seconds, alone and unobserved and appears to return to the ED pod. Video observation indicated that Patient #1 was placed in a hallway bed of the Behavioral Health (BH) area of the ED at 1:38 P.M. and 32 seconds.

Video observation indicated that Patient #1 was in the BH area of the ED from 1:38 P.M. until 7:08 P.M. The surveyor made the following observations during this time period:

1) From 1:52 P.M. 23 seconds until 2:14 P.M. 44 seconds, there was no constant observer (CO) observing Patient #1.

2) At 3:51 P.M. 29 seconds, CO #3 escorts a different patient, Patient #2 to the bathroom. The 1:1 protocol order for Patient #1 is not being followed as CO #3 follows Patient #2. In addition, CO #3 allows the bathroom door to be fully closed, and as a result, Patient #2 is also no longer under constant observation. This occurs until Patient #2 exits the bathroom at 3:53 P.M. and 58 seconds, and CO #3 returns to the observer desk area at 3:54 P.M. and 23 seconds.

3) CO #3 is seen leaving the entire BH area of the ED at 4:59 P.M. and 56 seconds, and does not return until 5:07 P.M. and 14 seconds. CO #3 fails to request for observer coverage prior to leaving the BH area of the ED.

4) CO #3 leaves Patient #1 area at 6:29 P.M. and 09 seconds, leaves the entire BH area of the ED at 6:29 P.M. and 35 seconds, and does not return to the BH area of the ED until 6:30 P.M. and 37 seconds.

5) At 6:59 P.M. and 31 seconds, CO #3 leaves and it appears a covering observer, CO #5 begins to cover Patient #1. However, at 7:00 P.M. and 45 seconds Patient #1 is unobserved until a new observer CO #4 enters the BH area of the ED and begins observing Patient #1 at 7:01 P.M. and 08 seconds.

6) At 7:05 P.M. and 20 seconds, while CO #4 is on CO #4's mobile phone, Patient #1 goes to the bathroom of the BH area of the ED. CO #4 does not accompany Patient #1 to the bathroom. The bathroom door is fully closed. Patient #1 does not exit the bathroom until 7:07 P.M. and 37 seconds.

7) At 7:08 P.M. and 38 seconds, Patient #1, accompanied by a transport staff member and a security staff member, exit the BH area of the ED.

Patient #1 remained in street clothes for the entire time period that Patient #1 was in the ED. Multiple constant observers (CO #3 and CO #4) responsible for providing constant observation of Patient #1 in the hospital ED were observed to be using mobile devices. Record review of Patient #1 did not indicate whether a clothing search ever occurred during Patient #1's stay in the ED.

The surveyor interviewed the Director of Risk Management on 07/25/2022 at 5:00 P.M. The Director of Risk Management indicated that after an evaluation of the timeline of Patient #1 including Patient #1's time in the BH area of the ED and Patient #1's transfer and overnight stay in the inpatient BHU, the Director stated that there were no specific findings identified in the BH area of the ED in response to Patient #1's event. In addition, the Director stated that there were no specific corrective actions identified in relation to the BH area of the ED in response to Patient #1's event.

Video observation indicated Patient #1 was in the inpatient BHU from approximately 06/16/2022 7:11 P.M. until 06/17/2022 leading up to Patient #1's unexpected death. Patient #1 was placed on 15 minute checks when in the inpatient BHU. The surveyor made the following observations during this time period.

1) There were six safety checks that were missed regarding Patient #1, between the hours of 6:37 A.M. and 10:04 A.M.

2) At 10:26 A.M. and 48 seconds Mental Health Counselor (MHC) #1 goes with Nurse #1 to check on Patient #1 and are in Patient #1's room. At 10:27 A.M. and 28 seconds, another staff member, Nurse #2 walks into Patient #1's room. At 10:27 A.M. and 48 seconds MHC #1 and Nurse #1 exit Patient #1's room and at 10:28 A.M. and 06 seconds Nurse #2 runs out of Patient #1's room. At 10:29 A.M. and 00 seconds Nurse #2 enters Patient #1's room with a code cart.

While Nurse #2 runs out of the room to retrieve the code cart, and is out of the room from 10:28 A.M. and 06 seconds until 10:29 A.M. and 00 seconds, there are no staff members in Patient #1's room. For approximately one minute of time, Patient #1 is alone in Patient #1's room and life saving measures are not being performed.

3) At 10:29 A.M. and 00 seconds Nurse #2 enters Patient #1's room with a code cart. At 10:29 A.M. and 25 seconds, inpatient BHU physician staff enter Patient #1's room. At 10:31 A.M. and 29 seconds, the initial members of the code team arrive/enter Patient #1's room. At 10:31 A.M. and 50 seconds, more code team staff arrive to Patient #1's room.

Personnel file (the hospital's record of an employee file) review of Nurse #1 indicated that Nurse #1 did not have on file a "Registered Nurse (RN) Competency Based Orientation Checklist" document, nor a "Competency Based Addendum, Psychiatry RN/MHC" checklist geared towards psychiatry RNs and MHCs, at the time of Patient #1's event date, 06/17/2022.

The RN Competency Based Orientation Checklist page 7, in a section titled "Ensures patient and unit safety at all times" has one of the performance objectives as, "Demonstrates knowledge of the following: d. Code procedures/emergency response and e. Rapid Response protocol."

The surveyor interviewed the interim nurse educator of the inpatient BHU on 07/29/2022 at 1:10 P.M. The nurse educator stated that the RN competency based orientation checklist is a hospital wide orientation checklist that applies to all nurses. The nurse educator stated that the psychiatry addendum is a combined checklist geared for MHCs and psychiatry RNs. The nurse educator stated that the RN Competency Based Orientation checklist and the psychiatry addendum checklist could not be located in Nurse #1's personnel file.

The document titled "Safety Reports, Inpatient Psychiatry" indicated a safety report was submitted into the hospital's internal event reporting system, in relation to Patient #1's 06/17/2022 event date. The reporter stated that responding staff did not appear familiar with protocols involved in code situations.

The document titled "Mock Code" indicated that the interim nurse educator of the inpatient BHU coordinated hands-on mock code drill sessions, which occurred on 06/22/2022. MHCs and RNs acknowledged attendance via signed attestation. Only 35 of 90 eligible staff attestations were recorded.

The surveyor interviewed the interim nurse educator of the inpatient BHU on 07/28/2022 at 11:00 A.M. The nurse educator stated that the mock code training session was a voluntary training, with 35 of 90 eligible staff completing the training, a completion percentage of only 39 percent.

The surveyor interviewed the associate CNO on 07/28/2022 at 10:30 A.M. The associate CNO stated that the mock code training was voluntary.

The surveyor interviewed the CNO on 07/28/2022 at 11:00 A.M. The CNO stated that the mock code training was done at the local level (inpatient BHU) with support from the central code team. The CNO stated that it was not expected for the mock code training of inpatient BHU staff to be forwarded to senior administration.

Although Nurse #2 was involved in the code response of Patient #1, Nurse #2 did not attend the mock code training session on 06/22/2022, as indicated in the staff attestation document titled "Mock Code."

The surveyor interviewed the risk manager on 07/28/2022 at 5:30 P.M. The risk manager said that Nurse #2 continued to work, working two shifts in the inpatient BHU (6/29, 6/30/2022) without ever completing the mock code training.

Although the hospital identified safety checks as an issue in the inpatient BHU and in response created a "Safety Checks Competency Checklist" as a re-training measure to ensure all pertinent staff (MHCs and RNs) are competent in conducting safety checks, the hospital failed to provide the re-training measures to all staff. 80 of 88 pertinent staff received the re-training, a completion percentage of 91%.

Record review indicated that on 07/22/2022, between the hours of approximately 12:44 A.M. and 2:15 A.M., Patient #5 had an order for 4 point restraints, (a type of restraint order where each arm and each leg is physically restrained, typically when a patient may pose a danger to themselves or others). Patient #5 was located in the BH area of the ED during this time period.

The policy titled "Restraint and Seclusion Policy," last revised 02/2020, effective 04/13/2020, states that: "1:1 observation by a PCA or RN is required at all times during any 4 point restraint."

Record review of Patient #5 indicated that on 07/22/2022 at 12:45 A.M. an order was placed for constant observation (defined per hospital policy as requiring an unimpeded view of assigned patient(s) for up to three patients), not 1:1 observation. Record review did not indicate a 1:1 observation order was ever placed, indicating a failure to follow the hospital restraint policy that patients in 4 point restraints must be on 1:1 observation.

Video observation also identified the following in regards to Patient #5:

1) Patient #5 was confirmed to be in restraints on 07/22/2022 at 1:01 A.M. CO #6 was identified as the observer for Patient #5.

2) CO #6 is seen leaving the BH area of the ED for at least one minute, from 1:10 A.M. and 46 seconds, until 1:11 A.M. and 50 seconds.

3) CO #6, at 1:24 A.M., goes to observe a different patient in a different room and as a result leaves Patient #5 unobserved.

4) CO #6, at 1:25 A.M. leaves the BH area of the ED entirely, and is gone for at least one minute. CO #6 appeared to be bringing a boxed lunch to a patient in a different room. CO #6 resumes visual contact of Patient #5 at 1:27 A.M., with loss of visual observation occurring for at least two minutes.

5) Between the hours of 1:10 A.M. and 2:30 A.M., CO #6 is seen leaving the observer desk multiple times, breaking constant observation with Patient #5 multiple times and leaves the BH area of the ED multiple times.

Based on record review, observations and interviews, the hospital failed, for one (Patient #1) of ten patients sampled, to maintain an effective, ongoing, quality assessment and performance improvement program to ensure the prevention and reduction of medical errors and patient adverse events.

See tag 0286.

Based on record review, observations and interviews, the hospital failed, for one (Patient #1) of ten patients sampled, to conduct a thorough investigation involving the unexpected death of Patient #1. Consequently, the hospital failed to implement timely, preventative actions throughout the hospital to ensure a similar event does not re-occur.

Findings include:

The hospital report, dated 06/29/2022, stated that Patient #1 arrived to the hospital ED on 06/16/2022 complaining of new onset suicidal ideation. After approximately seven hours in the ED, Patient #1 was transferred to the hospital behavioral health unit (BHU) the evening of 06/16/2022. Patient #1 was placed on 15 minute checks. During a safety check on 06/17/2022 at approximately 10:27 A.M. Patient #1 was found unresponsive. Resuscitation attempts were unsuccessful and Patient #1 was pronounced (declared passed away) at 10:55 A.M.

Record review indicated that Patient #1 was triaged in the Hospital ED on 06/16/2022 at 12:49 P.M., with the "chief complaints updated" section stating, "suicidal."

The policy titled Patients at Risk for Suicide, effective 09/27/2021, states under definitions that: a) 1:1 direct observation requires that the staff member has an unobstructed view of the patient at all times, including during toileting. b) Constant Observation requires an unimpeded view of assigned patient(s) for up to three patients.

Record review of Patient #1 indicated that on 6/16/2022 at 2:13 P.M. an order was placed for 1:1 constant observation. An order was placed for Patient #1 to be in snap pajamas (a designated safer type of hospital gown geared for patients at risk for suicide). An order was placed for a clothing search and a belongings search.

Video observation, conducted on 07/25/2022 at 11:00 A.M., indicated that Patient #1 was seen walking alone out of an ED pod (a pod is a space in the ED waiting area where patients may be initially triaged prior to being moved into the main ED area) and towards an ED bathroom. Patient #1 walked out of the ED pod alone at 1:00 P.M. and 56 seconds and is seen going to the bathroom. Patient #1 exits the bathroom at 1:04 P.M. and 46 seconds, alone and unobserved and appears to return to the ED pod. Video observation indicated that Patient #1 was placed in a hallway bed of the Behavioral Health (BH) area of the ED at 1:38 P.M. and 32 seconds.

Video observation indicated that Patient #1 was in the BH area of the ED from 1:38 P.M. until 7:08 P.M. The surveyor made the following observations during this time period:

1) From 1:52 P.M. and 23 seconds until 2:14 P.M. and 44 seconds, there was no constant observer (CO) observing Patient #1.

2) At 3:51 P.M. and 29 seconds, CO #3 escorts a different patient, Patient #2 to the bathroom. The 1:1 protocol order for Patient #1 is not being followed as CO #3 follows Patient #2. In addition, CO #3 allows the bathroom door to be fully closed, and as a result, Patient #2 is also no longer under constant observation. This occurs until Patient #2 exits that bathroom at 3:53 P.M. and 58 seconds, and CO #3 returns to the observer desk area at 3:54 P.M. and 23 seconds.

3) CO #3 is seen leaving the entire BH area of the ED at 4:59 P.M. and 56 seconds, and does not return until 5:07 P.M. and 14 seconds. CO #3 fails to request for observer coverage prior to leaving the BH area of the ED.

4) CO #3 leaves Patient #1 area at 6:29 P.M. and 09 seconds, leaves the entire BH area of the ED at 6:29 P.M. and 35 seconds, and does not return the BH area of the ED until 6:30 P.M. and 37 seconds.

5) At 6:59 P.M. and 31 seconds, CO #3 leaves and it appears a covering observer, CO# 5 begins to cover Patient #1. However, at 7:00 P.M. and 45 seconds Patient #1 is unobserved until a new observer CO #4 enters the BH area of the ED and begins observing Patient #1 at 7:01 P.M. and 08 seconds.

6) At 7:05 P.M. and 20 seconds, while CO #4 is on CO #4's mobile phone, Patient #1 goes to the bathroom of the BH area of the ED. CO #4 does not accompany Patient #1 to the bathroom. The bathroom door is fully closed. Patient #1 does not exit the bathroom until 7:07 P.M. and 37 seconds.

7) At 7:08 P.M. and 38 seconds, Patient #1, accompanied by a transport staff member and a security staff member, exit the BH area of the ED.

Patient #1 remained in street clothes for the entire time period that Patient #1 was in the ED. Multiple constant observers (CO #3 and CO #4) responsible for providing constant observation of Patient #1 in the hospital ED were observed to be using mobile devices. Record review of Patient #1 did not indicate whether a clothing search ever occurred during Patient #1's stay in the ED.

The surveyor interviewed the Director of Risk Management on 07/25/2022 at 5:00 P.M. The Director of Risk Management indicated that after an evaluation of the timeline of Patient #1 including Patient #1's time in the BH area of the ED and Patient #1's transfer and overnight stay in the inpatient BHU, the Director stated that there were no specific findings identified in the BH area of the ED in response to Patient #1's event. In addition, the Director stated that there were no specific corrective actions identified in relation to the BH area of the ED in response to Patient #1's event.

Video observation indicated Patient #1 was in the inpatient BHU from approximately 6/16/2022 7:11 P.M. until 6/17/2022 leading up to Patient #1's unexpected death. Patient #1 was placed on 15 minute checks when in the inpatient BHU. The surveyor made the following observations during this time period.

1) There were six safety checks that were missed regarding Patient #1, between the hours of 6:37 A.M. and 10:04 A.M.

2) At 10:26 A.M. and 48 seconds Mental Health Counselor (MHC) #1 goes with Nurse #1 to check on Patient #1 and are in Patient #1's room. At 10:27 A.M. and 28 seconds, another staff member, Nurse #2 walks into Patient #1's room. At 10:27 A.M. and 48 seconds MHC #1 and Nurse #1 exit Patient #1's room and at 10:28 A.M. and 06 seconds Nurse #2 runs out of Patient #1's room. At 10:29 A.M. and 00 seconds Nurse #2 enters Patient #1's room with a code cart.

While Nurse #2 runs out of the room to retrieve the code cart, and is out of the room from 10:28 A.M. and 06 seconds until 10:29 A.M. and 00 seconds, there are no staff members in Patient #1's room. For approximately one minute of time, Patient #1 is alone in Patient #1's room and life saving measures are not being performed.

3) At 10:29 A.M. and 00 seconds Nurse #2 enters Patient #1's room with a code cart. At 10:29 A.M. and 25 seconds, inpatient BHU physician staff enter Patient #1's room. At 10:31 A.M. and 29 seconds, the initial members of the code team arrive/enter Patient #1's room. At 10:31 A.M. and 50 seconds, more code team staff arrive to Patient #1's room.

Personnel file (the hospital's record of an employee file) review of Nurse #1 indicated that Nurse #1 did not have on file a "Registered Nurse (RN) Competency Based Orientation Checklist" document, nor a "Competency Based Addendum, Psychiatry RN/MHC" checklist geared towards psychiatry RNs and MHCs, at the time of Patient #1's event date, 06/17/2022.

The RN Competency Based Orientation Checklist page 7, in a section titled "Ensures patient and unit safety at all times" has one of the performance objectives as, "Demonstrates knowledge of the following: d. Code procedures/emergency response and e. Rapid Response protocol."

The surveyor interviewed the interim nurse educator of the inpatient BHU on 07/29/2022 at 1:10 P.M. The nurse educator stated that the RN competency based orientation checklist is a hospital wide orientation checklist that applies to all nurses. The nurse educator stated that the psychiatry addendum is a combined checklist geared for MHCs and psychiatry RNs. The nurse educator stated that the RN Competency Based Orientation checklist and the psychiatry addendum checklist could not be located in Nurse #1's personnel file.

The document titled "Safety Reports, Inpatient Psychiatry" indicated a safety report was submitted into the hospital's internal event reporting system, in relation to Patient #1's 06/17/2022 event date. The reporter stated that responding staff did not appear familiar with protocols involved in code situations.

The document titled "Mock Code" indicated that the interim nurse educator of the inpatient BHU coordinated hands-on mock code drill sessions, which occurred on 06/22/2022. MHCs and RNs acknowledged attendance via signed attestation. Only 35 of 90 eligible staff attestations were recorded.

The surveyor interviewed the interim nurse educator of the inpatient BHU on 07/28/2022 at 11:00 A.M. The nurse educator stated that the mock code training session was a voluntary training, with 35 of 90 eligible staff completing the training, a completion percentage of only 39 percent.

The surveyor interviewed the associate CNO on 07/28/2022 at 10:30 A.M. The associate CNO stated that the mock code training was voluntary.

The surveyor interviewed the CNO on 07/28/2022 at 11:00 A.M. The CNO stated that the mock code training was done at the local level (inpatient BHU) with support from the central code team. The CNO stated that it was not expected for the mock code training of inpatient BHU staff to be forwarded to senior administration.

Although Nurse #2 was involved in the code response of Patient #1, Nurse #2 did not attend the mock code training session on 06/22/2022, as indicated in the staff attestation document titled "Mock Code."

The surveyor interviewed the risk manager on 07/28/2022 at 5:30 P.M. The risk manager said that Nurse #2 continued to work, working two shifts in the inpatient BHU (6/29, 6/30/2022) without ever completing the mock code training.

Although the hospital identified safety checks as an issue in the inpatient BHU and in response created a "Safety Checks Competency Checklist" as a re-training measure to ensure all pertinent staff (MHCs and RNs) are competent in conducting safety checks, the hospital failed to provide the re-training measures to all staff. 80 of 88 pertinent staff received the re-training, a completion percentage of 91%.

Record review indicated that on 07/22/2022, between the hours of approximately 12:44 A.M. and 2:15 A.M., Patient #5 had an order for 4 point restraints, (a type of restraint order where each arm and each leg is physically restrained, typically when a patient may pose a danger to themselves or others). Patient #5 was located in the BH area of the ED during this time period.

The policy titled "Restraint and Seclusion Policy," last revised 02/2020, effective 04/13/2020, states that: "1:1 observation by a PCA or RN is required at all times during any 4 point restraint."

Record review of Patient #5 indicated that on 07/22/2022 at 12:45 A.M. an order was placed for constant observation (defined per hospital policy as requiring an unimpeded view of assigned patient(s) for up to three patients.), not 1:1 observation. Record review did not indicate a 1:1 observation order was ever placed, indicating a failure to follow the hospital restraint policy that patients in 4 point restraints must be on 1:1 observation.

Video observation also identified the following in regards to Patient #5:

1) Patient #5 was confirmed to be in restraints on 07/22/2022 at 1:01 A.M. CO #6 was identified as the observer for Patient #5.

2) CO #6 is seen leaving the BH area of the ED for at least one minute, from 1:10 A.M. and 46 seconds, until 1:11 A.M. and 50 seconds.

3) CO #6, at 1:24 A.M., goes to observe a different patient in a different room and as a result leaves Patient #5 unobserved.

4) CO #6, at 1:25 A.M. leaves the BH area of the ED entirely, and is gone for at least one minute. CO #6 appeared to be bringing a boxed lunch to a patient in a different room. CO #6 resumes visual contact of Patient #5 at 1:27 A.M., with loss of visual observation occurring for at least two minutes.

5) Between the hours of 1:10 A.M. and 2:30 A.M., CO #6 is seen leaving the observer desk multiple times, breaking constant observation with Patient #5 multiple times and leaves the BH area of the ED multiple times.