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Based on observation, interview, record review and policy review the facility failed to protect and promote the rights of 33 (Patient #s 1 through 33) to ensure their safety and freedom from abuse and neglect. Due to a fire set by Patient #1, 33 patients had to be evacuated from the 5th floor, including 15 staff members. The 33 patients and 15 staff members had to be evaluated in the hospital's Emergency Department due to smoke inhalation. Prior to setting the fire, Patient #1 exhibited aggressive behaviors which were not addressed, and he was not supervised by the hospital staff. A physician order for behavioral health consult and a sitter for Patient #1 was not implemented. In addition, patient #1 physically assaulted patient #2 while in her room.
Based on the findings, the Condition of Participation at 42 CFR, Part 482.13 Patient Rights was determined to be out of compliance and Immediate Jeopardy to the health and safety of patients was identified. The Immediate Jeopardy started on 10/30/2024 and was ongoing as of the exit on 11/08/2024.

The findings included:

1. Based on observation, interview, record review and policy review, the facility failed to ensure all patients received care in a safe setting. The cumulative effect resulted in Immediate Jeopardy at A144. Patient #1 had a history of self harm which was identified when he was admitted to the ED. There was a physician's order for behavioral health consultation and a sitter for Patient #1 which was not implemented. Patient #1's self harm behaviors worsened three days after admission. In addition, Patient #1 physically assaulted patient #2 while in her room at the time Patient #1 was setting fires.
(Patients #s 1 through 33) had to be evacuated from the fifth floor, including 15 staff members due to a fire set by Patient #1. The 33 patients and 15 staff members had to be evaluated in the hospital's Emergency Department (ED) due to smoke inhalation.
Refer to A144.

2. Based on observation, interview, record review and policy review, the facility failed to ensure all patients were free from abuse and neglect for 2 out of 33 sampled patients (Patients #1 and #2). There was a physician's order for behavioral health consultation and a sitter for Patient #1 due to a history of self harm and abnormal behaviors, which was not implemented. Additionally, the ED physician did not follow the hospital policies for ordering patient consultations. This resulted in a lack of necessary services to avoid physical harm and mental anguish for Patient #1 and Patient #2. Patient #1 physically assaulted patient #2 while in her room while he was setting fires. Thirty-three patients and 15 staff members had to be evaluated in the hospital's Emergency Department (ED) due to smoke inhalation.
Refer to A145

Based on observation, interview, record review and policy review, the facility failed to ensure all patients received care in a safe setting.
The cumulative effect resulted in Immediate Jeopardy at A144.
(Patients #s 1 through 33) had to be evacuated from the 5th floor, including 15 staff members due to a fire set by Patient #1. The 33 patients and 15 staff members had to be evaluated in the hospital's Emergency Department (ED) due to smoke inhalation.

Based on the findings, the Condition of Participation at 42 CFR, Part 482.13 Patient Rights was determined to be out of compliance and Immediate Jeopardy to the health and safety of patients was identified. The Immediate Jeopardy started on 10/30/24 and was ongoing as of the exit on 11/08/24. Refer to A115 and A145.

The findings included:

Policy Number COG.RAS.004, Effective Date July1, 2020 documented (in part) Procedure: All patients are to be treated in a manner that preserves their dignity, autonomy, self-esteem, civil rights and involvement in their own care. The patient's rights notification at a minimum will address the following patient rights as well as all additional federal, state, or local requirements. These statements include but are not limited to: (*) The right to receive considerate and respectful care, including consideration of cultural, spiritual psychosocial and personal values, beliefs and preferences and (*)The right to receive individualized care that fosters the patient's comfort and dignity, and is delivered in a setting that is free from abuse, discrimination and harassment.

Patient #1 was admitted to the hospital on 10/27/2024 with Altered Mental Status. Patient #1 had a history of a suicidal attempt 5 days prior to this admission and was admitted to the hospital and discharged. On 10/27/20/24, the ED physician ordered a behavioral health consultation and sitter. This order was missed and not implemented.

On 10/30/2024 at approximately 6:15 PM - A Code Red (a staff response alert for fire) was called for a fire. Patient #1 had set fires in his room and Patient #2's room. In addition, Patient #1 physically assaulted Patient #2 while in her room.

After additional review of the medical record, it was determined that the ED physician's order on 10/27/2024 at 4:11 PM for Patient #1 to have a behavioral health consult and sitter was missed and not implemented. The facility's failure to provide the behavioral health consult and a sitter to Patient #1 resulted in the patient setting a fire in his room and in Patient #2's room on 10/30/2024 at 6:15 PM which was three days after the ED physician had written the order. Additionally, the fire incident resulted in the evacuation of Patients #s 1 through 33 including 15 staff members in the hospital's ED due to smoke inhalation.

During an interview with facility staff on 11/06/2024 at 1:00 PM, about the missed order for the behavioral health consult and sitter for Patient #1 and the fire incident. It was reported that Patient #1 was not supervised as intended to ensure appropriate care and interventions were based on the potential risk of self-harm or harm to others. It was reported that Patient #1 was fine all shift on 10/30/2024 until the early evening when staff were seen running down the hall and smoke coming from Patient #1's room.

An interview with the Chief Nursing Officer (CNO) on 11/05/2024 at 12:53 PM revealed the ED nurse had no knowledge of the missed order. The ED physician recalls telling the ED charge nurse. The CNO stated Behavioral Health nurses are assigned to the ED for psych (psychological) consults. The ED physician reviewed Patient #1's prior admission history and noted that Patient #1 was previously Baker Acted (A Florida law that allows for emergency mental health services and temporary detention of individuals who are impaired due to mental illness and unable to determine their own treatment needs) and based on that the physician ordered a stat (immediate) psych consult. The agreed upon protocol for physicians calling their own consults was not followed and the consult was not called. If a psych consultation is ordered, a sitter is automatically ordered also. The CNO was asked if the Intensive Care Unit (ICU) nursing staff were able to review ED orders. The CNO verified that the (ICU) nurse could not see the ED list of orders because the medical record system is set up that way. Also, the ED nurses' access is restricted to current encounters only in the medical record. This prevented the ED nurse from reviewing Patient #1's previous history. The facility failed to ensure that the ED physician followed the agreed protocol for Patient #1 which is for physicians to call their own consults.

An interview conducted with 5th Floor Registered Nurse, Staff B on 11/05/2024 at 11:00 AM revealed her patient care assignment on 10/30/2024 included Patient #1 and Patient #2. During the end of the shift on 10/30/2024 while in the lavatory, loud talking was heard and upon opening the door to exit a colleague was seen running down the hall and smoke coming from one of the rooms. Staff B stated she ran into smoke to get patients. Room #5136 was the first room encountered, and the door would not close. A chair was pulled to the door to keep it closed. Staff B stated she was praying that someone would come to help. She informed the patient after unplugging everything that she was going to be moved. The patient had just received morphine for pain and wasn't comprehending but was moved down the hall near the nursing station. Between rooms #5130 and #5041, the hallway was full of black smoke. She went back into the area to get more patients and pulled out whoever she could. Staff B stated the events are blurry but remember checking rooms to pull out patients. The maintenance man grabbed her hand to tell her about a patient in room #5139. The patient was oxygen dependent. The maintenance man helped walk the patient out of the room. Once all patients were out, a head count was done but she did not see Patient #1. A family member or friend was asking for Patient #1. He went inside the room with her despite being told not to follow. After searching the room, Patient #1 was not found, but the friend was saying the remote control was on fire. Staff B stated she left the room and went back to the nursing station, continuing to search for Patient #1; she opened the door to Patient #2's room and the smoke covered her face, and her eyebrows felt hot while she called out for Patient #1. Staff B stated upon leaving the room her face was black with smoke. The fire department was on the floor. The unit clerk stated a whistling sound was coming from the intercom. The fire department was in the room and pulled Patient #1 out of his room. The ICU team was already on unit. Patient #1 had shallow breathing and was not responding verbally. Patient #1 was immediately intubated and moved to the ICU. During report to the nurse, Patient #1 woke up and became combative. Staff B returned to the step-down unit. The nurse manager insisted that she went to the ED.

Patient #2 is a 62-year-old admitted to the facility on 10/22/2024 for wheezing, shortness of breath and a cough. Patient #2 was diagnosed with status asthmaticus (acute severe asthma) and treated with systemic steroids (medications to treat inflammation) respiratory therapy aound the clock and empiric antibiotic therapy.
An interview was conducted with Patient #2 and daughter on 11/07/2024 at 5:43 PM via telephone. Patient #2 was admitted to the fifth floor Stepdown Unit, on 10/22/2024 for respiratory failure and acute asthma and discharged on 11/03/2024. Patient #2 stated that while sitting in the hospital room in the recliner next to the window, Patient #1 came in the room and looked around. Patient #2 thought it was someone who worked in the hospital and acknowledged the person. Patient #1 did not speak, but opened the closet door and removed two pillows and lit them with fire. Patient #2 started pressing the call button and got out of the recliner. As soon as Patient #2 started screaming for help, Patient #1 came toward her pushing her back into the recliner and holding her down trying to light the nasal cannula ( a medical device that delivers extra oxygen through a tube and into the nose) on fire. Patient #2 started blowing at the flames. Patient #1 then grabbed her gown around the neck area and tried to burn her face with the flames. Patient #2 stated she does not know where she got the strength to fight Patient #1 but when she got free, she ran out of the room into the hallway and started screaming for help. Patient #2 stated Patient #1 came out of the room not wearing a shirt. Patient #2 stated someone placed her in a chair. Patient #2 was later taken to the ICU and remained there for additional respiratory treatments. Patient #2 reported seeing the psychiatrist and will be followed for the next month. As the interview progressed, Patient #2's voice started to quiver, and sound strained. Patient #2 stated she would be alright.

Record review revealed a psychiatric consult performed on 10/31/2024 at 6:18 PM revealed Patient #2 was immediately transferred to the ICU after the incident and endorsed shortness of breath and rapid breathing. Patient #2 was treated with respiratory treatments and supplemental oxygen via non-rebreather mask. An arterial blood gas revealed excellent oxygenation and hyperventilation, most likely due to the traumatic event. Diagnoses include acute chronic asthma exacerbation, respiratory alkalosis (a condition where the blood becomes too alkaline due to low carbon dioxide levels), secondary to hyperventilation(fast breathing) and anxiety, possible post-traumatic stress syndrome (PTSD) from traumatic events. The psychiatric consult note documented the service was called to evaluate Patient #2 from a psychiatric perspective after sustaining a significant traumatic event while hospitalized in the last 24 hours. Patient #2 reported being assaulted by another patient while in her room on 5th floor step-down unit. Patient #2 stated an individual entered her room uninvited, setting a pillow on fire with a cigarette lighter and trying to burn her face and set her on fire. Patient #2 stated that she fought this individual and was able to disconnect herself from her oxygen cannula and started running toward the nursing station looking for assistance and help. Patient #2 stated she is fearful she may be attacked again and is experiencing a startle response, particularly when medical staff are entering her room. Patient #2 is also afraid of having the curtains in her room closed and experienced palpitations, sweating and a sense of dread and apprehension.

Plan: Patient #2 may be discharged from a psychiatric perspective once medically cleared with follow up with psychiatrist/psychotherapist due to traumatic events to improve coping skills, assist in eliminating anxiety, flashbacks, sense of dread, and startle response. Start psychotropic regimen, as needed medication for insomnia, anxiety, and agitation.

An interview was conducted with the Chief Financial Officer on 11/05/2024 at 2:30PM to review a video of the hallway outside of Patient #2's room who was physically assaulted by Patient #1 during around the time of the fire. The video had no sound but shows Patient #2 rapidly coming out of the room and holding on to the wall railing pacing and looking around. Staff members can be seen running toward Patient #2 who is pointing at the door. Several seconds later, Patient #1 is seen running out of the room. Patient #2 was led away from the scene to a safe area.

Review of the Emergency Department (ED) Provider Report dated 10/27/2024 at 4:17 PM documented Patient #1, a 63-year-old, presented to the Emergency Department via emergency medical services (EMS) for altered mental status. Per EMS Patient #1 was found in someone's backyard, altered, agitated, not following commands. Patient #1's history was independently obtained from past medical history and EMS reported Patient #1's altered mental status. Per prior hospital record, Patient #1 had a history of metastatic pancreatic cancer, recently diagnosed, depression, and prior suicide attempts. Patient #1 was discharged 5 days prior for a suicide attempt. On examination, Patient #1 responds to voice, moves all extremities, intermittently follows commands. Patient #1 is hemodynamically stable (patient's vital signs, such as heart rate, blood pressure, and oxygen saturation are within normal ranges), afebrile (without fever), without any tachycardia (rapid heart beat). Moving all extremities. Pupils are nonreactive (a medical condition characterized by the inability of the pupils to constrict or dilate in response to light stimuli cause by trauma, medications, neurological conditions, and eye injuries), Point of care glucose 160mg/dl (milligrams/deciliter). Independent reviews of images as well as radiology report indicated no evidence of intracranial hemorrhage (bleeding within the skull). No other evidence of acute intracranial (within the skull) pathology (the study of diseases and especially of the changes in the body produced by them) to explain Patient #1's altered mental status. Independently reviewed labs which were concerning for hyponatremia (low sodium level) of 115mEq/L (milliequilvalent/liter), suspected cause of Patient #1's altered mental status. 3 % saline(a sterile solution of sodium and water) ordered. Vital signs first documented at 3:50 PM: Temperature: 98.1Fahrenheit (F); Pulse: 85 beats per minute; Respirations: 18 breaths per minute; Blood Pressure 155/71mmHg(millimeters of mercury); Pulse Oximetry (a test used to measure the oxygen level (oxygen saturation) of the blood) 100% on room air. Discussed case with intensivist. Plan to admit Patient #1 to ICU for further evaluation and management.

Emergency Department Orders (in part):
10/27/2024 at 4:11 PM - Behavioral Health Observation
10/27/2024 at 4:11 PM - Behavioral Health Consult
10/27/2024 at 4:11 PM - Level 3: 1:1 Monitor
10/27/2024 at 4:13 PM - Ativan 2 mg (Milligram) IV(Intravenous) (sedative medication)
10/27/2024 at 6:36 PM - 3% Sodium Chloride 500 ml (Milliliters) IV X1(once)
10/27/2024 at 6:45 PM - Ativan 2 mg IV
10/27/2024 at 6:53 PM - Haldol 5 mg IV (antipsychotic medication)
10/27/2024 at 6:53 PM - Benadryl 50 mg IV
10/27/2024 at 6:50 PM - Medical Doctor (MD) made aware that Patient #1 is starting to become aggressive.
10/27/2024 at 7:00 PM - Patient #1 has been alert and extremely confused, eating own vomit, cardiac stickers, and the bed sheet. Patient #1 is becoming aggressive and not following commands and combative. Patient #1 ripped out IV.
10/27/2024 at 7:05 PM - Patient #1 refused straight catheterization (an insertion of a tube to empty the bladder of urine) and is aggressive. Patient #1 stood on the floor and urinated on himself and the floor, then proceeded to yell at nurses.
10/27/2024 at 9:27 PM - ICU Registered Nurse (RN) at bedside. Report given at this time. Patient #1 is currently sleeping. Transferred to ICU.

An interview conducted with ED Registered Nurse, Staff A on 11/05/2024 at 2:00 PM revealed Staff A has been working in the ED for approximately one year, first nursing job. Staff A stated usually for behavioral health patients, the physician tells the charge nurse who provides a behavioral form that is signed by the primary nurse, charge nurse and physician. Patient #1 was watched closely due to hyponatremia. Patient #1 would respond to commands but would not say his name. Staff A stated the orders for a behavioral health consultation and sitter were not seen. When asked what could have been done differently, Staff A replied she would have communicated more with the physician. Patient #1 was being treated for a medical issue when the issue was also behavioral. Staff A is unsure if nurses have access to view previous admissions. Staff A stated she has never attempted to look before at previous admissions. Staff A stated she spoke to charge nurse regarding Patient #1's acuity and needs when Patient #1 started eating EKG stickers. Patient #1's belongings were placed out of sight. Patient #1 threw up and started eating the vomit. The MD was made aware of Patient #1's behavior. The physician ordered Benadryl and Haldol which were effective. Patient #1 fell asleep after being medicated.

An interview conducted with ED Attending Physician, Staff C on 11/05/2024 at 2:50 PM revealed the physician started working at the facility in August 2023. Staff C stated Patient #1 could not answer questions, could not give a history. Patient #1 had a wallet and was previously admitted to the hospital for a suicide attempt. Patient #1 was Baker Acted for depression and withdrawal related to a pancreatic cancer diagnosis. Staff C stated there was a concern Patient #1 could have been suicidal, and Patient #1 was also hyponatremic. After an hour, Patient #1 responded to external stimuli. Patient #1 denied suicide attempt; order set for psych was completed. Staff C stated she thought it was discussed with the nursing staff but cannot guarantee the nurse was told about the order. Staff C stated she did not call the psych consult; none of the physicians call for consults. Usually when a psych order is placed someone from behavioral intake comes down to see the patient.

An interview conducted with Chief Medical Officer (CMO) on 11/05/2024 at 3:40 PM revealed the ED Physicians always go to the nurse, charge nurse or the secretary to make their phone calls. There is a process for psych consultants in the ED. The CMO stated the policy referred to (PolicyStat ED 13799062, Last Revised 12/2019 titled "Consultations") is related to Inpatient Physicians. When asked for the related ED Policy, the CMO stated there is not another policy specifically for ED Physicians.

The "Consultations" policy (PolicyStat ID 13799062, Last Revised 12/2019) documented Scope: Hospital-wide; Purpose: To define the requirements and responsibilities for obtaining and responding to medical staff consultations. Policy: A. Medical Staff will respond to requests for consultation in the time frames described below (3) Responsibility for Requesting Consultations. The patient's attending physician is primarily responsible for requesting appropriate consultation. All requests for consultation will be entered as an order in the medical record by the attending physician. All requests for consultation will be personally called by the requesting attending physician directly to the requested consultant.

An interview was conducted with the ED Medical Director on 11/05/2024 at 3:50 PM. The ED Medical Director stated the physician may have several patients requiring consults to be called. The nurse or unit clerks usually place the calls or texts.

A review of the medical record revealed Patient #1's suicide screening in the ICU on 10/27/2024 at 9:28 PM documented YES to questions (1) Active ideation without method, plan or intent in your lifetime and (2) Active ideation with some intent and without plan in your lifetime. Calculated suicide level: Low risk. Patient #1 remained in the ICU for 2 days and was transferred to the 5th Floor Stepdown Unit on 10/29/2024 at 5:01 PM .

Review of PolicyStat ID 13777265 titled, "Chart Check Process", Last Revised 04/2022 documented in part: SCOPE: Organization Wide; PURPOSE: To establish a process for review and verification of Computerized Provider Order Entry (CPOE) and non CPOE orders in a consistent and timely manner in the inpatient areas. The goal of the chart check process is to ensure that all orders are transcribed and carried out appropriately. If orders are missed or transcribed incorrectly, corrective action is initiated. POLICY: H. The charge nurse/unit clerk/designee runs the consult report every shift to ensure that all consults are called.

Based on observation, interview, record review and policy review, the facility failed to ensure all patients were free from abuse and neglect for 2 out of 33 sampled patients (Patients #1 and #2 ). The cumulative effect resulted in Immediate Jeopardy at A145. There was a physician's order for behavioral health consultation and a sitter for Patient #1 due to a history of self harm and abnormal behaviors, which was not implemented. Due to the setup of the hospital's electronic medical record system, staff were not able to see the physician's order after it was entered. Additionally, the ED physician did not follow the hospital policies for ordering patient consultations. This resulted in a lack of necessary services to avoid physical harm and mental anguish for 33 patients (Patient #s 1 through 33), but particularly for Patient #1 and Patient #2. Patient #1 physically assaulted patient #2 while in her room while he was setting fires.
(Patients #s 1 through 33) had to be evacuated from the 5th floor, including 15 staff members due to a fire set by Patient #1. The 33 patients and 15 staff members had to be evaluated in the hospital's Emergency Department (ED) due to smoke inhalation.

Based on the findings, the Condition of Participation at 42 CFR, Part 482.13 Patient Rights was determined to be out of compliance and Immediate Jeopardy to the health and safety of patients was identified. The Immediate Jeopardy started on 10/30/24 and was ongoing as of the exit on 11/08/24. Refer to A115 and A144.

The findings included:

PolicyStat ID 13800202, "Abuse, Neglect and Exploitation", Last Revised 09/2022 documented (in part) Scope: Organization wide; Purpose: The facility supports the safety of its patients by making the qualified staff engaged in the admission, examination, care or treatment of the patient aware of the signs, symptoms, physical and behavioral indicators of abuse, neglect, exploitation, physical assault, domestic violence, rape and/or sexual molestation.

Policy Number COG.RAS.004, "Patient Rights", Effective Date July 1, 2020 documented (in part) Procedure: All patients are to be treated in a manner that preserves their dignity, autonomy, self-esteem, civil rights and involvement in their own care. The patient's rights notification at a minimum will address the following patient rights as well as all additional federal, state, or local requirements. These statements include but are not limited to: (*) The right to receive considerate and respectful care, including consideration of cultural, spiritual psychosocial and personal values, beliefs and preferences and (*)The right to receive individualized care that fosters the patient's comfort and dignity, and is delivered in a setting that is free from abuse, discrimination and harassment.

Patient #1 was admitted to the hospital on 10/27/2024 with Altered Mental Status. Patient #1 had a history of a suicidal attempt 5 days prior to this admission and was admitted to the hospital and discharged. On 10/27/20/24, the ED physician ordered a behavioral health consultation and sitter. This order was missed and not implemented.

On 10/30/2024 at approximately 6:15 PM - A Code Red (a staff response alert for fire) was called for a fire. Patient #1 had set fires in his room and Patient #2's room. In addition, Patient #1 physically assaulted Patient #2 while in her room.

After additional review of the medical record, it was determined that the ED physician's order on 10/27/2024 at 4:11 PM for Patient #1 to have a behavioral health consult and sitter was missed and not implemented. The facility's failure to provide the behavioral health consult and a sitter to Patient #1 resulted in the patient setting a fire in his room and in Patient #2's room on 10/30/2024 at 6:15 PM which was three days after the ED physician had written the order. Additionally, the fire incident resulted in the evacuation of Patients #s 1 through 33 including 15 staff members in the hospital's ED due to smoke inhalation.

During an interview with facility staff on 11/06/2024 at 1:00 PM, about the missed order for the behavioral health consult and sitter for Patient #1 and the fire incident. It was reported that Patient #1 was not supervised as intended to ensure appropriate care and interventions were based on the potential risk of self-harm or harm to others. It was reported that Patient #1 was fine all shift on 10/30/2024 until the early evening when staff were seen running down the hall and smoke coming from Patient #1's room.

An interview with the Chief Nursing Officer (CNO) on 11/05/2024 at 12:53 PM revealed the ED nurse had no knowledge of the missed order. The ED physician recalls telling the ED charge nurse. The CNO stated Behavioral Health nurses are assigned to the ED for psych (psychological) consults. The ED physician reviewed Patient #1's prior admission history and noted that Patient #1 was previously Baker Acted (A Florida law that allows for emergency mental health services and temporary detention of individuals who are impaired due to mental illness and unable to determine their own treatment needs) and based on that the physician ordered a stat (immediate) psych consult. The agreed upon protocol for physicians calling their own consults was not followed and the consult was not called. If a psych consultation is ordered, a sitter is automatically ordered also. The CNO was asked if the Intensive Care Unit (ICU) nursing staff was able to review ED orders. The CNO verified that the ICU nurse could not see the ED list of orders because the medical record system is set up that way. Also, the ED nurses' access is restricted to current encounters only in the medical record. This prevented the ED nurse from reviewing Patient #1's previous history. The facility failed to ensure that the ED physician followed the agreed protocol for Patient #1 which is for physicians to call their own consults.


Review of the Emergency Department (ED) Provider Report dated 10/27/2024 at 4:17 PM documented Patient #1, a 63-year-old, presented to the Emergency Department via emergency medical services (EMS) for altered mental status. Per EMS Patient #1 was found in someone's backyard, altered, agitated, not following commands. Patient #1's history was independently obtained from past medical history and EMS reported Patient #1's altered mental status. Per prior hospital record, Patient #1 had a history of metastatic pancreatic cancer, recently diagnosed, depression, and prior suicide attempts. Patient #1 was discharged 5 days prior for a suicide attempt. On examination, Patient #1 responds to voice, moves all extremities, intermittently follows commands. Patient #1 is hemodynamically stable (patient's vital signs, such as heart rate, blood pressure, and oxygen saturation are within normal ranges), afebrile (without fever), without any tachycardia (rapid heart rate). Moving all extremities. Pupils are nonreactive (a medical condition characterized by the inability of the pupils to constrict or dilate in response to light stimuli cause by trauma, medications, neurological conditions, and eye injuries). Point of care glucose 160mg/dl. Independent reviews of images as well as radiology report indicated no evidence of intracranial hemorrhage(bleeding within the skull). No other evidence of acute intracranial pathology (the study of diseases and especially of the changes in the body produced by them) to explain Patient #1's altered mental status. Independently reviewed labs which were concerning for hyponatremia (low sodium blood level) of 115mEq/L, suspected cause of Patient #1's altered mental status. 3 % saline (a sterile solution of sodium and water) ordered. Vital signs first documented at 3:50 PM: Temperature: 98.1 Fahrenheit; Pulse: 85 beats per minute; Respirations: 18 breaths per minute; Blood Pressure 155/71mmHg; Pulse Oximetry (a test used to measure the oxygen level (oxygen saturation) of the blood) 100% on room air. Discussed case with intensivist. Plan to admit Patient #1 to ICU for further evaluation and management.

Emergency Department Orders (in part):
10/27/2024 at 4:11 PM - Behavioral Health Observation
10/27/2024 at 4:11 PM - Behavioral Health Consult
10/27/2024 at 4:11 PM - Level 3: 1:1 Monitor
10/27/2024 at 4:13 PM - Ativan 2 mg (Milligram) IV(Intravenous) (sedative medication)
10/27/2024 at 6:36 PM - 3% Sodium Chloride 500 ml (Milliliters) IV X1
10/27/2024 at 6:45 PM - Ativan 2 mg IV
10/27/2024 at 6:53 PM - Haldol 5 mg IV (antipsychotic medication)
10/27/2024 at 6:53 PM - Benadryl 50 mg IV
10/27/2024 at 6:50 PM - Medical Doctor (MD) made aware that Patient #1 is starting to become aggressive.
10/27/2024 at 7:00 PM - Patient #1 has been alert and extremely confused, eating own vomit, cardiac stickers, and the bed sheet. Patient #1 is becoming aggressive and not following commands and combative. Patient #1 ripped out IV.
10/27/2024 at 7:05 PM - Patient #1 refused straight catheterization (an insertion of a tube to empty the bladder of urine) and is aggressive. Patient #1 stood on the floor and urinated on himself and the floor, then proceeded to yell at nurses.
10/27/2024 at 9:27 PM - ICU Registered Nurse (RN) at bedside. Report given at this time. Patient #1 is currently sleeping. Transferred to ICU.

An interview conducted with ED Registered Nurse, Staff A on 11/05/2024 at 2:00 PM revealed Staff A has been working in the ED for approximately one year, first nursing job. Staff A stated usually for behavioral health patients, the physician tells the charge nurse who provides a behavioral form that is signed by the primary nurse, charge nurse and physician. Patient #1 was watched closely due to hyponatremia. Patient #1 would respond to commands but would not say his name. Staff A stated the orders for a behavioral health consultation and sitter were not seen. When asked what could have been done differently, Staff A replied she would have communicated more with the physician. Patient #1 was being treated for a medical issue when the issue was also behavioral. Staff A is unsure if nurses have access to view previous admissions. Staff A stated she has never attempted to look before at previous admissions. Staff A stated she spoke to charge nurse regarding Patient #1's acuity and needs when Patient #1 started eating EKG stickers. Patient #1's belongings were placed out of sight. Patient #1 threw up and started eating the vomit. The MD was made aware of Patient #1's behavior. The physician ordered Benadryl and Haldol which were effective. Patient #1 fell asleep after being medicated.

An interview conducted with ED Attending Physician, Staff C on 11/05/2024 at 2:50 PM revealed the physician started working at the facility in August 2023. Staff C stated Patient #1 could not answer questions, could not give a history. Patient #1 had a wallet and was previously admitted to the hospital for a suicide attempt. Patient #1 was Baker Acted for depression and withdrawal related to a pancreatic cancer diagnosis. Staff C stated there was a concern Patient #1 could have been suicidal, and Patient #1 was also hyponatremic. After an hour, Patient #1 responded to external stimuli. Patient #1 denied suicide attempt; order set for psych was completed. Staff C stated she thought it was discussed with the nursing staff but cannot guarantee the nurse was told about the order. Staff C stated she did not call the psych consult; none of the physicians call for consults. Usually when a psych order is placed someone from behavioral intake comes down to see the patient.

An interview conducted with Chief Medical Officer (CMO) on 11/05/2024 at 3:40 PM revealed the ED Physicians always go to the nurse, charge nurse or the secretary to make their phone calls. There is a process for psych consultants in the ED. The CMO stated the policy referred to (PolicyStat ED 13799062, Last Revised 12/2019 titled "Consultations") is related to Inpatient Physicians. When asked for the related ED Policy, the CMO stated there is not another policy specifically for ED Physicians.

The "Consultations" policy (PolicyStat ID 13799062, Last Revised 12/2019) documented Scope: Hospital-wide; Purpose: To define the requirements and responsibilities for obtaining and responding to medical staff consultations. Policy: A. Medical Staff will respond to requests for consultation in the time frames described below (3) Responsibility for Requesting Consultations. The patient's attending physician is primarily responsible for requesting appropriate consultation. All requests for consultation will be entered as an order in the medical record by the attending physician. All requests for consultation will be personally called by the requesting attending physician directly to the requested consultant.

An interview was conducted with the ED Medical Director on 11/05/2024 at 3:50 PM. The ED Medical Director stated the physician may have several patients requiring consults to be called. The nurse or unit clerks usually place the calls or texts.

An interview conducted with 5th Floor Registered Nurse, Staff B on 11/05/2024 at 11:00 AM revealed her patient care assignment on 10/30/2024 included Patient #1 in room #5138 and Patient #2 in room #5141. During the end of the shift on 10/30/2024 while in the lavatory, loud talking was heard and upon opening the door to exit a colleague was seen running down the hall and smoke coming from one of the rooms. Staff B stated she ran into smoke to get patients. Room #5136 was the first room encountered, and the door would not close. A chair was pulled to the door to keep it closed. Staff B stated she was praying that someone would come to help. She informed the patient after unplugging everything that she was going to be moved. The patient had just received morphine for pain and wasn't comprehending but was moved down the hall near the nursing station. Between rooms #5130 and #5041, the hallway was full of black smoke. She went back into the area to get more patients and pulled out whoever she could. Staff B stated the events are blurry but remember checking rooms to pull out patients. The maintenance man grabbed her hand to tell her about a patient in room #5139. The patient was oxygen dependent. The maintenance man helped walk the patient out of the room. Once all patients were out, a head count was done but she did not see Patient #1. A family member or friend was asking for Patient #1. He went inside the room with her despite being told not to follow. After searching the room, Patient #1 was not found, but the friend was saying the remote control was on fire. Staff B stated she left the room and went back to the nursing station, continuing to search for Patient #1; she opened the door to Patient #2's room and the smoke covered her face, and her eyebrows felt hot while she called out for Patient #1. Staff B stated upon leaving the room her face was black with smoke. The fire department was on the floor. The unit clerk stated a whistling sound was coming from the intercom. The fire department was in the room and pulled Patient #1 out his room. The ICU team was already on unit. Patient #1 had shallow breathing and was not responding verbally. Patient #1 was immediately intubated and moved to the ICU. During report to the nurse, Patient #1 woke up and became combative. Staff B returned to the step-down unit. The nurse manager insisted that she went to the ED.

Patient #2 is a 62-year-old admitted to the facility on 10/22/2024 for wheezing, shortness of breath and a cough. Patient #2 was diagnosed with status asthmaticus(acute severe asthma) and treated with systemic steroids (medications to treat inflammation), respiratory therapy around the clock and empiric antibiotic therapy.

An interview was conducted with Patient #2 and daughter on 11/07/2024 at 5:43 PM via telephone. Patient #2 was admitted to the 5th floor Stepdown Unit, on 10/22/2024 for respiratory failure and acute asthma and discharged on 11/03/2024. Patient #2 stated that while sitting in the hospital room in the recliner next to the window, Patient #1 came in the room and looked around. Patient #2 thought it was someone who worked in the hospital and acknowledged the person. Patient #1 did not speak but opened the closet door and removed two pillows and lit them with fire. Patient #2 started pressing the call button and got out of the recliner. As soon as Patient #2 started screaming for help, Patient #1 came toward her pushing her back into the recliner and holding her down trying to light the nasal cannula (a medical device that delivers extra oxygen through a tube and into the nose) on fire. Patient #2 started blowing at the flames. Patient #1 then grabbed her gown around the neck area and tried to burn her face with the flames. Patient #2 stated she does not know where she got the strength to fight Patient #1 but when she got free, she ran out of the room into the hallway and started screaming for help. Patient #2 stated Patient #1 came out of the room not wearing a shirt. Patient #2 stated someone placed her in a chair. Patient #2 was later taken to the ICU and remained there for additional respiratory treatments. Patient #2 reported seeing the psychiatrist and will be followed for the next month. As the interview progressed, Patient #2's voice started to quiver, and sound strained. Patient #2 stated she would be alright.

Record review revealed a psychiatric consult performed on 10/31/2024 at 6:18 PM revealed Patient #2 was immediately transferred to the ICU after the incident and endorsed shortness of breath and rapid breathing. Patient #2 was treated with respiratory treatments and supplemental oxygen via non-rebreather mask. An arterial blood gas revealed excellent oxygenation and hyperventilation, most likely due to the traumatic event. Diagnoses include acute chronic asthma exacerbation, respiratory alkalosis (a condition where the blood becomes too alkaline due to low carbon dioxide levels), secondary to hyperventilation(fast breathing) and anxiety, possible post-traumatic stress syndrome (PTSD) from traumatic events. The psychiatric consult note documented the service was called to evaluate Patient #2 from a psychiatric perspective after sustaining a significant traumatic event while hospitalized in the last 24 hours. Patient #2 reported being assaulted by another patient while in her room on 5th floor step-down unit. Patient #2 stated an individual entered her room uninvited, setting a pillow on fire with a cigarette lighter and trying to burn her face and set her on fire. Patient #2 stated that she fought this individual and was able to disconnect herself from her oxygen cannula and started running toward the nursing station looking for assistance and help. Patient #2 stated she is fearful she may be attacked again and is experiencing a startle response, particularly when medical staff are entering her room. Patient #2 is also afraid of having the curtains in her room closed and experienced palpitations, sweating and a sense of dread and apprehension.

Plan: Patient #2 may be discharged from a psychiatric perspective once medically cleared with follow up with psychiatrist/psychotherapist due to traumatic events to improve coping skills, assist in eliminating anxiety, flashbacks, sense of dread, and startle response. Start psychotropic regimen, as needed medication for insomnia, anxiety, and agitation.

Review of the Psychiatric Consultation Note for Patient #1 dated 10/31/2024 at 12:14 PM documented Reason for consultation: Homicidal Attempt. Chief complaint: Patient #1 reported being diagnosed with pancreatic cancer 7 days ago" and was in hospice care before being admitted to the hospital. Patient #1 reported trying to overdose on Xanax bars and must have taken 10 or 12. Stated, does not remember how he was brought to the hospital. Stated a male voice was telling him to overdose. Stated 3 overdose attempts in the past, the first time at age 14. Patient #1 stated does not recall anything about a fire and does not remember trying to set a fire or entering anybody's room.

Patient #1 is disorganized, incoherent and grossly dysfunctional. Patient #1 has poor reality testing and lack of judgement. Psychotic Process: Patient #1 exhibits psychotic signs and symptoms, has disorganized speech and impaired thought process. Patient #1 has proclivity (an inclination or predisposition toward a particular thing) for violence. Patient #1 is impulsive and explosive.