HospitalInspections.org

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Based on video recording, medical record (MR) review, document review, and interview, in one (1) of five (5) MRs, the facility failed to maintain a safe environment for patients.

This failure placed all patients at increased safety risk.

Findings:

- The facility failed to: (A) Conduct an effective contraband search of patients in the Psychiatric Emergency Department (ED); and (B) Timely implement their Cardiopulmonary Resuscitation (CPR) policy to provide immediate basic and advanced life support measures.

(See Tag A-0144)
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Based on observation, medical record (MR) review, document review and interview, in one (1) of five (5) MRs, the facility failed to: (A) Conduct an effective contraband search of patients in the Psychiatric Emergency Department (ED); and (B) Timely implement their Cardiopulmonary Resuscitation (CPR) policy to provide immediate basic and advanced life support measures.

These failures may have resulted in a serious adverse outcome for Patient #5.

Findings for (A):

Review of Patient #5's MR identified the following: This 41-year-old, with a history of polysubstance dependence (drug and alcohol addiction) was brought in by ambulance to the Emergency Department (ED) on 12/5/2022 at 3:00PM for a mental health evaluation. On presentation, Patient #5 was alert, oriented and hyperverbal. A Urine Toxicology Screen performed at 5:11PM resulted positive (+) for Amphetamines, Cocaine, Ethanol and PCP (Phenylcyclohexyl Piperidine, also known as angel dust), but was negative (-) for some Opioids [Fentanyl was not included in the facility's toxicology screening panel].

Patient #5 was triaged at 3:00PM and moved into the Psychiatric ED. A Registered Nurse (RN) note at 3:10PM stated that Patient #5 was screened for contraband using a Metal Detection Device (MDS). A Provider note at 6:00PM stated that Patient #5 was pronounced dead. As per a RN note at 6:20PM, a posthumous (after death) belongings search was performed. Contraband, including two (2) clear plastic baggies with white powdery substance and a razor blade wrapped in tissue, were found. The contraband items were sent to Security. Patient #5's belongings were not thoroughly searched prior to Patient #5's placement into the Psychiatric section of the ED.

Review of the facility policy and procedure (P&P) titled, "Search and Security Inspections," dated 9/2/2021, stated, " ...All items which may conceal property or contraband are subject to search by Public Safety Department (PSD) Officers and the search is to include use of a metal detection wand and a search of clothing and personal effects. When using the Scanner, scan all areas in a thorough and slow manner. Nursing will ascertain if the person has any clothing or personal belongings with them, and request that Security scan these items as well. It is the responsibility of every officer to conduct these MDS (Metal Detection Screenings) accurately and thoroughly."

Per interview of Staff J (Director of Quality/Behavioral Health) on 3/15/2023 at 12:40PM, Staff J confirmed that the MDS is performed on all patients before entry into the Behavioral Health areas, including the Psychiatric ED; and that patients are asked to empty their pockets, but their clothing is not necessarily searched, as patients can remain in their street clothes on the unit."

Review of the New York Patient Occurrence Reporting and Tracking System (NYPORT) Report and the facility's Corrective Action Plan prior to the start of this survey revealed that the facility re-educated most of their staff on the use of the metal detector wand for contraband searches. However, the facility failed to re-educate staff on performing thorough and effective search procedures of patients' belongings to include clothing for possible contraband.

This failure may have increased the risk that Patient #5 had access to contraband such as potential drugs or weapon while hospitalized.

These findings were confirmed with Staff I (Director of Quality) on 3/15/2023 at 2:40PM.

Findings for (B):

A Psychiatrist note dated 12/5/2022 at 11:11PM stated [retrospectively], "At 5:10PM, [Patient #5] was found unresponsive in the ED bathroom by staff and Code Blue [a response code indicating someone requires resuscitation or is in need of immediate medical attention] was called [initiated]."

Review of the Adult CPR Record Flowsheet dated 12/05/2022 at 5:16PM identified that a Code Blue was called for a witnessed cardiopulmonary arrest, and that CPR was initiated at 5:16PM. Patient #5's initial heart rhythm was asystole (flat line: an absence of electrical or mechanical activity of the heart). The patient was intubated, a urinary catheter and intravenous (IV) access were inserted, and medications including three (3) doses of Narcan (medication used for the treatment of a known or suspected opioid overdose) were administered.

Patient #5 did not respond to advance life support interventions. The Code Blue ended at 6:00PM, and Patient #5 was pronounced dead. A Urine Toxicology Screen obtained at 5:11 PM through the urinary catheter insertion during the code blue resulted positive (+) at 5:30PM for Amphetamines, Cocaine, Ethanol and PCP, but was negative (-) for some Opioids [Fentanyl was not included in the facility's toxicology screening panel].

Surveillance video recording dated 12/5/2022 from 3:00PM to 6:00PM, document review and interview of Staff B (Deputy Chief Nursing Officer), Staff D (Nurse Manager Psych ED), Staff I (Director of Quality and Performance Improvement) and Staff J (Director of Quality in Behavioral Health/BH) on 3/15/2023 at 11:15AM, identified the following:

- On 12/5/2022 at 4:59PM: Patient #5 entered a bathroom in the pediatric area of the Psych ED. A PCA (Patient Care Assistant) entered the bathroom after "hearing a thud," followed by three (3) Peace Officers [security officers recently called to the unit for a manpower code to assist in the administration of medication to Patient #5]. The Officers & PCA carried Patient #5, who appeared unresponsive, out of the bathroom. Patient #5 was placed onto a stretcher, in prone position, and remained motionless/unresponsive.

- 5:00PM - A RN approached Patient #5 and administered an intramuscular (IM) injection.

- 5:01PM - Patient #5 was turned onto his side with no apparent signs of agitation or resistance (patient's body appeared limp).

- 5:03PM - The RN attempted to obtain vital signs with an automatic sphygmomanometer (blood pressure) machine. Patient #5's Blood Pressure (BP) was 38/58 [normal range 110/70]; "Nurse thought the machine was broken," and no manual assessment for a radial or carotid pulse was performed.

- 5:05PM - A medical student arrived on scene.

- 5:06PM - The RN was viewed "fidgeting" with the pulse oximeter on the machine. The "nurse thought the oximeter was broken."

- 5:08PM - The medical student attempted a BP check with a second BP machine.

- 5:09PM - The medical student performed a manual pulse check.

- 5:10PM - A fingerstick (point of care testing of blood glucose/sugar) was performed.

- 5:11PM- A urinary catheter was inserted, and a urine specimen was collected.

- 5:11PM - Chest compressions were initiated
[There was a 12-minute delay in the initiation of CPR from the time the patient was found unresponsive on the floor].

- 5:16PM - A code blue response was started.

- 5:20PM - The first of three (3) Narcan administrations was given.

- 6:00PM - Patient #5 failed to regain a return of spontaneous circulation (ROSC); his electrocardiogram (heart rhythm) remained in asystole; the code blue was stopped; and Patient #5 was pronounced dead.

The facility P&P titled, "Code Blue," dated 7/29/2021, stated, "Anyone may initiate the calling of a code blue once cardiac arrest, pulmonary arrest, or a combination of the two is recognized ...in general, it should be started for all witnessed codes. If unsure, the patient should always receive the benefit of the doubt ..."

A review of the MR, Cardiac Arrest Flow Sheets, and the surveillance video recording identified that MR entries were not consistent with images and time stamps found on the video.

The facility failed to initiate timely CPR to Patient #5 as per their Cardiac Arrest/ Code Blue policy. Facility staff waited until 5:16PM (17 minutes, as per the cardiac arrest flow sheet), or until 5:11PM (12 minutes, as per the video recording) before initiating CPR, and delayed potentially life-saving interventions.

Review of the NYPORT Report and the facility's corrective actions prior to the start of this survey identified the facility re-educated most of their staff on "Identifying the Unresponsive Patient." However, the facility failed to re-educate staff on the urgency of Code Blue initiation.

During interview of Staff I (Director of Quality) on 3/15/2023 at 12:55PM, Staff I confirmed these findings.

An Immediate Jeopardy (IJ) situation was identified on 03/16/2023 at 5:57PM due to the facility's failures to effectively search for and confiscate contraband in a secured psychiatric area, and immediately initiate interventions to a patient in need of CPR, which may have resulted in a serious adverse outcome for Patient #5.

The facility's executive leadership and administrators were notified on 3/16/2023 at 5:57PM.

The facility provided an IJ Removal Plan to the SA on 3/17/2023 at 12:20AM.

The plan included the following:

- Hospital Executive Staff and Nursing leadership reviewed the following applicable policies and procedures to ensure effectiveness:
1) Code Blue Policy PC-050 and the Recognition/Response to the Unresponsive Patient was modified, and Staff Education Competency Performance Criteria was created by Clinical Education.
2) Security Search Policy EDNR-025 for Safety Procedures of Belongings in the Psychiatric ED was revised and Policy EDNR-008 Triage- Emergency Department was revised. Training and Staff Education Competency Performance Criteria was created by Clinical Education

- Leadership immediately provided in-service education to all Nursing RN's LPN's, PCA's, Security Officers and ancillary staff on revisions to these policies, with 100% of staff currently on shift in the hospital educated. Staff on incoming shifts were in-serviced prior to the start of their shift.

Interviews conducted on 3/17/2023 at 12:30AM with senior leadership confirmed that facility staff not in-serviced were not permitted to return to work until the in-service education was completed.

Surveyors conducted tours and interviews in the ED including the Psychiatric Area, Behavioral Health Inpatient Units, and the Medical Units to verify training of staff members on duty.

The IJ was lifted on 3/17/2023 at 2:50PM by onsite verification and validation of staff training and re-education to the reviewed and revised P&Ps. The IJ was abated when 463 of the 674 total house wide staff (69%) received training on the revised policies.

These figures included 100% of staff working in the ED, and 64% of staff working in the Inpatient Nursing Units. Attestations/signature pages were signed for all policy in-services.
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Based on observation, medical record (MR) review, document review and interview, the Quality Assurance Department staff failed to submit a Sentinel Event Root Cause Analysis (RCA) report to the Governing Body.

This failure placed all patients at increased risk of incomplete investigations, analyses and/or corrective actions for sentinel events.

Findings:

On 3/15/2023 at 10:30AM, the facility provided to surveyors a RCA and Corrective Actions Report for a Code 915 [the New York Patient Occurrence Reporting and Tracking System (NYPORTS) code for an unexpected adverse occurrence not directly related to the natural course of the patient's illness or underlying condition, resulting in death] for Patient #5. The investigation did not include the Executive Summary of the NYPORTs investigation.

Review of Patient #5's MR, video surveillance recording of the Code 915, Incident Report and staff interviews identified that the facility investigation contained gaps such as not identifying all possible root causes, not identifying all relative patient care areas, and not including corrective action plans for all identified issues.

Upon request, the facility could not furnish documented evidence that the RCA and corrective action plan had been reported to the Chief Executive Officer (CEO) or Governing Body.

Per interview of Staff I (Director of Quality) on 3/17/2023 at 10:20AM, Staff I confirmed
these findings.

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Based on observation, medical record (MR) review, document review, and interview, in one (1) of five (5) MRs, the facility failed to assess a patient found collapsed and unresponsive, and evaluate patient clinical criteria prior to medication administration, as per facility policies and procedures.

This failure placed all patients at increased risk of adverse events, including death.

Findings:

The facility failed to: (A) Assess the care needs of a patient found collapsed; and (B) Assess, monitor, and evaluate the patient's health status/conditioning prior to medication administration, in accordance with accepted standards of nursing practice and facility policy.

(See Tag A-0395)
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Based on observation, medical record (MR) review, document review and interview, in one (1) of five (5) MRs, the facility failed to: (A) Assess the care needs of a patient found collapsed; and (B) Assess a patient's health status/conditioning prior to medication administration, in accordance with accepted standards of nursing practice and facility policy.

These failures may have placed all patients at increased risk of serious adverse outcomes, including death.

Findings for (A):

Review of Patient #5's MR identified the following: This 41-year-old, with a history of polysubstance dependence (drug and alcohol addiction) was brought in by ambulance to the Emergency Department (ED) on 12/5/2022 at 3:00PM. Patient #5 was triaged and moved into the Psychiatric (Psych) ED at 3:10PM. A Psychiatric Evaluation note dated 12/5/2022 at 3:46PM stated that Patient #5 had no known history of mental illness or known medical history; was circumstantial and cooperative; admitted to drinking alcohol and taking cocaine; denied suicidal or homicidal ideation; and was not paranoid or hallucinating.

Security Surveillance Video Recording dated 12/5/2022, from 3:00PM to 6:00PM, and interviews of Staff B (Deputy Chief Nursing Officer), Staff D (Nurse Manager Psych ED), Staff I (Director of Quality and Performance Improvement) and Staff J (Director of Quality in Behavioral Health/BH) on 3/15/2023 at 11:15AM, identified the following:

- On 12/5/2022 at 4:59PM: Patient #5 entered a bathroom in the pediatric area of the Psych ED. A Patient Care Assistant (PCA) entered the bathroom after "hearing a thud," followed by three (3) Peace Officers [security officers recently called to the unit for a manpower code to assist in the administration of medication to Patient #5]. The Officers & PCA carried Patient #5, who appeared limp and unresponsive, out of the bathroom. Patient #5 was placed onto a stretcher, in prone position, and remained motionless. Patient #5 was not responsive to tactile stimuli at the time of discovery and when placed onto the stretcher. Registered Nurses (RNs) were observed in the general area of the Nurses' Station, a few feet opposite the bathroom. A RN did not investigate the fall or assess Patient #5 at the location where he was found collapsed on the bathroom floor.

Review of Patient #5's MR identified there was no documented assessment of Patient #5's level of consciousness, or signs and symptoms of injury immediately after he was found slumped on the bathroom floor.

During interview of Staff J (Director of Quality/Behavioral Health) on 3/15/2023 at 12:55PM, Staff J confirmed these findings.

Review of the facility policy and procedure (P&P) titled, "Assessment and Reassessment," dated 7/28/2021 stated, " ... Patients are assessed to determine their needs by collection of data through observation, interview, measurements...Decisions are made and executed regarding delivery of care on the basis of these assessments...Patient reassessments shall occur on an ongoing basis to determine the response to, and the effectiveness of the care and interventions."

This failure to assess Patient #5's safety needs, including level of consciousness after a fall, may have impeded the delivery of clinical care and interventions.

Findings for (B):

Review of Patient #5's MR identified a Psychiatrist's note dated 12/5/2022 at 11:11PM, which stated (retrospectively) that at 4:34PM, Patient #5 was increasingly agitated and refused oral medication. The psychiatrist prescribed Haldol (antipsychotic medication) 5 milligrams concurrently with Benadryl (antihistamine medication) 50 milligrams, by Intramuscular (IM) injection stat/PRN [immediately and on an as needed basis determined by the patient's signs and symptoms of agitation]. The dose was indicated for extreme agitation at 4:34PM.

Patient #5's Medication Administration Record (MAR) identified the RN administered the Haldol/Benadryl injection to Patient #5 on 12/5/2022 at 5:00PM.

Security Surveillance Video Recording, dated 12/5/2022 from 3:00PM to 6:00PM, identified that at 5:00PM, the RN approached Patient #5, who had collapsed at 4:59PM, and immediately administered an injection [later confirmed as Haldol 5mg/Benadryl 50mg]. At 5:01PM, Patient #5 was turned onto his side, appeared limp, and had no apparent signs of agitation.

The facility P&P titled, "Administration and Prescribing of Medication," dated 6/3/2021, stated "Before administrating a medication, the healthcare professional administering the medication...Verifies that there is no contraindication for administering the medication, verifies that the medication is being administered at the proper time...Monitors the patient before medication administration to assure that the medication may be given according to parameters indicated..."

During interview of Staff I (Director of Quality) on 3/15/2023 at 12:55PM, Staff I confirmed these findings.

The facility failed to ensure nursing staff:
- Conducted a patient assessment prior to medication administration, as per facility policy.
- Assessed the five rights (right patient, right drug/medication, right route, right time, right dose) of medication safety prior to administration as per accepted standards of nursing practice.
- Assessed and evaluated whether prescribed medications met all patient parameters and clinical criteria for administration prior to administration.
- Implemented the facility's P&P for patient assessment and reassessment when a patient was discovered collapsed and unresponsive.
- Monitored patients prior to the administration of a prn (as needed) medication prescribed for agitation when there were no indications of agitation.

An Immediate Jeopardy (IJ) situation was identified on 3/16/2023 at 5:57PM, due to the facility's failure to perform patient assessment and reassessment during nursing care delivery.

The facility's executive leadership and administrators were notified on 3/16/2023 at 5:57PM.

The facility provided an IJ Removal Plan to the state agency (SA) on 3/17/2023 at 12:20AM.

The plan included the following:

Hospital Executive Staff and Nursing Leadership reviewed the following applicable policies and procedures to ensure effectiveness:

1) Patient Assessment/Reassessment Policy NR-039 was reviewed and revised
2) Medication Administration Policy NR-036 was revised and Staff Education Competency Performance Criteria was created by Clinical Education.

- Leadership immediately provided in-service education to all Nursing RN's, LPN's, and PCA's on revisions to these policies, with 100% staff currently on shift in the hospital educated. Staff on incoming shifts were in-serviced prior to the start of their shift.

Interviews conducted on 3/17/2023 at 12:30AM with senior leadership confirmed that facility staff not in-serviced were not permitted to return to work until the in-service education was completed.

Surveyors conducted tours and interviews in the ED including the Psychiatric Are, Behavioral Health Inpatient Units, and the Medical Units to verify training of staff members on duty.

The IJ was lifted on 3/17/2023 at 2:50PM by onsite verification and validation of staff training and re-education to the reviewed and revised P&Ps. The IJ was abated when 463 of the 674 total house wide staff (69%) received training on the revised policies.

These figures included 100% Staff working in the ED, and 64% of staff working in the Inpatient Nursing Units. Attestations/signature pages were signed for all policy in-services.
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Based on medical record (MR) review, document review and interview, in (1) of five (5) MRs, the Emergency Department (ED) staff did not ensure patients presenting for psychiatric evaluations received medical evaluations, as per facility policy.

This failure to conduct a physical system review for a Psychiatric ED patient resulted in a lack of Main (medical) ED consultation and potential coordination of patient care, treatment and disposition.

Findings:

The facility policy and procedure (P&P) titled, "Medical Evaluation of Psychiatric Patients and Psychiatric Evaluation of Medical Patients," dated 9/29/2021 stated, "Patients presenting to the ED who have emergent or urgent medical conditions will be first evaluated and stabilized in the Main ED, regardless of their psychiatric history...patients with known psychiatric history who are brought to the ED for psychiatric problems will be evaluated in the Psychiatric ED with consultation from Main ED as needed. Patients who present to the ED for suspected psychiatric condition but have no prior psychiatric history shall be evaluated in the Main ED. A psychiatric ED consult may be requested by the Main ED provider when patient is deemed medically stable."

Review of Patient #5's MR identified the following: This 41-year-old, with a history of polysubstance dependence (drug and alcohol addiction) was brought in by ambulance to the Emergency Department (ED) on 12/5/2022 at 3:00PM for a mental health evaluation. Patient #5 was triaged and moved into the Psychiatric (Psych) ED at 3:10PM. A Psychiatric Evaluation note dated 12/5/2022 at 3:46PM stated that Patient #5 had no known history of mental illness or known medical history; admitted to drinking alcohol and taking cocaine; denied suicidal or homicidal ideation; and was not paranoid or hallucinating.

Patient #5 collapsed at 4:59PM and subsequently died at 6:00PM from unknown causes. A Urine Toxicology Screen performed at 5:11PM, during Patient #5's emergent resuscitation effort, resulted positive (+) for Amphetamines, Cocaine, Ethanol and PCP (Phenylcyclohexyl Piperidine, also known as angel dust), but was negative (-) for some Opioids (Fentanyl was not included in the facility's toxicology panel). A post-humous (after death) Belongings Search for Patient #5 found two (2) clear plastic baggies with a white powdery substance [at the time of this investigation, it was unknown what the powdery substance was].

There was no documented evidence the Psychiatric Evaluation was performed in consultation with the Main ED, as per facility policy. Patient #5's Psychiatric Evaluation documented a mental health evaluation, but no physical Review of Systems (ROS - an inventory of the body systems obtained through a series of questions to identify signs/symptoms which the patient may be experiencing) or physical examination with or by the Main ED. No physician order for a Urine Toxicology Screen was found upon Patient #5's initial evaluation.

Patient #5's cause of death was unknown at time of this investigation [autopsy and toxicology reports were requested from the medical examiner and were pending at the time of this investigation].

These findings were acknowledged by Staff I (Director of Quality) on 3/15/2023 at 12:20PM.
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