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Based on document review and interview, it was determined that the Hospital failed to ensure that the patient's right to safe care was protected. This places all current and future suicidal patients at potential risk for serious harm. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to appropriately monitor the patient, to ensure care was provided in a safe setting. See deficiency at A-144.

The immediate jeopardy began on 4/10/20, due to the Hospital's failure to ensure care in a safe setting for a patient with suicidal ideation, and resulted in the patient ability to commit suicide in a locked bathroom while being monitored by a care companion; and was identified on 5/1/20 at 42 CFR 482.13, Patient Rights. The IJ was announced at 5/1/20 at 4:10 PM, during a meeting with Vice President Patient Care Services anf Chief Nursing Officer, Risk Manager, Director of Clinical Excellence, Director of Patient Care Service, Director of Quality and Chief Medical Officer. The IJ was not removed by the survey exit date of 5/4/20.

Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) sampled patient admitted to 6 East Unit with suicidal ideation, the Hospital failed to appropriately monitor the patient, to ensure care was provided in a safe setting. This potentially affects all patients admitted to the unit requiring care companion (staff watching a patient to prevent injury).

Findings include:

1. On 4/29/2020, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 19 year old admitted to the Hospital with a diagnosis of COVID-19 (virus) and suicidal ideation. The clinical record included:

- The fire department ambulance run sheet, dated 4/5/2020 at 1:02 AM, included, "...crew was called for (Pt. #1)... Upon arrival at (the) scene, crew found (Pt. #1) with PD (police detective) and was handcuffed... PD and assisted living staff states that (Pt. #1) walked out of facility and walked into traffic ... Crew made the call to (the Hospital) ..."

-The ED physician progress note, dated 4/5/2020 at 1:23 AM, included, " ... (Pt. #1) ... accompanied by ...EMS (emergency medical services) ... From: Group Home... with (past medical history) of bipolar disorder and asthma... in restraints for (psychiatric evaluation). (Pt. #1) states (suicidal ideation) with plan, states she (Pt. #1) wants to walk into traffic ... Discussion with hospital management and psychiatry pending, might require medical admission with 1:1 sitter ..."

- The ED physician's order sheet, dated 4/5/2020 at 4:46 PM, included, " ...Place in observation ... Admit to inpatient: Medical Surgical ... Admitting MD (MD #3). Diagnosis: Suicidal ideation ... Consultant: (MD #1) Reason (suicidal ideation) ... Additional orders: 1:1 sitter ..."

- The nursing admission note, dated 4/6/2020 at 9:31 AM, included, " ... Sitter at bedside for suicidal ideation.". On 4/7/2020 at 12:54 PM, the nursing progress note included, "... Patient is ambulatory, continent of bowel and bladder ... One to one sitter in place for suicidal ideation ..."

- The nursing progress note, dated 4/10/2020 at 3:23 PM, included, "(Pt. #1) was very agitated this afternoon. She (Pt. #1) had her clothes on and was threatening to leave... (Pt. #1) continued to verbally lash out at staff and yell, 'I want to go home.' (Pt. #1) locked herself in the bathroom. Management and security were notified. Patient eventually came out in the bathroom ... (Physician) notified ... attempted to talk with the patient but she continued to shout out. 'They are all laughing at me! Nobody is helping me!''

- The nursing progress note, dated 4/10/2020 at 6:34 PM, included, "Received a call from the patient's sitter ... Patient had been crying out. She locked herself inside the bathroom. I knocked but no response. I was not made aware of how long the patient had been inside the bathroom when I arrived in the room. I managed to force the door open and found the patient on the floor, unresponsive and not breathing, with sock wrapped tightly around her neck. Code 33 (emergency code) was called at (6:00 PM). The sock was cut off and CPR (cardiopulmonary resuscitation) initiated ..."

- The code record sheet (medical emergency) for Pt. #1, dated 4/10/2020, indicated that at 6:03 PM, Pt. #1 was found on the floor in room entrance with no pulse and no heart rhythm. The record indicated that cardiopulmonary resuscitation efforts that included chest compression, airway management/intubation and intravenous administration were provided. ...Pt. #1 was transferred to the intensive care unit (ICU).

- The physician's progress note, dated 4/10/2020 at 7:03 PM, included, " ... This is an ICU evaluation ... (Pt. #1) apparently had a sitter with her because of some psychiatric problems. (Pt. #1) went to the bathroom, apparently tried to hang herself with a sock. The nursing staff found (Pt. #1)... unresponsive ... had no pulse ..."

- The discharge summary for Pt. #1, dated 4/11/2020 at 9:14 AM, included, " ... Hospital Course: (Pt. #1) was brought in for (psychiatric) evaluation for suspected suicidal ideation ... During hospitalization, (Pt. #1) threatened to walk out and hence sitter was arranged. On 4/10/20 evening approximately 5:45 PM, patient locked herself in the bathroom and the door was tried open, patient was found on the floor with sock tightly wrapped around her neck, was not breathing and did not had a pulse ... (Pt. #1) intubated and transferred to ICU ...passed away at 1:48 AM on 4/11/2020."

2. On 4/30/2020 at approximately 3:00 PM, the Hospital's policy and procedure titled, "Patient Rights and Responsibilities" was reviewed and included, " ... Purpose: (The Hospital) has an obligation to respect the rights of its patients ... Patient Rights ... 2. Patients have the right to ... t. Receive care in a safe setting ..."

3. On 4/30/2020 at approximately 3:30 PM, the Hospital's policy and procedure titled, "Suicide ... Precautions" included, "Purpose: (The Hospital) is committed to providing a safe environment for patients ... Definitions: Suicide or Homicidal Ideation Precautions ... are implemented for patients assessed as being potentially harmful to him/her-self or others. Patients who are actively suicidal are those that have made a recent suicide attempt, are expressing thoughts of suicide, or present psychotic behavior which may inadvertently cause harm to him/her-self... 3. Non-behavioral Health Unit: All inpatient medical units ... Policy ... a. One to One (1:1) Observation. The individual is considered actively suicidal ... A dedicated staff member is assigned to remain within arm's reach of the patient at all times ... 11 ... There should be no disruption of the observation and documentation process ... the Safety Attendant or qualitied gender appropriate personnel should remain under constant observation whenever possible including toileting ..."

4. On 4/30/2020 at approximately 4:00 PM, the Care Companion (CC) Guidelines (undated) was reviewed and included, "Purpose - the purpose of a Care Companion is to carefully watch a patient, so they do not ... injure themselves. These guidelines are to help guide the CC to know what to look for and how to react to patients as they are being observed. 1. The CC stays in close proximity of the patient at all times. Ideally this means line of sight of the patient. 2. The CC should give their entire attention to the patient. A. Do not leave the patient unattended for any reason ... 3. Patients must be watched carefully to prevent them from ... injury ..."

5. On 4/30/2020 at approximately 10:30 AM, a telephone interview was conducted with E #6 (Registered Nurse). E #6 stated, "I was taking care of (Pt. #1) ... The care companion was sitting outside (Pt. #1's) room because patient had Covid-19 ...The care companion told me that (Pt. #1) locked herself inside the bathroom ... crying ... I knocked on the door ... Did not hear anything, called the security immediately ... I was able to open the door ... (Pt. #1) was on the floor, unresponsive ... not breathing ... (Pt. #1) had a sock wrapped around her neck ... I immediately called code 33 (medical emergency) ... I had a scissor with me so I cut the sock, then performed cpr (cardiopulmonary resuscitation) ... She (Pt. #1) received advanced cardiac life sustaining measures ... (Pt. #1) regained pulse and was intubated (breathing tube) ... (Pt. #1) was transferred to the intensive care unit ..."

6. On 4/30/2020 at approximately 1:35 PM, a telephone interview was conducted with E #12 (Care Companion). E #12 stated, "I was (Pt. #1's) care companion ... I was only assigned for (Pt. #1) ... I worked from 7:00 AM to 7:00 PM ... They told me (Pt. #1) was not suicidal but I was the care companion to make sure that she would not leave the unit ... (She) was angry about not being able to leave the unit ... She (Pt. #1) would go to the bathroom ... I was sitting next to the door ... the door was locked when (Pt. 1) was in the bathroom."

7. On 5/1/2020 at approximately 10:00 AM and at 1:00 PM, interviews were conducted with E #13 (Director of Quality). E #13 stated that a root cause analysis (RCA) was conducted in response to this event. E #13 agreed that the discussion, analysis and identification in the root cause analysis included that care companion duties, training and documentation were identified as one of the issues for Pt. #1. However, E #13 stated that the plan for improvement had not been implemented.

Based on document review and interview, it was determined that for one (Pt. #10) of two clinical records reviewed for restraints, the Hospital failed to ensure the discontinuation of restraints was documented on the restraint flow sheet, as required.

Findings include:

1. On 4/30/20, the Hospital's policy titled, "Restraints and Seclusion" (reviewed 12/27/19) was reviewed. The policy included, "Discontinuation of Restraint: The attending physician or RN [Registered Nurse] should discontinue restraints at the earliest possible time ...Discontinuation of restraints should be documented in the release note on the RN (Registered Nurse) seclusion or Restraint Note Form ..."

2. On 04/30/2020 at approximately 8:45 AM, the clinical record of Pt. #10 was reviewed. Pt. #10 was admitted to the Telemetry Unit on 03/31/2020 with a primary diagnosis of Diabetes Mellitus and COVID positive. Pt. #10's clinical record included the following:

- Physician's order, dated 04/11/2020 at 6:00 PM, "Assess Restraints Medical-Surgical Vest/Jacket Soft Extremity every 2 hours once for 1 day."

- Nursing notes, dated 04/11/2020 at 6:00 PM, "Initiated the restraints flow sheet, restraints alternatives implemented."

- Pt. #10's restraint flow sheet documentation lacked the date and time when the posey vest and soft wrist restraints were discontinued.

3. On 04/30/2020 at approximately 9:00 AM, the Risk Manager (E #4) was interviewed. E #4 stated, "They should have documented the date and time when restraints were discontinued. I do not see any notes in the chart when the restraints were discontinued. We want to respect patient rights and make sure the patient was on restraints for less duration."

4. On 04/30/2020 at approximately 10:30 AM, the Nursing Manager (E #5) was interviewed. E #5 stated, "The nurse who discontinued the restraints should have documented the date and time of the discontinuation of restraints."

Based on document review, observation and interview, it was determined that the Hospital failed to ensure that nursing services were furnished or supervised by a Registered Nurse, by failing to ensure a Registered Nurse (Charge Nurse) assigned the care of each patient to nursing personnel. Subsequently, the nurse failed to ensure that a nursing admission assessment and nursing care were performed.

As a result, it was determined that the Condition of Participation for Nursing Services, CFR 482.23, was not in compliance.

Findings include:

1. The Hospital failed to perform a nursing assessment to a newly admitted patient. See deficiency at A-395.

2. The Hospital failed assign nursing personnel to the care of a newly admitted patient. See deficiency at A-397.

An immediate jeopardy began on 04/11/2020, due to the Hospital's failure to assign a patient, that was transported from the Emergency Department to an inpatient unit, the Nursing staff was not aware that the patient was on the unit, the patient was not asssigned to appropriate nursing care. Subsequently the patient died while on the inpatient unit; and was identified on 5/4/20 at 42 CFR 482.23, Nursing Services. The IJ was identified and announced on 05/04/2020 at 4:10 PM, during a meeting with the Director of Quality, the Vice President of Patient Care Service/Chief Nursing Officer and the Risk Manager. The IJ was not removed by the survey exit date of 05/04/2020.

A. Based on document review and interview, it was determined that for 1 of 10 (Pt. #2) patient records reviewed for patient care, the Hospital failed to ensure that a Registered Nurse assessed and evaluated the nursing care of each patient. This failure resulted in Pt. #2 not receiving nursing care and subsequently dying without having a nurse admission evaluation or assessment while on the inpatient unit.

Findings include:

1. On 4/29/2020, the Hospital's policy titled, "Charting-Daily Patient Assessment-Nursing Plan of Care" reviewed by the Hospital on 2/8/2019, was reviewed. The policy included, "Each shift - an assessment should occur in the HIS [Health Information System]. The RN [Registered Nurse] performs the initial assessment at the time of admission utilizing the Admission Database."

2. On 4/29/2020, Pt. #2's clinical record was reviewed. Pt. #2 was admitted on 4/11/2020 with a diagnosis pneumonia and rule out COVID-19.

-The Emergency Department Physician progress note dated 4/11/2020 at 3:54 PM, included, "Primary Complaint Details ...Hx [history] of dementia and schizophrenia presents to the ED [Emergency Department] via EMS [Emergency Medical Service] c/o [complaint of] worsening dyspnea [difficulty breathing] onset 1 week ago ...ED course ...Pt [Pt. #2] to be admitted to CTU [cardiac telemetry unit] for eval [evaluation] of pneumonia ...Diagnostic impression pneumonia - doing well on NRB [non-rebreather mask], saturating 98%, no labored breathing, does not require intubation [life support breathing tube] at this time - admit for COVID treatment, oxygen therapy, monitoring."

-The ED Physician order dated 4/11/2020 at 5:01 PM, included, "Admission order full admit status telemetry 2 midnight stay or more full CTU/E6 bed pneumonia, r/o [rule out] COVID from ER [Emergency Room]."

-The ED nursing disposition note dated 4/11/2020 at 6:53 PM, included, "RN [Registered Nurse] report given by [E #8/ED RN] ...level of care- telemetry, admission accepting Physician -Hospitalist, Internal Medicine ...Patient departure time 4/11/2020 at 6:49 PM."

-The Nursing progress note written by E #7/East 6 Charge Nurse, dated 4/12/20/20 at 12:28 AM, included, "Patient [Pt. #2] found unresponsive at 0027 [12:27AM]. Code 33 [Cardiopulmonary Arrest] called. CPR [Cardiopulmonary Resuscitation] started."

-Pt #2's clinical record lacked documentation of an admission evaluation or a nursing assessment from the time that Pt. #2 left the ED for inpatient admission at 6:49 PM until Pt. #2 was found unresponsive at 12:27 AM on East 6.

3. On 4/30/2020 at 9:04 AM, an interview was conducted with an East 6 Charge Nurse (E #7). E #7 stated that she was the charge nurse on the East 6 Unit on 4/11/2020 from 7:00 PM - 7:00 AM. E #7 stated that on 4/12/2020 at approximately 12:00 AM, she received a call from the Admissions department inquiring about the location of Pt. #2. E #7 stated that Pt. #2 was not admitted to the patient census on East 6 and she was not informed by that previous charge nurse that Pt. #2 was on the unit. E #7 stated that Pt. #2 would have received nursing care if she had known that Pt. #2 was on the nursing unit.

4. On 4/30/2020 at 10:30 AM, an interview was conducted with the East 6 Patient Care Nurse Manager (E #5). E #5 stated that the assigned nurse should go into the room of the new admission to evaluate the patient and review physician orders as soon as the patient arrives on the unit.





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B. Based on document review and interview, it was determined that for 1 of 1 patient's (Pt. #1) clinical record reviewed for medication administration, the Hospital failed to conduct a nursing reassessment, to ensure nursing care was evaluated.

Findings include:

1. On 5/1/2020 at approximately 9:30 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 19 year old female admitted to the Hospital with a diagnosis of COVID-19 (type of flu) and suicidal ideation. The clinical record indicated that Xanax 0.25 mg (as needed medication for anxiety) was administered on 4/10/2020 at 3:08 AM and on 4/10/2020 at 4:44 PM. However, the clinical record lacked documentation that a nursing reassessment was conducted.

2. On 5/1/2020 at approximately 10:30 AM, the Hospital's policy titled, "Medication Administration" (reviewed by the Hospital on 7/1/2018) was reviewed and included, "... F. Medication Administration. 1. The RN (registered nurse) who opens or prepares the medication should administer and document the medication administration in the medical record... 4. The RN administering the medication should... n. Evaluate patient response to medication based on medication indication..." The policy did not include a time-frame when a reassessment is conducted.

3. On 5/1/2020 at 9:50 AM, an interview was conducted with E #5 (Nurse Manager). E #5 stated that a reassessment should be conducted within an hour after an as needed medication has been administered. E #5 stated, "It needs to be re-assesed to see if the anxiety has decreased..." E #5 added that she could not find documentation that nursing reassessments were conducted when Pt. #1 received an as needed medication on 4/10/2020 at 3:08 AM and on 4/10/2020 at 4:44 PM.

Based on document review and interview, it was determined that for 1 of 10 (Pt. #2) patient records reviewed for patient care assignments, the Hospital failed to ensure that a Registered Nurse (Charge Nurse) assigned the care of each patient to nursing personnel. This failure resulted in Pt. #2 not being assigned a Nurse after being transferred from the Emergency Department to an inpatient unit. Subsequently Pt. #2 died while on the inpatient unit.

Findings include:

1. On 4/29/2020, Pt. #2's clinical record was reviewed. Pt. #2 was admitted on 4/11/2020 with a diagnosis pneumonia and rule out COVID-19.

-The Physician's order dated 4/11/2020 at 5:01 PM, included, "Admission order full admit status telemetry 2 midnight stay or more, full CTU [cardiac telemetry]/E6 bed pneumonia, r/o [rule out] COVID from ER [Emergency Room]."

-The ED nursing disposition note dated 4/11/2020 at 6:53 PM, included, "Upon arrival to ED pt. (Pt. #2) O2 (oxygen saturation) was 72% on room air. Pt. placed on NRB [non-re-breather] mask at 15L and O2 sats [saturation] increased to mid-90%'s. RN [Registered Nurse] report given by [E #8/ED RN] ...level of care- telemetry, admission accepting Physician -Hospitalist, Internal Medicine ...Patient departure time 4/11/2020 at 6:49 PM."

-The inpatient discharge summary dated 4/12/2020 at 1:03 PM, included, " ...Pt [Pt. #2] during the night was found to be unresponsive, CODE 33 (medical emergency) was called, high quality CPR (cardiopulmonary resusitation) was given per ACLS [Advanced Cardiac Life Support] protocol. Unfortunately pt [Pt. #2] was unable to be successfully revived despite ACLS protocol and was pronounced [dead] at 2:15 AM."

2. On 4/29/2020, the nurse staffing assignment sheet for the East 6 unit on 4/11/2020 from 7:00 PM - 7:00 AM was reviewed. The assignment sheet did not include Pt. #2's room number or if a nurse was assigned to his care.

3. On 4/29/2020, the East 6 unit patient census for 4/11/2020 and 4/12/2020 was reviewed. Pt. #2 was not included on the East 6 patient census for 4/11/2020 or 4/12/2020.

4. On 4/30/2020 at 9:04 AM, an interview was conducted with an East 6 Charge Nurse (E #7). E #7 stated that she was the charge nurse on the East 6 Unit on 4/11/2020 from 7:00 PM - 7:00 AM. E #7 stated that the during the handoff/change of shift report the previous shift charge nurse (E #10) stated that she had already assigned all new admissions. E #7 stated that when there is a new admission the charge nurse will receive a pager notification from the admitting department of the new admission, and the charge nurse must assign the patient to a RN. E #7 stated that she did not receive a pager notification of Pt. #2's admission and that Pt. #2 was not assigned to a nurse by the previous charge nurse. E #7 stated that shortly after 12:00 AM on 4/12/2020, she found (Pt. #2) in his room curled up on the floor between the back of the bed and the nightstand, unresponsive and cold to the touch. E #7 stated that (Pt. #2's) side rails were up, the IV was still connected, and (Pt. #2) had on a non-rebreather mask that was not connected to an oxygen source.

5. On 4/30/2020 at 10:54 AM, an interview was conducted with an East 6 Unit Charge Nurse (E #10). E#10 stated that she was the East 6 Charge Nurse on 4/11/2020 from 7:00 AM - 7:00 PM. E #10 stated she received pager notification on 4/11/2020 at approximately 6:35 PM that a new admission (Pt. #2) was assigned to the East 6 Unit. E#10 stated that she did not assign Pt. #2 a nurse because the pager notification came just before the change of shift. E #10 stated that if a pager notification comes just before the shift change after 6:30 AM or 6:30 PM the oncoming charge nurse is responsible for assigning the new admission. E #10 stated that she cleared (deleted) the pager notification for the oncoming shift and verbally endorsed to the oncoming charge nurse that a new admission was expected.

6. On 4/30/2020 at 10:30 AM, an interview was conducted with the East 6 Patient Care Nurse Manager (E #5). E #5 stated that it is the responsibility of the charge nurse that receives an admission pager notification to assign the new admission to a nurse. E#5 stated that the nursing patient assignments are made by the previous shifts charge nurse for the oncoming nursing staff.