HospitalInspections.org

Based on interview and document review, the governing body failed to have systems that were effectively established and implemented to ensure care was provided in a safe manner when a patient with psychiatric needs was placed in the general population on a medical unit under police supervision. These deficient practices had the potential to affect all patients.

The findings include:

The hospital was found out of compliance with the Condition of Participation of Governing Body 42 CFR 482.12.

Based on interview and document review, the governing body failed to ensure that the medical staff met requirements for the quality of care to patients, for 1 of 41 patients reviewed (P1), who was assessed and identified as suicidal, violent, and dangerous. The patient made multiple comments about killing himself but the patient was admitted to a medical unit with the general patient population on an involuntary 72 hour psychiatric hold with a 1:1 sitter and police officer supervision. The patient was never evaluated by a psychiatrist, and was not monitored by the department of psychiatry. Less than three days later the patient obtained the police officer's firearm, and shot and killed the police officer. The patient also died after he was tasered. (0044)

Based on interview and document review the hospital failed to ensure a patient with psychiatric problems who was admitted to the hospital received the continued services from a clinical psychologist for 1 of 41 patients (P1) reviewed. P1 was on a medical unit, was actively suicidal, on an involuntary 72-hour psychiatric commitment hold and did not received continued care for a psychiatric problem during the course of his hospitalization. (A-0068)

The hospital was found not to be in compliance with the Condition of Participation of Patient Rights with at 42 CFR 482.13 related to placing a patient (P1) identified as homicidal, suicidal, violent and dangerous on a medical unit in the general population after being placed on an involuntary psychiatric hold. The patient was not evaluated by a psychiatrist and was not monitored by the department of psychiatry during the entire course of admission. (A-0115 and A-0144)

The hospital was found out of compliance with the Condition of Participation of Quality Assessment and Performance Improvement Program at 42 CFR 428.21 related to the failure to ensure the hospital had a quality assessment and performance improvement program that reflected the complexity of the hospital's patient care services for patients who had active suicidal and homicidal ideation and were roomed on non-mental health units. This had the potential to affect all patients who receive services on the hospital's medical units. (A-0263)

The hospital was found not to be in compliance with the Condition of Participation of Medical Staff at 42 CFR 482.22 when a patient identified as suicidal and homicidal on an involuntary 72 hour psychiatric hold was never evaluated by a psychiatrist, and was not monitored by the department of psychiatry. The patient obtained the police officer's firearm, and shot and killed the police officer. The patient also died after he was tasered. (A-0347)

Based on interview and document review, the governing body failed to ensure that the medical staff met requirements for the quality of care to patients, for 1 of 41 patients reviewed (P1), who was assessed and identified as suicidal, violent, and dangerous. The patient made multiple comments about killing himself but the patient was admitted to a medical unit with the general patient population on an involuntary 72 hour psychiatric hold with a 1:1 sitter and police officer supervision. The patient was never evaluated by a psychiatrist, and was not monitored by the department of psychiatry. The patient obtained the police officer's firearm, and shot and killed the police officer. The patient also died after he was tasered.

Findings include:
The hospital's Medical Staff Bylaws, Policies and Rules and Regulations of the Hospital, not dated, indicated:
o The duties of the Department Chairperson is responsible for all clinically related activities of the department and integrating the department into the primary functions of the hospital by developing and implementing policies and procedures that guide and support the provision of care, treatment and services, continuing assessment and improvement of the quality of care, treatment, and services provided.
o Performance improvement functions of the Medical Staff included the measurement, assessment and improvement of medical assessment and treatment of patients, and, participates in the care, treatment, and services with other practitioners and hospital personnel.

Rules and Regulations of the Medical Staff of the Hospital, not dated, indicated:
o For the protection of patients, staff, and the hospital, certain principles are to be met in the care of potentially suicidal patients: suicidal patients are to be admitted to the psychiatric unit, if the unit is full, the suicidal patient should be referred to other institutions that would be available and not admit the patient to other floors of the hospital. However, in the judgement of the physician, if a serious medical problem exist of a higher priority than the underlying psychiatric problem, the patient is to be admitted to the necessary nursing unit with one-to-one nursing care. The admitting practitioner is responsible for giving information that may be necessary to protect the patient and others from self-harm whenever the patient might be a source of danger.
o Consult is a service provided by a physician whose opinion or advice regarding an evaluation and/or management of a specific problem is requested by another physician. Urgent consults will be called to the responding physician by the requesting physician; non-urgent consults will entered and handled by the contact center. Call groups can exercise the right to have consultation requests more stringent than the outline of urgent or non-urgent.
o Transfer of partial care is a transfer of a portion of a patient's care to another Medical Staff member who will become responsible for that portion of the patient's care.
o Judgement as to the serious nature of the illness, and the question of doubt as to the diagnosis and treatment rests with the practitioner responsible for the care of the patient, and is the duty of the organized Medical Staff through Department Chairpersons and Executive Committee to see that those clinic privileges do not fail in the matter of ordering consultation.

The Physician Assistant-Provider job description for the Behavioral Health Clinic and Adult Psychiatry dated April 1, 2014 indicated physician assistants assess, plan, evaluate, implement and coordinate care of the adult psychiatric patients with collaboration of the adult psychiatrist and is supervised by adult psychiatrist, but is responsible to the Care Center Medical Director of Behavioral Health Services.

The hospital's policy and procedure titled Hold Policy for Voluntary and Involuntary Admissions, 72-Hour Holds, dated 11/13 indicated 72-hour holds are initial steps in the Minnesota Commitment and Treatment Act and only a physician may order a 72-hour hold. The patient must be evaluated by a physician and the physician's initial assessment and statement in support of emergency admission must fill out Part B of the 72-hour hold form. If a physician other than a psychiatrist places a patient on the 72-hour hold a psychiatric consult is recommended within 24 hours. A physician must evaluate the continuation of the 72-hold within 48 hours of the admission. Only a physician may discontinue a hold order.

A review of the implemented 72 hour holds revealed 18 of 264 patients since 07/02/15 were placed on a 72 hour hold by a LIP.

P1's emergency department (ED) record indicated that P1 was air-lifted to the hospital's ED on 10/12/15 at 11:55 a.m., with an intentional prescription drug overdose. P1 was admitted to the ICU on 10/12/15 at 2:02 p.m. The ICU progress notes, dated 10/12/15, indicated that P1 was intubated and receiving critical care related to the drug overdose.
The ICU social service progress notes, dated 10/13/15 at 10:21 a.m., indicated that P1 had 13 warrants for his arrest and had a history of violence. Hospital staff were pursuing a plan to have law enforcement present at P1's bedside, whenever P1 was extubated. (The patient was not under law enforcement custody during the course of his hospital admission.) The ICU progress notes indicated that P1 received critical care for the drug overdose through 10/15/15. P1 was extubated on 10/15/15 at 10:58 a.m. The respiratory therapy progress notes at 10:58 a.m. indicated that P1 was actively trying to kill himself. P1 attempted to put pillows over his face and asked the therapist to do the same. The pillows were removed from P1's bed.The ICU nursing progress notes, dated 10/15/15 at 11:39 a.m., indicated that P1 was continually asking the nurse to kill him. P1 was holding his breath so he "will die." P1 asked the nurse to set him on fire.The ICU social service progress notes on 10/15/15 at 11:49 a.m., indicated that P1 told the social worker that he wanted to die, "kill me." A psychiatric consultation completed by Physician Assistant (PA)/K, dated 10/15/15 at 1:30 p.m., indicated that Physician Assistant (PA)/K evaluated P1 in the ICU. PA/K noted that P1 was alert and demonstrated anti-social personality traits. P1 verbalized that he was going to kill himself and that he wanted to kill his family member for calling 911 and saving him. P1 told PA/K that he had one other previous suicide attempt. PA/K noted that P1 was potentially violent and dangerous. P1 was a flight and suicide risk. P1's discharge plan was "incarceration," when P1 was medically stable. A 72-hour hold, dated 10/15/15, indicated that PA/K executed an involuntary 72-hour hold for further treatment and "for suicide attempt by intentional overdose." The progress notes indicated that P1 was transferred to a medical unit on 10/15/15 at 4:07 p.m. P1 was medically unstable, due to systemic effects of the drugs P1 took during intentional overdose. There were no diagnostic or treatment modalities indicated regarding what was being medically monitored in connection with the systemic effects of P1 ' s overdose. P1 was receiving IV antibiotics for suspected pneumonia. P1 was actively suicidal.

A psychiatric consultation completed by PA/K, dated 10/16/15 at 2:30 p.m., indicated P1 was on the Medical unit. Since extubation on 10/15/15, P1 endorsed suicidal ideation and insisted he wants to die. P1 made the statement, "I want to end it all the first chance I get." P1 told PA/K he would hurt any man who came into his room. P1's mood was identified as "terrible." P1's judgment and insight were impaired. P1 was potentially violent and dangerous, with law enforcement present in his room but P1 was not under police custody. P1 was on an involuntary 72-hour hold because P1 was a flight and suicide risk. P1 was in a general patient room. P1 was able to move freely about his room and was not physically restrained. PA/K noted that P1's suicide watch should continue when P1 was discharged to prison. PA/K wrote that "Psychiatry will sign off."

There was no evidence that the Hospital's Medical Staff provided any type of psychiatric service for P1 after 10/16/15. There was no evidence that a doctor was responsible for the psychiatric problems, care, and needs of P1 that were evident upon admission and during hospitalization. At no time was P1 evaluated by a Psychiatrist for the necessary clinical treatment plan to address P1's suicidal ideation: thinking about, considering, or planning of suicide, and the appropriateness of the environment with respect to P1's psychiatric problems.

Violence Risk Assessments completed by nursing staff on the medical unit from 10/15/15-10/17/15 indicated that P1 was at high risk for violence. P1 was actively suicidal.

A Violence Risk assessment completed by nursing on 10/17/17 at 11:43 p.m. indicated that P1's mental status was abnormal. P1's behavior was agitated. P1 was hyper-verbal. P1's insight was poor. RN/L contacted the hospitalist team (MD/J) about P1's demeanor. No new orders were written and no re-evaluation of the patient's psychiatric needs and/or treatment was completed.The nursing progress notes on 10/18/15 at 4:00 a.m. indicated that P1 refused the IV antibiotic. P1 told RN/L that he didn't "need it any more." RN/L notified the hospitalist team (MD/J) that P1 had declined administration of the IV antibiotic. The nursing progress notes at 4:11 a.m. indicated that P1's behavior had been escalating throughout the evening. P1 was irritable and agitated. At 4:50 a.m., P1 removed his own IV. P1 told RN/L that he didn't "need it any more." P1 started cleaning his room. At 5:10 a.m., RN/L heard gunshots fired.
PA/K was interviewed on 10/23/15 at 10:45 a.m. PA/K stated the ICU Medical Provider (MD/H) ordered a psychiatric consult and she was asked to see P1 in the ICU after P1 was extubated. The ICU case manager had informed PA/K about P1's criminal history and the discharge plan of incarceration, which was anticipated to pose potential problems. The anticipated date of discharge was 10/18/15. The case manager had already contacted the support of law enforcement during P1's hospitalization because P1 was "dangerous." PA/K assessed P1 on the afternoon of 10/15/15 before P1 was transferred to the medical unit. P1 had anti-social personality traits and verbalized that he wanted "to die." PA/K placed P1 on a 72-hour hold, which automatically generates 1:1 staffing by unlicensed personnel. In addition, P1 would have a law enforcement officer in attendance in his room for supervision and to intervene and manage a behavioral event. PA/K re-assessed P1 on the Medical unit on 10/16/15. A law enforcement officer was in the room as well as a 1:1 hospital PCA. P1 continued to demonstrate anti-social personality traits with underlying depression. P1 continued to be suicidal and told PA/K that he was "going to do it as soon as I can." PA/K determined that P1 still needed a suicide watch but did not need anything else from the Department of Psychiatry. PA/K signed off as the consultant service. PA/K didn't think P1's status warranted collaboration with the psychiatrist or continued support by psychiatric services, because she didn't believe the case was complex enough to involve a psychiatrist. Typically, the intensivist or hospitalist collaborate with psychiatry to determine which unit a patient should be admitted to. Patients with mental health needs and stable medical needs are admitted to the mental health unit. Patients with mental health needs who have unstable medical needs are admitted to medical units. It is routine practice to admit patients with active suicidal ideation to a general medical unit when the patient has unstable medical needs. All patients under police custody, regardless of the patient ' s medical or mental health needs, are admitted to medical units among the general population. The mental health unit does not allow any police presence on the mental health unit.

MD/I/Hospitalist was interviewed on 10/27/15 at 4:10 p.m. MD/I stated he evaluated P1's medical status on 10/16/15 and 10/17/15. When a patient is suicidal or on a mental health unit psychiatry is always involved. Generally, psychiatry provides continued monitoring of patients when they are on a 72-hour hold or when mental health patients are roomed among the general patient population. The psychiatry staff are skilled at diagnoses and pick up on things that might be overlooked by a generalists. MD/J/Hospitalist was interviewed on 10/26/15 at 3:10 p.m. MD/J stated she was the hospitalist on-call during the night of 10/17/15-10/18/15. MD/J had no prior involvement in P1's care. MD/J could not think of any situation when it would be appropriate to discontinue psychiatric services for a patient who was suicidal.
MD/Q/Medical Director of Psychiatry was interviewed on 10/27/15 at 2:20 p.m. and indicated when the admitting physician requests a consult from psychiatry an order is placed in the electronic medical record. A member of the consult team will then respond to the order by meeting with the patient to evaluated the psychiatric needs. MD/Q indicated the consult team collaboratively decides who will complete the ordered consult and it is primarily based on who is available to complete the task and not based on the acuity of the patient or skill set of the Licensed Independent Practitioner. MD/Q stated there is not one person who creates the patient assignments for the psychiatric consult team. MD/Q indicated the consult team is made-up of a combination of Psychiatrists, Physician Assistants and Certified Nurse Practitioners. MD/Q indicated it is at the discretion of the behavioral health Licensed Independent Practitioner as to whether or not a patient would benefit from the care of the psychiatrist. MD/Q indicated he had not reviewed the medical record of P1 and/or the events leading up to the incident that resulted in the death of the patient and the police officer. MD/Q indicated when determining if a patient's primary need is psychiatric or medical, it is the decision of the transferring hospitalist or intensivists. MD/Q indicated the mental health unit does not take patients who require IV therapy. MD/Q indicated psychiatric consult services, when a patient is on a medical unit, may be ended when the patient is in a safe situation such as on 1:1 PCA sitter observations, and medications are stable. And, when the discharge plan is to jail, there may not be anything more psychiatry could do to manage the patients suicidal ideation.
MD/P/Vice President Medical Affairs was interviewed on 10/27/15 at 3:20 p.m. MD/P stated that when a psychiatric consult is requested, it would most likely be performed by a Physician Assistant (PA) due to the time constraints of a psychiatrist. It is the expectation that the PA would consult with a psychiatrist if the PA felt physician expertise was necessary; the hallmark of any good provider is to know their limitations and ask for additional assistance when indicated. When a patient with psychiatric and medical needs is transferred to another level care, the transferring physician makes the determination about whether the patient ' s psychiatric or medical needs are greater. Most often, the patient ' s medical needs will trump psychiatric needs, and is more common to care for psychiatric needs on a medical floor than medical needs on a psychiatric floor. There is a potential that a patient may become medically stable and not transfer to the mental health unit if the patient is going to transfer to jail the next day.

Based on interview and document review the hospital failed to ensure a patient with psychiatric problems who was admitted to the hospital received the continued services from a clinical psychologist for 1 of 41 patients (P1) reviewed. P1 was on a medical unit, was actively suicidal, on an involuntary 72-hour psychiatric commitment hold and did not received continued care for a psychiatric problem during the course of his hospitalization.

The findings include:

The Hospital Bylaws, not dated, indicated the governing body oversees proposed bylaws, policies, rules, and regulations recommended by the medical staff. Each patient's general medical condition is the responsibility of a physician member of the medical staff and members of the medical staff are responsible for quality improvement, safety and clinical utilization improvement initiatives with the area of the practitioner's privileges.

Rules and Regulations of the Medical Staff of the Hospital, not dated, indicated:
o For the protection of patients, staff and the hospital certain principles are to be met in the care of potentially suicidal patients: suicidal patients are to be admitted to the psychiatric unit, if the unit is full the suicidal patient should be referred to other institutions that would be available and not admit the patient to other floors of the hospital. However, in the judgement of the physician, if a serious medical problem exist of a higher priority than the underlying psychiatric problem, the patient is to be admitted to the necessary nursing unit with one-to-one nursing care. The admitting practitioner is responsible for giving information that may be necessary to protect the patient and others from self-harm whenever the patient might be a source of danger.

P1's medical record was reviewed. The emergency department (ED) record indicated that P1 was air-lifted to the hospital's ED on 10/12/15 at 11:55 a.m., after intentional prescription drug overdose. P1 was admitted to the intensive care unit (ICU) on 10/12/15 at 2:02 p.m. The ICU progress notes, dated 10/12/15, indicated that P1 was intubated and receiving critical care related to the drug overdose. The ICU progress notes dated 10/15/15 indicated P1 received critical care for the drug overdose through 10/15/15. P1 was extubated on 10/15/15 at 10:58 a.m. The respiratory therapy progress notes at 10:58 a.m. indicated that P1 was actively trying to kill himself. P1 attempted to put pillows over his face and asked the therapist to do the same. The pillows were removed from P1's bed.

An ICU nursing note dated 10/15/15 at 11:35 a.m. indicated P1 bangs his head on the bed rail and does not stop when asked to do so. P1 repeatedly asked staff to kill him, wants to be set on fire, and holds his breath so he will die.

A licensed social worker (LSW) note dated 10/15/15 at 11:48 a.m. indicated P1 was on a 72-hour hold due to his suicide attempt. P1 repeatedly indicated he wanted to die and that he should be killed.

A psychiatric consultation completed by Physician Assistant (PA)/K, dated 10/15/15 at 1:30 p.m., P1 in the ICU. P1 was alert had demonstrated a violent history. P1 reassured the ICU staff that he would not harm a female nurse, but if a man walked in, he would break every bone in his body. A nurse reported that P1 made comments that something was at the foot of his bed was moving and P1 admitted that sometimes he sees things and validated his statement by saying "Like that", "pointing to the railing at the foot of the bed". P1 verbalized that he was going to kill himself and that he wanted to kill his family member for calling 911 and saving him. P1 said he had one other previous suicide attempt. P1 was potentially violent and dangerous, demonstrated anti-social personality traits, and the psychosis either acute or chronic. P1 was a flight and suicide risk and his discharge plan was "incarceration," when P1 was medically stable. P1's insight and judgment were impaired. P1's medication record indicated P1 had antipsychotic medication Zyprexa 5 milligrams by mouth or intramuscular, four times a day as needed for agitation.
A 72-hour hold, dated 10/15/15, indicated that PA/K executed an involuntary 72-hour hold on P1 for further treatment and "for suicide attempt by intentional overdose." The ICU progress notes indicated that P1 was transferred to a medical unit on 10/15/15 at 4:07 p.m. P1 was medically unstable, due to systemic effects of the drugs P1 took during intentional overdose. P1 was also receiving IV antibiotics for suspected pneumonia. P1 was actively suicidal.
A medical nursing note dated 10/16/15 at 6:37 a.m. indicated P1 did not sleep during the night. endorsed suicidal ideation. P1 continued with painful cough, was on oral antibiotics and was planned to discharge to jail today.

A hospitalist progress note by MD/I dated 10/16/15 at 9:39 a.m. indicated P1's principle problem was overdose of an antidepressant. The assessment and plan for the day was to continue fluids and oral antibiotics; P1 was improving. The physician deferred P1's antisocial personality traits and psychosis to psychiatry. The hospitalists noted P1's psychiatric status was cooperative, no agitation, and had suicidal ideation.

A Behavioral Health Case Manager nursing progress note dated 10/16/15 at 9:43 a.m. indicated the reason for the referral was for behavior, alcohol withdrawal observations. The recommended course was to monitor for withdrawal and this was discussed with the hospitalist and PA/K. The Behavioral Health Case Manager would continue to follow.

A LSW note dated 10/16/15 at 12:01 p.m. indicated P1 was on a 72-hour hold and had a law enforcement officer in his room at all times and would be taken into custody upon discharge. Psychiatry and Behavioral Health Case Manager were following P1.

A psychiatric consultation completed by PA/K, dated 10/16/15 at 2:30 p.m., indicated since extubation on 10/15/15, P1 endorsed suicidal ideation and insisted he wanted to die. P1 joked frequently and was very nice to the nurses asking not to be restrained and promised that he would not hurt any woman. P1 made the statement, "I want to end it all the first chance I get." P1 said he would hurt any man who came into his room. P1's mood was "terrible." P1's insight and judgement were impaired. P1 was potentially violent and dangerous, and law enforcement was present in his room. P1 was on an involuntary 72-hour hold because P1 was a flight and suicide risk. P1's suicide watch should continue when P1 was discharged to prison. PA/K wrote, "Psychiatry will sign off."

There was no evidence that a doctor was responsible for the psychiatric problems, care, and needs of P1 that were evident upon admission and during hospitalization. P1 did not receive psychiatric service after 10/16/15 when PA/K determined continued support for psychiatric services were no long warranted. At no time was P1 assessed and evaluated by a Psychiatrist for the necessary clinical treatment plan to address P1's suicidal ideation: thinking about, considering, or planning of suicide, and the appropriateness of the P1's environment with respect to P1's psychiatric problems.
A medical nursing note dated 10/16/15 at 10:28 p.m. indicated P1 made comments about wanting to die and asked the PCA if he would bleed to death if he removed the IV out of his arm. P1 was not going to eat so he could die.

A medical nursing note dated 10/17/15 at 6:38 a.m. indicated P1 was unable to sleep; multiple comments were made to end his life. P1 stated he could not discharge today because he was weak. The police officer was present at bedside and there was a possible discharge to jail today.

A hospitalist progress note by MD/I dated 10/17/15 at 9:37 a.m. indicated P1's principle problem was overdose of an antidepressant. The plan was switched P1 back to an IV antibiotic, for another day or two, and switched back to the oral antibiotics at discharge. The physician deferred P1's antisocial personality traits and psychosis to psychiatry.

A medical nursing note dated 10/17/15 at 11:51 p.m. indicated P1 was more hyperverbal and agitated in the past one to two hours, as needed Zyprexa was given.

A medical nursing note dated 10/18/15 at 4:11 a.m. indicated that P1 had escalated in behaviors through the night and had only slept about one hour in the last few days. Zyprexa was given with minimal effect, P1 removed his own IV, and P1 refused all medication and interventions by stating he was fine and he did not need it anymore. P1 was irritable and slightly agitated. The hospitalist was called, updated, and there was no change in the course to treatment.

A hospitalist progress note by MD/J dated 10/18/15 at 10:37 a.m. indicated MD/J was called several times during the evening of 10/17/15 and into the morning hours of 10/18/15 regarding P1's increased agitation. P1 started to refuse medications, was agitated, but was never aggressive. At approximately 4:00 a.m., P1 did get up to go to the bathroom, put on a pair of jeans, pulled out his IV and tried to walk out of his room when the police officer attempted to stop him. P1 was not restrained. P1 somehow gained access to the police officer's gun and the police officer was shot. P1 was reportedly tasered and became unresponsive.

The Emergency Department notes dated 10/19/15 at 2:02 a.m. indicated both the patient and the police officer died on 10/18/15 following the incident.


A review of 38 medical records from 07/04/15 - 10/24/15 established that 31 of 38 patients were placed on 72-hour holds due to volatile or suicidal behavior and then admitted to non-mental health units, among the hospital's general patient population. There was no evidence of any QAPI activity related to this high-risk practice

PA/K was interviewed on 10/23/15 at 10:45 a.m. PA/K stated she provided the psychiatric consults for P1. She did not think P1's status warranted collaboration with the psychiatrist or continued support by psychiatric services, because she didn't believe the case was complex enough to involve a psychiatrist and P1 would be discharged to jail with continued suicide precautions. PA/K indicated that she did not discuss her findings with the hospitalist and the hospitalist did not ask her about P1's psychiatric problems.

MD/I/Hospitalist was interviewed on 10/27/15 at 4:10 p.m. MD/I stated he evaluated P1's medical status on 10/16/15 and 10/17/15. Generally, psychiatry provides continued monitoring of patients when they are on a 72-hour hold or when mental health patients are roomed among the general patient population.

MD/Q/Medical Director of Psychiatry was interviewed on 10/27/15 at 2:20 p.m. and indicated that patients who may have psychiatric needs, with a violent history, would not be admitted to the mental health unit and there would be an alternate discharge plan in place. MD/Q indicated when determining if a patient's primary need is psychiatric or medical, it is the decision of the transferring hospitalist or intensivists. MD/Q indicated the mental health unit does not take patients who require IV therapy.

MD/P/Vice President Medical Affairs was interviewed on 10/27/15 at 3:20 p.m. and indicated the determination of the psychiatric or medical needs of a patient, when transferring to another level of care, is the decision of the transferring physician. Most often medical needs would trump psychiatric needs, and it is more common to care for psychiatric needs on a medical floor than medical needs on a psychiatric floor. There is a potential that a person may become medically stable and not transfer to the mental health unit if the patient is going to transfer to jail the next day. Other considerations would be if there was a bed available on the mental health unit, that the psychiatrist would accept the patient, and that a psychiatric nurse on the mental health unit could meet the minimal medical needs of a patient.

Based on interview and document review, the hospital failed to promote and protect the rights of patients for 1 of 1 patient reviewed (P1), who was actively suicidal and homicidal, was roomed on a medical unit among the general patient population, and was not provided with any psychiatric care or monitoring. The hospital ' s failure to ensure psychiatric oversight of P1 ' s active problems enabled P1 to obtain a police officer ' s firearm, shoot, and kill the police officer. P1 also died after being tasered. The findings include:

The hospital did not meet the Condition of Participation of Patient Rights at 42 CFR 482.13.

The hospital's medical staff routinely admits patients with acute psychiatric symptoms to general medical units. Any patient who requires law enforcement presence due to the patient's behavioral symptoms or criminal history is admitted to a general medical unit, rather than the mental health unit. This practice had the potential to impact the safety of all patients who required psychiatric care for acute needs and/or police supervision who were receiving services at the hospital on non-mental health units. This practice had the potential to jeopardize the safety of other patients on the unit, the safety of unit staff providing care to patients, and the safety of public visitors visiting patients.

Based on interview and document review, the hospital failed to ensure that all patients received care in a safe environment for 1 of 1 patients reviewed (P1), who was assessed as being homicidal, suicidal, violent, and dangerous, and was admitted to a medical unit among the general patient population after being detained on an involuntary 72 hour psychiatric hold with a 1:1 sitter and police officer supervision. The patient was never evaluated by a psychiatrist, was not monitored by the department of psychiatry, and did not receive necessary supportive psychiatric interventions. Less than three days later the patient obtained the police officer's firearm, shot, and killed the police officer. The patient also died after he was tasered.

Based on interview and document review, the hospital failed to ensure that all patients received care in a safe environment for 1 of 1 patients reviewed (P1), who was assessed as being homicidal, suicidal, violent, and dangerous, and was admitted to a medical unit among the general patient population after being detained on an involuntary 72 hour psychiatric hold with a 1:1 sitter and police officer supervision. The patient was never evaluated by a psychiatrist, was not monitored by the department of psychiatry, and did not receive necessary supportive psychiatric interventions. Less than three days later the patient obtained the police officer's firearm, shot, and killed the police officer. The patient also died after he was tasered.

Findings include:

P1's emergency department (ED) record indicated that P1 was air-lifted to the hospital's ED on 10/12/15 at 11:55 a.m., after being found unresponsive in his home due to an intentional prescription drug overdose with Lexapro and Amitriptyline. P1 was comatose upon arrival. P1 received emergency care and was then transferred to the intensive care unit (ICU) on 10/12/15 at 2:02 p.m. The ICU progress notes, dated 10/12/15, indicated that P1 was intubated and receiving critical care related to the drug overdose.

The ICU social service progress notes, dated 10/13/15 at 10:21 a.m., indicated that P1 had 13 warrants for his arrest and had a history of violence. Hospital staff were pursuing a plan to have law enforcement present at P1's bedside, whenever P1 was extubated. (The patient was not under law enforcement custody during the course of his hospital admission.)

The ICU progress notes indicated that P1 received critical care for the drug overdose through 10/15/15. P1 was extubated on 10/15/15 at 10:58 a.m. The respiratory therapy progress notes at 10:58 a.m. indicated that P1 was actively trying to kill himself. P1 attempted to put pillows over his face and asked the therapist to do the same. The pillows were removed from P1's bed.

The ICU nursing progress notes, dated 10/15/15 at 11:39 a.m., indicated that P1 was continually asking the nurse to kill him. P1 was holding his breath so he "will die." P1 asked the nurse to set him on fire.

The ICU social service progress notes on 10/15/15 at 11:49 a.m., indicated that P1 told the social worker that he wanted to die, "kill me."

A psychiatric consultation completed by Physician Assistant (PA)/K, dated 10/15/15 at 1:30 p.m., and indicated that Physician Assistant (PA) /K evaluated P1 in the ICU. PA/K noted that P1 was alert and demonstrated anti-social personality traits. P1 verbalized that he was going to kill himself and that he wanted to kill his family member for calling 911 and saving him. P1 told PA/K that he had one other previous suicide attempt. PA/K noted that P1 was potentially violent and dangerous. P1 was a flight and suicide risk. P1's discharge plan was "incarceration," when P1 was medically stable.

A 72-hour hold, dated 10/15/15, indicated that PA/K executed an involuntary 72-hour hold to detain P1 for further treatment. The 72-hour hold indicated that the reason for the hold was "for suicide attempt by intentional overdose."

The progress notes indicated that P1 was transferred to a medical unit on 10/15/15 at 4:07 p.m. P1 was medically unstable, due to systemic effects of the drugs P1 took during intentional overdose. There was no indication of any diagnostic or treatment modalities that pertained to P1 ' s medical instability from the drug overdose. P1 was receiving IV antibiotics for suspected pneumonia. P1 was actively suicidal.

A psychiatric consultation completed by PA/K, dated 10/16/15 at 2:30 p.m., indicated that PA/K evaluated P1 on the Medical unit. PA/K noted that since extubation on 10/15/15, P1 endorsed suicidal ideation and insisted he wants to die. P1 made the statement, "I want to end it all the first chance I get." P1 told PA/K he would hurt any man who came into his room. PA/K observed that P1's mood was "terrible." P1's judgment and insight were impaired. P1 was potentially violent and dangerous, with law enforcement present in his room, but P1 was not under police custody. P1 was on an involuntary 72-hour hold because P1 was a flight and suicide risk. P1 was in a general patient room. P1 was able to move freely about his room. P1 was not physically restrained. PA/K noted that P1's suicide watch should continue when P1 was discharged to prison. PA/K wrote that "Psychiatry will sign off."

There was no evidence that the Hospital's Medical Staff provided any type of psychiatric service for P1 after 10/16/15. There was no evidence that a doctor was responsible for the psychiatric problems, care, and needs of P1 that were evident upon admission and during hospitalization. At no time was P1 evaluated by a Psychiatrist for the necessary clinical treatment plan to address P1's suicidal ideation: thinking about, considering, or planning of suicide, and the appropriateness of the environment with respect to P1's psychiatric problems.

Violence Risk Assessments completed by nursing staff on the medical unit from 10/15/15-10/17/15 indicated that P1 was at high risk for violence. Nurses documented that P1 was on "Aggression Caution" and had a 1:1 sitter, which was a patient care attendant (unlicensed staff). Nurses documented that P1 was actively suicidal. P1's cooperation with medical interventions, such as taking medications, waxed and waned.

A Violence Risk assessment completed by nursing on 10/17/17 at 11:43 p.m. indicated that P1's mental status was abnormal. P1's behavior was agitated. P1 was hyper-verbal. P1's insight was poor. RN/L contacted the hospitalist team (MD/J) about P1's demeanor. No new orders were written and no re-evaluation of the patient's psychiatric needs and/or treatment was completed.

The nursing progress notes on 10/18/15 at 4:00 a.m. indicated that P1 refused the IV antibiotic. P1 told RN/L that he didn't "need it any more." RN/L notified the hospitalist team (MD/J) that P1 had declined administration of the IV antibiotic. The nursing progress notes at 4:11 a.m. indicated that P1's behavior had been escalating throughout the evening. P1 was irritable and agitated. At 4:50 a.m., P1 removed his own IV. P1 told RN/L that he didn't "need it any more." P1 started cleaning his room. At 5:10 a.m., RN/L heard gunshots fired.

PA/K was interviewed on 10/23/15 at 10:45 a.m. PA/K stated the ICU Medical Provider (MD/H) ordered a psychiatric consult and she was asked to see P1 in the ICU after P1 was extubated. The ICU case manager had informed PA/K about P1's criminal history and the discharge plan of incarceration, which was anticipated to pose potential problems. The anticipated date of discharge was 10/18/15. The case manager had already contacted the support of law enforcement during P1's hospitalization because P1 was "dangerous." PA/K assessed P1 on the afternoon of 10/15/15 before P1 was transferred to the medical unit. P1 had anti-social personality traits and verbalized that he wanted "to die." PA/K placed P1 on a 72-hour hold, which automatically generates 1:1 staffing by unlicensed personnel. In addition, P1 would have a law enforcement officer in attendance in his room for supervision and to intervene and manage a behavioral event. PA/K re-assessed P1 on the Medical unit on 10/16/15. A law enforcement officer was in the room as well as a 1:1 hospital PCA. P1 continued to demonstrate anti-social personality traits with underlying depression. P1 continued to be suicidal and told PA/K that he was "going to do it as soon as I can." PA/K determined that P1 still needed a suicide watch but did not need anything else from the Department of Psychiatry. PA/K signed off as the consultant service. PA/K didn't think P1's status warranted collaboration with the psychiatrist or continued support by psychiatric services, because she didn't believe the case was complex enough to involve a psychiatrist. Typically, the hospitalist or intensivist collaborates with psychiatry to determine which unit the patient should be admitted to. Patients with mental health needs who have stable medical needs are admitted to the mental health unit. Patients with mental health needs who have unstable medical needs are admitted to medical units, among the general patient population. All patients, regardless of medical and/or mental health needs, who are under police custody are admitted to medical units. The mental health unit does not allow police presence on the unit.

MD/I/Hospitalist was interviewed on 10/27/15 at 4:10 p.m. MD/I stated he evaluated P1's medical status on 10/16/15 and 10/17/15. P1 was alert, pleasant, and cooperative both days. P1 had no hallucinations. MD/I did not observe any behavioral concerns or psychotic features. MD/I talked to the nurses about how P1 was doing and read all the charting. MD/I didn't think any further interventions were warranted because P1 had a 1:1 sitter, a police officer was present in P1's room, and P1 was calm. Generally, when a patient is suicidal or on a mental health unit, psychiatry is always involved. Generally, psychiatry provides continued monitoring of patients when they are on a 72-hour hold or when mental health patients are roomed among the general patient population, which is routine practice. The psychiatry staff are skilled at diagnoses and pick up on things that might be overlooked by generalists.

MD/J/Hospitalist was interviewed on 10/26/15 at 3:10 p.m. MD/J stated she was the hospitalist on-call during the night of 10/17/15-10/18/15. MD/J had no prior involvement in P1's care. Around midnight, RN/L notified MD/J that P1 seemed on edge and was tense. MD/J reviewed P1's medications by telephone. PRN Zyprexa was already among P1's orders, which MD/J thought was adequate. Around 4:00 a.m., RN/L called MD/J again to report that she had given P1 the prn Zyprexa around midnight and now P1 was refusing to take any more prn Zyprexa. RN/L reported that P1 had only slept about an hour and had been up all night. MD/J didn't order anything new because RN/L reported that P1 was calm. MD/J had no further contact with P1's unit until sometime after 5:00 a.m. when MD/J heard the overhead pages for "Behavioral Situation" followed by "Code Blue." MD/J could not think of any situation when it would be appropriate to discontinue psychiatric services for a patient who was suicidal.

MD/P/Vice President Medical Affairs was interviewed on 10/27/15 at 3:20 p.m. MD/P stated that when a psychiatric consult is requested, it would most likely be performed by a Physician Assistant (PA) due to the time constraints of a psychiatrist. It is the expectation that the PA would consult with a psychiatrist if the PA felt physician expertise was necessary; the hallmark of any good provider is to know their limitations and ask for additional assistance when indicated. When a patient with psychiatric and medical needs is transferred to another level care, the transferring physician makes the determination about whether the patient ' s psychiatric or medical needs are greater. Most often, the patient ' s medical needs will trump psychiatric needs, and is more common to care for psychiatric needs on a medical floor than medical needs on a psychiatric floor. There is a potential that a patient may become medically stable and not transfer to the mental health unit if the patient is going to transfer to jail the next day.

RN/L was interviewed on 10/22/15 at 11:05 a.m. RN/L stated that it is general hospital practice for patients with both mental health and medical needs to be admitted to medical units, among the general patient population. Any patient who is under police custody is always admitted to a medical unit. RN/L stated she was assigned to P1's care during the night shifts of 10/16/15-10/17/15 and 10/17/15-10/18/15. P1 had a 1:1 sitter and a police officer present in his room both nights. P1's cooperation and mood varied from shift to shift. P1's suicidal ideation did not fluctuate. P1 consistently talked about killing himself. When RN/L came on duty for the night shift of 10/17/15-10/18/15, the evening shift nurse reported that P1 had refused the Zyprexa. As soon as shift report ended, RN/L went to P1's room around 11:45 p.m. P1 took the Zyprexa but declined the Melatonin. P1 shook RN/L's hand and was calm. The 1:1 sitter and police officer were in P1's room. P1 slept from midnight to 1:00 a.m. but was up all night after 1:00 a.m. RN/L was in P1's room at least every two hours. Sometimes P1 was sitting in the recliner or on the couch, conversing with the police officer. Around 4:00 a.m., P1 refused administration of the IV Cleocin. P1 told RN/L "I don't need that any more." RN/L asked the police officer and the 1:1 sitter to switch locations. The police officer was sitting by the doorway which is where the 1:1 is supposed to be located. The police officer and 1:1 sitter adjusted their locations to the proper room positions. At 4:50 a.m., RN/L observed the green staff assistance light come on for P1's room. RN/L responded to the room and learned that the 1:1 sitter had activated the light because P1 had removed his IV. RN/L assessed the IV site. P1 told RN/L "I don't need it any more." RN/L cleared the IV pump and turned it off. P1 began cleaning his room. RN/L gave P1 a cup of decaffeinated coffee. At 5:00 a.m., RN/L checked back with the 1:1 sitter and the police officer. Both indicated that everything was fine and the police officer said that his replacement would arrive soon. RN/L left the room and went to the nurse's station. At 5:10 a.m., RN/L heard gun shots fired. The red emergency assistance light in P1's room came on. RN/L ran to the room. P1 and the police officer were on their knees, interlocked in a struggle. A haze filled the room from gun powder. RN/L observed blood smears on the floor. The police officer was grunting and shoved P1 back away from him. P1 was quiet. RN/L ran away from P1's room and initiated the lockdown procedure for an "Active Shooter." All staff took immediate action to protect themselves and other patients. The hospital's Security team and local law enforcement were mobilized to P1's room. RN/L heard someone yell, "we need a nurse." At 5:19 a.m., RN/L went to P1's room and observed P1 lying on the floor in a prone position in the doorway. Taser electrodes were in P1's right flank. P1 was not moving or talking. Local law enforcement were placing handcuffs on P1. RN/L went over to the police officer, who had no signs of life. RN/L called a Code Blue and started CPR on the police officer. The house nursing supervisor had arrived in P1's room and instructed staff to remove P1's handcuffs because P1 was blue. CPR was started on P1. The Trauma teams arrived and assumed emergency care of P1 and the police officer, who were both transported to the ED. Neither survived.

Personal Care Attendant (PCA)/M was interviewed on 10/20/15 at 2:10 p.m. PCA/M stated that she was assigned sitter observations for P1 on the night shift that started at 11:00 p.m. on 10/17/15 and ended at 7:30 a.m. on 10/18/15. PCA/M indicated at shift report she was informed that P1 had a violent and criminal history, there was a warrant for P1's arrest and a felony pending, P1 was on a 72-hold for suicide by overdose, and there was a police officer assigned to P1. There were no special instructions provided in the care of P1. PCA/M stated at the beginning of the shift P1 allowed his vital signs to be taken and appeared kind, but she did observe P1 hallucinating because he kept asking PCA/M if she was smoking and to give him a cigarette as well as telling PCA/M that the hospital bed was leaking oil. P1 was not aggressive during the hallucination, but was restless and had only minimal sleep during the shift. PCA/M indicated she did report the hallucinations to the nurse and was not provided any instruction. PCA/M clarified it is not uncommon to have patients hallucinate after a drug overdose. PCA/M indicated at approximately 4:00 a.m. P1 refused his medication, refused to have his vital signs taken and pulled out his IV. P1 asked the police officer about his discharge and P1 thought he was going home and kept talking about getting his truck and his wife would get the house. P1 was informed by the police officer that P1 was not going home, but was going to jail. Shortly after, P1 started walking towards the door, the police officer stood up, P1 charged the police officer and obtained the firearm. P1 and the police officer struggled, PCA/M heard gun shots, and all emergency protocols were activated.

The hospital's policy on Rights and Responsibilities, dated December 2012, indicated " Patients shall have the right to appropriate medical and personal care based on individual needs. "

Rules and Regulations of the Medical Staff of the Hospital, not dated, indicated:
o For the protection of patients, staff and the hospital certain principles are to be met in the care of potentially suicidal patients: suicidal patients are to be admitted to the psychiatric unit, if the unit is full the suicidal patient should be referred to other institutions that would be available and not admit the patient to other floors of the hospital. However, in the judgement of the physician, if a serious medical problem exist of a higher priority than the underlying psychiatric problem, the patient is to be admitted to the necessary nursing unit with one-to-one nursing care. The admitting practitioner is responsible for giving information that may be necessary to protect the patient and others from self-harm whenever the patient might be a source of danger.
o Consult is a service provided by a physician whose opinion or advice regarding an evaluation and/or management of a specific problem is requested by another physician. Urgent consults will be called to the responding physician by the requesting physician; non-urgent consults will entered and handled by the contact center. Call groups can exercise the right to have consultation requests more stringent than the outline of urgent or non-urgent.

The hospital did not have a policy and procedure or guidelines for a police officer to guard a patient with a violent history, while on an inpatient medical unit and not in custody of law enforcement.

Based on interview and document review, the hospital failed to ensure a process for quality assessment and performance improvement activities that reflected the need for patient safety and enhanced health outcomes of provider treatments for patients with psychiatric symptoms receiving police supervision on medical units. This had the potential to affect all patients who receive services on the hospital's medical units.

The hospital's failure to incorporate surveillance activities of patients roomed on medical units with active suicidal and homicidal ideation, analyze services rendered, and develop measurable standards to reduce the risk of harm to all patients, staff, and public visitors on the medical units resulted the in the hospital ' s inability to meet the Condition of Participation of Quality Assessment Performance Improvement at 42 CFR 428.21.
A review of 38 medical records from 07/04/15 - 10/24/15 established that 31 of 38 patients were placed on 72-hour holds due to volatile or suicidal behavior and then admitted to non-mental health units, among the hospital's general patient population. There was no evidence of any QAPI activity related to this high-risk practice.

Based on interview and document review, the governing body failed to ensure the hospital had a quality assessment and performance improvement program that reflected the complexity of the hospital's patient care services for all patients, including 1 of 41 patients (P1) reviewed. P1 had active suicidal and homicidal ideation was roomed on non-mental health unit and obtained a firearm from law enforcement and shot and killed the law enforcement officer. The patient was tasered and died. This had the potential to affect all patients who receive services on the hospital's medical units. (A308)

Based on interview and document review, the governing body failed to ensure the hospital had a quality assessment and performance improvement program that reflected the complexity of the hospital's patient care services for all patients, including 1 of 41 patients (P1) reviewed. P1 had active suicidal and homicidal ideation was roomed on non-mental health unit and obtained a firearm from law enforcement and shot and killed the law enforcement officer. The patient was tasered and died. This had the potential to affect all patients who receive services on the hospital's medical units.

Findings include:

A review of 38 medical records from 07/04/15 - 10/24/15 established that 31 of 38 patients were placed on 72-hour holds due to volatile or suicidal behavior and then admitted to non-mental health units, among the hospital's general patient population. There was no evidence of any QAPI activity related to this high-risk practice.

P1's medical record was reviewed. The emergency department (ED) record indicated that P1 presented to the ED on 10/12/15 at 11:55 a.m., with an intentional prescription drug overdose. P1 was admitted to the intensive care unit (ICU) on 10/12/15 at 2:02 p.m.The ICU progress notes dated 10/15/15 indicated P1 received critical care for the drug overdose through 10/15/15. P1 was extubated on 10/15/15 at 10:58 a.m. A licensed social worker (LSW) note dated 10/15/15 at 11:48 a.m. indicated P1 repeatedly indicated he wanted to die and that he should be killed. A 72-hour hold, dated 10/15/15, indicated that PA/K executed an involuntary 72-hour hold on P1 for further treatment and "for suicide attempt by intentional overdose." The ICU progress notes indicated that P1 was transferred to a medical unit on 10/15/15 at 4:07 p.m. P1 was medically unstable, due to systemic effects of the drugs P1 took during intentional overdose. P1 was also receiving IV antibiotics for suspected pneumonia. P1 was actively suicidal. A psychiatric consultation completed by PA/K, dated 10/16/15 at 2:30 p.m., indicated since extubation on 10/15/15, P1 endorsed suicidal ideation and insisted he wanted to die. P1 made the statement, "I want to end it all the first chance I get." P1 said he would hurt any man who came into his room. P1's mood was "terrible." P1's insight and judgement were impaired. P1 was potentially violent and dangerous, and law enforcement was present in his room. P1 was on an involuntary 72-hour hold because P1 was a flight and suicide risk. P1's suicide watch should continue when P1 was discharged to prison. PA/K wrote, "Psychiatry will sign off." Medical nursing notes between 10/16/15 and 10/18/15 indicated the patient endorsed suicidal ideations. A hospitalist progress note by MD/J dated 10/18/15 at 10:37 a.m. indicated MD/J was called several times during the evening of 10/17/15 and into the morning hours of 10/18/15 regarding P1's increased agitation. P1 started to refuse medications, was agitated, but was never aggressive. At approximately 4:00 a.m., P1 did get up to go to the bathroom, put on a pair of jeans, pulled out his IV and tried to walk out of his room when the police officer attempted to stop him. P1 was not restrained. P1 somehow gained access to the police officer's gun and the police officer was shot. P1 was reportedly tasered and became unresponsive.

The Quality/Safety Committee monthly meeting minutes from 10/2014 to 10/2015 were reviewed. At the 10/13/15 Medical Executive Committee the VP of Medical Affairs brought forth a discussion to look at issues for specific processes that may fall short. It was observed that over last couple of years approximately one-third were related to mental health (suicide attempts and opioids), one-third were pressure ulcers and the other on-third were incidents not related to either. There was no evidence that data collected of hospitals complexity of patients with mental health needs to address psychiatric services delivered on non-mental health units was analyzed to determine deficiencies. The hospital failed to incorporate surveillance activities of patients roomed on medical units with symptoms of active suicidal and homicidal ideation, analyze services rendered, and develop measurable standards to reduce the risk of harm to all patients, staff, and public visitors on the medical units.

The hospital's Medical Staff Bylaws, Policies and Rules and Regulations of the Hospital, not dated, indicated:
o The duties of the Department Chairperson is responsible for all clinically related activities of the department and integrating the department into the primary functions of the hospital by developing and implementing policies and procedures that guide and support the provision of care, treatment and services, continuing assessment and improvement of the quality of care, treatment, and services provided.
o Performance improvement functions of the Medical Staff included the measurement, assessment and improvement of medical assessment and treatment of patients, and, participates in the care, treatment, and services with other practitioners and hospital personnel.

MD/Q/Medical Director of Psychiatry was interviewed on 10/27/15 at 2:20 p.m. and indicated that patients who may have psychiatric needs, with a violent history, would not be admitted to the mental health unit and there would be an alternate discharge plan in place. MD/Q indicated when determining if a patient's primary need is psychiatric or medical, it is the decision of the transferring hospitalist or intensivists. MD/Q indicated the mental health unit does not take patients who require IV therapy.

MD/P/Vice President Medical Affairs was interviewed on 10/27/15 at 3:20 p.m. and indicated the determination of the psychiatric or medical needs of a patient, when transferring to another level of care, is the decision of the transferring physician. Most often medical needs would trump psychiatric needs, and it is more common to care for psychiatric needs on a medical floor than medical needs on a psychiatric floor. There is a potential that a person may become medically stable and not transfer to the mental health unit if the patient is going to transfer to jail the next day. Other considerations would be if there was a bed available on the mental health unit, that the psychiatrist would accept the patient, and that a psychiatric nurse on the mental health unit could meet the minimal medical needs of a patient.

Based on interview and document review, the hospital's medical staff failed to all patients received quality medical care for 1 of 41 patients reviewed (P1), who was assessed by a physicians assistant to be dangerous, violent, and suicidal, was put on an involuntary 72 hour psychiatric hold on a medical unit with the general population, a 1:1 sitter and police officer supervision. Psychiatric services were discontinued and 24 hours later the patient obtained the police officers firearm, shot and killed the police officer and the patient was tasered and died. This results in an Immediate Jeopardy (IJ) situation for any psychiatric patient presenting to the hospital.
The findings include:

The hospital did not meet the Condition of Participation of Medical Staff at 42 CFR 482.22. These deficient practices had the potential to impact all psychiatric patients presenting to the hospital.

The IJ was called on 10/27/15 at 1:50 p.m. The IJ began on 10/16/15 at 2:30 p.m. when the hospital's medical staff terminated psychiatric services for an inpatient who had ongoing verbalizations that he planned to kill himself and others. The patient had been air-lifted to the hospital following an intentional drug overdose. The patient was comatose and was admitted to the ICU for three days. Immediately upon extubation in the ICU, the patient expressed suicidal and homicidal ideation. As a result, the patient was placed on an involuntary 72-hour hold by a Physician Assistant. The patient was considered violent and dangerous. The patient had a criminal history. Hospital staff requested support from law enforcement to guard the patient, after the patient was extubated. The patient was then transferred to a medical unit, among the general hospital patient population. The patient was hospitalized on the Medical unit from 10/15/15 - 10/18/15. The patient remained actively suicidal all three days on the medical unit and expressed that he was going to kill himself as soon as he got the chance as well as kill any male who came into his room. On 10/16/15, the physician's assistant determined that the patient did not need any psychiatric intervention and discontinued psychiatric consultation and service. The patient was never evaluated by a psychiatrist at any time. The Medical staff failed to ensure that the patient's care and treatment plan was organized to include services by medical specialty, in accordance with the patient's psychiatric needs and acute symptoms. On 10/18/15, the patient overtook a law enforcement officer, obtained the officer's firearm, and shot and killed the officer during a physical struggle. The patient died after tasered.

The hospital's medical staff routinely admits patients with acute psychiatric symptoms to general medical units. Any patient who requires law enforcement presence due to the patient's behavioral symptoms or criminal history is admitted to a general medical unit, rather than the mental health unit. The hospital's medical staff includes physicians and licensed independent practitioners (LIP), including physician assistants and advance nurse practitioners.

The IJ was unremoved at the time of exit on 10/28/2015.

On 11/5/2015 an unannounced visit was made to evaluate the hospital's implementation of the IJ removal plan. The IJ was removed on 11/6/15 at 11:00 a.m. after verification that all patient 72 hour holds were ordered by a physician. All current patients requiring psychiatric services received the necessary consults, supervision, and treatment. Patient's requiring both medical and psychiatric care received the necessary physician to physician consultations and correct placement on an in patient unit. All hospital staff and physicians received the required education as of 11/6/15. Condition-level noncompliance remained at the time of removal related to the Condition of Participation of Medical Staff at 42 CFR 482.22, Condition of Participation of Governing Body at 42 CFR 482.12, Condition of Participation of Patient Rights at 42 CFR 482.13, and the Condition of Participation of Quality Assessment and Performance Improvement at 42 CFR 482.21.

Based on interview and document review, the hospital failed to ensure that all patients received quality medical care for 1 of 41 patients reviewed (P1), who was assessed and identified as suicidal, violent, and dangerous. The patient made multiple comments about killing himself but the patient was admitted to a medial unit with the general patient population on an involuntary 72 hour psychiatric hold with a 1:1 sitter and police officer supervision. The patient was never evaluated by a psychiatrist, and was not monitored by the department of psychiatry. Less than three days later the patient obtained the police officer's firearm, and shot and killed the police officer. The patient also died after he was tasered.

Based on interview and document review, the hospital failed to ensure that all patients received quality medical care for 1 of 41 patients reviewed (P1), who was assessed and identified as suicidal, violent, and dangerous. The patient made multiple comments about killing himself but the patient was admitted to a medical unit with the general patient population on an involuntary 72 hour psychiatric hold with a 1:1 sitter and police officer supervision. The patient was never evaluated by a psychiatrist, and was not monitored by the department of psychiatry. Less than three days later the patient obtained the police officer's firearm, and shot and killed the police officer. The patient also died after he was tasered.

Findings include:

P1's emergency department (ED) record indicated that P1 was air-lifted to the hospital's ED on 10/12/15 at 11:55 a.m., after being found unresponsive in his home due to an intentional prescription drug overdose with Lexapro and Amitriptyline. P1 was comatose upon arrival. P1 received emergency care and was then transferred to the intensive care unit (ICU) on 10/12/15 at 2:02 p.m. The ICU progress notes, dated 10/12/15, indicated that P1 was intubated and receiving critical care related to the drug overdose.
The ICU social service progress notes, dated 10/13/15 at 10:21 a.m., indicated that P1 had 13 warrants for his arrest and had a history of violence. Hospital staff were pursuing a plan to have law enforcement present at P1's bedside, whenever P1 was extubated. (The patient was not under law enforcement custody during the course of his hospital admission.) The ICU progress notes indicated that P1 received critical care for the drug overdose through 10/15/15. P1 was extubated on 10/15/15 at 10:58 a.m. The respiratory therapy progress notes at 10:58 a.m. indicated that P1 was actively trying to kill himself. P1 attempted to put pillows over his face and asked the therapist to do the same. The pillows were removed from P1's bed.The ICU nursing progress notes, dated 10/15/15 at 11:39 a.m., indicated that P1 was continually asking the nurse to kill him. P1 was holding his breath so he "will die." P1 asked the nurse to set him on fire.The ICU social service progress notes on 10/15/15 at 11:49 a.m., indicated that P1 told the social worker that he wanted to die, "kill me." A psychiatric consultation completed by Physician Assistant (PA)/K, dated 10/15/15 at 1:30 p.m., indicated that Physician Assistant (PA)/K evaluated P1 in the ICU. PA/K noted that P1 was alert and demonstrated anti-social personality traits. P1 verbalized that he was going to kill himself and that he wanted to kill his family member for calling 911 and saving him. P1 told PA/K that he had one other previous suicide attempt. PA/K noted that P1 was potentially violent and dangerous. P1 was a flight and suicide risk. P1's discharge plan was "incarceration," when P1 was medically stable. A 72-hour hold, dated 10/15/15, indicated that PA/K executed an involuntary 72-hour hold to detain P1 for further treatment. The 72-hour hold indicated that the reason for the hold was "for suicide attempt by intentional overdose." The progress notes indicated that P1 was transferred to a medical unit on 10/15/15 at 4:07 p.m. P1 was medically unstable, due to systemic effects of the drugs P1 took during intentional overdose. P1 was also receiving IV antibiotics for suspected pneumonia. P1 was actively suicidal. A psychiatric consultation completed by PA/K, dated 10/16/15 at 2:30 p.m., indicated that PA/K evaluated P1 on the Medical unit. PA/K noted that since extubation on 10/15/15, P1 endorsed suicidal ideation and insisted he wants to die. P1 made the statement, "I want to end it all the first chance I get." P1 told PA/K he would hurt any man who came into his room. PA/K observed that P1's mood was "terrible." P1's judgment and insight were impaired. P1 was potentially violent and dangerous, with law enforcement present in his room. P1 was on an involuntary 72-hour hold because P1 was a flight and suicide risk. PA/K noted that P1's suicide watch should continue when P1 was discharged to prison. PA/K wrote that "Psychiatry will sign off."There was no evidence that the Hospital's Medical Staff provided any type of psychiatric service for P1 after 10/16/15. At no time was P1 evaluated by a Psychiatrist or provided treatment for his suicidal threats. Violence Risk Assessments completed by nursing staff on the medical unit from 10/15/15-10/17/15 indicated that P1 was at high risk for violence. Nurses documented that P1 was on "Aggression Caution" and had a 1:1 sitter, which was a patient care attendant (unlicensed staff). Nurses documented that P1 was actively suicidal. P1's cooperation with medical interventions, such as taking medications, waxed and waned.

A Violence Risk assessment completed by nursing on 10/17/17 at 11:43 p.m. indicated that P1's mental status was abnormal. P1's behavior was agitated. P1 was hyper-verbal. P1's insight was poor. RN/L contacted the hospitalist team (MD/J) about P1's demeanor. No new orders were written and no re-evaluation of the patient's psychiatric needs and/or treatment was completed.The nursing progress notes on 10/18/15 at 4:00 a.m. indicated that P1 refused the IV antibiotic. P1 told RN/L that he didn't "need it any more." RN/L notified the hospitalist team (MD/J) that P1 had declined administration of the IV antibiotic. The nursing progress notes at 4:11 a.m. indicated that P1's behavior had been escalating throughout the evening. P1 was irritable and agitated. At 4:50 a.m., P1 removed his own IV. P1 told RN/L that he didn't "need it any more." P1 started cleaning his room. At 5:10 a.m., RN/L heard gunshots fired. No new orders were written and no re-evaluation of the patient's psychiatric needs and/or treatment was completed. PA/K was interviewed on 10/23/15 at 10:45 a.m. PA/K stated the ICU Medical Provider (MD/H) ordered a psychiatric consult and she was asked to see P1 in the ICU after P1 was extubated. The ICU case manager had informed PA/K about P1's criminal history and the discharge plan of incarceration, which was anticipated to pose potential problems. The anticipated date of discharge was 10/18/15. The case manager had already contacted the support of law enforcement during P1's hospitalization because P1 was "dangerous." PA/K assessed P1 on the afternoon of 10/15/15 before P1 was transferred to the medical unit. P1 had anti-social personality traits and verbalized that he wanted "to die." PA/K placed P1 on a 72-hour hold, which automatically generates 1:1 staffing by unlicensed personnel. In addition, P1 would have a law enforcement officer in attendance in his room for supervision and to intervene and manage a behavioral event. PA/K re-assessed P1 on the Medical unit on 10/16/15. A law enforcement officer was in the room as well as a 1:1 hospital PCA. P1 continued to demonstrate anti-social personality traits with underlying depression. P1 continued to be suicidal and told PA/K that he was "going to do it as soon as I can." PA/K determined that P1 still needed a suicide watch but did not need anything else from the Department of Psychiatry. PA/K signed off as the consultant service. PA/K didn't think P1's status warranted collaboration with the psychiatrist or continued support by psychiatric services, because she didn't believe the case was complex enough to involve a psychiatrist.
MD/I/Hospitalist was interviewed on 10/27/15 at 4:10 p.m. MD/I stated he evaluated P1's medical status on 10/16/15 and 10/17/15. P1 was alert, pleasant, and cooperative both days. P1 had no hallucinations. MD/I did not observe any behavioral concerns or psychotic features. MD/I talked to the nurses about how P1 was doing and read all the charting. MD/I didn't think any further interventions were warranted because the patient had a 1:1 sitter, a police officer present in P1's room, the patient was calm, and when a patient is suicidal or on a mental health unit psychiatry is always involved. Generally, psychiatry provides continued monitoring of patients when they are on a 72-hour hold or when mental health patients are roomed among the general patient population. The psychiatry staff are skilled at diagnoses and pick up on things that might be overlooked by a generalists. MD/J/Hospitalist was interviewed on 10/26/15 at 3:10 p.m. MD/J stated she was the hospitalist on-call during the night of 10/17/15-10/18/15. MD/J had no prior involvement in P1's care. Around midnight, RN/L notified MD/J that P1 seemed on edge and was tense. MD/J reviewed P1's medications by telephone. PRN Zyprexa was already among P1's orders, which MD/J thought was adequate. Around 4:00 a.m., RN/L called MD/J again to report that she had given P1 the prn Zyprexa around midnight and now P1 was refusing to take any more prn Zyprexa. RN/L reported that P1 had only slept about an hour and had been up all night. MD/J didn't order anything new because RN/L reported that P1 was calm. MD/J had no further contact with P1's unit until sometime after 5:00 a.m. when MD/J heard the overhead pages for "Behavioral Situation" followed by "Code Blue." MD/J could not think of any situation when it would be appropriate to discontinue psychiatric services for a patient who was suicidal. RN/L was interviewed on 10/22/15 at 11:05 a.m. RN/L stated she was assigned to P1's care during the night shifts of 10/16/15-10/17/15 and 10/17/15-10/18/15. P1 had a 1:1 sitter and a police officer present in his room both nights. P1's cooperation and mood varied from shift to shift. P1's suicidal ideation did not fluctuate. P1 consistently talked about killing himself. When RN/L came on duty for the night shift of 10/17/15-10/18/15, the evening shift nurse reported that P1 had refused the Zyprexa. As soon as shift report ended, RN/L went to P1's room around 11:45 p.m. P1 took the Zyprexa but declined the Melatonin. P1 shook RN/L's hand and was calm. The 1:1 sitter and police officer were in P1's room. P1 slept from midnight to 1:00 a.m. but was up all night after 1:00 a.m. RN/L was in P1's room at least every two hours. Sometimes P1 was sitting in the recliner or on the couch, conversing with the police officer. Around 4:00 a.m., P1 refused administration of the IV Cleocin. P1 told RN/L "I don't need that any more." RN/L asked the police officer and the 1:1 sitter to switch locations. The police officer was sitting by the doorway which is where the 1:1 is supposed to be located. The police officer and 1:1 sitter adjusted their locations to the proper room positions. At 4:50 a.m., RN/L observed the green staff assistance light come on for P1's room. RN/L responded to the room and learned that the 1:1 sitter had activated the light because P1 had removed his IV. RN/L assessed the IV site. P1 told RN/L "I don't need it any more." RN/L cleared the IV pump and turned it off. P1 began cleaning his room. RN/L gave P1 a cup of decaffeinated coffee. At 5:00 a.m., RN/L checked back with the 1:1 sitter and the police officer. Both indicated that everything was fine and the police officer said that his replacement would arrive soon. RN/L left the room and went to the nurse's station. At 5:10 a.m., RN/L heard gun shots fired. The red emergency assistance light in P1's room came on. RN/L ran to the room. P1 and the police officer were on their knees, interlocked in a struggle. A haze filled the room from gun powder. RN/L observed blood smears on the floor. The police officer was grunting and shoved P1 back away from him. P1 was quiet. RN/L ran away from P1's room and initiated the lockdown procedure for an "Active Shooter." All staff took immediate action to protect themselves and other patients. The hospital's Security team and local law enforcement were mobilized to P1's room. RN/L heard someone yell, "we need a nurse." At 5:19 a.m., RN/L went to P1's room and observed P1 lying on the floor in a prone position in the doorway. Taser electrodes were in P1's right flank. P1 was not moving or talking. Local law enforcement were placing handcuffs on P1. RN/L went over to the police officer, who had no signs of life. RN/L called a Code Blue and started CPR on the police officer. The house nursing supervisor had arrived in P1's room and instructed staff to remove P1's handcuffs because P1 was blue. CPR was started on P1. The Trauma teams arrived and assumed emergency care of P1 and the police officer, who were both transported to the ED. Neither survived.

Personal Care Attendant (PCA)/M was interviewed on 10/26/15 at 2:10 p.m. PCA/M stated that she was assigned sitter observations for P1 on the night shift that started at 11:00 p.m. on 10/17/15 and ended at 7:30 a.m. on 10/18/15. PCA/M indicated at shift report she was informed that P1 had a violent and criminal history, there was a warrant for P1's arrest and a felony pending, P1 was on a 72-hold for suicide by overdose, and there was a police officer assigned to P1. There were no special instructions provided in the care of P1. PCA/M stated at the beginning of the shift P1 allowed his vital signs to be taken and appeared kind, but she did observe P1 hallucinating because he kept asking PCA/M if she was smoking and to give him a cigarette as well as telling PCA/M that the hospital bed was leaking oil. P1 was not aggressive during the hallucination, but was restless and had only minimal sleep during the shift. PCA/M indicated she did report the hallucinations to the nurse and was not provided any instruction. PCA/M clarified it is not uncommon to have patients hallucinate after a drug overdose. PCA/M indicated at approximately 4:00 a.m. P1 refused his medication, refused to have his vital signs taken and pulled out his IV. P1 asked the police officer about his discharge and P1 thought he was going home and kept talking about getting his truck and his wife would get the house. P1 was informed by the police officer that P1 was not going home, but was going to jail. Shortly after, P1 started walking towards the door, the police officer stood up, P1 charged the police officer and obtained the firearm. P1 and the police officer struggled, PCA/M heard gun shots, and all emergency protocols were activated.

The hospitals Medical Staff Bylaws, Policies and Rules and Regulations of the Hospital, not dated, indicated:
o The duties of the Department Chairperson is responsible for all clinically related activities of the department and integrating the department into the primary functions of the hospital by developing and implementing policies and procedures that guide and support the provision of care, treatment and services, continuing assessment and improvement of the quality of care, treatment, and services provided.
o Performance improvement functions of the Medical Staff included the measurement, assessment and improvement of medical assessment and treatment of patients, and, participates in the care, treatment, and services with other practitioners and hospital personnel.

Rules and Regulations of the Medical Staff of the Hospital, not dated, indicated:
o For the protection of patients, staff and the hospital certain principles are to be met in the care of potentially suicidal patients: suicidal patients are to be admitted to the psychiatric unit, if the unit is full the suicidal patient should be referred to other institutions that would be available and not admit the patient to other floors of the hospital. However, in the judgement of the physician, if a serious medical problem exist of a higher priority than the underlying psychiatric problem, the patient is to be admitted to the necessary nursing unit with one-to-one nursing care. The admitting practitioner is responsible for giving information that may be necessary to protect the patient and others from self-harm whenever the patient might be a source of danger.
o Consult is a service provided by a physician whose opinion or advice regarding an evaluation and/or management of a specific problem is requested by another physician. Urgent consults will be called to the responding physician by the requesting physician; non-urgent consults will entered and handled by the contact center. Call groups can exercise the right to have consultation requests more stringent than the outline of urgent or non-urgent.
o Transfer of partial care is a transfer of a portion of a patient's care to another Medical Staff member who will become responsible for that portion of the patient's care.
o Judgement as to the serious nature of the illness, and the question of doubt as to the diagnosis and treatment rests with the practitioner responsible for the care of the patient, and is the duty of the organized Medical Staff through Department Chairpersons and Executive Committee to see that those clinic privileges do not fail in the matter of ordering consultation.

Policy and Procedure titled Hold Policy for Voluntary and Involuntary Admissions, 72-Hour Holds dated 11/13 indicated 72-hour holds are initial steps in the Minnesota Commitment and Treatment Act and only a physician may order a 72-hour hold. The patient must be evaluated by a physician and the physician's initial assessment and statement in support of emergency admission must fill out Part B of the 72-hour hold form. If a physician other than a psychiatrist places a patient on the 72-hour hold a psychiatric consult is recommended within 24 hours. A physician must evaluate the continuation of the 72-hold within 48 hours of the admission. Only a physician may discontinue a hold order.

A review of the implemented 72 hour holds revealed 18 of 264 patients since 07/02/15 were placed on a 72 hour hold by a LIP.


The Physician Assistant-Provider job description for the Behavioral Health Clinic and Adult Psychiatry dated April 1, 2014 indicated physician assistants assess, plan, evaluate, implement and coordinate care of the adult psychiatric patients with collaboration of the adult psychiatrist and is supervised by adult psychiatrist, but is responsible to the Care Center Medical Director of Behavioral Health Services.

The hospital did not have a policy and procedure or guidelines for a police officer to guard a patient with a violent history, while on an inpatient medical unit and not in custody of law enforcement.