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Based on interview and record review the facility failed to ensure the Condition of Participation for Governing Body was met as evidenced by:

1. The Governing Body failed to ensure its Contracted Clinic performed all necessary tests (such as EKG [electrocardiogram, a recording of the heart's electrical activity] and Chest X-ray [a test that creates an image of the heart, lungs, and bones]) prior to admitting one of 30 sampled patients (Patient 1) to the facility and failed to ensure Patient 1 met the criteria for admission to the facility, in accordance with the facility's policy and procedure regarding criteria for admission.

This deficient practice had the potential for Patient 1 to have medical complications (such as cardiac arrest [when the heart stops beating]) that the facility may not be able to handle, making it unsafe to admit Patient 1. (Refer to A-0083)

2. The Governing Body failed to ensure an onsite physician (a physician who is physically present at the facility) was readily available for one of 30 sampled patients (Patient 1), who was experiencing a medical emergency (low blood pressure and low heart rate).

This deficient practice resulted in the nursing staff handling a medical emergency for Patient 1 without a physician physically present to evaluate Patient 1's condition including Patient 1's responses to interventions and give direction to nursing staff. This deficient practice also resulted in Patient 1's death. (Refer to A- 0093)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.

Based on interview and record review, the facility's Governing Body failed to ensure its Contracted Clinic performed all necessary tests (such as EKG [electrocardiogram, a recording of the heart's electrical activity] and Chest X-ray [a test that creates an image of the heart, lungs, and bones]) and clearance prior to admitting one of 30 sampled patients (Patient 1) to the facility and failed to ensure Patient 1 met the criteria for admission to the facility, in accordance with the facility's policy and procedure regarding criteria for admission.

This deficient practice had the potential for Patient 1 to have medical complications (such as cardiac arrest [when the heart stops beating]) that the facility may not be able to handle, making it unsafe to admit Patient 1.

Findings:

During a review of Patient 1's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/07/2023 at 10:06 p.m., the H&P indicated the following: Patient 1 was admitted to the facility on 12/6/2023 on a 5150-Hold (72-hour, involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) for being a danger to others and agitated (a feeling of irritability or severe restlessness) behavior.

Patient 1's diagnosis included paranoid schizophrenia (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucinations [sensing things such as visions, sounds or smells that seem real but are not]), morbid obesity (over 100 pounds over your recommended weight), type 2 diabetes (high blood sugar), hypertension (high blood pressure), and seizures (medical condition that happens due to uncontrolled activity in the brain).
During a review of Patient 1's "Vital Signs (include temperature, blood pressure, heart rate, respiratory rate)," record dated 12/14/203 at 8 a.m., the Vital Signs record indicated Patient 1 weighed 460 pounds (lbs., a unit of measurement)

During a review of Patient 1's "Nutrition Assessment," dated 12/14/2023 at 9:44 a.m., the Nutrition Assessment indicated the following: Patient 1 weighed 460 lbs. and was 68 inches tall. Body Mass Index (a measure of body fat based on height and weight): 69.94 (over 40 indicates morbid obesity).

During a concurrent interview and review of Patient 1's medical record on 1/08/2024 at 2:53 p.m., with Registered Nurse (RN) 1, RN 1 stated Patient 1 was admitted to the facility on 12/06/2023 to the Medical Surgical Unit (serves the general patient population hospitalized for various cases such as surgery, etc.) from the facility's Contracted Clinic (Clinic), located on the second (2nd) floor of the building. RN 1 stated Patient 1 was on a 5150 Hold for being a danger to others and agitation (a feeling of irritability or severe restlessness).

RN 1 stated Patient 1 weighed 460 pounds (lbs.) and was morbidly obese. RN 1 stated patients were medically cleared by the Clinic prior to admission. The medical clearance included an electrocardiogram (EKG, a recording of the heart's electrical activity) and a chest x-ray (a test that creates an image of the heart, lungs, and bones). RN 1 verified that an EKG and a chest X-ray were not performed by the Clinic prior to clearing Patient 1 for admission. RN 1 verified that on 12/16/2023, Patient 1's health declined, and Patient 1 expired on 12/16/2023 at 6:20 a.m.

During a concurrent interview and review of Patient 1's medical record on 1/11/2024 at 12:38 p.m., with House Supervisor (HS) 2, HS 2 verified Patient 1's documented weight was 460 lbs. HS 2 also verified Patient 1 had multiple co-morbidities (existence of more than one disease or condition within the body at the same time), including diabetes and hypertension. HS 2 stated patients who weigh 460 lbs. should not be admitted to the facility because their (referring to the patients) health can decline very quickly. HS 2 stated Patient 1 should not have been admitted to the facility because the facility does not have the capability to address the patient's (Patient 1) condition if the patient suffers from complications of morbid obesity along with Patient 1's multiple co-morbidities.

During an interview on 1/11/2024 at 2:20 p.m., with Physician (MD) 1, in the Contracted Clinic, MD 1 stated the Clinic medically cleared patients prior to admitting the patients to the facility. Medical clearance included an EKG and a chest X-ray for all the patients. MD 1 stated Patients who weigh 460 lbs. and have co-morbidities (such as hypertension and diabetes) should not be admitted to the facility.

During a review of the facility's policies and procedure (P&P) titled, "Admission Criteria," dated 3/2022, the P&P indicated the following: Purpose: To provide guidelines for admission to the Psychiatric Unit that conforms to the laws of California. Procedure: ...Patients must be medically cleared before they are admitted to the psychiatric unit ...Conditions that may prevent admission but are not limited to the following: ...Morbid Obesity (over 100 pounds over your ideal body weight).

During a review of the facility's "Service Agreement," between the facility and the Contracted Clinic (Company or Clinic), dated 10/2023, the Service Agreement indicated the following: "Applicable Standards. Company and its staff agree that the Services shall be performed in compliance with all applicable standards set forth by law or ordinance or established by the rules and regulations of any federal, state, or local agency, department, commission, association or other pertinent governing, accrediting, or advisory body, including the Joint Commission (an agency that oversees quality improvement and patient safety in health care), Healthcare Facilities Accreditation Program or other accrediting agencies, having authority to set standards for health care facilities. Exhibit A: Services and Fees: Medical Clearance ..."

Based on interview and record review, the facility's Governing Body failed to ensure an onsite physician (a physician who is physically present at the facility) was readily available for one of 30 sampled patients (Patient 1), who was experiencing a medical emergency (low blood pressure and low heart rate).

This deficient practice resulted in the nursing staff handling a medical emergency for Patient 1 without a physician physically present to evaluate Patient 1's condition including Patient 1's responses to interventions and give direction to nursing staff. This deficient practice also resulted in Patient 1's death.

On 1/09/2024 at 4:35 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Chief Nursing Officer (CNO), Vice President of Operations (VPO), Pharmacy Manager (Pharm M), Chief Strategist Officer (CSO), and the Director of Quality & Risk Management (DQRM). Prior to 1/8/2024, the facility failed to provide an on-site physician to be readily available for a patient (Patient 1) experiencing a medical emergency during the night shift.

Patient 1 was admitted to the facility on 12/6/2023 on a 5150-Hold (72-hour, involuntary hold- a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) for being a danger to others and agitated (a feeling of irritability or severe restlessness) behavior.

Patient 1's diagnosis included paranoid schizophrenia (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucinations [sensing things such as visions, sounds or smells that seem real but are not]), morbid obesity (over 100 pounds over your recommended weight), type 2 diabetes (high blood sugar), hypertension (high blood pressure), and seizures (medical condition that happens due to uncontrolled activity in the brain).

On 12/16/2023 at 5:45 a.m., a Rapid Response (a process for working with a rapidly declining patient) was called for Patient 1, who was found unresponsive (unconscious and possibly dead or dying). In addition, Patient 1's blood pressure (BP) was 60/35 (low, normal is 120/80) millimeters of mercury (mmHg, a unit of measurement), heart rate was 32 (Normal range 60 - 100), and oxygen saturation level (measures the amount of oxygen in the blood) was 48 % (normal is 90 - 100 %). No interventions addressing the abnormal vital signs (includes temperature, blood pressure, heart rate, respiratory rate) were documented during the Rapid Response. Nursing staff were not able to establish an intravenous (IV, into the vein) line, despite multiple attempts. The House Supervisor (HS 1) contacted a physician, by telephone, who ordered a stat (immediate) EKG (electrocardiogram, a recording of the heart's electrical activity) and Code Blue (patient with an unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]).

A Code Blue was called at 5:50 a.m., when CPR (cardiopulmonary resuscitation, an emergency procedure consisting of chest compressions and artificial ventilation [a means of assisting or stimulating breathing]) and assisted breathing were started. IV insertion efforts were still unsuccessful, and the facility was unable to administer emergency medications. There was no documentation that a provider (physician) arrived onsite at the facility to lead the Code Blue, assist with emergency IV access, or interpret the EKG results. At 5:59 a.m., the paramedics arrived and took over CPR. At 6:20 a.m., CPR was terminated and Patient 1 expired (died). There was no policy or process in place to provide on-site physician coverage overnight, to care for patients experiencing a medical emergency.

On 1/11/2024 at 5:23 p.m., the IJ was removed in the presence of the CNO, DQRM, Chief Executive Officer (CEO), and Administration (ADM) after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record reviews. The IJ Removal Plan indicated that the facility's Governing Body would ensure ongoing compliance and provide oversite for all hospital activities including 24-hour onsite physician coverage. The facility had a contract agreement with an on-site clinic to provide on-site physician coverage during the day shift from 9 a.m. to 9 p.m. The facility amended its contract agreement with the clinic to include 24-hour physician coverage by adding on-site physician coverage to respond to Rapid Reponses and Code Blues during the night shift from 9 p.m. to 9 a.m., effective 1/10/2024. The facility's Rules & Regulations were updated to include an on-site physician, from the contracted clinic, who would be available for 24-hours a day, 7 days a week.

Physician responsibilities included medical evaluation, assessment of patient's condition, interventions, and recommendations for the plan of care. The on-site physician must be prepared to respond promptly to emergencies including code blues, rapid responses, or other critical situations. The physicians are also required to provide consultations, prescribe medications if needed, and document all interactions and clinical decisions in the electronic medical record. In addition, the facility implemented its policy titled, "Hospital Plan for Provision of Care," to include 24 hour 7 days a week clinic on-site physician. All healthcare providers were expected to comply with this policy.


Findings:

During a review of Patient 1's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/07/2023 at 10:06 p.m., the H&P indicated the following: Patient 1 was admitted to the facility on 12/6/2023 on a 5150-Hold (72-hour, involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) for being a danger to others and agitated (a feeling of irritability or severe restlessness) behavior. Patient 1's diagnosis included paranoid schizophrenia (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucinations [sensing things such as visions, sounds or smells that seem real but are not]), morbid obesity (over 100 pounds over your recommended weight), type 2 diabetes (high blood sugar), hypertension (high blood pressure), and seizures (medical condition that happens due to uncontrolled activity in the brain).

During a review of Patient's 1's nurses note titled, "Interdisciplinary (comprise of the physician, nurse, respiratory therapist, etc. Involved in the care of a patient) Team Progress Note," dated 12/16/2023 at 5:45 a.m., the Interdisciplinary Team Progress Note indicated a Rapid Response (a process for working with a rapidly declining patient) was called for Patient 1 due to Patient 1 found unresponsive (unconscious and possibly dead or dying) with the following vital signs: Blood pressure (BP) 60/35 (normal 120/80) millimeters of mercury (mmHg, a unit of measurement), heart rate (HR) 32 (normal 60 - 100) and oxygen saturation level (sp02, measures the amount of oxygen circulating in the blood) 48% (normal 90 - 100), respirations were not documented. Rapid response (a process for working with a rapidly declining patient) was called. There was no documentation to indicate that Patient 1 was provided with supportive medical management (includes interventions such as face mask to deliver oxygen, intravenous [IV, into the vein] fluids, etc.) for the low saturation, low BP, and low HR.

During a review of Patient's 1's nurses note titled, "Nursing Progress Note," dated 12/16/2023 at 5:47 a.m., the Nursing Progress Note indicated that the facility was not able to establish the Intravenous (IV, into the vein) access on Patient 1 despite of numerous attempts during the Rapid Response.

During a review of Patient's 1's nurses note titled, "Progress Note," dated 12/16/2023, at 9:10 a.m., the Progress Note indicated, the house supervisor (HS 1) contacted the Nurse Practitioner (NP), and then the Medical Doctor (MD). MD gave a telephone order for a stat (immediate) EKG (electrocardiogram, a recording of the heart's electrical activity) and code blue (patient with an unexpected cardiac or respiratory arrest [when the heart stops beating] requiring resuscitation [methods used to restart the heart and lungs when they stop working]). There was no documentation that NP or MD arrived on-site to the facility to evaluate Patient 1's condition and guide the nursing staff with interventions to address Patient 1's medical emergency.

During a review of Patient 1's CPR (Cardiopulmonary Resuscitation, an emergency procedure consisting of chest compressions and artificial ventilation [a means of assisting or stimulating breathing]) Record," dated 12/16/2023, the CPR record indicated the Code Blue was initiated at 5:50 a.m., because Patient 1 was in asystole (no heart-beat or flatline) and assisted breathing (use of devices to help a patient breathe) was provided; at 5:50 a.m., IV access insertion was still unsuccessful. At 5:51 a.m. (6 minutes after the Rapid Response was initiated) 9-1-1 was called; at 5:58 a.m., code blue team continued CPR. At 5:59 a.m., paramedics arrived and took over CPR. At 6:20 a.m., CPR terminated and Patient 1 expired (died). The Code Blue for Patient 1 was initiated by Licensed Vocational Nurse (LVN) 1.

During an interview on 1/9/2024 at 11:11 a.m., RN 1 stated the House Supervisor leads the code blue team if a physician is not available.

During an interview on 1/9/2024, at 10:00 a.m., with the Chief Nursing Officer (CNO), the CNO stated, if a rapid response is called on a patient, the primary physician is notified. The CNO stated, during the Code Blue, staff should begin CPR, activate the ACLS (Advance Cardiac Life Support, a set of life-saving protocols and skills that goes beyond the basic life support [such as CPR]) protocol and call the on-call physician for further orders. Primary MD had to be informed of the patient's change of condition. The CNO further stated, the On-Call (means physician is available to work when called) physician is called for the orders and is expected to come on-site for further treatment. The CNO also stated, prior to 1/8/2024, the facility did not have an on-site physician to cover the night shift hours from 11:00 p.m. to 7:00 a.m., since November 2022 when the Intensive Care Unit (ICU, a specialized unit that cares for patients that require critical medical care) closed. The Rapid Response and the Code Blue for Patient 1 happened between 11:00 p.m. and 7:00 a.m. when there was no on-site physician present at the facility. This was verified by the CNO during an interview.

During an interview on 1/9/2024 at 11:20 a.m., with the Chief of Staff (COS), the COS stated physicians take on- call telephone calls. There was no on-site physician at night and the physicians taking on- call telephone calls at night were not present on-site.

During an interview on 1/9/2024 at 11:40 a.m., with the Chief Medical Officer (MD 2), the MD 2 stated the on-call schedule prepared by the facility was on-call physician schedule for phone calls and not in-person on-call which meant there was no on-site physician available at night to respond to medical emergencies. The physicians only take phone calls from the nursing staff and orders are given over the phone when there is a medical emergency.

There was no policy or process in place to provide on-site physician coverage overnight, to care for patients in the facility requiring care for medical emergencies. This was verified by the CNO during an interview.

Based on observation, interview and record review the facility failed to ensure the Condition of Participation for Patient Rights was met as evidenced by:

1. The facility failed to ensure that patient rights (ethical principles that apply to patient care; informs patient of their autonomy over medical decisions and rights as a patient in the hospital. Example: right to participate in decision-making regarding treatment plan, etc.) information and conditions of admissions (COA- a form that outlines the patient's obligations for hospital services received, including the duty to pay for services rendered) information was provided for one of 30 sampled patients (Patient 26).

This deficiency resulted in Patient 26 not being informed of his (Patient 26) rights as a patient, which may result in Patient 26 not being involved in the treatment plan and may cause delay in the patient's (Patient 26) recovery. (Refer to A-0117)

2. The facility failed to assess for environmental safety risks (such as ligature [anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation] risks) to identify potential hazards for patients at risk of harm to themselves or others for two of 30 sampled patients (Patient 15 and Patient 16). Both patients (Patient 15 and Patient 16) were admitted to the facility on a 5150-hold (72-hour involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) due to danger to self and others.

This deficient practice had the potential to compromise Patient 15's and Patient 16's health and safety due to the lack of proper environmental safety checks, to assess for presence of ligature risks, conducted by the facility, which may result in patient harm and/or death via hanging or strangulation (external pressure applied to the neck, by any means, that obstructs the blood flow and/or airflow) using available cords in the patient room. (Refer to A- 0144)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.

Based on interview and record review, the facility failed to ensure that patient rights (ethical principles that apply to patient care; informs patient of their autonomy over medical decisions and rights as a patient in the hospital. Example: right to participate in decision-making regarding treatment plan, etc.) information and conditions of admissions (COA- a form that outlines the patient's obligations for hospital services received, including the duty to pay for services rendered) information was provided for one of 30 sampled patients (Patient 26).

This deficiency resulted in Patient 26 not being informed of his (Patient 26) rights as a patient, which may result in Patient 26 not being involved in the treatment plan and may cause delay in the patient's (Patient 26) recovery.

Findings:

During a review of Patient 26' Face Sheet (a document that gives a patient's information at a quick glance), dated 1/4/2024, the Face Sheet indicated Patient 26 was admitted on 1/4/2024 at 9:00 p.m. with diagnoses of mental illness (changes in emotion, thinking or behavior), angry outbursts, and aggressive behavior.

During a review of Patient 26' "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 1/5/2024 at 1:19 p.m., the H&P indicated Patient 26 had a past medical history of Alzheimer's disease (a brain disorder that slowly affects a person's memory and thinking skills), major depression (a serious medical illness that affects how someone feels, the way they think and how they act), schizophrenia (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucinations [sensing things such as visions, sounds or smells that seem real but are not]) and psychosis (severe mental condition affecting thought processes and emotions, requiring hospitalization). The H&P further indicated Patient 26 was able to participate in a "review of systems (series of questions asked by a physician to identify signs and/or symptoms the patient may be experiencing)." The H&P did not indicate Patient 26 was unable to make independent decisions regarding medical care.

During a review of Patient 26' Psychiatric Evaluation (comprehensive evaluations conducted by qualified mental health physician), dated 1/5/2024 at 10:28 a.m., Patient 26' Psychiatric Evaluation indicated Patient 26 was admitted to the facility under a 5150 hold (72-hour, involuntary hold- a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) due to being a danger to others.

During a review of Patient 26' psychosocial assessment (an evaluation of a person's mental health, social status, and functional capacity within the community), dated 1/5/2024 at 12:25 p.m., Patient 26's psychosocial assessment indicated Patient 26 had no learning barriers (anything that prevents a learner from being fully engaged in the learning process) identified.

During a concurrent interview and record review on 1/11/2024 at 11:18 a.m. with the Behavioral Health Director (BHD), Patient 26' medical records indicated Patient 26' admissions forms (forms signed when admitted to the hospital), including the Conditions of Admission (COA- a form that outlines the patient's obligations for hospital services received, including the duty to pay for services rendered) and Patient's Rights (ethical principles that apply to patient care; informs patient of their autonomy over medical decisions and rights as a patient in the hospital. Example: right to participate in decision-making regarding treatment plan, etc.) forms, were not signed by Patient 26. BHD said the admission forms which included the COA, and the Patient Rights forms, were not signed by Patient 26 to indicate acknowledgement and receipt. BHD stated that when patients were on a 5150 hold, they (referring to patients) can make decisions for themselves, if they were assessed to have the capability such as in the case of Patient 26. BHD also said if patients can make decisions for themselves, they should be provided with and sign their own admission forms such as the COA and the Patient Rights form. BHD further stated that on admission, patients should be informed of their patient rights.

During a concurrent interview and record review on 1/11/2024 at 1:05 p.m. with Social Worker 1 (SW 1), SW 1 stated, when a patient was admitted, it was the social workers responsibility to meet with the patient and perform a psychosocial assessment. SW 1 confirmed that Patient 26' psychosocial assessment indicated Patient 26 had the ability to make independent decisions. SW 1 confirmed that Patient 26 should have signed the admission forms independently which included information regarding his (Patient 26) patient rights.

During an interview on 1/11/2024 at 2:13 p.m. with Admitting Clerk 1 (AC 1), AC 1 stated that upon admission, patients were registered by the admitting clerk. AC 1 stated the admitting clerk's duties were to gather information and obtain signatures for admission paperwork, including the conditions of admission and patient rights forms. AC 1 stated the admission paperwork was forwarded to the social worker for follow up. AC 1 stated it was the responsibility of the social worker to review the admission paperwork submitted by the admitting clerk and follow up with the patient to ensure the patients received and signed their admission forms and informed of their patient rights if capable of doing so.

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights: Rights of Involuntary Patients 5150," dated March 2019, the P&P indicated: "Policy: It is the policy ...to exhibit and adhere to the rights of involuntary patients as defined by the State of California ... Procedure: 3. All patients receiving involuntary inpatient mental health services have the right to be informed verbally and in writing within twenty-four (24) hours of admission, in the person's primary language, in simple, non-technical terms, of their rights ..."

Based on observation, interview, and record review, The facility failed to assess for environmental safety risks (such as ligature [anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation] risks) to identify potential hazards for patients at risk of harm to themselves or others for two of 30 sampled patients (Patient 15 and Patient 16). Both patients (Patient 15 and Patient 16) were admitted to the facility on a 5150-hold (72-hour involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) due to danger to self and others.

This deficient practice had the potential to compromise Patient 15's and Patient 16's health and safety due to the lack of proper environmental safety checks, to assess for presence of ligature risks, conducted by the facility, which may result in patient harm and/or death via hanging or strangulation (external pressure applied to the neck, by any means, that obstructs the blood flow and/or airflow) using available cords in the patient room.

Findings:

1a. During a review of Patient 15's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/28/2023, the H&P indicated, Patient 15 was admitted to the facility's medical/surgical (serves the general patient population hospitalized for various cases such as surgery, etc.) floor (a dual psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] and medical unit, for patients with psychiatric and medical health conditions) for a psychiatric treatment for increasing psychosis (severe mental condition affecting thought processes and emotions, requiring hospitalization).

During a review of Patient 15's Psychiatric Evaluation (Psych Eval, thorough mental health assessment), dated 12/28/2023, the Psychiatric Evaluation indicated, Patient 15 was admitted on 5150 hold (72-hour involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others), endorsing homicidal ideation (a thought pattern characterized by the desire to kill another person or persons, along with a mental plan for a method of doing it) to assault (attack violently).

During an observation on 1/8/2024, at 3:30 p.m., in Patient 15's room, Patient 15 was observed in bed, with privacy curtain pulled over visual field, preventing the line of sight (a level of observation wherein the patient remains in staff view at all times) from staff.

During a concurrent observation and interview on 1/8/2024 at 3:22 p.m. with Chief Nursing Officer (CNO), Patient 15's room was observed. Multiple ligature (anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) risk points were identified: an electric cord on bed, electric cords behind television exposed, call light with a long cord placed on Patient 15's bed, empty laundry basket with plastic liner parked inside the room, multiple door knobs, shoes with shoelaces, and the emergency pull cord in the bathroom were identified. The CNO stated, electric cords should be removed for psychiatric patients because this is not safe and CNO also stated maintenance should be called to remove the ligature risks.

During an interview on 1/8/2024 at 3:22 p.m. with the CNO, the CNO stated, the facility uses medical surgical units located on the 6th and 7th floors for patients with psychiatric and medical conditions alike. The CNO further stated, most patients on the 6th and 7th floors were psychiatric patients and multiple patients were on a 5150 hold or a 5250 hold (a law that allows a patient with mental, emotional and behavioral issues to be detained for 14 days involuntarily for stabilization treatment [interventions to address mental health]). The CNO stated, there were safety rounds (patient rounding, a best practice intervention to ensure patient safety) that were done by the assigned mental health workers every 15 minutes to check on patients, but there was no ligature risk assessment including the removal of ligatures that was done during those safety rounds.

During an interview on 1/8/2024 at 3:35 p.m. with Registered Nurse (RN 2), the RN 2 stated, the safety checks were conducted by mental health workers at every 15 minutes intervals, but the RN 2 further stated this safety check was not the primary nurse's duty to oversee the rounds for safety checks and the documentation by the mental health workers. The RN 2 also said, actively suicidal patients required a one-to-one (1:1 - consist of one-to-one staff observation with a patient never farther away at arm's length at all times) order for a sitter and patients with aggressive behavior were monitored by the mental health workers during the safety rounds. The RN 2 was not able to identify potential environmental hazards in patients' rooms.

During an interview on 1/8/2023 at 3:55 p.m. with mental health worker (MHW) 1, the MHW 1 was not able to identify ligature risks in the environment when conducting safety checks. MHW 1 stated, "I do round (patient rounding, a best practice intervention to ensure patient safety) on patients every 15 minutes and document observations and patients' whereabouts." However, MHW 1 was not able to verbalize that the presence of ligature risks in the patients' rooms were part of what was being observed during patient rounding. MHW 1 stated that the observations conducted only included observing what the patient was doing and does not include observing/checking the environment for any potential hazards that the patients can use to harm themselves or others.

During a concurrent interview and record review on 1/10/2024 at 2:25 p.m. with the facility's case manager (CM), Patient 15's record titled, "Patient Round Sheet," dated 1/7/2024 to 1/8/2024, was reviewed. The record indicated, on 1/8/2024 and 1/9/2024, the mental health worker (MHW) did not mark Patient 15's level of precautions (Level II: standard every 15 minutes round checks; or Level III: patient requires constant observation) and no measures indicating what precautions (safety precautions) were implemented for Patient 15, were marked. On 1/7/2024, the MHW marked both Level II and Level III, for Patient 15. The CM stated only one level of precautions must be marked for a patient, as well as measures/interventions implemented, based on precautions identified for the patient during safety rounds checks. The CM further stated, the MHU may need further training on conducting patient safety round checks.

During a concurrent interview and record review on 1/10/2024 at 2:25 p.m. with the Case manager (CM), Patient 15's medical record, dated 12/28/203 to 1/9/2023 was reviewed. The record indicated, no documentation of environment safety assessment for Patient 15 was documented anywhere in the records.

During an interview on 1/12/2024 at 1:24 p.m. with the Chief Nursing Officer (CNO), the CNO stated, there were many ligature risks in patients' room on the 6th and 7th floors because the floors were designed as medical floors, not psychiatric floors; however, the majority of patients admitted to these floors were psychiatric patients and many of the patients were on a hold for danger to self or others. The CNO further stated, patients can hurt themselves or others with ligature points and therefore, the environmental hazards needed to be identified and removed during safety checks. The CNO further stated, no ligature risk reduction training was ever provided to staff working in the facility and the facility did not have a process for safety risks assessment to be conducted by the staff to identify hazards and environmental risks to provide safety to patients at risk for harm to themselves or others.

During a review of the facility's policy and procedure (P&P) titled, "Ligature Risk Reduction/Mental Health Environment of Care Check List," dated 10/02/2023, the P&P indicated, "Inpatient psychiatric medical and psychiatric units, must achieve a ligature-resistant environment to promote safety for patients at risk of harm to themselves or others. Systematic environmental assessments using the facility assessment tool for the purpose of eliminating factors that could contribute to the attempted suicide (ending own life) or harm of a patient or staff members. Ligature risk points are defined as anything that could be used to create a sustainable attachment point, such as cord, rope, or other materials, for hanging or strangulation. Common points include doorknobs, handles, hooks, window frames, belts, sheets, towels, shoelaces."

1b. During a review of Patient 16's History and Physical (H&P, a formal and complete assessment of the patient and the problem) ), dated 1/5/2024, the H&P indicated, Patient 16 was admitted for a psychiatric (a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders) management to the facility's medical/surgical (serves the general patient population hospitalized for various cases such as surgery, etc.) floor (a dual psychiatric and medical floor, for patients with psychiatric disorders and medical health conditions) for a psychiatric treatment for increasing psychosis (severe mental condition affecting thought processes and emotions, requiring hospitalization) due to aggression toward others. Patient 16 was placed on a 5150 Hold (72-hour involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others).

During a review of Patient 16's psychiatric evaluation (Psych eval, thorough mental health evaluation), dated 1/5/2024, the Psychiatric Evaluation indicated, Patient 16 was placed on 5150 hold due to risk of striking out at others and required psychiatric treatment. The Psychiatric evaluation further indicated, Patient 16 had no regard for safety and required supervision to prevent violent acting out.

During a review of Patient 16's medical record titled, "Nursing Assessment," dated 1/5/2024, the Nursing Assessment record indicated, Patient 16 had poor insight (deficit of the capacity of Judgment), poor eye contact (avoidance of looking at someone directly in the eye), poor judgement (inability to make appropriate decisions), and irritable mood (feeling of agitation as a result of mental health condition). The record further indicated, Patient 1 was alert and oriented to self only.

During an interview on 1/8/2024 at 3:35 p.m. with Registered Nurse (RN 2), RN 2 stated, the safety checks were conducted by mental health workers at every 15 minutes intervals, but the RN 2 further stated this was not the primary nurse's duty to oversee the rounds (patient rounding, a best practice intervention to ensure patient safety) for safety checks and the documentation by the mental health workers. The RN 2 also stated, actively suicidal patients required a one-to-one (1:1- consist of one-to-one staff observation with a patient never farther away at arm's length at all times) order for a sitter and patients with aggressive behavior were monitored by the mental health workers during the safety rounds. The RN 2 was not able to identify potential environmental hazards in patients' rooms.

During an interview on 1/8/2023 at 3:55 p.m. with mental health worker (MHW) 1, the MHW 1 was not able to identify ligature risks in the environment when conducting safety checks. MHW 1 stated, "I do round (patient rounding, a best practice intervention to ensure patient safety) on patients every 15 minutes and document observations and patients' whereabouts." However, MHW 1 was not able to verbalize that the presence of ligature risks in the patients' rooms were part of what was being observed during patient rounding. MHW 1 stated that the observations conducted only included observing what the patient was doing and does not include observing/checking the environment for any potential hazards that the patients can use to harm themselves or others.

During a concurrent interview and record review on 1/10/2024 at 2:25 p.m. with the facility's case manager (CM), Patient 16's record titled, "Patient Round Sheet," dated 1/7/2024 to 1/8/2024, was reviewed. The record indicated, on 1/8/2024 and 1/9/2024, the mental health worker (MHW) did not mark Patient 16's level of precautions (Level II: standard every 15 minutes round checks; or Level III: patient requires constant observation) and no measures indicating what precautions (safety precautions) were implemented for Patient 16, were marked. On 1/7/2024, the MHW marked both Level II and Level III, for Patient 16. The CM stated only one level of precautions must be marked for a patient, as well as measures implemented, based on precautions identified for the patient during safety rounds checks. The CM further stated, the MHW may need further training on conducting patient safety round checks.

During an interview and concurrent record review on 1/11/2024, at 11:17 a.m., with the case manager (CM), Patient 16's medical record (MR) dated 1/5/2024 to 1/8/2024 was reviewed. The MR contained no record of environmental safety screening. The CM stated, the facility does not have an assessment tool to screen for and identify environmental hazards.

During an interview on 1/11/2024 at 2:14 p.m. with facility supervisor (HS 2), the HS 2 stated, environmental safety checks on both 6th & 7th medical/surgical floors, should be conducted, but there was nothing that can be done about the ligature (anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) risks. The HS 2 further stated, if a patient was actively suicidal, a 1:1 sitter may be assigned, otherwise, the staff does frequent rounding which was done by the mental health workers for safety and nurses conduct routine behavior assessment for each patient.

During an interview on 1/11/2024 at 2:14 p.m. with facility supervisor (HS 2), the HS 2 was not able to state what was meant by Level II and Level III precautions (Level II: standard every 15 minutes round checks; or Level III: patient requires constant observation) documented on "Patient Round Sheet" and stated, mental health workers should know.

During an interview on 1/12/2024 at 1:24 p.m. with the Chief Nursing Officer (CNO), the CNO stated, there were many ligature risks in patients' room on the 6th and 7th floors because the floors were designed as medical floors, not psychiatric floors; however, the majority of patients admitted to these floors were psychiatric patients and many of the patients were on a hold for danger to self or others. The CNO further stated, patients can hurt themselves or others with ligature points and therefore, the environmental hazards needed to be identified and removed during safety checks. The CNO further stated, no ligature risk reduction training was ever provided to staff working in the facility and the facility did not have a process for safety risks assessment to be conducted by the staff to identify hazards and environmental risks to provide safety to patients at risk for harm to themselves or others.

During a review of the facility's policy and procedure (P&P) titled, "Ligature Risk Reduction/Mental Health Environment of Care Check List," dated 10/02/2023, the P&P indicated, "Inpatient psychiatric medical and psychiatric units, must achieve a ligature-resistant environment to promote safety for patients at risk of harm to themselves or others. Systematic environmental assessments using the facility assessment tool for the purpose of eliminating factors that could contribute to the attempted suicide or harm of a patient or staff members. Ligature risk points are defined as anything that could be used to create a sustainable attachment point, such as cord, rope, or other materials, for hanging or strangulation. Common points include doorknobs, handles, hooks, window frames, belts, sheets, towels, shoelaces."

Based on interview and record review the facility failed to ensure the Condition of Participation for Quality Assurance Performance Improvement (QAPI) was met as evidenced by:

1. The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI, a process used to ensure services are meeting quality standards and assuring care reaches a certain level) department analyze and provide measurable data to track the facility's rapid response (a process for working with a rapidly declining patient) and code blue (patient with an unexpected cardiac or respiratory arrest [when the heart stops beating] requiring resuscitation [methods used to restart the heart and lungs when they stop working]) events for one of two sampled patients (Patient 1).

This deficient practice resulted in the facility's inability to assess and monitor its staff performance including effectiveness of staff intervention in a rapid response and/or code blue event as evidenced by staff not following the facility's rapid response/code blue protocols (standard procedures to be followed and implemented during a medical emergency) which led to Patient 1's death. (Refer to A- 0273)


2. The facility failed to perform a root cause analysis (RCA, a structured, facilitated team process to identify the root cause of an event that resulted in an undesired outcome and develop corrective actions) on the facility's rapid response (a process for working with a rapidly declining patient) and code blue (patient with an unexpected cardiac or respiratory arrest [when the heart stops beating] requiring resuscitation [methods used to restart the heart and lungs when they stop working]) events for one of one sampled patient (Patient 1).

This deficient practice resulted in the facility's inability to identify potential system or process changes that could improve performance or improve patient safety and prevent any undesired outcome such as Patient 1's death or prevent harm and/or death to other patients admitted to the facility. (Refer to A- 0286)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments, thus compromising patient safety.

Based on interview and record review, the facility failed to ensure its Quality Assurance and Performance Improvement (QAPI, a process used to ensure services are meeting quality standards and assuring care reaches a certain level) department analyze and provide measurable data to track the facility's rapid response (a process for working with a rapidly declining patient) and code blue (patient with an unexpected cardiac or respiratory arrest [when the heart stops beating] requiring resuscitation [methods used to restart the heart and lungs when they stop working]) events for one of two sampled patients (Patient 1).

This deficient practice resulted in the facility's inability to assess and monitor its staff performance including the effectiveness of staff intervention in a rapid response and/or code blue event as evidenced by staff not following the facility's rapid response/code blue protocols (standard procedures to be followed and implemented during a medical emergency) which led to Patient 1's death.

Findings:

During a review of Patient 1's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/07/2023 at 10:06 p.m., the H&P indicated the following: Patient 1 was admitted to the facility on 12/6/2023, on a 5150-hold (72-hour involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others)) due to danger to others and agitated (a feeling of irritability or severe restlessness) behavior. Patient 1's admission diagnoses included paranoid schizophrenia (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucination [sensing things such as visions, sounds or smells that seem real but are not]), type 2 diabetes (high blood sugar), hypertension (high blood pressure), seizure (medical condition that happens due to uncontrolled activity in the brain), and morbid obesity (weight over 100 pounds over the recommended weight).

During a review of Patient's 1's nurses note titled, "Interdisciplinary Team Progress Note," dated 12/16/2023 at 5:45 a.m., the Interdisciplinary (comprise of the physician, nurse, respiratory therapist, etc. Involved in the care of a patient) Team Progress Note indicated a Rapid Response (a process for working with a rapidly declining patient) was called for Patient 1 due to Patient 1 found unresponsive (unconscious and possibly dead or dying) with the following vital signs: Blood pressure (BP) 60/35 (normal 120/80) millimeters of mercury (mmHg, a unit of measurement), heart rate (HR) 32 (normal 60 - 100) and oxygen saturation level (sp02, measures the amount of oxygen in the blood) 48% (normal 90 - 100), respirations were not documented. Rapid response was called. There was no documentation to indicate that Patient 1 was provided with supportive medical management for the low saturation, low BP, and low HR.

During a review of Patient 1's CPR (cardiopulmonary resuscitation, an emergency procedure consisting of chest compressions and artificial ventilation [a means of assisting or stimulating breathing]) Record," dated 12/16/2023, the CPR record indicated that a Code Blue (patient with an unexpected cardiac or respiratory arrest [when the heart stops beating] requiring resuscitation [methods used to restart the heart and lungs when they stop working]) was initiated at 5:50 a.m., because Patient 1 was in asystole (no heart-beat or flatline) and assisted breathing was provided; at 5:50 a.m., IV (intravenous, into the vein) access insertion was still unsuccessful. At 5:51 a.m., (6 minutes after the Rapid Response was initiated) 9-1-1 was called; at 5:58 a.m., code blue team continued CPR. At 5:59 a.m., paramedics arrived and took over CPR. At 6:20 a.m., CPR terminated and Patient 1 expired (died).

During a concurrent interview and review of Patient 1's nurses notes, on 01/10/2024, at 11:18 a.m., with the House supervisor (HS) 1, HS 1 confirmed that HS 1 responded to Patient 1's rapid response called on 12/16/2023 at 5:45 a.m. with arrival time at 5:47 a.m. Upon arrival, Patient 1 was unresponsive and was on oxygen with 2 liters per minute via nasal canula (a device used to deliver supplemental oxygen). HS 1 stated Patient 1's heart rate of 32 and spO2 (oxygen saturation) of 48% were out of range. Nursing staff attempted to insert IV in anticipation for IV fluids and emergency medications but were unsuccessful. HS 1 stated Code Blue was activated due to no pulse, no blood pressure and no respiration; at 5:49 a.m., Physician called back with orders to insert an IV line, intubate (a process of inserting a plastic tube into a patient's airway to assist with breathing) the patient, continue CPR, and give Epinephrine (a hormone used to restore heart rhythm) 1 mg every 3 minutes.

HS 1 stated Patient 1 was connected to the vital signs machine which monitored blood pressure and heart rate. Then nursing staff connected Patient 1 to a defibrillator (a device that applies an electric charge to the heart to restore a normal heartbeat). HS 1 stated, Patient 1 "had no pulse and was flat line for 10 minutes before the fire department's arrival." HS 1 stated the fire department arrived at 5:59 a.m. Upon arrival of fire department, the fire department staff took over CPR and established an intraosseous (IO, an emergency route for fluid and drug delivery) access on Patient 1's left shin. In addition, the fire department administered total of 3 doses of Epinephrine. CPR was terminated and Patient 1 was pronounced dead by the fire department at 6:20 a.m.

In addition, on 01/10/2024, at 11:30 a.m., HS 1 reviewed Patient 1's cardiac "Rhythm Strip (a record of the electrical activity of the heart)," dated 12/16/2023 at 5:59 a.m. and Patient 1's Code Blue cardiac rhythm strips dated 12/16/2023 at 5:52 a.m. and at 6:01 a.m. were reviewed. HS 1 stated she (HS 1) was the team leader for the Code Blue. HS 1 interpreted the rhythm strip after the Code Blue was over. HS 1 stated the cardiac rhythm at 5:52 a.m. and 6:01 a.m. indicated ventricular fibrillation (a life-threatening heart rhythm). HS 1 further stated with this rhythm, the patient should be shocked (shock, using an electrical charge to stop the heart's abnormal rhythm by a defibrillator). HS 1 stated the shock should have been delivered at 5:52 a.m. for Patient 1, but no shock was delivered during the code blue. HS 1 further stated the EKG completed on 12/16/2023 at 5:59 a.m. was never sent to a physician for interpretation.

During a review of the facility's Quality Council "2023 Risk Management Incident Dashboard (dashboard, a summary of different, but related data sets, presented in a way that makes the related information easier to understand)," dated 11/1/2023, the dashboard indicated, there were seven cases of "mortality (death)/code blue/rapid (responses)" in 2022 and nine cases of "mortality/code blue/rapid (responses)" up to third quarter in 2023. This was verified by the Director of Quality and Risk Management (DQRM) during an interview.

During an interview on 1/12/2024 at 2:53 p.m. with the Director of Quality & Risk Management (DQRM), DQRM stated code blue historical data was presented in a summary fashion but not aggregated (to collect into one) and not broken down into analytical data. There was no review of code blue events to analyze if protocol was followed, and no review of the outcome from the code blue. DQRM further stated Quality Assessment and Performance Improvement did not provide oversight to rapid response and code blue events.

During a record review of the facility's policy and procedure (P&P) titled, "Rapid Response Team," dated 2023, the P&P indicated, "A copy of the Rapid Assessment Team (RAT) record ... will also be sent to the Quality Improvement Coordinator, who will measure and trend the utility and effectiveness of the interventions employed."

During a record review of the facility's 2023 Hospital Performance Improvement Plan, dated 2023, the Hospital Performance Improvement Plan indicated, "the primary goal is to provide a comprehensive Performance Improvement Program that will coordinate and integrate all performance improvement activities hospital wide to assure that the highest achievable safe and quality of care is delivered to the patient ...the organization collects data on measures as outlined by regulatory agencies and as needed to evaluate the services provided by the organization ... at a minimum the organization collects data on these measures: outcomes related to resuscitation (methods used to restart the heart and lungs when they stop working) ... on an ongoing basis, the data collected is analyzed to provide information about the facility and the systems within."

Based on interview and record review, the facility failed to perform a root cause analysis (RCA, a structured, facilitated team process to identify the root cause of an event that resulted in an undesired outcome and develop corrective actions) on the facility's rapid response (a process for working with a rapidly declining patient) and code blue (patient with an unexpected cardiac or respiratory arrest [when the heart stops beating] requiring resuscitation [methods used to restart the heart and lungs when they stop working]) events for one of one sampled patient (Patient 1).

This deficient practice resulted in the facility's inability to identify potential system or process changes that could improve performance or improve patient safety and prevent any undesired outcome such as Patient 1's death or prevent harm and/or death to other patients admitted to the facility.

Findings:

During a review of Patient 1's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/07/2023 at 10:06 p.m., the H&P indicated the following: Patient 1 was admitted to the facility on 12/6/2023, on a 5150-hold (72-hour involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) due to danger to others and agitated (a feeling of irritability or severe restlessness) behavior. Patient 1's admission diagnoses included paranoid schizophrenia (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucination [sensing things such as visions, sounds or smells that seem real but are not]), type 2 diabetes (high blood sugar), hypertension (high blood pressure), seizure (medical condition that happens due to uncontrolled activity in the brain), and morbid obesity (weight over 100 pounds over the recommended weight).

During a review of Patient's 1's nurses note titled, "Interdisciplinary Team Progress Note," dated 12/16/2023 at 5:45 a.m., the Interdisciplinary (comprise of the physician, nurse, respiratory therapist, etc. Involved in the care of a patient) Team Progress Note indicated a Rapid Response (a process for working with a rapidly declining patient) was called for Patient 1 due to Patient 1 found unresponsive (unconscious and possibly dead or dying) with the following vital signs: Blood pressure (BP) 60/35 (normal 120/80) millimeters of mercury (mmHg, a unit of measurement), heart rate (HR) 32 (normal 60 - 100) and oxygen saturation level (sp02, measures the amount of oxygen in the blood) 48% (normal 90 - 100), respirations were not documented. Rapid response was called. There was no documentation to indicate that Patient 1 was provided with supportive medical management for the low saturation, low BP, and low HR.

During a review of Patient 1's CPR (cardiopulmonary resuscitation, an emergency procedure consisting of chest compressions and artificial ventilation [a means of assisting or stimulating breathing]) Record," dated 12/16/2023, the CPR record indicated that a Code Blue (patient with an unexpected cardiac or respiratory arrest [when the heart stops beating] requiring resuscitation [methods used to restart the heart and lungs when they stop working]) was initiated at 5:50 a.m., because Patient 1 was in asystole (no heart-beat or flatline) and assisted breathing was provided; at 5:50 a.m., IV (intravenous, into the vein) access insertion was still unsuccessful. At 5:51 a.m., (6 minutes after the Rapid Response was initiated) 9-1-1 was called; at 5:58 a.m., code blue team continued CPR. At 5:59 a.m., paramedics arrived and took over CPR. At 6:20 a.m., CPR terminated and Patient 1 expired (died).

During a concurrent interview and review of Patient 1's nurses notes, on 01/10/2024, at 11:18 a.m., with the House supervisor (HS) 1, HS 1 confirmed that HS 1 responded to Patient 1's rapid response called on 12/16/2023 at 5:45 a.m. with arrival time at 5:47 a.m. Upon arrival, Patient 1 was unresponsive and was on oxygen with 2 liters per minute via nasal canula (a device used to deliver supplemental oxygen). HS 1 stated Patient 1's heart rate of 32 and spO2 (oxygen saturation) of 48 % were out of range. Nursing staff attempted to insert IV in anticipation for IV fluids and emergency medications but were unsuccessful. HS 1 stated Code Blue was activated due to no pulse, no blood pressure and no respiration; at 5:49 a.m., Physician called back with orders to insert an IV line, intubate (a process of inserting a plastic tube into a patient's airway to assist with breathing) the patient, continue CPR, and give Epinephrine (a hormone used to restore heart rhythm) 1 milligram (mg- a unit of measurement) every 3 minutes.

HS 1 stated Patient 1 was connected to the vital signs machine which monitored blood pressure and heart rate. Then nursing staff connected Patient 1 to a defibrillator (a device that applies an electric charge to the heart to restore a normal heartbeat). HS 1 stated, Patient 1 "had no pulse and was flat line (represents cessation of mechanical activity of the heart) for 10 minutes before the fire department's arrival." HS 1 stated the fire department arrived at 5:59 a.m. Upon arrival of the fire department, the fire department staff took over CPR and established an intraosseous (IO, an emergency route for fluid and drug delivery) access on Patient 1's left shin. In addition, the fire department administered total of 3 doses of Epinephrine. CPR was terminated and Patient 1 was pronounced dead by the fire department at 6:20 a.m.

In addition, on 01/10/2024, at 11:30 a.m., HS 1 reviewed Patient 1's cardiac "Rhythm Strip (a record of the electrical activity of the heart)," dated 12/16/2023 at 5:59 a.m. and Patient 1's Code Blue cardiac rhythm strips dated 12/16/2023 at 5:52 a.m. and at 6:01 a.m. were also reviewed. HS 1 stated she (HS 1) was the team leader for the Code Blue. HS 1 interpreted the rhythm strip after the Code Blue was over. HS 1 stated the cardiac rhythm at 5:52 a.m. and 6:01 a.m. indicated ventricular fibrillation (a life-threatening heart rhythm). HS 1 further stated with this rhythm, the patient should be shocked (shock, using an electrical charge to stop the heart's abnormal rhythm by a defibrillator). HS 1 stated the shock should have been delivered at 5:52 a.m. for Patient 1, but no shock was delivered during the code blue. HS 1 further stated the EKG completed on 12/16/2023 at 5:59 a.m. was never sent to a physician for interpretation.

During an interview on 1/12/2024 at 2:53 p.m. with the Director of Quality & Risk Management (DQRM), DQRM stated no root cause analysis (RCA, a structured, facilitated team process to identify the root cause of an event that resulted in an undesired outcome and develop corrective actions) was done for rapid response and code blue events in 2023. DQRM further stated root cause analysis is important because it could point out the root cause problem of the event so that the team can address the issue by providing intervention and education for staff as needed. DQRM also said that there was no RCA done for the code blue incident involving Patient 1.

During a record review of the facility's policy and procedure (P&P) titled, "Rapid Response Team," dated 2023, the P&P indicated, "A copy of the Rapid Assessment Team (RAT) record ... will also be sent to the Quality Improvement Coordinator, who will measure and trend the utility and effectiveness of the interventions employed."

During a record review of facility's 2023 Hospital Performance Improvement Plan (a process used to ensure services are meeting quality standards and assuring care reached a certain level) dated 2023, the Hospital Performance Improvement Plan indicated, "Performance Improvement activities will track and trend data on critical patient safety indicators including, but not limited to, medical errors and adverse patient events (an event that resulted in an undesirable outcome such as death) and provide feedback and education throughout the hospital ... discuss the root cause analysis (RCA) and failure mode and effects analysis (FMEA, a step-by-step approach to identify all possible failures in a process)."

Based on interview and record review, the facility failed to ensure that a History & Physical (H&P, a formal and complete assessment of the patient and the problem) was completed and documented within 24 hours of admission for one of 30 sampled patients (Patient 24). Likewise, the facility also failed to ensure that a Psychiatric (a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders) Evaluation (a mental health assessment performed by a Physician used to determine a person's mental state and guide recommendations) was completed within 24 hours of an order written for a psychiatric consult and document completion of the Psychiatric Evaluation within 24 hours of the consultation for one of 30 sampled patients (Patient 24) in accordance with the facility's policy and procedure regarding completion of a History and Physical and consultation orders.

This deficient practice had the potential to result in delayed diagnoses, medical treatments, and/or medications for Patient 24, which may worsen Patient 24's medical and psychiatric conditions.

Findings:

During a review of Patient 24's Face Sheet (a document that gives a patient's information at a quick glance), the Face Sheet indicated Patient 24 was admitted on 12/29/2023 at 4:18 p.m. with diagnoses of dehydration (not enough water in the body) and hypernatremia (when the concentration of sodium [helps maintain a normal blood pressure and regulates the body's fluid balance] in blood is abnormally low).

During a review of Patient 24's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/31/2023 at 5:07 a.m., the H&P indicated Patient 24 was admitted to the facility due to multiple medical and psychiatric (a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders) conditions.

During a review of Patient 24's Physicians Orders, dated 12/29/2023 at 4:58 p.m., the Physicians Orders indicated, Patient 24 had an order for a Psychiatric Consult (mental health assessment by a psychiatrist [mental health physician]).

During a review of Patient 24's Psychiatric Progress Note, dated 1/1/2024 at 8:52 p.m., the Psychiatric Progress Note indicated Patient 24 had a diagnosis of schizoaffective disorder (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucinations [sensing things such as visions, sounds or smells that seem real but are not]), Bipolar type (a mental illness that can affect your thoughts, mood and behavior).

During a concurrent interview and record review of Patient 24's medical record on 1/11/2024 at 10:30 a.m. with the Behavioral Health Director (BHD), BHD verified Patient 24's H&P was completed after 24 hours of admission (completed on 12/31/2023 while Patient 24 was admitted on 12/29/2023). BHD stated that Patient 24 was admitted initially as a medical patient. BHD said that the H&P was important because it sets up the plan of care that is used as a reference point for the care of a patient. Likewise, BHD verified there was an order for a psychiatric consult on 12/29/2023 and stated this should have been completed within 24 hours of the ordered date and time. Instead, the psychiatric consult was completed on 1/1/2024 (3 days [72 hours] after the psychiatric consult was ordered on 12/29/2023 by the primary medical doctor). BHD stated that a delay in the psychiatric consult can result in a delay in care for Patient 24 who needed psychiatric care.

During an interview on 1/12/2024 at 1:24 p.m. with the Chief Nursing Officer (CNO), CNO stated that if there was an order for a psychiatric consult, the patient must be seen by a psychiatrist within 24 hours. CNO stated that if this was not completed, the patient may not get the proper treatment and the patient's psychiatric condition may get worse.

During a review of the facility's policy and procedure (P&P) titled, "History and Physical," dated 9/2022, the P&P indicated: "Policy: The History and Physical must be completed within 24 hours of admission and should contain adequate information to support the diagnosis and treatment plan. This information should be comprehensive enough to inform a surgeon, consultant, or other practitioner of all the precautions to be taken during treatment."

During a review of the facility's policy and procedure (P&P) titled, "Consultations," dated 9/2020, the P&P indicated: "Policy: ...as a courtesy consultants have twenty-four (24) hours to accept or decline a case. The existence of the consultation request must be documented in the patient's chart. Procedure: The Consultation Report must be completed within twenty-four (24) hours of accepting a case and include the following criteria at a minimum: 1. Patient name 2. Medical Record Number 3. Age 4. Sex 5. Date of Admission, Consultation, Operation, etc. 6. Name of referring physician 7. Name of Consultant 8. Reason for Consultation 9. Current History 10. Past Medical History 11. Examination of the patient if applicable 12. Diagnosis and recommendations 13. Treatments, orders, and dispositions."

Based on interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by:

1. The facility failed to ensure completion of training and competency check (an assessment tool which checks and determines the skill of a staff) for four of four sampled nursing staff (House Supervisor [HS] 1, Registered Nurses [RNs] 2, 3 and 4) regarding their role in a rapid response (a process for working with a rapidly declining patient) call for one of 30 sampled patients (Patient 1).

This deficient practice resulted in nursing staff (HS 1, RN 2, RN 3, and RN 4) not knowing how to manage a rapid response team call properly as evidenced by nursing staff failing to render supportive medical management for one of 30 sampled patients (Patient 1) during a rapid response call which led to Patient 1's condition to further deteriorate into a code blue (patient with an unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]), which eventually resulted in Patient 1's death. (Refer to A- 0397)

2. Nursing staff failed to adhere and follow rendering supportive medical management for low oxygen saturation (measures the amount of oxygen in the blood) levels, low blood pressure, and low heart rate during a rapid response (a process for working with a rapidly declining patient) event and also failed to analyze the heart rhythm (when the heart beats too quickly or too slowly) and deliver a shock (using an electrical charge to stop the heart's abnormal rhythm by a defibrillator [a device that can detect an abnormal heart rhythm and applies an electric charge [shock] or current to the heart to restore a normal heartbeat]) for one of 30 sampled patients (Patient 1) during a Code blue (patient with an unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]), in accordance with the facility's policy and procedure regarding Advanced Cardiac Life Support (ACLS, a set of life-saving protocols and skills that goes beyond the basic life support [such as CPR, Cardiopulmonary Resuscitation - an emergency procedure consisting of chest compressions and artificial ventilation, a means of assisting or stimulating breathing]) guidelines.

This deficient practice resulted in Patient 1's condition to further worsen and resulted in Patient 1's death. (Refer to A- 0398)

3. Nursing staff failed to perform vital signs (VS, temperature, blood pressure, pulse, respiratory rate, and pain) check every four (4) hours and failed to address and report abnormal vital signs to the physician for one of 30 sampled patients (Patient 1). This deficient practice had the potential for changes in Patient 1's condition to go unidentified by staff and Patient 1's needs not being addressed in the event of a change of condition, which may result in patient harm and/or death. (Refer to A- 0398)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment and resulted in Patient 1's death.

Based on interview and record review, the facility failed to ensure completion of training and competency check (an assessment tool which checks and determines the skill of a staff) for four of four sampled nursing staff (House Supervisor [HS] 1, Registered Nurses [RNs] 2, 3 and 4) regarding their role in a rapid response (a process for working with a rapidly declining patient) call for one of 30 sampled patients (Patient 1)

This deficient practice resulted in nursing staff (HS 1, RN 2, RN 3, and RN 4) not knowing how to manage rapid response team call properly as evidenced by nursing staff failing to render supportive medical management for one of 30 sampled patients (Patient 1) during a rapid response call which led to Patient 1's condition to further deteriorate into a code blue (patient with an unexpected cardiac or respiratory arrest [when the heart stops beating] requiring resuscitation [methods used to restart the heart and lungs when they stop working]), which eventually resulted in Patient 1's death.

Findings:

During a review of Patient 1's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/07/2023 at 10:06 p.m., the H&P indicated the following: Patient 1 was admitted to the facility on 12/6/2023, on a 5150-hold (72-hour involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) due to danger to others and agitated (a feeling of irritability or severe restlessness) behavior.

Patient 1's admission diagnoses included paranoid schizophrenia (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucination [sensing things such as visions, sounds or smells that seem real but are not]), type 2 diabetes (high blood sugar), hypertension (high blood pressure), seizure (medical condition that happens due to uncontrolled activity in the brain), and morbid obesity (weight over 100 pounds over the recommended weight).

During a review of Patient's 1's nurses note titled, "Interdisciplinary Team Progress Note," dated 12/16/2023 at 5:45 a.m., the Interdisciplinary (comprise of the physician, nurse, respiratory therapist, etc. Involved in the care of a patient) Team Progress Note indicated a Rapid Response (a process for working with a rapidly declining patient) was called for Patient 1 due to Patient 1 found unresponsive (unconscious and possibly dead or dying) with the following vital signs: Blood pressure (BP) 60/35 (normal 120/80) millimeters of mercury (mmHg, a unit of measurement), heart rate (HR) 32 (normal 60 - 100) and oxygen saturation level (sp02, measures the amount of oxygen in the blood) 48% (normal 90 - 100), respirations were not documented. Rapid response was called. There was no documentation to indicate that Patient 1 was provided with supportive medical management for the low saturation, low BP, and low HR.

During a review of Patient 1's CPR (cardiopulmonary resuscitation, an emergency procedure consisting of chest compressions and artificial ventilation [a means of assisting or stimulating breathing]) Record," dated 12/16/2023, the CPR record indicated that a Code Blue was initiated at 5:50 a.m., because Patient 1 was in asystole (no heart-beat or flatline) and assisted breathing was provided; at 5:50 a.m., IV (intravenous, into the vein)access insertion was still unsuccessful. At 5:51 a.m., (6 minutes after the Rapid Response was initiated) 9-1-1 was called; at 5:58 a.m., code blue team continued CPR. At 5:59 a.m., paramedics arrived and took over CPR. At 6:20 a.m., CPR terminated and Patient 1 expired (died).

During a concurrent interview and record review on 01/12/2024 at 10:37 a.m. with the Human Resources Coordinator (HRC), the facility's orientation record (orientation pathway, a process to ensure that staff receive consistent information regarding facility policies, procedures, standards, and documentation) titled, "Orientation Pathway Charge Nurse/Support Registered Nurse, Medication Nurse, Licensed Vocation Nurse, Licensed Psychiatric Technician" was reviewed for HS 1 and RN 4. The HRC stated the orientation pathway was completed as the nursing staff received training and demonstrate skills listed. HRC verified that rapid response topic was not included in the orientation pathway. HRC stated the role of the rapid response team should be included in the orientation pathway section 5 "responding to Emergency Codes."

During an interview on 01/12/2024 at 10:52 a.m. with HRC, HRC stated the orientation pathway was not done for RN 3.

During a concurrent interview and record review on 01/12/2024 at 11:03 a.m. with HRC, contracted Registered Nurse (RN 2) 2's orientation record titled, "orientation/contract list registry," dated 12/23/2023, was reviewed. HRC stated that the role of the rapid response team was not included in the orientation record.

During an interview on 01/12/2024 at 1:41 p.m. with Chief Nursing Officer (CNO), CNO stated the role of the rapid response team should be part of the orientation so nursing staff would know how to respond to rapid response calls including knowledge of what to do such as provision of supportive medical management (airway support and CPR).

During a review of the facility's policy and procedure (P&P) titled, "Rapid Response Team," dated 2023, the P&P indicated, "Guidelines for better patient care through a collaborative interdisciplinary team approach for clinical support, expert assessment, early intervention, and stabilization of patients. Also, to prevent further clinical deterioration or cardiopulmonary arrest to all patients ... Respiratory and nursing will be in-serviced upon hire and annually on the Rapid Assessment Team."

Based on interview and record review, the facility failed to ensure the following:

1. Nursing staff failed to adhere and follow rendering supportive medical management for low oxygen saturation (measures the amount of oxygen in the blood) levels, low blood pressure, and low heart rate during a rapid response (a process for working with a rapidly declining patient) event and also failed to analyze the heart rhythm (when the heart beats too quickly or too slowly) and deliver a shock (using an electrical charge to stop the heart's abnormal rhythm by a defibrillator [a device that can detect an abnormal heart rhythm and applies an electric charge [shock] or current to the heart to restore a normal heartbeat]) for one of 30 sampled patients (Patient 1) during a Code blue (patient with an unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]), in accordance with the facility's policy and procedure regarding Advanced Cardiac Life Support (ACLS, a set of life-saving protocols and skills that goes beyond the basic life support [such as CPR, Cardiopulmonary Resuscitation - an emergency procedure consisting of chest compressions and artificial ventilation, a means of assisting or stimulating breathing]) guidelines.

This deficient practice resulted in Patient 1's condition to further worsen and resulted in Patient 1's death.

2. Nursing staff failed to perform vital signs (VS, temperature, blood pressure, pulse, respiratory rate, and pain) check every four (4) hours and failed to address and report abnormal vital signs to the physician for one of 30 sampled patients (Patient 1). This deficient practice had the potential for changes in Patient 1's condition to go unidentified by staff and Patient 1's needs not being addressed in the event of a change of condition, which may result in patient harm and/or death.

On 1/11/2024 at 10:05 a.m., the survey team called a 2nd Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Director of Quality and Risk Management (DQRM), Chief Nursing Officer (CNO), Chief Executive Officer (CEO), and the Medical Staff Manager (MSM). The facility failed to ensure nursing staff adhered to BLS (Basic Life Support, use of CPR [cardiopulmonary resuscitation, an emergency procedure consisting of chest compressions and artificial ventilation [a means of assisting or stimulating breathing]) and ACLS (Advance Cardiac Life Support, a set of life-saving protocols and skills that goes beyond the basic life support) guidelines, and rendered supportive medical management for low oxygenation levels, low blood pressure and heart rate during a Rapid Response (a process for working with a rapidly declining patient) and Code Blue (patient with an unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]) for Patient 1.

Patient 1 was admitted to the facility on 12/6/2023 on a 5150-Hold (72-hour, involuntary hold- a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) for being a danger to others and agitated (a feeling of irritability or severe restlessness) behavior.

Patient 1's diagnosis included paranoid schizophrenia (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucinations [sensing things such as visions, sounds or smells that seem real but are not]), morbid obesity (over 100 pounds over your recommended weight), type 2 diabetes (high blood sugar), hypertension (high blood pressure), and seizures (medical condition that happens due to uncontrolled activity in the brain).

On 12/16/2023 at 5:45 a.m., a Rapid Response (a process for working with a rapidly declining patient) was called for Patient 1, who was found unresponsive (unconscious and possibly dead or dying). In addition, Patient 1's blood pressure (BP) was 60/35 (low, normal is 120/80) millimeters of mercury (mmHg, a unit of measurement), heart rate was 32 (Normal range 60 - 100), and oxygen saturation level (measures the amount of oxygen in the blood) was 48 % (normal is 90 - 100 %). No interventions addressing the abnormal vital signs (include temperature, blood pressure, heart rate, respiratory rate) were documented during the Rapid Response. Nursing staff were not able to establish an IV (intravenous, into the vein) line, despite multiple attempts. The House Supervisor (HS 1) contacted a physician, by telephone, who ordered a stat (immediate) EKG (electrocardiogram, a recording of the heart's electrical activity) and Code Blue (patient with an unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]).

A Code Blue was called at 5:50 a.m., due to no pulse, no respirations. CPR (cardiopulmonary resuscitation, an emergency procedure consisting of chest compressions and artificial ventilation [a means of assisting or stimulating breathing]) and assisted breathing were started. IV insertion efforts were still unsuccessful, and the facility was unable to administer emergency medications. Patient 1 was connected to a defibrillator (a device that can detect an abnormal heart rhythm and applies an electric charge [shock] or current to the heart to restore a normal heartbeat). An EKG was performed. There was no documentation that Patient 1's heartbeat was analyzed by the defibrillator, nurse, or physician to determine whether Patient 1 required continued chest compressions or a shock to restore the heartrate. At 5:59 a.m., the paramedics arrived and took over CPR. At 6:20 a.m., CPR was terminated and Patient 1 expired. During an interview, the House Supervisor (HS 1) stated she (HS 1) reviewed the heart monitoring strips from the defibrillator after the code blue was over. HS 1 interpreted Patient 1's heart rhythm strips as ventricular fibrillation (a life-threatening heart rhythm, that can be triggered from a heart attack) and stated Patient 1 should have been shocked. HS 1 stated the shock should have been delivered at 5:52 a.m., per ACLS guidelines.

On 1/12/2024 at 4:42 p.m., the 2nd IJ was removed in the presence of the CNO, DQRM, and CEO after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record reviews. The IJ Removal Plan included the following: On-site 24-hour physician support to respond to Rapid Responses and Code Blues, Mock code (a simulation exercise with a mannequin that mimics real life clinical situations to improve response times and efficiency) education and training, Code blue education and reminders: including assessments and recognition, CPR, Defibrillation (use of a device that can detect an abnormal heart rhythm and applies an electric charge [shock] or current to the heart to restore a normal heartbeat), Airway Management and Breathing, Medication Administration, Rhythm Assessment and Monitoring, Team Communication and Roles ...Documentation. In addition, the Plan included Rapid Response Training for responsibilities for non-licensed and licensed staff who identify the significant change in patient's condition. This includes notifying other staff members, staying with the patient, and immediate assessment of the patient until the Rapid Response Team takes over the process. The facility mandates that all registered nurses stay current with ACLS guidelines and receive regular training. The facility obtained an intraosseous (process of injecting medications, fluids, and blood products directly into the marrow [a soft, fatty tissue inside the bone] of the bone) vascular device to be used in the event of a code where IV access is difficult to obtain, in order to administer emergency medications. In addition, the facility updated and implemented the following policies:

1. 1/9/2024 - Code Blue - updated to include standing orders (written protocols that authorize designated members of the health care team such as nurses to complete certain clinical tasks without having to first obtain a physician order) and documentation.

2. 1/9/2024 - Rapid Response - updated to include signs and symptoms including criteria for RRT (Rapid Response Team) activation.

3. 1/10/2024 - Hospital Plan for Provision of Care- implemented (includes 24-hours 7 days a week clinic on-site physician)

4. 1/11/2024 - Policy implemented- Responsibilities of On Call/Clinic On-Site Physician Coverage

Findings:

1. During a review of Patient 1's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/07/2023 at 10:06 p.m., the H&P indicated the following: Patient 1 was admitted to the facility on 12/6/2023, on a 5150-hold (72-hour involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) due to danger to others and agitated (a feeling of irritability or severe restlessness) behavior.

Patient 1's admission diagnoses included paranoid schizophrenia (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucination [sensing things such as visions, sounds or smells that seem real but are not]), type 2 diabetes (high blood sugar), hypertension (high blood pressure), seizure (medical condition that happens due to uncontrolled activity in the brain), and morbid obesity (weight over 100 pounds over the recommended weight).

During a review of Patient's 1's nurses note titled, "Interdisciplinary Team Progress Note," dated 12/16/2023 at 5:45 a.m., the Interdisciplinary (comprise of the physician, nurse, respiratory therapist, etc. Involved in the care of a patient) Team Progress Note indicated a Rapid Response (a process for working with a rapidly declining patient) was called for Patient 1 due to Patient 1 found unresponsive (unconscious and possibly dead or dying) with the following vital signs: Blood pressure (BP) 60/35 (normal 120/80) millimeters of mercury (mmHg, a unit of measurement), heart rate (HR) 32 (normal 60 - 100) and oxygen saturation level (sp02, measures the amount of oxygen in the blood) 48% (normal 90 - 100), respirations were not documented. Rapid response was called. There was no documentation to indicate that Patient 1 was provided with supportive medical management for the low saturation, low BP, and low HR.

During a review of Patient's 1's nurses note titled, "Nursing Progress Note," dated 12/16/2023 at 5:47 a.m., the Nursing Progress Note indicated that the facility was not able to establish the Intravenous (IV, into the vein) access on Patient 1 despite of numerous attempts during the Rapid Response.

During a review of Patient's 1's nurses note titled, "Progress Note," dated 12/16/2023, at 9:10 a.m., Patient 1's Progress Note indicated, the house supervisor contacted the Nurse Practitioner (NP), and then the Medical Doctor (MD). MD gave a telephone order for a stat (immediate) EKG (electrocardiogram, a recording of the heart's electrical activity) and code blue (patient with an unexpected cardiac or respiratory arrest requiring resuscitation [methods used to restart the heart and lungs when they stop working]).

During a review of Patient 1's CPR (cardiopulmonary resuscitation, an emergency procedure consisting of chest compressions and artificial ventilation [a means of assisting or stimulating breathing]) Record," dated 12/16/2023, the CPR record indicated that a Code Blue was initiated at 5:50 a.m., because Patient 1 was in asystole (no heart-beat or flatline) and assisted breathing was provided; at 5:50 a.m., IV (intravenous, into the vein) access insertion was still unsuccessful. At 5:51 a.m., (6 minutes after the Rapid Response was initiated) 9-1-1 was called; at 5:58 a.m., code blue team continued CPR. At 5:59 a.m., paramedics arrived and took over CPR. At 6:20 a.m., CPR terminated and Patient 1 expired (died).

During a concurrent interview and review of Patient 1's nurses notes, on 01/10/2024, at 11:18 a.m., with the House supervisor (HS) 1, HS 1 confirmed that HS 1 responded to Patient 1's rapid response called on 12/16/2023 at 5:45 a.m. with arrival time at 5:47 a.m. Upon arrival, Patient 1 was unresponsive and was on oxygen with 2 liters per minute via nasal canula (a device used to deliver supplemental oxygen). HS 1 stated Patient 1's heart rate of 32 and spO2 (oxygen saturation) of 48 % were out of range.

Nursing staff attempted to insert IV in anticipation for IV fluids and emergency medications but were unsuccessful. HS 1 stated Code Blue was activated due to no pulse, no blood pressure and no respiration; at 5:49 a.m., Physician called back with orders to insert an IV line, intubate (a process of inserting a plastic tube into a patient's airway to assist with breathing) the patient, continue CPR, and give Epinephrine (a hormone used to restore heart rhythm) 1 milligram (mg- a unit of measurement) every 3 minutes.

HS 1 stated Patient 1 was connected to the vital signs machine which monitored blood pressure and heart rate. Then nursing staff connected Patient 1 to a defibrillator (a device that applies an electric charge to the heart to restore a normal heartbeat). HS 1 stated, Patient 1 "had no pulse and was flat line (represents the cessation of the mechanical activity of the heart) for 10 minutes before the fire department's arrival." HS 1 stated the fire department arrived at 5:59 a.m. Upon arrival of fire department, the fire department staff took over CPR and established an intraosseous (IO, an emergency route for fluid and drug delivery) access on Patient 1's left shin. In addition, the fire department administered total of 3 doses of Epinephrine. CPR was terminated and Patient 1 was pronounced dead by the fire department at 6:20 a.m.

On 01/10/2024, at 11:30 a.m., HS 1 reviewed Patient 1's cardiac "Rhythm Strip (a record of the electrical activity of the heart)," dated 12/16/2023 at 5:59 a.m. and Patient 1's Code Blue cardiac rhythm strips dated 12/16/2023 at 5:52 a.m. and at 6:01 a.m. were also reviewed. HS 1 stated she (HS 1) was the team leader for the Code Blue. HS 1 interpreted the rhythm strip after the Code Blue was over. HS 1 stated the cardiac rhythm at 5:52 a.m. and 6:01 a.m. indicated ventricular fibrillation (a life-threatening heart rhythm). HS 1 further stated with this rhythm, the patient should be shocked (shock, using an electrical charge to stop the heart's abnormal rhythm by a defibrillator). HS 1 stated the shock should have been delivered at 5:52 a.m. for Patient 1, but no shock was delivered during the code blue. HS 1 further stated the EKG completed on 12/16/2023 at 5:59 a.m. was never sent to a physician for interpretation.

During an interview on 1/10/2023 at 10:10 a.m., with the Respiratory Therapist (RT) 1, RT 1 stated he (RT 1) responded to a Rapid Response on 12/16/2023 for Patient 1. Upon arrival at 5:50 a.m., Patient 1 was unresponsive, not breathing, and without a pulse. Staff was "bagging" (using a self-inflating bag to deliver ventilation) Patient 1 and chest compressions had already been started. RT 1 placed defibrillator pads on Patient 1 and connected Patient 1 to the defibrillator. A code blue was called. 911 was called. RT 1 stated that during the Code Blue, there was no pause in chest compressions to allow the defibrillator to analyze Patient 1's cardiac rhythm strip, nor did RT 1 hear the defibrillator prompt the staff to deliver a shock. RT 1 stated a shock was not delivered during the Code Blue.

During a review of the Facility's policy and procedure (P&P) titled, "Rapid Response Team," dated 02/2023, the P&P indicated, "The RN and RCP (Respiratory Care Practitioner) will perform a patient assessment to determine the status of the patient. Based on findings, the identified RN leader may institute ACLS (Advanced Life Support) measures and applicable standardized procedures to assist a patient emergent situation."

During a review of the Facility's policy and procedure (P&P) titled, "Cardiopulmonary Emergencies Code Blue," dated 3/2022, the P&P indicated, "it is the responsibility of all personnel discovering a cardiopulmonary emergency to follow the hospital policy of initiating a 'code blue' ... The Code Blue standing orders per ACLS Guideline can be followed by ACLS-certified nurses and cardiopulmonary personnel during the code ... When the on-call physician is not present, the House Supervisor, then Charge Nurse will act as the Code Blue Team Leader ... ACLS protocol will be adhered to during the Code Blue. The "Adult Cardiac Arrest Algorithm (a set of step-by-step instructions to complete a task)" indicated, Start CPR, give oxygen and attach monitor/defibrillator, for rhythm ventricular fibrillation (VF) or pulseless Ventricular tachycardia (a type of life- threatening cardiac rhythm), shock the patient."

2. During a review of Patient 1's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/07/2023 at 10:06 p.m., the H&P indicated the following: Patient 1 was admitted to the facility on 12/6/2023, on a 5150-hold (72-hour involuntary hold - a law which allows an adult experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to self or others) due to danger to others and agitated (a feeling of irritability or severe restlessness) behavior.

Patient 1's admission diagnoses included paranoid schizophrenia (a type of brain disorder in which a person experiences delusions [fixed beliefs that are not based in reality] and hallucination [sensing things such as visions, sounds or smells that seem real but are not]), type 2 diabetes (high blood sugar), hypertension (high blood pressure), seizure (medical condition that happens due to uncontrolled activity in the brain), and morbid obesity (weight over 100 pounds over the recommended weight).

During a review of Patient 1's "Vital Signs (VS- temperature, blood pressure, pulse, respiratory rate, and pain)," record dated 12/06/2024 to 12/16/2023, the Vital Signs record indicated the following: Normal vital signs ranges: Blood pressure (BP), 90/60 to 120/80. Resting heart rate (HR), 60 to 100 beats per minute. Respiratory Rate (RR), 12 to 18 breaths per minute. Oxygen saturation (O2 sat, measures the amount of oxygen in the blood), 95 % to 100 %. Body Temperature (Temp), 97.8 degrees Fahrenheit (F, a unit of measurement) to 99 degrees F or 36.5 degrees Celsius (C, a unit of measurement) to 37.2 degrees C.

On 12/06/2023 at 9:36 p.m., BP 162/83 (high), HR 78, RR 18, O2 sat 95 %, Temp was not documented, Pain No.

On 12/07/2023 at 1:17 a.m., BP 165/75 (high), HR 82, RR 18, O2 sat 94 % (low), Temp was not documented, Pain No

On 12/07/2023 at 8 a.m., BP 154/70 (high), HR 82, RR 16, O2 sat 93 % (low) on room air, Temp 97.9 F, Pain 0.

On 12/07/2023 at 4 p.m., BP 167/87 (high), HR 77, RR 18, O2 sat 94 % (low) on room air, Temp 98.4 F, Pain was not documented. Provider notified of abnormal values: Not Applicable.

On 12/07/2023 at 8:13 p.m., BP 171/83 (high), HR 78, RR 18, O2 sat 95 %, Temp 97.8 F, Pain was not documented.

On 12/07/2023 at 8:54 p.m., BP 131/69, HR 76, RR 17, O2 sat 90 % (low), Temp 97.4, Pain: No. Nurse notified of abnormal values: No

On 12/08/2023 at 8 a.m., BP 144/77, HR 86. RR 16, O2 sat 96 %, on room air, Temp 97.7 F, Pain: 0

On 12/08/2023 at 12:06 p.m., BP 131/69, HR 102 (high), RR 18, O2 sat 93 % (low) on room air, Pain: 0, Provider notified of abnormal values: Not Applicable.

On 12/08/2023 at 4 p.m., BP 154/75 (High), HR 97, RR 18, O2 sat 93 % (low) on room air, Temp 97.6, Pain: 0, Provider notified of abnormal values: Not Applicable.

On 12/08/2023 at 8:31 p.m., BP 140/66, HR 92, RR 18, O2 sat 92 % (low), Temp 97.7 F, Pain: No, Nursing notified of abnormal values: Not Applicable.

On 12/08/2023 at 12:08 a.m., BP 140/70, HR 96, RR 18, O2 sat 92 % (low), Temp 97.5, Pain: No, Nursing notified of abnormal values: No Applicable

On 12/08/2023 at 4:07 a.m., BP 145/74, HR 94, RR 18, O2 sat 90 % (low), Temp 97.4 F, Pain: No, Nurse notified of abnormal values: Not Applicable.

On 12/09/2023 at 8:17 a.m., BP 138/70, HR 72, RR 18, O2 sat 95 %, Temp 98.1, Pain: No

On 12/09/2023 at 4:41 p.m., BP 140/63, HR 74, RR 18, O2 sat 94 % (low), Temp 97.7 F, Pain was not documented.

On 12/10/2023 at 12:09 a.m., BP 132/64, HR 67, RR 18, O2 sat 92 % (low), Temp 97 F, Pain was not documented. Nurse notified of abnormal values: Not Applicable.

On 12/10/2023 at 4:15 a.m., BP 127/74, HR 75, RR 148, O2 sat 90 % (low), Temp 97.6 F, Pain: No. Nurse notified of abnormal values: Not Applicable.

On 12/10/2023 at 8:28 p.m., BP 155/69 (High), HR 74, RR 18, O2 sat 93 % (low), Temp 97.3 F, Pain: No. Nurse notified of abnormal values: Not Applicable.

On 12.11.2023 at 8:48 p.m., BP 141/78 (High), HR 73, RR 17, O2 sat 94 % (low), Temp 97.1, Pain: No

On 12/12/2023 at 12 p.m., BP 130/77, HR 62, RR 18, O2 sat 94 % (low) on room air, Temp 97.8 F, Pain No.

On 12/12/2023 at 12:15 a.m., BP 128/63, HR 76, RR 18, O2 sat 94 % (low), Temp 97.1 F, Pain: No

On 12/14 /2023 at 8 a.m., BP 136/63, HR 83, RR 18, O2 sat 92 % (low), Temp 98 F, Pain: No

On 12/14/2023 at 8:54 p.m., BP 154/68 (high), HR 109 (high), RR 18, O2 sat 92 % (low), Temp was not documented, Pain: No

On 12/15/2023 at 12:21 a.m., BP 138/87 (high), HR 101 (high), RR 18, O2 sat 92 % (low), Temp was not documented, Pain: No

12/15/2023 at 4 a.m., no vital signs were documented.

12/15/2023 at 8 a.m., no vital signs were documented.

12/15/2023 at 12 p.m., no vital signs were documented.

12/15/2023 at 4 p.m., no vital signs were documented.

On 12/15/2023 at 8:12 p.m., BP 155/68 (High), HR 95, RR 18, O2 sat 91 % (low), Temp 98.2 F, Pain; was not documented.

On 12/16/2023 at 12:07 a.m., BP 139/86 (high), HR 82, RR 18, O2 sat 91 % (low), Temp 98.4 F, Pain was not documented.

On 12/16 /2023 at 3:56 a.m., BP 128/82, HR 86, RR 18, O2 sat 98% on room air, Temp 98.6 F, Pain: 0

During a concurrent interview and review of Patient 1's Vital Signs Record, on 1/9/2023 at 11:38 a.m., with registered nurse (RN) 1, RN 1 stated Patient 1 was located in the Medical Surgical Unit (serves the general patient population hospitalized for various cases such as surgery, etc.) and vital signs should be done every four (4) hours.

RN 1 reviewed the vital signs for Patient 1 from 12/15/2023 to 12/16/2023 and verified Patient 1 had abnormal vital signs. The blood pressure and heart rate were high. The oxygen saturation was low. The vital signs were not done every 4 hours. RN 1 also reviewed the nursing notes and stated that the abnormal vital signs were not reported to the physician. RN 1 said the nurse assigned to Patient 1 should have notified the physician "if the vital signs are out of range to "fix" the vital signs and prevent a change in the patient's condition such as worsening of clinical condition."

During a review of the facility's policy and procedure (P&P) titled, "Vital signs," dated 3/2022, the P&P indicated the following: "Vital signs i.e., Temperature, Pulse Rate, Respiratory Rate, Blood Pressure, Pain, Oxygen saturation shall be performed routinely ...Vital signs will be taken per unit routine unless otherwise ordered by the physician ...MS (Medical Surgical, serves the general patient population hospitalized for various cases such as surgery, etc.) and Telemetry (a unit in the hospital where patient's undergo continuous cardiac [heart rate and rhythm] monitoring) - every four (4) hours and charted on Vital Signs record and M/S Flow sheet (8 a.m., 12 p.m., 4 p.m., 8 p.m.,) ...Any vital signs which are outside normal limits or are unusual for that patient, are to be reported to the patient's nurse who will evaluate the situation and report to the physician if this is indicated."