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Based on interview and record review, the hospital's registered nurse failed to supervise and evaluate the nursing care of Patient #1 in that the following were not implemented:

A. Physician #13's "Subsequent Day Note" reflected LOS (line of sight) during sleep while CPAP is used." This directive was not implemented in 3 of 3 days (09/06/2020 to 09/08/2020); and

B. Physician #14 ordered "DME Needed. CPAP device...Order comments: Please supply equipment for patient staying another in AIU (Adolescent Inpatient Unit)." There was no documentation found if this order was carried out.


Findings included:

Patient #1 presented in the hospital's Psychiatric Emergency Clinic on 09/03/2020 at 8:36 PM via detention warrant and was admitted for observation. Patient #1 was subsequently admitted to the hospital's Adolescent Inpatient Unit (AIU) on 09/04/2020 at 11:22 PM for DMDD (disruptive mood dysregulation disorder). Other medical diagnoses were OSA (obstructive sleep apnea), HTN (hypertension), and Diabetes mellitus type 2. Patient #1 was allowed to bring her CPAP machine and accessories in the hospital to be used during sleep. Patient #1 had been using the CPAP machine during sleep due to her obstructive sleep apnea (OSA).

A. On 09/06/2020 at 12:09 PM a "Subsequent Day Note" written by Physician #13 indicated "Patient's Condition: same. Treatment Engagement: passive. Residual psychiatric symptoms from prior presentation: severe...Patient global clinical improvement: worse...Changes in Medical Status: skin break on bridge of nose. This was present yesterday. Patient denies pain. No sign of infection...Plan...#Sleep Apnea - CPAP machine at home, nursing to inform CPS worker to bring in. LOS (line of sight) during sleep while CPAP is used..."

Close Observation Record on 09/06/2020 indicated "LOS with CPAP." There was no specific time noted when the CPAP was in use or not during sleep.

Close Observation Record on 09/07/2020 indicated "LOS while on CPAP." There was no specific time noted when the CPAP was in use or not during sleep.

Close Observation Record on 09/08/2020 indicated "LOS while on CPAP machine." There was no specific time noted when the CPAP was in use or not during sleep.

B. On 09/09/2020 at 5:40 PM, "Orders & Results. Case Management for DME (durable medical equipment) signed by Physician #14 reflected "DME Needed. CPAP device...Frequency: Today Once 09/09/20 5:41 PM - 1 occurrence...Order comments: Please supply equipment for patient staying another in AIU." There was no documentation found if this order was carried out.

In a phone interview on 05/05/21 at 1:30 PM, Personnel #4 was asked about the above findings. Personnel #4 replied she did not know about Physician #14's order. Furthermore, she stated she worked on day shifts and did not know about the LOS (line of sight) during sleep while CPAP directive. She stated it should have been documented.

Based on interview and record review, the hospital failed to ensure appropriate arrangement for securing medical durable equipment (CPAP mask) required for post-hospital care was provided, citing 1 of 1 patient (Patient #1).

Findings included:

Patient #1 presented in the hospital's Psychiatric Emergency Clinic on 09/03/2020 at 8:36 PM via detention warrant and was admitted for observation. Patient #1 was subsequently admitted to the hospital's Adolescent Inpatient Unit (AIU) on 09/04/2020 at 11:22 PM for DMDD (disruptive mood dysregulation disorder). Other medical diagnoses were OSA (obstructive sleep apnea), HTN (hypertension), and Diabetes mellitus type 2. Patient #1 was allowed to bring her CPAP machine and accessories in the hospital to be used at night. Patient #1 had been using the CPAP machine every night due to obstructive sleep apnea (OSA).

On 09/09/2020 at 3:22 PM, Progress Notes by Personnel #3 reflected "...called CPS liaison to discuss problem with guardian not picking up Patient #1 due to CPAP mask...spoke to guardian/group home owner over the phone. Informed her that the mask was not damaged by staff, that the patient reported to nursing that the mask had ripped when she was putting it on. Guardian/group home owner verbalized understanding, but insisted that she needed to be given a mask before Patient #1 could return to her home. Personnel #3 explained that this is a matter that CPS and the group home would need to discuss and solve together, that the hospital is not a part of the medical equipment replacement. Personnel #3 explained that Patient #1 needs to be picked up from the hospital..."

On 09/09/2020 at 6:00 PM, Progress Notes by Personnel #4 showed "Group Home representative (caregiver)...came to pick up Patient #1. Group Home representative was provided with discharge instructions and Patient #1's CPAP machine. Patient #1 was handed over to the care-giver. Group Home representative asked for a note that would indicate that the hospital broke the CPAP mask and that the hospital will not be replacing the broken mask. Group home representative called Patient #1's guardian/group home owner and informed her about what was going on. Group Home manager requested to speak to the House Supervisor. House Supervisor was not available right away. House Supervisor was informed about what was going on and she was given the Group Home owner's number, supervisor said she would call the Group Home owner."

After the patient was discharged from the AIU (adolescent Inpatient Unit) on 09/09/2020 at 6:35 PM, three (3) minutes later at 6:38 PM, Patient #1 presented in the Emergency Department (Medicine). Provider Notes by the ED (emergency department) physician (Physician #7) indicated "Arrival Complaint: CPAP machine malfunction...Comment: patient's caregiver stating that she just picked up patient from the AIU and her CPAP machine is broken - patient instructed to come through ED [by CPS] to get new Rx for CPAP machine - no medical complaints, patient with group home representative. Patient #1 is a 16 y. o. female with past medical history of intellectual disability, sleep apnea on CPAP at night...hypertension amongst others who presents to the emergency department today brought by a caregiver for a new CPAP machine. She was recently discharged from the AIU...and when her caregiver picked her up she noticed that the CPAP machine was broken and not working. She has severe sleep apnea requires this to sleep at night, so her caregiver brought her here. Her group home will reportedly not allow her back in her care until she has a working CPAP..."

Per ED physician's "Disposition & Condition. Final Impression/Diagnosis: 1. Obstructive sleep apnea on CPAP, Patient #1 was placed on 'social hold' until the appropriate supplies for the CPAP machine could be obtained."

On 09/09/2020 8:28 PM, Progress Notes by Personnel #8 reflected "Patient #1 was just discharged from AIU. While she was there, her CPAP mask broke. At this time, her machine is also not working. The AIU would not replace mask/machine. Patient cannot go back home without functioning CPAP. CPS advised patient be brought to the ED until solution is found. CPAP machine is from MSP...someone from MSP is coming in the morning to look at machine...SW will continue to follow."

In the ED, Patient #1 was provided a CPAP machine for her nightly therapy and oral medication administration of Depakote ER 500 mg and Singulair 10 mg.

On 09/10/2020 at 12:15 PM, ED Notes by Personnel #9 reflected "New CPAP provided to patient. Patient DC'ed (discharged) per orders. Patient in NAD (no acute distress) at time of DC. RR (respiratory rate) even and unlabored. Vss (vital signs stable). Patient ambulatory with steady gait. Patient. DC'ed with caregiver from group home."

In a phone interview on 05/05/21 at 1:30 PM, Personnel #4 stated she knew that Patient #1 reported her CPAP mask was broken. Personnel #4 stated Personnel #3 said the patient and guardian could buy the CPAP mask somewhere and the patient was ready for discharged
In a phone interview on 05/05/21 at 2:01 PM, Personnel #5 was asked if she called Patient #1's guardian per her request. And, a progress note of Personnel #4 dated 09/09/2020 at 6:00 PM indicated Personnel #5 was informed about the much needed CPAP mask. Personnel #5 replied yes she called the guardian. Personnel #5 stated she could not recall what they talked about since it had been a long time. She was asked if she documented the conversation. She replied no.

In a phone interview on 05/05/21 at 2:02 PM, Personnel #6 was asked when Patient #1 reported her CPAP mask was damaged, did anyone looked into this matter. She replied she did not know if anyone examined the mask. She stated earlier that day on 09/09/2020 Personnel #3 told her that the patient was "okay" to be discharged. Personnel #6 confirmed she was with Personnel #4 discharging the patient to the group home representative/caregiver. The group home representative asked for the patient's CPAP mask. She replied the Adolescent Inpatient Unit did not have a CPAP mask.

In a phone interview on 05/05/21 at 2:23 PM, Personnel #10 stated Personnel #3 called the durable medical equipment supplier for Patient #1's CPAP mask. When asked for the documentation, Personnel #10 replied it was not documented. Personnel #10 stated Personnel #3 was not available for interview. The surveyor read back to Personnel #10 what Personnel #3 wrote with regards to the CPAP mask in part "Personnel #3 explained that this is a matter that CPS and the group home would need to discuss and solve together, that the hospital is not a part of the medical equipment replacement. Personnel #3 explained that Patient #1 needs to be picked up from the hospital..."
Personnel #10 was asked if this was an accurate statement, that the facility could not get the needed mask for Patient #1. Personnel #10 stated the facility could have ordered the CPAP mask for the patient.