HospitalInspections.org

Based on policy and procedure review, closed medical record review, and staff and physician interviews the hospital's leasdership failed to provide oversight and have systems in place to ensure the protection and promotion of Patient's Rights to ensure care in a safe setting and failed to have an organized Nursing Service to meet the patient care needs by failing to ensure staff were trained to monitor and supervise care rendered to a patient exhibiting aggressive, escalating behaviors in 1 of 3 sampled patients (Patient #2). The following tags are cross-referred: A0144, A0178, and A0395.


Findings Include:

1. Based on facility policy and procedure review, medical record review, staff and physician interviews, the facility failed to promote and protect patient's rights by failing to ensure staff were trained to monitor and supervise care rendered to a patient exhibiting aggressive, escalating behaviors in 1 of 3 sampled patients (Patient #2).

~ Cross refer A: 0144

2. Based on hospital policy review, medical record review and physician interview, the facility staff failed to document a face-to-face assessment within one hour after a violent restraint intervention for 1 of 3 sampled patients. (Patient #2)

~ Cross refer A: 0178

3. Based on review of hospital policies and procedures, medical record review and staff and physician interviews, the hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations to ensure a patient received safe delivery of care by failing to ensure nursing staff were trained to monitor and supervise care rendered to a patient exhibiting aggressive, escalating behaviors in 1 of 3 sampled patients (Patient #2).

~ Cross refer A: 0395

Based on facility policy review, medical record review, staff and physician interviews, the facility failed to promote and protect patient's rights by failing to ensure staff were trained to monitor and supervise care rendered to a patint exhibiting aggressive, escalating behaviors in 1 of 3 sampled patients (Patient #2). The following tags are cross-referred: A0144, A0178, and A0395.

Findings Include:

1. Based on facility policy and procedure review, medical record review, staff and physician interviews, the facility failed to promote and protect patient's rights by failing to ensure staff were trained to monitor and supervise care rendered to a patient exhibiting aggressive, escalating behaviors in 1 of 3 sampled patients (Patient #2).

~ Cross refer A: 0144

2. Based on hospital policy review, medical record review and physician interview, the facility staff failed to document a face-to-face assessment within one hour after a violent restraint intervention for 1 of 3 sampled patients. (Patient #2)

~ Cross refer A: 0178

3. Based on review of hospital policies and procedures, medical record review and staff and physician interviews, the hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations to ensure a patient received safe delivery of care by failing to ensure nursing staff were trained to monitor and supervise care rendered to a patient exhibiting aggressive, escalating behaviors in 1 of 3 sampled patients (Patient #2).

~ Cross refer A: 0395

Based on policy and procedure review, medical record review and staff interviews, the facility failed to provide care in a safe setting as evidenced by the failure to ensure staff were trained to monitor and supervise care rendered to a patient exhibiting aggressive, escalating behaviors in 1 of 3 sampled patients. (Patient #2).

Findings Include:

Review of hospital policy titled "Patient Rights and Responsibilities..." last revised 09/2020 revealed,"...You and the right to ... Considerate and respectful care in a safe setting..."

Review of hospital policy titled "Restraint and Seclusion Application and Types, including Behavioral Health Services..." last revised 09/2020 revealed, "...The goal of (Named Facility) is to be as restrain-free as possible, and when warranted, to use the least restrictive methods of restraint for the shortest time possible ... Non-Violent. Non-Self Destructive Behavior ... Includes action, but not limited to pulling at tubes, lines and medical devices or entangling legs in side rails, or similar activities with the potential of unintended harm (trauma/injury) to the patient, team members or others. Violent / Self Destructive Behavior ... Includes actions by the patient which compromises the physical safety of the patient, a team member or others including but not limited to hitting, kicking, mutilating, or other physically aggressive behaviors ... Criteria for Release of Restraint or Seclusion ... The registered nurse has the authority to discontinue the restraints at the earliest possible time this may occur before the time-limited order has expired ... Velcro Cuffs (without Key Locks) - Physical control for extremely agitated patients. May be used for both wrists and ankles (Cuffs are color-coded). Application: a. Place limb in cuff and secure by pushing strap through D-Ring loop. Pass strap through-Ring to hold in place. Make sure the straps and buckle are on the outside of the restraint. B. Use method i or ii to attach straps to the bed, stretcher or bed with restraint loops: i. Triangulation method; to restrict patient's range of motion: Separate the straps and attach them to different points along the bed frame using a quick release tie. ii. To increase the patient's range of motion: Place the straps together and attach to sings points along the bed frame using a quick release tie ... Velcro Cuffs (with Key lock(s)) - Physical control for extremely agitated and/or violent patients. May be used for both wrists and ankles (cuffs are color coded). Application: a. Ascertain availability of restraint key. B. To avoid patient using the device with the metal buckle as a weapon, attach key lock restraints to bed prior to placing restraint on the patient. C. Thread the strap to moveable part of bed frame utilizing loops under mattress intended for this purpose by bed manufacturers. D. Fasten by pushing the strap through the locking mechanism and push down on metal plate to lock the restrain. Make sure the straps and buckle are on the outside of the restraint..."

Closed medical record review conducted on 09/15/2020 revealed Patient (PT) #2 was a 32-year-old male who presented to the facility's Emergency Department (ED) on 09/01/2020 at 1802. Review of an ED Provider Note written by Medical Doctor (MD) #1 on 09/02/2020 (untimed) revealed, "...This is a 32-year-old male with past medical history of seizure disorder who presents for evaluation for concern of overdose. Patient was trying to kill himself almost entire bottle (sic). Patient has 100 mg (milligram) pills. His bottle was last prescribed on August 23 and 150 pills at night (sic). He states he took 148. Patient otherwise is currently with altered mental status. He is tangential (erratic) in speaking as well as rapid and pressured. He is having hallucinations. He keeps repeating 'there is a frog in my mouth.' He denies taking any other medications. He is otherwise unable to provide ROS (Review of Systems) 2/2 (secondary to) mental status changes. Past Medical History - Seizure... Differential includes overdose on phenytoin (a medication to control seizures) secondary to suicidal attempt. Patient only admits to phenytoin ... He is agitated this time (sic). Will use Ativan (a medication to calm and/or sedate a patient) to try and control patient. However with any tone (sic) should watch for CNS (Central Nervous System) involvement including respiratory depression with need for intubation and supportive care ... As per toxicology recommendation follow phenytoin level until is less than 20. Continue use (sic) Ativan for agitation or seizures ... Patient needs to be admitted to medicine service in order to be evaluated overnight. Due to his suicidal ideations would need psych consult once cleared from a toxicology standpoint. Gust (sic) all these recommendations with admitting team, the hospitalist service. They were agreeable to come down see patient (sic) for admission..." PT #2 was evaluated by Hospitalist #2, who issued admission and Psychiatric consult orders. Review of a History and Physical written by Hospitalist #2 revealed, "...(PT #2 Named) is a 32yrs (years old) Male brought in for intentional overdose of phenytoin that happened around 5 pm (in the evening). Per review of chart, patient took all the pills he was prescribed on August 23rd. He takes 500 mg daily. Unclear whether there was co-ingestion of other substances. I could not obtain any meaningful information from the patient. He was confused, mumbling some words. Hx (history) obtained from review of chart and from ED resient report Past medical History: Diagnosis Depression Seizure ... Assessment and plan ... Serial EKG (a diagnostic study to evaluate the electrical activity of the heart) and Phenytoin levels. IV (intravenous) fluids. Neuro checks and tele monitoring. Tox (Toxicology) consult. Check UDS (Urine Drug Screen). Sitter at bedside. Inpatient psych (psychiatric) consult for suicide attempt ... On phenytoin-presented with overdose. Hold off on Dilantin (phenytoin) for now. Ativan (a medication to calm and/or sedate a patient) as needed for agitation and breakthrough seizure..." Review of a Consult Note written by MD #3 on 09/02/2020 (untimed) revealed, "...Date of Service: 09/02/2020 0848 ... Psychiatry Consult ... Chief Complaint: Unfortunately the patient was too somnolent (sleepy) to participate in the interview ... Patient has medical history of seizure disorder and psychiatric history of none. Patient appears to be a Impaired (sic) historian ... Patient seen by toxicology an recommended medical admission due to up-trending phenytoin level and monitoring of EKG (Electrocardiogram) for prolonged QTC or QRS (electrical component of the heart beat). Per chart review, pt has been restless and had vomited and urinated on himself multiple times, along with up-trending phenytoin level currently 70.7 (high, normal therapeutic level is 10 to 20). Patient additionally received Ativan 1 mg at 2:05 am (morning) ... Spoke to (PT #2's Mother, Named with phone number) ... She states she is aware of the overdose and his actions, meaning agitated ... She reports had a video conference visit with his neurologist yesterday, and noted at this time the patient was confused, she states that at baseline he is friendly and enjoyable person to be around ... She notes that neurologist was going to prescribe another medication, doe to patient having breakthrough seizures ... She notes that yesterday during the neurologist appointment he did SI (Suicidal Ideation) due to his seizures. She notes that this was the first time he had stated anything like this. She notes that leading up to this presentation the seizures, his medical condition, has taken a toll on him and caused him to be depressed ... Per collateral from the patient's mother patient has no significant psychiatric history and has never expressed any SI previously. Additionally she does note patient has never established with psychiatry/mental health due to cost and patient currently does not have disability. Plan: - Please do not discharge without psychiatry clearance. - Will need to re-assess patient when he/she is more alert and able to participate in this evaluation - Please continue to address the patient's medical concerns..." PT #2 was admitted to 3 East, a medical-surgical unit on the facility's 3rd floor on 09/02/2020 at 2141. Review of a Nursing Note written by Registered Nurse (RN) #4 on 09/03/2020 at 0800 revealed, "During morning report, patient was sleeping with sitter at bedside. Patient woke up after report was given. Patient was asking the RN to leave the room so he can talk to the sitter privately. Patient was visibly upset. I continued my assessment and patient was aggressively talking '25,000, 50,000,' as he was counting the people in the room. He did not make sense. Patient at this point was trying to scoot to the side of the bed to get up., I asked him to sit back so he does not pull his IV (intravenous access) out. Patient did calm down and sit back for about a minute. As I was giving report to (Named Staff) the CP (Care Partner), the patient jump (sic) over the end up the bed. He pulled his PIV (Peripheral Intravenous access) out and chased me down the hallway. Patient then fell because he was unstable. Patient continued to crawl, walk, and flailing around the unit running into walls and falling to the ground multiple times which lasted for about 5-10 minutes. Police were called to assist. MD (Medical Doctor) notified. Violent restraint orders placed. IM (Intramuscular) Haldol (a medication to calm and/or sedate patients) given. Mother updated by Charge nurse on the situation. Will continue to monitor." Review revealed an order for "restraints for non-violent reasons... 4 point Velcro (Fabric restraints placed on a patient's ankles and wrists. On the extremity end, the ankle or wrist is secured by hook and loop closure and the restraint is tied to the hospital bed frame by fabric extensions.)..." was issued by Hospitalist #5 on 09/03/2020 at 0758, noting a purpose of "-Unintentional Interference with necessary treatment/devices -High risk of unintentional injury/trauma to self", and 4 point Velcro restraints were applied on 09/03/2020 between 0758 and 0800. Review revealed an order for "restraints for violent reasons ... 4 point Velcro Keylock (Restraints of the same general design as the previously mentioned restraints, however secured on the extremity side and the bedframe side with a metal lock. Utilized for patients requiring stronger restraint measures.)..." was issued by Hospitalist #5 on 09/03/2020 at 0819, noting a purpose of "-Severely Aggressive - Violent against other" and the restraints were changed to 4 point Velcro Key Lock on 09/03/2020 at 0819. Review of Follow Up Note written by MD #3 on 09/03/2020 (untimed) revealed, "...Date of Service 09/03/2020 0903 ... Psychiatry Consult Liaison ... Informed by primary team and nursing staff patient became acutely agitated and had to be placed in restraints due to leaving his room and running down the hall and hitting his shoulder ... Per collateral from the patient's mother patient has no significant psychiatric history and has never expressed any SI (Suicidal Ideation) previously. Additional she does note patient has never established with psychiatry/mental health due to cost and patient currently does not have disability Patient's UDS + (positive) for THC (the active psychotropic chemical in marijuana) Plan: - Please do not discharge without psychiatry clearance. -Will need to re-assess patient when he is more alert and able to participate in this evaluation - Please continue to address the patient's medical concerns, and continue to monitor the patient's phenytoin level of 68.6. - Can consider using Ativan 1mg TID (three times daily) PRN (as needed) for acute agitation. If Ativan ineffective may consider 2.5mg Haldol (another medication that can calm and/or sedate a patient) TID PRN..." The restraint order was renewed by Hospitalist #5 on 09/03/2020 at 1257. Review of a Progress Note written by Hospitalist #5 on 09/03/2020 (untimed) revealed, "...Date of Service: 09/03/2020 1413 ... Patient very agitated this morning, running down the hall. He hit his head to wall and also injured his shoulder. Patient seen bedside (sic) this morning, placed on violent restraints. Followed up with psychiatry ... Assessment and Plan ... Serial EKG's, will follow Phenytoin levels Continue IV fluids (sic). Psychiatry following for suicide attempt. Suicide precautions. Bedside sitter in place ... Acute Agitation: Dose of haldol given. Psych follow up recommended ativan 1 mg TID PRN and if ativan is ineffective will consider 2.5 mg haldol TID PRN. Placed on 4 point violent restraints this morning, will change to non violent restraints later..." Review revealed an order for "restraints for non-violent reasons ... 4 point Velcro..." was issued by Hospitalist #5 on 09/03/2020 at 1453, noting a purpose of "-Unintentional Interference with necessary treatment/devices -High risk of unintentional injury/trauma to self", and PT #2's restraints were changed to 4 point Velcro restraints. Review revealed an order for "restraints for non-violent reasons ... Bilateral (both sides) Upper (upper extremities) Velcro Cuff ..." was issued by Hospitalist #5 on 09/03/2020 at 1820, noting a purpose of "-Unintentional Interference with necessary treatment/devices -High risk of unintentional injury/trauma to self", and PT #2's ankle restraints were removed, noting his arms were still in restraints. Review of an End of Shift Summary written by RN #6 (untimed) revealed, "...Date of Service: 09/04/2020 0111 ... Pertinent Events This Shift ... PRN Ativan for minor agitation x1 (administered once)..." Review of a Nursing Note written by RN #1 on 09/04/2020 (untimed) revealed, "...Date of Service: 09/04/2020 0930 ... At approximately 0930 while outside of patient room I heard patient talking to sitter about going home. Upon entering the room, patient appeared agitated and frustrated. Patient had not been like this on previous assessment. Patient asked me 'Why can't I go home?' Attempted to deescalate patient without desired result. Exited room to get PRN (as needed) Ativan as ordered for agitation. Sitter remains at bedside. Before I could get to the med pyxis (medication distribution device) the sitter was calling for help. Immediately returned to room and patient was pulling at Velcro wrist restraints. I asked for secretary to call hospital police and called for help. Multiple staff members responded to assist in room. Staff unable to physically restrain patient. Patient broke loose of restraints. Patient started throwing items in room. Patient smashed window open with his hands. Patient unable to be redirected despite multiple attempts to deescalate the situation. I stepped out of the room into hallway to see if police had arrived after I visualized patient had shards of glass in his hands and bleeding. Unable to approach patient to assist due to his presentation." Review of an Emergency Response Team Note written by RN #7 on 09/04/2020 (untimed) revealed, "... Date of Service: 09/04/2020 1010 ... Reason for Call 'Main lobby person has jumped from building' ... Time Called 0945 Arrival Time 0947 ... ERT (Emergency Response Team) paged to assist with 'main lobby person has jumped from building.' Pt jumped from E301 window, onto concrete pad in the auditorium courtyard. Found by ERT at 0947. ERT first on scene. Code blue activated by primary RN, at 0947, 2/2 compromised airway. Patient found in pronned (sic) position, face down. Copious amounts of blood noted. Multiple lacerations noted. Spinal precautions initiated. Patent placed on back. Carotid pulse (pulse felt on the neck) palpable at 0948. Unresponsive. GCS (Glascow Coma Scale - a measure of alertness - 3 is unresponsive) 3. C-collar (a device to stabilize the neck in case it is injured) placed at 0948. Blood noted in airway. Placed on side. Spine protected. Patient breathing on own. Chest rise noted. (Named Hospitalist #5) arrived to scene at 0948. Placed on backboard at 0949. Lost pulse at 0950. ACLS (Advanced Cardiac Life Support) protocol/CPR (Cardiopulmonary Resuscitation) started. IO (Intraosseous-access to the bone marrow to administer medications) placed at 0950 ... L (left) leg with deformity ... King airway (a device utilized to rapidly secure a patient's airway to provide artificial ventilation) ... placed at 0953. Moved onto bed, utilizing back board. ED charge called at 1001, pt to be placed in trauma bay. CPR maintained during transfer to ED. Arrived to ED at 1005..." Review of a Discharge Summary written by Hospitalist #5 on 09/04/2020 (untimed) revealed, "...Date of Service 1400 ... Patient was being followed by psychiatry service, was on suicide precautions with one to one watch. This morning, patient was shouting and throwing things violently. When I personally approached the room he had already removed the restraints by force. Bedside staff was unable to physically restrain the patient, as the patient was violent. Despite our best efforts to dissuade him, the patient broke the window with his own hands and jumped out of the window. Immediately, we went downstairs, ERT already present at the scene. CPR was initiated and code team was at the scene. ERT and Critical care (sic) took over care and started resuscitation measures. Subsequently patient was transferred to the trauma bay ... Code blue continued in trauma bay by ER team. Patient passed away on 09/04 at 10:10 AM (morning)."

Review of hospital police dispatch log revealed on 09/04/2020 the initial call for assistance on the 3East unit came in at 0941. Officers were dispatched at 0943. Due to distance from their responding location, officers were not able to arrive to 3East before Patient #2 jumped from the window. They checked on-scene in the courtyard where he fell at 0945. Two (2) additional officers were dispatched at 0948 and 0949, with both checking on-scene in the courtyard at 0949.

Review of a medication retrieval log from the Pyxis (a machine storage and dispensing machine) revealed RN #1 withdrew Ativan prescribed to Patient #2 on 09/04/2020 at 0942.

Staff interview was conducted with RN #1 on 09/15/2020 at 1300. Interview revealed when she came on shift on the morning of 09/03/2020 she assumed care for PT #2 and received report at the bedside. Interview revealed initially he was sleeping. While she was talking to a care partner he woke up and began "getting antsy," and began moving about the bed, and RN #1 warned him he may pull his IV line. RN #1 exited the room to continue nursing duties for another patient and PT #2 ran out of the room after her, with an unsteady gait. Hospital Police were called. PT #2 chased her down the hallway and RN #1 hid in a room. Interview revealed while this transpired PT #2 apparently was running into walls and broke a tooth. PT #2 was subdued by Hospital Police. Interview revealed RN #1 did not witness this. PT #2 subsequently received medications to calm him down, was placed in restraints, and assigned a sitter. Interview revealed it is hospital policy to begin to get patients out of restraints as soon as possible as their behavior improves. Interview revealed by the end of her shift on 09/03/2020 PT #2 had progressed from 4 point Velcro Key Lock restraints, to 4 point Velcro restraints, to bilateral wrist Velcro restraints. Interview revealed RN #1 was assigned as the primary nurse for PT #2 again on 09/04/2020. PT #2 was still in bilateral wrist restraints. PT #2 at times would dose off, but upon awakening would not recall where he was and what his situation was regarding being admitted to the hospital. Interview revealed he declined breakfast and seemed "antsy" again at the beginning of the shift. PT #2 requested to call his mother and the sitter dialed the number for him and RN #1 exited the room. While RN #1 was talking to her orientee, a new graduate nurse, she heard the volume of PT #2's voice increasing while talking to his sitter saying, "I'm ready to go home; Why are you keeping me here against my will?" RN #1 entered the room to assess PT #2 and he was pulling against his wrist restraints with the sitter still at the bedside. RN #1 went to the Pyxis room, which was only one room over to get Ativan to help calm him. RN #1 heard the sitter "yelling" for help, so RN #1 went back to the room and immediately called overhead for help and for Hospital Police. 5 other staff members responded and began trying to hold PT #2 and tighten his restraints, so RN #1 again attempted to get Ativan because there were so many people in the room. As the Pyxis door opened RN #1 heard someone say, "He's loose, everybody get out of room." (sic) When RN #1 walked out of the Pyxis room PT #2 was still in room E301 and she could hear things getting thrown around the room. She then heard something smash and the sound of glass falling. RN #1 could see PT #2 repeatedly bashing the window (RN #1 raised her arms with bent elbows and demonstrated a striking motion with alternating closed fists). She noted PT #2 was now bleeding and had a shard of glass in his hands. Interview revealed PT #2 was not responding to de-escalation and not listening to any verbal redirection, with staff asking him to stop what he was doing. RN #1 went back towards the nursing station to see where the Police were. Interview revealed "if we'd gotten anywhere close there is no telling what he would do to us." RN #1 then heard someone say, "he just jumped." RN #1 did leave the floor to attempt to find PT #2, and by the time she got to the courtyard where he fell the ERT team was working on him. RN #1 went to go them a stretcher to transport PT #2 to the ED and went back up to 3East.

Telephone interview was conducted with Sitter #8 on 09/15/2020 at 1345. Interview revealed at the beginning of the shift on 09/04/2020 PT #2 seemed calm and asked to call his mother. Sitter #8 offered him hydration. Sitter #8 dialed his mother 3 times before she answered. Sitter #8 could assess PT #2 was getting angry. Sitter #8 advised he was asking his mother to come get him from the hospital, but Sitter #8 could not hear the mother's response. PT #2 began demanding to leave, and Sitter #8 notified RN #1, who was trying to get medications. Interview revealed Sitter #8 was in the room the whole time. PT #2 began trying to get his restraints off and Sitter #8 grabbed him and asked him to stop. Other nurses responded quickly to the call for assistance. Interview revealed PT #2 was trying to "squirm" to loosen the restraints and "that's why I was holding his hand, another nurse was getting his arm. Interview revealed Sitter #8 transitioned position to his legs and she did not witness how he got his hand's free from the restraints. PT #2 kicked Sitter #8 off of his legs. Interview revealed PT #2 was very combative and determined to get up and get away. Interview revealed PT #2 began banging on the window and broke it and he was bloody. He had broken glass in his hand and at that point Sitter #8 feared bodily harm if she approached him. Sitter #8 was waiting for Hospital Police "at that point." Interview revealed Sitter #8 did not know how long it took for PT #2 to break the room's window. Interview revealed "people were screaming, don't know (sic) how long the whole incident took to be honest."

Interview was conducted with the Director of Risk Management (DRM) on 09/15/2020 at 1400. Interview revealed the DRM did not have a Medical Examiner's report for PT #2 as it was not yet complete. Interview revealed the restraints were not broken by PT #2. Interview revealed the DRM heard in conversation that there were no restraints on his body. Interview revealed the restraints were not saved when the room was cleaned up. Interview revealed "he must have worked them off."

Interview was conducted with the Director of Accreditation on 09/15/2020 at 1528. Interview revealed the nursing staff on 3East is not CPI (Nonviolent Crisis Intervention) trained. Interview revealed sitters, ED and Behavioral Health nurses are CPI trained.

Repeat telephone interview was conducted with Sitter #8 on 09/15/2020 at 1533. Interview revealed she was holding the phone for PT #2 while he was talking to his mother. Interview revealed Sitter #8 felt the restraints were appropriately applied, as he had "a little lee-way, but couldn't reach far." Interview revealed initially he was trying to pull against the restraints to remove them. Interview confirmed Sitter #8 had "no idea" how PT #2 got out of the restraints. Interview confirmed Sitter #8 has received training on verbal de-escalation and CPI.

Staff interview was conducted with RN #9 on 09/16/2020 at 1100. Interview revealed he was a on orientation and RN #1 was his preceptor. Interview revealed on 09/04/2020 he was approximately 2 rooms over from PT #2's room and he heard PT #2 start "yelling" that he knew his rights and wanted to go home. When RN #9 got into the room he could see that PT #2 was in bilateral wrist restraints and RN #9 started trying to hold him down. RN #9 advised PT #2 was able to get out of one restraint by force. RN #9 estimated 4 staff members in the room at the time. Interview revealed the staff members left the room due to PT #2's behavior the previous day (09/03/2020) when he was running down the halls and stumbling chasing staff. Interview revealed when the facility staff exited the room, PT #2's left arm was restrainted. RN #9 advised an unknown number of staff went to the nursing station briefly and then returned to the hall by the entrance to PT #2's room. Interview revealed RN #9 got back to the room PT #2 was banging on the widow which was already broken. RN #9 then saw PT #2 had broken glass in his hand. RN #9 witnessed PT #2 jump out of the window.

Telephone interview was conducted with RN #10 on 09/16/2020 at 1130. Interview revealed on 09/04/2020 RN #10 was on his assigned hall and heard an urgent call for assistance in room 301. Upon his arrival there were multiple staff members in the room attempting to tighten PT #2's restraints. While RN #10 was in the room PT #2 freed his right hand and was reaching to his still restrained left. Interview revealed RN #10 advised staff to "get back" because he was pulling out of his restraints. RN #10 then ran to a phone to call hospital police, and police dispatch informed RN #10 the police had already been called and were on their way. RN #10 was at the nursing station and there were numerous (RN #10 could not recall how many) staff standing at the doorway to the room. RN #10 was watching down the hallway for the police. RN #10 heard glass breaking and staff calling PT #2's name and yelling "Stop stop what you are doing!" RN #10 advised PT #2 was a "big guy and kicking" and RN #10 didn't want anyone to get hurt. RN #10 didn't recall who was attempting to hold each extremity however when PT #2 got his right hand free of its Velcro restraint, his left hand was still in its Velcro restraint. It was then RN #10 told everyone to get back. When RN #10 ran to call hospital police everyone was backing up.

Telephone interview was conducted with RN #11 on 09/16/2020 at 1200. Interview revealed PT #2's primary RN called for help with a combative patient. Interview revealed upon RN #11 ' s arrival to the room staff were trying to tighten PT #2's wrist restraints. RN #11 did not recall which arm got free first, but when the arm was free, one of the other nurses stated we (staff) had to go or he was going to hurt someone. Interview revealed the patient was left with one arm still restrained to the bed. RN #11 did not see PT #2 remove the final restraint. Interview revealed RN #11 joined other staff at the nurse's station where staff were attempting to contact hospital police. RN #11 looked back toward room and saw PT #2 hitting the window. RN #11 did not witness PT #2 jump out of the window, but RN #11 joined RN #4 when she left the unit to attempt to find him.

Physician interview was conducted with Hospitalist #5 on 09/16/2020 at 1305. Interview revealed PT #2 was on the medical unit for medical clearance prior to admission to the behavioral health unit. Interview revealed toxicology had recommended monitoring the level of the medication PT #2 overdosed on and performing heart monitoring serial electrocardiograms to ensure his heart was not receiving any damage. Interview revealed on the morning of 09/03/2020 PT #2 was very violent, so he was restrained, but by afternoon his behavior had begun to stabilize so he was changed to non-violent restraints. Interview revealed on the morning of 09/04/2020 Hospitalist #5 was on the unit talking on the phone to psychiatry about a different patient, and Hospitalist #5 began hearing noises saw people running to PT #2's room. Hospitalist #5 heard nurses trying to get medications and hospital police being called and heard glass breaking. Hospitalist #5 then came from around the nurse's station and saw PT #2 throwing items from his room into the hallway. Hospitalist #5 advised the nurses were scared and saying, "stop it stop it." Interview revealed PT #2 never looked at Hospitalist #5, but there was blood and glass "everywhere." Hospitalist #5 advised he did witness the final strike on the glass and PT #2 jumping out of the window. Interview revealed the hospital requires physicians to undergo training on restraint utilization.

Interview was conducted with the Director of Patient Safety (DPS) on 09/16/2020 at 1610. Interview revealed a declaration number, which starts the process of a Root Cause Analysis (RCA - a systematic process for identifying causes of problems or events and an approach for responding to them), was issued regarding PT #2 on 09/04/2020. The RCA process, which has a 45-day timeline, normally consists of 3 meetings, the first of which was completed on 09/15/2020. The first activities include a review of the patient's chart and any other data available; and identification of personnel to interview. Interview revealed about 8 staff members have been interviewed. Interview revealed the RCA is not complete, however the Patient Safety Committee plans to expedite meetings 2 and 3 for completion next week.

Based on hospital policy review, medical record review and physician interview, the facility staff failed to document a face-to-face assessment within one hour after a violent restraint intervention for 1 of 3 sampled patients. (Patient #2)

Findings include:

Review of hospital policy titled "Restraint and Seclusion Application and Types, including Behavioral Health Services..." last revised 09/2020 revealed, "...Face to Face Assessment for Violent Restraints A. A Phsician... must conduct a 'face to face' assessment of the patient to determine the need for restraint within ONE hour after the initiation of the violent restraint or seclusion... B. Documentation of the 'face-to-face' assessment will include ALL of the following: 1. the patient's immediate situation; 2. the patient's reaction to the intervention; 3. the patient's medical and behavioral condition; and 4. the need to continue or terminate the restraint or seclusion..."

Closed medical record review conducted on 09/15/2020 revealed Patient (PT) #2 was a 32-year-old male who presented to the facility's Emergency Department (ED) on 09/01/2020 at 1802. Review of an ED Provider Note written by Medical Doctor (MD) #1 on 09/02/2020 (untimed) revealed, "...This is a 32-year-old male with past medical history of seizure disorder who presents for evaluation for concern of overdose. Patient was trying to kill himself almost entire bottle (sic). Patient has 100 mg (milligram) pills. His bottle was last prescribed on August 23 and 150 pills at night (sic). He states he took 148. Patient otherwise is currently with altered mental status. He is tangential (erratic) in speaking as well as rapid and pressured. He is having hallucinations. He keeps repeating 'there is a frog in my mouth.' He denies taking any other medications. He is otherwise unable to provide ROS (Review of Systems) 2/2 (secondary to) mental status changes. Past Medical History - Seizure... Differential includes overdose on phenytoin (a medication to control seizures) secondary to suicidal attempt. Patient only admits to phenytoin ... He is agitated this time (sic). Will use Ativan (a medication to calm and/or sedate a patient) to try and control patient. However with any tone (sic) should watch for CNS (Central Nervous System) involvement including respiratory depression with need for intubation and supportive care ... As per toxicology recommendation follow phenytoin level until is less than 20. Continue use (sic) Ativan for agitation or seizures ... Patient needs to be admitted to medicine service in order to be evaluated overnight. Due to his suicidal ideations would need psych consult once cleared from a toxicology standpoint. Gust (sic) all these recommendations with admitting team, the hospitalist service. They were agreeable to come down see patient (sic) for admission..." PT #2 was evaluated by Hospitalist #2, who issued admission and Psychiatric consult orders. Review of a History and Physical written by Hospitalist #2 revealed, "...(PT #2 Named) is a 32yrs (years old) Male brought in for intentional overdose of phenytoin that happened around 5 pm (in the evening). Per review of chart, patient took all the pills he was prescribed on August 23rd. He takes 500 mg daily. Unclear whether there was co-ingestion of other substances. I could not obtain any meaningful information from the patient. He was confused, mumbling some words. Hx (history) obtained from review of chart and from ED resient report Past medical History: Diagnosis Depression Seizure ... Assessment and plan ... Serial EKG (a diagnostic study to evaluate the electrical activity of the heart) and Phenytoin levels. IV (intravenous) fluids. Neuro checks and tele monitoring. Tox (Toxicology) consult. Check UDS (Urine Drug Screen). Sitter at bedside. Inpatient psych (psychiatric) consult for suicide attempt ... On phenytoin-presented with overdose. Hold off on Dilantin (phenytoin) for now. Ativan (a medication to calm and/or sedate a patient) as needed for agitation and breakthrough seizure..." PT #2 was admitted to 3 East, a medical-surgical unit on the facility's 3rd floor on 09/02/2020 at 2141. Review of a Nursing Note written by Registered Nurse (RN) #4 on 09/03/2020 at 0800 revealed, "During morning report, patient was sleeping with sitter at bedside. Patient woke up after report was given. Patient was asking the RN to leave the room so he can talk to the sitter privately. Patient was visibly upset. I continued my assessment and patient was aggressively talking '25,000, 50,000,' as he was counting the people in the room. He did not make sense. Patient at this point was trying to scoot to the side of the bed to get up., I asked him to sit back so he does not pull his IV (intravenous access) out. Patient did calm down and sit back for about a minute. As I was giving report to (Named Staff) the CP (Care Partner), the patient jump (sic) over the end up the bed. He pulled his PIV (Peripheral Intravenous access) out and chased me down the hallway. Patient then fell because he was unstable. Patient continued to crawl, walk, and flailing around the unit running into walls and falling to the ground multiple times which lasted for about 5-10 minutes. Police were called to assist. MD (Medical Doctor) notified. Violent restraint orders placed. IM (Intramuscular) Haldol (a medication to calm and/or sedate patients) given. Mother updated by Charge nurse on the situation. Will continue to monitor." Review revealed an order for "restraints for non-violent reasons... 4 point Velcro (Fabric restraints placed on a patient's ankles and wrists. On the extremity end, the ankle or wrist is secured by hook and loop closure and the restraint is tied to the hospital bed frame by fabric extensions.)..." was issued by Hospitalist #5 on 09/03/2020 at 0758, noting a purpose of "-Unintentional Interference with necessary treatment/devices -High risk of unintentional injury/trauma to self", and 4 point Velcro restraints were applied on 09/03/2020 between 0758 and 0800. Review revealed an order for "restraints for violent reasons ... 4 point Velcro Keylock (Restraints of the same general design as the previously mentioned restraints, however secured on the extremity side and the bedframe side with a metal lock. Utilized for patients requiring stronger restraint measures.)..." was issued by Hospitalist #5 on 09/03/2020 at 0819, noting a purpose of "-Severely Aggressive - Violent against other" and the restraints were changed to 4 point Velcro Key Lock on 09/03/2020 at 0819. The restraint order was renewed by Hospitalist #5 on 09/03/2020 at 1257. Review revealed an order for "restraints for non-violent reasons ... 4 point Velcro..." was issued by Hospitalist #5 on 09/03/2020 at 1453, noting a purpose of "-Unintentional Interference with necessary treatment/devices -High risk of unintentional injury/trauma to self", and PT #2's restraints were changed to 4 point Velcro restraints. Review revealed an order for "restraints for non-violent reasons ... Bilateral (both sides) Upper (upper extremities) Velcro Cuff ..." was issued by Hospitalist #5 on 09/03/2020 at 1820, noting a purpose of "-Unintentional Interference with necessary treatment/devices -High risk of unintentional injury/trauma to self", and PT #2's ankle restraints were removed, noting his arms were still in restraints. Review revealed no evidence of documentation of a face to face assessment by a phtysician within one hour of the restraint episode.

Telephone physician interview was conducted with Hospitalist #5 on 09/17/2020 at 1323. Interview revealed Hospitalist #5 was present and assessed PT #2 on 09/03/2020 when he was initially restrained. Interview confirmed there was no documentation of the assessment. Interview revealed Hospitalist #5 has received education regarding the existing template in the hospital's electronic medical record system that "will cover items" for the face to face assessment.

Based on review of hospital policies and procedures, medical record review and staff and physician interviews, the hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations to ensure a patient received safe delivery of care by failing to ensure nursing staff were trained to monitor and supervise care rendered to a patient exhibiting aggresive, escalating behaviors in 1 of 3 sampled patients (Patient #2). The following tags are cross-referred: A0144, and A0395.


Findings Include:

1. Based on facility policy and procedure review, medical record review, staff and physician interviews, the facility failed to promote and protect patient's rights by failing to ensure staff were trained to monitor and supervise care rendered to a patient exhibiting aggressive, escalating behaviors in 1 of 3 sampled patients (Patient #2).

~ Cross refer A: 0144


2. Based on review of hospital policies and procedures, medical record review and staff and physician interviews, the hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations to ensure a patient received safe delivery of care by failing to ensure nursing staff were trained to monitor and supervise care rendered to a patient exhibiting aggressive, escalating behaviors in 1 of 3 sampled patients (Patient #2).

~ Cross refer A: 0395

Based on policy and procedure review, medical record review and staff interviews, the facility's nursing staff failed to monitor and supervise care rendered to a patient exhibiting aggressive, escalating behaviors in 1 of 3 sampled patients. (Patient #2).

Findings Include:

Review of hospital policy titled "Patient Rights and Responsibilities..." last revised 09/2020 revealed,"...You and the right to ... Considerate and respectful care in a safe setting..."

Review of hospital policy titled "Restraint and Seclusion Application and Types, including Behavioral Health Services..." last revised 09/2020 revealed, "...The goal of (Named Facility) is to be as restrain-free as possible, and when warranted, to use the least restrictive methods of restraint for the shortest time possible ... Non-Violent. Non-Self Destructive Behavior ... Includes action, but not limited to pulling at tubes, lines and medical devices or entangling legs in side rails, or similar activities with the potential of unintended harm (trauma/injury) to the patient, team members or others. Violent / Self Destructive Behavior ... Includes actions by the patient which compromises the physical safety of the patient, a team member or others including but not limited to hitting, kicking, mutilating, or other physically aggressive behaviors ... Criteria for Release of Restraint or Seclusion ... The registered nurse has the authority to discontinue the restraints at the earliest possible time this may occur before the time-limited order has expired ... Velcro Cuffs (without Key Locks) - Physical control for extremely agitated patients. May be used for both wrists and ankles (Cuffs are color-coded). Application: a. Place limb in cuff and secure by pushing strap through D-Ring loop. Pass strap through-Ring to hold in place. Make sure the straps and buckle are on the outside of the restraint. B. Use method i or ii to attach straps to the bed, stretcher or bed with restraint loops: i. Triangulation method; to restrict patient's range of motion: Separate the straps and attach them to different points along the bed frame using a quick release tie. ii. To increase the patient's range of motion: Place the straps together and attach to sings points along the bed frame using a quick release tie ... Velcro Cuffs (with Key lock(s)) - Physical control for extremely agitated and/or violent patients. May be used for both wrists and ankles (cuffs are color coded). Application: a. Ascertain availability of restraint key. B. To avoid patient using the device with the metal buckle as a weapon, attach key lock restraints to bed prior to placing restraint on the patient. C. Thread the strap to moveable part of bed frame utilizing loops under mattress intended for this purpose by bed manufacturers. D. Fasten by pushing the strap through the locking mechanism and push down on metal plate to lock the restrain. Make sure the straps and buckle are on the outside of the restraint..."

Closed medical record review conducted on 09/15/2020 revealed Patient (PT) #2 was a 32-year-old male who presented to the facility's Emergency Department (ED) on 09/01/2020 at 1802. Review of an ED Provider Note written by Medical Doctor (MD) #1 on 09/02/2020 (untimed) revealed, "...This is a 32-year-old male with past medical history of seizure disorder who presents for evaluation for concern of overdose. Patient was trying to kill himself almost entire bottle (sic). Patient has 100 mg (milligram) pills. His bottle was last prescribed on August 23 and 150 pills at night (sic). He states he took 148. Patient otherwise is currently with altered mental status. He is tangential (erratic) in speaking as well as rapid and pressured. He is having hallucinations. He keeps repeating 'there is a frog in my mouth.' He denies taking any other medications. He is otherwise unable to provide ROS (Review of Systems) 2/2 (secondary to) mental status changes. Past Medical History - Seizure... Differential includes overdose on phenytoin (a medication to control seizures) secondary to suicidal attempt. Patient only admits to phenytoin ... He is agitated this time (sic). Will use Ativan (a medication to calm and/or sedate a patient) to try and control patient. However with any tone (sic) should watch for CNS (Central Nervous System) involvement including respiratory depression with need for intubation and supportive care ... As per toxicology recommendation follow phenytoin level until is less than 20. Continue use (sic) Ativan for agitation or seizures ... Patient needs to be admitted to medicine service in order to be evaluated overnight. Due to his suicidal ideations would need psych consult once cleared from a toxicology standpoint. Gust (sic) all these recommendations with admitting team, the hospitalist service. They were agreeable to come down see patient (sic) for admission..." PT #2 was evaluated by Hospitalist #2, who issued admission and Psychiatric consult orders. Review of a History and Physical written by Hospitalist #2 revealed, "...(PT #2 Named) is a 32yrs (years old) Male brought in for intentional overdose of phenytoin that happened around 5 pm (in the evening). Per review of chart, patient took all the pills he was prescribed on August 23rd. He takes 500 mg daily. Unclear whether there was co-ingestion of other substances. I could not obtain any meaningful information from the patient. He was confused, mumbling some words. Hx (history) obtained from review of chart and from ED resient report Past medical History: Diagnosis Depression Seizure ... Assessment and plan ... Serial EKG (a diagnostic study to evaluate the electrical activity of the heart) and Phenytoin levels. IV (intravenous) fluids. Neuro checks and tele monitoring. Tox (Toxicology) consult. Check UDS (Urine Drug Screen). Sitter at bedside. Inpatient psych (psychiatric) consult for suicide attempt ... On phenytoin-presented with overdose. Hold off on Dilantin (phenytoin) for now. Ativan (a medication to calm and/or sedate a patient) as needed for agitation and breakthrough seizure..." Review of a Consult Note written by MD #3 on 09/02/2020 (untimed) revealed, "...Date of Service: 09/02/2020 0848 ... Psychiatry Consult ... Chief Complaint: Unfortunately the patient was too somnolent (sleepy) to participate in the interview ... Patient has medical history of seizure disorder and psychiatric history of none. Patient appears to be a Impaired (sic) historian ... Patient seen by toxicology an recommended medical admission due to up-trending phenytoin level and monitoring of EKG (Electrocardiogram) for prolonged QTC or QRS (electrical component of the heart beat). Per chart review, pt has been restless and had vomited and urinated on himself multiple times, along with up-trending phenytoin level currently 70.7 (high, normal therapeutic level is 10 to 20). Patient additionally received Ativan 1 mg at 2:05 am (morning) ... Spoke to (PT #2's Mother, Named with phone number) ... She states she is aware of the overdose and his actions, meaning agitated ... She reports had a video conference visit with his neurologist yesterday, and noted at this time the patient was confused, she states that at baseline he is friendly and enjoyable person to be around ... She notes that neurologist was going to prescribe another medication, doe to patient having breakthrough seizures ... She notes that yesterday during the neurologist appointment he did SI (Suicidal Ideation) due to his seizures. She notes that this was the first time he had stated anything like this. She notes that leading up to this presentation the seizures, his medical condition, has taken a toll on him and caused him to be depressed ... Per collateral from the patient's mother patient has no significant psychiatric history and has never expressed any SI previously. Additionally she does note patient has never established with psychiatry/mental health due to cost and patient currently does not have disability. Plan: - Please do not discharge without psychiatry clearance. - Will need to re-assess patient when he/she is more alert and able to participate in this evaluation - Please continue to address the patient's medical concerns..." PT #2 was admitted to 3 East, a medical-surgical unit on the facility's 3rd floor on 09/02/2020 at 2141. Review of a Nursing Note written by Registered Nurse (RN) #4 on 09/03/2020 at 0800 revealed, "During morning report, patient was sleeping with sitter at bedside. Patient woke up after report was given. Patient was asking the RN to leave the room so he can talk to the sitter privately. Patient was visibly upset. I continued my assessment and patient was aggressively talking '25,000, 50,000,' as he was counting the people in the room. He did not make sense. Patient at this point was trying to scoot to the side of the bed to get up., I asked him to sit back so he does not pull his IV (intravenous access) out. Patient did calm down and sit back for about a minute. As I was giving report to (Named Staff) the CP (Care Partner), the patient jump (sic) over the end up the bed. He pulled his PIV (Peripheral Intravenous access) out and chased me down the hallway. Patient then fell because he was unstable. Patient continued to crawl, walk, and flailing around the unit running into walls and falling to the ground multiple times which lasted for about 5-10 minutes. Police were called to assist. MD (Medical Doctor) notified. Violent restraint orders placed. IM (Intramuscular) Haldol (a medication to calm and/or sedate patients) given. Mother updated by Charge nurse on the situation. Will continue to monitor." Review revealed an order for "restraints for non-violent reasons... 4 point Velcro (Fabric restraints placed on a patient's ankles and wrists. On the extremity end, the ankle or wrist is secured by hook and loop closure and the restraint is tied to the hospital bed frame by fabric extensions.)..." was issued by Hospitalist #5 on 09/03/2020 at 0758, noting a purpose of "-Unintentional Interference with necessary treatment/devices -High risk of unintentional injury/trauma to self", and 4 point Velcro restraints were applied on 09/03/2020 between 0758 and 0800. Review revealed an order for "restraints for violent reasons ... 4 point Velcro Keylock (Restraints of the same general design as the previously mentioned restraints, however secured on the extremity side and the bedframe side with a metal lock. Utilized for patients requiring stronger restraint measures.)..." was issued by Hospitalist #5 on 09/03/2020 at 0819, noting a purpose of "-Severely Aggressive - Violent against other" and the restraints were changed to 4 point Velcro Key Lock on 09/03/2020 at 0819. Review of Follow Up Note written by MD #3 on 09/03/2020 (untimed) revealed, "...Date of Service 09/03/2020 0903 ... Psychiatry Consult Liaison ... Informed by primary team and nursing staff patient became acutely agitated and had to be placed in restraints due to leaving his room and running down the hall and hitting his shoulder ... Per collateral from the patient's mother patient has no significant psychiatric history and has never expressed any SI (Suicidal Ideation) previously. Additional she does note patient has never established with psychiatry/mental health due to cost and patient currently does not have disability Patient's UDS + (positive) for THC (the active psychotropic chemical in marijuana) Plan: - Please do not discharge without psychiatry clearance. -Will need to re-assess patient when he is more alert and able to participate in this evaluation - Please continue to address the patient's medical concerns, and continue to monitor the patient's phenytoin level of 68.6. - Can consider using Ativan 1mg TID (three times daily) PRN (as needed) for acute agitation. If Ativan ineffective may consider 2.5mg Haldol (another medication that can calm and/or sedate a patient) TID PRN..." The restraint order was renewed by Hospitalist #5 on 09/03/2020 at 1257. Review of a Progress Note written by Hospitalist #5 on 09/03/2020 (untimed) revealed, "...Date of Service: 09/03/2020 1413 ... Patient very agitated this morning, running down the hall. He hit his head to wall and also injured his shoulder. Patient seen bedside (sic) this morning, placed on violent restraints. Followed up with psychiatry ... Assessment and Plan ... Serial EKG's, will follow Phenytoin levels Continue IV fluids (sic). Psychiatry following for suicide attempt. Suicide precautions. Bedside sitter in place ... Acute Agitation: Dose of haldol given. Psych follow up recommended ativan 1 mg TID PRN and if ativan is ineffective will consider 2.5 mg haldol TID PRN. Placed on 4 point violent restraints this morning, will change to non violent restraints later..." Review revealed an order for "restraints for non-violent reasons ... 4 point Velcro..." was issued by Hospitalist #5 on 09/03/2020 at 1453, noting a purpose of "-Unintentional Interference with necessary treatment/devices -High risk of unintentional injury/trauma to self", and PT #2's restraints were changed to 4 point Velcro restraints. Review revealed an order for "restraints for non-violent reasons ... Bilateral (both sides) Upper (upper extremities) Velcro Cuff ..." was issued by Hospitalist #5 on 09/03/2020 at 1820, noting a purpose of "-Unintentional Interference with necessary treatment/devices -High risk of unintentional injury/trauma to self", and PT #2's ankle restraints were removed, noting his arms were still in restraints. Review of an End of Shift Summary written by RN #6 (untimed) revealed, "...Date of Service: 09/04/2020 0111 ... Pertinent Events This Shift ... PRN Ativan for minor agitation x1 (administered once)..." Review of a Nursing Note written by RN #1 on 09/04/2020 (untimed) revealed, "...Date of Service: 09/04/2020 0930 ... At approximately 0930 while outside of patient room I heard patient talking to sitter about going home. Upon entering the room, patient appeared agitated and frustrated. Patient had not been like this on previous assessment. Patient asked me 'Why can't I go home?' Attempted to deescalate patient without desired result. Exited room to get PRN (as needed) Ativan as ordered for agitation. Sitter remains at bedside. Before I could get to the med pyxis (medication distribution device) the sitter was calling for help. Immediately returned to room and patient was pulling at Velcro wrist restraints. I asked for secretary to call hospital police and called for help. Multiple staff members responded to assist in room. Staff unable to physically restrain patient. Patient broke loose of restraints. Patient started throwing items in room. Patient smashed window open with his hands. Patient unable to be redirected despite multiple attempts to deescalate the situation. I stepped out of the room into hallway to see if police had arrived after I visualized patient had shards of glass in his hands and bleeding. Unable to approach patient to assist due to his presentation." Review of an Emergency Response Team Note written by RN #7 on 09/04/2020 (untimed) revealed, "... Date of Service: 09/04/2020 1010 ... Reason for Call 'Main lobby person has jumped from building' ... Time Called 0945 Arrival Time 0947 ... ERT (Emergency Response Team) paged to assist with 'main lobby person has jumped from building.' Pt jumped from E301 window, onto concrete pad in the auditorium courtyard. Found by ERT at 0947. ERT first on scene. Code blue activated by primary RN, at 0947, 2/2 compromised airway. Patient found in pronned (sic) position, face down. Copious amounts of blood noted. Multiple lacerations noted. Spinal precautions initiated. Patent placed on back. Carotid pulse (pulse felt on the neck) palpable at 0948. Unresponsive. GCS (Glascow Coma Scale - a measure of alertness - 3 is unresponsive) 3. C-collar (a device to stabilize the neck in case it is injured) placed at 0948. Blood noted in airway. Placed on side. Spine protected. Patient breathing on own. Chest rise noted. (Named Hospitalist #5) arrived to scene at 0948. Placed on backboard at 0949. Lost pulse at 0950. ACLS (Advanced Cardiac Life Support) protocol/CPR (Cardiopulmonary Resuscitation) started. IO (Intraosseous-access to the bone marrow to administer medications) placed at 0950 ... L (left) leg with deformity ... King airway (a device utilized to rapidly secure a patient's airway to provide artificial ventilation) ... placed at 0953. Moved onto bed, utilizing back board. ED charge called at 1001, pt to be placed in trauma bay. CPR maintained during transfer to ED. Arrived to ED at 1005..." Review of a Discharge Summary written by Hospitalist #5 on 09/04/2020 (untimed) revealed, "...Date of Service 1400 ... Patient was being followed by psychiatry service, was on suicide precautions with one to one watch. This morning, patient was shouting and throwing things violently. When I personally approached the room he had already removed the restraints by force. Bedside staff was unable to physically restrain the patient, as the patient was violent. Despite our best efforts to dissuade him, the patient broke the window with his own hands and jumped out of the window. Immediately, we went downstairs, ERT already present at the scene. CPR was initiated and code team was at the scene. ERT and Critical care (sic) took over care and started resuscitation measures. Subsequently patient was transferred to the trauma bay ... Code blue continued in trauma bay by ER team. Patient passed away on 09/04 at 10:10 AM (morning)."

Review of hospital police dispatch log revealed on 09/04/2020 the initial call for assistance on the 3East unit came in at 0941. Officers were dispatched at 0943. Due to distance from their responding location, officers were not able to arrive to 3East before Patient #2 jumped from the window. They checked on-scene in the courtyard where he fell at 0945. 2 additional officers were dispatched at 0948 and 0949, with both checking on-scene in the courtyard at 0949.

Review of a medication retrieval log from the Pyxis (a machine storage and dispensing machine) revealed RN #1 withdrew Ativan prescribed to Patient #2 on 09/04/2020 at 0942.

Staff interview was conducted with RN #1 on 09/15/2020 at 1300. Interview revealed when she came on shift on the morning of 09/03/2020 she assumed care for PT #2 and received report at the bedside. Interview revealed initially he was sleeping. While she was talking to a care partner he woke up and began "getting antsy," and began moving about the bed, and RN #1 warned him he may pull his IV line. RN #1 exited the room to continue nursing duties for another patient and PT #2 ran out of the room after her, with an unsteady gait. Hospital Police were called. PT #2 chased her down the hallway and RN #1 hid in a room. Interview revealed while this transpired PT #2 apparently was running into walls and broke a tooth. PT #2 was subdued by Hospital Police. Interview revealed RN #1 did not witness this. PT #2 subsequently received medications to calm him down, was placed in restraints, and assigned a sitter. Interview revealed it is hospital policy to begin to get patients out of restraints as soon as possible as their behavior improves. Interview revealed by the end of her shift on 09/03/2020 PT #2 had progressed from 4 point Velcro Key Lock restraints, to 4 point Velcro restraints, to bilateral wrist Velcro restraints. Interview revealed RN #1 was assigned as the primary nurse for PT #2 again on 09/04/2020. PT #2 was still in bilateral wrist restraints. PT #2 at times would dose off, but upon awakening would not recall where he was and what his situation was regarding being admitted to the hospital. Interview revealed he declined breakfast and seemed "antsy" again at the beginning of the shift. PT #2 requested to call his mother and the sitter dialed the number for him and RN #1 exited the room. While RN #1 was talking to her orientee, a new graduate nurse, she heard the volume of PT #2's voice increasing while talking to his sitter saying, "I'm ready to go home; Why are you keeping me here against my will?" RN #1 entered the room to assess PT #2 and he was pulling against his wrist restraints with the sitter still at the bedside. RN #1 went to the Pyxis room, which was only one room over to get Ativan to help calm him. RN #1 heard the sitter "yelling" for help, so RN #1 went back to the room and immediately called overhead for help and for Hospital Police. 5 other staff members responded and began trying to hold PT #2 and tighten his restraints, so RN #1 again attempted to get Ativan because there were so many people in the room. As the Pyxis door opened RN #1 heard someone say, "He's loose, everybody get out of room." (sic) When RN #1 walked out of the Pyxis room PT #2 was still in room E301 and she could hear things getting thrown around the room. She then heard something smash and the sound of glass falling. RN #1 could see PT #2 repeatedly bashing the window (RN #1 raised her arms with bent elbows and demonstrated a striking motion with alternating closed fists). She noted PT #2 was now bleeding and had a shard of glass in his hands. Interview revealed PT #2 was not responding to de-escalation and not listening to any verbal redirection, with staff asking him to stop what he was doing. RN #1 went back towards the nursing station to see where the Police were. Interview revealed "if we'd gotten anywhere close there is no telling what he would do to us." RN #1 then heard someone say, "he just jumped." RN #1 did leave the floor to attempt to find PT #2, and by the time she got to the courtyard where he fell the ERT team was working on him. RN #1 went to go them a stretcher to transport PT #2 to the ED and went back up to 3East.

Telephone interview was conducted with Sitter #8 on 09/15/2020 at 1345. Interview revealed at the beginning of the shift on 09/04/2020 PT #2 seemed calm and asked to call his mother. Sitter #8 offered him hydration. Sitter #8 dialed his mother 3 times before she answered. Sitter #8 could assess PT #2 was getting angry. Sitter #8 advised he was asking his mother to come get him from the hospital, but Sitter #8 could not hear the mother's response. PT #2 began demanding to leave, and Sitter #8 notified RN #1, who was trying to get medications. Interview revealed Sitter #8 was in the room the whole time. PT #2 began trying to get his restraints off and Sitter #8 grabbed him and asked him to stop. Other nurses responded quickly to the call for assistance. Interview revealed PT #2 was trying to "squirm" to loosen the restraints and "that's why I was holding his hand, another nurse was getting his arm. Interview revealed Sitter #8 transitioned position to his legs and she did not witness how he got his hand's free from the restraints. PT #2 kicked Sitter #8 off of his legs. Interview revealed PT #2 was very combative and determined to get up and get away. Interview revealed PT #2 began banging on the window and broke it and he was bloody. He had broken glass in his hand and at that point Sitter #8 feared bodily harm if she approached him. Sitter #8 was waiting for Hospital Police "at that point." Interview revealed Sitter #8 did not know how long it took for PT #2 to break the room's window. Interview revealed "people were screaming, don't know (sic) how long the whole incident took to be honest."

Interview was conducted with the Director of Risk Management (DRM) on 09/15/2020 at 1400. Interview revealed the DRM did not have a Medical Examiner's report for PT #2 as it was not yet complete. Interview revealed the restraints were not broken by PT #2. Interview revealed the DRM heard in conversation that there were no restraints on his body. Interview revealed the restraints were not saved when the room was cleaned up. Interview revealed "he must have worked them off."

Interview was conducted with the Director of Accreditation on 09/15/2020 at 1528. Interview revealed the nursing staff on 3East is not CPI (Nonviolent Crisis Intervention) trained. Interview revealed sitters, ED and Behavioral Health nurses are CPI trained.

Repeat telephone interview was conducted with Sitter #8 on 09/15/2020 at 1533. Interview revealed she was holding the phone for PT #2 while he was talking to his mother. Interview revealed Sitter #8 felt the restraints were appropriately applied, as he had "a little lee-way, but couldn't reach far." Interview revealed initially he was trying to pull against the restraints to remove them. Interview confirmed Sitter #8 had "no idea" how PT #2 got out of the restraints. Interview confirmed Sitter #8 has received training on verbal de-escalation and CPI.

Staff interview was conducted with RN #9 on 09/16/2020 at 1100. Interview revealed he was a on orientation and RN #1 was his preceptor. Interview revealed on 09/04/2020 he was approximately 2 rooms over from PT #2's room and he heard PT #2 start "yelling" that he knew his rights and wanted to go home. When RN #9 got into the room he could see that PT #2 was in bilateral wrist restraints and RN #9 started trying to hold him down. RN #9 advised PT #2 was able to get out of one restraint by force. RN #9 estimated 4 staff members in the room at the time. Interview revealed the staff members left the room due to PT #2's behavior the previous day (09/03/2020) when he was running down the halls and stumbling chasing staff. Interview revealed when the facility staff exited the room, PT #2's left arm was restrainted. RN #9 advised an unknown number of staff went to the nursing station briefly and then returned to the hall by the entrance to PT #2's room. Interview revealed RN #9 got back to the room PT #2 was banging on the widow which was already broken. RN #9 then saw PT #2 had broken glass in his hand. RN #9 witnessed PT #2 jump out of the window.

Telephone interview was conducted with RN #10 on 09/16/2020 at 1130. Interview revealed on 09/04/2020 RN #10 was on his assigned hall and heard an urgent call for assistance in room 301. Upon his arrival there were multiple staff members in the room attempting to tighten PT #2's restraints. While RN #10 was in the room PT #2 freed his right hand and was reaching to his still restrained left. Interview revealed RN #10 advised staff to "get back" because he was pulling out of his restraints. RN #10 then ran to a phone to call hospital police, and police dispatch informed RN #10 the police had already been called and were on their way. RN #10 was at the nursing station and there were numerous (RN #10 could not recall how many) staff standing at the doorway to the room. RN #10 was watching down the hallway for the police. RN #10 heard glass breaking and staff calling PT #2's name and yelling "Stop stop what you are doing!" RN #10 advised PT #2 was a "big guy and kicking" and RN #10 didn't want anyone to get hurt. RN #10 didn't recall who was attempting to hold each extremity however when PT #2 got his right hand free of its Velcro restraint, his left hand was still in its Velcro restraint. It was then RN #10 told everyone to get back. When RN #10 ran to call hospital police everyone was backing up.

Telephone interview was conducted with RN #11 on 09/16/2020 at 1200. Interview revealed PT #2's primary RN called for help with a combative patient. Interview revealed upon RN #11 ' s arrival to the room staff were trying to tighten PT #2's wrist restraints. RN #11 did not recall which arm got free first, but when the arm was free, one of the other nurses stated we (staff) had to go or he was going to hurt someone. Interview revealed the patient was left with one arm still restrained to the bed. RN #11 did not see PT #2 remove the final restraint. Interview revealed RN #11 joined other staff at the nurse's station where staff were attempting to contact hospital police. RN #11 looked back toward room and saw PT #2 hitting the window. RN #11 did not witness PT #2 jump out of the window, but RN #11 joined RN #4 when she left the unit to attempt to find him.

Physician interview was conducted with Hospitalist #5 on 09/16/2020 at 1305. Interview revealed PT #2 was on the medical unit for medical clearance prior to admission to the behavioral health unit. Interview revealed toxicology had recommended monitoring the level of the medication PT #2 overdosed on and performing heart monitoring serial electrocardiograms to ensure his heart was not receiving any damage. Interview revealed on the morning of 09/03/2020 PT #2 was very violent, so he was restrained, but by afternoon his behavior had begun to stabilize so he was changed to non-violent restraints. Interview revealed on the morning of 09/04/2020 Hospitalist #5 was on the unit talking on the phone to psychiatry about a different patient, and Hospitalist #5 began hearing noises saw people running to PT #2's room. Hospitalist #5 heard nurses trying to get medications and hospital police being called and heard glass breaking. Hospitalist #5 then came from around the nurse's station and saw PT #2 throwing items from his room into the hallway. Hospitalist #5 advised the nurses were scared and saying, "stop it stop it." Interview revealed PT #2 never looked at Hospitalist #5, but there was blood and glass "everywhere." Hospitalist #5 advised he did witness the final strike on the glass and PT #2 jumping out of the window. Interview revealed the hospital requires physicians to undergo training on restraint utilization.

Interview was conducted with the Director of Patient Safety (DPS) on 09/16/2020 at 1610. Interview revealed a declaration number, which starts the process of a Root Cause Analysis (RCA - a systematic process for identifying causes of problems or events and an approach for responding to them), was issued regarding PT #2 on 09/04/2020. The RCA process, which has a 45-day timeline, normally consists of 3 meetings, the first of which was completed on 09/15/2020. The first activities include a review of the patient's chart and any other data available; and identification of personnel to interview. Interview revealed about 8 staff members have been interviewed. Interview revealed the RCA is not complete, however the Patient Safety Committee plans to expedite meetings 2 and 3 for completion next week.

NC00169172; NC00169182; NC00165087

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