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Based on records reviewed and interviews for one of ten Patients, the Hospital failed to notify the family of Resident #2's acute transfer to Critical Care. Patient #2's condition deteriorated and he/she was intubated.

Findings include:

The Hospital Rules and Regulations of the Medical Staff, dated 8/9/16, indicated the attending licensed independent practitioner is personally responsible for promptly notifying a family when a patient's condition changes substantially for the worse and there is serious risk of death.

The Screening/Intake Tool, dated 2/1/17, indicated that, in case of emergency, Patient #2 wanted a designated Family Member notified.

Patient #2 was admitted in 2/2017 for treatment of Alcohol and Suboxone (a narcotic medication) dependency.

The Physician Transfer note, dated 2/2/17 indicated Patient #2 was admitted to the Detoxification Unit and transferred to the Intensive Care Unit for severe withdrawal and delirium tremens on the same day. Patient #2 required intubation for five days and was transferred to the Medical floor seven days later (2/10/17).

The Grievance Report, dated 5/23/17, indicated a Family Member complained that Patient #2's condition deteriorated and he/she was intubated, but the Family was not notified even though contact information specified family contact involvement in Patient #2's care.

The Surveyor interviewed Quality Assurance Nurse #1 on 5/24/17 at 5:00 P.M.. Quality Assurance Nurse #1 said that when Patient #2's condition deteriorated, the Family should have been notified.

Based on records reviewed and interviews, the Hospital failed to develop a patient assessment and individualized plan of care to address Patient #1's behavioral and safety issues before and after two Code Gray's (Psychiatric Emergency) were called on 4/13/17.

Findings include:

The Policy for Interdisciplinary Care Plan, dated 10/18/15, indicated that the interdisciplinary care plan was to provide an individualized plan of care for every hospitalized patient. The care plan will be based on identified patient problems and will assist in the coordination of care among disciplines. Interdisciplinary assessment will identify problems and will be utilized to establish the plan, the treatment and the individual care providers responsible for meeting these goals.

The Policy for Code Gray Procedure, dated 8/25/15, indicated a Code Gray is to provide assistance to staff members who are confronted by an individual who is demonstrating aggressive or violent behavior. Pre-alert activities included the overall situation will be assessed and a plan of care developed and initiated in an attempt to prevent violent or aggressive behavior.

Patient #1 was admitted 4/2017. Diagnoses included surgery on 4/13/17 for a leg hematoma evacuation and fasciotomy (cutting in to a thin sheath that cover muscle to relieve pressure) and a history of alcohol dependency.

Patient #1 was transferred to The Surgical East Unit on 4/13/17 and was alert and oriented to person, place and time and forgetful at times. On 4/13/17 at 2:53 A.M., Patient #1 pulled out the intravenous port and the surgical bulb/drain for the leg wound was missing. Patient #1's disorientation had started on the previous shift.

The Nurse Progress Note, dated 4/14/17, indicated that, between 5:00 A.M. to 6:00 A.M., Patient #1 was belligerent and attempted to leave the Unit to go home. Patient #1 was found walking at a very quick pace in the halls. The Patient was given Ativan (an anti-anxiety medication) one milligram at 5:00 A.M. but became more agitated. Security was called and the Patient #1 became more agitated, yelling out and arguing with Security in the hall. A Code Gray was called, Patient #1 punched Security Personnel and Patient #1 was taken down to the floor by Security Personnel. Patient #1 sustained a right ankle fracture.

The Nurse Progress Note, dated 4/14/17 at 10:00 A.M., indicated Patient #1 was agitated and was unable to calm down, was pulling at the blood pressure cuff and pulse oximeter cord (a device for measure the blood saturation with oxygen and the pulse) and was attempting to get out of bed. Patient #1 attempted to hit staff with a folding chair. A second Code Gray was called (Security was on stand-by on the unit). For safety, a Sitter was assigned to Patient #1. A Family Member indicated that Patient had a history of alcohol dependency and the plan was to treat for alcohol withdrawal.

The Nurse Progress Note, dated 4/14/17 at 11:56 P.M., indicated Patient #1 was alert to person only.

The Nurse Progress Note, dated 4/17/17 at 5:10 A.M., indicated that Patient #1 was sweating, was confused to place and time and had mild tremors.

The Surveyor interviewed Nurse #1 at 11:45 A.M. at 5/24/17. Nurse #1 said there should have been a care plan for Patient #1's change in mental status with behaviors and new safety concerns.