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Based on observation, interview and document review, the facility failed to ensure an effective governing body was responsible for the conduct of the hospital and failed to; 1) ensure that the medical staff was accountable to the governing body for the quality of care provided to a patient with blood borne pathogen exposure (Tag A 0049) and 2) have its Chief Executive Officer effectively manage issues affecting patient rights/safety, quality assurance, nursing services and emergency services (Tag A 0057).

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver appropriate care to patients per the facility's policy.

Based on observation, interview and document review, the Governing Body failed to ensure a physician was accountable to the Governing Body for failing to follow-up with a patient (Patient #1) who received a deep stab wound with a bloody knife previously used to stab another patient (Patient #2) multiple times.

Findings include:

On 6/23/2022 at 1:47 AM, facility video showed Patient #3 stabbed Patient #2 multiple times with a knife. Within seconds, Patient #3 exited Patient #2's room and stabbed Patient #1, who was positioned on a gurney in the hallway of the nursing unit, with the same bloody knife. On 6/23/2022 at 2:23 AM, Patient #1 was entered as a transfer to critical care unit room 6.

On 7/13/2022 at 7:37 AM, the Registered Nurse (RN) assigned to the unit the night in question indicated Patient #1 ran off the unit to the unit next door after being stabbed and the RN followed the patient.

The medical record revealed Patient #1 sustained an acute traumatic injury of a laceration to the medial right thigh due to the stabbing. Patient #1 received 4 milligrams of intravenous morphine for pain, 1000 milligrams of prophylactic intravenous ancef, a tetanus vaccination, and bedside surgical repair by the trauma team. Patient #1 was then admitted for medical observation. The medical record lacked documented evidence a physician ordered lab testing for blood borne pathogen exposure for Patient #1 following being stabbed by a bloody knife, which was used by Patient #1 during stabbing Patient #2.

On 7/15/2022 at 8:45 AM, the Quality, Patient Safety and Regulatory Officer and Quality Manager confirmed the facility failed to complete a blood borne pathogen follow-up exam for Patient #1.

The Blood Borne Pathogen Exposure Control Plan policy dated June 2021 revealed: Per the OSHA Blood Borne Pathogen Standard, the organisms of primary concern are the human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV).

On 7/15/2022 at 12:09 PM, the Director of Infection Control responded with the following information:

Infection Prevention/Control was not notified of a potential BBP exposure more than likely due to the crisis at hand (two different patients stabbed requiring urgent interventions). The Patient Exposure policy would apply. It was too late now to do blood work on the source Patient #2 or offer PEP therapy to Patient #3. [According to the Centers for Disease Control, PEP is the use of antiretroviral drugs after a

single high-risk event to stop HIV seroconversion. PEP must be started as soon as possible to be effective and always within 72 hours of a possible exposure]. The facility could contact Patient #1 for continued blood work monitoring with testing at 6 weeks and 16 weeks post exposure.

On 7/15/2022 at 4:20 PM, the Medical Director for Infectious Diseases indicated the following:

Patient #1's stabbing would be categorized as an exposure incident. For the hepatitis C virus, testing was periodically repeated, and there was no prophylaxis. For the hepatitis B virus, immunity against surface antibodies was checked. If they were present, then prophylaxis was not needed. If no antibodies were present, then hepatitis B treatment was offered. For HIV, post-exposure prophylaxis was started. The patient should be contacted, and testing should be done because these [hepatitis b and HIV] were both treatable. The patient should be tested, even though the risk of transmission was very low. The hospital needed to reach out to this patient and start testing for 12 weeks, and if positive, then start treatment immediately.


Complaint #NV00066544

Based on document review, interview and observation, the facility's Governing Body failed to ensure the chief executive officer (CEO) was responsibly managing the facility.

Findings include:

On 7/19/2022 at 2:05 PM, the CEO verbalized being responsible for overseeing Patient Rights, Quality Assurance and Performance Improvement, Nursing Services and Emergency Services. The CEO indicated quality and improvement processes and patient service issues were funneled up from the Clinical Quality and Professional Affairs Committee.

Within the CEO's stated responsibilities, failures occurred in medical staff accountability, patient rights, restraint use, and quality assurance. These failures were acknowledged by the CEO.

Additionally, Article 3 Bylaw areas not met:

(Q) Oversight of quality improvement, performance, and measurements.

(R) Risk identification and compliance oversight to ensure the facility maintains compliance with all federal, state, and local laws and regulations.

(S) Oversight of patient admission policies and policies that support patient care.

(X) Responsibility for the Governing Board's effective, efficient performance.


Complaint #NV00066544

Based on observation, interview and document review, the facility failed to ensure patients received care in a safe setting and failed to ensure patients with ordered violent/self-destructive behavioral restraints were monitored every 15 minutes.

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver safe and appropriate care to patients (See Tag A 0144 and Tag A 0205).

Based on observation, interview and document review, the facility failed to ensure patients received care in a safe setting for 3 of 4 patients (Patient #s 1, 2, and 3).

Findings include:

Patient Rights Policy, effective November 2019, under Quality of Care Delivery documented, Patients have a right to receive care in a safe and secure environment.

Patient #1

Patient #1 was admitted at 12:05 AM on 6/23/2022, with unspecified schizophrenia and suicidal ideation. At 12:03 AM, the patient was assessed as a high suicide risk, requiring a patient assistant to initiate and document every 15-minute checks. At 1:20 AM, a physician ordered a sitter at the bedside with suicide precautions and a legal hold.

The patient's medical record lacked documented evidence of every 15-minute checks for high-risk suicide designation. Video evidence revealed Patient #1 did not have a sitter and was positioned on a gurney in the hallway. Video evidence revealed Patient #3 left Patient #2's room on 6/23/22 at 1:47 AM and stabbed Patient #1 in the medial right thigh, requiring urgent intervention and treatment. Patient #1 required wound suturing, prophylactic antibiotic ancef, tetanus injection, intravenous morphine for acute pain and was admitted for medical observation.

Patient #2

Patient #2 was admitted at 10:13 PM on 6/22/2022, with suicidal ideation, substance abuse and bizarre behavior. At 10:01 PM, the patient was assessed as a high suicide risk. At 10:18 PM, the patient was assessed as a low suicide risk. At 10:34 PM, the patient was placed on a legal hold. At 10:35 PM, a physician ordered a sitter at the bedside with suicide precautions. At 10:49 PM, violent/behavioral restraints were ordered. Public Safety Officers applied 4-point restraints, requiring every 15-minute checks.

Video evidence revealed Patient #2 did not have a sitter. Review of video surveillance lacked evidence of a staff member having performed 15-minute restraint checks after 1:15 AM on 6/23/2022. Review of medical record documentation revealed the restraint checks were completed. Video evidence showed Patient #3 entered unabated into Patient #2's room on 6/23/2022 at 1:47 AM and stabbed Patient #2, in the left side of the neck with a knife multiple times in rapid succession. Video revealed Patient #2 was in 4-point (both arms and both legs) restraints at the time of the attack.

On 6/23/22 at 1:50 AM, video evidence revealed the patient's assigned registered nurse entered Patient #2's room and worked on unfastening Patient #2's 4-point restraints. Video revealed the patient bleeding from the knife wounds and gasping at this time, while the RN made no attempts to stop the bleeding or assess for airway patency. At 1:52:03 AM, a second nurse, identified as the charge nurse entered Patient #2's room and placed a covering on the wound. At 1:52:45 AM, Patient #2 was wheeled off the unit and off video with the nurses accompanying. The video lacked evidence of urgent life-sustaining measures, except pressure to the wound area. Patient #2 was pronounced deceased at 2:09 AM.

Patient #3

Patient #3 was admitted at 10:51 PM on 6/22/2022, with suicidal ideation and auditory hallucinations. At 11:08 PM, the patient was assessed as a high suicide risk, requiring a patient assistant to initiate and document every 15-minute checks.

At 10:57 PM on 6/22/22, video surveillance revealed Patient #3 was wheeled on to the unit accompanied by a third-party emergency medical services (EMS) individual. Video revealed EMS let the patient off the gurney, and Patient #3 walked unassisted to the assigned room with EMS walking and pointing to the room. Video displayed the patient was still clothed and no safety check was performed.

Video surveillance revealed, once in the room EMS turned away from the patient, looking toward the nursing station, leaving Patient #3 unobserved. At this time, Patient #3 pulled out a knife from the front/center of the waistband. Video showed Patient #3 placed the knife underneath folded linen atop the mattress.
At 10:59 PM, video showed a Public Safety Officer wanded Patient #3 in the room.
At 11:02 PM, video showed Patient #3 was changed into a green gown with nonskid socks.
At 11:11 PM, video showed Patient #3 moved the knife to underneath the left thigh, hidden under a blanket/sheet.
At 11:40 PM, video showed the resident visited Patient #3.

On 6/23/22 at 12:36 AM, a physician ordered a sitter at the bedside with suicide precautions and a legal hold. At 1:46 AM, a Registered Nurse documented the patient was continuously at the doorway pacing back and forth to the bathroom.

The patient's medical record lacked documented evidence of every 15-minute checks for a high-risk suicide designation. Video evidence showed the patient did not have a sitter.

At 1:47 AM on 6/23/2022, video evidence showed Patient #3 entered Patient #2's room unabated and stabbed Patient #2 in the left side of the neck multiple times in rapid succession. Within seconds, Patient #3 left Patient #2's room and proceed to attack Patient #1, lying on the hallway gurney, stabbing Patient #1 in the right medial thigh.

Patient #30

Patient #30 was admitted the evening of 6/26/2022, with high suicide risk designation documented at 7:18 PM, requiring 15-minute checks. At 8:20 PM, the patient was placed on a legal hold. At 8:41 PM, a physician ordered a sitter at the bedside with suicide precautions. On 6/27/2022 at 11:38 AM, a registered nurse documented a sitter request was tubed to 2 south. The medical record lacked documented evidence the request was fulfilled. On 6/27/2022 at 7:00 PM, a certified nursing assistant initiated documentation of 15-minute checks, nearly 24 hours after the requirement. There was no documented evidence central staffing pool received a request for a patient assistant, although a general request for a sitter was in evidence.

On 7/12/2022 in the morning, the ED Director indicated reports regarding lack of sitters had been received.

On 7/12/2022 at 11:15 AM, the Manager of Clinical Support Services indicated units were staffed with patient assistants according to the ED matrix, and since October 2021, the facility set up a pool of patient assistants both licensed and unlicensed to facilitate additional sitter requests and staffing around the clock, and there should always be sitters available, but units had to either call by phone or ask for one or scan a request form to the central staffing pool. They sometimes obtained one from other units.

On 7/15/2022 at 2:40 PM, the Quality Assurance Director confirmed there was no answer regarding what happened with Patient #30's sitter, and there were no Columbia suicide risk assessments documented on 6/27/2022.

The facility lacked the ability to track sitter requests/fulfillment of requests due to the multiple methods of obtaining sitters, which included: per scheduled unit/department, informal request to another unit or formal request via central staffing pool.

On 6/27-28/2022, video surveillance from the incident with Patient #1, #2 and #3 revealed there were no sitters for any of the three patients stationed outside their doors. A period of three video hours was reviewed prior to and up to the incident. Video was observed with the Quality Assurance Director and Director of Public Safety who confirmed the video findings.

On 7/12/2022 at 5:05 PM, the Quality Assurance Director indicated there was no documented evidence for sitter requests for Patient #1, #2 and #3.

On 7/13/2022 at 7:37 AM, a Registered Nurse (RN) indicated the charge nurse was generally responsible for requesting sitters; sitters were supposed to sit outside the doorway of high-risk patients. The nurse requested sitters in the past without receiving them. Even with using the sitter forms (patient attendant request worksheet), sitters were not provided because none were to be had. The nurse did not recall the sitter orders for these patients and did not request sitters for them.

Interviews revealed the unit was full. The Licensed Practical Nurse was away from the unit delivering a urine specimen and one of the two patient assistants assigned was on lunch break at the time of the incident, leaving one RN and one patient assistant at the time of the incident [when three sitters were required].

Systemic issues identified affecting patient safety included the following:

1) The facility lacked a formal process for escorting patients to rooms per observation, interview, and document review, allowing EMS personnel to escort a patient to a room (bypassing a security check), resulting in a window of opportunity for a patient to hide contraband later used to attack and injure/harm patients.

On 7/20/2022 at 2:05 PM, the Administrator indicated a long-standing practice of EMS, that is a consistent thing in all hospitals, is they have EMS help the patient get off the gurney.

2) LEGAL HOLDS: Per document review and interview, the facility lacked a policy outlining criteria used, when and who placed patients on legal holds per interview and document review. This resulted in patients assigned to and admitted to rooms before staff was completely aware of a legal hold. Nevada Revised Statutes allows any licensed law enforcement officer or medical professional to initiate a legal hold.

On 7/12/2022 in the morning, the ED Director indicated Patient #3 would have been wanded prior to coming to the unit had someone declared Patient #3 a legal hold.

On 7/13/2022 at 7:37 AM, a Registered Nurse indicated placing patients on legal holds was left up to physician evaluations.

On 7/14/2022 at 10:30 AM, an ED Manager indicated prior to the above incident, clinical judgment was used to determine whether a patient would be on a legal hold based on a nurse's comfort level. There was no policy or guideline governing clinical judgment.

3) SITTERS: Per interview, document review and observation, the facility lacked a policy specifying how sitters were requested and provided to nursing units for high-risk patients and auditing of the same, ensuring the process was followed. This resulted in multiple patients in high-risk situations with ordered sitters who were not assigned, obtained or otherwise present.

4) SAFETY CHECKS: Per document review and interview, the facility lacked a policy specifying how public security officers conducted safety checks for A) walk-in patients vs. B) patients arriving by ambulance/EMS vs. C) uncooperative patient walk-ins and/or arriving by ambulance/EMS, requiring alternative checks or deviations from routine safety checks. The policy provided did not distinguish safety checks of and types of patients at entry points, resulting in significant variation in how many times and where patients were safety checked. There was no documented evidence safety checks were routinely audited to ensure policy/process compliance.

On 6/27/2022 at 10:20 AM, an ED Manager and Director of Public Safety (DPSO) indicated patients were wanded once generally, for a safety check. The ED Manager indicated when working as a regular nurse, there was a recollection of two wandings.

On 6/27-28/2022 in the afternoon while watching video of the incident with Patient #1, #2 and #3, the DPSO indicated Patient #3 was not wanded prior to arriving on the nursing unit in the video. The video had revealed the patient was wanded once.

On 7/14/2022 at 9:55 AM, a PSO Lieutenant described the difference between the old and new process of wanding, since the incident:
- The old process generally involved the patients being escorted to the unit and wanded on the unit, then changed into a gown in the bathroom and wanded a second time on the unit.
- The new process had patients met by PSO and nursing by the decontamination (decon) area, patients were wanded, then entered the decon room and changed into a green gown, then patients exited the decon room and were re-wanded in the decon area a second time before being escorted to the unit. Patients remained in PSO custody while escorted to the unit.

On 7/15/2022 at 12:50 PM, the PSO Manager described the new wanding process for ambulance patients as wanding, change into gown in decon room, escorted to unit and then wanded again. This process differed from the process described by the PSO Lieutenant on 7/14/22.

On 7/15/2022 in the afternoon, the Quality Assurance Director provided two different sets of documents delineating the lobby patient arrival from the EMS patient arrival. One set was called a workflow document for the lobby patient arrival and a workflow document for the EMS patient arrival. The other set illustrated the safety check process superimposed on an ED map with a red star inset with self-presenting patient on one and EMS arriving patient on the other.

An issue was identified when comparing the workflow document for the lobby patient arrival with the self-presenting patient document with the red star inset. The workflow had two safety checks occurring at the decon area; whereas the red star document had one safety check occurring at the decon area.

Contraband/Weapons (Patient Search) policy dated August 2021, revealed all patients and their belongings were subject to search for reasonable cause. The policy lacked documented evidence of any references targeting legal hold patients and homicidal/suicidal ideation patients for safety checks. If a search was carried out, it must be documented in the patient's progress notes. Record review revealed patient searches were not documented in the medical record. A PSO report was utilized for documentation, which was not part of the patients' medical record.

Contraband/Weapons (Patient Search) policy dated August 2021 documented: Whether a patient consents or not, request nursing or another employee to be present. Patient wand/search is mandatory for all (3) security levels. Upon arrival, the officer will wand and pat search the patient simultaneously for weapons. Officers will accompany the ambulance crew to the ED unit with the patient. Once the patient was assigned a room, the officer will collect the patient's property to include clothing and will once again wand the patient. Wandings will be documented utilizing the Security Alert Documentation and Checklist (wanding protocol).

5) SAFETY ALERT DOCUMENTATION: Per document review and interview, the Public Security Officers (PSO) failed to follow the tri-level security protocol identified on the safety alert form, which called for initiating a security level based on the patient threat and documenting the number of safety checks performed per wanding protocol.

Security Alert Documentation was not in evidence for Patient #1, #2 and #3. On 6/28/2022 in the afternoon, the Quality Assurance Director confirmed there was no required security alert documentation.

On 7/13/2022 at 7:37 AM, a Registered Nurse and Licensed Practical Nurse indicated security alert forms were supposed to be used by PSOs, documented on, and placed on a patient's clipboard.

6) SECURITY REPORTS: Per document review, interview and observation, the facility lacked a guideline or policy specifying documentation requirements to ensure safety check process compliance. There was no way to identify how many safety checks patients had by paper review and/or with video correlation. The CAD report documentation varied from patient to patient.

An example, on June 22-23, 2022, according to the CAD reports:

Patient #1 did not have type of safety check documented.

Patient #2 had one wanding and search.

Patient #3 had one wanding and search.

Patient #5 had two wandings.

Patient #44 had one wanding.

The same PSO performed the safety checks of Patient #5 and #44.


7) TRAINING: Per document review and interview, the Public Safety Officer training recently renewed by employees and provided on site did not A) identify legal hold patients who expressed suicidal/homicidal ideation would be searched and B) identify that any patient would be wanded; instead, the officers were allowed to wand or pat search for each safety check.

The Public Safety Officer Manager and Quality Assurance Director provided training documents at 12:50 PM on 7/15/2022.

Review of the training lacked documented evidence legal hold patients who expressed suicidal/homicidal ideation would be searched, which was what the criteria was as expressed by numerous employees.

The facility was unable to provide safety check criteria and documentation processes uniform to the particular type of patient and point of entry to distinguish the location, number, and type of safety checks /searches from one patient to the next.



Complaint #NV00066544

Based on observation, interview and document review, the facility failed to visually monitor 2 of 2 patients (Patient #2 and #24) with ordered restraints for self-destructive/violent behavior.

Findings include:

Patient #2

On 6/22/2022 at 10:13 PM, Patient #2 was admitted with suicidal ideation, substance abuse and bizarre behavior.

On 6/22/2022 at 10:49 PM, a physician ordered violent/behavioral restraints because the patient was documented as combative, imminent risk of harm to others, physically threatening and other interventions had failed.

On 6/27-28/2022 in the afternoon, surveillance video observed in real time revealed the assigned nurse and all public safety officers exited the patient's room for the last time at 1:14 AM on 6/23/2022. From 1:14 AM until 1:47 AM, no other staff entered the patient's room or spoke to the patient from the doorway, until Patient #3 entered Patient #2's room and attacked the patient at 1:47 AM. Patient #2's medical record showed the assigned nurse documented restraint monitoring at 1:15 AM. The assigned nurse also documented the next restraint check at 1:30 AM, despite not entering the room.

On 7/13/2022 at 7:37 AM, a Licensed Practical Nurse indicated Patient #2 was in 4-point restraints requiring 15-minute checks for water and toileting. Public Safety was contacted several times to readjust the restraints. The assigned Registered Nurse indicated charting a restraint check out of view of the patient (1:30 AM) and verified that was not the way it was supposed to be done.

On 7/13/2022 at 1:00 PM, the Chief Nursing Officer indicated the nurse should actually touch the restraint to check for looseness and tightness.

Patient #24

On 6/25/2022, Patient #24 was admitted with a legal hold for combative behavior.

On 6/25/2022 at 8:11 PM, a physician ordered violent/behavioral restraints because the patient was documented as combative.

On 7/13/2022 at 3:55 PM, surveillance video observed in real time with the Director of Public Safety and the Quality Assurance Director present, revealed the assigned nurse failed to perform required every 15-minute restraint checks on video, and a nurse re-entered the patient's room at 9:30 PM and removed the restraints. Video review lacked evidence a nurse had entered the patient's room and conducted a restraint check.

Patient #24's medical record contained documented evidence a nurse performed 15-minute checks between 8:11 PM and 9:30 PM.

The Restraints policy, approved November 2021, documented: For violent and/or self-destructive behavior:

- Components required every 15 minutes (or more often as needed): assessment, interventions, and documentation (by monitoring components, the patient's rights, dignity, and safety is maintained).

- Monitoring will include where appropriate: basic needs (food, fluids, elimination), condition of skin, range of motion and release of limbs, vital signs will be taken upon initiation and as clinically indicated, consideration of less restrictive interventions, patient's response to restraint, behavior indicating reason for continuation of restraint and signs of injury associated with application of restraint (if any).


Complaint #NV00066544

Based on observation, interview and document review, the facility failed to ensure the Governing Body established clear expectations for safety practices regarding its processes for admitting patients to the hospital's emergency department, declaring legal holds, requesting/ providing and auditing patient sitters, establishing consistent written criteria for performing and documenting safety checks and auditing the same, following its security alert documentation, consistent documentation of safety checks in Public Safety Officer (PSO) CAD reports and conducting training consistent with the actual performance of safety checks and intention of eliminating security associated risks.

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver statutory-mandated care to patients. See Tag A 0286.

Based on observation, interview and document review, the facility failed to ensure the Governing Body established clear expectations for safety practices regarding its processes for admitting patients to the hospital's emergency department including: declaring legal holds, requesting and providing physician ordered sitters and auditing the same, establishing consistent written criteria for performing and documenting safety checks and auditing the same, following its security alert documentation, consistent documentation of safety checks in CAD reports and conducting training consistent with the actual performance of safety checks and intention of eliminating security associated risks.

Findings include:

Patient #1:

Patient #1 was admitted at 12:05 AM on 6/23/2022, with unspecified schizophrenia and suicidal ideation. At 12:03 AM, the patient was assessed as a high suicide risk, requiring a patient assistant to initiate and document every 15-minute checks. At 1:20 AM, a physician ordered a sitter at the bedside with suicide precautions and a legal hold.

Patient #1's medical record lacked documented evidence of every 15-minute checks for high-risk suicide designation. Video evidence revealed the patient did not have a sitter and was positioned on a gurney in the hallway. Patient #2 was attacked by another patient and sustained injury while on the hallway gurney with no sitter present at the bedside.

Patient #2

Patient #2 was admitted at 10:13 PM on 6/22/2022, with suicidal ideation, substance abuse and bizarre behavior. At 10:01 PM, the patient was assessed as a high suicide risk. At 10:18 PM, the patient was assessed as a low suicide risk. At 10:34 PM, the patient was placed on a legal hold. At 10:35 PM, a physician ordered a sitter at the bedside with suicide precautions. At 10:49 PM, violent/behavioral restraints were ordered. Public Safety Officers applied 4-point (all 4 extremities) restraints, requiring every 15-minute checks.

Video evidence revealed Patient #2 did not have a sitter, and 15-minute restraint checks were not performed after 1:15 AM on 6/23/2022, despite documentation to that effect. Video evidence revealed Patient #2 was attached and fatally wounded by another patient at 1:47 AM, while still in 4-point restraints.

Patient #3

Patient #3 was admitted at 10:51 PM on 6/22/2022, with suicidal ideation and auditory hallucinations. At 11:08 PM, the patient was assessed as a high suicide risk, requiring a patient assistant to initiate and document every 15-minute checks. At 12:36 AM, a physician ordered a sitter at the bedside with suicide precautions and a legal hold. At 1:46 AM, a Registered Nurse documented the patient was continuously at the doorway pacing back and forth to the bathroom.

Video surveillance revealed at 10:57 PM, the patient was wheeled on to the unit accompanied by emergency services (EMS). Video showed the patient was still clothed and did not have a safety check. Video showed once in the room, EMS turned toward the nursing station, leaving Patient #3 unobserved at which point Patient #3 pulled out a knife from the front/center of the waistband. Video showed Patient #3 placed the knife underneath folded linen atop the mattress. At 10:59 PM, video showed a Public Safety Officer wanded Patient #3 in the room. At 11:02 PM, video showed Patient #3 was changed into a green gown with nonskid socks. At 11:11 PM, video showed Patient #3 moved the knife underneath the left thigh hidden under a blanket/sheet. At 11:40 PM, video showed the resident visited Patient #3.

The patient's medical record lacked documented evidence of every 15-minute checks for a high-risk suicide designation. Video evidence revealed Patient #3 did not have a sitter.

Review of surveillance video from 6/23/22 at 1:47 AM revealed Patient #3 entered Patient #2's room unabated and fatally stabbed Patient #2 in the neck, and then proceeded to attack Patient #1, stabbing Patient #1 in the right medial thigh.

Patient #30

Patient #30 was admitted on the evening of 6/26/2022, with high suicide risk designation documented at 7:18 PM, requiring 15-minute checks. At 8:20 PM, the patient was placed on a legal hold. At 8:41 PM, a physician ordered a sitter at the bedside with suicide precautions. On 6/27/2022 at 11:38 AM, a registered nurse documented a sitter request was tubed to 2 south. The medical record lacked documented evidence the request was fulfilled. On 6/27/2022 at 7:00 PM, a certified nursing assistant (CNA) initiated documentation of 15-minute checks for the first time, nearly 24 hours after the requirement. There was no documented evidence central staffing pool received a request for a patient assistant, although a general request for a sitter was in evidence.

On 6/27-28/2022 in the afternoon, video from the incident with Patient #1, #2 and #3 observed with the Quality Assurance Director and Director of Public Safety present revealed there were no sitters for any of the three patients stationed outside their doors. A period of three video hours was reviewed prior to and up to the incident.

Systemic issues identified affecting patient safety included the following:

1) Per observation, interview, and document review, the facility lacked a formal process for escorting patients to rooms, allowing EMS personnel to escort a patient to a room (bypassing a security check), resulting in a window of opportunity for a patient to hide contraband later used to attack and injure/harm patients.

2) LEGAL HOLDS: Per document review and interview, the facility lacked a policy outlining criteria used, when and who placed patients on legal holds per interview and document review. This resulted in patients assigned to and admitted to rooms before staff was completely aware of a legal hold. Nevada Revised Statutes allows any licensed law enforcement officer or medical professional to initiate a legal hold.

On 7/12/2022 in the morning, the ED Director indicated Patient #3 would have been wanded (Using a wand to check a person for metal objects) prior to coming to the unit had someone declared Patient #3 a legal hold.

On 7/13/2022 at 7:37 AM, a Registered Nurse indicated placing patients on legal holds was left up to physician evaluations.

On 7/14/2022 at 10:30 AM, an ED Manager indicated prior to the June 23rd incident, clinical judgment was used to determine whether a patient would be on a legal hold based on a nurse's comfort level. There was no policy or guideline governing clinical judgment. Now it was a nursing expectation.

3) SITTERS: Per interview, document review and observation, the facility lacked a policy specifying in detail how sitters were requested and provided to nursing units for high-risk patients and auditing of the same. This resulted in multiple patients in high-risk situations with ordered sitters who were not assigned, obtained or otherwise present.

On 7/12/2022 at 11:15 AM, the Manager of Clinical Support Services indicated units were staffed with patient assistants according to the ED matrix, and since October 2021, the facility set up a pool of patient assistants both licensed and unlicensed to facilitate additional sitter requests and staffing around the clock, and there should always be sitters available, but units had to either call by phone and ask for one or scan a request form to the central staffing pool. They sometimes obtained one from other units.

The facility lacked the ability to audit for sitter requests/fulfillment of requests due to the multiple methods of obtaining sitters: per scheduled unit/department, informal request to another unit or formal request via central staffing pool.

On 7/12/2022 at 5:05 PM, the Quality Assurance Director indicated there was no documented evidence for sitter requests for Patient #1, #2 and #3.

On 7/13/2022 at 7:37 AM, a Registered Nurse (RN) indicated the charge nurse was generally responsible for requesting sitters and the sitters were supposed to sit outside the doorway of high-risk patients. The nurse explained had requested sitters in the past without receiving them and even with using the sitter forms (patient attendant request worksheet), sitters were not provided because none were to be had. The nurse did not recall the sitter orders for these patients and did not request sitters for them.

4) SAFETY CHECKS: Per document review and interview, the facility lacked a policy specifying in detail how its public security officers conducted safety checks for A) walk-in patients vs. B) patients arriving by ambulance/EMS vs. C) uncooperative patient walk-ins and/or arriving by ambulance/EMS, requiring alternative checks or deviations from routine safety checks. The policy provided did not distinguish safety checks of and types of patients at entry points, resulting in significant variation in how many times and where patients were safety checked. There was no documented evidence safety checks were routinely audited to ensure policy/process compliance.

Contraband/Weapons (Patient Search) policy dated August 2021, revealed all patients and their belongings were subject to search for reasonable cause. If a search was carried out, it must be documented in the patient's progress notes. In many instances, patient searches were not documented in the medical record. The PSO CAD report was utilized, which was not part of the patients' medical record.

Contraband/Weapons (Patient Search) policy revised August 2021: Whether a patient consents or not, request nursing or another employee to be present. Patient wand/search is mandatory for all (3) security levels. Upon arrival, the officer will wand and pat search the patient simultaneously for weapons. Officers will accompany the ambulance crew to the ED unit with the patient. Once the patient was assigned a room, the officer will collect the patient's property to include clothing and will once again, wand the patient. Wandings will be documented utilizing the Security Alert Documentation and Checklist (wanding protocol).

5) SAFETY ALERT DOCUMENTATION: Per document review and interview, the Public Security Officers failed to follow the tri-level security protocol identified on the safety alert form, which called for initiating a security level based on the patient threat and documenting the number of safety checks performed per wanding protocol.

Security Alert Documentation was not in evidence for Patient #1, #2 and #3. On 6/28/2022 in the afternoon, the Quality Assurance Director confirmed there was no required security alert documentation.

On 7/13/2022 at 7:37 AM, a Registered Nurse and Licensed Practical Nurse indicated security alert forms were supposed to be used by PSOs and documented on and placed on a patient's clipboard.

6) Public Service Officer's CAD REPORTS: Per document review, interview and observation, the facility lacked a guideline or policy specifying documentation requirements to ensure safety check process compliance. There was no way to identify how many safety checks patients had by paper review and/or with video correlation. The CAD report documentation varied from patient to patient.

Patient #1 did not have type of safety check documented.

Patient #2 had one wanding and search.

Patient #3 had one wanding and search.

Patient #28 did not have documented evidence of a safety check via CAD report (June 14-28, 2022) despite legal hold status during the stay.

Patient #36 had a CAD report, dated 6/27/2022, without a nurse present.

7) TRAINING: Per document review and interview, the Public Safety Officer training recently renewed by employees and provided on site did not A) identify legal hold patients who expressed suicidal/homicidal ideation would be searched and B) identify that any patient would be wanded; instead, the officers were allowed to wand or pat search for each safety check.

Training Document titled, Property and Persons Search written by the Public Safety Officer Manager was reviewed.

- Training Booklet under the "who is searched" section: Public Safety Officers were allowed to use discretion and awareness of circumstances to determine if a person needed to be searched. Examples of persons to be searched included persons who acted angry and aggressive; persons who wore unusual clothes for the temperature, such as a trench coat during summer temperatures and any behavior articulated as suspicious.

The training provided failed to describe processes for searching legal hold patients who expressed suicidal/homicidal ideation

- Training Booklet under the section "how to use the metal detector": Complete the wanding procedure. Once patient was changed into a hospital gown, re-check for weapons (by pat down or wand).

The actual security check was presented as a choice to pat down or wand at each reference juncture in the training.

Procedure #2 of an additional document, entitled Contraband/Weapons Search Appendix provided on the afternoon of July 15, 2022, presented the safety check as an option between pat down or wand at each juncture.

The training documents presented lacked documented evidence of any method of searching above the crotch area on any patient.

The Quality Assurance Director presented process changes, dated as of 6/23/2022 forward, which conflicted with later training dated 7/1/2022, regarding the safety checks. Both process change documents, dated 6/23/2022, revealed two wandings before and after patients changed into green gowns.

Training entitled Management of the Behavioral Patient in the Adult ED, dated 7/1/2022, revealed Red star self-presenting patient document: Safety checked preliminary wanding in breezeway, then patient handed off to EMS PSO who completed a second wanding, and then escorted patient to decon room where patient changed into green gown and PSO wanded patient once.

On 7/15/2022 at 8:45 AM, the Quality, Patient Safety and Regulatory Officer (QPSRO) and Quality Assurance Director (QAD) indicated the following:

Quality meetings were held monthly; Quality meetings were reviewed.

The Governing Body selected quality indicators to review. Departments had their own identified quality indicators as well. Public Safety Officers fell under the environment of care, and they did report on workplace violence. Patient Assistants were rolled into other indicators; they were not analyzed by job title but within the overall department (nursing). Audits of the Public Safety Officers did not occur until after the incident. Restraint auditing did not include any observational review to ensure monitoring was occurring.

There was no documented evidence the facility audited the request/provision of sitters to the units.

On July 15, 2022, at 12:50 PM, the Public Safety Officer Manager indicated officers and CAD reports were audited at the point of contact. Clarification was obtained at the point of submission of reports.
Workplace violence reports were sent to quality meetings. There was no observational auditing of safety checks.


Complaint #NV00066544

Based on observation, interview and document review, the facility failed to ensure nursing established clear expectations regarding requesting and providing physician ordered patient sitters and assessing patients and documenting information necessary to monitor patients.

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver statutory-mandated care to patients. (See Tags A 0392 and Tag A 0467).

Based on observation, interview and document review, the facility failed to ensure sitters were requested and provided per physician orders for 4 of 45 patients (Patient #1, #2, #3 and #30).

Findings include:

On 6/27 and 6/28/2022, video from the June 23 incident with Patient #1, #2 and #3 revealed there were no sitters for any of the three patients stationed outside the patient's doors. A period of three video hours was reviewed prior to and up to the incident. Video was observed with the Quality Assurance Director and Director of Public Safety present, who confirmed the video findings.

Patient #1

Patient #1 was admitted at 12:05 AM on June 23, 2022, with unspecified schizophrenia and suicidal ideation. At 1:20 AM, a physician ordered a sitter at the bedside with suicide precautions and a legal hold. Video evidence revealed the patient did not have a sitter and was positioned on a gurney in the hallway. Video evidence revealed Patient #1 was attacked by another patient requiring urgent intervention and treatment.

Patient #2

Patient #2 was admitted at 10:13 PM on June 22, 2022, with suicidal ideation, substance abuse and bizarre behavior. At 10:35 PM, a physician ordered a sitter at the bedside with suicide precautions.
Video evidence revealed the patient did not have a sitter. Video evidence revealed Patient #2, while still in 4-point restraints (All 4 extremities) was attacked and fatally wounded by another patient.

Patient #3

Patient #3 was admitted at 10:51 PM on June 22, 2022, with suicidal ideation and auditory hallucinations. At 12:36 AM, a physician ordered a sitter at the bedside with suicide precautions and a legal hold. Video evidence showed the patient did not have a sitter. At 1:47 AM, video evidence revealed Patient #3 left the room and attacked 2 other patients.


Patient #30

Patient #30 was admitted on the evening of June 26, 2022, with high suicide risk designation. At 8:41 PM, a physician ordered a sitter at the bedside with suicide precautions. On 6/27/2022 at 11:38 AM, a

registered nurse documented a sitter request was tubed to 2 south. The medical record lacked documented evidence the request was fulfilled. On 6/27/2022 at 7:00 PM, a nursing assistant had initiated documentation of 15-minute checks for the first time, approximately 24 hours after the requirement. There was no documented evidence central staffing pool received a specific patient assistant request for Patient #30. There was evidence a general request was made.

On 7/12/2022 at 11:15 AM, the Manager of Clinical Support Services indicated units were staffed with patient assistants according to the ED matrix, and since October 2021, the facility set up a pool of patient assistants both licensed and unlicensed to facilitate additional sitter requests and staffing around the clock, and there should always be sitters available, but units had to either call by phone and ask for one or scan a request form to the central staffing pool. They sometimes obtained one from other units.

The facility lacked the ability to audit for sitter requests/fulfillment of requests due to the multiple methods of obtaining sitters: per scheduled unit/department, informal request to another unit or formal request via central staffing pool.

On 7/12/2022 at 5:05 PM, the Quality Assurance Director indicated there was no documented evidence for sitter requests for Patient #1, #2 and #3.

On 7/13/2022 at 7:37 AM, a Registered Nurse (RN) indicated the charge nurse was generally responsible for requesting sitters; sitters were supposed to sit outside the doorway of high-risk patients. The nurse had requested sitters in the past without receiving them. Even with using the sitter forms (patient attendant request worksheet), sitters were not provided because none were available. The nurse did not recall the sitter orders for these patients and did not request sitters for them. Workload contributed to the incident. The unit was full. The Licensed Practical Nurse was away from the unit delivering a urine specimen and one of the two patient assistants assigned to the unit were on lunch break at the time of the incident, leaving one RN and one patient assistant at the time of the incident.

The facility lacked a policy specifying in detail how sitters were requested and provided to nursing units for high-risk patients and auditing of the same, ensuring the process was followed and issues eliminated. This resulted in multiple patients in high-risk situations with ordered sitters who were not assigned, obtained or otherwise present.


Complaint #NV00066544

Based on record review, interview and document review, the facility failed to ensure clinicians documented information necessary to monitor a patient's condition for 4 of 45 patients (Patient #10, #15, #30 and #41).

Findings include:

Patient #10

On 6/25/2022, the emergency department (ED) admitted Patient #10 with suicidal ideation, legal hold, and police custody.

On 6/28/2022 at 8:27 AM, Patient #10 was classified as a high risk for suicide according to the Columbia Suicide Severity Rating Scale.

On 6/28/2022 at 9:45 AM, a patient assistant log was initiated for the required every 15-minute checks. Documented evidence revealed the patient assistant log did not commence until 78 minutes after the high-risk designation.

On 6/28/2022, Patient #10's medical record lacked documented evidence of required 15-minute checks from 1:00 PM to 1:45 PM.

On 6/28/2022, nurses continued to reassess Patient #10 at a high suicide risk until 8:00 PM, when the patient was reclassified as a low risk.

On 7/13/2022 at 10:00 AM, the Quality Assurance Director confirmed the above findings.

Patient #15

On 6/27/2022, the ED admitted Patient #15 with suicidal ideation, homicidal ideation, and a legal hold.

On 6/27/2022 at 12:39 PM, Patient #15 was classified as a high risk for suicide according to the Columbia Suicide Severity Rating Scale.

On 6/27/2022 at 2:00 PM, a patient assistant log was initiated for the required every 15-minute checks. Documented evidence revealed the patient assistant log did not commence until 81 minutes after the high-risk designation.

On 7/13/2022 at 10:00 AM, the Quality Assurance Director confirmed the above findings.

Patient #30

On 6/26/2022, the ED admitted Patient #30 with high suicide risk designation documented at 7:18 PM, requiring 15-minute checks.

At 8:20 PM, the patient was placed on a legal hold. At 8:41 PM, a physician ordered a sitter at the bedside with suicide precautions.

On 6/27/2022 at 11:38 AM, a registered nurse documented a sitter request was tubed to 2 south. The medical record lacked documented evidence the request was fulfilled.

On 6/27/2022 at 7:00 PM, a certified nursing assistant initiated documentation of 15-minute checks for the first time, approximately 24 hours after the requirement.

There was no documented evidence central staffing pool received a request for a patient assistant for Patient #30.

On 7/14/2022 at 10:30 AM, an ED Manager indicated the Columbia suicide risk assessment was generally performed each shift.

On 7/15/2022 at 2:40 PM, the Quality Assurance Director confirmed there was no answer regarding what happened with Patient #30's sitter, and there were no Columbia suicide risk assessments documented on 6/27/2022.

Patient #41

On 6/27/2022, Patient #41 was admitted with suicidal ideation with a plan, homicidal ideation, and a legal hold.

On 6/27/2022 at 2:40 PM, Patient #41 was classified as a high risk for suicide according to the Columbia Suicide Severity Rating Scale.

On 6/28/2022, Patient #41's medical record lacked documented evidence of the required 15-minute checks from 8:30 AM to 11:00 AM and 11:00 AM to 1:45 PM.

On 7/13/2022 at 10:00 AM, the Quality Assurance Director confirmed the above findings.

The document titled Standards of Care For A Patient Presenting With Mental Illness or Suicidal Ideation, dated July 2021, revealed when the patient was on a legal hold or high-risk status according to the Columbia Suicide Severity Rating Scale, documentation would be every 15 minutes by the patient assistant or sitter and once every shift by the registered nurse.



Complaint #NV00066544

Based on observation, interview and document review, the facility failed to ensure the Governing Body established clear expectations for safety practices regarding its processes for admitting patients to the hospital's emergency department with mental health needs. See Tag A 1112.

Based on observation, interview and document review, the facility failed to ensure the Governing Body established clear expectations for safety practices in the emergency department (ED) regarding its processes for admitting patients with mental health needs to the hospital's ED units related to 1) patient supervision; 2) safety checks and 3) training.

Findings include:

1) Patient Supervision

Patient #1

Patient #1 was admitted at 12:05 AM on 6/23/2022, with unspecified schizophrenia and suicidal ideation. At 12:03 AM, the patient was assessed as a high suicide risk, requiring a patient assistant to initiate and document every 15-minute checks. At 1:20 AM, a physician ordered a sitter at the bedside with suicide precautions and a legal hold.

Review of video surveillance revealed Patient #1 did not have a sitter and was positioned on a gurney in the hallway.

Patient #2

Patient #2 was admitted at 10:13 PM on 6/22/2022, with suicidal ideation, substance abuse and bizarre behavior. At 10:01 PM, the patient was assessed as a high suicide risk. At 10:18 PM, the patient was assessed as a low suicide risk. At 10:34 PM, the patient was placed on a legal hold. At 10:35 PM, a physician ordered a sitter at the bedside with suicide precautions. At 10:49 PM, violent/behavioral restraints were ordered. Public Safety Officers applied 4-point (all four extremities) restraints, requiring every 15-minute checks.

Review of video surveillance revealed Patient #2 did not have a sitter.

Patient #3

Patient #3 was admitted at 10:51 PM on 6/22/2022, with suicidal ideation and auditory hallucinations. At 11:08 PM, the patient was assessed as a high suicide risk, requiring a patient assistant to initiate and
document every 15-minute checks. At 12:36 AM, a physician ordered a sitter at the bedside with suicide precautions and a legal hold. At 1:46 AM, a Registered Nurse documented the patient was continuously at the doorway pacing back and forth to the bathroom.

Review of video surveillance revealed the patient did not have a sitter.

Patient #30

Patient #30 was admitted on the evening of 6/26/2022, with high suicide risk designation documented at 7:18 PM, requiring 15-minute checks. At 8:20 PM, the patient was placed on a legal hold. At 8:41 PM, a physician ordered a sitter at the bedside with suicide precautions.

On 6/27/2022 at 11:38 AM, a registered nurse documented a sitter request was tubed to 2 south. The medical record lacked documented evidence the request was fulfilled.

On 6/27/2022 at 7:00 PM, a certified nursing assistant initiated documentation of 15-minute checks for the first time, approximately 24 hours after the requirement. There was no documented evidence central staffing pool received a request for a patient assistant, although a general request for a sitter was in evidence.

The facility lacked a policy specifying in detail how sitters were requested and provided to nursing units for high-risk patients and auditing of the same, ensuring the process was followed and issues eliminated. This resulted in multiple patients in high-risk situations with ordered sitters who were not assigned, obtained or otherwise present

On 7/12/2022 in the morning, the ED Director indicated reports regarding lack of sitters had been received.

On 7/12/2022 at 11:15 AM, the Manager of Clinical Support Services indicated units were staffed with patient assistants according to the ED matrix, and since October 2021, the facility set up a pool of patient assistants both licensed and unlicensed to facilitate additional sitter requests and staffing around the clock, and there should always be sitters available, but units had to either call by phone and ask for one or scan a request form to the central staffing pool. They sometimes obtained one from other units.

On 7/15/2022 at 2:40 PM, the Quality Assurance Director confirmed there was no answer regarding what happened with Patient #30's sitter, and there were no Columbia suicide risk assessments documented on 6/27/2022.

The facility lacked the ability to audit for sitter requests/fulfillment of requests due to the multiple methods of obtaining sitters: per scheduled unit/department, informal request to another unit or formal request via central staffing pool.

On 6/27-28/2022 in the afternoon, video from the June 23 incident with Patient #1, #2 and #3 revealed there were no sitters for any of the three patients stationed outside their doors. A period of three video hours was reviewed prior to and up to the incident. Video was observed with the Quality Assurance Director and Director of Public Safety present, who confirmed the video findings.

On 7/12/2022 at 5:05 PM, the Quality Assurance Director indicated there was no documented evidence for sitter requests for Patient #1, #2 and #3.

On 7/13/2022 at 7:37 AM, a Registered Nurse (RN) indicated the charge nurse was generally responsible for requesting sitters; sitters were supposed to sit outside the doorway of high-risk patients. The nurse had requested sitters in the past without receiving them.

The nurse explained, even with using the sitter forms (patient attendant request worksheet), sitters were not provided because none were available. The nurse did not recall the sitter orders for these patients and did not request sitters for them. The nurse indicated workload contributed to the June 23 incident. The unit was at full census. A Licensed Practical Nurse was away from the unit delivering a urine specimen and one of the two patient assistants assigned to the unit was on lunch break at the time of the incident, leaving one RN and one patient assistant at the time of the incident, when three sitters were requested.


2) Safety Checks

Patient #1

Patient #1 was admitted at 12:05 AM on 6/23/2022, with unspecified schizophrenia and suicidal ideation. At 12:03 AM, the patient was assessed as a high suicide risk, requiring a patient assistant to initiate and document every 15-minute checks. At 1:20 AM, a physician ordered a sitter at the bedside with suicide precautions and a legal hold.

The patient's medical record lacked documented evidence of every 15-minute checks for high-risk suicide designation.

Patient #2

Patient #2 was admitted at 10:13 PM on 6/22/2022, with suicidal ideation, substance abuse and bizarre behavior. At 10:01 PM, the patient was assessed as a high suicide risk. At 10:18 PM, the patient was assessed as a low suicide risk. At 10:34 PM, the patient was placed on a legal hold. At 10:35 PM, a physician ordered a sitter at the bedside with suicide precautions. At 10:49 PM, violent/behavioral restraints were ordered. Public Safety Officers applied 4-point (all four extremities) restraints, requiring every 15-minute checks.

Review of video surveillance revealed staff failed to perform 15-minute restraint checks after 1:15 AM on 6/23/2022, despite documentation to that effect.


Patient #3

Patient #3 was admitted at 10:51 PM on 6/22/2022, with suicidal ideation and auditory hallucinations. At 11:08 PM, the patient was assessed as a high suicide risk, requiring a patient assistant to initiate and document every 15-minute checks. At 12:36 AM, a physician ordered a sitter at the bedside with suicide precautions and a legal hold. At 1:46 AM, a Registered Nurse documented the patient was continuously at the doorway pacing back and forth to the bathroom.

At 10:57 PM on 6/22/2022, video revealed Patient #3 was wheeled on to the unit accompanied by emergency services (EMS). Video showed EMS let the patient off the gurney, and Patient #3 walked unassisted to the assigned room with EMS walking and pointing to the room. Video showed the patient was still clothed and did not have a safety check. Video showed once in the room, EMS turned toward the nursing station, leaving Patient #3 unobserved at which point Patient #3 pulled out a knife from the front/center of the waistband. Video showed Patient #3 placed the knife underneath folded linen atop the mattress. At 10:59 PM, video showed a Public Safety Officer wanded Patient #3 in the room. At 11:02 PM, video showed Patient #3 was changed into a green gown with nonskid socks. At 11:11 PM, video showed Patient #3 moved the knife underneath the left thigh hidden under a blanket/sheet. At 11:40 PM, video showed the resident visited Patient #3.

The patient's medical record lacked documented evidence of every 15-minute checks for a high-risk suicide designation.

The facility document titled, Standards of Care For A Patient Presenting With Mental Illness or Suicidal Ideation, dated July 2021, revealed when the patient was on a legal hold on high-risk status according to the Columbia Suicide Severity Rating Scale documentation would be every 15 minutes by the patient assistant or sitter and once every shift by the registered nurse.

The Restraints policy, approved November 2021, revealed for violent and/or self-destructive behavior:

Components required every 15 minutes (or more often as needed): assessment, interventions, and documentation (by monitoring components, the patient's rights, dignity, and safety is maintained).

Monitoring will include where appropriate: basic needs (food, fluids, elimination), condition of skin, range of motion and release of limbs, vital signs will be taken upon initiation and as clinically indicated, consideration of less restrictive interventions, patient's response to restraint, behavior indicating reason for continuation of restraint and signs of injury associated with application of restraint (if any).

Per document review and interview, the facility lacked a policy specifying in detail how its public security officers conducted safety checks for A) walk-in patients vs. B) patients arriving by ambulance/EMS vs. C) uncooperative patient walk-ins and/or arriving by ambulance/EMS, requiring alternative checks or deviations from routine safety checks. The policy provided did not distinguish safety checks of and types of patients at entry points, resulting in significant variation in how many times and where patients were safety checked. There was no documented evidence safety checks were routinely audited to ensure policy/process compliance.

On 6/27/2022 at 10:20 AM, an ED Manager and Director of Public Safety (DPSO) indicated patients were wanded once generally for a safety check. The ED Manager indicated when working as a regular nurse, there was a recollection of two wandings. Upon showing the DPSO the policy, which described two wandings in general, the DPSO verbalized, "it IS two."

On 7/15/2022 in the afternoon, safety check guidelines were provided. The Quality Assurance Director provided two different sets of documents delineating the lobby patient arrival from the EMS patient arrival. One set was called a workflow document for the lobby patient arrival and a workflow document for the EMS patient arrival. The other set illustrated the safety check process superimposed on an ED map with a red star inset with self-presenting patient on one and EMS arriving patient on the other.

Upon comparing the workflow document for the lobby patient arrival with the self-presenting patient document with the red star inset, the workflow had two safety checks occurring at the decon area; whereas the red star document had one safety check occurring at the decon area.

Contraband/Weapons (Patient Search) policy dated August 2021, revealed all patients and their belongings were subject to search for reasonable cause. Upon review, the policy lacked documented evidence of any diagnostic references targeting legal hold patients and homicidal/suicidal ideation patients for safety checks. If a search was carried out, it must be documented in the patient's progress notes. In many instances, patient searches were not documented in the medical record. The PSO CAD report was utilized, which was not part of the patients' medical record.

Contraband/Weapons (Patient Search) policy revised August 2021: Whether a patient consents or not, request nursing or another employee to be present. Patient wand/search is mandatory for all (3) security levels. Upon arrival, the officer will wand and pat search the patient simultaneously for weapons. Officers will accompany the ambulance crew to the ED unit with the patient. Once the patient was assigned a room, the officer will collect the patient's property to include clothing and will once again wand the patient. Wandings will be documented utilizing the Security Alert Documentation and Checklist (wanding protocol).

Per document review and interview, the Public Security Officers failed to follow the tri-level security protocol identified on the safety alert form, which called for initiating a security level based on the patient threat and documenting the number of safety checks performed per wanding protocol.

Security Alert Documentation was not in evidence for Patient #1, #2 and #3. On 6/28/2022 in the afternoon, the Quality Assurance Director confirmed there was no required security alert documentation.

On 7/13/2022 at 7:37 AM, a Registered Nurse and Licensed Practical Nurse indicated security alert forms were supposed to be used by PSOs and documented on and placed on a patient's clipboard.


3) Training

Review of video surveillance revealed Patient #3 entered unabated into Patient #2's room at 1:47 AM on 6/24/2022 and stabbed Patient #2 who was in 4-point restraints, in the left side of the neck multiple times.

Video surveillance revealed on 6/24/2022 at 1:50 AM, the assigned registered nurse entered Patient #2's room and worked on unfastening the gasping Patient #2's 4-point restraints with no efforts to assess respirations or control the bleeding.

At 1:52:03 AM, a second nurse, identified as the charge nurse entered Patient #2's room and placed a covering on the wound. At 1:52:45 AM, Patient #2 was wheeled off the unit and off video with the nurses accompanying. The video lacked evidence of urgent life-sustaining measures, except pressure to the wound area. Patient #2 was pronounced deceased at 2:09 AM.

Per document review and interview, the facility lacked a policy outlining criteria used, when and who placed patients on legal holds per interview and document review. This resulted in patients assigned to and admitted to rooms before staff was completely aware of a legal hold. Nevada Revised Statutes allows any licensed law enforcement officer or medical professional to initiate a legal hold.

On 7/12/2022 in the morning, the ED Director indicated Patient #3 would have been wanded prior to coming to the unit had someone declared Patient #3 a legal hold.

On 7/13/2022 at 7:37 AM, a Registered Nurse indicated placing patients on legal holds was left up to physician evaluations.

On 7/14/2022 at 10:30 AM, an ED Manager indicated prior to the above incident, clinical judgment was used to determine whether a patient would be on a legal hold based on a nurse's comfort level. There was no policy or guideline governing clinical judgment, but now it was a nursing expectation.

Training Documents: Property and Persons Search written by the Public Safety Officer Manager:

Training Booklet under the "who is searched" section documented: Public Safety Officers were allowed to use discretion and awareness of circumstances to determine if a person needed to be searched. Examples of persons to be searched included persons who acted angry and aggressive; persons who wore unusual clothes for the temperature, such as a trench coat during summer temperatures and any behavior articulated as suspicious.

Review of the training revealed there was a lack of training regarding how legal hold patients who expressed suicidal/homicidal ideation would be searched

Training Booklet under the section "how to use the metal detector" documented: Complete the wanding procedure. Once patient was changed into a hospital gown, re-check for weapons (by pat down or wand).

Review of training revealed the actual security check was presented as a choice to pat down or wand at each reference juncture in the training.

Procedure #2 of an additional document, entitled Contraband/Weapons Search Appendix provided on the afternoon of July 15, 2022, presented the safety check as an option between pat down and wand at each juncture.

On 7/15/2022 at 12:50 PM, the PSO Manager indicated the pat down of the crotch would be performed from the sides of the hips with fingers pointed inward to the patient's midline, reaching, and touching across the area below the navel from each side.

The training documents presented lacked documented evidence of any method of searching above the crotch area on any patient.


Complaint #NV00066544