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Based on observation, document review, and interview, it was determined that the Hospital failed to ensure that patient rights were protected by failing to ensure safety precautions were adequate for a patient change in condition (behavioral) while on the medical-surgical unit. This potentially placed current, and future patients admitted to the Hospital's Medical-Surgical/Telemetry Unit with behavioral conditions at risk for serious harm. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure care in a safe setting by failing to provide an elopement risk reassessment, the use of de-escalation techniques and ensure safety interventions were adequate for a patient with a change of condition (behavioral) while on medical-surgical unit. See deficiency cited at A-144-A and B.

The immediate jeopardy began on 01/21/2022, due to the Hospitals' failure to ensure care in a safe setting by failing to ensure safety assessments were conducted and safety interventions were appropriate for a patient with a change in condition (behavioral) on a medical surgical floor. The patient was able to jump out the unit hallway window, and subsequently died.

The Immediate Jeopardy (IJ) was identified on 01/21/2022, at 42 CFR 482.13, Patient Rights. The IJ was announced on 01/21/2022 at 2:15 PM, during a meeting with the President/CEO, System Chief Nursing Officer, System Chief Operations Officer, Executive Director of Quality, Associate Chief Medical Officer, Interim Chair Revenue Cycle, and Associate Chief Nursing Officer. The Immediate Jeopardy was removed by the survey exit date of 01/25/2022.

A. Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) patient, the Hospital failed to ensure care in a safe setting by failing to provide an elopement risk reassessment, the use of de-escalation techniques and ensure safety interventions were adequate for a patient with a change of condition (behavioral) while on medical-surgical unit.

Findings include:

1. On 01/20/2022, the clinical record of Pt. #1 was reviewed. Pt. #1 was brought to the Hospital by paramedics on 01/17/2022 with chief complaint of altered mental status and agitation. The clinical record included:

-The Emergency Department (ED) History and Physical dated 01/17/2022, at 8:30 AM included, " ... (Pt. #1) brought in by EMS (emergency medical services) for agitation ...spoke to father ...reports that his son lost job and girlfriend 3 months ago ...noticed he was growing more irritable ...father reports 3 days ago (Pt. #1) stated hearing voices ...becoming more agitated ...reports he had to call 911 after episode of trying to injure the cat ...(Pt. #1) presented with increased irritability ...hallucinations ...delusions and homicidal ideations which point to acute psychotic episode ...2 mg (milligrams) of Ativan (anti-anxiety medication) and 5 mg Haldol (anti-psychotic) given ...remains non-verbal ...crisis worker unable to evaluate ...Tachycardic [increased heart rate above 100 beats per minute] on admission ...labs [laboratory] significant ...in setting of acidosis of unknown origin and acute psychotic episode, patient endorsed to hospitalist ...for admission to medical floor with psych (psychiatric) consult ... Patient wasn't violent, however, patient was agitated and kept trying to pace the department ..."

-Physicians' order (entered by MD #1) dated 01/17/2022 at 8:40 AM included, "Procedure: Sitter ...STAT (immediately) ...Purpose: Psychosis ..."

-Psychiatry progress note dated 01/17/2022 at 8:45 AM (entered by E #8/Psychiatric Nurse Practitioner) included, "Attempted to meet with the patient for psychiatric evaluation, however patient appeared sleepy and sedated. He is unable to ...meaningfully participate with this evaluation ...Psychiatry will reattempt at a later time when patient is able to participate ..."

-PCT (Patient Care Technician) progress noted dated 01/17/2022, at 4:16 PM included, "While preparing for transport, patient stating he does not need to be here. He feels better and should not be admitted. Patient displays actions of being a potential flight risk [elopement risk] ...having conversations with himself. RN (Registered Nurse) made aware."

-History and Physical dated 01/17/2022 at 4:53 PM included, "Pt. #1 presents due to ...acute agitation ...admits to cocaine ["binges"] ...UDS (urine drug screen) ordered ...Assessment and Plan ...1. AMS ...2. Acute Psychosis ...3. Metabolic acidosis ...no PMH (past medical history) ...found to have elevated CK in ED. Will be admitted for further management ...AMS? (possible) Psychiatric ...Patient denies hearing voices but ...his father said he did ...CT (computed tomography) Head and Neck negative ...Psychiatry on board. Sitter ..."

-ED PCT progress noted dated 01/17/2022, at 5:12 PM included, "Patient transported to the fourth floor with sitter escort via cart. Patient having audible hallucinations conversations with himself with ideations of absconding. RN made aware. Patient care and info (information) transferred to RN."

-The clinical record indicated that Pt. #1 was in the ED (emergency department) from 01/17/2022 at 8:16 AM through 01/17/2022 at 5:12 PM. Pt. #1 was transferred to 4th floor Medical Surgical Unit on 01/17/2022 at 5:12 PM.

-Nurses note dated 01/17/2022, at 9:00 PM included, "Pt. awake, A &OX (alert and oriented times) 2-3, but psychotic, screaming loud at times, talking to self and other invisible persons, redirectable stating he is sorry for causing trouble, sitter in the room, will medicate ...ambulatory ....refusing to put on a gown ..."

-Nurses note dated 01/17/2022, at 10:30 PM included, "Pt (Pt. #1) restless, sitter in the room, writer went in the pt. room to medicate him, security called, pt. combative, tried to jump on the window in the room, trying to escape from the room by the door where he put an arm outside to attempt to open the door, security tried to push the door to detain pt. who was c/o (complaining of) hurting his arm, Security released the door a little, Pt. escaped in the hallway where with speed (he) was running to the end of the hallway, where he broke the window and jumped outside, charge RN, Supervisor called, 911 called, the case started to be investigated."

-The ED Trauma History and Physical dated 01/17/2022 at 11:10 PM included, "Pt. #1 with unknown medical history presented as a trauma. Patient admitted to the hospital earlier in the day for agitation ...admitted to medicine with a sitter for lab abnormalities ...with psych consult. Patient then jumped out of a fourth-floor window. Code Blue (medical emergency) was called to the scene. Patient was found outside, near a parked vehicle with obvious deformities and trauma. Patient was pulseless at that time, ACLS (advanced cardiac life support) initiated ...Patient initially with PEA (pulseless electrical activity) then asystolic. Despite aggressive resuscitative measures, ROSC (return of spontaneous circulation) was not able to be achieved. Time of death was called at 2308 [11:08 PM] ..."

-The clinical record indicated that Pt. #1 was on 1:1 (direct supervision sitter) monitoring from 01/17/2022 at 8:40 AM through 01/17/2022 at 10:30 PM for Psychosis. The clinical lacked a behavior specific behavior precautions and elopement risk precautions.

2. On 01/21/2022, the Hospital's policy titled, "Monitoring of Psychiatric Patients" dated 08/2021 was reviewed and required, " ...B. Higher Level Safety Precautions: 1. One or more of the following safety precautions may be ordered when clinically indicated. 1. Suicide Precautions and Self-Injury ... 3. Escape/Elopement Precautions - Patients who pose an escape risk ...1. The nurse obtains a physician order for monitoring and safety precautions ...6. Patients on safety precautions are monitored for behaviors associated with that precaution ..."

3. On 01/21/2022, the Hospital's policy titled, "Nursing Assessment and Reassessment" dated 10/2020 was reviewed and included, "...Reassessment is based on the patient's diagnosis, need for care, desire for care and response to any previous care...Frequency of Reassessments: 1. On the non-critical care units, a full shift assessment should be performed once every twelve hours. In addition, a focused shift assessment should be performed as needed based on the patient' condition as identified problems..."

4. On 01/20/2022 at approximately 2:00 PM, the Nurse Manager on 4th and 5th Floor Medical-Surgical Unit (E #7) was interviewed. E #7 stated that after the incident on 01/17/2022, she interviewed the direct care staff involved with Pt. #1's incident. E #7 stated that Pt. #1 was assigned a 1:1 sitter due to being identified as a flight risk (elopement) in the emergency department. E #7 stated there was no documentation in Pt. #1's medical record indicating that he was on elopement precautions. E #7 stated that if a patient's behavior is changing, the nurse can initiate safety precautions then call the physician for an order.

5. On 01/20/2022 at 2:35 PM, a Registered Nurse (E #4) was interviewed. E #4 stated that when she received Pt. #1 on 01/17/2022 she was not aware that the patient was an elopement risk. E #4 stated that Pt. #1 had a 1:1 sitter for psychiatric behaviors but was not on elopement precautions. E #4 stated that Pt. #1's behavior began escalating around 9 PM and at 10:03 PM, she called Security to come up and assist with Pt. #1's medication administration for safety..."

6. On 01/20/2022 at 3:15 PM, the Psychiatric Nurse Practitioner (E #8) was interviewed regarding the incident on 01/17/2022. E #8 stated that Pt. #1 was sleeping when she assessed him. E #8 stated that although Pt. #1 had an order for a 1:1 sitter, no safety or elopement precautions were ordered. E #8 stated that given the patients psychiatric history he should have been placed on SI/HI (suicidal/homicidal) precautions.

7. On 01/21/2022, between 9:20 AM and 10:25 AM, interviews were conducted with E #7 (Unit Manager) and #10 (Assistant Chief Nursing Officer). E #7 stated, "I understand there should have been behavior specific safety precautions, because we would be able to communicate with each other and stay on the same page while monitoring safety". E #10 stated, "We do not have a behavioral assessment or safety precautions policy on the medical unit, there is no elopement assessment on the medical unit."

B. Based on document review and interview, for 1 of 1 (Pt. #1) sampled patient on the medical-surgical unit, the Hospital failed to ensure care in a safe setting by failing to provide a timely behavioral emergency response for a patient with altered mental status experiencing a change in condition (behavioral).

Findings include:

1. The Hospital's policy titled, "Code Gray" dated 06/2019 was reviewed and required, "A. ...the objective of calling "code gray" is to assure a timely security response to situations involving an actual or potential...threat...D. Procedure...When any employee or physician perceives that the situation may/or has become threatening verbally or physically, he/she shall call the Hospital Operator...and State "Code Gray"...the operator will then overhead page...with the location of the incident...The operator will proceed to contact the security dispatcher...The Security dispatcher will advise all available units respond to the code gray...Security Department staff shall assess the situation to see if it can be handles appropriately and safely..."

2. The Hospital's policy titled, "Code Bert (Behavioral Emergency Response Team)" (rev. 01/2021) was reviewed and required, "...A. This policy is to give guidelines regarding prevention of, and response to...activation of the response for the agitated person, response team staff roles and responsibilities...D. The response team may be activated when...A. Any behavior that is escalating or potentially harmful to self, others.... B. The patient does not respond to verbal redirection and the behavior continues to be threatening and/or to property...E. Members of the: Code BERT: 1. De-escalation Lead...2. Medical Lead: Hospitalist/Resident...3. Primary Members...a. Primary Nursing caring for the patient...b. Security Officers...H. Team Member Responsibilities: 1. Utilized de-escalation techniques to address the escalating and potentially violent situation...2. Seeks direction from De-escalation Leader..."

3. On 01/20/2022, the clinical record of Pt. #1 was reviewed. Pt. #1 was brought to the Hospital by paramedics on 01/17/2022 with chief complaint of altered mental status and agitation. The clinical record indicated:

-Pt. #1 was in the ED (emergency department) from 01/17/2022 at 8:16 AM through 01/17/2022 at 5:12 PM. Pt. #1 was transferred to 4th floor Medical Surgical Unit on 01/17/2022 at 5:12 PM.
.

-Nurses note dated 01/17/2022 at 9:00 PM included, "Pt. awake, A &OX 2-3, but psychotic, screaming loud at times, talking to self and other invisible persons, redirectable stating he is sorry for causing trouble, sitter in the room, will medicate ...ambulatory ....refusing to put on a gown ..."

-Nurses note dated 01/17/2022, at 10:30 PM included, "Pt (Pt. #1) restless, sitter in the room, writer went in the pt. room to medicate him, security called, pt. combative, tried to jump on the window in the room, trying to escape from the room by the door where he put an arm outside to attempt to open the door, security tried to push the door to detain pt. who was c/o (complaining of) hurting his arm, Security released the door a little, Pt. escaped in the hallway where with speed (he) was running to the end of the hallway, where he broke the window and jumped outside ..." Pt. #1 expired on 1/17/2022 at 11:08 PM.

-Code Sheets were reviewed for 01/17/2022 and indicate that there were no behavioral call codes for Pt. #1 on 01/17/2022.

4. On 01/20/2022 at 2:35 PM, a Registered Nurse (E #4) was interviewed...E #4 stated that Pt. #1's behavior began escalating around 9 PM and at 10:03 PM, she called Security to come up and assist with Pt. #1's medication administration for safety...Pt. #1 became agitated and attempted to jump out of the room window at approximately 10:15 PM. E #4 stated that Pt. #1 then immediately attempted to escape from the room. E #4 stated that incident escalated quickly and there were no attempts made to call a code BERT (behavioral emergency response team) or Code Gray (violent patient) during the incident prior to the patient exiting his room and jumping the 4th floor hallway window at approximately 10:30 PM.

5. On 01/20/2022 at approximately 11:00 AM, an interview was conducted with E #5 (Public Safety Officer). E #5 stated that he was called to the unit by the nurse down at the Security desk. She wanted someone to help the patient calm down and assist with medication administration. Pt. #1 was sitting upright in the fetal position, talking to himself and displaying bizarre behavior...At this point his behavior was escalating. I got on the radio to call for the public safety officers to come help me..."

6. On 01/20/2022 at approximately 2:00 PM, an interview was conducted with Nurse Manager Medical-Surgical/Telemetry Unit (E #7). E #7 stated, " The staff did not call a code...the nurse said there was no time..."

C. Based on document review and interview, it was determined that for 1 of 2 (Pt. #8) clinical records reviewed for suicidal ideation (SI) precautions, the Hospital failed to ensure, that SI precautions were conducted for every two (2) hours by the sitter while in the ED (emergency department), per the physician orders.

Findings include:

1. On 01/21/2022, at approximately 2:00 PM, the Hospital's policy titled, "Monitoring of Psychiatric Patients" dated 08/2021 was reviewed and included, "...Higher level Safety Precautions: Suicide Precautions: will be monitored every 15 minutes ...physician orders a 1:1 (one-to-one) observation ...Patient's on safety precautions are monitored for behaviors associated with that precaution ..."

2. Pt. #8 was admitted to the ED on 01/15/2022, with a chief complaint of AKI (acute kidney injury), Heroin OD [Overdose] and suicidal ideation. Pt. #8's clinical record included ED physician's order dated 01/15/2022 at 2:52 PM, to place the patient on SI precautions with sitter at bedside.

- Pt. #8's every two (2) hour precaution indicated; the sitter documentation started from 01/16/2022 at 2:00 PM.
-Pt. #8's clinical record lacked every two- hour documentation by the sitter beginning from 01/15/2022 until 01/16/2022 2:00 PM.

3. On 01/21/2022, at approximately 2:30 PM, the Executive Director of Quality (E #1) was interviewed. E #1 stated that there should be every 15 minutes monitoring for all SI patients.

Based on document and interview, it was determined that for 2 of 2 (Pt. #6 and Pt. #10) allegations of abuse, the Hospital failed to ensure patient rights to be free from all forms of abuse by not reporting the allegation of abuse to State Agency as required.

Findings include:

1. The Hospital's policy titled, "Patient Safety Event Reporting/Sentinel & Never Event Management" dated 07/2020 was reviewed and included, " ...Any hospital administrator, agent, employee, or medical staff member who has reasonable cause to believe that any patient ...subjected to abuse in the hospital ...report to Patient Safety Department ...shall submit the report to the Illinois Department of Public Health within 24 hours after obtaining such report ..."

2. On 01/21/2022 at approximately 11:00 AM, the Hospital's Incidents log from 07/01/2021 to 01/20/2022 was reviewed. From the log two (Pt. #6 and Pt. #10) patients were randomly selected and reviewed for incident of abuse allegation reporting and handling.

-Pt. #6's clinical record included an allegation of sexual abuse on 10/01/2021 at 1:33 PM. The incident # 21-742 was reviewed and analyzed by the hospital. The incident included, "...she [Pt. #6] reports that a nurse described as being a white male with black hair was examining her ...during the examination he lifted her shirt, felt near her breast , and was fingering with her nipples ..." The incident lacked the documentation notifying the local state agency.

-Pt. #10's clinical record included the allegation of physical abuse on 01/13/2022 at 10:09 AM. The incident # 22 - 27 was reviewed and analyzed by the hospital. The incident included, "...the patient [Pt. #10] reported to the interpreter ...no more Spanish and then the nurse hit her with her hospital phone on her hand ..." The incident lacked the documentation notifying the local state agency.

3. On 01/21/2022 at approximately 2:20 PM, the Executive Director of Quality (E #1) was interviewed. E #1 stated that the allegation of abuse should have be reported to the State Agency, but she's not sure how both the incidents were not reported.