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Based on interview, record review and policy review, the facility failed to ensure staff in the Behavioral Health Emergency Department (BHED) reassessed one patient (#1) of one discharged patient reviewed for a change in condition. This had the potential to place all patients seeking care and treatment in the facility's BHED at risk to receive proper care and treatment after a change in condition occurred. The facility census was 206. The BHED census was 19.

Please refer to A0395 for citation.

This failure contributed to the facility's failure to meet the minimum requirements for the Condition of Participation: Nursing Services.

Based on interviews, policy review and record reviews, the facility failed to ensure staff in the Behavioral Health Emergency Department (BHED) reassessed one patient (#1) out of one discharged patient reviewed for a change in condition. This had the potential to place all patients seeking care and treatment in the facility's BHED at risk to receive proper care and treatment after a change in condition occurred. The facility census was 206. The BHED census was 19.

Findings included:

1. Record review of the facility's policy titled, "Guidelines for Staff Documentation," dated 07/25/12, showed the following directive for staff:
- Continued client assessment completed on every shift (i.e. development of new symptoms).
- Therapeutic interventions and client responses to treatment are documented either on the ongoing assessment by the RN (Registered Nurse), if completed during assessment or on Clinical Notes by designated staff.
- Any further interventions and client interactions can be documented throughout the shift as an addendum on the Clinical Notes.

2. Record review of Patient #1's medical record showed the following timeline:
- On 05/28/15 at 7:49 PM, the patient presented to the facility's Main Medical Emergency Department (MMED).
- On 05/29/15 at 3:18 AM, the patient was transported from the MMED to the facility's BHED.
- On 05/29/15 at 4:45 AM BHED staff triaged (process to determine priority of care) the patient.
- On 05/29/15 at 10:30 AM, the patient received a BHED Evaluation, approximately seven hours after he had arrived.
- On 05/29/15 at approximately 1:00 PM, the patient was found unresponsive, CPR was initiated (cardiopulmonary resuscitation), 911 and the Code Blue Team was called (staff trained in advanced cardiopulmonary resuscitation.)
- On 05/29/15 at 1:27 PM, the patient was transferred from the BHED to
the MMED per ambulance.
- On 05/29/15 at 2:46 PM, the patient was admitted to the ICU (Intensive Care Unit).
- On 05/30/15 at 6:55 PM, the patient died.

3. Record review of the patient's MMED record showed staff documented the following information:
- The patient first presented to the MMED on 05/28/15 at 7:49 PM, per ambulance with complaints of drinking an unknown amount of alcohol along with taking three pills that start with the letter "V" in an attempt to "end it all."
- On 05/28/15 at 8:48 PM, the patient's blood alcohol level (BAL) was 393 and was reported to the physician. (A BAL of 300 to 400 is potentially fatal).
- On 05/29/15 at 1:02 AM, the patient received a consult by the Qualified Mental Health Practitioner who recommended transfer to the BHED for psychiatric evaluation due to suicidal ideations, substance abuse and for detoxification (detox, a process to prevent alcohol withdrawal, which can be a life-threatening condition due to heavy drinking. Sudden withdrawal can cause severe complications such as seizures).
- On 05/29/15 at 3:18 AM, the patient was transported from the MMED to the BHED.

Record review of the BHED triage record showed the patient had multiple medical problems including a tracheostomy (trach, a surgical procedure to create an opening through the neck into the trachea [windpipe] to assist in breathing).

Record review of the Behavioral Health ED Evaluation by Staff EEE, Behavior Health Unit Psychiatrist showed a late entry after the patient was transported to the MMED on 05/29/15 at approximately 1:22 PM. The documentation was dated 05/29/15 at 2:46 PM.
- Identification Data and Reason for Evaluation: The patient has a long history of chronic (persisting for a long time) alcohol dependence, came to our emergency room (BHED) at the referral of the MMED for safe medical detox and reported suicidal ideation. The patient reported drinking an unknown amount of alcohol and took three pills that start with the letter "V", in an attempt to end it all. Reportedly was medically evaluated/cleared and transferred to our facility around 1:00 AM today. With several patients in the BHED ahead of the patient, he could not be evaluated by the night shift resident physician, and ultimately was seen by me (Staff EEE) around 10:30 AM today. The patient's blood alcohol level was 393 on 05/28/15 at 7:58 PM. (This is inconsistent with the record from the MMED, which showed the BAL was reported at 8:48 PM).
- History of Presenting Illness: The patient reported he is homeless, drinks regularly and has not taken his medication for a couple of days. The patient stated that he wanted to drink himself to death.
- Medical Issues: The patient has a history of hypertension (high blood pressure), seizure disorder, withdrawal seizures (occurs when alcohol consumption is stopped), hepatitis C, diabetes and vocal cord paralysis leading to tracheostomy.
- Plan: Recommended hospitalization for a safe medical detox and for reported suicidal statements. Will place him on CIWA (Clinical Institute Withdrawal Assessment for Alcohol Scale, a tool used to assess the severity of alcohol withdrawal symptoms) protocol. Planned orders for above medication/detox placed secondary to nursing reports that there will be an inpatient psychiatric bed available right now (planned orders are to be carried out for medications and CIWA protocol when the patient is admitted to the BHU).
- Added Note: Patient reportedly was noticed unresponsive by a Registered Nurse around 1:30 PM. CPR initiated along with oxygen. A Code Blue Team was called. The patient was taken to the MMED by ambulance at 1:22 PM.
- I was informed by nursing at a much later time that the patient reportedly had an episode of vomiting after lunch today with no hematemesis (blood in vomit) or retching (dry heaving). The patient reportedly claimed he was doing fairly well and did not want any medications for nausea/vomiting. The patient reportedly took his seizure medicine without any problem 30 minutes after vomiting and reportedly appeared to be doing fairly well; reportedly he did not exhibit any overt alcohol withdrawal symptoms during contacts.

Record review of the BHED physician orders dated 05/29/15 showed no order to admit the patient as an inpatient to the facility's Behavioral Health Unit.

During an interview on 06/25/15 at 10:25 AM, Staff J, Mental Health Technician (MHT), stated that she found the patient unresponsive. She stated that earlier that day she was doing rounds (a scheduled check on each patient's location and safety) when she heard someone in the restroom making vomiting sounds. She stated that the next time she saw the patient he was lying flat on a mat on the floor (patients are placed on mats on the floor when the BHED exceeds their 10 bed capacity) and was snoring. Staff J stated right after that she walked by him and he was no longer snoring and his eyes were half open. Staff J stated that she got Staff OO, Registered Nurse (RN), to check his pulse. Staff J stated that the patient looked sweaty and paler than usual.

During an interview on 06/25/15 at 11:55 AM, Staff OO, RN, stated that:
- She found the patient on a mat on the floor on his side facing the wall.
- He looked diaphoretic (sweaty), his eyes were half open, his skin was clammy to touch, he was more pale than usual, his pulse was thready (pulse is difficult to feel or disappears easily with slight pressure) and he was unresponsive to stimulus (a response to name, questions or touch).
- They were trying to resuscitate (give artificial respiration) him.
- "Our nurses don't do trach care, but could visually inspect it and could have suctioned it if necessary or in an emergency. If the patient showed any signs of distress we would send him across the street, we wouldn't do any deep suctioning."
- The patient was not physically assessed until the incident occurred because he had been medically cleared nine and a half hours earlier at the MMED.

Record review of the patient's Multidisciplinary Documentation showed the following information (this documentation was entered in the patient's BHED record after he was transported to the facility's MMED on 05/29/15 at approximately 1:22 PM):
- On 05/29/15 at 1:41 PM staff documented that the patient was alert and oriented times three (aware of time, location and self) with no complaints of pain. The patient does have some vague SI, no plan. (There is no documentation of the time the staff saw the patient and determined he was alert and oriented).
- On 05/29/15 at 2:28 PM staff documented that the patient threw up as reported by the Mental Health Technician (There is no documentation of the time the patient vomited). The patient had just eaten lunch and denied retching or blood in vomit. The patient denied any need for medication and laid down to rest. Psychiatrist notified.
- On 05/29/15 at 1:26 PM (time contradicts other documentation) the patient was lying on a cot (mat on the floor) on his side at 1:00 PM with
eyes open, skin diaphoretic and when attempted to rouse patient, he would not respond. Breathing was shallow and barely noticeable to fingers from mouth and trach. Pulse was thready and CPR initiated.
- 911 (paramedics) called at 1:01 PM and they arrived at approximately 1:05 PM.
- No VS (vital signs: blood pressure, pulse and respirations) or oxygen SATs (saturation, which is the oxygen level in the blood) registered on equipment.
- Code Blue Team called at 1:07 PM and arrived several minutes later.
- Glucometer (machine used to measure blood sugar) reading was 195 (normal reading after meals is 180).
- Patient left by ambulance at 1:22 PM.

Record review of the patient's BHED record showed that staff:
- Did not document until after the patient left the BHED at 1:22 PM for the MMED.
- Did not document that they assessed the patient after he experienced an episode of vomiting.
- Did not document that they assessed his airway or condition of his tracheostomy to ensure his airway was clear.

Record review of the patient's Behavioral Observation Record dated 05/29/15; showed staff documented the following information:
- Observation: Routine without accompanied status (routine 15 minute checks without constant staff observation).
- From 12:30 PM to 1:00 PM staff documented the patient's visual was calm (he looked calm), his behavior was composed/sleeping and location was hallway.
- At 1:22 PM staff documented the patient was transferred to the main facility (the patient was transferred to the MMED after staff found him unresponsive and initiated a Code Blue).

4. Record review of the patient's medical record from the MMED showed staff documented that:
- On 05/29/15 at 1:37 PM, the patient arrived at the MMED.
- At 1:39 PM, the patient's trach canula (tube placed into the hole in the windpipe making it easier for a person to breathe) was exchanged for a 6.0 Shiley (size of a trach canula). Breath sounds positive.
- At 1:56 PM, noted obstruction (blockage) present in patient found by Staff JJJ, Senior Attending Emergency Physician.
- At 2:46 PM the patient was transported to the ICU.

Record review of the physician orders dated 05/29/15 at 2:32 PM, showed an order for Critical Care, upper respiratory tract obstruction/cardiopulmonary arrest.

During an interview on 06/25/15 at 3:15 PM, Staff JJJ, Senior Attending Emergency Physician, stated that when the patient was brought into the ED after the incident, "They were bagging (artificial ventilation performed with a respirator bag. The bag is squeezed to deliver air to the patient's lungs through a mask, an endotracheal [a flexible plastic tube that is put in the mouth and then down into the trachea] tube, or another breathing device) him through his trach and it was difficult, so we replaced it." Staff JJJ stated that after the trach was replaced there was no difficulty squeezing air through the trach. Staff JJJ stated that in the case of a chronic trach we would reassess the airway and make sure it was patent (open and working properly).

During an interview on 06/24/15 at 1:15 PM, Staff EEE, Physician, Behavior Health Unit (BHU) Psychiatrist, stated that the patient had a trach and should remain upright after eating for 30 minutes or so to prevent an emetic (causing vomiting) event. Staff EEE stated that she expected staff to place a patient in an upright position after an emesis (vomiting) episode especially if the patient had a trach and she would not expect the patient to lie flat. Staff EEE stated that she did not know if staff suctioned the patient after his emesis.

During an interview on 06/25/15 at 9:20 AM, Staff III, Emergency Medical Physician, Emergency Department Chairman, stated that his expectations for care after vomiting for any patient with a trach would be to observe the patient, suction the trach and supply oxygen to the patient if necessary. He stated that it may be necessary to provide an airway cart (an emergency medical cart containing medical equipment necessary to open or maintain an airway) and change the trach if needed. He stated that it could be necessary to have anesthesia and respiratory staff paged to the area and keep the patient elevated in a bed if he was awake.

During an interview on 06/25/15 at 8:50 AM, Staff KK, Chief Executive Officer, stated that he would have expected the staff to assess the patient's trach. He stated that it could have been done but not documented.

During an interview on 06/25/15 at 10:15 AM, Staff E, RN, Chief Nursing Officer, stated that she would have expected the nurse to assess the trach at admission and after any emesis.

During an interview on 06/25/15 at 4:05 PM, Staff KKK, MHT, stated that the day of the incident that she gave the patient a regular food tray on his mat on the floor. Staff KKK stated that the patient stated that he was sick and didn't know if he could eat and then it sounded like he was vomiting. Staff KKK stated, "I can't remember telling his nurse, but I normally would." Staff KKK stated that she didn't know if the nurse assessed him after that.

During an interview on 06/25/15 at 11:50 AM, Staff I, RN, Director of Nursing of the Behavior Health, stated that it was not common for the facility to admit patients with trachs but she believed her staff could take care of patients with them.

During an interview on 06/25/15 at 12:04 PM, Staff H, Associate Administrator of BHU, stated, "My perception was he could care for his trach on his own."

Record review of the patient's medical record showed he expired on 05/30/15 at 6:55 PM.







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