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Based on medical record review, facility policies, and staff interviews, the facility's Governing Body failed to ensure nursing care and services were administered in a safe and effective manner for one (1) patient (#1), which resulted in the death of the patient.

Findings:

Cross reference A0385 as it relates to the failure of the facility to provide nursing care and services in a safe and effective manner.
Cross reference A0115 as it relates to the failure of the facility to protect and promote each patient's rights.

Based on medical record review, facility policies, and staff interviews, the facility failed to maintain a patient's right to receive care in a safe setting, for one (1) patient (#1), which resulted in the death of the patient.

Findings:

Cross reference A0385 as it relates to the failure of the facility to provide nursing care and services in a safe and effective manner.

Cross reference A0043 as it relates to the failure of the governing body to ensure that the protect and promote each patient's rights.

Based on medical record review, facility policies, and staff interviews, the facility failed to ensure nursing care and services were administered in a safe and effective manner for one (1) Patient (#1), which resulted in the death of the patient.

Specifically,

· the facility failed to ensure that qualified nursing staff walked into the patient's room at 15-minute intervals per facility policy, and assess the status of the patient.
· facility failed to assess Patient #1 every 15 minutes according to hospital policy. Patient #1 was found unresponsive and cold in the morning after a night in which the patient was supposed to have been assessed frequently and visually monitored.
· the facility failed to provide qualified staff to conduct every fifteen (15) minute checks who are trained to recognize a patient who is in distress.
· the facility failed to make attempts were to resuscitate the patient after the patient was found unresponsive in the room.
· the facility failed to activate emergency response to aid the patient found unresponsive and a registered nurse determined there was no need for CPR.

Cross-reference A0043 as it relates to the failure of the governing body to ensure that they protect and promote each patient's rights.

Cross-reference A0115 as it relates to the failure of the facility to protect and promote each patient's rights.

Findings:

A review of Patient #1's record revealed that Patient #1 was stabilized in the facility's ICU (Intensive Care Unit) for a suicide attempt by drug overdose. On 2/14/18 Patient #1 was discharged from the ICU and admitted to the facility's psychiatric unit.

On 2/18/18 at 8:15 a.m. RN #5 documented in Patient #'1's record to have found Patient #1 in the room with no pulse or respirations present. Patient #1's color was mottled. House Supervisor and MD #1 were notified. At 9:15 a.m. RN #6 documented that Patient #1 was pronounced dead by the coroner. The patient's body was released to the morgue. No Code Blue (CPR - cardiopulmonary resuscitation) documentation could be found in the records.

During the course of Patient #1's admission, it is documented that he/she consistently maintained stable vital signs. On 2/16/18 at 8:21 a.m. MD#1 documented that Patient #1 stated that the methadone treatment was not working, and he/she complained of early morning insomnia (inability to sleep). Patient #1 stated that he/she was angry that his/her suicide attempt was unsuccessful and that he/she did not want to live in chronic pain. A nursing note on the same day at 8:30 a.m. from RN#5 confirmed that Patient #1 had sleep disturbances and suicidal ideations. A note by RN #7 at 7:59 p.m. validated the notes of MD#1 and RN#5. The note reported that Patient #1 stated that he/she was upset that his/ her suicide attempt had failed. On 2/17/18 at 8:49 a.m. Patient #1 stated again that he/she was disappointed in his/her failed suicide attempt. It is also noted that Patient #1 was preoccupied with chronic pain issues. Patient #1 had auditory (hearing voices) hallucinations and was speaking with a deceased family member. The note further stated that Patient #1 appeared to be seeking medications and he/she was detoxing (rid the body of toxic or unhealthy substances) from narcotics and Benzodiazepines (anti-anxiety medications). At 9:57 a.m. Patient #1 continued to state that he/she wished he/she had died in the suicide attempt. Patient #1 also reported feeling sad and hopeless. Patient #1 stated that he/she was actively looking for something with which to hang himself/herself. At 9:23 p.m. Patient #1 reported feeling better, but was still hearing the voice of a deceased sibling. On 2/18/18 at 5:10 a.m. RN #7 documented that Patient #1 was somnolent (sleepy) with no distress. At 8:15 a.m. RN #5 documented that Patient #1 was found in his/her room without a pulse (heartbeat), respirations, and with mottled (marked with smears of color) skin. The house supervisor and MD #1 were notified. At 12:31 p.m. RN # 6 documented that Patient #1 was pronounced deceased at 9:15 a.m. by the coroner. Patient #1's body was released to the morgue. The medical record further revealed that Patient #1 was transported to the crime lab. There was no record of CPR (Cardio Pulmonary Resuscitation) being initiated or a Code Blue being called. Patient #1's fifteen (15) minute observation sheet was completed up until the patient was found unresponsive by staff.

A review of facility policy labeled Code Blue, Code Blue PALS, and Resuscitation Program effective 2015 revealed that the phrase "Code Blue" will be used to rapidly summon a defined emergency response team with special training and competencies in emergency life support and cardiovascular care. The Code Blue response team will respond to all codes in the main building. All associates are authorized to initiate the Code Blue response when a patient, visitor, or associate demonstrates a sudden or immediate inability to sustain respiratory or cardiovascular function or is experiencing seizure activity. Any deterioration in a patient status where respiratory and circulatory functions are adequate the Rapid Response Team (RRT) will be summons as per policy ("Rapid Response Team"). Code Blue training is mandatory for all associates and included in the annual environment of care educational program. The first BLS certified provider on the scene should ensure appropriate notification has been implemented then begin BLS. All associates routinely involved in direct patient care are required to maintain current AHA BLS for Healthcare Providers certification or an equivalent approved by Educational Services.

A review of facility's policy labeled Death Pronouncements effective August 2015 revealed that when a death occurs, the responsible nursing personnel should notify the attending physician. At the attending physician's request, the Hospitalist is available to do death pronouncements. In the rare event the Hospitalist is not available, the Emergency Department physicians are available to perform this service when requested. If the attending physician requests the Hospitalist physician to pronounce the patient, the nurse should ask if he/she would like to talk with the requested physician and offer to transfer the call.

A review of facility policy labeled Patient's Rights effective March 2017 revealed that the Trustees, Medical Staff, Administration and employees of the facility recognize and appreciate the basic rights of patients, as human beings, for independence of expression, decision and action for considerate, respectful care at all times and under all circumstances, including the preservation of personal dignity and recognition of the psychosocial, spiritual and cultural values that impact the patient ' s attitude and response to the care delivered. During the registration process, all patients and/or their representative sign a copy of the Patient Rights and Responsibilities Document. A printed copy of the signed document is provided to the patient and/or representative, and a copy is kept on file. Patients presenting for a series of treatments are provided a copy at the time of the first treatment in the series of such recurring encounters. When the series of treatments end and the patient presents at a future date for other services, they will be provided with another copy of the Patient Rights and Responsibilities. Individuals shall be accorded impartial access to treatment or accommodations that are available or medically indicated, regardless of race, creed, sex, national origin, age, identity, religion, culture, preferred language, physical or mental disability, socioeconomic status, sexual orientation, gender expression, or sources of payment for care at all times and under all circumstances, with recognition of his/her personal dignity.

During an interview on 2/21/18 at 12:30 p.m. CNO #9 stated that he/she expects all staff to initiate Code Blue on any patient to be found without a pulse or respirations. CNO #9 also confirmed that an RN is not qualified to decide if a patient is dead.

An interview with Staff #3 on 2/21/18 at 1645 in the boardroom revealed that he/she was a certified nursing assistant and had been employed at the facility since August 2017. He/she worked until midnight on 2/17/18 going into 2/18/18. He/she stated that all patients on the behavioral health unit are to be checked every 15 minutes. When patients are in their bedroom, the staff member is to step inside the patient's room and visualize the patient. Staff #3 stated that he/she had observed Patient #1 and completed the fifteen (15) minute check until the end of his/her shift at midnight. Patient #1 was found unresponsive at 8:15 a.m. on 2/18/18.

An interview with Director #2 on 2/21/18 at 5:00 p.m. in the boardroom revealed that he/she had been Director of Westcott Behavioral Health unit since January 2017. He/she was notified on 2/18/18 that Patient #1 was found in the bed deceased. Director #2 stated that the expectation of staff when finding an unresponsive person was to initiate emergency policies such as calling a Code Blue. He/she stated that staff are expected to have current basic life support training qualification.

A telephone interview with Staff #4 was conducted on 2/22/18 at 7:55 a.m. He/she had been employed at the facility since May 2016 as a nurse technician. Staff #4 recalled Patient #1 and that the patient was in private room. He/she stated that at approximately 7:20 a.m. on 2/18/18, he/she checked on Patient #1 who was asleep in his/her bed. Staff #4 did not physically touch the patient and did not note the color of Patient #1's skin. At approximately 8:10 a.m. Staff #4 went back to the patient's room to take vital signs and advise Patient #1 that breakfast was in the dining room. Staff #4 approached Patient#1 in bed and noted his/her skin to be cool to touch, discolored and that the patient was not moving. Staff #4 called out to the patient and did not get a response. Staff #4 immediately left the room to get RN #5, who was at the nurse's station. Staff #4 and RN #5 returned to Patient #1's room and RN #5 checked the patient for a pulse and breathing. RN #5 declared 'she ' s gone'. Staff #4 again left Patient #1's room to get additional help and returned to the room with RN #6. RN #5 and RN #6 exited Patient #1's room and locked the door. At that time, the house supervisor was called who in turn called the coroner. Staff #4 did not know what time the coroner arrived. Staff #4 stated that all patient rooms have a call bell. He/she stated that the staff wear a whistle to use when they need assistance. Staff #4 stated that he/she did not think that anyone would hear the whistle from Patient #1's room.

A telephone interview was conducted with RN #5 on 2/22/18 at 8:10 a.m. RN #5 had been employed at the facility as a registered nurse for approximately eighteen (18) months. RN #5 worked from 7 a.m. to 7 p.m. on 2/18/18. He/she recalled that Staff #4 approached him/her at the nurse's station and reported that Patient #1 did not look right. RN #5 and Staff #4 went Patient #1's room and RN #5 noted that the patient was not breathing and his/her skin was mottled. RN #5 further stated that CPR would not have been helpful at that time. When asked what signs and symptoms would necessitate initiating CPR, he/she replied the patient's skin would not be mottled and cool to the touch. RN #5 stated that the house supervisor was notified who in turn called the coroner. RN #5 stated that call bells are in each patient's room. RN #5 did not observe anything in Patient #1's room that would indicate that Patient #1 harmed himself/herself.

A telephone interview with RN #6 was conducted on 2/22/18 at 8:25 a.m. RN #6 had been employed at the facility since 2014 as a was a registered nurse. On 2/18/18 he/she was working from 7:00 a.m. to 7:00 p.m. RN #6 recalled that at approximately 8:00 a.m., Staff #4 approached him/her in the medication room and requested assistance in Patient #1's room. RN #6 stated that the medication room was on the adjacent hallway. Staff #4 relayed to Staff #6 that Patient# 1 had expired. RN #6 found RN #5 in Patient #1's room. RN #5 told RN #6 that the patient had expired. At that time, all staff exited the patient's room and locked the room. The house supervisor was called.

A telephone interview on 2/22/18 at 9:45 a.m. with RN #7 revealed that RN #7 had been employed at the facility as a registered nurse for nine (9) years. RN #7 worked from 7:00 p.m. on 2/17/18 until 7:00 a.m. on 2/18/18. He/she last checked in on Patient #1 between 6:30 a.m. and 6:45 a.m. He/she stated that Patient #1 appeared to be asleep in bed. RN #7 reported that he/she was very familiar with the patient. He/she stated that during this admission, Patient #1 was extremely depressed and had said 'I'm disappointed that I did not die'. RN #7 stated that the patient had been alert and oriented with no complaints during the previous shift. RN #7 stated staff check on all patients on the unit every fifteen (15) minutes. RN #7 stated that staff are expected to initiate CPR and call a code blue when a patient is found unresponsive and not breathing.

A telephone interview with LPN #8 (Licensed Practical Nurse) on 2/22/18 at 9:53 a.m. revealed that he/she had worked from 7:00 p.m. on 2/17/18 until 7:30 a.m. on 2/18/18. He/she recalled checking in on Patient #1 around 6:30 a.m. He/she stated that Patient #1 appeared to be breathing. LPN #8 recalled that the patient appeared sad and had a flat affect during the evening of 2/17/18. He/she recalled that the patient was asleep by 9:30 p.m. on 2/17/18.

A review of eight (8) personnel files (#2,3,4,5,6,7,8 and 9) revealed all contained evidence of current licensure, department orientation, annual competency testing, and mandatory in-service attendance.

A review of one (1) credentialed files (#1) revealed current licensure, DEA certificate, insurance, appointment, privileges, and quality reviews.

Review of nine (9) additional medical records (#2, 3, 4, 5, 6, 7, 8, 9, and 10) revealed that all patients had signed consent forms and information regarding how to file a complaint. All nine (9) patients had evidence of clinical assessments, appropriate care plans, and discharge planning.