HospitalInspections.org

Based on observations, record reviews, and interviews, the hospital failed to ensure the requirements of the Condition of Participation of Patient Rights were met. This deficient practice was evidenced by the hospital's failure to ensure patients admitted for harm to self or others received care in a safe setting as evidenced:
1. Failure to ensure staff observed patients every 15 minutes, as ordered by the psychiatrist, for 9 sampled patients (Patient #2, Patients #R1- #R8) observed via hospital provided video recordings from a total patient sample of 6 (#1 - #6) and a random patient sample of 9 (#R1- #R9). (See findings in tag A-0144); and
2. Failure to ensure patients admitted for harm to self or others did not have access to contraband items for 2 ( #2, #R9) of 2 sampled patient records reviewed for access to contraband from a total patient sample of 6 ( #1- #6) and a random patient sample of 9 (#R1- #R9). (See findings in tag A-0144).

Findings:

Failure to ensure staff observed patients every 15 minutes, as ordered by the psychiatrist:

An Immediate Jeopardy situation was identified on 9/6/19 at 3:10 p.m. and reported to S1CEO and S4QA. The Immediate Jeopardy was that patients admitted for harm to self or others were not observed as ordered by the psychiatrist for 9 sampled patients on ordered Q 15 minute observations.

An observation was made with S7PlantOps on 9/6/19 at 8:10 a.m. on Unit A of a video recording of the hallway of room 420 to which Patient #2 was assigned on 5/27/19 from 4:07 a.m. - 7:45 a.m. Based on video review the patient had the following lapses in every 15 minute observations:
Patient was not observed via staff rounding beginning at 4:07 a.m. - 5:31 a.m. ( 1 hour and 24 minutes)
From 5:31 a.m. - 6:03 a.m. ( 32 minutes); At 6:03 a.m. S3MHT was observed unlocking the door and carrying 2 bags into Patient #2's room.
From 6:13 a.m. - 6:43 a.m. (30 minutes); At 6:43 a.m. S26MHT was observed walking in the hall where Patient #2's room was located. S26MHT was observed looking into Patient #2's room from the doorway.
From 6:43 a.m.- 7:35 a.m. (52 minutes); At 7:35 a.m. S24MHT was observed going into Patient #2's room. Further observation revealed S24MHT walked out of Patient #2's room, walked down the hallway toward the nurses' station area, and then nursing staff was observed walking down the hallway and entering Patient #2's room.

Review of Patient #2's observation records for the night shift of 5/26/19 - 5/27/19 revealed S3MHT had documented observations of Patient #2 every 15 minutes from 4:07 a.m. - 7:45 a.m. Based on video review S3MHT was only seen entering Patient #2's room at 5:31 a.m., 6:03 a.m., and 6:13 a.m.

An observation was made on 9/6/19 at 9:30 a.m. of a video of Unit A from 2:44 a.m. - 6:42 a.m. on 9/6/19 of rooms 416 (2 patients - #R2, #R3); 417 (1 patient - #R4 with altered thought processes); 418 (2 patients - #R5, #R6 - both with altered thought processes and #R6 also had Depression) 419 (2 patients - 1 with homicidal ideations # R7, and 1 with homicidal precautions - #R1) and room 420 (1 patient - #R8 with Suicidal Ideations). All of the patients referenced in these rooms were on ordered every 15 minute observations.
During the observation of the video recording the following lapses in patient observations were noted:
From the beginning of observation at 2:44 a.m. - 6:14 a.m. there was a 2 hours and 30 minute gap between rounds on Room 419.
From 2:44 a.m. - 4:35 a.m. (2 hours and 39 minutes) no observations were made on patients in rooms 416, 417, and 418.
From 4:35 a.m. - 6:11 a.m. (1 hour and 36 minutes): No rounds were performed on rooms 416, 417, 418, 419, and 420.

Review of the observations sheets dated 9/6/19 for the patients in rooms 416, 417, 418, 419 and 420 revealed from 3:15 a.m. - 6:30 a.m. S3MHT documented observations all of the patients in the above referenced rooms every 15 minutes. Review of the video footage on 9/6/19 between 3:15 a.m. and 6:30 a.m. revealed S3MHT was observed on the hallway near rooms 416-420 only once at 6:15 a.m. in contrast to her documentation of every 15 minute rounds.

An Immediate Jeopardy situation was identified on 9/6/19 at 3:10 p.m. and reported to S1CEO and S4QA.


Plan of Removal:

On 9/9/19 at 6:55 a.m. an observation was made of S2DON conducting on-site staff monitoring of staff supervision of patients on Unit A. MHT staff were observed supervising patients in the commons areas.

On 9/9/19 from 7:01 a.m. - 7:57 a.m. interviews were conducted with the following staff members who worked both A Unit and B Unit: S14MHT, S15RN, S16LPN, S17MHT, S18MHT, S19MHT, S21MHT, S22MHT, S24MHT, and S25LPN. The staff members referenced above were interviewed regarding training they had received. All of the referenced staff indicated they had received education related to performing patient observations as ordered and accurate completion of patients' Q 15 minute patient observation documentation. All staff further indicated they had been instructed to go in patient rooms if they were asleep/could not be monitored adequately from the hallway in order to check for signs of life. The nursing staff interviewed indicated there was a new monitoring log initiated to document their oversight of the MHTs, every 3 hours, attesting that they had reviewed their observation sheets for correctness/completeness and indicating they had also observed the MHTs performing their patient supervision duties.

On 9/9/19 between 10:00 a.m. and 10:30 a.m. observations were made of staff monitoring patients in the common areas of both Unit A and Unit B.

On 9/9/19 at 8:15 a.m. S1CEO and S4QA presented the first plan for lifting the immediacy of the Immediate Jeopardy situation, and the plan included the following:

1. Staff education prior to the beginning of each shift to be initiated on 9/6/19. The education focus area - completion of every 15 minute patient observation documentation, including going into patient rooms if they were asleep/could not be monitored adequately from the hallway in order to check for signs of life. Staff will be required to sign an attestation upon completion of the referenced education which includes notification of being subject to termination if it was found that every 15 minute patient observations were not being conducted but were documented as such.

2. All nursing staff to be educated on the importance of the observation and completion of Q 3 hour rounding of patients whereby they are observed by the nurse.

3. On 9/6/19 beginning immediately members of the management team will complete monitoring of staff at 2-3 hour intervals beginning on 9/6/19 at 7:00 p.m. and ending on 9/9/19 at 7:00 a.m. The safety officer will review camera footage for compliance with Q 15 minute documentation from 9/6/19 - 9/9/19 for the hours of 1:00 a.m. - 7:00 a.m. Beginning 9/9/19 observations from Monday - Friday will include random times including, but not limited to, 1:00 a.m. - 7:00 a.m. A report of findings will be provided to the management team for disciplinary follow-up.

4. Policy for Q 15 minute observations will be changed to include RN must round every 3 hours, observing every patient.

5. Members of Senior Management Team (CEO, Assistant Administrator, Plant Operations Manager, DON, ADON, and QA/Risk Manager) will be allowed to have access to hospital cameras on their personal devices to allow for observation of staff completing Q15 minute observations. Random monitoring will be conducted via viewing hospital cameras.

6. DON/ADON will conduct random on-site surveillance for completion of correct observations by floor staff.

7. Members of the Senior Management Team will rotate random scheduled weekend onsite monitoring of patient observations Q 15 minutes.

Further review revealed random inspections were begun on 9/6/19 and will continue indefinitely. Random onsite surveillance will begin on 9/13/19 and will continue indefinitely.

Camera review monitoring logs to observe staff supervision of patients every 15 minutes, as ordered, provided by S4QA and S1CEO, for 9/6/19 - 9/9/19, were reviewed.

Documentation of Q 3 hour nursing monitoring logs for Units A and B, begun night shift of 9/6/19 - 9/9/19, provided by S1CEO and S4QA, were reviewed.

Revised policies and procedures referenced in the plan for lifting, provided by S1CEO and S4QA, were reviewed.

Signed staff training attestations acknowledging training related to patient observations as ordered and disciplinary actions up to and including termination for failure to perform patient observations as ordered, provided by S1CEO and S4QA, were reviewed.

Corrective action - suspension (1 day) documentation for S17MHT and S24MHT related to patient observation failures observed during administration team monitoring, provided by S1CEO and S4QA, was reviewed.

Corrective action - termination documentation for S3MHT related to patient observation failures observed during video review by surveyors on 9/6/19 for the night shifts of 5/26/19 and 9/5/19 night, provided by S1CEO and S4QA, was reviewed.

In an interview on 9/9/19 at 8:30 a.m. with S1CEO, he reported all staff had undergone education prior to the beginning of their shift which had been initiated on 9/6/19. He further reported staff was educated on completion of every 15 minute patient observation documentation, including going into patient rooms if they were asleep/could not be monitored adequately from the hallway in order to check for signs of life. He explained staff was required to sign an attestation upon completion of the referenced education and they were informed they were subject to termination if it was found that every 15 minute patient observations were not being conducted but were documented as such. He reported 2 MHTs ( S17MHT and S24MHT) had recevied one day suspensions based upon lapses in patient supervision identified through Administrative staff review of recordings of staff supervision of patients performed from 9/6/19 - 9/9/19. S1CEO also indicated S3MHT was being terminated upon her return to work due to failure to provide patient observations as ordered every 15 minutes and her falsification of documentation of supervision of patients on 5/26/19 - 7:00 p.m. shift and on 9/5/19 - 7:00 p.m. shift.

In an interview on 9/9/19 at 10:00 a.m., the surveyors informed S4QA that the 1st plan for lifting the immediacy of the IJ situation was not accepted due to monitoring addressed in the plan not having a defined frequency.

S4QA presented the second plan for lifting the immediacy of the IJ situation on 9/9/19 at 10:35 a.m. with the following revisions:

6. Documentation of assigned scheduled rotations for members of the Senior Management Team which included weekend on-site visits, conducted at random times, to observe for documentation, observation and 3 hour nurse rounding. Monitoring will occur with the same scheduled rotation indefinitely (CEO > Assistant Administrator > DON>QA/Risk> ADON).

7. DON/ADON will conduct random on-site surveillance for completion of correct observations by floor staff , alternating between 2 or more observations and 3 or more observations per week for a minimum of 4 weeks pending compliance.

Line item 8. was added to the revised plan: Members of Senior Management Team will rotate random scheduled weekend on-site surveillance for approximately 2 hours for monitoring of patient observation completion Q 15 minutes.

In an interview on 9/9/19 at 12:09 p.m. S1CEO and S4QA were informed that the Immediate Jeopardy Plan for lifting the immediacy of the IJ situation was accepted. S1CEO and S4QA were informed that, since there was not enough evidence to determine sustainability of the plan, the Condition of Participation of Patient Rights would remain at the condition level.

Based on record review, observation and interview the hospital failed to ensure patients at risk for harm to self and others were provided care in a safe setting as evidenced by:

1. Failure to ensure direct care staff observed patients every 15 minutes, as ordered by the psychiatrist for 9 sampled patients (Patient #2, Patients #R1- #R8) observed via hospital provided video recordings from a total patient sample of 6 (#1 - #6) and a random patient sample of 9 (#R1-#R9).

2. Failure to ensure the patients admitted for harm to self or others did not have access to contraband items for 2 ( #2, #R9) of 2 sampled patient records reviewed for access to contraband from a total patient sample of 6 ( #1- #6) and a random patient sample of 9 (#1- #9).; and

3. Failure to ensure the patient's physical environment was free from safety risks and did not afford opportunities for self injury and harm to others.

Findings:


1. Failure to ensure patients were monitored as ordered by the psychiatrist:

Review of the hospital policy titled, "Precautions", Policy Number: NSG- 004, last revised: 2/15/16, revealed in part: It is the policy of this hospital to identify those patients who require special precautions and determine adequate actions to alleviate the threat posed by the particular precaution through additional observation, staff communication, room changes, or other process variations. Any changes in patient conditions will be reported to the treatment team. Accurate and complete documentation should be included in the medical record to support the necessity of the precautions.

Precautions: 1. Suicide: A patient with suicidal thoughts, ideas, or plan. ; 2. Assault/Homicide: A patient with a recent history of physically assaulting others or one who has physically assaulted others while a patient at the hospital.
Review of the hospital policy titled, "Patient Observation", Policy Number: PC- 032, last revised: 1/31/19, revealed in part: Purpose: This policy is to ensure staff has guidelines for the monitoring of psychiatric patients via staff observation due to their mental or physical conditions.
Scope: This applies to all nursing staff of this hospital system.
Definitions: 1. Standard precautions: Visual contact is made between staff member and patient at least every 15 minutes. This observation must be documented in real time per visual contact performed.
Procedure: 1. All patients admitted to the hospital are automatically placed on standard observation ( q 15 minute checks), unless deemed necessary for a higher level of precaution by the admitting physician or charge nurse.

Review of the hospital policy titled,"Acute Changes in Patient Conditions", Policy Number: PC-038, last revised: 2/4/19, revealed the following, in part: 5. For psychiatric changes in Patient Conditions, staff should follow the following protocols. A. Make all necessary attempts to secure patient. C. Notify on-call or attending physician as soon as possible. D. Follow orders of practitioner.

Review of Patient #2's medical record revealed the patient was admitted on 5/23/19 and the patient's legal status was PEC on 5/23/19 at 3:56 p.m. due to being violent, dangerous to others, rambling, not making sense, agitated, and delusional with poor impulse control and CEC due to being dangerous to others, gravely disabled, unwilling/unable to seek voluntary admission. The patient had a history of Schizoaffective disorder. The patient was on ordered every 15 minute observations.

An observation was made with S7PlantOps on 9/6/19 at 8:10 a.m. on Unit A of a video recording of the hallway of room 420 to which Patient #2 was assigned on 5/27/19 from 4:07 a.m. - 7:45 a.m. Based on video review the patient had the following lapses in every 15 minute observations:
Patient was not observed via staff rounding beginning at 4:07 a.m. - 5:31 a.m. ( 1 hour and 24 minutes)
From 5:31 a.m. - 6:03 a.m. ( 32 minutes); At 6:03 a.m. S3MHT was observed unlocking the door and carrying 2 bags into Patient #2's room.
From 6:13 a.m. - 6:43 a.m. (30 minutes); At 6:43 a.m. S26MHT was observed walking in the hall where Patient #2's room was located. S26MHT was observed looking into Patient #2's room from the doorway.
From 6:43 a.m.- 7:35 a.m. (52 minutes); At 7:35 a.m. S24MHT was observed going into Patient #2's room. Further observation revealed S24MHT walked out of Patient #2's room, walked down the hallway toward the nurses' station area, and then nursing staff was observed walking down the hallway and entering Patient #2's room.

Review of Patient #2's observation records for the night shift of 5/26/19 - 5/27/19 revealed S3MHT had documented observations of Patient #2 every 15 minutes from 4:07 a.m. - 7:45 a.m. Based on video review S3MHT had actually entered Patient #2's room at 5:31 a.m., 6:03 a.m., and 6:13 a.m.

Review of Patient #2's medical record revealed the patient had been transferred to Hospital "A" for a higher level of care via emergency medical services after having been found cyanotic, with agonal breathing and unresponsive requiring CPR on 5/27/19 at 7:30 a.m.

Review of Patient #2's medical records from Hospital "A" revealed the patient's liver function test results were as follows: ALT (Alanine Transaminase) : 5/27/19: 1487 Units/Liter (Reference range: 13-56 Units/Liter);
AST (Aspartate Transaminase): 1847 Units/Liter (Reference range: 15-37 Units/Liter). Further review of the patient's History and Physical from Hospital "A", dated 5/27/19 at 2:34 p.m., revealed the following, in part: GI: Shock Liver/Transaminitis: Given severe elevation of liver function tests suspect Patient #2 may have had shock/hypotension for many hours prior to presentation.

In an interview on 9/5/19 at 1:37 p.m. with S5Psych, he confirmed Patient #2 had been found in the morning on 5/27/19, with a thready pulse, cyanotic, and was transported immediately to Hospital "A" via emergency medical services.

In an interview on 9/5/19 at 4:17 p.m. with S24MHT, he indicated when the MHTs first come on shift they do a room check. He said his coworkers were doing vitals and he was getting patients up on the morning of 5/27/19. S24MHT reported he had arrived at work at 7:00 a.m. and had found Patient #2 about 7:20 a.m. He reported change of shift is 6:45 a.m. - 7:00 a.m. and he explained there were usually 3 MHTs working. S24MHT indicated the MHTs divided up their duties as follows: 1 MHT does Q15's ( patient rounding), 1 MHT does morning patient vitals , and he, as the 3rd MHT, checks the breakroom, signs the refrigerator log, gets linens from the linen closet and checks patient rooms to make sure patients are awake. S24MHT reported he moves the patients up to the front of the unit for vitals. He reported the patients have their morning meeting, get their breakfast, and have their vitals taken. He said when he first walked in Patient #2 she looked like she was sleeping, with her head facing the window. He indicated he had called Patient #2's name and he realized she wasn't responding. He said he could see she was breathing slower and her eyes were halfway open. S24MHT reported he had gone to tell the nurses to go in and check on her. He indicated the nurses called a Code Blue when they saw the patient and they started CPR.

An observation was made on 9/6/19 at 9:30 a.m. of a video of Unit A from 2:44 a.m. - 6:42 a.m. on 9/6/19 of rooms 416 (2 patients - #R2, #R3); 417 (1 patient- #R4 with altered thought processes); 418 (2 patients - #R5, #R6 - both with altered thought processes and #R6 also had Depression) 419 (2 patients - 1 with homicidal ideations # R7, and 1 with homicidal precautions- #R1) and room 420 (1 patient- #R8 with Suicidal Ideations). All of the patients referenced in these rooms were on ordered every 15 minute observations.

During the observation of the video recording the following lapses in patient observations were noted:
From the beginning of observation at 2:44 a.m. - 6:14 a.m. there was a 2 hours and 30 minute gap between rounds on Room 419.
From 2:44 a.m. - 4:35 a.m. (2 hours and 39 minutes) no observations were made on patients in rooms 416, 417, and 418.
From 4:35 a.m. - 6:11 a.m. (1 hour and 36 minutes): No rounds were performed on rooms 416, 417, 418, 419, and 420.

Review of the observations sheets dated 9/6/19 for the patients in rooms 416, 417, 418, 419 and 420 revealed from 3:15 a.m. - 6:30 a.m. S3MHT documented she had observed all of the patients in the above referenced rooms every 15 minutes.

Review of the video footage on 9/6/19 between 3:15 a.m. and 6:30 a.m. revealed S3MHT was observed on the hallway near rooms 416-420 only once at 6:15 a.m. in contrast to her documentation of every 15 minute rounds.
S7PlantOps assisted surveyors with video footage review on 9/6/19 and was present for the duration of the review of the video footage.

In an interview on 9/6/19 at 7:37 a.m. with S13RN, she confirmed she was working the day shift on Monday (5/27/19) when Patient #2 was sent to the hospital. She said S24MHT came into the kitchen area where they were getting report and said Patient #2 was not looking right at 7:30 a.m. She said she went down there with the night nurse and saw she was having difficulty breathing. She was having agonal breathing with Rhonchi, was cyanotic, and had a slow thready pulse with oxygen saturations in the 60's. S13RN reported they had lost Patient #2's pulse and they had started CPR with chest compressions and provided 100 % oxygen with an ambu bag.

In an interview on 9/6/19 at 8:56 a.m. with S3MHT, she reported she was assigned the back part of the hall on Unit A from 7:00 p.m. - 7:00 a.m. on 5/26/19 and had Rooms 415- 420 which included Patient #2's room ( Patient #2 was in Room 420 A) . S3MHT further reported she is assigned patient phone use and laundry. S3MHT said sometimes from 7:00 p.m. -10:00 p.m. there is a lot of running around and she has to help with other duties. When she was informed there were observed gaps in her performing her patient observations every 15 minutes during video review she reported she could have either had a new admit or she was doing laundry. She indicated she spent a lot of time doing laundry. S3MHT also indicated she has to help with female admits if she is the only female working and then she couldn't perform her Q 15 minute rounds.

In an interview on 9/6/19 at 7:54 a.m. with S12RN, he confirmed he was working the day shift on 5/27/19 when Patient #2 coded (requiring CPR). S12RN reported S24MHT had come in during report and notified them Patient #2 "didn't look good." He said by the time they reached the door he could tell her breathing was labored and she was apneic. S12RN reported the patient's oxygen saturation levels were in 60% 's. He reported the staff had been giving chest compressions and bagging. He yelled down the hall to call a code, call 9-1-1 and get the crash cart. He indicated when they tried to place her on nasal cannula oxygen her oxygen saturations fell. S12RN indicated Patient #2 remained unresponsive and never came to.

In an interview on 9/9/19 at 7:44 a.m. with S25LPN, she confirmed nurses should be rounding every 2-3 hours monitoring the MHTs' Q 15 minute patient observations to ensure they are being done.

In an interview on 9/9/19 at 7:11 a.m. with S15RN, he reported RN's should have been signing off on MHTs' Q 15 minute patient observations.

In an interview on 9/9/19 at 3:47 p.m. with S10RN, she confirmed she was coming off of the night shift on the morning Patient #2 was found. S10RN explained the next morning they were in report and one of the MHTs came in and asked them to come and look at Patient #2 because she wasn't getting up for breakfast and "she didn't look right." S10RN reported Patient #2 was unresponsive. She said as far as she knew the MHTs were rounding, but she did not remember specifically whether she checked the patient's observation sheets to ensure MHTs were observing patients as ordered.

In an interview on 9/6/19 at 1:04 p.m. with S2DON, she confirmed staff should be rounding on the patients every 15 minutes as ordered. S2DON further confirmed staff should have been rounding on the patients (Patients #R1- #R8) as ordered on 9/5/19 - 9/6/19. S2DON reported patient room doors were to be left open and staff should have been "laying eyes" on patients. S2DON indicated staff was expected to observe patients until they see movement and should be looking for signs of any issues with patients. S2DON confirmed each unit has a charge nurse on each shift and they should also be rounding every 3 hours to ensure the patients' Q 15 minute observations were being done as ordered. S2DON confirmed she had not been aware Patient #2 had not been observed for 52 minutes prior to being found in her room unresponsive. S2DON explained MHTs on the nightshift washed clothing and also assisted with admissions in addition to providing patient supervision. S2DON further explained if a MHT has to perform any other duties they should have handed off their assigned patients to another MHT. S2DON confirmed the staff member who is actually watching the patients is the only staff member who should be signing off on the patient's observation sheets.


2. Failure to ensure patients did not have access to contraband

Review of the hospital policy titled "Contraband", Policy number: PC-042, last revised 1/31/19, revealed in part: 1. Contraband shall be defined and controlled according to applicable state laws, rules regulation, and SHS (Seaside Health System) policies and procedures. The most restrictive definition shall prevail...5. Contraband list: a. The following is a list of items that are considered contraband. They are prohibited from being brought into SHS (Seaside Health System) by staff or patients. They may not be sent in packages or brought into the facility by any visitors.
i. Any intoxicating beverage that causes or may cause intoxication effects.
ii. Any controlled substances..
iv. Any property of the state or SHS (Seaside Health System) in a person's possession which was obtained without proper authorization and approval from the person(s) responsible for the safekeeping of that property...
The facility has also designated the following items as contraband, but certain circumstances may permit access under supervision of staff or as part of a therapeutic activity...vi. Poisonous liquids vii. Bottles and glass.

Review of the hospital policy titled," Intake Assessment and Treatment", Policy number: PC-024, last revised 2/4/19, revealed in part: Intake/Admission: A Mental Health Technician will conduct a security assessment and inventory of the patient's belongings. This security assessment will identify any items of contraband found on the patient, as well as the patient's belongings.

Review of the hospital policy titled, "Visitor Contraband Search", Policy number: SEC-010, last revised 4/5/18, revealed in part: Purpose: The purpose of this policy is to thoroughly check visitors, packages, purses, and clothing to ensure a contraband free environment. Policy: It is the policy of this hospital that visitors and their possessions will be searched if it is suspected that contraband is in their possession. Procedure: 1. All packages, luggage, etcetera will be searched before being given to a patient. 2. All purses, briefcases, electronic devices, backpacks, etcetera are requested to be locked in the visitor's vehicle. 3. If a visitor is suspected of having contraband in his/her clothing, staff reserves the right to request the visitor empty his/her pockets to ensure that no contraband is present. 4. If a visitor refuses to cooperate with the searches and/or if staff performing the search feels the visitor still has contraband on him/her, that visitor may be denied access to the patient and asked to leave the premises.

Review of the hospital policy titled," Pre-Admission Search for Weapons", Policy Number: SEC-015, last revised 4/7/19, revealed in part: Policy: It is the policy of this hospital that all patients will be searched prior to admission. Procedure: 1. Upon admission, a safety search will be completed. 2. Two persons complete the search of the person. 3. The search is a two- step process: A. "Patting down" the patient for any obvious weapons or contraband and turning out pockets; check any open cigarette packs for contraband and B. Using hand-held metal detector, screening the whole person from head to toe. The patient will remove their shoes during this procedure and their soles will be checked.

Review of the hospital policy titled, "Contraband", Policy Number: PC-042, last revised 1/31/19, revealed in part: It is the policy of this hospital that staff shall ensure the strict control of contraband and unauthorized use of permitted items to provide a safe and secure environment for patients, staff, and visitors.
Procedure: Contraband List: A. The following is a list of items that are considered contraband. They are prohibited from being brought into the hospital by staff or patients. They may not be sent in packages or brought into the facility by any visitors. B. i. Any intoxicating beverages that causes or may cause intoxicating effects. ii. Any controlled substances.

Patient #2
Review of Patient #2's medical record revealed the patient was admitted on 5/23/19 after having been in jail for 1 - 2 weeks for being aggressive toward a police officer. Further review revealed the patient had a history of Schizoaffective disorder. Patient #2's legal status was PEC on 5/23/19 at 3:56 p.m. due to being violent, dangerous to others, rambling, not making sense, agitated, and delusional with poor impulse control and CEC due to being dangerous to others, gravely disabled, and unwilling/unable to seek voluntary admission.

Review of Patient #2's admission orders to the inpatient psychiatric hospital, dated 5/23/19, revealed an order for a Urine Drug Screen.

Review of Patient #2's lab results revealed a urine drug screen had been collected on 5/24/19 5:00 a.m. and reported on 5/24/19 8:00 a.m. Further review revealed the drug screen had been negative for Ecstasy, Amphetamines, Barbiturates, Benzodiazepines, THC Cannabinoid, Cocaine, Opiates, Methadone, and Propoxyphene (Darvon).

Review of Patient #2's toxicology screen (conducted on the first tube of blood collected from Patient #2 at Hospital "A", upon admission, after having been transported to the hospital via emergency medical services on the morning of 5/27/19) revealed the following:
The Toxicology Analysis performed via High Performance Liquid Chromatography/Tandem Mass Spectrometry revealed the following positive results:
Compound: Ketamine; Positive Findings: Result: Ketamine: Unit: 1100 ng/mL; Reportable limit: 40 ng/mL; Matrix Source: Hospital blood;
Compound: Norketamine: Positive Findings: Result: Norketamine: Unit: 810 ng/mL; Reportable limit: 40 ng/mL; Matrix Source: Hospital blood;
Compound: 11-Hydroxy Delta- 9 THC: Positive Findings: Result: Unit: 2.1 ng/mL; Reportable limit: 1.0 ng/mL; Matrix Source: Hospital blood;
Compound: Delta- 9 Carboxy THC (handwritten notation beside this finding was "within 1 day"): Positive Findings: Result: Unit: 50 ng/mL; Reportable limit: 5 ng/mL; Matrix Source: Hospital blood; and
Compound: Delta- 9 THC: Findings: Result: Positive; Reportable limit: 0.5 ng/mL; Matrix Source: Hospital blood; unable to quantitate due to interfering substance.

Review of Patient #2's medication administration record at the inpatient psychiatric hospital revealed no documented evidence that the patient had received Ketamine during her hospital stay, prior to being transported to Hospital "A" via emergency medical services.

Review of Patient #2's "run record" from the emergency medical services company that transported the patient to Hospital "A" on 5/27/19 revealed no documented evidence that the patient had been administered Ketamine.

Review of Patient #2's medical record from Hospital "A" revealed no documented evidence that the patient had been administered Ketamine at any time during her hospital stay.

In an interview on 9/5/19 at 1:37 p.m. with S5Psych, he indicated Patient #2 had been found unresponsive on 5/27/19 and had been sent to Hospital "A" for a higher level of care. He reported he had received a call from the Coroner and the Coroner had asked him about Ketamine. S5Psych reported he thought emergency medical service providers used Ketamine. He indicated S8Coroner had informed him Patient #2's toxicology screen had been positive for Ketamine and the patient had died from anoxic brain injury from Ketamine overdose. S5Psych reported the inpatient psychiatric hospital did not use or stock Ketamine for treating patients. He stated when the patient was found unresponsive that she may have been under the influence of Ketamine. He explained Marijuana can stay in system for a while. S5Psych confirmed Patient #2 was negative for marijuana on her urine drug screen collected on 5/24/19 at 5:00 a.m.

In an interview on 9/5/19 at 1:40 p.m. with S1CEO, he indicated he confirmed the routine urine drug screens used by the hospital did not screen for Ketamine. He said he and S4QA had talked about other visitors and someone bringing in contraband as possible scenarios for Ketamine being brought into the hospital. S1CEO indicated they don't perform random contraband searches. S1CEO confirmed they don't do contraband searches on the patients after their visitors had left. S1CEO acknowledged occasionally contraband gets into the hospital.

A telephone interview was conducted on 9/9/19 at 10:00 a.m. with S9Invest from the Coroner's office. S8Coroner was also present during telephone interview. S9Invest reported Patient #2 had been found unresponsive at the psychiatric hospital and had been transported to Hospital "A" on 5/27/19. S9Invest reported Patient #2 "was high when she was taken to Hospital "A" and was THC positive." S9Invest reported the first tube of blood collected from Patient #2 at Hospital "A" had tested positive for THC and Ketamine. S9Invest indicated THC can be laced with Ketamine. S9Invest indicated the Delta - 9 THC findings were from very recent use because if the use had been 5-8 days before the blood testing the metabolite should have cleared. S9Invest explained the Coroner had interviewed the Medical Director for the Emergency Medical Service that transported the patient, the medical staff at Hospital "A", and S5Psych (from the inpatient psychiatric hospital) and none of them had administered Ketamine to the patient. S5Psych had also confirmed the inpatient psychiatric hospital did not keep Ketamine on the premises and did not use Ketamine in patient treatment.

An observation was conducted on 9/9/19 at 10:30 a.m. of Unit A and B's medication room. No Ketamine was observed in the hospital's medication rooms.

A phone interview was conducted with S23Pharm on 9/9/19 at 11:45 a.m. She reported her pharmacy (Pharmacy Company "B") provides the medications for the hospital. She further reported Pharmacy Company "B" does not stock Ketamine and has not supplied Ketamine to the hospital.


Patient #R9
Review of patient #R9's medical record revealed an admission date of 5/18/19 with admission diagnoses including Opioid abuse disorder, Opioid dependence, Major Depressive Disorder, and Anxiety disorder. The patient's legal status was formal voluntary status.

Review of Patient #R9's admit orders revealed on 5/18/19 at 01:25 a.m. the patient was admitted to inpatient psychiatric hospital revealed the patient was on ordered Subutex for Opiate Detox Level III.

Review of a facility provided incident report dated 5/23/19 at 11:00 a.m. revealed Patient #R9 was brought to his room and searched after another patient reported Patient #R9 had been handing out pills to peers. Further review revealed the patient reporting the incident had given staff the pill Patient #R9 had given to him. A white powdery substance, wrapped in plastic, was found in Patient #R9's sock. Patient #R9 came to the nursing station and said it was Subutex and he wanted it back. S6MD notified. Will continue to monitor, following discovery. All patients were searched and entire unit was searched for possible contraband. No additional pills were found on patients or in rooms.

Further review revealed the corrective action taken was to conduct unit sweep, noting possible contraband locations, monitor abnormal behaviors, or vitals. Notify physician if any abnormalities present.

Review of Patient #R9's medical record revealed the following Psychiatric Progress note, dated 5/23/19: Per staff Patient #R9 had white powder in sock, presumed to be crushed medication and was seen giving it to other patients also. He strongly denies giving to other patients. Says he was "saving up" "his prescribed medications to use when he needed it but he doesn't know what medication it is.

In an interview on 9/5/19 at 4:17 p.m. with S24MHT, he indicated when they 1st come on shift they do a room check. He reported they check for contraband 2 times a day. He indicated he grabs any contraband such as hygiene cups and trash. S24MHT further indicated after visitation they check the patients' skin for new cuts or sores and if any new places are seen, they check to see if patients had anything to cut themselves with. S24MHT said most of the time they find out about patients having contraband items by word of mouth from other patients. S24MHT reported he had to take down an irate patient in July of this year (2019). He said the patient was trying to throw a chair through the window and they took him down. He said the patient had "MoJo" and he said he thinks the patient had gotten the "MoJo" during visitation, but he couldn't remember the patient's name. He indicated patients may have someone hand off contraband items to them during visitation. He explained a friend may come to visit and they hand it off to patients at that time. S24MHT reported if the patients willingly give up contraband items the staff doesn't always write it up.

In an interview on 9/9/19 at 11:00 a.m. with S4QA, he reported Patient #R9 had been "cheeking" his medications and had saved them in the plastic bag that the plastic silverware had been packaged in. S4QA confirmed the hospital had not increased the frequency of contraband searches after this incident. He further confirmed the hospital still had not increased the frequency of contraband searches after becoming aware of Patient #2's overdose on Ketamine.

In an interview on 9/9/19 at 12:53 p.m. with S1CEO and S4QA they confirmed contraband checks were not performed after patient visitation unless triggered by erratic behavior/behavior changes of patients and/or visitors.

In an interview on 9/9/19 at 3:17 p.m. with S6MD, he reported he is a Medical Doctor and an Addictionologist. He indicated he remembered Patient #2 and that she had been found unresponsive and been transported out to an acute care hospital. S6MD further reported he had heard, per hearsay, that the Coroner had found Ketamine in Patient #2's system. S6MD confirmed Ketamine is not stocked at this hospital and is not used for treating patients in the inpatient psychiatric hospital. S6MD said he just does not know where Patient #2 could have gotten the Ketamine. S6MD said he would suggest someone do a gas chromatography on Patient #2's blood. S6MD reported drug metabolites in blood go away faster and they stay in urine for 2-3 days. S6MD confirmed they perform urine drug screens at this hospital and not via blood sampling. S6MD reported patients could sometimes hide drugs in places they can't search. He said in the past 5 years he has seen where patients smuggled in medication twice and shared it with other patients. He indicated one of the two times was here at this hospital.

3. Failure to ensure the patient's physical environment was free from safety risk

An observation was conducted on 9/6/19 at 11:30 a.m. of Hallway B on Unit B. Hallway B was directly behind the nurses station. The nurses and staff were unable to directly visualize the hallway from the nurse's station. A set of double doors separated the end portion of Hallway B from the rest of the hallway. Directly after passing through the double doors there were two patient rooms: 102 and 101. The door next to the patients' rooms was a staff conference room and directly in front of staff conference room was a exit door (the hallway ended at the conference room). The double doors and the exit door on Hallway B had elbow hinge closures at top of the doorways that protruded about 5 inches that were a ligature risk.

Review of the nurse's notes for Patient #4 on 7/13/19 revealed in part, "1605 Pt found by staff with sheet tied a round her neck and sheet tied to the top of the exit door in the hallway. Pt was standing up and no pressure was applied. Pt tearful but refusing to talk.."

Review of the Incident/Summary/Investigation report dated 7/13/19 at 4:00 p.m. for Patient #4 revealed the following in part, Type of event: suicide attempt. At approximately 4:00 p.m., patient was seen on camera attempting to place a sheet on the door closure exiting the building. Other part of sheet was tied to her neck... Corrective actions: 1. Patient placed on 1:1 observation and provided suicide blanket (individual) 2. Investigate withholding family visit/phone calls (individual) 3. Investigate with plant operations possible removal of door closure on exiting door (organizational).

An observation was conducted on 9/06/19 at 11:30 a.m. of Unit B, Hallway B with S4QA. The exit door at the end of Hallway B of Unit B was observed to continue to have the elbow hinge closure at the top of the doorway.

An interview was conducted with S4QA on 9/06/19 at 11:30 a.m. He reported staff found Patient #4 attempting to hang self with a sheet on the closure device on top of the exit door of Hallway B/Unit B. Patient #4 was assigned to room 102 on Hallway B. He further reported the staff saw the patient on the camera at the nurse's station attempting to hang self. S4QA stated there are cameras that video the back hallway of Unit B and the video is streaming to the monitors at the nurses' station. When questioned if there was someone assigned to watch the cameras continuously, he stated no. No further action was taken by the facility to mitigate the ligature risk.



30984

Based on record review, observation, and interview, the hospital failed to ensure the hospital wide QAPI program set priorities aimed at performance improvement activities that focused on high risk, high volume, or problem prone areas that affected health outcomes, patient safety, and quality of care. This deficient practice was evidenced by failure of the hospital's QAPI program to perform a thorough investigation related to lapses in Patient #2's Q 15 minute observations prior to being found unresponsive, cyanotic and with agonal breathing.

Findings:

Patient #2
Review of Patient #2's medical record revealed the patient was admitted on 5/23/19 after having been in jail for 1 - 2 weeks for being aggressive toward a police officer. Further review revealed the patient had a history of Schizoaffective disorder.

An observation was made on 9/6/19 at 8:10 a.m. on Unit A of a video recording of the hallway of room 420 to which Patient #2 was assigned on 5/27/19 from 4:07 a.m. - 7:45 a.m. Based on video review the patient had the following lapses in ordered 15 minute observations:
Patient was not observed via staff rounding from 4:07 a.m. - 5:31 a.m. (1 hour and 24 minutes)
From 5:31 a.m. - 6:03 a.m. (32 minutes); At 6:03 a.m. S3MHT was observed unlocking the door and carrying 2 bags into Patient #2's room.
From 6:13 a.m. - 6:43 a.m.: (30 minutes); At 6:43 a.m. S26MHT was observed walking in the hall where Patient #2's room was located. S26MHT was observed looking into Patient #2's room from the doorway.
From 6:43 a.m.- 7:35 a.m. (52 minutes); At 7:35 a.m. S24MHT was observed going into Patient #2's room. Further observation revealed S24MHT walked out of Patient #2's room, walked down the hallway toward the nurses' station area, and then nursing staff was observed walking down the hallway and entering Patient #2's room.

Patient was not observed via staff rounding beginning at 4:07 a.m. - 5:31 a.m. (1 hour and 24 minutes);
From 5:31 a.m. - 6:03 a.m. (32 minutes);
From 6:13 a.m. - 6:43 a.m. (30 minutes);
From 6:43 a.m.- 7:35 a.m. (52 minutes);

Review of Patient #2's observation records for the night shift of 5/26/19 - 5/27/19 revealed S3MHT had documented observations of Patient #2 every 15 minutes from 4:07 a.m. - 7:45 a.m. Based on video review S3MHT was only seen entering Patient #2's room at 5:31 a.m., 6:03 a.m., and 6:13 a.m. No nursing staff was observed rounding on Patient #2 during the referenced time frame.

Review of a hospital provided Investigation Report revealed the investigation had been conducted to evaluate staff Code Blue Response when Patient #2 had required resuscitation on 5/27/19. Further review revealed the summary of investigation included vital sign assessments, staff emergency response to Code Blue being called, CPR performance, and patient status based on MHT staff observation prior to shift change/after shift change, and interviews with 2 MHTs (S24MHT from day crew and S26MHT from night crew). S3MHT who had been assigned to Patient #2 had not been included in the interviews. Further review revealed no documented evidence of nursing staff interviews.

Review of the Mortality Review documentation, dated 6/12/19, presented by S4QA, revealed the section of the document containing a question referring to "were there any omissions or commissions in the managment of this case that may have affected the outcome" was answered, "No omissions or commissions were made in the care of this patient." Further review revealed no documented evidence completion of every 15 minute observations, as ordered, had been reviewed as part of the Mortality Review.

In an interview on 9/9/19 at 3:00 p.m. with S4QA, he explained the investigation had been based upon staff response to a Code Blue and was not focused on lapses in patient Q 15 minute observations.

In an interview on 9/9/19 at 3:47 p.m. with S10RN, she confirmed she had worked the night shift of 5/26/19. S10RN reported the surveyor was the first person who talked to her about finding Patient #2 down. S10RN confirmed no one questioned her about it. S10RN further reported she didn't think anyone had ever asked S11LPN anything about finding Patient #2 either.

Based on record observation, record review, and interview, the hospital failed to ensure the requirements of the Condition of Participation of Nursing Services were met as evidenced by:

Failure of the RN to supervise direct care staff to ensure patients at risk for harm to self and others were observed every 15 minutes, as ordered by the psychiatrist, for 9 sampled patients (Patient #2, Patients #R1- #R8) observed via hospital provided video recordings from a total patient sample of 6 (#1 - #6) and a random patient sample of 9 (#R1-#R9). (See findings in tag A-0395)

Based on record observation, record review, and interview, the RN failed to supervise the care of patients. This deficient practice was evidenced by:
1. failure of the RN to ensure direct care staff observed patients at risk for harm to self and others every 15 minutes, as ordered by the psychiatrist, for 9 sampled patients (Patient #2, Patients #R1 - #R8) observed via hospital provided video recordings from a total patient sample of 6 (#1 - #6) and a random patient sample of 9 (#R1 - #R9).; and

2. failure to ensure a patient (#2) with orders for one hour of seclusion was either placed in seclusion as ordered or orders were obtained to cancel the orders for seclusion if the patient's behavior indicated seclusion was no longer needed for 1 (#2) of 1 sampled patient records reviewed for restraint/seclusion from a total patient sample of 6 (#1- #6).

Findings:

1. Failure of the RN failed to ensure direct care staff observed patients at risk for harm to self and others every 15 minutes, as ordered by the psychiatrist:

Review of the hospital policy titled, "Precautions", Policy Number: NSG- 004, last revised: 2/15/16, revealed in part: It is the policy of this hospital to identify those patients who require special precautions an determine adequate actions to alleviate the threat posed by the particular precaution through additional observation, staff communication, room changes, or other process variations. Any changes in patient conditions will be reported to the treatment team. Accurate and complete documentation should be included in the medical record to support the necessity of the precautions. Precautions: 1. Suicide: A patient with suicidal thoughts, ideas, or plan.; 2. Assault/Homicide: A patient with a recent history of physically assaulting others or one who has physically assaulted others while a patient at the hospital.

Review of the hospital policy titled, "Patient Observation", Policy Number: PC- 032, last revised: 1/31/19, revealed in part: Purpose: This policy is to ensure staff has guidelines for the monitoring of psychiatric patients via staff observation due to their mental or physical conditions.
Scope: This applies to all nursing staff of this hospital system.
Definitions: 1. Standard precautions: Visual contact is made between staff member and patient at least every 15 minutes. This observation must be documented in real time per visual contact performed.
Procedure: 1. All patients admitted to the hospital are automatically placed on standard observation (Q 15 minute checks), unless deemed necessary for a higher level of precaution by the admitting physician or charge nurse.

Review of Patient #2's medical record revealed the patient was admitted on 5/23/19 and the patient's legal status was PEC on 5/23/19 at 3:56 p.m. due to being violent, dangerous to others, rambling, not making sense, agitated, and delusional with poor impulse control and CEC due to being dangerous to others gravely disabled, unwilling/unable to seek voluntary admission. The patient had a history of Schizoaffective disorder. The patient was on ordered every 15 minute observations.

An observation was made on 9/6/19 at 8:10 a.m. on Unit A of a video recording of the hallway of room 420 to which Patient #2 was assigned on 5/27/19 from 4:07 a.m. - 7:45 a.m. Based on video review the patient had the following lapses in ordered 15 minute observations:
Patient was not observed via staff rounding from 4:07 a.m. - 5:31 a.m. (1 hour and 24 minutes)
From 5:31 a.m. - 6:03 a.m. (32 minutes); At 6:03 a.m. S3MHT was observed unlocking the door and carrying 2 bags into Patient #2's room.
From 6:13 a.m. - 6:43 a.m.: (30 minutes); At 6:43 a.m. S26MHT was observed walking in the hall where Patient #2's room was located. S26MHT was observed looking into Patient #2's room from the doorway.
From 6:43 a.m.- 7:35 a.m. (52 minutes); At 7:35 a.m. S24MHT was observed going into Patient #2's room. Further observation revealed S24MHT walked out of Patient #2's room, walked down the hallway toward the nurses' station area; and then nursing staff was observed walking down the hallway and entering Patient #2's room.

Review of Patient #2's observation records for the night shift of 5/26/19 - 5/27/19 revealed S3MHT had documented observations of Patient #2 every 15 minutes from 4:07 a.m. - 7:45 a.m. Based on video review S3MHT was only seen entering Patient #2's room at 5:31 a.m., 6:03 a.m., and 6:13 a.m.

Review of Patient #2's medical record revealed the patient had been transferred to Hospital "A" for a higher level of care, via emergency medical services, after having been found cyanotic, with agonal breathing and unresponsive, requiring CPR on 5/27/19 at 7:35 a.m.

Review of Patient #2's medical records from Hospital "A" revealed the patient's liver function test results were as follows: ALT (Alanine Transaminase) : 5/27/19: 1487 Units/Liter (Reference range: 13-56 Units/Liter);
AST (Aspartate Transaminase): 1847 Units/Liter (Reference range: 15-37 Units/Liter).

Further review of Patient #2's History and Physical from Hospital "A", dated 5/27/19 at 2:34 p.m., revealed the following, in part: GI: Shock Liver/Transaminitis: Given severe elevation of liver function tests suspect Patient #2 may have had shock/hypotension for many hours prior to presentation.

In an interview on 9/5/19 at 4:17 p.m. with S24MHT, he indicated when the MHTs first come on shift they do a room check. He reported change of shift is 6:45 a.m. - 7:00 a.m. He said his coworkers were doing vitals and he was getting patients up on the morning of 5/27/19. S24MHT reported he had arrived at work at 7:00 a.m. and had found Patient #2 about 7:20 a.m. He said when he first walked in Patient #2 had looked like she was sleeping, with her head facing the window. He indicated he had called Patient #2's name and he realized she wasn't responding. He said he could see she was breathing slower and her eyes were halfway open. S24MHT reported he had gone to tell the nurses to go in and check on her. He indicated the nurses called a Code Blue when they saw the patient and they started CPR.

In an interview on 9/6/19 at 7:37 a.m. with S13RN, she confirmed she was working the day shift on Monday (5/27/19) when Patient #2 was sent to the hospital. She said S24MHT came into the kitchen area where they were getting report and said Patient #2 "was not looking right" at 7:30 a.m. She said she went down there with the night nurse and saw she was having difficulty breathing. She was having agonal breathing with Rhonchi, was cyanotic, and had a slow thready pulse with oxygen saturations in the 60's. S13RN reported they had lost Patient #2's pulse and they had started CPR with chest compressions and provided 100 % oxygen with an ambu bag.

In an interview on 9/6/19 at 8:56 a.m. with S3MHT, she reported she was assigned the back part of the hall on Unit A and had Rooms 415- 420 (Patient #2 was in Room 420 - A, the bed closest to the door). S3MHT further reported she is assigned patient phone use and laundry. S3MHT said sometimes from 7:00 p.m. -10:00 p.m. there is a lot of running around and she has to help with other duties. When she was informed there were observed gaps in her performing her patient observations every 15 minutes during video review she reported she could have either had a new admit or she was doing laundry. She indicated she spent a lot of time doing laundry. S3MHT also indicated she has to help with female admits if she is the only female working and then she couldn't perform her Q 15 minute rounds.

In an interview on 9/6/19 at 7:54 a.m. with S12RN, he confirmed he was working the day shift on 5/27/19 when Patient #2 coded. S12RN reported S24MHT had come in during report and notified them Patient #2 "didn't look good." He said by the time they reached the door he could tell her breathing was labored and she was apneic. S12RN reported the patient's oxygen saturation levels were in 60%'s. He reported the staff had been giving chest compressions and bagging. He yelled down the hall to call a code, call 9-1-1 and get the crash cart. He indicated when they tried to place her on nasal cannula oxygen her oxygen saturations fell. S12RN indicated Patient #2 remained unresponsive and never came to.

In an interview on 9/9/19 at 3:47 p.m. with S10RN, she confirmed she was coming off of the night shift on the morning Patient #2 was found unresponsive. She said as far as she knew the MHTs were rounding, but she did not remember specifically whether she checked the patient's observation sheets to ensure MHTs were observing patients as ordered.

An observation was made on 9/6/19 at 9:30 a.m. of a video of Unit A from 2:44 a.m. - 6:42 a.m. on 9/6/19 of rooms 416 (2 patients - #R2, #R3); 417 (1 patient - #R4 with altered thought processes); 418 (2 patients - #R5, #R6 - both with altered thought processes and #R6 also had Depression) 419 (2 patients - 1 with homicidal ideations #R7, and 1 with homicidal precautions - #R1) and room 420 (1 patient - #R8 with Suicidal Ideations). All of the patients referenced in these rooms were on ordered every 15 minute observations.

During the observation of the video recording the following lapses in patient observations were noted:
From the beginning of observation at 2:44 a.m. - 6:14 a.m. there was a 2 hours and 30 minute gap between rounds on Room 419.
From 2:44 a.m. - 4:35 a.m. (2 hours and 39 minutes) no observations were made on patients in rooms 416, 417, and 418.
From 4:35 a.m. - 6:11 a.m. (1 hour and 36 minutes): No rounds were performed on rooms 416, 417, 418, 419, and 420.
Review of the observations sheets dated 9/6/19 for the patients in rooms 416, 417, 418, 419 and 420 revealed from 3:15 a.m. - 6:30 a.m. S3MHT documented she had observed all of the patients in the above referenced rooms every 15 minutes.
Review of the video footage on 9/6/19 between 3:15 a.m. and 6:30 a.m. revealed S3MHT was observed on the hallway near rooms 416-420 only once at 6:15 a.m. in contrast to her documentation of every 15 minute rounds.
RN staff was not observed rounding on the patients during the referenced time frames.
S7PlantOps assisted surveyors with video footage review on 9/6/19 and was present for the duration of the review of the video footage.

In an interview on 9/9/19 at 7:44 a.m. with S25LPN, she confirmed nurses should be rounding every 2-3 hours monitoring the MHTs' Q 15 minute patient observations to ensure they are being done.

In an interview on 9/9/19 at 7:11 a.m. with S15RN, he reported RN's should have been signing off on MHTs' Q 15 minute patient observations. S15RN did not specify the frequency of RNs signing off on the MHTs' Q 15 minute patient observations during the interview.

In an interview on 9/6/19 at 1:04 p.m. with S2DON, she confirmed staff should be rounding on the patients every 15 minutes as ordered. S2DON further confirmed staff should have been rounding on the patients (Patients #R1 - #R8) as ordered on 9/5/19 - 9/6/19. S2DON reported patient room doors were to be left open and staff should have been "laying eyes" on patients. S2DON indicated staff was expected to observe patients until they see movement and should be looking for signs of any issues with patients. S2DON confirmed each unit has a charge nurse on each shift and they should also be rounding every 3 hours to ensure the patients' Q 15 minute observations were being done as ordered. S2DON confirmed she had not been aware Patient #2 had not been observed for 52 minutes prior to being found in her room unresponsive. S2DON explained MHTs on the nightshift washed clothing and also assisted with admissions in addition to providing patient supervision. S2DON further explained if a MHT has to perform any other duties they should have handed off their assigned patients to another MHT. S2DON confirmed the staff member who is actually watching the patients is the only staff member who should be signing off on the patient's observation sheets.

2. Failure to ensure a patient (#2) with orders for one hour of seclusion was either placed in seclusion as ordered or orders were obtained to cancel the orders for seclusion if the patient's behavior indicated seclusion was no longer needed

Review of the hospital policy titled, "Acute Changes in Patient Conditions", Policy Number: PC-038, last revised: 2/4/19, revealed the following, in part: 5. For psychiatric changes in patient conditions, staff should follow the following protocols. A. Make all necessary attempts to secure patient. C. Notify on-call or attending physician as soon as possible. D. Follow orders of practitioner.

Review of Patient #2's medical record revealed the patient was admitted 5/23/19 at 5:05 p.m. with an admission diagnosis of Schizoaffective Disorder.

Review of Patient #2's physician's orders revealed the following orders:
5/24/19 at 11:15 a.m.: Haldol 5 mg IM, Benadryl 50 mg IM, Ativan 2 mg IM 1 hour seclusion ordered.;

5/24/19 at 5:00 p.m.: Zyprexa Zydis 15 mg SL now, Benadryl 50 mg po now after Zyprexa Zydis and 1 hour seclusion ordered.; and

5/25/19 3:26 p.m.: Ativan 2mg IM x 1, Haldol 5 mg IM and 50 Mg Benadryl IM with an order for 1 hour seclusion for extreme agitation, extreme psychosis, and EPS.

Review of Patient #2's entire medical record revealed no documentation indicating Patient #2 had been placed in seclusion as ordered in the above referenced orders.

Further review of Patient #2's physician's orders revealed no documented evidence the orders for seclusion had been discontinued/cancelled.

In an interview on 9/5/19 at 1:00 p.m. with S4QA, he explained, after review of Patient #2's medical record, that the patient may have just been in seclusion room for low stimulus then may have calmed down and had not required locked seclusion, only low stimulus, so perhaps that is why the seclusion packet and vital signs were not completed for each ordered seclusion. S4QA indicated S5Psych should have been called for an order each time a patient was placed in restraint/seclusion.

In an interview on 9/5/19 at 1:50 p.m. with S2DON, she confirmed, after review of Patient #2's entire medical record, that there was no documentation that Patient #2 had been placed in seclusion as ordered in the above referenced orders. S2DON further confirmed an order should have been obtained to cancel the orders for seclusion of the patient's condition no longer warranted being placed in locked seclusion for behavioral control.