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Based on policy review, closed medical record review, behavioral health contact sheet review, staff interview, staffing schedule review and personnel file review, the hospital failed to ensure 1 of 4 sampled registered nurses was qualified and trained to meet the needs of patients that presented to the hospital's behavioral health emergency department (RN #1).

The findings include:

Review of current hospital policy entitled "Orientation Program, RN & LPN (registered nurse and licensed practical nurse): Nursing Services" dated 01/2006 revealed, "...An orientation checklist is completed during the orientation period indicating competency of the new employee to perform job responsibilities. Competency assessment is required before the new employee independently performs job responsibilities....The preceptor and Unit Manager will evaluate the readiness of the new employee to begin his/her regular schedule....The Unit Manager maintains the orientation checklist with department records at the completion of orientation...."

Review of current hospital policy entitled "Duty To Protect Or Warn, Policy CA-6" dated 01/2010 revealed the organizational group of physicians, nurses and therapists will "exercise best professional judgement to protect the lives and physical safely of our patients and of any known potential victims of possible imminent violence....When, during the course of an assessment or therapy, a professional learns that there is a clear and imminent reasonable foreseeable danger of harm by a patient to a known specific victim, including another staff member, the therapist should: A. attempt to dissuade the patient; B. consider alternative therapeutic measures such as hospitalization; C. consult with the Department Head and, if appropriate, notify the police and intended victim; and D. clearly document all such incidents and notify Administration and Risk Management."

Closed medical record review for Patient #7 revealed a 33 year old male that presented to the hospital's behavioral health emergency department (ED) on 02/28/2010 at 1806 with a complaint of "Depressed...fighting with his wife". Record review revealed the patient documented the reason he came to the ED on an "Emergency Department Patient Information" form when he arrived at the ED. Review of the patient's documentation on the form revealed, "Im feeling depressed and I feel like hurting someone or myself. Ive been fighting with my spouse a lot and words that she said to me that have made me angry. I want to talk to someone about my mental status." Review of the triage nurse's note on 02/28/2010 at 1828 revealed the patient stated his complaint was "Feeling depressed and is going through a divorce from his wife. He has his 10 year old child here with him and states he doesn't have anyone that (to) come and watch her while he is being assessed. He states he has a lot of pent up anger and in the past he has had homicidal ideation. He denies current suicidal/homicidal ideations or auditory/visual hallucinations". Further review of the triage nurse's risk assessment revealed the patient "Has a rifle and a 45" (access to firearms/weapons). Review of the ED Detailed Assessment Form revealed documentation of RN #1's nursing assessment of the patient. Review of RN #1's assessment note revealed, "presents with request of 'I need some help'.... new to area and 'wants to get into the system'....Reports history of depression and denies current suicidal/homicidal ideations and auditory or visual hallucinations." Further review of RN #1's assessment note revealed the patient had access to firearms that were "locked up". Review of the Mental Status Examination completed by the ED physician (a psychiatrist) on 02/28/2010 revealed the patient's mood and affect was "somewhat depressed" with his insight and judgement "impaired". Review of the physician's documentation revealed the patient voluntarily requested treatment for depression and a chronically volatile relationship with his wife that included verbal and physical conflict from both of them. Further review of the physician's documentation revealed the patient had no suicidal or homicidal ideations. Record review revealed the patient was discharged to home at 2002 with prescriptions for the following medications: Citalopram (antidepressant medication) 20 milligrams daily and Buspirone (antianxiety medication) 10 milligrams twice a day for 2 weeks. Record review revealed the patient was instructed to call the behavioral health clinic the next day to schedule an appointment for follow up as an outpatient.

Further closed medical record review for Patient #7 revealed the patient presented to the hospital's behavioral health emergency department again on 03/16/2010 at 0215 with a complaint of "wanting to hurt his wife". Review of documentation by the patient on the hospital's "Emergency Department Patient Information" form at the time of his second presentation to the hospital revealed the patient documented his reason for coming to the ED as "Harm somebody". Review of the patient's documentation on the form also revealed the patient expected "help" and "Therapy" from the visit to the hospital. Review of RN#1's triage assessment note at 0243 revealed the patient was triaged as "urgent". Further review of RN #1's triage assessment note revealed, "When patient first arrived he told the registrar that he wanted 'to kill my wife'. After search and in triage he denies that he wants to kill her but 'I'm tired of the BS.'" Review of the triage form revealed "diagnoses (Active)...Homicidal Thoughts". Documentation in the risk assessment section of the triage form revealed the patient denied homicidal ideations and had access to firearms/weapons, with the details documented as "Have safety locks on them". Review of the triage assessment documentation revealed documentation the patient had visual hallucinations. Review of the triage form revealed, "I see shadows of people every day but I don't ever hear any voices." Review of the ED Detailed Assessment Form revealed documentation of RN #1's nursing assessment of the patient. Review of RN #1's assessment note revealed the patient had sad mood with thought processes coherent, logical goal directed with orientation to person, place, day/time and situation. Review of the reason for visit on the assessment form revealed, "I want to kill my wife." Further review of the RN #1's notes revealed, "Later during triage he denies it, but stated he was tired of her BS. Reports that they were arguing this evening. Reports he was here 2 weeks ago and meds are helping some. Denies suicidal ideations, auditory hallucinations. Admits to visual hallucinations, 'I see shadows of people everyday'." Review of documentation under the risk assessment section for (Danger to Others) revealed "Homicidal Ideations...NO...was earlier." Review of ED physician's (a psychiatrist) documentation on 03/16/2010 at 0445 revealed the patient's mood and affect was euphoric, mild to moderate, with judgment decreased but adequate. Review of the ED physician's notes revealed the patient "Reported homicidal ideations to coordinator earlier, now denying saying 'I just had to get out.' Here in 02/2009 (incorrect, hospital visit was 02/2010) for same....therapy initiating soon. Has spoken of marital therapy and now will pursue this. Endorses capacity to refrain from harm to self and others." Review of the ED physician's notes revealed the diagnosis for the patient was "Depression NOS (Not Otherwise Specified)." Record review revealed the patient's condition at discharge was documented as "stable, home by self with discharge instructions to keep other appointments with an increase in Buspar (no dosage documented)." Record review revealed the patient was discharged to home on 03/16/2010 at 0535. Review of nursing documentation revealed, "Home instructions discussed. Questions and concerns addressed. Discharged to home self-care." Record review revealed no documentation that the nurse or physician notified the patient's wife or the police of the patient's threats to harm his wife.

Review of the hospital's behavioral health contact sheet dated 03/30/2010 at 1830 revealed a request by a government agency for the release of Patient #7's medical record. Review of the contact sheet revealed the representative called the hospital regarding a "high profile situation" and stated that the patient after discharge "killed his wife and himself". Interview with the hospital's administrative staff on 04/14/2010 at 1530 revealed the patient had killed his wife and children at an unknown time after discharge. Interview revealed the hospital declared the event as a sentinel event and were investigating the visits that the patient made to the hospital's behavioral health ED.

Interview with RN #1 on 04/14/2010 at 1429 revealed the nurse did not remember the patient. The interview revealed, as the nurse reviewed her charting in the patient record, the patient had weapons locked up at home as noted during both visits. In reference to the 03/16/2010 visit, while reading her notes, the nurse in the interview revealed the patient denied homicidal ideations to her after previously admitting to them to the registration person. Interview revealed the nurse did not talk or discuss any details with the registration person that heard the comments. Interview revealed the nurse remembered no other information about the patient's treatment on 02/28/2010 or 03/16/2010. Interview revealed the nurse did not notify the patient's wife or the police of the patient's threats to harm his wife. Further interview revealed the nurse started working at the behavioral health hospital in early February 2010. Interview revealed the nurse was no longer on orientation, but she was not sure whether or not she was still on orientation on 03/16/2010.

Review of staffing schedules revealed RN #1 worked on the night of 02/28/2010 under the supervision of a preceptor. Review revealed RN #1 independently staffed (without the supervision of a preceptor) on the night of 03/15/2010 (until 0700 on 03/16/2010).

Review of RN #1's personnel file on 04/15/2010 revealed the nurse began working at the hospital on 02/01/2010 (one and a half months before Patient #7 was discharged to home on 03/16/2010). File review revealed an "Orientation Schedule and Preceptor Guidelines" form that included a checklist for the training expectations and competency validations of the nurse. Review of the checklist revealed a column for "Preceptor Signature" and "Date" beside each competency to be validated or policy to be reviewed. Review of the checklist revealed the following policy reviews were signed by the preceptor and dated 03/27/2010 (11 days after RN #1 independently staffed on the night of 03/15/2010): Breathalyzer, Glucometer, Pulse Oximetry, Vital Signs and Precaution Levels. Review of the checklist revealed the following competency validations were signed by the preceptor and dated 03/27/2010 (11 days after RN #1 independently staffed on the night of 03/15/2010): Admission Assessment, Elopement (Assessment), Falls (Assessment), Preparing/administration (Medications) and Storage and security (Medications). Further personnel file review revealed, "I have reviewed and completed the above checklist. I understand that I am now considered to have completed orientation and have a basic knowledge of the job expectations as described in the job description and as reviewed in the above checklist. Employee (followed by blank - not signed) Date (followed by blank - not dated)...Manager signs off (followed by the manager's signature) Dated (followed by 4/14/10 - one month after RN #1 independently staffed on the night of 03/15/2010)." Further personnel file review revealed no documented evidence that RN #1 had reviewed the hospital's "Duty To Protect Or Warn" policy.

Interview on 04/15/2010 at 1510 with administrative nursing staff confirmed RN #1 was not on orientation on 03/16/2009 when she staffed in the hospital's behavioral health ED. Interview revealed the nurse had finished orientation but her competency sheet had not been completed. Interview revealed, "Her competency sheet was found yesterday in the house supervisor's box of things to do." Interview confirmed the competency sheet should have been completed and the nurse should have signed the checklist at the end of her orientation.


NC00063419