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Based on interview and record review, the facility failed the Condition of Participation for Governing Body was met as as evidenced by:

1. For one (1) of 34 sampled patient, Patient 1 had mental behavior changes of auditory (related to hearing) hallucination (an experience involving the apparent perception of something not present) in the emergency department (ED) after admission and was not reassessed utilizing facility's Behavioral Health Assessment (BHA - a mental health assessment used to gain an accurate picture of a patient's emotional and psychological state to help determine their need for treatment), the Columbia-Suicide Severity Rating Scale (C-SSRS, a suicide screening tool involving a set of simple questions to assess the severity and immediacy of suicide risk), and the Patient Health Questionnaire 4 (PHQ-4 -an ultra-brief screening scale used for detecting core signs and symptoms of anxiety and depressive disorders). (Refer to A - 0063).

2. Ensure 1 of 34 sampled patients (Patient 1), who had an Emergency Department (ED) physician order for continuous Telemetry monitoring (heart/cardiac monitor, monitoring of a patient's heart activity while automatically transmitting information to a central monitor), was continuously connected to the Telemetry monitor, and ED staffs did not respond/address the critical alarms (patient alarms that could result in harm if that alarm response were delayed) of Patient 1's heart monitor. (Refer to A - 0091).

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation for Governing Body. Patient 1, who was depressed, was found with a cord wrapped around his neck. Patient 1's heart monitor was not connected to Patient 1 for unknown amount of time, and Patient 1 was pronounced dead 4 hours and 25 minutes after ED admission.

Based on interview and record review, the facility's governing body failed to ensure facility had a policy and procedure for registered nurses in the Emergency Department (ED) to reassessed one (1) of 34 sampled patient (Patient 1) utilizing facility's Behavioral Health Assessment (BHA - a mental health assessment used to gain an accurate picture of a patient's emotional and psychological state to help determine their need for treatment), the Columbia-Suicide Severity Rating Scale (C-SSRS, a suicide screening tool involving a set of simple questions to assess the severity and immediacy of suicide risk), and the Patient Health Questionnaire 4 (PHQ-4 -an ultra-brief screening scale used for detecting core signs and symptoms of anxiety and depressive disorders). Patient 1 had mental behavior changes of auditory (related to hearing) hallucination (an experience involving the apparent perception of something not present) in the ED after admission and was not reassessed using the BHA, C-SSRS, and PHQ-4.

This deficient practices resulted in Patient 1, who was depressed on admission, was found with a cord wrapped around his neck and committed suicide. The facility was not able to revive. Patient 1 was pronounced dead 4 hours and 25 minutes after admission.Findings:

Findings:

A review of Patient 1's admission information (Face sheet) indicated Patient 1 was admitted, on 10/16/2022 at 19:58 (7:58 p.m.).

A review of Patient 1's "ED (Emergency Department) Provider Notes," dated 10/16/2022 at 8:00 p.m., indicated Patient 1 presented to the ED for evaluation of chest pain and shortness of breath that started 1 hour prior to arrival. Patient 1 has history of hypertension (high blood pressure), diabetes (a disease that occurs when your blood sugar is too high), smoking, and illicit drug use. Patient 1 also stated he was feeling, "Depressed."

A review of Patient 1's Patient Care Timeline, dated 10/16/2022 to 19:56 [7:59 p.m.] to 10/17/2022 02:36 [2:36 a.m.], indicated the following, on 10/16/2022 at 20:07 (8:07 p.m.) indicated Patient 1's C-SSRS did not indicate suicide risk. Patient 1's PHQ-4 (PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression) scored zero (0).

A review of Patient 1's Patient Care Timeline, dated 10/16/2022 at 7:59 p.m. to 10/17/2022 at 2:36 a.m., indicated on 10/16/2022 at 8:15 p.m., Patient 1's Behavioral Health Assessment (BHA - a mental health assessment used to gain an accurate picture of a patient's emotional and psychological state to help determine their need for treatment) under current safety status indicated the following findings:
1. Self-injury behavior: No.
2. Violence to other: No.
3. Elopement (run away secretly) risk: No.
4. Thoughts of Suicide: No.

A review of Patient 1's Patient Care Timeline, dated 10/16/2022 at 7:59 p.m. to 10/17/2022 at 2:36 a.m., indicated on 10/16/2022 at 8:15 p.m., Patient 1's Behavioral Health Assessment (BHA - a mental health assessment used to gain an accurate picture of a patient's emotional and psychological state to help determine their need for treatment) under mental status exam the following:
1. Cooperation was within define limit (WDL, normal status).
2. Orientation was WDL.
3. Thought process was WDL.
4. Insight/Judgement was WDL.
5. Interaction with peer and staff was WDL.

A review of Patient 1's Patient Care Timeline, dated 10/16/2022 at 7:59 p.m. to 10/17/2022 at 2:36 a.m., indicated the only documented assessment for C-SSRS and PHQ-4 was on 10/16/2022 at 8:07 p.m. Patient 1's BHA was only assessed on 10/16/2022 at 8:15 p.m.

A review of Patient 1's Patient Care Timeline, dated 10/16/2022 at 7:59 p.m. to 10/17/2022 at 2:36 a.m., indicated on 10/16/2022 at 20:07 (8:07 p.m.) brief assessment was conducted for neurological assessment, Airway/Breathing/Circulation (ABCs), and skin assessment with results as WDL. Patient 1 was also screen for immunization status for COVID - 19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus).

A review of Patient 1's Vital Signs (clinical measurements of pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) record indicated the following:

1. On 10/16/2022 at 23:00 (11:00 p.m.) blood pressure was, "120/93," (A normal blood pressure level is less than 120/80 millimeters of mercury (mmHg, unit of measurement). Patient 1's heart rate was, "123" (A normal resting heart rate for adults ranges from 60 to 100 beats per minute). Patient 1's respiratory rate was, "24" (A normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute).

2. On 10/16/2022 at 23:30 (11:30 p.m.) indicated Patient 1's blood pressure was, "87/26," heart rate was, "122", and respiratory rate was, 24."

3. On 10/16/2022 at 23:40 (11:40 p.m.), indicated Patient 1's heart rate was, "117." The record indicated no blood pressure and no respiratory rate.

A review of Patient 1's Patient Care Timeline, dated 10/16/2022 at 7:59 p.m. to 10/17/2022 at 2:36 a.m., indicated on 10/16/2022 at 20:15 (8:15 p.m.) Patient 1 was place on cardiac monitor, and on 10/16/2022 at 20:17 (8:17 p.m.) Patient 1 had a physician order for continuous Telemetry - Cardiac Telemetry and drug screen. Patient 1's urine drug screen resulted at 00:06 (12:06 a.m.) indicated positive for amphetamine (stimulant drugs, which means they speed up the messages traveling between the brain and the body).

A review of Patient 1's Patient Care Timeline, dated 10/16/2022 at 7:59 p.m. to 10/17/2022 at 2:36 a.m., indicated at 00:11 (12:11 a.m.), under ED Quick Note (nursing note) the following:

1. Medical Doctor 1 (MD 1) found Patient 1, "Bend over behind gurney (emergency room bed) with lamp cord wrapped around neck and assisted to the ground."

2. "Cord unwrapped from neck and assisted to ground."

3. "Pulse checked, no pulse."

4. "CPR (Cardiopulmonary Resuscitation, an emergency life-saving procedure performed when the heart stops beating) immediately started."

A review of Patient 1's Code (an adult having a medical emergency, usually cardiac or respiratory arrest) Summary report indicated, Patient 1's Code ended on 10/17/2022 at 00:25 (12:25 a.m.) with the time of death (TOD) also on 10/17/2022 at 00:25 (12:25 a.m.)

On 10/19/2022, at 2:50 p.m., during an interview with EDD and concurrent record review of Patient 1's "Patient Care Timeline (10/16/2022 19:56 [7:56 p.m.] to 10/17/2022 02:36 [2:26 a.m.])," EDD stated the facility policy and procedure indicated the used of C-SSRS, PHQ-4, and BHA for patients presenting with a behavioral health behaviors as chief complaint in the ED. EDD stated the facility does not have a policy and procedure specific for RNs to utilized the C-SSRS, PHQ-4, and BHA to reassess patients in the ED. The EDD stated RNs were expected to complete assessments and reassessments of ED patients' physical and mental health status at the beginning of their shift, at hand off to another RN, before transfer or discharge of the patient, and when a patient has a change of condition (a decline or improvement in a resident's mental, psychosocial, or physical functioning that requires a change in the resident's comprehensive plan of care).

On 10/23/2022, at 7:14 p.m., during an interview with the emergency department assistant nurse manager (ANM), ANM stated a BHA is not a major assessment for a patient whose chief complaint is not related to behavioral health. ANM stated an assessment or reassessment was triggered when patients present with changes in psychiatric (mental illness) presentations.

On 10/23/2022, at 8:19 p.m., during an interview with RN 3 and concurrent review of facility's admission and triage process for patients via Epic (an electronic health record software system used by the facility), RN 3 stated a behavioral health chief compliant will trigger an RN to perform a BHA. However, RN 3 was not aware of a facility policy or requirement for RNs to screen for behavioral health and perform a CSSR-S, PHQ-4, or BHA for all other patients.

A review of the facility's policy and procedure for Standard Procedure for Emergency Department Triage RN, revised date 06/2022, indicated facility's standard procedures included assessment for abdominal pain, chest pain, respiratory distress, fever in adult, pediatric (child) fever, extremity deformity for trauma with pain, and severe pain. The policy did not indicate standard procedure for utilizing assessment for the Patient Health Questionnaire 4 (PHQ-4 -an ultra-brief screening scale used for detecting core signs and symptoms of anxiety and depressive disorders), and Behavioral Health Assessment (BHA - a mental health assessment used to gain an accurate picture of a patient's emotional and psychological state to help determine their need for treatment).

A review of the facility's policy and procedure for Suicide Risk Assessment and Prevention, revised date 10/2022, indicated the policy and procedure serves as a foundation for caregivers to screen and assess for acute risk of self-harm or suicide and take necessary steps to protect the patient. The facility utilizes the Columbia Suicide Severity Rating Scale (C-SSRS) Screener Tool. The tool was applicable for all ages and populations. The policy and procedure under, "E. Imminent Risk Assessment/Re-Assessment," indicate, "Once initial C-SSRS Risk Assessment Tool was completed, any change in resource required will be reported to the physician. Document suicide risk level and monitoring plan in the medical record."

Based on interview and record review, the facility Governing Body failed to ensure 1 of 34 sampled patients (Patient 1), who had an Emergency Department (ED) physician order for continuous Telemetry monitoring (heart/cardiac monitor, monitoring of a patient's heart activity while automatically transmitting information to a central monitor), was continuously connected to the Telemetry monitor, and ED staffs did not respond/address the critical alarms (patient alarms that could result in harm if that alarm response were delayed) of Patient 1's heart monitor.

This deficient practice resulted to licensed nursing staffs in the ED failing to response to Patient 1's telemetry monitoring alarms. Patient 1 was off the telemetry monitor for unknown amount of time. Patient 1 was found with a cord wrapped around his neck, and the facility was not able to revive. Patient 1 was pronounced dead on 4 hours and 25 minutes after admission.

Findings:

A review of Patient 1's admission information (Face sheet) indicated Patient 1 was admitted, on 10/16/2022 at 19:58 (7:58 p.m.).

A review of Patient 1's fire department report, date 10/16/2022 at 19:11 (7:11 p.m.), indicated under narrative that Patient 1 was found sitting complaining of chest pain, substernal (below the sternum/chest) radiating to right arm. Patient 1 described the pain as pressure. Patient 1 complained of shortness of breath and was transported to the hospital ED.

A review of Patient 1's "ED (Emergency Department) Provider Notes," dated 10/16/2022 at 8:00 p.m., indicated Patient 1 presented to the ED for evaluation of chest pain and shortness of breath that started 1 hour prior to arrival. Patient 1 has history of hypertension (high blood pressure), diabetes (a disease that occurs when your blood sugar is too high), smoking, and illicit drug use.

A review of Patient 1's Vital Signs (clinical measurements of pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) record indicated the following:

1. On 10/16/2022 at 23:00 (11:00 p.m.) blood pressure was, "120/93." A normal blood pressure level is less than 120/80 millimeters of mercury (mmHg, unit of measurement). Patient 1's heart rate was, "123" (A normal resting heart rate for adults ranges from 60 to 100 beats per minute). Patient 1's respiratory rate was, "24" (A normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute).

2. On 10/16/2022 at 23:30 (11:30 p.m.) indicated Patient 1's blood pressure was, "87/26," heart rate was, "122", and respiratory rate was, 24."

3.. On 10/16/2022 at 23:40 (11:40 p.m.), indicated Patient 1's heart rate was, "117." The record indicated no blood pressure and no respiratory rate.

A review of Patient 1's Patient Care Timeline, dated 10/16/2022 at 7:59 p.m. to 10/17/2022 at 2:36 a.m., indicated on 10/16/2022 at 20:15 (8:15 p.m.) Patient 1 was place on cardiac monitor, and on 10/16/2022 at 20:17 (8:17 p.m.) Patient 1 had a physician order for continuous Telemetry - Cardiac Telemetry and drug screen. Patient 1's urine drug screen resulted at 00:06 (12:06 a.m.) indicated positive for amphetamine (stimulant drugs, which means they speed up the messages traveling between the brain and the body).

A review of Patient 1's Patient Care Timeline, dated 10/16/2022 at 7:59 p.m. to 10/17/2022 at 2:36 a.m., indicated at 00:11 (12:11 a.m.), under ED Quick Note (nursing note) the following:

1. Medical Doctor 1 (MD 1) found Patient 1, "Bend over behind gurney (emergency bed) with lamp cord wrapped around neck and assisted to the ground."

2. "Cord unwrapped from neck and assisted to ground."

3. "Pulse checked, no pulse."

4. "CPR (Cardiopulmonary Resuscitation, an emergency life-saving procedure performed when the heart stops beating) immediately started."

A review of Patient 1's Code (an adult having a medical emergency, usually cardiac or respiratory arrest) Summary report indicated, Patient 1's Code ended at 00:25 (12:25 a.m.) with the time of death (TOD) also on 10/17/2022 at 00:25 (12:25 a.m.)

On 10/19/2022 at 2:50 p.m., during an interview, the EDD stated Patient 1 was brought in via ambulance due to chest pain. Patient 1 had orders to be on continuous cardiac telemetry (a heart monitor that continuously monitor a patient's heart activity). On 10/17/22 at 00:11 a.m. (12:11 a.m.), Patient 1 was found by MD 1 (Medical Doctor 1) behind the gurney in a kneeling position, unresponsive, with a cord around neck. Patient 1 was detached from his heart monitor. The EDD stated when a patient has been detached from the heart monitor an auditory alarm is triggered to alert staff of a medical emergency. The EDD stated the RN assigned to the patient on heart monitor was responsible to monitor his assigned patient and should respond to alarm triggered by the heart monitor.

On 10/19/2022, at 2:50 p.m., during an interview, the EDD stated RN 1, who was assigned to Patient 1, was with another patient in a different room starting an intravenous line (a small, short plastic catheter that is placed through the skin into a vein, used to give fluids and medications to your body) prior to patient being found by MD 1. The EDD stated patients on telemetry monitoring were continuously monitored by the nursing staffs to ensure patients were connected to the monitor and alarms were responded/addressed. RN 1 failed to monitor Patient 1's telemetry continuously. EDD stated during facility's investigation, the facility had identified that RN 1 failed to respond to Patient 1's heart monitor alarms.

On 10/20/2022 at 8:53 a.m., during an interview, RN 1 stated he was the assigned nurse for Patient 1, who was admitted for chest pain, on 10/16/22. Patient was placed on continuous telemetry monitoring. Patient was found by MD 1 in a kneeling position, unresponsive with a cord around neck. Patient 1's cardiac monitor was detached. Patient was laid to the floor and staff immediately started CPR. CPR was not successful. Patient 1 was pronounced dead by MD 1 on 10/17/2022 at 00:11 a.m. (actual documented date and time: 10/17/2022 at 12: 25 a.m.). Patient 1 telemetry reading were reflected on the monitors available at bedside and central monitor outside in the hallway. All staff nurses must keep an eye on monitor for any heart irregularities and alarms. Telemetry monitor device would trigger an alarm for change in heart rhythm or when detached/not connected to a patient. Patient 1 was found disconnected from his telemetry monitor. RN 1 stated he cannot remember when Patient 1's telemetry monitor had triggered to alarm. RN 1 stated any nurses sitting in the workstation next to the telemetry central monitor in the hallway was responsible to monitor patients' telemetry. RN 1 stated he was being unsure if there was staff monitoring Patient 1 from the central monitor in the hallway. RN 1 stated Patient 1 was not continuously monitored and was not sure how long the patient was off telemetry monitoring. RN 1 stated the ED had no Monitor Technicians (staff who observe heartbeats and electrocardiograms to assist with the interpretation and diagnosis of conditions related to the heart).

On 10/20/2022 at 12:47 p.m., during an interview, MD 1 stated he found Patient 1 on his knee at the head of bed. MD 1 stated Patient 1 found with cord around neck. Patient 1 was cyanotic (a bluish or purplish discoloration of the skin and mucous membranes due to deficient oxygenation of the blood) and unresponsive, and CPR initiated on the floor. CPR was performed on Patient 1 for 15 minutes but was unsuccessful. MD 1 stated Patient 1 was pronounced dead on 11/17/2022 at 12:25 a.m. MD 1 stated Patient 1 had an ordered to be on continuous telemetry monitoring, and Patient 1's telemetry monitor alarms were not heard by ED staffs.

A review of facility policy and procedure for Clinical Alarms, revised date 04/2021, indicated clinical alarm systems - "Patient care device or monitoring equipment with an alarm including, but not limited to, physiological monitors (cardiac telemetry, BP, and pulse oximetry [a test used to measure the oxygen level ]) ...going directly to or coming from the patient." The policy and procedure indicated, critical alarms such as patient alarms or patient equipment alarms, "Would result in harm if the response were delayed," and "Critical alarms will be audible to staff with respect to distance and competing noise." The policy and procedure indicated the alarms were monitored by the nurses and/or monitor technician (staff trained to monitor cardiac rhythm) if applicable.

Based on interview and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as as evidenced by failing to:

1. Ensure 1 of 34 sampled patients (Patient 1) was reassessed and reevaluated using facility's Behavioral Health Assessment (BHA - a mental health assessment used to gain an accurate picture of a patient's emotional and psychological state [related to the mental and emotional state of a person] to help determine their need for treatment) after Patient 1 exhibited mental behavior changes of auditory (related to hearing) hallucination (an experience involving the apparent perception of something not present). (Refer to A - 395)

2. Ensure 1 of 34 sampled patients (Patient 1), who had an Emergency Department (ED) physician order for continuous Telemetry monitoring (heart/cardiac monitor, monitoring of a patient's heart activity while automatically transmitting information to a central monitor), was continuously connected to the Telemetry monitor, and ED staffs did not respond/address the critical alarms (patient alarms that could result in harm if that alarm response were delayed) of Patient 1's heart monitor. (Refer to A - 395).

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation: Nursing Services. Patient 1, who was depressed, was found with a cord wrapped around his neck. Patient 1's heart monitor was not connected to Patient 1 for unknown amount of time, and Patient 1 was pronounced dead 4 hours and 25 minutes after ED admission.

Based on interview and record review, the facility failed to:

1. Ensure 1 of 34 sampled patients (Patient 1) was reassessed and reevaluated using facility's Behavioral Health Assessment (BHA - a mental health assessment used to gain an accurate picture of a patient's emotional and psychological state [related to the mental and emotional state of a person] to help determine their need for treatment) after Patient 1 exhibited mental behavior changes of auditory (related to hearing) hallucination (an experience involving the apparent perception of something not present).

2. Ensure 1 of 34 sampled patients (Patient 1), who had an Emergency Department (ED) physician order for continuous Telemetry monitoring (heart/cardiac monitor, monitoring of a patient's heart activity while automatically transmitting information to a central monitor), was continuously connected to the Telemetry monitor, and ED staffs did not respond/address the critical alarms (patient alarms that could result in harm if that alarm response were delayed) of Patient 1's cardiac monitor.

This deficient practices resulted in Patient 1, who was depressed on admission, was found with a cord wrapped around his neck and committed suicide. Patient 1 was found not connected to Telemetry monitoring. The facility was not able to revive. Patient 1 and was pronounced dead 4 hours and 25 minutes after admission.

On 10/22/2022 at 4:25 p.m., an Immediate Jeopardy (IJ - a situation I which the facility's noncompliance with one or more requirements caused, or was likely to cause serious injury, harm, impairment, or death to a patient) situation was called in the presence of the Executive Director of Quality and Risk (EDQ), Patient Safety Program Manager, Risk and Quality Improvement associate, Chief Nursing Officer (CNO), Emergency Department Director (EDD) and Chief Executive Officer (CEO). The facility failed to ensure Patient 1's care and treatment in the ED included an assessment and reassessment for acute psychiatric symptoms. This deficient practice resulted in Patient 1 committing suicide in the ED while awaiting medical clearance.

On 10/23/2022 at 9:03 p.m., during an onsite visit, the IJ was removed in the presence of the facility's Executive Director of Quality and Risk and CEO via phone plus Emergency Department Director after the hospital submitted an acceptable IJ removal plan (an intervention to correct the deficiency practice) and the surveyors validated the hospital's IJ removal plan through observation, interview, and limited record review.

The acceptable action plan was as follows:
1. Facility provided evidence of increased volume on all central station monitoring systems to ensure alarms were sufficiently audible to staff with respect to distances and competing noise within the ED.
2. Facility provided evidence of staff and physicians re-education regarding the Clinical Alarms policy, this includes the importance of responding to the alarms and ensuring appropriate action.
3. Facility provided plan to ensure patient safety by creating an audit tool to capture rounding was done by Charge Nurse to ensure audibility of cardiac (heart) monitors. Rounding results will be reviewed at the ED unit-based council, Quality Committee, and Emergency Department medical staff committee.
4. Facility provided evidence of staff re-education regarding the completion of the BHA, the Patient Health Questionnaire 4 (PHQ 4, an ultra brief screening scale used for detecting core signs and symptoms of anxiety and depressive disorders), and the Columbia Suicide Severity Rating Scale (C-SSRS, a suicide screening tool involving a set of simple questions to assess the severity and immediacy of suicide risk) ) tools. The re-education includes ensuring that a reassessment was completed when patient exhibits a change in condition or behavior that in accordance with safe practices. Any change noted will be communicated to the physician and such communication will be documented in the patient's chart.
5. Facility provided plan to ensure patient safety by creating an audit tool that will be completed on at least 30 patient charts per months to ensure that appropriate assessments and reassessments were conducted. Results of this audit will be reviewed at the ED unit-based council, quality committee, and the emergency department medical staff committee.
6. Facility provided evidence that the Psychiatric (mental illness) Emergencies in the Emergency Department policy has been updated to include BHA. BHA tool will be utilized for any observed or expressed change in behaviors. This policy will go through a fast-tracked approval process via the Clinical Policy Committee, Emergency Department, Medical Executive Committee, and Governing Board.

Findings:

1. A review of Patient 1's admission information (Face sheet) indicated Patient 1 was admitted, on 10/16/2022 at 19:58 (7:58 p.m.).

A review of Patient 1's "ED (Emergency Department) Provider Notes," dated 10/16/2022 8:00 p.m., indicated Patient 1 presented to the ED for evaluation of chest pain and shortness of breath that started 1 hour prior to arrival. Patient 1 has history of hypertension (high blood pressure), diabetes (a disease that occurs when your blood sugar is too high), smoking, and illicit drug use. Patient 1 also stated he was feeling, "Depressed."

A review of Patient 1's Patient Care Timeline, dated 10/16/2022 to 19:56 [7:59 p.m.] to 10/17/2022 02:36 [2:36 a.m.], indicated the following, on 10/16/2022 at 20:07 (8:07 p.m.) indicated Patient 1's C-SSRS did not indicate suicide risk. Patient 1's PHQ-4 (PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression) scored zero (0).

A review of Patient 1's Patient Care Timeline, dated 10/16/2022 at 7:59 p.m. to 10/17/2022 at 2:36 a.m., indicated on 10/16/2022 at 8:15 p.m., Patient 1's BHA under current safety status indicated the following findings:
1. Self-injury behavior: No.
2. Violence to other: No.
3. Elopement (run away secretly) risk: No.
4. Thoughts of Suicide: No.

A review of Patient 1's Patient Care Timeline, dated 10/16/2022 at 7:59 p.m. to 10/17/2022 at 2:36 a.m., indicated on 10/16/2022 at 8:15 p.m., Patient 1's BHA under mental status exam the following:
1. Cooperation was within define limit (WDL, normal status).
2. Orientation was WDL.
3. Thought process was WDL.
4. Insight/Judgement was WDL.
5. Interaction with peer and staff was WDL.

A review of Patient 1's Patient Care Timeline, dated 10/16/2022 at 7:59 p.m. to 10/17/2022 at 2:36 a.m., indicated the only documented assessment for C-SSRS and PHQ-4 was on 10/16/2022 at 8:07 p.m. Patient 1's BHA was only assessed on 10/16/2022 at 8:15 p.m.

A review of Patient 1's Patient Care Timeline, dated 10/16/2022 at 7:59 p.m. to 10/17/2022 at 2:36 a.m., indicated on 10/16/2022 at 20:07 (8:07 p.m.) brief assessment was conducted for neurological assessment, Airway/Breathing/Circulation (ABCs), and skin assessment with results as WDL. Patient 1 was also screen for immunization status for COVID - 19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus).

A review of Patient 1's Vital Signs (clinical measurements of pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) record indicated the following:

1. On 10/16/2022 at 23:00 (11:00 p.m.) blood pressure was, "120/93," (A normal blood pressure level is less than 120/80 millimeters of mercury (mmHg, unit of measurement). Patient 1's heart rate was, "123" (A normal resting heart rate for adults ranges from 60 to 100 beats per minute). Patient 1's respiratory rate was, "24" (A normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute).

2. On 10/16/2022 at 23:30 (11:30 p.m.) indicated Patient 1's blood pressure was, "87/26," heart rate was, "122", and respiratory rate was, 24."

3. On 10/16/2022 at 23:40 (11:40 p.m.), indicated Patient 1's heart rate was, "117." The record indicated no blood pressure and no respiratory rate.

A review of Patient 1's Patient Care Timeline, dated 10/16/2022 at 7:59 p.m. to 10/17/2022 at 2:36 a.m., indicated on 10/16/2022 at 20:15 (8:15 p.m.) Patient 1 was place on cardiac monitor, and on 10/16/2022 at 20:17 (8:17 p.m.) Patient 1 had a physician order for continuous Telemetry - Cardiac Telemetry and drug screen. Patient 1's urine drug screen resulted at 00:06 (12:06 a.m.) indicated positive for amphetamine (stimulant drugs, which means they speed up the messages traveling between the brain and the body).

A review of Patient 1's Patient Care Timeline, dated 10/16/2022 at 7:59 p.m. to 10/17/2022 at 2:36 a.m., indicated at 00:11 (12:11 a.m.), under ED Quick Note (nursing note) the following:

1. Medical Doctor 1 (MD 1) found Patient 1, "Bend over behind gurney (emergency bed) with lamp cord wrapped around neck and assisted to the ground."

2. "Cord unwrapped from neck and assisted to ground."

3. "Pulse checked, no pulse."

4. "CPR (Cardiopulmonary Resuscitation, an emergency life-saving procedure performed when the heart stops beating) immediately started."

A review of Patient 1's Code (an adult having a medical emergency, usually cardiac or respiratory arrest) Summary report indicated, Patient 1's Code ended at 00:25 (12:25 a.m.) with the time of death (TOD) also on 10/17/2022 at 00:25 (12:25 a.m.)

On 10/19/2022, at 2:50 p.m., during an interview with the Emergency Department Director (EDD) and concurrent record review of Patient 1's "Patient Care Timeline (10/16/2022 19:56 [7:56 p.m.] to 10/17/2022 02:36 [2:36 a.m.])," EDD stated the facility policy used the C-SSRS, PHQ-4, and BHA for patients presenting with a behavioral health behaviors as chief complaint in the ED.

On 10/19/2022, at 2:50 p.m., during an interview, the EDD stated the facility does not have a policy specific to behavioral health when to reassessment for registered nurses (RN's) to perform CSSR-S, PHQ-4, BHA assessments during triage and bedding process (an ED patient has been assigned a bed). The EDD stated RNs were expected to complete assessments and reassessments of ED patients' physical and mental health status at the beginning of their shift, at hand off to another RN, before transfer or discharge of the patient, and when a patient has a change of condition (a decline or improvement in a resident's mental, psychosocial, or physical functioning that requires a change in the resident's comprehensive plan of care).

On 10/19/2022, at 2:50 p.m., during an interview with the EDD and record review of Patient 1's BHA and Patient Care Timeline, the EDD stated RN 1 completed the BHA tool on Patient 1, on 10/16/22 at 8:15 p.m. The EDD stated Patient 1's BHA tool indicated WDL (within define limit).

On 10/19/2022, at 2:50 p.m., during a concurrent interview with the EDD and record review of Patient 1's Patient Care Timeline, the EDD indicated RN 1 noted the following:

1. On 10/16/22 at 8:15 p.m., Patient 1 stated, "Not sure of hearing voices,"
2. On 10/16/22 at 9:13 p.m., the EDD verified the record indicated Patient 1 stated, "Hearing people, hearing rumor that he rob a bank."
3. On 10/16/22 at 11:33 p.m., Patient 1 stated "Heard people talking about him."
4. On 10/16/22 at 11:40 p.m., Patient 1's last monitored vital signs (heart rate was 117, no blood pressure and no respiratory rate record) were prior to code blue (hospital code used to indicate a patient requiring immediate resuscitation).
5. On 10/17/22 at 00:11 a.m. MD 1 found patient bent over behind gurney (emergency bed) with lamp cord wrapped around the neck.

A review of Patient 1's Code (an adult is having a medical emergency, usually cardiac or respiratory arrest) Summary report indicated on 10/17/2022 at 00:14 (12:14 a.m.), a code was started and ended at 00:25 (12:25 a.m.) after MD 1 found Patient 1 with the cord wrapped around the neck.

On 10/19/2022, at 2:50 p.m., during an interview with the EDD, the EDD stated Patient 1 showed signs of auditory hallucination (on 10/16/22 at 9:13 p.m.). The EDD stated RN 1 should have re-assessed Patient 1 using BHA tool. The EDD stated BHA was a behavioral health assessment done to all patient with behavioral history, complaint, or symptoms.

On 10/20/2022, at 8:25 a.m., during an interview with RN 1 (Patient 1's ED nurse) and concurrent record review of Patient 1's "Patient Care Timeline (10/16/2022 19:56 [7:56 p.m.] to 10/17/2022 02:36 [2:36 a.m.])," RN 1 stated, BHA screening was conducted for all assigned patients. RN 1 stated Patient 1's BHA screening/assessment and "ED Quick Note," were done on 10/16/2022 at 20:15 (8:15) p.m. RN 1 stated RN 1's routine admission assessment to all patients assigned under his care was to do a BHA and ED Quick Note. RN 1 stated that was not the facility norm (standard procedure) for the ED staffs (RN's). RN 1 stated a BHA was generally performed on a patient with behavioral or psychiatric chief complaint upon arrival to the ED.

On 10/23/2022, at 7:14 p.m., during an interview with the ED Assistant Nurse Manager (ANM), the ANM stated a BHA was not an assessment for a patient with chief complaint that was not related to behavioral health. The ANM stated an assessment or reassessment was triggered when patient present with changes in psychiatric (relating to mental illness) health conditions. The ANM stated the facility requires RN's to perform basic (brief) assessment that included neurological assessment or a Glasgow Coma Scale (GCS - a scoring system used to describe the level of consciousness in a person), Airway/Breathing/Circulation (ABCs), fall risk, skin assessment, and immunization status for COVID - 19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus) for all patients.

On 10/23/2022, at 8:19 p.m., during an interview with RN 3 and concurrent review of facility's admission and triage process for patients via Epic (an electronic health record software system used by the facility), RN 3 stated a behavioral health chief compliant will trigger an RN to perform a CSSR-S, PHQ-4, and BHA. However, RN 3 was not aware of a facility policy or requirement for RN's to screen for behavioral health and perform a CSSR-S, PHQ-4, or BHA for all other patients.

On 10/23/2022, at 8:53 p.m., during an interview, the EDD stated that the facility has no policy or requirement for RN to assess for behavioral health. The EDD stated the RNs perform a BHA when there was a change in presentation observed on a patient or a positive rate on CSSR-S but purely at their discretion.

A review of the facility's policy and procedure for Standard Procedure for Emergency Department Triage RN, revised date 06/2022, indicated facility's standard procedures included assessment for abdominal pain, chest pain, respiratory distress, fever in adult, pediatric (child) fever, extremity deformity for trauma with pain, and severe pain. The policy did not indicate standard procedure for utilizing assessment for the PHQ-4 and BHA.

A review of the facility's policy and procedure for Suicide Risk Assessment and Prevention, revised date 10/2020, indicated the policy and procedure serves as a foundation for caregivers to screen and assess for acute risk of self-harm or suicide and take necessary steps to protect the patient. The facility utilizes C-SSRS Screener Tool. The tool was applicable for all ages and populations. The policy and procedure under, "E. Imminent Risk Assessment/Re-Assessment," indicate, "Once initial C-SSRS Risk Assessment Tool was completed, any change in resource required will be reported to the physician. Document suicide risk level and monitoring plan in the medical record."

2. A review of Patient 1's fire department report, date 10/16/2022 at 19:11 (7:11 p.m., indicated under narrative that Patient 1 was found sitting complaining of chest pain, substernal (below the sternum/chest) radiating to right arm. Patient 1 described the pain as pressure. Patient 1 complained of shortness of breath and was transported to the hospital ED.

A review of Patient 1's admission information (Face sheet) indicated Patient 1 was admitted, on 10/16/2022 at 19:58 (7:58 p.m.).

A review of Patient 1's "ED (Emergency Department) Provider Notes," dated 10/16/2022 at 8:00 p.m., indicated Patient 1 presented to the ED for evaluation of chest pain and shortness of breath that started 1 hour prior to arrival. Patient 1 has history of hypertension (high blood pressure), diabetes (a disease that occurs when your blood sugar is too high), smoking, and illicit drug use.

On 10/19/2022 at 2:50 p.m., during an interview, the EDD stated Patient 1 was brought in via ambulance due to chest pain. Patient 1 had orders to be on continuous cardiac telemetry (a heart monitor that continuously monitor a patient's heart activity). On 10/17/22 at 00:11 a.m. (12:11 a.m.), Patient 1 was found by MD 1 (Medical Doctor 1) behind the gurney in a kneeling position, unresponsive, with a cord around neck. Patient 1 was detached from his heart monitor. The EDD stated when a patient has been detached from the heart monitor an auditory alarm is triggered to alert staff of a medical emergency. The EDD stated the RN assigned to the patient on heart monitor was responsible to monitor his assigned patient and should respond to alarm triggered by the heart monitor.

On 10/19/2022, at 2:50 p.m., during an interview, the EDD stated RN 1, who was assigned to Patient 1, was with another patient in a different room starting an intravenous line (a small, short plastic catheter that is placed through the skin into a vein, used to give fluids and medications to your body) prior to patient being found by MD 1. The EDD stated patients on telemetry monitoring were continuously monitored by the nursing staffs to ensure patients were connected to the monitor and alarms were responded/addressed. RN 1 failed to monitor Patient 1's telemetry continuously. EDD stated during facility's investigation, the facility had identified that RN 1 failed to respond to Patient 1's heart monitor alarms.

On 10/20/2022 at 8:53 a.m., during an interview, RN 1 stated he was the assigned nurse for Patient 1, who was admitted for chest pain, on 10/16/22. Patient was placed on continuous telemetry monitoring. Patient was found by MD 1 in a kneeling position, unresponsive with a cord around neck. Patient 1's cardiac monitor was detached. Patient was laid to the floor and staff immediately started CPR. CPR was not successful. Patient 1 was pronounced dead by MD 1 on 10/17/2022 at 00:11 a.m. (actual documented date and time: 10/17/2022 at 12: 25 a.m.). Patient 1 telemetry reading were reflected on the monitors available at bedside and central monitor outside in the hallway. All staff nurses must keep an eye on monitor for any heart irregularities and alarms. Telemetry monitor device would trigger an alarm for change in heart rhythm or when detached/not connected to a patient. Patient 1 was found disconnected from his telemetry monitor. RN 1 stated he cannot remember when Patient 1's telemetry monitor had triggered to alarm. RN 1 stated any nurses sitting in the workstation next to the telemetry central monitor in the hallway was responsible to monitor patients' telemetry. RN 1 stated he was being unsure if there was staff monitoring Patient 1 from the central monitor in the hallway. RN 1 stated Patient 1 was not continuously monitored and was not sure how long the patient was off telemetry monitoring. RN 1 stated the ED had no Monitor Technicians (staff who observe heartbeats and electrocardiograms to assist with the interpretation and diagnosis of conditions related to the heart).

On 10/20/2022 at 12:47 p.m., during an interview, MD 1 stated he found Patient 1 on his knee at the head of bed. MD 1 stated Patient 1 found with cord around neck. Patient 1 was cyanotic (a bluish or purplish discoloration of the skin and mucous membranes due to deficient oxygenation of the blood) and unresponsive, and CPR initiated on the floor. CPR was performed on Patient 1 for 15 minutes but was unsuccessful. MD 1 stated Patient 1 was pronounced dead on 11/17/2022 at 12:25 a.m. MD 1 stated Patient 1 had an ordered to be on continuous telemetry monitoring, and Patient 1's telemetry monitor alarms were not heard by ED staffs.

A review of facility policy and procedure for Clinical Alarms, revised date 04/2021, indicated clinical alarm systems - "Patient care device or monitoring equipment with an alarm including, but not limited to, physiological monitors (cardiac telemetry, BP, and pulse oximetry [a test used to measure the oxygen level ]) ...going directly to or coming from the patient." The policy and procedure indicated, critical alarms such as patient alarms or patient equipment alarms, "Would result in harm if the response were delayed," and "Critical alarms will be audible to staff with respect to distance and competing noise." The policy and procedure indicated alarms were monitored by the nurses and/or monitor technician (staff trained to monitor cardiac rhythm) if applicable.