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Based on interview, record review and policy review, the facility failed to ensure staff appropriately assessed, reassessed, documented assessments and appropriately responded to the care needs of one discharged patient (#1) of one discharged patient record reviewed, who experienced a significant change in condition that resulted in death. These failed practices by the facility placed all patients at increased risk for injury or death. (A-0395)

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Nursing Services.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 11/09/17, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

As of 11/09/17, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- A policy was modified to include a reassessment to be conducted at a minimum on all inpatient units by a Registered Nurse (RN) every eight hours.
- A policy was modified to include changes in the patient's condition as physical condition, mental status, and vital signs out of range (defined in separate policy), lack of position changes during sleep, physical complaint, seclusion and/or restraint procedures, and medication side effects.
- Detoxification orders were revised to reflect vital signs were to be taken every two hours for 24 hours, followed by every four hours for the next 24 hours, and continue every four hours, regardless if the patients was sleeping.
- Policy revisions were initiated that if Mental Health Technician (MHT) or other staff within patient contact shall report any changes in psychiatric or medical stability to the nurse immediately. The nurse will immediately reassess the patient including but not limited to the Clinical Institute Withdrawal Assessment for Alcohol (CIWA, a ten item scale used in the assessment and management of alcohol withdrawal)/Clinical Opiate Withdrawal Scale (COWS, an eleven item scale designed for assessment and management of opiate withdrawal,) and physical assessment including vital signs (blood pressure, heart rate, respirations and temperature).
- A policy was modified to include level of observation orders that a flashlight will be used to illuminate the room when rounds were performed during patient sleep hours.
- Education began on 11/09/17 that included reassessment, reporting of patient's psychiatric or medical changes and/or reassessment of patient's psychiatric or medical changes, detoxification orders, and level of observation orders for all current staff and prior to start of staff's next scheduled shift. Education focused on performance and documentation of reassessments and rounded observations/monitoring started on 11/09/17 for compliance.
- Change in condition drills will be conducted on all shifts for two weeks until compliant, then conducted on alternating shifts until revisit.
- The Charge RN will round with MHT during patient sleep hours two times per shift daily for two weeks to observe compliance with use of flashlights. The Director of Nursing will coordinate audit rounds sheet daily per each shift for two weeks until compliant, and then daily alternating until revisit.
- The MHTs identified as noncompliant during the survey were given written discipline/counseling.
- The RN staff identified as noncompliant during the survey was suspended pending investigation.



37921

Based on interview, record review and policy review, the facility failed to ensure staff appropriately assessed, reassessed, documented assessments and appropriately responded to the care needs of one discharged patient (#1) of one patient record reviewed, who experienced a significant change in condition that resulted in death. These failed practices by the facility placed all patients at increased risk for injury or death. The facility census was 96.

Findings included:

1. Record review of the facility's policy titled, "Recognition and Reporting Changes in a Patient Condition," revised 11/18/16, showed the following directives for staff:
- All patients will be assessed for changes in psychiatric and medical stability at least each shift and as believed appropriate by the nurse.
- Mental Health Technicians (MHT) and other staff with patient contact shall report any changes in psychiatric or medical stability to the nurse immediately. The nurse must address the change in status immediately.
- Changes in psychiatric condition included changes in mental status, changes in level of physical activity and verbalization or thoughts, intent or attempts to elope.
- Changes in medical condition included changes in level of consciousness or alertness, changes or decompensation (failure) in respiratory (breathing), cardiac (heart and blood vessels), and/or vital signs (blood pressure, heart rate/pulse, respirations, and temperature).
-The nurse shall assess all reports of changes in condition immediately, and review as appropriate with the nursing supervisor, attending physician, or the covering physician on-call.

Record review of the facility's policy titled, "Detoxification/Nursing Care," revised 02/08/16, showed the following directives for staff:
- The Nursing Staff will assess the patient every shift. This includes but is not limited to vital signs, observation for withdrawal symptoms (symptoms related cessation of drinking alcohol, such as tremors, nausea, vomiting, confusion, etc.), level of consciousness, emotional status and any verbal complaints.
- The Nursing Staff will assess the safety needs and provide the level of supervision required to maintain the safety for those patients who may be confused, disoriented, or unsteady during detoxification (detox, medical treatment to prevent severe symptoms related to withdrawal).
- Staff will document pertinent observations and care of the patient during detox on the Progress Notes every shift.
- Clinical Institute Withdrawal Assessment for Alcohol (CIWA - a ten item scale used in the treatment and management of alcohol withdrawal) showed that when a CIWA was completed, vital signs should also be completed, although not part of the CIWA score.
- If the withdrawal is moderate to severe, always awaken the client for the assessment. Severe withdrawal symptoms can be exhibited upon wakening.
- The CIWA could be stopped when the patient's score was less than 10 for three consecutive assessments.

Record review of the facility's policy titled, "Reassessment: Acute Units," revised 11/29/11, showed the following directives for staff:
- Reassessment is conducted by a Registered Nurse (RN) every 8 hours at a minimum on the acute inpatient units.
- Additionally, reassessment occurs in the following circumstances: Change in the patient's condition.
- RN findings from the reassessment are documented on the flow sheet.

Record review of the facility's "Competency for Proper Completion of Rounds," revised 12/09/13, showed that when staff completed patient rounds (frequent observation of patient to ensure patient is safe and breathing) at night, a flashlight must be used to illuminate the room. If the patient is asleep, staff should observe a BODY PART and check respirations.

2. Record review of the discharged medical record for Patient #1, showed that he was admitted to the facility on 11/01/17 at 12:44 PM for complaints of alcohol dependence (inability to stop drinking).

Record review of the History and Physical (H&P) for Patient #1, dated 11/01/17, showed that the patient complained of difficulty breathing with minimal activity.

3. Record review of Physician's Orders - Alcohol Detox Orders for Patient #1, dated 11/01/17, showed the following information:
- If the patient showed any signs of withdrawal, administer the CIWA, assign a score to each item, and add up the numbers and assign a total score.
- Always awaken the patient when administering the CIWA.
- If the CIWA score is greater than 10 and the patient is 125 pounds or greater (the patient weighed 205 pounds), administer Librium (medication used to treat withdrawal symptoms of alcoholism) 50 milligrams (mg, unit of measure) by mouth every two hours until score is less than 10.
- Do not hesitate to call the doctor if you have any concerns or questions or symptoms persist despite above orders.

Record review of the CIWA for Patient #1 showed the following information:
-On 11/02/17 at 1:00 AM, staff documented the patient's CIWA score was 22.
-On 11/02/17 at 8:57 AM, staff documented the patient's CIWA score was 10.
-On 11/02/17 at 1:30 PM, staff documented the patient's CIWA score was 10.
-On 11/02/17 at 6:50 PM, staff documented the patient's CIWA score was 21.

Record review of the medical record for Patient #1, showed staff's last documented vital signs on the patient was on 11/02/17 at 6:50 PM.

During an interview on 11/07/17 at 5:40 PM, Staff G, RN, Evening Charge Nurse, Unit 4 - Acute Unit, stated the goal for the CIWA score was less than 10, and if the CIWA score was above 10, the patient was to be assessed every two hours.

Staff failed to follow policy when the patient's CIWA score was greater than 10, failed to follow physician's order and reassess the patient's CIWA score every two hours until the patient's CIWA score fell below 10. The facility also failed to complete the CIWA until the patent's score was less than 10 for three consecutive assessments, as per policy.

4. Record review of the Admission Psychiatric Evaluation and Discharge Summary for Patient #1, dated 11/07/17, showed that on 11/02/17, the patient was confused and acted strange, going through withdrawal, and was sent to the acute unit (Unit 4).

Record review of an order for Patient #1, dated 11/02/17 at 4:35 PM, showed to transfer the patient to the acute unit (patient was admitted to Unit 3 - Detox Unit and was transferred to Unit 4 - Acute Unit) for safety.

Record review of Progress Records for Patient #1 showed the following information:
-On 11/02/17 at 4:00 PM, staff documented that the patient was confused, wandering, tried to leave the unit when staff entered, required constant redirection and would be transferred to the Acute Unit (Unit 4) per physician orders.
-On 11/02/17 at 8:08 PM, staff documented that the patient was very confused and poured ranch dressing on the table and tried to eat it with a fork.
-On 11/02/17 at 10:17 PM, staff documented the patient had an unsteady gait, was very confused at times, complained of agitation and anxiety, and had stable vital signs.

Record review of the Clinical Status Report 15 Minute Rounds for Patient #1, dated 11/02/17 - 11/03/17, showed staff documented the patient was in his room sleeping from 11:00 PM until 6:48 AM.

During a telephone interview on 11/09/17 at approximately 9:30 AM, Staff O, MHT, stated that:
- She worked the night shift on 11/02/17 and was on orientation and worked with Staff P, Night MHT, preceptor.
- Staff P, had received report from the evening shift that the patient had vomited, and was not to be woken.
- Prior to 11/07/17, staff did not want MHTs to go into patients' room to do vital signs on patients because staff did not want to wake sleeping patients.
- Staff P, informed her that Unit 4 - Acute Unit did not use a flashlight in patients' rooms during rounds, and she did not use a flashlight when she rounded on Patient #1.
- Before going on break (between 4:00 AM and 4:30 AM), she and Staff P, informed Staff J, RN, that the patient's breathing was shallow and that he had not changed position since 11:00 PM.
- Staff J, RN, rounded on Patient #1 while they were on break.
- The last time she saw the patient breathing was at the 6:00 AM rounds.
- When she entered the patient's room at 7:04 AM, the patient was in the same position he was when she rounded on him at 11:00 PM.

During a telephone interview on 11/15/17 at 9:13 AM, Staff P, Night MHT, stated that:
- She received report that Patient #1 was admitted to the unit because of decreased ADL (activities of daily living) function and confusion.
- When she checked on Patient #1 at the beginning of her shift (11:00 PM), his abdomen barely moved up and down, his breathing was "shallow", and Staff O, MHT orientee, agreed that the patient's breathing was faint.
- The patient was in the same position every time she made rounds throughout the shift.
- She reported her concerns to Staff J, RN, between 2:00 AM and 3:00 AM, and Staff J went to check on the patient.
- The last time she saw the patient alive was at 5:00 AM.
- Around 7:00 AM, she found Patient #1 unresponsive, cold, pulseless, in the same position he had been in all night, and she believed the patient was not breathing and notified Staff J.

During interview on 11/08/17 at 8:00 AM, Staff H, RN, Night Charge Nurse, Unit 4 - Acute Unit stated that:
- She was the charge nurse on the night shift on Unit 4 on 11/02/17 from 11:00 PM until 7:30 AM, but did not round on Patient #1.
- Between 4:30 AM and 5:30 AM, Staff P, MHT informed Staff J, RN, that it was hard to tell if Patient #1 was breathing.
- If there was a change in a patient's condition, the patient should be reassessed.

During an interview on 11/8/17 at 9:40 AM, Staff J, RN, Night Staff Nurse, Unit 4 - Acute Unit, stated that:
- He received report that the patient was transferred to Unit 4 - Acute Unit, because he was confused and detoxing from alcohol.
- His first contact with the patient was on 11/03/17 at approximately 4:46 AM, when he made rounds on the patient.
- He did not hear any noise (such as breath sounds, snoring, etc.) coming from the patient, and although it was not easy to see, he observed the patient's abdomen rise and fall, and had no indication anything was wrong with the patient's breathing.
- He did not visualize the patient's chest for rise and fall (to verify the patient was breathing).
- He counted the patient's respirations when he made rounds at 4:46 AM and 5:08 AM but did not document them in the medical chart.
- Shortly after 5:00 AM, Staff P, MHT and Staff O, MHT, informed him that the patient's breathing was "shallow".
- When the MHTs told him about the patient's shallow breathing, he instructed Staff P, MHT, to watch the patient because he was concerned the patient had not moved his position during his rounds, and typically patient's that were detoxing were restless.
- He did not make rounds on the patient after 5:08 AM.
- Around 7:05 AM, he responded to the patient's room and found the patient was unresponsive, his face was pale, he was cold, he was not breathing, without pulse, and in the same position as he was when he made rounds on the patient at 4:46 AM.

The last staff documented vital signs were dated 11/02/17 at 6:50 PM and the last documented assessment by staff in the Progress Notes was dated 11/02/17 at 10:17 PM. Staff did not document vital signs or Progress Notes on the patient until 11/03/17 at approximately 7:04 AM, when the patient was found in his room without respirations.

The patient had been transferred from Unit 3 - Detox Unit, to Unit 4 - Acute Unit, around 5:30 PM on 11/02/17 for changes in his mental status. Staff failed to follow policy when the RN failed to assess/reassess the patient every eight hours at minimum, and when staff failed to document vital signs every eight hours on the acute inpatient unit.

5. Record review of Progress Record for Patient #1, dated 11/03/17 at 8:15 AM, showed that staff documented that at approximately 7:04 AM, the patient appeared to have shallow respirations (breathing) and was unresponsive. Staff J, RN, responded to the patient's room, noticed the patient's respirations stopped, and the patient was pulseless (without a heartbeat). Resuscitation (medical attempts to restore life) began, and 911 (Emergency response) was contacted. Emergency Medical Services (EMS) responded, continued unsuccessful resuscitative efforts, and the patient was pronounced dead at 7:20 AM, by EMS.

During an interview on 11/08/17 at 8:50 AM, Staff I, RN, Night Charge Nurse, Units 5 and 6, stated that when he responded to Patient #1's resuscitation, the patient's face was pale and gray, skin was cooler than normal, and he believed the patient had been without a pulse for a while. Staff I added that when EMS responded to the patient's resuscitation, they reported that the patient was in "rigor" (rigor mortis, stiffness of the arms and legs that begins four or more hours after death occurs).

During a telephone interview on 11/08/17 at 1:35 PM, Staff N, Medical Physician, stated that:
- If the patient had a change in medical condition staff would have called him, but he did not receive a call with any changes in Patient #1.
- If a patient had shallow breathing staff should do an assessment that included vital signs, a pulse oxygen level and notify the medical doctor.
- He was "shocked" when staff called him to tell him that the patient had expired.