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Based on record review, staff interview and policy review, the governing body failed to ensure that one (1) of five (5) Patients reviewed (Patient #1) was free from neglect by failure to follow the established facility policy for searching patients for contraband at the time of admission. The Nursing Staff failed to follow established policy and procedures for reporting a critical lab result to the Physician. Patient #1 had a serum glucose level of 29 mg/dl (milligrams per deciliters) on 10/15/10 at 5:45 a.m. The lab reported the serum glucose level to RN #3 on 10/15/10 at 9:30 p.m. RN #3 did not report the low serum glucose to the Physician. The Nursing Staff failed to follow established policy and procedures for calling a Code Blue when Patient #1 was found unresponsive. (Patient #1 was admitted to the facility on 10/14/10 and assessed as exhibiting homicidal and suicidal ideations).

Patient #1 was found on 10/18/10 at approximately 3:50 a.m. without respirations and a weak pulse. They moved Patient #1 to the floor and initiated CPR. 911 was activated. Resident #1 was pronounced dead on 10/18/10 at 4:43 a.m. at the hospital Emergency Room.

Findings Include:
This Condition of Participation (CoP) was not met due to the facility's failure to search Resident #1 for contraband at the time of admission; failure to report a critical serum glucose level; and failing to follow their established policy and procedure in communicating a Code Blue.

Cross refer findings to A 115 (Patients' Rights).

Cross refer findings to A 385 (Nursing Service).

Based on medical record review, staff interview and policy review, the facility failed to ensure that one (1) of five (5) residents reviewed was free from neglect. This is for Patient #1. Patient #1 was admitted to the facility on 10/14/10 and was assessed as exhibiting homicidal and suicidal ideations. The facility failed to follow established policy and procedures related to searching for contraband at the time of admission; failing to report a critical serum glucose level of 29 mg/dl (milligram per deciliter) to the Physician; and failed to follow established policy and procedures for calling a Code Blue to communicate a medical emergency when Patient #1 was found without respirations and a weak pulse on 10/18/10 at approximately 3:50 a.m.

Resident #1 was pronounced dead on 10/18/10 at 4:43 a.m. at the hospital Emergency Room.

Findings Include:

This Condition of Participation (CoP) was not met due to the facility's failure to ensure that Patient #1 was free from neglect.

Cross refer findings to A 145.

Based on medical record review, staff interview and policy review, the facility failed to ensure that one (1) of five (5) residents reviewed was free from neglect. This is for Patient #1. Patient #1 was admitted to the facility on 10/14/10 and was assessed as exhibiting homicidal and suicidal ideations. The facility failed to follow policy and procedures related to searching for contraband at the time of admission; failed to report a critical glucose level of 29 mg/dl (milligrams per deciliter) to the Physician; and failed to follow established policy and procedures for calling a Code Blue to communicate a medical emergency when Patient #1 was found without respirations and a weak pulse on 10/18/10 at 3:50 a.m.

Resident #1 was pronounced dead on 10/18/10 at 4:43 a.m. at the hospital Emergency Room.

Findings include:
Review of the facility's "Alleged Patient Abuse, Neglect, Exploitation Policy Number: (RI.2.150)", page 2; reviewed/revised on 8/08 contained the following requirements. "The definition for Neglect includes: An act or omission by an individual responsible for providing services in a hospital which caused or may have caused injury or death and includes an act or omission such as: (4.3) Failure to establish or carry out an appropriate individual program plan or treatment plan for a patient. (4.4) The failure to provide adequate nutrition, clothing, or health care to a patient; (4.5) The failure to provide a safe environment for a patient, including the failure to maintain adequate numbers of appropriate trained personnel.

Record review revealed that Patient #1 was admitted to the hospital on 10/14/2010 for treatment of Poly-substance Dependence and Bipolar.

Review of the Pre-Admission tool 10/14/10 revealed the following information. "The patient was assessed to be at risk for homicide. (His/her) Homicide Risk Factors included: Previous history of violence; Violence/Threats towards others; and Heavy alcohol or drug use."

The patient was assessed at the time of admission to be at risk for suicide. The "Suicide Assessment" revealed the following information. "The patient thought about suicide on the day prior to admission to the facility. (He/she) had current Suicidal ideation, plan, and intent."
"Suicidal Risk Factors included: history of command hallucinations; alcohol or heavy drug use; severe financial difficulties; organized plan with lethal intent; problems with significant other; loss of employment; divorced; history of major depression; and history of Bipolar. The patient's parents were afraid he/she was going to overdose."

Review of the nurse's comprehensive admission assessment dated 10/14/10 revealed the following information. "The patient jumped off of a barn and sustained fractures to the left leg and toes six (6) weeks prior to admission to the facility. The patient was 34 years of age. (He/she) admitted to using Cocaine, Crystal Methamphetamine, Dilaudid, Oxycotin, Percocet, Xanax and Valium. (He/she) drank five (5) quarts of malt liquor the night prior to admission. (He/she) drank two (2) quarts on the way to the facility."

There was no documented evidence that the Patient #1's belongings were searched for drugs and other contraband at the time of admission. The section was left blank on the form.

The facility's "Personal Searches of Patient and Property Policy Number RI.046", reviewed/revised on 8/10, contained the following requirements. "It is the policy (Name of Facility) that all patients and patient's possessions are searched upon admission, and at any time the patient is suspected of possessing drugs, sharp objects, matches or other items potentially dangerous to themselves or others."

Review of the Physician's orders at the time of admission revealed lab work which included blood glucose. Other orders included: "Suicidal precautions; observation checks every 15 minutes; and blood glucose for lab. Review of a Lab report revealed that blood was drawn for a glucose level on 10/15/2010 at 5:44 a.m. The facility received a faxed report from the Lab on 10/15/2010 at 9:01 p.m.stating that the Patient #1's blood glucose was 29 mg/dl (low). This was a critical value. The reference range was 65-100 mg/dl. The following statement was written on the report. "A decrease in the glucose result may possibly be due to delayed separation of serum from cells. Evaluate results with cautions ' was written on the report. A registered nurse's progress note on 10/15/2010 at 9:30 stated, " (Name of person) called & (and) stated pt's (patients) glucose was low on initial blood draw on 10/15/10 a.m.; BS (blood sugar) was 29. Labs (laboratory reports) on chart & circled for MD (medical doctor) to see. Will continue to monitor." The laboratory report was initialed by the Physician. The date and time the Physician reviewed the report was not documented. There was no documented evidence that another blood glucose level or an accucheck was obtained.

On 11/13/2010 from 4:40 p.m. to 4:45 p.m. a telephone interview was conducted with Registered Nurse (RN) #3 that revealed the following information: RN #3 did receive the report that the Pateint #1's blood glucose was 29. The RN made the following statements. "I believe the lab (laboratory) did call me." "I left it (laboratory report) on the chart for the doctor to see." "It was two (2) days later (after the lab was drawn)." "He/she (patient) was obviously having no distress." "(He/she) was eating (his/her) meals and (he/she) was oriented." "I suppose I could have called the doctor." "Sometimes patients don't eat well before they come and their blood glucose is low." "(He/she) was eating. (He/she) was getting better." "(He/she) had no history of diabetes." The surveyor asked RN #2 if anyone in the hospital talked to her or counseled her about her not reporting the low glucose to the doctor. She stated "No."

The facility's Alert Values Policy GEN-Y-0017.02 page 1 contained the following requirements. "Failure to notify the physician as soon as possible with critical test results can have a profoundly detrimental effect on patient care. Therefore, failing to follow this procedure could result in disciplinary action." Critical alert values included Glucose below 40 mg/dl.

Review of a Nurse's Progress Notes signed by RN #1 on 10/18/2010 revealed the following information: At 12:00 a.m. "Pt observed sleeping in the floor beside bed on rounds. Awake & instructed to return to bed. Pt did so s (without) difficulty."
There was no documented evidence that an assessment was performed to determine if the patient had an un-witnessed fall and to determine the patient's mental and neurological status.

A nurse's progress note on 10/18/2010 at 3:50 a.m. revealed the following information. Patient #1 was found not breathing. Cardiopulmonary Resuscitation (CPR) was initiated. An ambulance was called. The patient was transported to an emergency department at approximately 4:30 p.m. The patient was pronounced dead at the emergency department.

A nursing progress note signed by RN #1 on 10/18/2010 at 3:50 a.m. stated, " Returned to pt (patient) due to unexplainable concern for the patient. Pt noted c (with) no respiration, weak pulse. Summoned help from adjacent Unit immediately. Moved pt onto floor & initiated CPR (cardiopulmonary resuscitation), Placed AED (Automatic External Defibrillator), & summoned 911. Continued BLS until arrival of paramedics. Pt released to care of emergency response team (Name of EMS). At approximately 4:20 a.m. pt transported via ambulance to (Name of hospital). Left message via mother ' s phone # (number) @ (at) approximately 4:30 a. (a.m.) and the physician notified by (Name of RN) at 4:30 a.m. " Record review revealed no additional documentation of the patient on 10/18/2010 from 3:50 a.m. through 4:20 a.m.

A signed report by RN #1 on 11/11/2010, contained the following information. "(Name of MHT #1) (Mental Health Technician) made rounds @ 3:30 a.m. then went on break. When I made rounds @ 3:45 a.m., (Patient #1) was asleep. I observed the rise & fall of his/her chest 3 times, which is policy. I went to the desk, wrote an all sheets (this took less than 5 min). All of a sudden, I got a strange, unexplainable concern & need to check on him/her again. I rolled him/her on his/her side because, there was a lot of secretions in his/her mouth coming out. @ this time, he/she was not breathing. At this time, he/she had a weak brachial pulse. When I rolled him/her back over, he/she still was not breathing. I ran to West Wing, which was only a few doors away & called for help. (RN #2) was the first to arrive. We rolled him onto the floor, (RN #2) at the feet & me @ the head. We began CPR (cardiopulmonary resuscitation). Someone brought the AED (Automatic External Defibrillator) right away. When placed on the pt & at all times the AED reported 'No shock advised.' CPR continued until the ambulance arrived." There were @ least two (2) failed attempts to intubate."

The facility's Code Blue Policy Number PC.057, reviewed and revised on 8/10 contained the following requirements. "It is the policy of (Name of Facility) to use the designation of {' Code Blue'} to communicate medical emergencies." "1.0 The first person to discover the medical emergency assesses the need for cardio-pulmonary resuscitation." 2.0 The first person should call for help and tell the next person arriving to call {Code Blue}. The second person should contact the operator and inform him/her of the location of the { ' Code Blue '}. The operator should page { ' Code Blue '} three times on the overhead intercom." " 8.0 The designated Nursing Supervisor or designee shall record all {Code Blue '} data on the flow sheet. " " 13.0 The charge nurse documents the following information in the patient ' s medical record. " "A. Detailed description of the patient ' s status." "B. Interventions implemented and patient ' s response."

An interview with RN #4 on 11/11/2010 from 7:45 a.m. to 8:05 a.m. revealed that a Code Blue was not called. She reported that there was an intercom in the facility, but it is not used at night. Medical record review revealed no documentation of code interventions.

An interview was conducted on 11/12/2010 from 11:30 a.m. to11:38 a.m. with the Director of Risk Management and the Director of Nursing (DON). At that time, the DON reported that staff failed to document the process of the code. Review of the patient ' s medical record revealed that a detailed description of the patient ' s status and interventions implemented were not documented.

Review of the patient's medical record revealed that a detailed description of the patient ' s status and interventions implemented were not documented.

A signed statement by RN #2 revealed the following information: The night of the incident, a (RN #1) opened the door between East and West unit, and yelled out I need some help. By the time they got to Patient #1's room, he/she was not breathing. (RN #1) said she had a faint pulse. The two nurses got him off the bed on the floor. (RN #1) started CPR at that time.

A signed statement by RN #4 revealed the following information: "Was sitting at the nurses station on the Adolescent unit when MHT #3 ran to me saying, ' They need you on East. Someone's passed out or something. I immediately began down the hall saying to MHT #3, ' Grab the oxygen tank and follow me.' Staff pointed me to the room where I entered and saw a middle aged male/female patient lying on his/her back on the floor. He/she was gray and looked dead. I asked (RN #1), 'Is there a pulse?' She was checking for a pulse at the right carotid artery. (RN #1) said, No pulse." "I could see vomit in the patient's mouth. There was also vomit on the floor. I also noted the patient had urinated. " (RN #1) held his/her head and jaw in order to open his/her airway. His/her jaw was clenched. The patient was mottling on his/her forehead, looking gray/dark purple, with white pale extremities. His/her body was feeling cool. We never got a pulse."

RN #2 provided the following written Statement on 11/12/2010 at 10:55 a.m. " I was sitting at the nurses station on the Adolescent Unit when MHT (mental health technician) ran to me saying;. ' They need you on East, someone's passed out or something.' I immediately began quickly down the hall saying to (MHT), Grab the oxygen tank and follow me' Staff pointed me to the room where I entered and saw a middle age male/female patient lying on his back on the floor. He was gray and looked dead."

Review of the patient's emergency department record at the receiving hospital revealed the following information. "Death in the Emergency Department Note: Seen by myself on October 18th, this morning at 0436 (4:36 a.m.) hours after being transported by (name of fire department) to our facility from (Name of Hospital) where he/she had been admitted to 'detox from some drugs'. EMS states that he/she already had some signs of rigor mortis on their arrival, such as when they tried to intubate the patient his/her jaw was already stiff and occlusion of the oropharynx orifice. He/she was asystole (without rhythm or flat line) on their first monitor evaluation. They started an IV (intravenous) and had given epinephrine, atropine and bicarbonate while in route and had never deviated from that asytole on the monitor. They were able to successfully intubate him/her and on arrival, he/she had breath sounds on the right side. However, there were none on the left. His/her endotracheal tube was pulled back 4 cm (centimeters) until 22 and a tenth were reached with bilateral breath sounds achieved at that time. Given the history of his/her presentation, Narcan 2 mg (milligrams) was given IV, as was 1 amp of Calcium, as was 1 amp (ampule) of D50 (Dextrose 50 milligrams) secondary to us not knowing his medical history status and the fact that he could have overdosed on some opiate-type Narcotic, even though he was inpatient, with detox from an unknown substance in process. CPR was continued for several minutes after administration of those drugs with no response from the patient with fixed and dilated pupils, and continuous asystole on the monitor when CPR was paused. Therefore, the patient was soon pronounced dead at 0443 (4:43 a.m.) hours. The patient was effectively dead on arrival; however, we did the minimum resuscitation efforts given the drug abuse history and EMS had not done Accu-check, therefore we gave D50, all of which was without response.

The Physician's Discharge Summary contained the following information. "The patient was started on Neurotin, 600 mg (milligrams) p.o. (orally) b.i.d. (twice a day); Hydrocodone 10 mg po q 6 hours prn pain; and a Librium Detox to address the alcohol dependence and withdrawal and also the Klonopin that I did not continue at admission given that we were attempting a detox. The patient was started on Seroquel, 200 mg po at bedtime and Celexia to address to mood symptoms. This was initiated on 10/15/10. The patient described himself to be going through a difficult detox. He/she claimed that he/she was sweating a lot. He/she was restless and craving for cocaine. An additional dose of Librium was given to him on 10/16/10 to address the reported severe anxiety and withdrawal symptoms." "On 10/16/10 Seraquel was increased to 300 mg po at bedtime and Neurotin to 600 mg po t.i.d. this latter, after the patient clarified that he had been on Neurotin, 800 mg po b.i.d. The patient was evaluated on 10/17/20 at approximately 9:45 in the morning. The patient complained of severe pain to his/her fractured toes to be continuing. He/she stated that his physician was giving him Lortab every four hours, instead of every six and that pain control was not lasting for more than four hours. He requested that the Lortab be placed at the original dose schedule of 10 mg po q. 4 hours. This was done on 10/17/2010. The patient continued to insist that he/she was not sleeping well and that he/she felt labile. He/she requested the Seroquel to be increased. He/she reported that he/she had previously been well stabilized on Seroquel at a daily dose of 900 mg po at bedtime. The Seroquel was increased to 400 mg po at bedtime, effective 10/17/2010."

A telephone interview was conducted with the Physician on 11/12/10 at 1:20 p.m. The Physician did remember seeing the lab report that about the patients low glucose of 29 mg/dl. The report also indicated that is might be inaccurate. The Phyisician stated that he thought the report was inaccurate. The Physician stated that no one called him at that time to report the low glucose level. The Physician stated that he would have asked staff to check the patients cognitive status and to check a glucose level. The Physician could not recall when he actually saw the glucose report. The Physician stated that he reviewed the Patients health history. The patient reported that (he/she) did not have Diabetes.

The Risk Management Director provided the following documentation. "An autopsy was requested and the preliminary report we received listed the cause of death was an accidental overdose related to benzodiazepine and opiates."

All findings were discussed and confirmed during the exit interview with the Chief Executive Officer, Director of Nursing and Risk Management Director on 11/13/2010 from 8:05 p.m. to 8:50 p.m.

Based on staff interview and policy review the facility failed to ensure that the performance improvement activities included tracking for an adverse patient event for one (1) of five (5) resident's reviewed. This is for Resident #1.

Findings include:
Patient #1 was admitted to the hospital on 10/14/2010 for treatment of Poly-substance Dependence and Bipolar.

Review of the Pre-Admission tool 10/14/10 revealed the following information: The patient was assessed to be at risk for suicide. The Suicide Assessment revealed the following information: The patient thought about suicide on the day prior to admission to the facility. (He/she) had current suicidal ideation, plan, and intent. Suicidal Risk Factors included: history of command hallucinations; alcohol or heavy drug use; severe financial difficulties; organized plan with lethal intent; problems with significant other; loss of employment; divorced; history of major depression; and history of Bipolar. The patient's parents were afraid (he/she) was going to overdose.

Review of the nurse's admission assessment revealed the following information: The patient jumped off of a barn and sustained fractures to the left leg and toes six (6) weeks prior to admission to the facility. The patient was 34 years of age. (He/she) admitted to using Cocaine, Crystal meth, Dilaudid, Oxycotin, Percocet, Xanax and Valium. (He/she) drank five (5) quarts of malt liquor the night prior to admission. (He/she) drank two (2) quarts on the way to the facility. There was no documented evidence that the patient's belongings were searched for drugs and other contraband. This section was left blank on the form.

The facility's Personal Searches of Patient and Property Policy Number RI.046, reviewed/revised on 8/10, contained the following requirements; "It is the policy of (Name of Facility) that all patients and patient's possessions are searched upon admission, and at any time the patient is suspected of possessing drugs, sharp objects, matches or other items potentially dangerous to themselves or others."

Review of the Physician's orders on admission revealed an order for blood work which included blood glucose. Other orders were for suicidal precautions and observation checks every 15 minutes. Review of a laboratory report revealed that blood was drawn for a glucose level on 10/15/2010 at 5:44 a.m. The facility received a faxed report from the laboratory on 10/15/2010 at 9:01 p.m. that the patient's blood glucose was 29 mg/dl (low). This was a critical value. The reference range was 65-100 mg/dl. The following statement was written on the report: "A decrease in the glucose result may possibly be due to delayed separation of serum from cells. Evaluate results with cautions was written on the report." A registered nurse's progress note on 10/15/2010 at 9:30 p.m. stated, " (Name) called & stated pt's glucose was low on initial blood draw on 10/15/10 a.m.; BS (blood sugar) was 29. Labs (laboratory reports) on chart & circled for MD (medical doctor) to see. Will continue to monitor." The laboratory report was initialed by the physician. The date and time the physician reviewed the report was not documented. There was no documented evidence that another blood glucose level or an accucheck was obtained.

A telephone interview was conducted with registered nurse (RN) #3 on 11/13/2010 from 4:40 p.m. to 4:45 p.m. RN #3 revealed the following information: RN #3 did receive the report that the patient's blood glucose was 29 mg/dl. RN #3 made the following statements. "I believe the lab (laboratory) did call me." "I left it (laboratory report) on the chart for the doctor to see." "It was two (2) days later (after the lab was drawn)." "Patient #1 was obviously having no distress." "(He/she) was eating (his/her) meals and (he/she) was oriented." RN #3 stated: "I suppose I could have called the doctor." "Sometimes patients don't eat well before they come and their blood glucose is low." "(He/she) was eating. (He/she) was getting better." "(He/she) had no history of diabetes." The surveyor asked RN #3 if anyone in the hospital talked to her or counseled her about her not reporting the low glucose to the doctor. She stated "No."

The facility's Alert Values Policy GEN-Y-0017.02 page 1 contained the following requirements: "Failure to notify the physician as soon as possible with critical test results can have a profoundly detrimental effect on patient care. Therefore, failing to follow this procedure could result in disciplinary action." "Critical alert values included Glucose below 40 mg/dl."

A signed report by RN #1 on 11/11/2010 at 1:47 p.m. contained the following information: "(He/she) aroused easily & was somewhat unsteady as (he/she) ambulated back to (his/her) room, however (he/she) was alert, oriented x 4."

Review of a Nurse's Progress note signed by RN #1 on 10/18/2010 revealed the following information: At 12:00 a.m. "Pt observed sleeping in the floor beside bed on rounds. Awake & instructed to return to bed. Pt did so s (without) difficulty."

There was no documented evidence that an assessment was performed to determine if the patient had an un-witnessed fall and to determined the patient's mental and neurological status.

The interview with Mental Health Technician (MHT) #2 on 11/11/2010 revealed the following information: "She observed the patient asleep on the floor at about 1:15 a.m. to 1:20 a.m. She had not seen the patient doing this before. (He/she) seemed like (he/she) was overly tired."

A nursing progress note signed by RN #1 on 10/18/2010 at 3:50 a.m. stated, "Returned to pt (patient) due to unexplainable concern for the patient. Pt noted c (with) no respiration, weak pulse. Summoned help from adjacent Unit immediately. Moved pt onto floor & initiated CPR (cardiopulmonary resuscitation), Placed AED (Automatic External Defibrillator), & summoned 911. Continued BLS until arrival of paramedics. Pt released to care of emergency response team - (Name of EMS). At approximately 4:20 a.m. pt transported via ambulance to (Name of Hospital). Left message via mother's phone # (number) @ (at) approximately 4:30 a. (a.m.) (Name of Physician) notified by (Name of RN) at 4:30 a.m."

Record review revealed no additional documentation of the patient on 10/18/2010 from 3:50 a.m. through 4:20 a.m.

A signed report by RN #1 on 11/11/2010, contained the following information: " (MHT (Mental Health Technician) #1 made rounds @ 3:30 a.m., then went on break. When I made rounds @ 3:45 a.m., (Name of Patient #1) was asleep. I observed the rise & fall of his/her chest 3 times, which is policy. I went to the desk and wrote on all sheets this took (less than) 5 min. All of a sudden, I got a strange, unexplainable concern & need to check on him/her again. I rolled him/her on his/her side because, there was a lot of secretions in his/her mouth coming out. @ (at) this time, he/she was not breathing. At this time, he/she had a weak brachial pulse. When I rolled him/her back over, (he/she) still was not breathing. I ran to West Wing, which was only a few doors away & called for help. (Name of RN #2) was the first to arrive. We rolled him onto the floor, (Name of RN #2) at the feet & me @ the head. We began CPR (Cardiopulmonary Resuscitation). Someone brought the AED
(Automatic External Defibrillator) right away. When placed on the pt & at all times the AED reported 'No shock advised.' CPR continued until the ambulance arrived." There were @ least 2 failed attempts to intubate."

The Risk Management Director provided the following documentation: "An autopsy was requested and the preliminary report we received listed the cause as accidental overdose related to benzodiazepine and opiates."

An interview with the Director of Risk Management and Quality Improvement and the Director of Nursing on 11/13/2010 from 2:00 p.m. to 2:10 p.m. revealed the following information: There was no evidence of any investigation conducted regarding the death of the patient.

Based on record review, staff interview and policy review, the Nursing Staff failed to ensure that three (3) of five (5) Patients assessed at risk for suicide (Patients #1, #2, and #3) had documented evidence in the medical record that searches for contraband were conducted at the time of admission. The Nursing Staff failed to follow established policy and procedures for reporting a critical lab result to the Physician and failed to follow established policy and procedure for communicating a Code Blue for one (1) of five (5) Patients reviewed (Patient #1). Patient #1 had a serum glucose level of 29 mg/dl on 10/15/10 at 5:45 a.m. The lab reported the serum glucose level to Registered Nurse (RN) #3 on 10/15/10 at 9:30 p.m. RN #3 did not report the critical serum glucose to the Physician in a timely manner.

Patient #1 was found on 10/18/10 at approximately 3:50 a.m. without respirations and a weak pulse. Patient #1 was pronounced dead on 10/18/10 at 4:43 a.m. at the hospital Emergency Room.

Findings include:

This Condition of Participation (CoP) was not met due to the Nursing Staff's failure to search Resident #1 for contraband at the time of admission; failure to report a critical serum glucose level; and failure to follow their established policy and procedure in communicating a Code Blue.

Cross refer findings to A 395.

Based on record review, staff interview and policy review, the Nursing Staff failed to ensure that three (3) of five (5) Patients assessed at risk for suicide (Patients #1, #2, and #3) had documented evidence in the medical record that searches for contraband were conducted at the time of admission. The Nursing Staff failed to follow established policy and procedures for reporting a critical lab result to the Physician and failed to follow established policy and procedure for communicating a Code Blue for one (1) of five (5) Patients reviewed (Patient #1). Patient #1 had a serum glucose level of 29 mg/dl on 10/15/10 at 5:45 a.m. The lab reported the serum glucose level to Registered Nurse (RN) #3 on 10/15/10 at 9:30 p.m. RN #3 did not report the critical serum glucose to the Physician in a timely manner. The Nursing Staff failed to follow established policy and procedures to communicate an Emergency by calling a Code Blue.

Findings include:
Record review revealed that Patient #1 was admitted to the hospital on 10/14/2010 for treatment of Poly-substance Dependence and Bipolar.

Review of the Pre-Admission tool dated 10/14/10 revealed the following information: "The patient was assessed to be at risk for homicide. (His/her) Homicide Risk Factures included: Previous history of violence; Violence/Threats towards others; and Heavy alcohol or drug use."

The patient was assessed at the time of admission to be at risk for suicide. The "Suicide Assessment" revealed the following information: "The patient thought about suicide on the day prior to admission to the facility. (He/she) had current Suicidal ideation, plan, and intent."
"Suicidal Risk Factors included: history of command hallucinations; alcohol or heavy drug use; severe financial difficulties; organized plan with lethal intent; problems with significant other; loss of employment; divorced; history of major depression; and history of Bipolar. The patient's parents were afraid he/she was going to overdose."

Review of the nurse's comprehensive admission assessment dated 10/14/10 revealed the following information: "The patient jumped off of a barn and sustained fractures to the left leg and toes six (6) weeks prior to admission to the facility. The patient was 34 years of age. (He/she) admitted to using Cocaine, Crystal Methamphetamine, Dilaudid, Oxycotin, Percocet, Xanax and Valium. (He/she) drank five (5) quarts of malt liquor the night prior to admission. (He/she) drank two (2) quarts on the way to the facility."
There was no documented evidence that Patient #1's belongings were searched for drugs and other contraband at the time of admission. The section was left blank on the form."

The facility's "Personal Searches of Patient and Property Policy Number RI.046", reviewed/revised on 8/10, contained the following requirements: "It is the policy of (Name of Facility) that all patients and patient's possessions are searched upon admission, and at any time the patient is suspected of possessing drugs, sharp objects, matches or other items potentially dangerous to themselves or others."

Review of the Physician's orders at the time of admission revealed lab work which included blood glucose. Other orders included: "Suicidal precautions; observation checks every 15 minutes; and blood glucose for lab. Review of a Lab report revealed that blood was drawn for a glucose level on 10/15/2010 at 5:44 a.m. The facility received a faxed report from the Lab on 10/15/2010 at 9:01 p.m. stating that Patient #1's blood glucose was 29 mg/dl (low). This was a critical value. The reference range was 65-100 mg/dl. The following statement was written on the report: "A decrease in the glucose result may possibly be due to delayed separation of serum from cells. 'Evaluate results with cautions ' was written on the report. A registered nurse's progress note on 10/15/2010 at 9:30 p.m. stated: "(Name of person) called & (and) stated pt's glucose was low on initial blood draw on 10/15/10 a.m.; BS (blood sugar) was 29. Labs (laboratory reports) on chart & circled for MD (medical doctor) to see. Will continue to monitor." The laboratory report was initialed by the Physician. The date and time the Physician reviewed the report was not documented. There was no documented evidence that another blood glucose level or an accucheck was obtained.

On 11/13/2010 from 4:40 p.m. to 4:45 p.m. a telephone interview was conducted with Registered Nurse (RN) #3 that revealed the following information: RN #3 did receive the report that Pateint #1's blood glucose was 29 mg/dl. The RN made the following statements: "I believe the lab (laboratory) did call me." "I left it (laboratory report) on the chart for the doctor to see." "It was two (2) days later (after the lab was drawn)." "He/she (patient) was obviously having no distress." "(He/she) was eating (his/her) meals and (he/she) was oriented." "I suppose I could have called the doctor." "Sometimes patients don't eat well before they come and their blood glucose is low." "(He/she) was eating. (He/she) was getting better." "(He/she) had no history of diabetes." The surveyor asked RN #2 if anyone in the hospital talked to her or counseled her about her not reporting the low glucose to the doctor. She stated "No."

The facility's Alert Values Policy GEN-Y-0017.02 page 1 contained the following requirements: "Failure to notify the physician as soon as possible with critical test results can have a profoundly detrimental effect on patient on patient care. Therefore, failing to follow this procedure could result in disciplinary action." Critical alert values included Glucose below 40 mg/dl.

Review of a Nurse's Progress Notes signed by RN #1 on 10/18/2010 revealed the following information: At 12:00 a.m. "Pt observed sleeping in the floor beside bed on rounds. Awake & instructed to return to bed. Pt did so s (without) difficulty."

There was no documented evidence that an assessment was performed to determine if the patient had an un-witnessed fall and to determine the patient's mental and neurological status.

A nurse's progress note on 10/18/2010 at 3:50 a.m. revealed the following information. Patient #1 was found not breathing. Cardiopulmonary Resuscitation was initiated. An ambulance was called. The patient was transported to an emergency department at approximately 4:30 p.m. The patient was pronounced dead at the emergency department.

A signed report by RN #1 on 11/11/2010, contained the following information: (Name of MHT #1) made rounds @ 3:30 a.m., then went on break. When I made rounds @ 3:45
a.m., (Patient #1) was asleep. I observed the rise & fall of his/her chest 3 times, which is policy. I went to the desk, wrote an all sheets (this took less than 5 min). All of a sudden, I got a strange, unexplainable concern & need to check on him/her again. I rolled him/her on his/her side because, there was a lot of secretions in his/her mouth coming out. @ (At) this time, he/she was not breathing. At this time, he/she had a weak brachial pulse. When I rolled him/her back over, he/she still was not breathing. I ran to West Wing, which was only a few doors away & called for help. (RN #2) was the first to arrive. We rolled him onto the floor, (RN #2) at the feet & me @ the head. We began CPR (cardiopulmonary resuscitation). Someone brought the AED (Automatic External Defibrillator) right away. When placed on the pt & at all times the AED reported ' No shock advised. ' CPR continued until the ambulance arrived." There were @ least 2 failed attempts to intubate."

The facility's Code Blue Policy Number PC.057, reviewed and revised on 8/10 contained the following requirements. " It is the policy of (Name of Faciltiy) to use the designation of { ' Code Blue '} to communicate medical emergencies." "1.0 The first person to discover the medical emergency assesses the need for cardio-pulmonary resuscitation." 2.0 - The first person should call for help and tell the next person arriving to call {Code Blue}. The second person should contact the operator and inform him/her of the location of the { 'Code Blue'}. The operator should page { ' Code Blue '} three times on the overhead intercom." " 8.0 The designated Nursing Supervisor or designee shall record all {Code Blue'} data on the flow sheet." "13.0 The charge nurse documents the following information in the patient's medical record." " A. Detailed description of the patient's status." "B. Interventions implemented and patient's response."

An interview with RN #4 on 11/11/2010 from 7:45 a.m. to 8:05 a.m. revealed that a Code Blue was not called. RN #4 reported that there was an intercom in the facility, but it is not used at night. Medical record review revealed there was no documentation of code interventions.

An interview was conducted on 11/12/2010 from 11:30 a.m. to11:38 a.m. with the Director of Risk Management and the Director of Nursing (DON). At that time, the DON reported that staff failed to document the process of the code. Review of the patient's medical record revealed that a detailed description of the patient's status and interventions implemented were not documented.

Review of the patient's medical record revealed that a detailed description of the patient ' s status and interventions implemented were not documented.

A signed statement by RN #2 revealed the following information: The night of the incident, a (RN #1) opened the door between East and West unit, and yelled out I need some help. By the time they got to Patient #1's room, he/she was not breathing. (RN #1) said (he/she) had a faint pulse. The two nurses got him off the bed on the floor. (RN #1) started CPR at that time.

A signed statement by RN #4 revealed the following information: " I was sitting at the nurses station on the Adolescent unit when MHT #3 ran to me saying, ' They need you on East. Someone's passed out or something. I immediately began down the hall saying to MHT #3, ' Grab the oxygen tank and follow me.' Staff pointed me to the room where I entered and saw a middle aged male/female patient lying on his/her back on the floor. He/she was gray and looked dead. I asked (RN #1), ' Is there a pulse? ' She was checking for a pulse at the right carotid artery. (RN #1) said, No pulse. " "I could see vomit in the patient's mouth. There was also vomit on the floor. I also noted the patient had urinated." "(RN #1) held his/her head and jaw in order to open his/her airway. His/her jaw was clenched. The patient was mottling on his/her forehead, looking gray/dark purple, with white pale extremities. His/her body was feeling cool. We never got a pulse."

RN #2 provided the following written Statement on 11/12/2010 at 10:55 a.m.: "I was sitting at the nurses station on the Adolescent Unit when MHT (mental health technician) ran to me saying ' They need you on East, someone's passed out or something.' I immediately began quickly down the hall saying to (MHT), Grab the oxygen tank and follow me.' Staff pointed me to the room where I entered and saw a middle age male/female patient lying on his back on the floor. He was gray and looked dead."

Review of the patient's emergency department record at the receiving hospital revealed the following information: " Death in the Emergency Department Note: Seen by myself on October 18th, this morning at 0436 (4:36 a.m.) hours after being transported by (name of fire department) to our facility from (Name of Hospital) where (he/she had been admitted to 'detox from some drugs '. EMS states that he/she already had some signs of rigor mortis on their arrival, such as when they tried to intubate the patient his/her jaw was already stiff and occlusion of the oropharynx orifice. He/she was asystole (without rhythm or flat line) on their first monitor evaluation. They started an IV (intravenous) and had given epinephrine, atropine and bicarbonate while in route and had never deviated from that asytole on the monitor. They were able to successfully intubate him/her and on arrival, he/she had breath sounds on the right side. However, there were none on the left. His/her endotracheal tube was pulled back 4 cm (centimeters) until 22 and a tenth were reached with bilateral breath sounds achieved at that time. Given the history of his/her presentation, Narcan 2 mg (milligrams) was given IV, as was 1 amp (ampule) of Calcium, as was 1 amp of D50 (Dextrose 50 milligrams) secondary to us not knowing his medical history status and the fact that he could have overdosed on some opiate-type Narcotic, even though he was inpatient, with detox from an unknown substance in process. CPR was continued for several minutes after administration of those drugs with no response from the patient with fixed and dilated pupils, and continuous asystole on the monitor when CPR was paused. Therefore, the patient was soon pronounced dead at 0443 (4:43 a.m.) hours. The patient was effectively dead on arrival; however, we did the minimum resuscitation efforts given the drug abuse history and EMS had not done Accu-check, therefore we gave D50, all of which was without response.

A telephone interview was conducted with the Physician on 11/12/10 at 1:20 p.m. The Physician did remember seeing the lab report about the patients low glucose of 29 mg/dl. The report also indicated that it might be inaccurate. The Physician stated that he thought the report was inaccurate. The Physician stated that no one called him at that time to report the low glucose level. The Physician stated that he would have asked staff to check the patients cognitive status and to check a glucose level. The Physician could not recall when he actually saw the glucose report. The Physician stated that he reviewed the Patients health history. The patient reported that (he/she) did not have Diabetes.

The Physician's Discharge Summary contained the following information: "The patient was started on Neurotin, 600 mg (milligrams) p.o. (orally) b.i.d. (twice a day); Hydrocodone 10 mg po q 6 hours prn pain; and a Librium Detox to address the alcohol dependence and withdrawal and also the Klonopin that I did not continue at admission given that we were attempting a detox. The patient was started on Seroquel, 200 mg po at bedtime and Celexia to address to mood symptoms. This was initiated on 10/15/10. The patient described himself to be going through a difficult detox. He/she claimed that he/she was sweating a lot. He/she was restless and craving for cocaine. An additional dose of Librium was given to him on 10/16/10 to address the reported severe anxiety and withdrawal symptoms." "On 10/16/10 Seraquel was increased to 300 mg po at bedtime and Neurotin to 600 mg po t.i.d. this latter, after the patient clarified that he had been on Neurotin, 800 mg po b.i.d. The patient was evaluated on 10/17/20 at approximately 9:45 in the morning. The patient complained of severe pain to his/her fractured toes to be continuing. He/she stated that his physician was giving him Lortab every four hours, instead of every six and that pain control was not lasting for more than four hours. He requested that the Lortab be placed at the original dose schedule of 10 mg po q. 4 hours. This was done on 10/17/2010. The patient continued to insist that he/she was not sleeping well and that he/she felt labile. He/she requested the Seroquel to be increased. He/she reported that he/she had previously been well stabilized on Seroquel at a daily dose of 900 mg po at bedtime. The Seroquel was increased to 400 mg po at bedtime, effective 10/17/2010."

The Risk Management Director provided the following documentation. "An autopsy was requested and the preliminary report we received listed the cause as accidental overdose related to benzodiazepine and opiates."

Resident #2
Patient #2 was admitted to the facility on 11/10/2010. Patient #2 was assessed as a risk for suicide. There was no documented evidence that the Patients belongings were searched at the time of admission. This section on the Comprehensive Assessment was left blank.

Resident #3
Resident #3 was admitted to the facility on 9/10/10. Resident #3 was at risk for suicide. There was no documented evidence that the patient's belongings were searched. This section on the Comprehensive Assessment was left blank.

All findings were discussed and confirmed during the exit interview with the Chief Executive Officer, Director of Nursing and Risk Management Director on 11/13/2010 from 8:05 p.m. to 8:50 p.m.