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Based on policy review, medical record review, and document review, the facility did not promptly notify Patient #2's family and/or appointed surrogate of the hospital admission, despite having documentation and contact information.

Findings Include:

Review of policy "Emergency Department (ED) Triage Policy" last revised 10/21 indicates the triage nurse, charge nurse or designee is to notify the family or next of kin when a seriously injured/ill patient is brought to the ED. The successful or unsuccessful contact must be recorded in the EDM/ED Nursing Care Record with the name of contact person, date, and time.

Review of ED record dated 06/28/2022 at 01:45 PM revealed Patient #2 arrived at the facility and was triaged at 01:55 PM for a psychiatric evaluation due to anxiety related to being homeless, and increased paranoia, but denied suicidal ideation.

Review of the ECMC Patient Information Sheet (Face Sheet) lists Patient #2's mother as the "Person to Notify."

Review of the CPEP Triage Assessment dated 06/28/22 at 03:37 PM indicates the "Advance Directives" section lists Patient #2's sister as the FHCDA (Family Health Care Decisions Act) Surrogate with her phone number. (New York's FHCDA (NY PHL Article 29-CC effective June 1, 2010- establishes the authority of a patient's family member or close friend to make health care decisions for the patient in cases where the patient lacks decisional capacity and did not leave prior instructions or appoint a health care agent).

Review of the Provider Note dated 06/29/2022 at 05:14 PM revealed a Mental Health Assessment was completed by a psychiatrist and Patient #2 was admitted involuntarily on a 9.27 legal status (involuntary admission for substantial risk of physical harm to other persons as manifested by violent behavior). At 08:30 PM Patient #2 was admitted to inpatient Behavioral Health (BH) unit 5 zone 2.

Review of Nursing documentation on 06/29/22 at 11:37 PM revealed Patient #2 required 4 point restraints and received three doses of Versed 10mg IM and one dose of Thorazine 50mg IM due to entering other patient rooms, attempting to leave the unit, and verbally threating/combative towards staff. On 06/30/22 at 12:34 AM, restraints were removed, and Patient #2 was sleeping. At 01:25 AM, a rapid response was called due to Patient #2 not breathing and pulseless.

Review of the Provider Note dated 06/30/22 at 01:45 AM indicates an attempt was made to contact the mother, however, they were unable to make contact.

Review of a Health Care Proxy document dated 06/02/21(included in the 06/29/22 medical record), lists Patient #2's sister as his Health Care Proxy. The document "never expires" and indicates no limitations.

Based on policy review and medical record review, nursing staff did not evaluate the care provided to Patient #2. Specifically, vital signs were not assessed during/after a psychiatric emergency and for the re-assessment post Versed administration.

Findings Include:

Review of the policy "Intramuscular Medication Administration of Versed to the Agitated Psychiatric Patient" undated indicates that that patient reassessment occurs after each intervention once enough time has elapsed for treatment to reach peak effect. The nurse will notify the provider immediately of any of the following: tachycardia greater than150 beats per minute (BPM) or bradycardia, less than 60 bpm, rise or fall in respiratory rate, Oxygen saturation less than ninety percent, marked decrease in patient responsiveness to verbal, and any change in the patient condition. Staff must monitor and record the patient's respirations continuously for 30 minutes post injection. Respirations will be recorded at a minimum of every 15 minutes. Monitor for signs of respiratory depression or other adverse reactions. Staff must make every effort to apply a pulse oximeter during observation for 30 minutes post injection and report to the RN if the pulse ox drops below 90%. Activate the Emergency Response Team immediately for signs and symptoms of respiratory distress.

Review of policy "Restraint and Seclusion- Psychiatry" last revised 01/20 indicates while in restraints, the patient must be monitored on a 1:1 basis. An RN must assess the patient at least every 15 minutes and must document findings in the "every 15 RN Reassessment Intervention". Upon release, the RN will evaluate the physical and psychiatric status of the patient (Patient Evaluation and Patient Debriefing as part of the Post Event Analysis). This will be documented on the Post Event Analysis Intervention.

Review of Nursing note dated 06/29/22 at 09:04 PM indicates Patient #2 arrived at the unit (Behavioral Health 5 zone 2) from CPEP at 08:30 PM.

Review of Physician Orders and the Medication Administration Record dated 06/29/22 at 11:30 PM revealed Versed 10mg IM was ordered and administered.

Review of Nursing Flowsheets dated 06/29/22 at 11:37 PM revealed restraints were applied. The RN restraint re-assessment notes at 11:39 PM, and at 11:53 PM indicate vital signs were refused, respirations regular/easy, skin/circulation checked. Patient #2 is yelling and does not meet criteria for release. Nursing Note at 11:51 PM indicates Patient #2 began entering other patient rooms and banging on unit doors attempting to get out. He was offered oral medications but threw the medication and water cup on the floor making vague threats to staff. When approached with IM medication, Patient #2 became combative with staff. The panic alarm was initiated, and Patient #2 was escorted by staff to the seclusion room where he became combative again. The physician was notified and arrived on the unit at 11:48 PM.

Review of Physician Orders and the Medication Administration Record dated 06/29/22 at 11:57 PM revealed Versed 10mg IM was ordered and administered. Vital signs are not listed.

Review of Nursing Flowsheets dated 06/30/22 12:07 AM revealed the RN restraint (4-point restraints) re-assessment note indicates vital signs refused, respirations are regular/easy, and skin/circulation was checked.

Review of Physician Orders and the Medication Administration Record dated 06/30/22 at 12:09 AM revealed Versed 10mg IM was ordered and administered. Vital signs are not listed.

Review of Nursing Flowsheets dated 06/30/22 at 12:18 AM the RN Versed Post Administration assessment indicates Patient #2 was verbally aggressive and combative towards staff prior to the administration of a total of 30mg of Versed. Patient #2 continues to be agitated. At 12:22 AM, the RN restraint (4-point restraints) re-assessment note indicates vital signs refused, respirations are regular/easy, and skin/circulation was checked. Patient #2 is awake and talking but does not meet criteria for release.

Review of Physician Orders & the Medication Administration Record dated 06/30/22 at 12:26 AM revealed Thorazine 50mg IM was ordered and administered once.

Review of the Nursing Flowsheet dated 06/30/22 at 12:32 AM, the RN restraint (4-point restraints) re-assessment note indicates vital signs not taken as Patient #2 is sleeping, respirations are regular/easy, and skin/circulation was checked. The section documenting blood pressure, pulse, O2 saturation are left blank. At 12:35 AM, the RN documents restraints (4-point restraints) were released at 12:34 AM. The Post-Event Analysis indicates Patient #2 has no complaints, is calmer and is able to return to milieu. Questions related to the restraint intervention list "no response. "

Review of Physician Orders & the Medication Administration Record dated 06/30/22 at 12:43 AM revealed the nursing medication reassessment for all three Versed administrations indicated a sedation level of 4 and sedation scale of "calm and cooperative." No vital signs are listed.

Review of the Nursing Flowsheet dated 06/30/22 at 01:29 AM revealed the RN Rapid Response Record indicates a rapid response was called at 01:25 AM.

Review of Nursing Note dated 06/30/22 at 02:00 AM revealed Patient #2 was sleeping following a behavioral event and staff noticed a change in his condition. He did not appear to be breathing and was pulseless. Staff immediately began CPR and rapid response was called overhead, followed by an adult medical emergency. The response team arrived at the unit and Patient #2 was transferred to the MICU.

No assessment of vital signs were documented during the psychiatric emergency event and/or for the reassessment of the Versed administration (10mg administered IM three times). The sections in the RN restraint reassessment for documenting blood pressure, pulse, O2 saturation are left blank. There are no documented rates of respiration or oxygen saturation for monitoring the Versed administration.