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Based on observation, staff interview, and document review, the Critical Access Hospital's (CAH) Behavioral Heatlh Unit administrative staff failed to ensure BHU staff protected and promoted all patients' rights when the BHU staff:

-Failed to provide inpatient beds in the Behavioral Health Unit safe for use around suicidal patients (Refer to C-221 and A-144);

-Failed to appropriately assess a patient who had recently intentionally overdosed on seizure medications (Refer to C-294);

-Failed to ensure nursing staff did not administer medication to a patient after laboratory tests indicated a nearly toxic level of the medication (Refer to C-276 and C-294); and

-Failed to identify the symptoms of an overdose of Tegretol (Refer to C-294).

The cumulative effect of these systemic failures and deficient practices resulted in the CAH's inability to protect each patient's rights to receive care in a safe setting. CAH administrative staff identified an average census of 4 inpatients in the Behavioral Health Unit.

Based on observation, staff interview, and document review, the Critical Access Hospital (CAH) Behavioral Health Unit (BHU) administrative staff failed to ensure 4 of 7 electric beds in the BHU had shortened electrical cords. The BHU administrative staff also failed to ensure suicidal patients couldn't use 3 of 7 electric beds to crush their heads with the electrically controlled steel mattress platform of the bed. The BHU administrative staff identified an average of 4 inpatients per day.

Failure to ensure electric beds had a shortened electrical cord could potentially allow suicidal patients to wrap the cord around their neck and strangle themselves. Failure to ensure electric beds had a shortened cord could also potentially allow the bed to remain plugged in to an electrical outlet and patients to operate controls on the side of the bed, resulting in the patient potentially placing their head under the bed, lowering the bed onto their head, and crushing their head.

Findings include:

1. Observations during a tour of the Behavioral Health Unit on 3/16/11 at 3:30 PM revealed:

Room 228 contained a standard Medical/Surgical electric patient care bed. The bed had an electric motor to adjust the bed's height and position. The bed's base frame stayed approximately 6-8 inches off the floor. The lower frame contained 2 rails, approximately 2 inch diameter and 5 feet long, in addition to a platform at the foot and head of the bed approximately 3 feet wide, and 1 foot deep. The mattress rested on a steel platform, and nursing staff could raise the mattress platform approximately 3 feet off the ground, leaving approximately 2.5 feet between the base and mattress platform. The bed had controls to raise and lower the height of the bed on the outside of the side rails by the patient's head, and at the foot of the bed. The bed also contained an approximately 6 foot long, thick electrical cord, plugged into the wall electrical outlet.

During the observations, the surveyor could wrap the electrical cord in a loop twice, approximately the diameter of a patient's neck. The cord was securely attached to the bed frame, and resisted a strong tug. The surveyor was also able to place their head under the bed, on the lower bed frame, and operate the controls on the exterior side rails by a patient's head, to lower the steel mattress platform of the bed.

Room 228 also contained a fixed position closed circuit video camera, which allowed staff to observe activity in the room from the nurses station.

Observations during a tour of the Behavioral Health Unit on 3/16/11 at 5:35 PM revealed room 225 also contained an electric bed with an electric cord approximately 6 feet long.

2. During an interview on 3/16/11 at 3:30 PM, the BHU Clinical Director acknowledged a patient could potentially wrap the 6 foot long electrical cord around their neck, and hang themselves on the bed. The Clinical Director also acknowledged a patient could potentially crush their head with the moving steel mattress platform on the bed.

The Clinical Director stated nursing staff could monitor patients in the room using the cameras. However, the Clinical Director stated the nursing staff did not continuously monitor the cameras, especially if the nursing staff left the nursing station. If nursing staff were not in the nursing station, the staff could not monitor the cameras, or observe if a patient attempted to harm themselves. The Clinical Director acknowledged the bed would obscure the camera's view of a patient that attempted to hang themselves with the bed's electrical cord. The Clinical Director also acknowledged the bed would obscure most of the camera's view of a patient attempting to crush themselves with the steel mattress platform.

The Clinical Director stated nursing staff normally placed patients with limited mobility in the Medical/Surgical style electric beds. However, the patient assigned to room 228 at the time of the tour did not have limited mobility. The Clinical Director also stated suicidal patients could potentially access the electric Medical/Surgical beds, since the rooms lacked a locking mechanism on the door.

The Clinical Director stated the BHU had 7 inpatient beds, including the 3 electric Medical/Surgical beds (room 221, room 228, and the pediatric inpatient room), the bed in room 225 with a 6 foot long electrical cord, 2 patient beds with appropriately shortened electrical cords, and 1 patient bed with a wooden frame.

3. Review of the undated policy "Safety Policies", revealed in part, "Cords are removed from the beds - each patient room has been modified for patient safety related to mental health disorders."

4. During an interview on 3/16/11 at 3:30 PM, the Clinical Director acknowledged staff had not modified the power cords on 4 of the 7 electric beds, in accordance with CAH policies.

Based on observation, staff interview, and document review, the Critical Access Hospital's (CAH) Behavioral Health Unit (BHU) administrative staff failed to ensure BHU staff provided safe and appropriate services to patients. The BHU staff:

-Failed to appropriately assess a patient who had recently intentionally overdosed on seizure medications (Refer to C-294);

-Failed to ensure nursing staff did not administer medication to a patient after laboratory tests indicated a nearly toxic level of the same medication (Refer to C-276 and C-294); and

-Failed to identify the symptoms of an overdose of Tegretol in a patient that had overdosed on a number of medications including Tegretol (Refer to C-294).

The cumulative effect of these systemic failures and deficient practices resulted in the CAH's inability to assure staff provided safe and appropriate services to patients. The CAH administrative staff identified an average census of 4 inpatients in the Behavioral Health Unit.

Based on document review and staff interview, the Critical Access Hospital (CAH) Behavioral Health Unit (BHU) administrative staff failed to ensure a system was in place to prevent nursing staff from administering medications to 1 (of 1) mental health patients (Patient #1) with a nearly toxic blood level of the same drug from a drug overdose. The CAH BHU administrative staff identified an average daily inpatient BHU census of 4 patients.

Failure to ensure nursing staff did not administer medications to a patient with a toxic level of the same medication could potentially result in additional harm and/or the death of the patient.

Findings include:

1. Review of Patient #1's medical record revealed:

a. Patient #1 transferred from another CAH to the BHU on 12/22/10 at 8:00 PM after the patient received initial treatment in the other CAH's Emergency Department for a medication overdose, that included Tegretol and Keppra, and tricyclic antidepressants. The Patient's medical record lacked evidence of nursing staff, or the psychiatrist, ordering blood tests on Patient #1 to determine the patient's level of Tegretol on admission.

b. The patient's medical record showed Psychiatrist C ordered a Tegretol level for Patient #1 on 12/23/10. The order lacked documentation of the time Psychiatrist C gave the order.

c. At 9:05 AM, on 12/23/10, Registered Nurse (RN) B accepted a telephone order from Psychiatrist C to administer Tegretol to Patient #1.

d. At 9:49 AM (44 minutes later), on 12/23/10, laboratory staff reported Patient #1's Tegretol level as 14.9 ug/ml. The report included, "Toxic [level]: [greater than] 15 ug/ml"

e. At 10:21 AM (32 minutes after the laboratory report), on 12/23/10, RN F administered Tegretol to Patient #1.

f. At 3:55 PM, on 12/23/10, RN H notified Psychiatrist C Patient #1's Tegretol level was at nearly toxic levels. Psychiatrist C gave a verbal order (per the telephone) to RN H to hold any additional administration of Tegretol for Patient #1.

g. At 6:25 PM, on 12/23/10, laboratory staff reported Patient #1's Tegretol level was 16.8 ?g/mL. The written report showed the toxic level for Tegretol was 15 ?g/mL.

2. During an interview on 3/17/11 at 10:30 AM, RN F stated nursing staff normally review laboratory tests provided by the facility that transferred the patient to the BHU. If the nursing staff noticed the sending facility had not performed a laboratory test, nursing staff requested the Psychiatrist to order the test. When caring for a patient who had overdosed on a medication, the nurse should have looked at the laboratory results for the medication level before administering the medication.

3. During an interview on 3/17/11 at 4:15 PM, RN F acknowledged administering Patient #1's Tegretol on the morning of 12/23/10. RN F stated s/he assumed s/he reviewed Patient #1's Tegretol level prior to administering the Tegretol, but did not remember reviewing the Tegretol level prior to administering the Tegretol.

4. During an interview on 3/17/11 at 3:15 PM, the Clinical Director of the BHU stated if a nurse knew the physician had ordered CAH staff to determine the level of a medication in a patient, such as Tegretol, the nurse should check to ensure the medication was not at an elevated level, prior to administering the medication.

5. During an interview on 3/22/11 at 2:20 PM, the Education Director reported the CAH did not have a policy in place that required nurses to hold medications, if the physician had ordered laboratory tests to determine the medication levels in a patient, until laboratory staff provided the results of the tests. The CAH also failed to have a policy in place that required nursing staff to check laboratory test results for blood levels of medications prior to administering the same medication.

Based on document review and staff interview, the Critical Access Hospital (CAH) Administrative Staff failed to ensure Behavioral Health Unit (BHU) nursing staff provided appropriate assessment, monitoring, and treatment for 1 of 3 patients treated in the BHU for an acute suicide attempt by intentionally overdosing on medication. The CAH Administrative staff identified an average census of 4 Behavioral Health Unit inpatients per day.

Failure to provide appropriate assessment, monitoring, and treatment resulted in the nursing staff failing to identify the patient had overdosed on Tegretol, and delayed appropriate monitoring, including monitoring of the patient's heart rhythm for over 24 hours. The delay could potentially have resulted in permanent disability and/or death for the patient.

Findings include:

1. Review of the manufacturer's product insert for Tegretol XR (extended release), revised 3/11, revealed the following information, in part. Overdose signs and symptoms include a fast heart rate, and high blood pressure. Motor restlessness, such as, constantly moving fingers, toes, arms, and legs, muscular twitching, tremor, difficulty walking. Other symptoms included drowsiness, dizziness, large pupils, and twitching of the eyes.

2. Review of Patient #1's medical record revealed:

a. Patient #1's spouse called Cass County BHU on 12/22/10 at 12:10 PM, seeking help because Patient #1 took an overdose of medication. Cass County BHU Licensed Practical Nurse (LPN) A instructed Patient #1's spouse to contact 911, and obtain medical treatment for Patient #1 at the nearest Emergency Department (ED). At 4:21 PM, the patient's local CAH staff (CAH A) contacted Cass County BHU Registered Nurse (RN) B, and RN B stated Psychiatrist C would accept Patient #1 for inpatient treatment in the Behavioral Health Unit (BHU).

b. On 12/22/10 at 5:35 PM, a judge ordered Patient #1 to receive treatment at the CAH's BHU following Patient #1's intentional overdose of medications in a suicide attempt. According to the court document, found in Patient #1's medical record, Patient #1's spouse documented the patient took an overdose of seizure medications while trying to commit suicide in their house.

c. Patient #1 arrived at the CAH ' s BHU on 12/22/11 at 8:00 PM, and nursing staff performed an admission assessment and examination at 8:00 PM. RN J ' s assessment documentation on 12/22/10 at 8:00 showed Patient #1 ' s blood Pressure was 125/91 and Pulse was 103 beats per minute. RN J also documented the patient took a handful of Tegretol and Keppra and the patient wanted to die. The Patient was very sleepy due to the overdose of medications and was hard to understand when speaking. At 9:53 PM, RN J documented the Patient ' s Speech was garbled, slow, and slurred and the Patient leans forward and slumps.

d. On 12/22/11 (night of admission), Psych Tech E documented in Patient #1's medical record that Patient #1 arrived at the inpatient BHU with their home medications, including Tegretol. On 12/23/10, Pharmacy staff documented receiving Patient #1's home medications, which included an extended release form of Tegretol (Tegretol XR) from nursing staff on the night of 12/22/10.

e. The medical record lacked evidence showing CAH staff requested or obtained Patient #1's Tegretol level on the day of admission.

f. At 9:29 PM on 12/22/10, Psych Tech E documented in Patient #1's medical record that the Patient was unable to stand or walk. The Patient's speech was slurred and the patient had a hard time sitting up.

g. At 5:40 AM, on 12/23/10, RN L documented Patient #1 was up at around 12:50 AM and went to the bathroom independently. RN L noted the Patient ' s gate was unsteady, widely staggering and the Patient ran into the wheelchair causing it to hit the wall when going from the recliner to the bathroom. The Patient admitted to being dizzy and the dizziness was new. RN J recorded the following vital signs following the incident: blood pressure 139/95 and pulse 87 beats per minute.

h. Review of Psychiatrist C ' s History and Physical examination, dictated on 12/23/10 at 9:07 AM, showed Patient #1 had intentionally overdosed on several medications, including Tegretol and Keppra.

i. On 12/23/10, Psychiatrist C ordered a Tegretol level for Patient #1. Psychiatrist C failed to document the time he wrote the order.

j. At 9:05 AM, on 12/23/10, RN B accepted a telephone order from Psychiatrist C to administer Tegretol to Patient #1.

k. At 9:49 AM 12/23/11, laboratory staff reported Patient #1's Tegretol level was 14.9 ?g/mL. The written report showed the toxic level for Tegretol was 15 ?g/mL.

l. Review of the Medication Administration Record revealed RN F administered Tegretol to Patient #1 on 12/23/10 at 10:21 AM.

m. At 7:27 PM on 12/23/10, Psych Tech E documented they took Patient #1 to an appointment with Internal Medicine Physician G at 1:30 PM that day. After arriving in the examination room, Patient #1 became nauseated, and vomited 3 times. Physician G examined Patient #1, and Psych Tech E transported Patient #1 back to the BHU.

n. Physician G ' s documentation in Patient #1's medical record on 12/23/10 at 1:30 PM, showed the Patient was nauseated and vomiting, spitting up clear fluid. Physician G documented the results from Patient #1's Topamax level had not returned. However, Psychiatrist C had ordered laboratory staff to determine Patient #1's Tegretol level, and had reported the level at 9:49 AM on 12/23/10.

o. At 3:00 PM, on 12/23/10, Psych Tech E assisted RN B in transferring Patient #1 to the patient room closest to the nurses station, for closer monitoring. Patient #1 attempted to read court paperwork with difficulty at the time of the room change.

p. At 3:55 PM, on 12/23/10, RN H notified Psychiatrist C that Patient #1's Tegretol level was 14.9 ?g/mL. Psychiatrist C gave RN H a telephone order to hold any additional administration of Tegretol to Patient #1.

q. At 4:35 PM, on 12/23/10, Psych Tech E documented Patient #1's vital signs as blood pressure 143/100, and pulse 97 beats per minute. Psych Tech E informed RN H of Patient #1's vital signs. RN H notified Psychiatrist C about Patient #1's condition. Patient #1 refused the evening meal, and only drank clear soda. Patient #1 did not throw up again.

r. At 4:38 PM, on 12/23/10, RN H documented Patient #1 developed nystagmus (twitching of the eyes). RN B verified Patient #1 developed nystagmus, and the nystagmus was not present earlier in the day. Patient #1 reported to RN B they noticed twitching in their fingers. Patient #1 had not experienced twitching of their fingers before, and it developed on 12/23/10. Patient #1 also reported to RN H they had difficulty seeing. When RN H inquired further, Patient #1 stated they could only see items clearly when Patient #1 held the item a few inches from his/her face.

s. At 4:42 PM, on 12/23/10, RN H documented Psychiatrist C requested RN H contact Physician G regarding Patient #1's vital signs, weakness, and difficulty seeing. Physician G instructed RN H to have Patient #1 seen in the Emergency Department, since Physician G's staff had finished seeing patients for the day. RN H notified Psychiatrist C about Physician G's instructions. Psychiatrist G contacted Internal Medicine Physician I via telephone.

t. At 5:05 PM, on 12/23/10, Physician I called RN H, and inquired about what Poison Control had recommended for the treatment of Patient #1. RN H informed Physician I that neither nursing staff at the CAH, nor staff at the facility (CAH A) that transferred Patient #1 to the CAH, had contacted Poison Control. Physician I ordered RN H to contact Poison Control.

u. At 5:17 PM, on 12/23/10, RN H contacted Poison Control.

v. At 5:55 PM, on 12/23/10, Psych Tech E documented Patient #1's vital signs as blood pressure 140/103, and pulse 107 beats per minute. Psych Tech E notified RN H of Patient #1's vital signs.

w. At 6:25 PM, on 12/23/10, RN H documented Poison Control called RN H, and gave recommendations for nursing staff to transfer Patient #1 to the Intensive Care Unit, where nursing staff could monitor Patient #1's heart rhythm; and suggested CAH staff perform additional laboratory tests. Laboratory staff also reported Patient #1's Tegretol level was 16.8 ?g/mL. The report showed the toxic level for Tegretol was 15 ?g/mL.

x. At 6:30 PM, on 12/23/10, RN H contacted Physician I, and relayed Poison Control's recommendations. Physician I gave RN H orders to follow Poison Controls's suggestions, including transferring Patient #1 to the Intensive Care Unit.

y. At 7:40 PM, on 12/23/10, Psych Tech E documented Patient #1's vital signs as blood pressure 143/104, pulse 112 beats per minute, and Patient #1 was still nauseated. Nursing staff then transferred Patient #1 to the Intensive Care Unit for closer observation, and monitoring of Patient #1's condition.

3. During an interview on 3/17/11 at 11:30 AM, RN reported relying on Patient #1's transferring physician to ensure Patient #1 did not have any medical problems that prevented Patient #1 from receiving care in the BHU. RN B stated Psychiatrist C ordered Patient #1 to resume taking Tegretol. Since Psychiatrist C gave the order in the morning, RN B made sure Patient #1 received the Tegretol on the morning of 12/23/10.

4. During an interview on 3/17/11 at 1:30 PM, Psychiatrist C reported relying on the transferring physician for Patient #1 to ensure Patient #1 did not have any medical problems preventing Patient #1 from receiving care in the BHU. Psychiatrist C reported examining Patient #1 at approximately 8:00 AM on 12/23/10. Psychiatrist C had a hard time waking Patient #1 up to complete the examination. Patient #1 complained about not feeling well to Psychiatrist C. Psychiatrist C also saw Patient #1's hands trembling (tremors). Psychiatrist C ordered a Tegretol level for Patient #1, because of the tremors in Patient #1's hands. Psychiatrist C was concerned the level of Tegretol was elevated in Patient #1.

5. During an interview on 3/17/11 at 2:15 PM, RN J stated Patient #1's blood pressure at the CAH A was 109/67 and the patient was staggering, prior to transfer to the BHU. RN J stated Patient #1 was unsteady when standing, but walked 4 or 5 steps to sit in a chair at the nurses ' station after Patient #1 arrived in the BHU. During the admission process, Patient #1 was weak and sleepy. Patient #1 fell asleep during the admission process several times. RN J also reported Patient #1's pupils were big.

6. During an interview on 3/17/11 at 10:03 AM, RN K stated when a patient arrived from another facility, the nurse looked through the paperwork, and examined the laboratory tests the other facility had completed. If a laboratory test was missing, the nurse would ensure the staff completed the test. If the nurse noticed staff had not determined a Tegretol level for a patient who had overdosed on Tegretol, the nurse should ensure staff determined the patient's Tegretol level.

7. During an interview on 3/17/11 at 10:30 AM, RN F stated if nursing staff did not know what symptoms to watch for in a patient that overdosed on a medication, the nurse could call the ED physician, find the symptoms in medication books available in the BHU nurses station, or use the resource books available in the pharmacy. RN F also acknowledged administering Patient #1 Tegretol on the morning of 12/23/10. RN F stated s/he assumed s/he reviewed Patient #1's Tegretol level prior to administering the Tegretol, but did not remember reviewing the Tegretol level prior to administering the Tegretol.

8. During an interview on 3/17/11 at 9:35 AM, Psych Tech E stated upon arrival at the BHU, Patient #1 was drowsy, had a very unsteady walking pattern (gait), was tired, slouched in the chair while Psych Tech E asked Patient #1 questions, and Patient #1 had a hard time walking because they could not stand. When Psych Tech E transported Patient #1 to Physician G's office, Patient #1 walked to the wheelchair, but appeared very weak and moved very slowly while walking to the wheelchair. Psych Tech E noticed Patient #1 had problems reading the paperwork Patient #1 had to fill out in Physician G's office, because Patient #1 was having problems with eyesight. Psych Tech E stated Patient #1 refused the evening meal on 12/23/10, since the Patient was nauseated.

9. During an interview on 3/17/11 at 2:45 PM, RN L stated when Patient #1 attempted to walk to the bathroom during the night of 12/22/10, Patient #1 had an unsteady gait, and RN L was concerned Patient #1 would fall. RN L stated Patient #1's blood pressure, especially the diastolic (bottom number) was elevated. Patient #1 told RN L s/he was dizzy, and the dizziness had started that day (12/22/10).

10. During an interview on 3/22/11 at 11:28 AM, Physician G stated they examined Patient #1 on 12/23/10 at approximately 1:30 PM. During the examination, Physician G examined Patient #1's heart, lungs, and belly. Physician G did not identify any concerns with Patient #1's examination. During the examination, Patient #1 was spitting a clear fluid, that looked like saliva, into a spit container. Physician G did not identify any concerns with the liquid Patient #1 was spitting up. Physician G did not examine Patient #1's ability to walk. Physician G attempted to review Patient #1's Tegretol level, but did not find the laboratory result. Physician G did not look later in the day to determine if laboratory staff had determined Patient #1's Tegretol level.

11. During an interview on 3/17/11 at 3:50 PM, Physician I reported receiving a call from Psychiatrist C about Patient #1 on the evening of 12/23/10. Physician I called the BHU nurse, and asked the nurse what Poison Control staff recommended for the treatment of Patient #1. The BHU nurse stated neither staff at the CAH, nor sending facility (CAH A) had contacted Poison Control. Physician I instructed the nurse to contact Poison Control. Physician I stated, "It is a basic question, what did Poison Control say? It's a knee jerk reaction [to get Poison Control's recommendations for patients that have overdosed on medications]. [All of the treatment for patients that had overdosed] is based on Poison Control's recommendations."

12. During an interview on 3/17/11 at 3:15 PM, the Clinical Director of the BHU stated if a nurse knew the physician had ordered CAH staff to determine the level of a medication in a patient, such as Tegretol, the nurse should check to ensure the medication was not at an elevated level, prior to administering the medication.

13. During an interview on 3/22/11 at 2:20 PM, the Education Director stated the CAH did not have a policy in place that required nurses not to administer medications, if the physician had ordered laboratory tests to determine the medication levels in a patient, until laboratory staff provided the results of the tests. The CAH failed to have a policy that required nursing staff to check laboratory test results for medications prior to administering the same medication. The CAH also failed to have a policy that addressed when, or if, nursing staff should contact Poison Control about patients that overdosed on medications.